Cluster headache care gaps among primary healthcare physicians in the Middle East, North Africa, and Türkiye: a multinational study
Abstract
Cluster headache is one of the most severely disabling primary headache disorders and is frequently associated with diagnostic delay, inappropriate treatment, disability, and substantial psychosocial burden. Because primary healthcare (PHC) physicians are commonly the first point of contact for patients with new headache presentations, their ability to recognize the disorder and initiate evidence-based management is clinically important. However, data on PHC-level cluster headache competency across the Middle East and North Africa (MENA) and Türkiye are limited. We assessed knowledge, attitudes, practice patterns, perceived barriers, and educational needs among PHC physicians across this region. We conducted a cross-sectional study of 3,045 PHC physicians in 14 countries from May to July 2026 using non-probability, network-based recruitment. A pilot-tested, study-specific questionnaire aligned with the International Classification of Headache Disorders, third edition, and contemporary treatment guidance assessed knowledge, attitudes, practice, resources, barriers, and educational needs. Prespecified pragmatic thresholds defined adequate performance. Multivariable logistic regression estimated adjusted odds ratios, and modified Poisson regression with robust standard errors provided sensitivity estimates as adjusted prevalence ratios. Adequate knowledge was observed in 42.2% of participants, positive attitudes in 53.4%, adequate practice in 23.9%, and adequate composite performance in 34.4%. Only 13.3% correctly recognized the complete constellation of cranial autonomic features. High-flow oxygen was routinely available in 36.0% of facilities. Previous formal headache training was associated with a higher prevalence of adequate knowledge (adjusted prevalence ratio 2.80, 95% confidence interval 2.46–3.18), adequate practice (1.57, 1.32–1.86), and adequate composite performance (3.53, 2.97–4.19). Limited neurology referral access was associated with lower prevalence of adequate knowledge (0.60, 0.52–0.70) and adequate composite performance (0.63, 0.53–0.75). This large multinational study documents substantial, actionable gaps in cluster headache competency among PHC physicians. The findings support targeted headache-specific continuing medical education, reliable facility-level oxygen access, and structured referral pathways as priorities for improving care. Not applicable.
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Authors: Ahmed H. Dahshan, Marwa Ibrahim Mahfouz Khalil, Merve Ceren Akgör, Derya Uludüz, Mahmood Khalifa Al Hinai, Ahmed Abdelfattah Nassar, Mahmoud Ali Khazbak, Kamal Khaled Hamad, Mohamed Elsayed Ahmed Allawy, Mohammed Salfeeq H. Alshammari, Ali Malik Tiryag, Samaa Al Tabbah, Nabih Mohammad Lawand, Moath Abu Ejheisheh, Anter Mothenna Abdullah Nasser, Aussan Al-Athwari, Fatima Adnan Hallaj, Tajeldinn Helal, Wael Abdulgader Alwahchi, Sarra Chouaib, Ahmed Allioueche, Mohamed A. Marouf, Walaa Mansour Ahmed, Sameh El Rayes, Zeyad Yassin, Mona Nada, Hesham Eissa, Ahmed Ahmed Mohamed Kamal Ebied
Institutions: Prince Sattam Bin Abdulaziz University, Cairo University, Ankara Atatürk Eğitim ve Araştırma Hastanesi, Mansoura University, Istanbul University, King Faisal University, Al-Azhar University, Lebanese American University, Alexandria University, École Nationale d'Agriculture de Meknès, Northern Border University, Université Moulay Ismail de Meknes, Zagazig University, Latakia University, Suez Canal University, University Frères Mentouri Constantine 1, University of Aden, Université Constantine 2, École Normale Supérieure de Constantine, University of Basrah, University of Nizwa, Beirut Arab University, Thamar University, Palestine Ahliya University, Ministry of Health, Khoula Hospital, Al Fashir University, Tripoli Central Hospital