The Headache Evaluation
Your evaluation at the Headache Center includes an interview with at least two headache specialists. These include a review of prior records and diagnostic studies, review of additional testing information, diagnostic interview, and headache examination. Imaging studies are often conducted through the New England Medical Center, while we can accommodate patients at other sites depending upon issues of convenience and insurance coverage. Diagnostic and treatment recommendations are generally made at that time, and we directly communicate with your referring and/or primary physician.
Treatments at the Headache Center
While many headaches can be managed by adjusting medications, patients presenting to the Headache Center often have a complex history. In many cases, patients feel that prior treatments have worsened their pain condition. Some patients become frustrated, encounter sleep loss, become disabled, and develop changes in mood due to chronic headaches. Complex headaches often require an interdisciplinary approach, certainly at the evaluation stage. Evidence-based treatments may include pharmacotherapies, ranging from the traditional triptan medications to more complex regimens that involve neuropathic pain medications or opioids. Biobehavioral approaches such as surface EMG and biofeedback also have been shown to be highly successful with complex headaches, and we have staff that possesses special expertise in this area. Similarly, some chronic headaches are inherently disabling, and we’ve been fortunate to recruit staff with knowledge in disability assessment. In all cases, our goal is to assist the patient in reducing the frequency, duration, and severity of their headaches, while maintaining or returning the patient to optimum function. Additionally, we provide coordinated services that ultimately are designed to allow the patient to be independent of healthcare providers.
Communication with your referring and primary care physician
We believe in the importance cross communication with your other treating clinicians. A report will be mailed to your physician, as well as phone contacts where necessary. When a patient presents with a complex medication history, we also work with the other clinicians to provide the best coordination of care.
With many headaches, medication management can be as simple as providing clear instruction to the primary care physician, and additional follow-up is not needed. With more complex cases, our staff may manage the patient’s complex medication regimen through regular visits. With any medication management program, the benefits must always outweigh the risks, and such decisions are discussed at length with the patient. Newer medications also are in development, and our clinicians are in an ideal position to give the patient an objective review of the latest discoveries in this area. In some cases, an approach at the Headache Center may include the tapering of inappropriate or ineffective medications, as some medications have been found to be a primary cause of some headaches, e.g., “rebound headache” or “hyperalgesia.”
Interventional Procedures and Injection Approaches
There has been a growing interest in the area of interventional procedures for chronic headache. Some members of our staff are experienced with approaches including trigger point therapy, botulinum toxin therapy, and various craniofacial and cervical nerve blocks. A nerve block involves the injection of a local anesthetic drug around a nerve. On occasion, more complex interventional approaches are considered such as occipital nerve stimulation. In these cases, our staff maintain affiliations at academic medical centers where these are commonly performed.
We often see patients with complex medical histories and headaches that have been resistant to many prior treatments. While many of our patients suffer from “typical” headache syndromes, some of our patients arrive with an unclear diagnosis and a history of frustration from prior unsuccessful treatment attempts. We have been fortunate to host a head and neck “clinical rounds” at Tufts where we offer patients the option of having their case reviewed by 10-15 specialists from various academic centers in New England. These formal presentations include participation by the patient. The Rounds often result in diagnostic and treatment feedback valuable for the patient, and assist in the coordination of your care. While there are scheduling demands for these rounds, you can discuss this with your doctor at the time of your evaluation.
Behavioral and Biofeedback Therapies
Biobehavioral treatments on chronic tension type and migraine headache have been shown to be very effective. Through use of surface EMG or thermal biofeedback, headache suffers learn to control bodily functions previously thought to be involuntary. Cognitive therapies and relaxation approaches are particularly helpful with headache conditions. These procedures are meant to provide the patient with improved control of their symptoms, and reduce overall suffering. Patients with complex headaches may be able to reduce or eliminate medications with these techniques. As a result, a patient may be free of the side effects sometimes accompanying medication. These techniques are relatively brief, time limited, and often reimbursed by insurance carriers.
Behavioral and Pain Workshop
The Pain Workshop is a short, 4-week program designed for patients at the Pain Center. This is an educational program with content that includes a review of recent scientific advances in pain management. Additionally, we review specific self-management techniques and provide relaxation and coping skills training for the management of persistent pain. Patients monitor their pain and work toward reducing frequency, duration and severity of pain or related symptoms. Open discussion occurs during each session, and extensive lecture materials are provided. Your individualized pain diaries are discussed in detail, and you have the opportunity to closely review your progress with the program coordinators.
|1||Introduction to Chronic PainSuffering and Costs of PainTheories of PainTypes of Pain
Precipitants (Dietary, Stress, Genetic, Hormonal, Medication, Sleep)
Self-Monitoring and Goal Setting
(Baseline Pre-Treatment Assessment)
|Relaxation Training Overview: Breathing Exercises, Body Mechanics & ExerciseBiofeedback Review/Demonstration|
|2||Pharmacotherapy & PainSelf-Monitoring Review|
|Progressive Muscle Relaxation|
|3||Cognitive Therapy & PainSelf-Monitoring Review|
|Muscle Pain, Anxiety, and Autonomic Arousal Guided Visual Imagery & Progressive Muscle IISelf-Monitoring Review|
|4||Sleep and Pain|
|Behavioral Pain Management: Cognitive Therapy and RelaxationSelf-Monitoring Review(Post Treatment Assessment: EMG, Self-Report)|
Due to the educational focus of this program, services are generally not covered by medical insurance. This is not a substitute for any necessary medical or psychological treatment.
Dental and Occlusal Appliances
The role of the jaw and related muscles has been shown to be important when evaluating chronic headache, particularly headaches of musculoskeletal origin. The Tufts Craniofacial Pain Center has been managing these and related disorders for more than 20 years, often with conservative approaches involving occlusal appliance therapies. Conditions commonly seen by the orofacial pain specialist include disc displacements with and without reduction, deviation in form, dislocation, subluxation, inflammatory conditions, ankylotic changes, and osteoarthritides. Muscle Disorders may involve the masticatory musculature as well as other skeletal muscles of the head and neck. Subgroup classifications include myofascial pain, myositis, myospasm, protective muscle splinting and muscle contracture. With proper selection, patients have been shown to achieve substantial benefit from their headaches with these approaches.
Management of Environmental and Physical Triggers
Environmental triggers that effect headache are variable, and can be critical in reducing a patient’s headache. Activities and posture, humidity, lighting, fumes and vapors, and diet have been implicated as triggers. While the role of diet and eating habits in muscle tension headache has been controversial, specific dietary trigger factors in migraine are commonly known. While many patients assume they are aware of the headache triggers, careful headache diary monitoring often results in the discovery of significant triggers. While changes in diet rarely eliminate chronic headaches, a careful analysis of triggers has been shown to reduce frequency, duration, and severity of migraine.
Interdisciplinary headache and pain facilities have had a long history of incorporating selective rehabilitation approaches into an effective treatment regimen. The role of particular exercises for the neck, head and face has been show to reduce headache, particular when myofascial problems are present. Disability associated with chronic headache often can be best managed by intensive rehabilitation approaches. More palliative rehabilitation interventions and manual therapies such as massage also may have success with headaches of myofascial origin.
The role of acupuncture in the management of pain problems in the United States has been increasing. The National Institute of Health has identified acupuncture as a potentially promising treatment modality in osteoarthritis, migraine, tension-type headache and regional myofascial pain. As many people are now aware, acupuncture is a system in which needles are inserted in specific points in the body in an attempt to positively affect an individual’s health. This system was first developed in China over two thousand years ago, and is still used to treat the ailments of millions of Chinese. Over time, traditional Chinese acupuncture evolved into a separate style of acupuncture in Japan. Selected patients are offered Traditional Chinese Acupuncture or Japanese-style acupuncture as an adjunctive treatment for their pain problems. A series of treatments is often required to achieve positive results. There is developing evidence that acupuncture may be effective at several levels for the relief of pain including muscle relaxation, and the stimulation of the body’s descending pain inhibitory system. Acupuncture is most appropriate for those patients who wish to limit their intake of medications for pain management.
Alternative Medicine Treatments
In an effort to minimize unnecessary medication approaches, complementary or alternative treatments are considered for some patients. As with any treatment, we believe that our interventions should have some basis in science. We have two primary clinicians have a clinical and research background in the evaluation of complementary treatments. Dr. Scrivani has had a research and clinical interest in the use of herbal and dietary supplement treatments with headache. Interventions such as magnesium therapy have been employed with some success. Similarly, Dr. Maloney provides specialty services in acupuncture for headache, as well as other related neck and facial pain disorders.
Referral for additional subspecialty consultation & treatment
While we endeavor to provide the most comprehensive services for our patients, we cannot address all diagnoses or cover all specialty services. As a result, we do refer patients where another subspecialist may be more familiar with their particular diagnosis. We maintain a close relationship with other medical centers, and cross referrals are common. Subspecialty referrals often occur in areas such as anesthesia, neurosurgery, endocrinology, and other disciplines. As part of our weekly Head and Neck Scientific Education Program, we’ve been fortunate to host internationally known speakers in other specialties form the Boston area. We maintain contacts with headache specialists in various parts of the world, as we see many patients from outside of New England.
While newly developed medications and treatments have result in a dramatic decrease in emergency room visits by headache suffers, we recognize that many patients visit hospital emergency departments on occasion. Overall, most patients agree that this often is an unpleasant experience. During regular hours, we make every attempt to rapidly offer services at the Headache Center, and have an established protocol for doing so. However, there are occasions when this cannot occur. In those cases, we may establish a written protocol for the patient and the hospital emergency department, thereby minimizing the patient’s suffering.
Patients often lament the lack of coordination between their healthcare providers, especially in the case of chronic medical conditions. With all of our patients, a primary clinician is assigned to each case. Except under special circumstances, patients are never “rotated” to doctors unfamiliar with their ongoing care. Additionally, we believe that cross communication with other healthcare providers is the mainstay of effective treatment for our patients. This is especially important where the patient requires a complex medication regimen or has other concurrent medical problems.
Research Protocols and Clinical Trials
All of the Headache Center staff maintain an academic affiliation, and most are engaged in active research programs. Recent studies include work in functional magnetic resonance imaging and pain, use of topical analgesic formulas, sleep disorder and pain, dental occlusal appliances with headache, tinnitus, and patient selection for chronic opioid therapy. We also maintain and active Fellowship program, with attending staff participating in academic training conferences throughout the world. At your discretion, you can enquire about ongoing clinical trials in areas relevant to your headache diagnosis. Additionally, attending staff are delighted to provide patients with recent publications in areas of their interest.