Public policies in headache disorders: needs and possibilities

Abstract Although headaches have recognized impact, there are no public policies in Brazil addressing this problem. The Brazilian Headache Society and the Brazilian Association of Cluster Headache and Migraine promoted a summit to discuss Public Policy and Advocacy for headache disorders. Professionals from various segments, representing various sectors of society, gathered in April 2019 in Brasília, defining the most important points for achieving advances in public policies in headache in Brazil, such as: inclusion in the chronic diseases surveillance agenda; improving public understanding and access to diagnosis and treatment; teaching in colleges and medical residences, structuring care networks, intervention models, clinical protocols and legislation supporting public policies in headache.

Overuse Headache (MOH) affects another 58.5 million people around the world 1 . These three conditions account for 17% of the global impact of all neurological diseases, with migraine, despite not causing an increase in mortality, is considered the second most disabling disease 1,2 . Including in this estimate individuals suffering from MOH -originally mostly migraine -it becomes the first cause of disability from 15 to 49 years of age, during a period of high professional, family and social productivity 3 .
Cluster headache, considered the most severe among primary headaches, and even worse than the pain in conditions such as renal colic, pancreatitis, and labor 4-6 , is associated with severe disability in 80% of patients 7 . Nevertheless, the diagnosis is established on average only seven to eight years after the first episode 8 .
Although there are several effective treatment options for most patients with any major primary headache, access to trained professionals in this area is limited, making it difficult to establish the correct diagnosis and proper management in most cases [6][7][8][9][10] .
Formally, it is acknowledged that the prospects for the care of primary headache sufferers in Brazil depend predominantly on 74% coverage of the SUS (Unified Health System) 11 , that there is a need for public managers to be aware of the headache, and that implementation of educational strategies and public policies are fundamental. On April 27, 2019, professionals from various segments gathered in Brasília, representing various sectors of society: doctors, researchers, patients, representatives of government agencies for the first summit specifically dedicated to public policies in the area of headache in Brazil.
This forum was organized by SBCe (Brazilian Headache Society) and ABRACES (Brazilian Association of Cluster Headache and Migraine [Headache Advocacy Association]). Topics presented and discussed included: epidemiological data and studies of headaches in Brazil, advocacy for headache patients in Brazil, experiences of training primary care teams in headache care, public policy experiences and advocacy in other diseases (mental health, cancer, multiple sclerosis), experience of primary health care / family health strategy, and the role of ANVISA.
The discussion during the Summit led to a consensus statement that it is necessary and important to: • Include primary headaches in the non-communicable disease surveillance agenda.
• Improve public understanding of headaches and reduce their stigma through awareness-raising campaigns and monitoring of painkillers' advertising.
• Provide patients with primary headaches adequate access to necessary medical care.
• Encourage the teaching of headache in undergraduate medical courses.
• Encourage the teaching of headaches and their inclusion in the syllabus of medical residences, especially in neurology, medical clinic, gynecology and obstetrics, pediatrics, and family medicine.
• Provide health care professionals with access to headache training.
• Structure a public sector headache care network at the primary, secondary, and tertiary levels.
• Identify the current percentage of patients diagnosed, treated and in remission, with cluster headache and episodic or chronic migraine and set goals to be achieved in two, five, and ten years regarding the proper diagnosis and treatment of these headaches after implantation, interventions, and planned improvements.
• Write the clinical protocols and therapeutic guidelines for cluster and other headache, as well as specific situations that may require special management.
• Propose and pass laws for public policies defined in the area of headache.

CONCLUSION
The Brasília Declaration sets out the most important points for achieving advances in public policies in headache disorders in Brazil, as a milestone in the beginning of a joint work to improve knowledge, both by the population and health professionals about primary headaches, and the care dedicated to those who suffer from these health problems and who are treated in the public health system.