Inpatient Headache Treatment
Although inpatient management of headache is needed relatively infrequently, when the treatment regimen is complex and/or there are concomitant medical problems, initiation of treatment in an outpatient setting may not be feasible. As a result, overall hospital rates for migraineurs have been reported to be twice as high as overall rates for a normal population.
Compared with outpatient treatment, inpatient management is more costly for the patient, the employer, and the insurance industry. Therefore, clinicians should consider several factors when deciding on a course of therapy. Seven major factors have been identified for determining whether the indication is for treatment in an outpatient or an inpatient setting (see table below).
| Outpatient versus Inpatient Treatment: Factors to Consider |
- Degree and intractability of pain
- Refractoriness to established regimens
- Need for supportive medical measures
- Degree of toxicity and drug dependence
- Degree of coping ability
- Psychological health considerations
- Comorbid medical disease considerations
|
Inpatient treatment of headache may be needed in selected patients. For example, hospitalization, followed by careful outpatient follow-up, may increase the chance of a successful treatment outcome in patients with numerous failed attempts at outpatient treatment. Treatment situations requiring repetitive parenteral therapy, such as status migraine, are probably the most common reason for hospitalization. Hospitalization may be necessary if a patient is severely dehydrated or if a secondary or organic cause of headache is confirmed by appropriate testing. About 4% of the population has chronic daily headache. Some of these patients, because of their headache severity, their refractoriness to standard therapies, and their comorbid medical and psychiatric disorders, require a comprehensive headache treatment program initiated in an inpatient program. Occasionally, initial treatment may aggravate the condition or cause severe adverse reactions, in which case inpatient treatment may be necessary. Similarly, the use of drugs that may interact with each other, such as monoamine oxidase inhibitors and beta-blockers, demands careful observation and may require hospitalization.
Patients who overuse medication and are unable to discontinue such use as an outpatient, which unfortunately occurs in the majority of cases, can benefit from safe and rapid detoxification along with adjunctive management of the underlying migraine headache. In a recent survey of 473 headache-treating physicians, 30 to 60% of patients required inpatient treatment for withdrawal of medication.
The use of repetitive intravenous (IV) dihydroergotamine (DHE) (Refer to table 9.2 of the original guideline document) may help initiate rapid control of the headaches. Metoclopramide, 10 mg IV, can be coadministered to control nausea. Intravenous neuroleptics, such as chlorpromazine, droperidol, and prochlorperazine, and/or corticosteroids may be used for patients for whom DHE is not an option. Other alternatives include the repetitive administration of IV valproic acid or the repetitive use of IV ketorolac, other analgesics, or muscle relaxants. These agents may also supplement repetitive IV DHE in refractory patients.
In a meta-analysis of outcomes of inpatient hospitalization, it was reported that up to 91% of patients reported significant (>50%) improvement in symptoms at follow-up intervals up to 6 months; at intervals greater than 6 months, up to 71% of patients reported significant improvement, as shown in Table 9.3 of the original guideline document; outcomes in rebound and cluster patients are shown in Tables 9.4 and 9.5 of the original guideline document, respectively.
Another recent study examined a range of patients attending a tertiary headache center. Although this study did not specifically address the benefits of hospitalization, preliminary data assessing the correlation of health care utilization with the Migraine Disability Assessment Score (MIDAS), demonstrated significant reductions in emergency department visits and utilization of new medication both over-the-counter and prescription. Changes in MIDAS scores correlated well with all measured parameters, except repeat hospitalization.
Finally, clinicians should not underestimate the importance of appropriate patient counseling. Taking time during hospitalization to educate patients about behavioral methods of pain control as well as working with patients to establish realistic acute and preventive outpatient treatment plans can increase the chances of a successful outcome.
