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Outpatient Program Improves Function in Chronic Headache

By Pauline Anderson
WebMD Health News

February 02, 2017

Patients with chronic headache participating in an interdisciplinary outpatient program experienced a significant decrease in headache severity, functional disability, and psychological distress, a new study has found.

"The results show that there is hope for these people," said lead author Steven J. Krause, PhD, Department of Psychiatry & Psychology, Cleveland Clinic Foundation, Ohio.

"We can usually help people reclaim their lives and get back to fulfilling, productive living, even in the event that we don't have a cure for their illness."

The study was published online January 27 in Headache.

The comprehensive Interdisciplinary Method for the Assessment and Treatment of Chronic Headaches (IMATCH) program is offered to adults with chronic headaches refractory to prior medical intervention. It provides 8 hours of outpatient treatment a day, 5 days a week, for 3 weeks.

During the program, participants have various evaluations, receive medical and psychological treatment and a customized exercise program, and identify their functional goals — for example, to go back to school or to take better care of their kids. They also receive controlled intravenous medications to withdraw from "inappropriate" use of drugs, such as opioids, triptans, benzodiazepines, and hypnotics, said Dr Krause.

"If we didn't use these infusions, most people would go into drug withdrawal and be in agony and probably drop out of treatment. Why put people through that kind of cruelty when we can bridge them with medicines and get them through that transition in reasonable comfort?"

In group sessions, participants discuss various topics, such as using their medications for maximum benefit, managing mood changes, and handling perceptions of others who don't understand what it's like to live with chronic headaches.

"They learn answers to some practical questions, such as 'How do you keep this condition from affecting your marriage?'; 'How do you get some sleep at night?'; and 'How do you know when to push and when to rest?'" said Dr Krause.

The goal of the program is not to reduce pain but to improve the ability to function with pain, he said.

"We tell them point blank that we are not going to make them headache-free; if I knew how to do that, I would, but I don't."

Many people "get stuck" on the idea that their pain has to be eliminated before they can go on with their life, added Dr Krause. "We are saying that you have to regain your life even if we can't get rid of the pain, and that's doable and we'll show you how."

Self-Report Instruments

For the study, patients completed self-report instruments on admission, at discharge, and at 1-year follow-up. To indicate headache severity, they used a 0 to 10 scale (with 0 representing no pain and 10 the worst possible pain). They rated their least, worst, and average pain levels in the previous week.

They also answered surveys on functioning. These included the Headache Impact Test (HIT-6), where the highest score (70) is the most severe; the seven-item Pain Disability Index (PDI), with 40 being the worst score; and the 42-item Depression, Anxiety and Stress Scales (DASS-42), with 16 being the most severe for each of the subscales.

Of the initial participant pool, 348 patients finished treatment. Of these, 40.1% completed 12-month follow-up questionnaires.

The estimated marginal mean of participants' average headache severity in the prior week declined from 6.15 at admission to 3.49 at discharge and 3.26 at follow-up (P ‹ .001). The analysis indicated significantly higher headache severity at admission compared with both discharge and follow-up, but no difference between discharge and follow-up.

The participants' mean "least" and "worst" headache pain was reduced as well.

While patients still had headaches when they left the program, they were, on average, less severe, noted Dr Krause. "Some people leave with the same pain as they had when they arrived, but if they can reclaim their lives, if they can function again, I'm going to call that a success."

Participants did enjoy improvements in physical functioning following treatment. The estimated marginal mean HIT-6 score was 66.13 at admission, 55.38 at program completion, and 51.94 at follow up (P ‹ .001). Similar results were noted for the PDI.

There were significant improvements on each for the DASS-42 subscales. The estimated marginal mean anxiety score declined from 8.68 at admission to 5.17 at discharge and 4.44 at follow-up (P ‹ .001).

For depression, the estimated marginal mean score declined from 13.25 at admission to 4.07 at discharge, but increased to 6.65 at follow-up (P ‹ .001).

Dr Krause surmised that the discharge numbers might be artificially low for depression because participants were surveyed at the end of the program — after they had spent 3 weeks with other group members with whom they might have developed a camaraderie.

Graduation Day

"It's graduation day and they're happy to go home, and they feel they have accomplished something, so they tend to be in good mood at that point."

The outcome a year out "is probably a more realistic estimate of what we have accomplished," he said.

As for stress, the estimated marginal mean score decreased from 14.88 at admission to 7.24 at discharge and 7.56 at follow-up (P ‹ .001).

Dr Krause wanted to explore whether people who were better to begin with were more likely to complete the follow-up forms, which he said would have biased the results.

"I tested to see if I could differentiate the people who competed follow-up from people who did not, and the only thing I found was that they were slightly more likely to be female."

No one element of the integrated IMATCH program can explain its success. "This is a complex problem with a bunch of moving parts," said Dr Krause. "I always say that treating chronic headache is like wrestling an octopus; you can't hold down one leg and expect to succeed. You have to address the psych issues; you have to address the medical issues; you have to get patients off medications; and you have to get them back into shape."

Dr Krause and his colleagues did not collect follow-up data on return to work, but those data would have been helpful, he noted.

Promising Program

Reached for a comment, Elizabeth Loder, MD, chief, Division of Headache and Pain, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, said the approach to treatment offered by the IMATCH program "has promise."

"Comprehensive multimodality treatment is likely to be the best approach for severely disabled headache patients, but evidence to support that assumption is limited," said Dr Loder. "The improvements in outcome for patients who completed this study are encouraging."

She pointed out, however, that "a substantial amount of information about outcomes is missing and that could affect the findings."

And, she said, without a control group, "it's not possible to know how much of the improvement is due to the intervention itself or other factors such as natural improvement over time or expectation or belief."

Dr Loder agreed that as with all studies that evaluate complex interventions, it's not possible to study the contribution of individual treatment components.

The authors and Dr Loder have disclosed no relevant financial relationships.

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SOURCE: Medscape, February 2, 2017. Headache. Published online January 27, 2017.

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