Essential components of care in a multidisciplinary headache center: Perspectives from headache neurology specialists

Abstract

Background and Objective: Comprehensive headache care involves numerous specialties and components that have not been well documented or standardized. This study aimed to elicit best practices and characterize important elements of care to be provided in multidisciplinary headache centers.Methods: Qualitative, semi-structured telephone interviews with a purposive sample of headache neurology specialists from across the US, using open-ended questions.Interviews were recorded, transcribed, and coded. Coded data were further analyzed using immersion/crystallization techniques for final interpretation.Results: Mean years providing headache care was 17.7 (SD = 10.6). Twelve of the 13 participants held United Council for Neurologic Subspecialties headache certification. Six described their practice site as providing multidisciplinary headache care.Participants explained most of their patients had seen multiple doctors over many years, and had tried numerous unsuccessful treatments. They noted patients with chronic headache frequently present with comorbidities and become stigmatized. All participants asserted successful care depends on taking time to talk with and listen to patients, gain understanding, and earn trust. All participants believed multidisciplinary care is essential within a comprehensive headache center, along with staffing enough headache specialists, implementing detailed headache intake and follow-up protocols, and providing the newest medications, neuromodulation devices, botulinum toxin injections, monoclonal antibodies, nerve blocks and infusions, and treatment from a health psychologist. Other essential services for a headache center are other behavioral health practitioners providing cognitive behavioral therapy, mindfulness, biofeedback and pain management; and autonomic neurology, neuropsychology, vestibular audiology, sleep medicine, physical therapy, occupational therapy, exercise physiology, speech therapy, nutrition, complementary integrative health modalities, and highly trained support staff.| 307 HEADACHE INTRODUC TI ONComprehensive specialty headache care involves numerous processes, components, and workflow protocols intended to promote delivery of high-quality care. However, these have not been standardized or clearly delineated. Over the years, initiatives have arisen to define and measure quality in headache care, stemming from more general explications of quality in health care. 1 Reviews of quality in headache care include multiple dimensions of quality indicators, standards, and guidelines for outcomes and safety, along with structure, processes, and outcomes of patient care and services. [2][3][4][5] The European Headache Federation, in conjunction with the Lifting The Burden campaign, 6 have proposed criteria for specialized headache centers, including offering multidisciplinary headache care. 7 Currently, there is no certifying body or definitive list of core components requisite or suggested for headache centers in the United States (US).Multidisciplinary treatment has been s...

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“…The Migraine Disability Assessment (MIDAS), 39 is a 5-item, self-report measure of life disruption due to headache in the last 1 month. Cut points represent thresholds for little or no disability (0-5), mild disability (6-10), moderate disability (11)(12)(13)(14)(15)(16)(17)(18)(19)(20), and severe disability (21þ). The Headache-related disability inventory (HDI), 40 is a 25-item self-report questionnaire that assesses both the emotional and functional impact of headache on daily activities.…”

“…Items are rated from 0 to 3 (0 ¼ not at all to 3 ¼ nearly every day) with total score ranging from 0 to 24 for the PHQ-8. The PHQ-9 provides thresholds for severity of depressive symptoms: none-minimal (0-4), mild (5-9), moderate (10)(11)(12)(13)(14), moderately severe (15)(16)(17)(18)(19), and severe (20)(21)(22)(23)(24)(25)(26)(27) depressive symptoms. The PHQ-8 has demonstrated exceptionally high correlation with the PHQ-9 (r ¼ 0.997) and identical cutoffs are advised.…”

“…Total scores range from 0 to 21. Cut points represent thresholds for none-minimal (0-4), mild (5-9), moderate (10)(11)(12)(13)(14), and severe (15)(16)(17)(18)(19)(20)(21) anxious symptoms. The GAD-7 has demonstrated high internal consistency (Cronbach a ¼ 0.92) and test-retest reliability (r ¼ 0.83), and high sensitivity (0.66-0.89) and specificity (0.80-0.81) across multiple anxiety disorders compared to structured mental health interviews.…”

“…Items are rated from 0 to 4 with responses tailored to the question (e.g., symptom severity rated 0 ¼ none to 4 ¼ very severe), with total scores ranging from 0 to 28. Cut points represent thresholds for no clinically significant insomnia (0-7), subthreshold insomnia (8)(9)(10)(11)(12)(13)(14), clinical insomnia (moderately severe) (15)(16)(17)(18)(19)(20)(21), clinical insomnia (severe) (22)(23)(24)(25)(26)(27)(28). The ISI has demonstrated strong reliability (Cronbach a ¼ 0.90-0.91) and good convergent validity with other measures of insomnia (r ¼ 0.80) and sleep diaries (r ¼ 0.54-0.59), and is particularly well-suited to detecting changes in perceived insomnia.…”

“…15,16 More practitioners are embracing the biopsychosocial framework as part of comprehensive, multidisciplinary, headache care. 17 Consequently, patients are increasingly encouraged to prevent and ameliorate symptomatology through pharmacologic and non-pharmacologic treatment, which is especially relevant in people with PTH given the complexities of the disease. 7 Psychological therapies for headache are evidence-based interventions 18 that aim to reduce the frequency and severity of headache attacks and improve an individual's quality of life.…”