Patients with chronic headache often face significant challenges pertaining to daily function and psychological health. Research suggests that up to 34% of these individuals experience restricted activity in multiple areas of their lives, including employment, household management, and family activities, and up to 78% of patients have comorbid psychiatric disorders.1
Due to the complexity of such cases, headache specialists agree that the optimal approach is multidisciplinary treatment (MDT), which may consist of psychological support and physical or occupational therapy along with the medical care provided by the referring physician.2 MDT programs may be provided in the context of inpatient, outpatient, or day hospital settings.1 The typical patient for whom MDT is indicated has more than 15 headache days per month and may suffer from more than one headache type, such as chronic migraine and medication overuse headache.2
Benefits of MDT
Study results support the benefits of MDT in these patients, including the Cleveland Clinic’s 3-week Interdisciplinary Method for the Assessment and Treatment of Chronic Headache (IMATCH) program.1 In 340 patients who completed the 3-week intensive outpatient program, improvements in headache severity, functional status, and psychological impairment were observed at the end of treatment and at the 12-month follow-up assessment.
There were reductions in mean ratings on a 0 to 10 scale for average headache pain in the prior week (admission 6.1, discharge 3.5, follow-up 3.3), as well as improvements on measures of function (mean Headache Impact Test-6 score: admission 66.1, discharge 55.4, follow-up 51.9; mean Pain Disability Index score: admission 36.2, discharge 14.1, follow-up 11.6). Significant improvements in anxiety, depression, and stress were also found.
Various other studies of MDT programs have demonstrated improvements in health status and quality of life, and reductions in headache intensity, frequency, and duration, as well as days missed from work, depression, and pain-related disability.3-6 Similar results have been observed in children and adolescents.7 In addition, MDT may prevent further headache “chronification” and medication overuse.8
Components of MDT
Although there is a lack of consensus on which specialists should be included in a comprehensive team, the 4 main components of MDT often consist of a headache specialist, physical therapist, occupational therapist, and mental health clinician, according to a recent review co-authored by Soma Sahai-Srivastava, MD, FANA, FAHS, professor of clinical neurology at the Keck School of Medicine at the University of Southern California (USC), Los Angeles, and director of the headache program at the USC Headache and Neuralgia Center.2 “Our main partners at USC are occupational therapy, physical therapy, pain management, neurosurgery, and dentistry for orofacial pain, among other complementary medicine and alternative medicine modalities,” she said.
Steven J. Krause, PhD, clinical psychologist and director of rehabilitation programs at the Neurological Center for Pain at Cleveland Clinic, Ohio, told Neurology Advisor that he considers the following components essential:
- A physician from the medical specialty appropriate to the patient population served, whose role is medical evaluation and treatment, including medication management and pain relief procedures. Because complete pain relief is rarely possible in patients with chronic pain, the “physician focuses instead on safely removing inappropriate or ineffective medications, and establishing a stable regimen of long-term medications as appropriate,” Dr Krause explained. Physicians should avoid giving the patient false hope of complete relief, while emphatically supporting the “value of non-medical treatments and lifestyle changes, and managing care methodically without reacting to pain flare-ups.”
- A psychologist with a pain management background, who teaches nonpharmacologic pain management techniques, helps the patient overcome psychosocial barriers to the implementation of these techniques, and evaluates for and sometimes treats substance abuse and other mental health issues.
- A physical therapist (PT) who evaluates and treats musculoskeletal impairments that may contribute to the patient’s pain or functional impairment, using active treatment modalities such as stretching and exercise. Passive modalities such as massage are rarely used. The PT’s “role in demonstrating to patients that they can safely increase activity is invaluable,” Dr Krause noted.
- Nursing staff who educate patients on self-care and provide case coordination. A nurse often coordinates efforts of the other MDT team members.
- Other specialties, as indicated, may include occupational therapy, pharmacy, vocational counseling, or addiction medicine.