Outcomes of a headache-specific cross-sectional multidisciplinary treatment program

Aim.— Chronic headache is a disabling disorder that is frequently poorly managed in general clinical practice. Objectives.— To investigate primary (headache frequency in days/month) and secondary (headache‐related disability, lost work/school time, anxiety and depression, amount and intake frequency of acute medication) 12‐month outcomes of a headache‐specific cross‐sectional outpatient and inpatient multidisciplinary treatment program using a dedicated computer system for data collection and corresponding between integrated care team in a tertiary headache center and practicing headache specialists. Background.— A need for integrated headache care using comprehensive and standardized assessment for diagnosis of headache, psychiatric comorbidity, and burden of disease exists. There are little published data on long‐term efficacy of multidisciplinary treatment programs for chronic headache. Design.— A prospective, observational, 12‐month, follow‐up study. Subjects and Methods.— Prospectively recruited consecutive patients with frequent difficult‐to‐treat headaches (n = 201; 63 migraine, 11 tension‐type headache, 59 combined migraine/tension‐type headache, and 68 medication overuse headache) were enrolled. Outcome measures included prospective headache diaries, a medication survey, Migraine Disability Assessment, 12‐item short form health survey, and the Hospital Anxiety and Depression Scale. Results.— The primary outcome of a reduction of ≥50% of headache frequency (days/month) was observed in 62.7%. Mean headache frequency decreased from 14.4 ± 8.2 to 7.6 ± 8.3 days/month, P < .0001. Secondary outcomes improved significantly in the total cohort and all headache subgroups. Predictors for good outcome were younger age, few days lost at work/school, and familiarity with progressive muscle relaxation therapy at baseline. Conclusions.— The present analysis provided support for a cross‐sectional multidisciplinary integrated headache‐care program.     

Efficacy of multidisciplinary treatment in a tertiary referral headache centre

Despite the high prevalence of headaches, multidisciplinary headache clinics are few and their efficacy still needs validation. We set out to describe the procedures, characterize the patients and evaluate the treatment results in Danish Headache Centre. All clinical records for patients discharged in 2002 were systematically reviewed. Diagnoses were classified in accordance with ICHD-II. Outcome results were analysed with respect to headache diagnoses, frequency, intensity, absence from work and medication use. Five hundred and five patients were included and 336 were eligible for the study. Mean age was 46 years and male/female ratio 1:2.4. For patients without medication overuse headache (MOH) a reduction in headache frequency (P<0.01) and intensity (P<0.05) was seen for frequent episodic and chronic tension-type headache (TTH), migraine, cluster and other headaches. No reduction was seen in post-traumatic headache. Absence from work decreased significantly for migraine (P<0.001) and frequent episodic TTH (P<0.05). For patients with MOH a reduction in headache frequency was seen for TTH and migraine (P<0.001). A specialized headache centre is valuable in treatment of patients with complex headache disorders.     

Clinical characteristics and patient-reported outcomes of chronic and episodic migraine patients at a US tertiary headache center: A retrospective observational study

Objective

To describe differences in clinical and demographic characteristics between patients with episodic migraine (EM) or chronic migraine (CM) and determine the effect of migraine subtype on patient-reported outcome measures (PROM).

Background

Prior studies have characterized migraine in the general population. While this provides a basis for our understanding of migraine, we have less insight into the characteristics, comorbidities, and outcomes of migraine patients who present to subspecialty headache clinics. These patients represent a subset of the population that bears the greatest burden of migraine disability and are more representative of migraine patients who seek medical care. Valuable insights can be gained from a better understanding of CM and EM in this population.

Methods

We conducted a retrospective observational cohort study of patients with CM or EM seen in the Cleveland Clinic Headache Center between January 2012 and June 2017. Demographics, clinical characteristics, and patient-reported outcome measures (3-Level European Quality of Life 5-Dimension [EQ-5D-3L], Headache Impact Test-6 [HIT-6], Patient Health Questionnaire-9 [PHQ-9]) were compared between groups.

Results

Eleven thousand thirty-seven patients who had 29,032 visits were included. More CM patients reported being on disability 517/3652 (14.2%) than EM patients 249/4881 (5.1%) and had significantly worse mean HIT-6 (67.3 ± 7.4 vs. 63.1 ± 7.4, p < 0.001) and median [interquartile range] EQ-5D-3L (0.77 [0.44–0.82] vs. 0.83 [0.77–1.00], p < 0.001), and PHQ-9 (10 [6–16] vs. 5 [2–10], p < 0.001).

Conclusions

There are multiple differences in demographic characteristics and comorbid conditions between patients with CM and EM. After adjustment for these factors, CM patients had higher PHQ-9 scores, lower quality of life scores, greater disability, and greater work restrictions/unemployment.     

The prediction of treatment outcome at a multidisciplinary pain center

The purpose of this study was to determine if some commonly used admission variables could predict treatment outcome on a multidisciplinary pain center. Specifically, it was designed as a prospective study of an index proposed by Maruta et al. The subjects were 104 patients. The 4 outcome measures used were staff judgment, patient judgment, change in pain scores and change in mood. With the exception of a negative correlation with age, none of the other variables predicted outcome. The index of Maruta did not predict outcome.     

Development of a bereavement program in a tertiary medical center

Despite the fact that our institution has approximately 40 inpatient deaths per month, until recently virtually no support was provided to families/friends of the deceased. We developed and implemented a comprehensive bereavement program to prepare individuals for the loss and also to support them through the grieving process.     

Use of venous thromboprophylaxis and adherence to guideline recommendations: a cross-sectional study

BACKGROUND: Consensus Conferences and Guidelines for deep vein thrombosis prophylaxis have been published, which recommend the use of prophylactic heparins in patients with risk of venous thromboembolism (VTE). The aim of this study was the assessment of the prophylaxis of VTE and the adherence to accepted guideline recommendations throughout the hospital. METHODS: A cross-sectional study was carried out in a teaching hospital after guidelines were implemented. Patients' risk factors of deep vein thrombosis, risk categories of patients, and prophylaxis used in different wards were recorded. Appropriate adherence to the guidelines was analysed. RESULTS: Of 397 patients, prophylaxis was used in 231 patients (58%), and low-molecular-weight heparins (LMWH) were used in 224 of them (97%). Patients with prophylaxis had a higher mean number of risk factors (SD) than those without prophylaxis [3.1 (1.4) vs 1.9 (1.4); p < 0.05)]. Prophylaxis was used in 72% and 90% of moderate and high-risk patients respectively. Appropriate adherence to all guideline recommendations was observed in 42% of patients. Adherence to guidelines was high as regards the use of prophylaxis according to patients' risk factors (78%) and the use of appropriate types of prophylaxis (99%), but was low regarding appropriate heparin dosage (47%) and preoperative dosage (37%). Appropriate prophylaxis use was higher in critical care and surgical wards than in medical wards. CONCLUSION: Prophylaxis of VTE is generally used in risk patients, but appropriate adherence to guidelines is less frequent and variable among different wards. Continuing medical education, discussion and dissemination of guidelines, and regular clinical audit are necessary to improve prophylaxis of VTE in clinical practice.     

Validation of criterion-based patient assignment and treatment effectiveness of a multidisciplinary modularized managed care program for headache

This prospective observational study evaluates the validity of an algorithm for assigning patients to a multidisciplinary modularized managed care headache treatment program. N = 545 chronic headache sufferers [migraine (53.8 %), migraine + tension type (30.1 %), tension type (8.3 %) or medication overuse headache (6.2 %), other primary headaches (1.5 %)] were assigned to one of four treatment modules differing with regard to the number and types of interventions entailed (e.g., medication, psychological intervention, physical therapy, etc.). A rather simple assignment algorithm based on headache frequency, medication use and psychiatric comorbidity was used. Patients in the different modules were compared with regard to the experienced burden of disease. 1-year follow-up outcome data are reported (N = 160). Headache frequency and analgesic consumption differed significantly among patients in the modules. Headache-related disability was highest in patients with high headache frequency with/without medication overuse or psychiatric comorbidity (modules 2/3) compared to patients with low headache frequency and medication (module 0). Physical functioning was lowest in patients with chronic headache regardless of additional problems (modules 1/2/3). Psychological functioning was lowest in patients with severe chronicity with/without additional problems (module 2/3) compared to headache suffers with no/moderate chronicity (module 0/1). Anxiety or depression was highest in patients with severe chronicity. In 1-year follow-up, headache frequency (minus 45.3 %), consumption of attack-aborting drugs (minus 71.4 %) and headache-related disability decreased (minus 35.9 %). Our results demonstrate the clinical effectiveness and the criterion validity of the treatment assignment algorithm based on headache frequency, medication use and psychiatric comorbidity.     

Team players against headache: multidisciplinary treatment of primary headaches and medication overuse headache

Multidisciplinary approaches are gaining acceptance in headache treatment. However, there is a lack of scientific data about the efficacy of various strategies and their combinations offered by physiotherapists, physicians, psychologists and headache nurses. Therefore, an international platform for more intense collaboration between these professions and between headache centers is needed. Our aims were to establish closer collaboration and an interchange of knowledge between headache care providers and different disciplines. A scientific session focusing on multidisciplinary headache management was organised at The European Headache and Migraine Trust International Congress (EHMTIC) 2010 in Nice. A summary of the contributions and the discussion is presented. It was concluded that effective multidisciplinary headache treatment can reduce headache frequency and burden of disease, as well as the risk for medication overuse headache. The significant value of physiotherapy, education in headache schools, and implementation of strategies of cognitive behavioural therapy was highlighted and the way paved for future studies and international collaboration.     

Effects of a 1.5-day multidisciplinary outpatient treatment program for fibromyalgia: a pilot study

OBJECTIVE: The purpose of this pilot study was to determine the effect of a 1.5-day multidisciplinary fibromyalgia treatment program on impact of illness, depression, and life fulfillment. DESIGN: A sample of 100 consecutive enrollees in a 1.5-day multidisciplinary group outpatient fibromyalgia treatment program between February 14, 2000, and May 9, 2000, in a tertiary medical center was used for this study. The Fibromyalgia Impact Questionnaire, the Life Fulfillment and Satisfaction Scales, and the Center for Epidemiologic Studies Depression Scale were administered to subjects immediately preceding the treatment program and by mail 1 mo after completing the program. RESULTS: The 78 subjects who returned their surveys 1 mo after treatment demonstrated significant improvement in the area of the impact of illness as measured by the Fibromyalgia Impact Questionnaire total score (51.3-44.7, P < 0.002). There was no significant improvement in depressive symptoms (P < 0.056) or the level of life fulfillment (P < 0.53). Subjects with depression improved on the Fibromyalgia Impact Questionnaire to the same degree as those without depression. The 22 nonresponders did not differ significantly from the responders in the variables of sex, age, pretreatment Fibromyalgia Impact Questionnaire score, marital status, educational level, family income, duration of symptoms, or history of depression. CONCLUSIONS: These results suggest that a 1.5-day multidisciplinary fibromyalgia treatment program does have a significant positive effect on the impact of illness among patients with fibromyalgia with or without concomitant depression and may be a cost-effective model for the treatment of these patients.     

Behavioral self-management in an inpatient headache treatment unit: increasing adherence and relationship to changes in affective distress

OBJECTIVE: To evaluate prospectively the contribution of a psychological self-management program to the amelioration of headache-related distress of patients with intractable migraine treated in a comprehensive, multidisciplinary, inpatient program. BACKGROUND: Previous research has shown the effectiveness of this overall inpatient program but did not examine the relationships between the use of relaxation and other headache-related behavioral factors. METHODS: Data from 221 admissions to a Commission on Accreditation of Rehabilitation Facilities-accredited, nationally recognized, inpatient treatment unit were analyzed for the current study. On admission and on discharge (average length of stay, 12.9 days), subjects completed a 7-day retrospective, self-report questionnaire assessing health behavior compliance and emotional factors. The intervention consisted of intensive medical therapy in addition to cognitive-behavioral treatment delivered in a group setting. RESULTS: Adherence increased significantly for relaxation practice and life-style modifications of diet, exercise, and sleep regulation for headache prevention (P<.00001). Beck Depression Inventory scores decreased significantly (P<.00001), and a greater decrease in depression by the end of the program was reported by subjects who practiced relaxation most compared with those who practiced relaxation least. CONCLUSIONS: Low baseline adherence rates for health behavior increased significantly during the final week of inpatient treatment. Behavioral self-management variables, not headache reduction, were significantly associated with patients' reduction in affective distress.     

Use of complementary and alternative medical therapies by patients referred to a fibromyalgia treatment program at a tertiary care center

OBJECTIVE: To evaluate the frequency and pattern of complementary and alternative medicine (CAM) use in patients referred to a fibromyalgia treatment program at a tertiary care center. PATIENTS AND METHODS: Patients referred to the Mayo Fibromyalgia Treatment Program between February 2003 and July 2003 were invited on their initial visit to participate in a survey regarding CAM use during the previous 6 months. An 85-question survey that addressed different CAM domains was used. RESULTS: Of the 304 patients invited to participate, 289 (95%) completed the survey (263 women and 26 men). Ninety-eight percent of the patients had used some type of CAM therapy during the previous 6 months. The 10 most frequently used CAM treatments were exercise for a specific medical problem (48%), spiritual healing (prayers) (45%), massage therapy (44%), chiropractic treatments (37%), vitamin C (35%), vitamin E (31%), magnesium (29%), vitamin B complex (25%), green tea (24%), and weight-loss programs (20%). CONCLUSION: CAM use is common in patients referred to a fibromyalgia treatment program.     

Tendo-Achilles injury: An observational study in a tertiary care hospital

Objective: To report demographic and injury characteristics of tendo-Achilles (TA) injury, and determine its association with the use of Indian style commode seat (ISCS), the clinical and functional outcomes. Methods: This observational study was conducted between 1 January 2016 and 31 December 2019, and a total of 44 patients with TA injury were included in the study. Their demographic profile, etiology, operative details, and functional outcomes were studied. All patients underwent primary repair followed by standard postoperative management and follow-up for 6 months. Results: Out of 44 patients, 7 (15.9％) sustained closed injuries while 37 (84.1％) sustained open injuries. In open injury cases, 30 (81％) patients suffered an injury due to slipping in ISCS, 4 (11％) from road traffic accidents, and 3 (8％) due to falling of a heavy object. Besides, 20.45％ of cases of ISCS injury had associated neurovascular injury. Twenty (45％) patients took more than 90 days to start independent ambulation. At 6 months follow-up, no one could reach pre-injury fitness status. Conclusions: Open TA injury by ISCS is an important, under-reported, and preventable cause of loss of physically active manpower in institutional setups.     

Dynamic mechanical (brush) allodynia in cluster headache: a prevalence study in a tertiary headache clinic

Cutaneous allodynia (CA) has been described in migraine and has been related to treatment failure. There are little data about the incidence of CA in other primary headache syndromes such as cluster headache (CH). The objectives of this study are to evaluate the prevalence of dynamic mechanical (brush) allodynia (BA) in CH patients attending a tertiary headache clinic, and to assess its relation to disease characteristics. Adult patients with episodic or chronic CH were recruited. We obtained demographic data and data on disease characteristics through a structured questionnaire, and tested the patients for brush allodynia BA by applying a 4 × 4 gauze pad over the V₁, C₂/C₃ and C₈ skin areas bilaterally. The prevalence of allodynia in the entire study population and in the different sub-groups was calculated. We also examined the association between CA and demographic parameters, and its association with disease characteristics. Forty-one patients were recruited (22 men, 19 women; mean age 44.9 years). Twenty-two had chronic CH (CCH) and 19 had episodic CH (ECH). Mean disease duration was 14.1 years (12.3 the CCH group and 15.7 in the ECH group). Overall, 20 (49%) patients were allodynic. There was no statistically significant association between the presence of allodynia and age, gender, diagnosis (episodic vs. chronic CH), disease duration or disease severity. In conclusion, BA was common in this CH patient sample. The therapeutic implications of the presence of BA in CH need to be further studied.