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Background Chronic migraine is a disabling condition, affecting 2–4% of adults globally. With the introduction of expensive calcitonin gene-related peptide monoclonal antibodies, it is timely to compare the clinical effectiveness and cost-effectiveness of preventive drugs for chronic migraine. Objective To assess the clinical effectiveness and cost-effectiveness of medications used for chronic migraine through systematic reviews and economic modelling. Eligibility criteria Randomised controlled trials of drug treatments for efficacy with > 100 participants with chronic migraine per arm; for adverse events > 100 participants with episodic or chronic migraine per arm. Previous economic analyses of preventive drugs for chronic migraine. Data sources Eight databases. Reviews methods Systematic reviews, network meta-analysis and economic modelling. Outcomes Monthly headache days, monthly migraine days, headache-related quality of life, cost-effectiveness. Results We found 51 individual articles, reporting 11 randomised controlled trials, testing 6 drugs (topiramate, Botox, eptinezumab, erenumab, fremanezumab, galcanezumab), versus placebo, on 7352 adults with chronic migraine. Calcitonin gene-related peptide monoclonal antibodies, Botox and topiramate reduced headache/migraine days by 2.0–2.5, just under two, or by less than 1.5 days per month, respectively. In the network meta-analysis, eptinezumab 300 mg and fremanezumab monthly ranked in first place in both monthly headache day and monthly migraine day analyses. The calcitonin gene-related peptide monoclonal antibodies were consistently the best choices for headache/migraine days and headache-related quality of life. Topiramate was very unlikely to be the best choice for headache/migraine days and headache-related quality of life when compared to calcitonin gene-related peptide monoclonal antibodies or Botox. We found no trials of the commonly used drugs, such as propranolol or amitriptyline, to include in the analysis. The adverse events review included 40 randomised controlled trials with 25,891 participants; 3 additional drugs, amitriptyline, atogepant and rimegepant, were included. There were very few serious adverse events – none of which were linked to the use of these medications. Adverse events were common. Most people using some calcitonin gene-related peptide monoclonal antibodies reported injection site issues; and people using topiramate or amitriptyline had nervous system or gastrointestinal issues. The cost-effectiveness review identified 16 studies evaluating chronic migraine medications in adults. The newer, injected drugs are more costly than the oral preventatives, but they were cost-effective. Our economic model showed that topiramate was the least costly option and had the fewest quality-adjusted life-year gains, whereas eptinezumab 300 mg was more costly but generated the most quality-adjusted life-year gains. The cost-effectiveness acceptability frontier showed that topiramate was the most cost-effective medication if the decision maker is willing to pay up to £50,000 per quality-adjusted life-year. Our consensus workshop brought together people with chronic migraine and headache experts. Consensus was reached on the top three recommendations for future research on medications to prevent chronic migraine: (1) calcitonin gene-related peptide monoclonal antibodies and Botox versus calcitonin gene-related peptide monoclonal antibodies, (2) candesartan versus placebo and (3) flunarizine versus placebo. Limitations Topiramate was the only oral drug for which we were able to include data. We did not find sufficient quality evidence to support the use of other oral drugs. Conclusions We did not find evidence that the calcitonin gene-related peptide monoclonal antibodies are more clinically and cost-effective when compared to topiramate or Botox. We identified directions for future research these drugs might take. Study registration This study is registered as PROSPERO CRD42021265990, CRD42021265993 and CRD42021265995. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR132803) and is published in full in Health Technology Assessment; Vol. 28, No. 63. See the NIHR Funding and Awards website for further award information. Plain language summary What is the problem? Chronic migraine is a disabling condition that can destroy work and family life. Treatments include cheap tablets (e.g. amitriptyline, propranolol and topiramate), Botox and expensive new drugs (the calcitonin gene-related peptide monoclonal antibodies). It is not known which of these drugs is the best choice. What did we want to find out? We wanted to find out which of these drugs works best. We wanted to know if they reduced the number of headache/migraine days and improved headache-related quality of life, how many side effects people experienced, and if they provided good value for the National Health Service. How did we do this? We first looked for research comparing these drugs to placebo (fake) drugs, and to each other. We then worked out which provide best value for money. What did we find out? Calcitonin gene-related peptide monoclonal antibodies reduced headache/migraine days by 2.0–2.5 days per month; Botox reduced headache/migraine days per month by around 1.9; and topiramate reduced headache/migraine days by 1.1–1.5 days per month. Many people taking topiramate or amitriptyline have nervous system and/or stomach/bowel side effects. Some people using calcitonin gene-related peptide monoclonal antibodies reported side effects associated with injections. Some calcitonin gene-related peptide monoclonal antibodies and Botox provide worthwhile benefits on headache-related quality of life. We were not able to identify any studies of sufficient quality to assess the effectiveness of other oral drugs. The best value drug was topiramate which gave better health outcomes at a lower cost than the placebos. What does this mean? After sharing the results with a panel of people with chronic migraine and headache experts, we identified a need for new studies comparing commonly used cheap oral drugs with placebo, Botox and calcitonin gene-related peptide monoclonal antibodies. Scientific summary Background Chronic migraine is a profoundly disabling condition and affects 2–4% of the world’s adult population. It is defined as headaches on 15 days or more a month with features of migraine on at least 8 of those days. Since 2020, expensive calcitonin gene-related peptide (CGRP) monoclonal antibodies (MAbs) have become established as specific treatments for people with chronic migraine who have failed to improve with other medications. Little is known about the effectiveness of these drugs when compared with each other, or with other well-established, cheaper, oral drugs used to treat chronic migraine. Therefore, it is timely to compare the clinical effectiveness and cost-effectiveness of these medications to treat chronic migraine. We set out to address the following research question: What is the clinical effectiveness and cost-effectiveness of prophylactic drug treatments for people with chronic migraine? Objectives Our overall aim is to produce evidence needed for people with chronic migraines and their doctors to make more informed decisions about prophylactic medications for chronic migraine. Our objectives were: What is the comparative effectiveness of prophylactic drugs for chronic migraine? What are the comparative incidences of adverse events (AEs) of prophylactic drugs used for migraine? What is known about the cost-effectiveness of prophylactic drugs for chronic migraine? Which prophylactic drugs for the management of chronic migraine are the most cost-effective? Based on our findings, what should the research recommendations be? Methods Systematic reviews of trial evidence on: The clinical effectiveness of prophylactic medications for chronic migraine; analyses included headache days, migraine days and headache-related quality of life: migraine- specific quality of life (MSQ); headache impact test-6 (HIT-6). Only randomised controlled trials (RCTs) with at least 100 people per arm were included. We report the comparative effectiveness using a network meta-analysis (NMA) for these different outcomes to see which drug was the most ‘effective’. To identify the comparative incidence of AEs of prophylactic drugs used for chronic or episodic migraine. RCTs with at least 100 people per arm were included. The cost-effectiveness studies of prophylactic drugs used for treatment of chronic migraine. We developed an economic model comparing the cost-effectiveness of prophylactic drugs for chronic migraine for the adult population from a National Health Service (NHS) and personal social services (PSS) perspective. The base-case analysis used a 2-year time horizon, with a starting age of 30 years for the patient cohort. Health states in the model were based on effectiveness data [reduction in the mean difference (MD) in monthly headache days (MHDs)] from the NMA. Costs are in 2021–2 prices and utilities were estimated based on EuroQol-5 Dimensions, five-level version (EQ-5D-5L) scores from the CHESS trial using the Hernandez-Alava crosswalk algorithm. Cost-effectiveness was measured in terms of an incremental cost per quality-adjusted life-year (QALY) gained [Institute for Clinical and Economic Review (ICER)]. Probabilistic sensitivity analysis (PSA) was undertaken to account for uncertainty in model parameters. Uncertainty around the cost-effectiveness of the various medications showing which is the preferred strategy is presented using a cost-effectiveness acceptability frontier (CEAF). At the end of the project, we held a consensus workshop bringing together people with chronic migraine and clinicians and other health professionals who are experts in chronic migraine. We presented the findings from our reviews, NMA, the economic model and some potential recommendations. We then split into groups (mixed with health professionals and participants) and asked them to discuss our suggested research recommendations, identify any other recommendations, and rank these recommendations in terms of priority. We then had another breakaway session, where all participants with chronic migraine met and all health professionals met. Finally, everyone was bought back together to discuss their rankings as a wider group and to reach a consensus using anonymous polling. Results The clinical effectiveness review focused on prophylactic medications which might be used in the UK for the prevention of chronic migraine. We found 11 RCTs reported across 51 individual publications, involving 7352 adult participants with chronic migraine, which showed that all pharmacological treatments for all outcomes of interest were beneficial in preventing migraine when compared to placebo. There were no trials of sufficient quality of the commonly used drugs, such as amitriptyline, candesartan, flunarizine or propranolol. Overall, the CGRP MAbs reduced headache/migraine days by 2.0 to 2.5 days per month. The most effective medication in reducing MHDs was eptinezumab 300 mg which reduced MHDs by 2.46 [95% credible interval (CrI) 3.24 to −1.67] days. The most effective medication in reducing monthly migraine days (MMDs) was fremanezumab monthly which reduced MMDs by 2.76 (95% CrI −3.36 to −2.15) days. Botox (BTA) reduced MHDs by 1.87 (95% CrI −2.55 to −1.18) days per month and MMDs by 1.96 (95% CrI −2.69 to −1.24) days per month. Topiramate was the least effective, prescribable drug and only reduced headache/migraine days by less than 1.5 fewer headache/migraine days per month. The NMA results showed that eptinezumab 300 mg had the highest probability ranking to reduce MHDs and MMDs – Surface Under the Cumulative Ranking Area (SUCRA) was 0.88 and 0.77, respectively. The CGRP MAbs provided a worthwhile improvement on the HIT-6 measure of headache-related quality of life (eptinezumab 300 mg reducing the HIT-6 by a score of 3.22 points); BTA had a worthwhile effect on the HIT-6 measure, reducing the HIT-6 score by 2.10 points; and there was no convincing benefit of topiramate on the MSQ measure. Galcanezumab 120 mg provided the best improvement in quality of life for the preventative role dimension of migraine-specific quality of life (MSQ-PR) (MD 6.97, 95% CrI 3.79 to 10.24, SUCRA 0.88), but for two other dimensions of the MSQ, erenumab 140 mg was superior to other treatments: for migraine-specific quality of life-restrictive role (MSQ-RR) – MD: 7.28, 95% CrI: 3.05 to 11.65, SUCRA 0.75, and for migraine- specific quality of life-emotional function (MSQ-EF) – MD: 8.89, 95% CrI: 3.20 to 14.55, SUCRA 0.79. The results from the quality assessment using the revised Cochrane risk-of-bias (RoB 2) tool for RCTs found that approximately 46% of the included RCTs in this review had low RoB and 36% of the RCTs had some concerns of bias. The incidence of AEs and serious adverse events (SAEs) review used evidence from 40 RCTs reported across 67 articles, which investigated pharmacological interventions to manage chronic or episodic migraine. These trials included 25,891 participants and 3 additional drugs were included – amitriptyline, atogepant and rimegepant. There were very few SAEs – none of which were linked to the use of these drugs. Non-SAEs were common, and results suggested that all the pharmacological medications included in this review were found to be tolerable. There were differences in the incidence of AEs between the CGRP MAbs, with most people using fremanezumab and one in four people using galcanezumab reporting injection site issues. These issues were much less common in people using eptinezumab or erenumab. Most people using topiramate or amitriptyline had nervous system or gastrointestinal side effects; topiramate was also linked to a higher prevalence of psychiatric disorders; and AEs related to BTA were uncommon. The cost-effectiveness review identified nine peer-reviewed journal articles and seven published reports of chronic migraine prophylactic medications in the adult population. All articles were model-based evaluations, and none were trial-based economic evaluations. We found that although these newer drugs (BTA and CGRP MAbs) were more costly than the oral preventatives, they were however deemed cost-effective. Generally, the articles were classed as high quality when appraised by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting tool. We developed a Markov (state-transition) model to assess the cost-effectiveness of different pharmacological medications to treat or prevent chronic migraine in the adult population. Our base-case deterministic results showed when comparing each of the medications separately against placebo, topiramate dominated placebo (cheaper and more effective); and each of the other medications, when compared separately, were more expensive than placebo; however, they generated more QALYs than placebo. The best value medication when compared with placebo was BTA, with the cost per QALY around £25,000. When comparing all medications together, the deterministic results showed that topiramate was the least costly option and had slightly more QALY gains than placebo, whereas eptinezumab 300 mg was the more costly option but generated the most QALY gains. Most medications were eliminated due to dominance. The ICER between BTA and topiramate and the ICER between eptinezumab 300 mg and BTA were not within plausible cost-effectiveness thresholds. Probabilistic results were similar to deterministic results. The CEAF showed that when comparing all medications topiramate was the most cost-effective medication if the decision maker is willing to pay up to £50,000 per QALY. None of the CGRP MAbs represented good value for money in this comparative analysis. Extensive sensitivity analyses showed that when MHDs is used as an outcome measure, the results were generally in line with the base-case results. The main exception was when using MMDs as an outcome measure instead of MHDs, fremanezumab monthly generated more QALY gains than eptinezumab 300 mg; the ICERs between the plausible options, once any dominated options were removed, were not within plausible cost-effectiveness thresholds. Our consensus workshop brought together 8 participants with chronic migraine and 11 health professionals with expertise in chronic migraine to set research priorities for preventive drugs for chronic migraine. Each of the small groups found that the need for trials of cheaper, oral medications, tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors (SNRIs) when compared with placebo were ranked highly; and for trials comparing the medications with each other, the CGRP MAbs and BTA separately or in combination with each other were ranked highly. The final (anonymised) rankings showed that the top three research priorities versus placebo were: (1) candesartan, (2) flunarizine and (3) melatonin; and for medications compared with each other were: (1) CGRP MAbs and BTA versus CGRP MAbs, (2) CGRP MAbs versus BTA and (3) a multi-arm trial of CGRPs MAbs receptor (erenumab) versus CGRP MAbs ligand (eptinezumab, fremanezumab and galcanezumab). In terms of priority, a consensus was established regarding the three most recommended medication comparisons for treating chronic migraine: (1) CGRP MAbs and BTA versus CGRP MAbs, (2) candesartan compared to placebo and (3) flunarizine in comparison to placebo. Discussion and conclusions Of the treatments included in the NMA, the CGRP MAbs overall were consistently the best choices for headache days, migraine days and headache-related quality of life. BTA was less likely than CGRP MAbs to be the best choice for headache days, migraine days and headache-related quality of life. Topiramate was very unlikely to be the best choice for headache days, migraine days and headache-related quality of life when compared to CGRP MAbs or BTA. The economic model found that topiramate was the best value drug if you are prepared to pay up to £50,000 per QALY. It is likely that CGRP MAbs are likely to be cost-effective in people who have failed treatment with BTA. At the workshop, general consensus was agreed on the top three choices of medication for chronic migraine. Topiramate was the only established oral drug for which we were able to include data. It is disappointing that we did not find a sufficient quality evidence base to support the use of drugs, such as amitriptyline, candesartan, flunarizine and propranolol that are recommended by National Institute for Health and Care Excellence (NICE) and/or Scottish Intercollegiate Guidelines Network (SIGN). Our consensus meeting identified the need for trials comparing candesartan and flunarizine with placebo as the top priorities for placebo-controlled trials. Only for topiramate can we make any observations for how this may compare with CGRP MAbs. The CGRP MAbs appear to be clinically superior, but even so topiramate, in spite of its high incidence of AEs, represents the best value for money. Within the current care pathway, it is unlikely that CGRP MAbs will be recommended ahead of topiramate without a very substantial reduction on price. What is perhaps a more critical decision point is whether BTA or CGRP MAbs might be preferred as the first choice after failure of oral medication. Our findings support continuing with the current care pathway since our CEAF found that only topiramate met an acceptable threshold. Data from our health economics review, however, do support the use of CGRP MAbs after failure of BTA for chronic migraine. Our consensus group identified the direct comparison of BTA and CGRP MAbs as a key research question. They also identified the question of whether these drug effects might be additive. The effect sizes, in terms of mean monthly migraine/headache days for each of these drugs, are at best modest, the largest being 2.76 days for fremanezumab monthly dose. As these drugs work through different pathways, it might be that more substantial effects are possible. Adding together the effects of BTA and a CGRP MAb, assuming no negative interaction, might have a mean effect size of 4–5 days that would be transformative for many people with chronic migraine. Our consensus group identified the comparative, and additive, effects of BTA and CGRP MAbs as high priority research questions. In conclusion, we have summarised the existing clinical and cost-effectiveness data on preventive drugs for chronic migraine and identified which directions future research on these drugs might take. We did not find convincing evidence that the CGRP MAbs are more clinically effective and cost-effective compared to topiramate or BTA. Study registration This study is registered as PROSPERO CRD42021265990, CRD42021265993 and CRD42021265995. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR132803) and is published in full in Health Technology Assessment; Vol. 28, No. 63. See the NIHR Funding and Awards website for further award information.

Abstract Background Migraine is the world’s second most common disabling disorder, affecting 15% of UK adults and costing the UK over £1.5 billion per year. Several costly new drugs have been approved by National Institute for Health and Care Excellence. Aim To assess the cost-effectiveness of drugs used to treat adults with chronic migraine. Methods We did a systematic review of placebo-controlled trials of preventive drugs for chronic migraine. We then assessed the cost-effectiveness of the currently prescribable drugs included in the review: Onabotulinum toxin A (BTA), Eptinezumab (100mg or 300mg), Fremanezumab (monthly or quarterly dose), Galcanezumab or Topiramate, each compared to placebo, and we evaluated them jointly. We developed a Markov (state-transition) model with a three-month cycle length to estimate the costs and quality-adjusted life years (QALYs) for the different medications from a UK NHS and Personal Social Services perspective. We used a two-year time horizon with a starting age of 30 years for the patient cohort. We estimated transition probabilities based on monthly headache days using a network meta-analysis (NMA) developed by us, and from published literature. We obtained costs from published sources and applied discount rates of 3.5% to both costs and outcomes. Results Deterministic results suggest Topiramate was the least costly option and generated slightly more QALYs than the placebo, whereas Eptinezumab 300mg was the more costly option and generated the most QALYs. After excluding dominated options, the incremental cost-effectiveness ratio (ICER) between BTA and Topiramate was £68,000 per QALY gained and the ICER between Eptinezumab 300mg and BTA was not within plausible cost-effectiveness thresholds. The cost-effectiveness acceptability frontier showed that Topiramate is the most cost-effective medication for any amount the decision maker is willing-to-pay per QALY. Conclusions Among the various prophylactic medications for managing chronic migraine, only Topiramate was within typical cost-effectiveness threshold ranges. Further research is needed, ideally an economic evaluation alongside a randomised trial, to compare these newer, expensive CGRP MAbs with the cheaper oral medications.

Abstract Background Chronic migraine can be a profoundly disabling disorder that may be treated with preventive medications. However, uncertainty remains as to which preventive medication is the most effective. We present a network meta-analysis to determine the effectiveness and rank of preventive drugs for chronic migraine in adults. Methods We identified, reviewed, and extracted data from randomised controlled trials (RCTs) of preventive drugs for chronic migraine with at least 200 participants. Data were analysed using network meta-analysis. Findings We included 12 RCTs of six medications (Eptinezumab, Erenumab, Fremanezumab, Galcanezumab, Onabotulinumtoxin A, and Topiramate) compared to placebo or each other. All drugs effectively reduced monthly headache and migraine days compared with placebo. The most effective drug for monthly headache days was Eptinezumab 300mg, with a mean difference of -2.46 days, 95% Credible Interval (CrI): -3.23 to -1.69. On the Surface Under the Cumulative Ranking Area (SUCRA) analysis, the probability that Eptinezumab 300mg was ranked highest was 0.82. For monthly migraine days, the most effective medication was Fremanezumab-monthly, with a mean difference: -2.77 days, 95% CrI: -3.36 to -2.17, and 0.98 probability of being ranked the highest. All included drugs, except Topiramate, improved headache-related quality of life. No eligible studies were identified for the other common preventive oral medications such as Amitriptyline, Candesartan, and Propranolol. The main reasons were that the studies did not define chronic migraine, were undertaken before the definition of chronic migraine, or were too small. Interpretation All six medications were more effective than the placebo on monthly headache and migraine days. The absolute differences in the number of headache/migraine days are, at best, modest. No evidence was found to determine the relative effectiveness of the six included drugs with other oral preventive medications. Registration PROSPERO (number CRD42021265990).

Background Migraine is the second most common prevalent disorder worldwide and is a top cause of disability with a substantial economic burden. Many preventive migraine medications have notable side effects that affect different body organs.Method We systematically searched for published randomised controlled trials (RCTs) using terms for migraine/headache and preventive medications. Using eligibility criteria, two reviewers independently assessed the articles. Cochrane risk-of-bias tool was applied to assess the quality of the studies. Data were classified by system organ class (SOC).Results Thirty-two RCTs with 21 780 participants met the eligibility criteria for the incidence of adverse events (AEs). Additionally, 33 RCTs with 22 615 participants were included to synthesise the incidence of serious AEs (SAEs). The percentage of attributed AEs and SAEs to each SOC for 10 preventive drugs with different dosing regimens was calculated. Amitriptyline and topiramate had a higher incidence of nervous system disorders; Topiramate was also associated with a higher incidence of psychiatric disorders. All drugs showed a certain incidence of infections and infestations, with Onabotulinumtoxin A (BTA) having the lowest rate. BTA had a higher incidence of musculoskeletal disorders than the other drugs. Calcitonin gene-related peptide (CGRP) monoclonal antibodies (MAbs) such as fremanezumab and galcanezumab were linked to more general disorders and administration site conditions than other drugs.Conclusion Notably, the observed harm to SOCs varies among these preventive drugs. We suggest conducting head-to-head RCTs to evaluate the safety profile of oral medications, BTA, and CGRP MAbs in episodic and/or chronic migraine populations.PROSPERO registration number CRD42021265993.

Abstract Background and aims Chronic migraine is a common neurovascular brain disorder with substantial economic costs. We performed a systematic review to identify economic evaluations of pharmacological treatments for adults with chronic migraine. Methods We undertook systematic literature searches using terms for migraine/headache and prophylactic drug interventions, combined with economic/cost terms where appropriate. Using inclusion and exclusion criteria, two reviewers independently assessed the citations and abstracts, and full-text articles were retrieved. A review of study characteristics and methodological quality was assessed. Results Sixteen citations met the inclusion criteria and were model-based cost-utility studies evaluating: Botox (n = 6); Erenumab (n = 8); Fremanezumab (n = 2); and Galcanezumab (n = 1) as the main treatment. They varied in their use of comparators, perspective, and model type. Botox was cost-effective compared to placebo with an incremental cost-effectiveness ratio (ICER) ranging between £15,028 (€17,720) and £16,598 (€19,572). Erenumab, Fremanezumab and Galcanezumab when compared to Botox, was associated with ICERs ranging between £59,712 ($81,080) and £182,128 (€218,870), with the ICERs above the most common willingness-to-pay thresholds (WTPs). But they were cost-effective within the commonly used WTPs among the population for whom the previous treatments including Botox were failed. Three studies compared the cost-effectiveness of Erenumab against the placebo and found that Erenumab was dominant. All studies performed sensitivity analyses to check the robustness of their results. None of the findings from the included articles were generalisable and none of the included studies fulfilled all the criteria mentioned in the CHEERS 2022 reporting checklist and Phillips’s checklist for economic models. Conclusions Evidence to support the cost-effectiveness of pharmacological treatments of chronic migraine in the adult population using Botox and Erenumab were identified. Our findings suggest that both Botox and Erenumab, are cost-effective compared to placebo; although Erenumab had more incremental economic benefits compared to Botox, the ICERs were above the most common willingness-to-pay thresholds. Hence, Erenumab might be an acceptable treatment for chronic migraine for patients whom other treatments such as Botox do not work. Further research is needed to help characterise the data to adequately structure and parameterise an economic model to support decision-making for chronic migraine therapies.

Objective To assess the knowledge, attitudes and practices of healthcare professionals regarding the diagnosis and management of spontaneous intracranial hypotension (SIH).Methods We performed a cross-sectional, web-based survey of multiple healthcare professional groups in the UK from June to August 2021. There were 227 respondents to the survey, including 62 general practitioners, 39 emergency medicine physicians, 38 neurologists, 35 radiologists, 20 neurosurgeons, 18 anaesthetists and 15 headache nurse specialists. The majority of the respondents were at the consultant level and all worked in the UK National Health Service.Results Few general practitioners or emergency medicine physicians had ever been involved in the care of a patient with SIH or received teaching about SIH. Only 3 of 62 (4.8%) general practitioners and 1 of 39 (2.5%) emergency medicine physicians were confident in recognising the symptoms of SIH. Most neurologists were confident in recognising SIH and performed MRI of the brain as a first-line investigation, although there was variability in the urgency of the request, whether contrast was given or MRI of the spine organised at the same time. Most said they never or rarely performed lumbar puncture for diagnosis of SIH. Most neuroradiologists, but few general radiologists, were confident in interpreting imaging of patients with suspected SIH. Lack of access to epidural blood patching, personnel able to perform myelography, and established management pathways were identified by many respondents as barriers to the treatment of SIH.Conclusions We have identified a lack of awareness of SIH among non-specialists, several barriers to optimal treatment of SIH and a variation in current management pathways. The results highlight the need for education of healthcare professionals about SIH and the development of clinical practice guidelines to enable delivery of optimal and equitable care for patients with SIH.