PO-59 | Questioning online survey-based physiotherapy treatment referral in headache treatment: differences in developed and developing countries

D. Onan,^1,2 A.K. Erdemoğlu,³ P. Gelener,⁴ S. Velioğlu,⁵ S. Ulutaş,⁶ N. Taşdemir,⁷ M. Waliszewska-Prosół,⁸ E. Ekizoğlu,⁹ M. Straburzyński,¹⁰ M. Kodounis,¹¹ B. Raffaelli,¹² C. Tana,¹³ F. De Cesaris,¹⁴ R. Messina,¹⁵ E.I. Sen,¹⁶ S. Ray,¹⁷ G. Sebastianelli,¹⁸ F. Granella,¹⁹ U. Pensato,²⁰ S. Crema,²¹ S. Cevol,²² K. Chakravarty,²³ M. Pia Prudenzano,²⁴ A. Casalena,²⁵ M. Romozzi,²⁶ T. Takizawa,²⁶ W. Rattanawong,²⁷ A. Gantenbein,²⁸ V. Favoni,²⁹ C. Gaul,³⁰ L.F.I. Iannone,³¹ B. Schäfer,²³ D.A. Montisano,³³ O. Grosu,³⁴ A.B. de Oliveira,³⁵ F. Puledda,³⁶ V. Romanenko,³⁷ I. Ros González,³⁸ M. Castaldo,³⁹ H. Al-Khazali,⁴⁰ A. Hassan,⁴¹ D. Garcia-Azorin,⁴² L.-L. Hope Pan,⁴³ R. Gil-Gouveia,⁴⁴ M. Sanchez del Rio,⁴⁵ M. Lisicki,⁴⁶ H.W. Schytz,⁴⁷ P. Anukoolwittaya,⁴⁸ T. Mavridis,⁴⁹ M. Lanteri-Minet,⁵⁰ D.B. Swerts,⁵¹ C. Altamura,⁵² K. Hirata,⁵³ M. Togha,⁵⁴ M. Kyung Chu,⁵⁵ T. Pongpitakmetha,⁵⁶ M.-H. Bjørk,⁵⁷ M. Minen,⁵⁸ K. Skorobogatykh,⁵⁹ D. Chowdhury,⁶⁰ A.-M. Torgersen Dalgeir,⁶¹ J. Versijpt,⁶² P. Cras,⁶³ A. Govaerts,⁶⁴ A. Chiarugi,⁶⁵ N. Vashchenko,⁵⁹ L. Dobbels,⁶⁶ T.S. Monteith,⁶⁷ F. De Bruyne,⁶⁸ E. Garay,⁶⁷ S.L. Sava,⁶⁹ Z. Salinas,⁶⁷ M. Nordtveit,⁷⁰ K. Delmotte,⁷¹ A. Gonzalez-Martinez,⁷² S. Debray,⁷³ C. Deligianni,⁷⁴ W. De Hertogh,⁷⁵ R. Castien,⁷⁶ E. Caronna,⁷⁷ C. Valerija,⁷⁸ F. Ahmed,⁷⁹ G. De la Meilleure,⁸⁰ L.L. Panneerchelvam,⁸¹ G.H. Bringeland,⁸² R. Ornello,² S. Sacco² | ¹Yozgat Bozok University, Physiotherapy and Rehabilitation, Ankara, Turkey;²University of L'Aquila, Department of Biotechnological and Applied Clinical Sciences, L'Aquila, Italy;³Clinic of Prof. Dr. Ali Kemal Erdemoğlu, Neurology, Ankara, Turkey;⁴Elite Research and Surgical Hospital , Nicosia, Cyprus;⁵Karadeniz Technical University, Department of Neurology, Trabzon, Turkey;⁶Bahcesehir University, Department of Neurology, İstanbul, Turkey;⁷Ağrı İbrahim Çeçen University, Department of Neurology, Ağrı, Turkey;⁸Wroclaw Medical University, Wroclaw, Germany;⁹Istanbul University, Department of Neurology, Istanbul, Turkey;¹⁰University of Warmia and Mazury, Olsztyn, Poland;¹¹National & Kapodistrian University of Athens, First Neurology Department, Eginitio Hospital, School of Medicine, Athens, Greece;¹²Charité Universitätsmedizin Berlin, Department of Neurology,Headache Center, Berlin, Germany;¹³SS Annunziata Hospital of Chieti, Chieti, Italy;¹⁴Centro Cefalee e Farmacologia Clinica - AOU Careggi , Florence, Italy;¹⁵Vita-Salute San Raffaele University, Milano, Italy;¹⁶Istanbul University Istanbul Faculty of Medicine, Department of Physical Medicine and Rehabilitation, İstanbul, Turkey;¹⁷Department of Neurology, PGIMER, Chandigarh, India;¹⁸Sapienza University of Rome, Latina, Italy;¹⁹University of Parma, Parma, Italy;²⁰Humanitas University, Milan, Italy;²¹Fleni Hospital, Buenos Aires, Argentina;²²University of Bologna, Bologna, Italy;²³Post Graduate Institute Of Medical Education and Research, Chandigarh, India;²⁴AOUC Policlinico, Centro Cefalee - Clinica Neurologica L Amaducci, Bari, Germany;²⁵Centro Cefalee UOC Neurologia, Teramo, Italy;²⁶Keio University School of Medicine, Tokyo, Japan;²⁷King Mongkut's Institute of Technology Ladkrabang, Bangkok, Thailand;²⁸ZURZACH Care, Zürich, Switzerland;³⁰IRCCS Istituto delle scienze neurologiche di Bologna, Bologna, Italy;³⁰Headache Center Frankfurt, Frankfurt, Germany;³¹Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy, Modena, Italy;³²Migraine and Headache Clinic Königstein , Frankfurt, Germany;³³SSD Centro Cefalee - Fondazione IRCCS Istituto Neurologico C.Besta, Milan, Italy;³⁴Diomid Gherman Institute of Neurology and Neurosurgery, Kişinev, Moldova;³⁵Center for Clinical and Epidemiological Research, University of Sao Paulo , Sao Paolo, Brazil;³⁶King's College London, London, United Kingdom;³⁷Vita Medical Clinic, Kyiv, Ukraine;³⁸Hospital Clínico Universitario de Valladolid, Vallodolid, Spain;³⁹Parma University, Parma, Italy;⁴⁰Danish Headache Center, Copenhagen, Denmark;⁴¹Cairo University , Cairo, Egypt;⁴²University of Valladolid, Valladolid, Spain;⁴³Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan;⁴⁴Hospital da Luz. Lisboa, Lisboa, Portugal;⁴⁵Clinica Universidad de Navarra, Navarra, Spain;⁴⁶Mercedes & Martín Ferreyra Institute for Medical Research, Córdoba, Argentina;⁴⁷University of Copenhagen, Copenhagen, Denmark;⁴⁸King Chulalongkorn Memorial Hospital, Bangkok, Thailand;⁴⁹Tallaght University Hospital, Dublin, Ireland;⁵⁰CHU Nice and Cote D'azur University, Nice, France;⁵¹Santa Casa de Sao Paolo, Sao Paolo, Brazil;⁵²Fondazione Policlinico Universitario Campus BIo-Medico, Rome, Italy;⁵³Dokkyo Medical University, Mibu, Tochigi, Japan;⁵⁴Tehran University, Tehran, Iran;⁵⁵Yonsei University, Seoul, South Korea;⁵⁶Chulalongkorn University, Bangkok, Thailand;⁵⁷University of Bergen , Bergen, Norway;⁵⁸NYU Langone Health, New York, United States;⁵⁹University Headache Clinic, Moscow, Russian Federation;⁶⁰ G B Pant Institute of Post Graduate Medical Education and Research, New Delhi, India;⁶¹Haukeland University Hospital, NorHead, Bergen, Norway;⁶²UZ Brussel, Brussel, Belgium;⁶³Universiteit Antwerpen, Antwerpen, Belgium;⁶⁴Rz Tienen, Tienen, Belgium;⁶⁵University of Florence, Florence, Italy;Neurology Department İmelda Ziekenhuis, Bonheiden, Belgium;⁶⁷University of Miami, Miami, United States;⁶⁸University College Ghent, Ghent, Belgium;⁶⁹University of Liège, Liege, Belgium;⁷⁰Haukeland Universitetssykehus, Bergen, Norway;⁷¹Universitair Ziekenhuis Leuven, Leuven, Belgium;⁷²Hospital Universitario de la Princesa e Instituto de Investigación Sanitaria Princesa, Madrid, Spain;⁷³Europa Ziekenhuizen, Brussel, Belgium;⁷⁴Athens Naval Hospital, Athens, Greece;⁷⁵University of Antwerp , Antwerpen, Belgium;⁷⁶Vrije Universiteit Amsterdam, Amsterdam, Netherlands;⁷⁷Vall d'Hebron Hospital, Barcelona, Spain;⁷⁸Private hospital, Riga, Latvia;⁷⁹Hull University, Hull, United Kingdom;⁸⁰VITAZ - General Hospital, Sint-Niklaas, Belgium;⁸¹James Cook University Hospital, Middlesbrough, United Kingdom; ⁸²Haukeland University Hospital, Bergen, Norway

Background: Both pharmacological and non-pharmacological treatments for migraine vary between developed and developing countries. When drugs are ineffective or avoided, physiotherapy becomes important. Developed countries, having better healthcare resources, may have easier access to physiotherapy. This study examines whether physiotherapy treatment and resource use differ between developed and developing countries.

Methods: An international online survey was sent to healthcare professionals (n=84) working in the headache field. Questions included demographic characteristics, experience, workplace, frequency of physiotherapy recommendations, and use of specific clinical criteria for referral to physiotherapy.

Results: The study included 25 professionals from developing countries (Group 1) and 59 from developed countries (Group 2). Group 1 included 22 neurologists, 1 physiotherapist, 1 physical therapist, and 1 exercise physiologist, while Group 2 comprised 45 neurologists, 7 physiotherapists, 1 general practitioner, 2 internal medicine specialists and 1 general practitioner-research assistant. There was no significant difference in profession distribution (p=0.600) or years of experience (p=0.656). No difference was found in types of headache centers attended (p=0.745). A significant association was found between country development level and headache care level (p<0.001): developed countries had a more balanced distribution, while developing countries primarily provided tertiary care (84%). Frequency of physiotherapy recommendations differed (p=0.007): developed countries recommended it occasionally (52.5%) or rarely (28.8%) whereas, developing countries recommended physiotherapy very frequently (52%), possibly due to greater use of calcitonin gene-related peptide-targeted pharmacological treatments. Use of specific clinical criteria for physiotherapy was more common in developed countries (p=0.014), while developing countries often recommended without criteria. Approaches to physiotherapy also differed: in developed countries, some professionals recommended physiotherapy based on specific clinical features such as neck pain (38; 64%), while others recommended it only after pharmacological treatment failure (10; 17%), or did not recommend it at all but left it to patients’ choice (11; 19%). In contrast, in developing countries, physiotherapy was almost always recommended when such clinical signs were present, like neck pain (23; 92%) (p=0.024).

Conclusion: This study shows significant differences in headache care and physiotherapy approaches between developed and developing countries. Resource availability, healthcare infrastructure, and treatment preferences likely explain these variations. Understanding these differences can guide tailored interventions and improve headache management worldwide.