Publication Details

Title :

The headache under-response to treatment (HURT) questionnaire, an outcome measure to guide follow-up in primary care: development, psychometric evaluation and assessment of utility.


J Headache Pain.

Impact Factor:



Steiner TJ1,2, Buse DC3,4, Al Jumah M5, Westergaard ML6, Jensen RH6, Reed ML7, Prilipko L8, Mennini FS9,10, Láinez MJA11, Ravishankar K12,13, Sakai F14, Yu SY15, Fontebasso M16, Al Khathami A5, MacGregor EA17, Antonaci F18,19, Tassorelli C16,19, Lipton RB3,4; Lifting The Burden: The Global Campaign against Headache.


1 Department of Neuromedicine and Movement Science, NTNU Norwegian University of Science and Technology, NO-7941, Trondheim, Norway.

2 Division of Brain Sciences, Imperial College London, London, UK.

3 Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA.

4 Montefiore Headache Center, Montefiore Medical Center, Bronx, NY, USA.

5 King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, National Guard Health Affairs, Riyadh, Saudi Arabia.

6 Danish Headache Centre, Department of Neurology, Rigshospitalet Glostrup University of Copenhagen, Glostrup, Denmark.

7 Vedanta Research, Chapel Hill, NC, USA.

8 Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland.

9 CEIS EEHTA, Faculty of Economics, University of Rome “Tor Vergata”, Rome, Italy.

10 Institute of Leadership and Management in Health, Kingston University, Kingston upon Thames, UK.

11 Department of Neurology, University Clinic Hospital, Catholic University of Valencia, Valencia, Spain.

12 The Headache and Migraine Clinic, Jaslok Hospital and Research Centre, Mumbai, India.

13 Lilavati Hospital and Research Centre, Mumbai, India.

14 Saitama International Headache Center, Tokyo, Japan.

15 Department of Neurology, Chinese PLA General Hospital, Bejing, People’s Republic of China.

16 Headache Expert, Author and Headache Education Facilitator, York, UK.

17 Centre for Neuroscience & Trauma, Blizard Institute of Cell and Molecular Science, London, UK.

18 Headache Science Centre, C Mondino National Neurological Institute, Pavia, Italy.

19 Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy.

Year of Publication:






Headache disorders are both common and burdensome but, given the many people affected, provision of health care to all is challenging. Structured headache services based in primary care are the most efficient, equitable and cost-effective solution but place responsibility for managing most patients on health-care providers with limited training in headache care. The development of practical management aids for primary care is therefore a purpose of the Global Campaign against Headache. This manuscript presents an outcome measure, the Headache Under-Response to Treatment (HURT) questionnaire, describing its purpose, development, psychometric evaluation and assessment for clinical utility. The objective was a simple-to-use instrument that would both assess outcome and provide guidance to improving outcome, having utility across the range of headache disorders, across clinical settings and across countries and cultures.


After literature review, an expert consensus group drawn from all six world regions formulated HURT through item development and item reduction using item-response theory. Using the American Migraine Prevalence and Prevention Study’s general-population respondent panel, two mailed surveys assessed the psychometric properties of HURT, comparing it with other instruments as external validators. Reliability was assessed in patients in two culturally-contrasting clinical settings: headache specialist centres in Europe (n = 159) and primary-care centres in Saudi Arabia (n = 40). Clinical utility was assessed in similar settings (Europe n = 201; Saudi Arabia n = 342).


The final instrument, an 8-item self-administered questionnaire, addressed headache frequency, disability, medication use and effect, patients’ perceptions of headache “control” and their understanding of their diagnoses. Psychometric evaluation revealed a two-factor model (headache frequency, disability and medication use; and medication efficacy and headache control), with scale properties apparently stable across disorders and correlating well and in the expected directions with external validators. The literature review found few instruments linking assessment to clinical advice or suggested actions: HURT appeared to fill this gap. In European specialist care, it showed utility as an outcome measure across headache disorders. In Saudi Arabian primary care, HURT (translated into Arabic) was reliable and responsive to clinical change.