Background
East Sussex Healthcare Trust (ESHT) recorded 756 A&E attendances for migraine over a 12-month period. Standard A&E environment - bright, loud and busy, worsens symptoms like photo/phonophobia, so patients in crisis were feeling much worse as well as getting the wrong level of care.
Amanda Combes (Advanced Practitioner Neurology) and the Headache Service team had been seeing this directly: patients emailing the Headache Service, having exhausted usual treatments, with A&E as their only apparent option. Amanda and Sam Morley (Virtual Ward Clinical Lead) set out to establish whether hospital-level rescue treatment for migraine could be delivered safely at home instead.
Amanda commented saying: “It is so good to be able to use an existing system (Patients Know Best - PKB) which we had in place at the trust and an existing service, the Virtual Ward to provide such a beneficial change to the way migraine sufferers receive a more timely service in a way to suit them. When suffering with refractory migraine the last thing a patient wants or needs is to have to travel to be sat in a brightly lit, noisy A&E waiting room. This virtual ward pathway has revolutionised the service for both patients and staff”.
Problem
Patients with refractory migraine (attack lasting more than 12 hours, pain >7/10, usual medication failed) had no route to hospital-level treatment other than A&E. This meant:
- Unnecessary CT/MRI and blood investigations for a condition where these are rarely needed.
- Ambulance use and bed occupancy for a cohort that doesn't need admission.
- A treatment environment that actively aggravates migraine symptoms.
- Barriers to access for patients who can't easily manage travel, parking, or childcare while in crisis.
A&E treatment for migraine versus the Virtual Ward
Cost comparison: A&E treatment for migraine (including diagnostics) runs to an estimated £927.33. Equivalent Virtual Ward treatment costs £54.72 — a difference of £872.61 per case.
Approach
Alongside PKB and the ESHT DPMO, the Headache and Migraine service and the Virtual ward team built a home-based Virtual Ward pathway with PKB (integrated with the NHS App) as the access point:
- Digital front door. Patients access a PKB care plan and self-management advice, and submit a digital questionnaire when an attack becomes refractory. This triggers rapid clinical assessment rather than a default to A&E.
- Inclusion/exclusion criteria. Referral requires migraine >12 hours, pain >7/10, and failed usual medication. Red flags: new visual loss, motor aura, postural change, are excluded and routed straight to A&E, keeping the home pathway safe.
- Referral and drug administration. A formal Situation, Background, Assessment, Recommendation (SBAR) referral framework, shared care plans and drug charts let Headache Service Advanced Clinical Practitioners (ACPs) hand clear instructions to Virtual Ward nurses.
- Workforce training. Three one-hour sessions (recorded for future staff) on migraine management and red-flag recognition, run by the Headache Service for Virtual Ward staff.
- Systems integration. SystmOne configured to support patient flow between Headache Service and Virtual Ward, The ESHT DPMO provided critical oversight to ensure the new pathway aligned with Trust-wide digital transformation goals and the national ambition to use the NHS App as the digital front door.
- Governance. SOP written to embed the pathway, a shared audit database, and a "Virtual Ward Migraine link" Teams channel for live escalation.
Target: home treatment within 2 hours of referral.
Outcomes
Since go-live in February 2026:
- 50% of patients using the digital questionnaire have been treated via the Virtual Ward, with early cases resolving without hospital admission.
- £872.61 saved per treatment diverted from A&E.
- Projected £26,178/year saved at the current 50%-reduction target for the existing Headache Service cohort; up to £660,000/year system-wide if extended to the full 756 annual migraine attenders, including primary care referrals.
- Patients avoid travel, parking and childcare costs, widening access regardless of socioeconomic circumstances.
- PKB "traffic light" (Green/Amber/Red) self-management triggers give patients a way to manage attacks independently, reducing reliance on emergency services.
- Reduced pressure on A&E by diverting known migraine sufferers, releasing vital capacity, radiology resources, and ambulance usage for life-threatening emergencies.
