Inpatient Treatment
Admission Criteria
Inpatient headache treatment occurs in 2 different hospital environments: community/regional hospitals and specialty headache treatment units. A recent survey was conducted in 174 physicians with an interest in headache selected from the membership of the American Headache Society (American Association for the Study of Headache at the time of the study). Over 50% used inpatient hospitalization on at least some occasions for detoxification from opioids, barbiturates, or prescription analgesics in patients with headache.
A second survey (see table 3 of the original guideline document) was undertaken of a selection of physicians with a special interest in headache. This included 5 physicians, who had dedicated inpatient treatment programs of varying size and complexity, as well as 10 community-based physicians and 6 university-based physicians, who did not have inpatient programs. Of these 21 physicians, 19 had criteria they used for admitting patients, or were interested in obtaining criteria. One of the 2 physicians not interested in criteria was a community-based physician who no longer even attempted the process because of the high managed care penetration in his area; the second was a university-based physician who did not believe in treatment guidelines in general. Attempts were also made to obtain specific criteria from insurance industry utilization review organizations for inpatient hospitalization of headache. This data was available from only 7 insurance companies.
Though this survey relied upon a convenience sample, clinicians and the insurance industry had a surprisingly convergence of interests and criteria given the high profile of cost containment. Criteria from inpatient programs substantially overlapped in their admission criteria guidelines, as did the criteria of community- and university-based physicians who did not have inpatient programs.
Previously, there had been 2 sets of published criteria for admission to headache treatment centers (see tables below entitled "Admission Criteria of Michigan Headache and Neurological Institute for Inpatient Headache Treatment Program at Chelsea Hospital" and "Admission Criteria of the National Headache Foundation for Treatment of Headache"). The historic background of these criteria has certainly contributed to the criteria found in the survey and utilized today.
Table: Admission Criteria of Michigan Headache and Neurological Institute for Inpatient Headache Treatment Program at Chelsea Hospital
- Presence of moderate to severe intractable headache that fails to respond to appropriate and aggressive outpatient or emergency department measures and requires repetitive sustained parenteral treatment (e.g., dihydroergotamine [DHE])
- Presence of continuing nausea, vomiting, or diarrhea
- Need to detoxify and treat toxicity, dependency, or rebound phenomena and/or monitor protectively against withdrawal symptoms, including seizures, in cases in which this cannot be achieved effectively or safely on an outpatient basis
- Presence of dehydration, electrolyte imbalance, and prostration that requires monitoring and intravenous (IV) fluids
- Presence of unstable vital signs
- Presence of repeated previous emergency department treatments
- Likely presence of serious disease (e.g., subarachnoid hemorrhage, intracranial infection, cerebral ischemia, severe hypertension)
- Need to rapidly develop both immediate pain reduction and an effective pharmacologic prophylaxis in order to sustain improvement achieved by parenteral therapy (aggressive daily drug manipulation, requiring careful monitoring and drug level evaluation)
- Need to urgently address other comorbid conditions contributing to or accompanying the headache, including medical and/or psychological illness
- Presence of concurrent medical and/or psychological illnesses requiring careful monitoring in high-risk situations
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Table: Admission Criteria of the National Headache Foundation for the Treatment of Headache
- Severe dehydration, for which inpatient parenteral therapy may be necessary
- Diagnostic suspicion (confirmed by appropriate diagnostic testing) of organic etiology, such as an infectious disorder involving the central nervous system (e.g., brain abscess, meningitis), acute vascular compromise (e.g., aneurysm, subarachnoid hemorrhage), structural disorder with accompanying symptoms (e.g., brain tumor)
- Prolonged unrelenting headache with associated symptoms such as nausea and vomiting, which, if allowed to continue, would pose a further threat to the patient's welfare
- Status migraine or dependence on analgesics, ergots, opiates, barbiturates, or tranquilizers
- Pain that is accompanied by serious adverse reactions or complications from therapy - continued use of such therapy aggravates or induces further illness
- Pain that occurs in the presence of significant medical disease, but appropriate treatment of headache symptoms aggravates or induces further illness
- Failed outpatient detoxification, for which inpatient pain and psychiatric management may be necessary
- Intractable and chronic cluster headache, for which inpatient administration of histamine or DHE may be necessary
- Treatment requiring copharmacy with drugs that may cause a drug interaction, thus necessitating careful observation (e.g., monoamine oxidase inhibitors and beta-blockers)
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Treatment
Inpatient care differs depending on the type of facility and the nature of the headache. Although community-based inpatient treatment, regional or university centers, and dedicated headache inpatient treatment centers may all share the common elements of IV protocols and 24-hour nursing care, significant differences exist in the level and sophistication of other aspects of medical management, the diversity and coordination of multidisciplinary services, and the intractability of the patient population. Other factors that influence both the need for hospitalization and the type of care rendered include: medical stability of the patient, presence of coexisting medical illness, medication overuse headache (MOH) or drug dependency issues, psychological and psychiatric comorbidities, and need for patient monitoring during administration of medical therapies.
The Consortium does not know if one specific treatment environment for inpatient care is more successful than another. Efforts to compare one treatment setting with another must include a careful comparison of patient populations. The patient population in published outcome studies of specialized headache treatment centers predominantly includes patients who have failed other treatments, which in many cases have included more limited previous inpatient protocols. Evidence exists that patients with MOH, using small amounts of agents, treated on an outpatient basis, may have outcomes as good as those with inpatient care - no clear guidelines exist for the patient with MOH. Dedicated inpatient programs, however, suggest that patients with highly complex headache problems associated with significant MOH and medical and psychological comorbidities are more likely to need treatment in multidisciplinary treatment environments (see table below).
Table: Typical Treatment Modalities in a Multidisciplinary Inpatient Headache Treatment Program
- Detoxification
- Pharmacologic therapy
- Nursing intervention
- Physical therapy
- Dietary management and education
- Stress management
- Exercise programs
- Biofeedback and relaxation therapy
- Cognitive-behavioral treatment
- Group psychotherapy
- Individual and family psychotherapy
- Family groups
- Interactions between patients
- Lifestyle management
- Discharge planning
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It may be necessary to hospitalize a patient when severe headache is associated with significant changes in vital signs or clinical condition, such as repetitive vomiting. Repetitive IV DHE used >2 days has been recognized by the American Academy of Neurology in their practice parameter as necessitating inpatient monitoring.
Overuse of acute treatments for migraine and its associated pain (e.g., analgesics, alone or combined with caffeine; sympathomimetics; barbiturates; opiates; triptans; ergots) is a major problem. The International Headache Society (IHS) guidelines for drug dependency headache were revised in late 2004. The new terminology is medication-overuse headache (MOH).
Treatment of MOH is crucial, since preventive therapy often does not work. It may take as long as 12 weeks to reverse the effects of medication overuse. Failure to achieve successful detoxification as an outpatient occurs in over 50% of patients due to increased pain during the initial period of withdrawal, and acute withdrawal symptoms in cases of high levels of analgesic use, including butalbital and opioid use, can occur. Even when withdrawal could be managed safely in an outpatient setting, patients have a fear of pain, which interferes with successful withdrawal. Techniques, such as the use of clonidine for opiate withdrawal, may be of benefit in the outpatient arena. Phenobarbital can be used for withdrawal of short-acting barbiturates. This requires at least a short-term hospital stay for observation and dose titration.
Management of the patient with MOH requires acute and preventive therapies for the underlying headache, as well as symptom management related to the withdrawal of the agent producing rebound. The IV use of diverse agents including antidopaminergics, muscle relaxants, nonopioid analgesics, and valproic acid may be required to provide interim control of headaches while initiating treatment with preventive medications.
Significant complications of withdrawal of opiates, benzodiazepines, and barbiturates may occur. Observation of patient with close medical monitoring may be required in the first several days of withdrawal of these agents.
Some patients with chronic cluster headaches (CCHs) do not respond to standard methods of treatment. Adjunctive therapies such as IV DHE or IV histamine, which are rendered on an ongoing basis over the course of days to a week, have proven effective in leading to improved treatment outcomes.
Rapid transitions in medical therapies are sometimes initiated to reduce the length of hospitalization and to gain control of the patient's headaches. One example is the patient who needs to undergo a rapid transition from selective serotonin reuptake inhibitor antidepressants to monoamine oxidase inhibitor types, or the reverse. Product labeling specifies that in almost all of these cases, a drug-free interval of 10 to 14 days is required before starting the new agent. This is not a practical solution for patients who suffer profound disabling headaches, and a more rapid transition with a shorter evaluation period should be initiated. Generally, this type of transition has proven safe for most patients, although on occasion this type of therapy may be potentially dangerous. Warning signs include the serotonin syndrome with elevated temperature, agitation, and other serotonergic indications. If left untreated, a potentially morbid situation could occur. Careful observation of these patients during this transition period is essential.
Chronic pain, including headache, may be significantly aggravated by psychological problems. Long-term follow-up research has found that patients with multiple psychiatric diagnoses have a more negative long-term prognosis than patients with little or no psychiatric disturbance. Accurate diagnosis by qualified psychologists and psychiatrists is essential if development of a long-term treatment program is indicated. Treatment for the patient with CH attempts to identify specific components of suffering and pain behaviors. Specific psychological intervention occurs on 2 levels. Group therapy sessions, such as assertiveness training, are conducted with a focus on problems common to patients with headache. If indicated, individual psychological counseling is also initiated during the first few days of hospitalization, and continued, as necessary, during and after hospitalization. Intractable headache has a significant impact on family functioning, and both individual family and family group intervention is often an important part of the program. Patients with refractory headache usually have psychological issues affecting their ability to respond to treatment. In many patients, the headache process is obscured by personality characteristics, coexisting depression, or other major psychiatric conditions including personality disorders. After an initial assessment and basic psychological intervention, it is imperative to establish a pain management program to help these patients deal with the varied aspects of their condition.
Education of the patient with headache provided by physicians, psychologists, pharmacists, and dieticians, is essential in enhancing the patient's understanding of the headache problem and ensuring a successful treatment program. Family members also are encouraged to be involved in the program.
