Comprehensive/tertiary care for headache: a 6-month outcome study

To assess programwide (outpatient plus inpatient) outcome using prospective measures for the first 6 months of treatment at a comprehensive headache center. Background.-There is little published data on the overall programwide efficacy of comprehensive, multidisciplinary treatment centers for severe, refractory headache disorders.

For 1 week each month over a 2-year period, all new patients completed an initial questionnaire noting frequency/severity of headaches and other headache-relevant measures. A follow-up version mailed at 6 months was returned by 218 of 421 patients (response rate 52%). Sixteen percent were treated both in and out of the hospital, with 84% treated as outpatients only. Patients had a mean of 2.50 medical visits after the initial evaluation, and 43% met with a psychologist.

Mean headache frequency dropped from 5.30 to 3.45 days per week (P<.00001), with severe headaches declining from 2.31 to 1.33 days per week (P<.00001). Sixty-seven percent of the patients had at least a 50% reduction in headaches, with a mean percentage improvement per patient in severe headaches of 56% (median 67%). Emergent care visits within 6 months dropped from 4.39 to 1.67 (P<.00001). Days with significant headache-related work impairment declined from 2.04 to 0.67 days per week (P<.00001), a net annualized reduction of 71.24 impaired workdays per year per patient. For full-time workers, missed work days in 6 months dropped from 5.46 to 2.68 (P<.00261). The mean percentage improvement for headache-impaired workdays was 67% (median 88%), and for work absence was 63% (median 100%). Total days incapacitated per week dropped from 1.72 to 0.89 (P<.00001), with a mean percentage improvement of 67% (median 91%). Significant treatment satisfaction was reported by 89%. A weighted Goal Attainment Scale based on the percentage of patients showing significant improvement in pain control, functioning, work performance, reliance on emergent care, depression, and satisfaction revealed an overall Goal Attainment score of 72%.

Despite a mean of only 3.50 medical visits in a population of complex patients, significant improvement was demonstrated in several key economically relevant variables within 6 months of referral. If maintained over the long term, the results support the concept that matching intensity of treatment (comprehensive/tertiary care) to severity of illness (complex/refractory cases) is cost-effective.