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Abstract and Introduction
Abstract
Objective: (1) To assess outcome at discharge for a consecutive series of admissions to a comprehensive, multidisciplinary inpatient headache unit; (2) To identify outcome predictors.
Background: An evidence-based assessment (2004) concluded that many refractory headache patients appear to benefit from inpatient treatment, underscoring the need for more research, including outcome predictors.
Methods: The authors completed a retrospective chart review of 283 consecutive admissions over 6 months. The inpatient program (mean length of stay = 13.0 days) included intravenous and oral medication protocols, drug withdrawal when indicated, cognitive-behavior therapy, and other services when needed, including anesthesiological intervention. Patient-reported pain levels and consensus of medical staff determined outcome status.
Results: The 267 completers (94%) included 212 women and 55 men (mean age = 40.3 years, range = 13–74) from 43 states and Canada. The modal diagnosis was intractable, chronic daily headache (85%), predominantly migraine. Most (59%) had medication overuse headache (MOH), involving opioids (48%), triptans (16%), or butalbital-containing analgesics (10%). Psychiatric diagnoses included stress-related headache (82%), mood disorders (70%), anxiety disorders (49%), and personality disorders (PD, 26%). More patients with a PD (62%) had opioid-related MOH than those with no PD (38%), P < .005. Of the completers, 78% had moderate to significant pain reduction, with comparable improvement in mood, function, and behavior. Clinical factors predicting moderate-significant headache improvement were limited to MOH (84% vs 69%, P < .007) and presence of a PD (68% vs 81%, P < .03).
Conclusions: Most patients (78%) improved following aggressive, comprehensive inpatient treatment. Maintenance of improvement is likely to depend on multiple post-discharge factors, including continuity of care, compliance, and home or work environment.
Introduction
There exists a group of headache sufferers, many of whom become dependent on opioids, whose pain and impairment remain refractory to outpatient treatment. In most cases of chronic headache, daily opioids fail to provide sustained relief or reduce functional impairment. Frequent opioid use is likely to contribute to central sensitization and progressive worsening of the headache through multiple mechanisms.
Meaningful headache control, improved functioning and enhanced quality of life require a level of care intensity that matches the severity of illness. For patients with medication overuse headache (MOH) involving opioids, butalbital-containing analgesics, triptans, or ergotamine tartrate, successful drug withdrawal with aggressive headache treatment may require inpatient level care. An evidence-based assessment (2004) concluded that many intractable headache patients benefit from inpatient treatment, and underscored the need for more research, including identification of outcome predictors.
We previously published 6- to 8-month outcome studies of patients admitted to our inpatient unit, and later as part of a comprehensive evaluation of both inpatient and outpatient outcome for our entire center. The population referred has become increasingly complex over time, often with multiple psychiatric and medical comorbidities.
This study addresses 2 objectives:
To assess outcome at discharge for a large consecutive series of admissions from a national referral base, and
To identify clinical factors predicting successful outcome.
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