Use of an interdisciplinary rehabilitation program designed to improve functioning and reduce psychological impairment in patients with chronic headaches (≥15 days monthly for ≥3 months) can have a positive effect on these measures for at least 1 year, as indicated by results from a prospective cohort study published in Headache.1
Patients in the study demonstrated improvements in headache pain and reductions in functional impairment and psychological distress, including depression, stress, and anxiety. “These benefits were achieved despite the high proportion of the sample who began treatment using opioids and other medications known to induce medication overuse headache,” the researchers wrote.
The interdisciplinary rehabilitation program assessed, known as IMATCH, included medical, psychological, nursing, and physical therapy components. Key interventions included 4 days of intravenous therapy; biofeedback, individual psychotherapy, and psychoeducational group sessions; nursing consultations focused on dietary counseling, relaxation techniques, and use of a headache diary; and individual physical therapy and group exercise sessions. Various monitoring and assessment protocols were also undertaken as part of the program, such as drug testing to rule out illicit drug use, an electrocardiogram, and as-needed medication adjustments. The outpatient program took 3 weeks to complete, and required 8 hours of program interventions daily, provided 5 days weekly. During downtime, patients were encouraged to practice the skills they were taught during the program, and to focus on engaging in activities that were meaningful to them.
During the study, pain severity, functional status resulting from headache, and psychological distress levels were assessed using a variety of self-report instruments at program admission, 2 days before program completion, and at 12-month follow-up. Of the 379 patients initially admitted to IMATCH, 348 (91.8%) completed the program, and 152 (40.1%) provided 12-month follow-up data.
IMATCH was found to be efficacious, resulting in significant improvements in headache pain and physical function. Using the 0 to 10 Numeric Pain Rating Scale, the estimated marginal mean of average headache severity decreased from 6.15 at admission to 3.49 at program completion and 3.26 at 12-month follow-up (P <.001). The Headache Impact Test-6 (scored on a 36-78 scale, with 78 indicating highest impact) and Pain Disability Index (scored on a 0-70 scale, with 70 indicating total disability) were used to assess physical function. These instruments showed estimated marginal mean scores of 66.13 at admission, 55.38 at program completion, and 51.94 at follow-up on Headache Impact Test-6 (P <.001), and 36.19 at admission, 14.06 at program completion, and 11.58 at follow-up on Pain Disability Index (P <.001).
Patients also demonstrated significant psychological improvements, including less depression, anxiety, and stress, which were measured using subscales of the Depression, Anxiety, and Stress Scale-42 (scored on a 0-42 scale, with 42 indicating the most debilitating levels on these measures). Estimated marginal mean anxiety scores decreased from 8.68 at admission to 5.17 at program completion, and to 4.44 at 12-month follow-up (P <.001). Depression and stress scores were also improved from admission, but were slightly increased from program completion. Estimated marginal mean depression scores were 13.25 at admission, 4.07 at program completion, and 6.65 at follow-up. Estimated marginal mean stress scores were 14.88 at admission, 7.24 at program completion, and 7.56 at follow-up.
“This discrepancy [in depression scores] may perhaps be explained by the structure of the treatment program,” the researchers wrote. “The predominantly group format is designed to reduce feelings of isolation accompanying chronic headaches, and patients frequently become emotionally close through their shared rehabilitation experience…. Consequently, depression scores may be artificially reduced at discharge by this temporary emotional uptick, and by the anticipation of returning home with improved functional capacity,” the investigators explained, noting such an effect has previously been reported.
Summary and Clinical Applicability
The present study lends further evidence that an interdisciplinary rehabilitation approach can significantly reduce pain, physical impairment, depression, stress, and anxiety in patients experiencing chronic headaches. However, it is unclear how long these positive effects last, and how interventions can best be tailored to individual patients.
The authors reported several study limitations, including lack of a control group, stringent inclusion criteria vs including all available patients with chronic headaches, and 12-month follow-up data from less than half of the study population, potentially introducing self-selection bias.
- Krause SJ, Stillman MJ, Tepper DE, Zajac D. A prospective cohort study of outpatient interdisciplinary rehabilitation of chronic headache patients. Headache. 2017;57(3):428-440. doi: 10.1111/head.13020