Keywords: Continuity of care; Tension-type headache; Migraine; Primary care; Headache calendar

Background:

Tension-type headache (TTH) and migraine are common in general practice and require continuity of follow-up. However, it is often inconsistent and relies on recall rather than structured longitudinal data. A low-burden calendar linked to explicit “Stop–Go–Escalate” decisions may standardise follow-up and support timely escalation within stepped care.

Research questions:

Does a GP-led modified headache calendar combined with a “Stop–Go–Escalate” decision template improve continuity of monitoring and decision-making compared with usual care over 12 weeks?

Method:

Pilot controlled study in general practice comparing usual care with a structured follow-up toolkit. Consecutive adults (≥18 years) with ICHD-defined TTH or migraine will be enrolled. The toolkit uses cyclical monitoring to minimise burden: a 28-day baseline headache calendar plus 14-day pre-visit windows. Daily items capture headache occurrence, peak pain severity, acute medication use, and brief activity impact; a care-events log records exposures (physiotherapy and procedures). At the 4-week review, GO schedules the next review in 4 weeks, while STOP/ESCALATE schedules the next review in 2 weeks. Stop–Go–Escalate rules guide decisions: GO = continue; STOP = stop the current approach and revise the plan when there is no meaningful improvement without safety concerns; ESCALATE = step-up/urgent actions for safety triggers (red flags, suspected medication overuse, chronic high frequency, high disability). This decision-adaptive cycle continues until week 12. Primary outcomes are completion, attendance, and documented decisions; secondary outcomes include changes in headache days, medication days, and pain severity.

Results:

We expect high feasibility and improved continuity, reflected by calendar completion, follow-up attendance, and consistent documentation of GO/STOP/ESCALATE decisions. We anticipate signals toward fewer headache days and acute medication days and fewer uncertainty-driven repeat consultations versus usual care.

Conclusions:

A modified headache calendar plus Stop–Go–Escalate rules and decision-adaptive review intervals may operationalise continuity of care for TTH and migraine in general practice. Findings will refine thresholds and inform a larger trial.

Points for discussion:

What thresholds should define GO/STOP/ESCALATE in GP (frequency, pain severity, medication days, activity impact)?

Is the decision-adaptive schedule (4 weeks if improving; 2 weeks if not) feasible across settings?

What is the most acceptable activity-impact measure (daily marker vs days with activity limitation vs goal attainment)?