An integrated care program was established to provide multidisciplinary treatment of chronic headache sufferers with frequent migraine, TTH or MOH and/or difficult-to-treat headache. Integrated care at HCB focussed on a comprehensive assessment including a headache diagnosis according to ICDH-II criteria [
28], standardized screening for psychiatric comorbidity and provision of treatment according to clinical guidelines [
29,
30]. Patients were assigned to three treatment modules following a simple algorithm based on headache frequency, medication use and psychiatric comorbidity. This procedure allowed a valid patient assignment with regard to patients’ headache-related disability and quality of life and tailored treatment to patients’ needs. Recently, this criterion-based assignment for modularized managed care headache treatment has been validated by our study group [
40]. A dedicated computer documentation system [
35] was introduced to integrated headache care for the first time to enhance the process quality and to realize cross-sectional communication between supply partners and the managed care clinic, as well as online documentation, collection of data from chronic headache patients and risk management.
This study demonstrates that a multidisciplinary in- and outpatient integrated care program is effective in treating chronic headache patients and results in a decrease of burden of disease. Mean reduction in headache frequency was 6.9 days per month at 1-year follow-up. In the present study cohort, a significant difference of headache frequency from baseline to 6- and 12-month follow-ups was observed in all headache subgroups. Harpole et al. [
14], treating chronic headache patients in a multidisciplinary management program, reported a reduction of 14.5 headache days on average within 3 months. However, a 3-month follow-up measures mainly short-term effects. Furthermore, in their study, 20 % of the patients had MOH and suffered to 30 % from psychiatric comorbidities, while burden of disease measured by MIDAS was 40.9 points on average. In contrast, an alarming number of 33.8 % patients participating in our study suffered from MOH with a MIDAS-score of 52 points on average, indicating more severely affected patients. A further study by Lemstra et al. [
13] reported a reduction of 33.6 % in pain frequency at 3-month follow-up in a small group of migraine patients participating in a 6-week multidisciplinary treatment program. In this study, headaches had existed on average for 101.7 months at baseline (in our study 240 months) and Beck Inventory mean depression levels suggested marked depressed mood levels. Maizels et al. [
15] established a group-based model of disease management for patients with headache. During a 6-month period they recognized that severe headache frequency was reduced in 86 % of patients who initially had severe headaches more than 2 days per week. Recently, Gaul et al. [
25] reported a reduction of headache frequency of about 36.8 % after 1 year in a large cohort of headache patients treated in a non-modularized multidisciplinary integrated care program. In a 6-month outcome study, Saper et al. [
11] assessed that 67 % of mainly physician-referred refractory headache patients who participated in a comprehensive, multidisciplinary, out- and inpatient treatment in a tertiary headache center met the 50 % criterion for both parameters of improvement of headache frequency and frequency of severe headaches. Gaul et al. [
24], treating 295 adult patients with a headache-specific multidisciplinary program, and Kabbouche et al. [
41], treating children in a comprehensive tertiary care, are the only authors reporting 1-year primary outcome data of multidisciplinary approaches. Headache frequency decreased from 13.4 to 8.8 days/month in adult chronic headache patients, while days with headache/month were 13.4 at baseline and 4.9 after 1 year in children. Jensen et al. [
23] reported a reduction of headache frequency from 20 days/month on admission to 11 days/month at the end of treatment after analyzing a total of 1326 patients in a 2-year systematic follow-up study in the Danish Headache Center. In their cohort, 25.5 % of patients had MOH, but unfortunately the authors did not report data indicating burden of disease or psychiatric comorbidity of patients. Furthermore, multidisciplinary integrated care as demonstrated in this study causes a significant reduction of headache-related disability of 18.6 MIDAS points at 12-month follow-up. In the present study, patients with TTH profited most in burden of disease with a reduction of 27.7 MIDAS points, while migraineurs experienced a MIDAS reduction of 11.8 points. This may be due to the fact that in our cohort the TTH subgroup was affected fewest consisting mainly of episodic TTH sufferers (54.5 %), having the shortest history of disease, being fewest anxious and consuming lowest amount of attack-aborting medication/month. Additionally, we observed an absolute reduction of 8.8 lost days at work/school per 3 months. These findings are in accordance with the observations of Harpole et al. [
14], who reported a reduction of 21.2 MIDAS points in their study, while Matchar et al. [
20] observed just a decrease of 14.9 points. Finally, the present integrated care program was effective in reducing intake frequency of attack-aborting medication (days/month). Intake frequency decreased in the total cohort by about 6.5 days/month and in MOH of about 12.3 days/month. However, medication consumption was examined in just a few studies dealing with multidisciplinary headache treatment. In contrast to our findings, Lemstra et al. [
13] investigated a multidisciplinary management program for migraine treatment in comparison with a control group and reported no significant changes in medication use. Furthermore, Maizels et al. [
15] studied triptan costs for 6 months before and after intervention using a group-based model of disease management in patients with miscellaneous headaches (mainly transformed migraine with medication overuse). They observed an increase of 19 % in 6-month triptan costs during the interventional phase. On the other hand, observations by Gaul et al. [
25] are in accordance with our findings. They described a reduction of acute medication days with intake of analgesics and triptans from 9 to 5 days/month in their multidisciplinary treatment program, which had lifestyle recommendations as an important element in their behavioral treatment concept. Integrated headache care presented in our study focusses likewise on cognitive-behavioral pain management aspects and information about efficacy and possible adverse effects of acute and prophylactic medication and its correct use in headache attack management. Moreover, all patients learned PMR or get another non-pharmacological treatment option in our integrated headache care. The behavioral concept also expected the patients to immediately integrate newly gained knowledge about treating headache into their daily lives. Patients at all treatment levels also received regular instruction to reinforce what they had learned. In particular, cooperating secondary care physicians were requested to provide their headache patients with positive motivation to implement the behavioral changes. Due to this, persistence of medication overuse for one year was documented in only 1.6 % of patients in our study, while at baseline 33.8 % of participants suffered from MOH. This is notable, because in the present study the group of MOH patients was strongly affected, had psychiatric comorbidity in 84 % of cases and prior experience with withdrawal in 88 %; moreover, 53 % of these had multiple withdrawal treatments. The 1-year follow-up outcome after withdrawal of headache medication is assumed in the literature to be up to 40 % [
42‐
47]. However, at the 1-year follow-up, no patients in our study were identified with a newly developed MOH. Epidemiological studies report an incidence for MOH of about 1–4 % [
48‐
52]. In tertiary centers, by contrast, the incidence of MOH reported in studies by Katzarava et al. [
53] may even be as high as 14 %. On the other hand only 37.9 % of our patients had experience with non-drug methods of attack relief at baseline. At the end of treatment, the number had risen to 87.0 %, of whom 75 % regularly used PMR. This impressively illustrates that our integrated headache care program results in a long-lasting change in treatment style, away from passive measures and acute medication overuse to an active coping strategy using more non-pharmacological therapies.
A methodological strength of the presented study is its prospective design, the large number of patients, classification of patients according ICHD-II, a comprehensive assessment including measurement of psychiatric comorbidity, implementation of a cross-sector computer documentation system and the long follow-up period of 12 months. The latter especially may help to distinguish between short- and long-term effects. The selected care-research approach may better reflect reality than a controlled study design. But this point also gives rise to a major limitation of our study with a lack of control condition. This non-randomized, open study was conducted at a tertiary headache center taking care of severely affected and chronic headache patients, which may lead to a typical bias. But selection criteria for admission to the integrated headache care could not be influenced by the authors. Future studies should use controlled and randomized design and should clarify the therapeutic role of the different components of treatment in integrated care.
In summary, the present study has provided support for the usefulness of a multidisciplinary integrated care program for severely affected and patients with difficult-to-treat chronic headache, frequent migraine, TTH and MOH. Integrated headache care led to a decrease in anxiety and depression at 12-month follow-up. Further prospective and controlled studies are needed to understand the role of different components of integrated headache care.