Outpatient Interventional Treatments for Migraines and Pain Flare-ups
Headaches/migraines and intractable ongoing pain flareups can be treated in any number of ways by healthcare practitioners. A patient can surely be sent to the ED to have their headache treated, but, we all know this is fraught with multiple frustrations and failures. And, most often, the patient surely doesn’t win. This article attempts to describe more aggressive and definitive treatments available in the outpatient pain and headache clinic setting. In a specialized setting, used by practices that offer intravenous therapy services, intractable pain, headaches and migraine flareups can be successfully treated. Of course, it does require nursing staff trained in IV therapy to start and monitor IV lines. Also, pulse oximetry monitoring can be very desirable in many cases as I will note for some of the medications. A comfortable room or rooms where patients can be treated—hopefully where lights can be dimmed—would also be ideal. Many of my IV rooms are multi-use so that the psychologists or the nurse practitioner may use them as well. We have a room that we use for cervical and lumbar traction and also an EEG room that can be used for IV treatments. These treatment rooms have easy chairs in them.
Our clinic compiled its track record in treating headache and pain patients with refractory problems utilizing IV medication therapy. We presented this data in 1998 at an international pain conference.1 Our initial experience was that in excess of 97% of our treated clinic patients fared exceedingly well as far as their headache and pain symptoms were concerned. Extremely few had to be retreated after they saw us in the clinic (30 out of 1000 patients treated). This suggested that we were not only clinically efficient but, on a cost basis, aggressive clinic treatment of headache was less expensive than treatment in the ED, as well. There are multiple lines of data to suggest that having headaches is an enormous economic burden to the person, their employer, and society.2-17
A recently published study quantified the direct and total costs of migraines in adults, and in children. This was also done with respect to the presence or absence of comorbidities such as depression and anxiety.3 Adults and children with migraines had increased costs of treatment between 2.4 and 3 times that of cohorts without migraines. Children with migraines and anxiety/depression comorbidities had up to 8.4 times the annual costs for treatment. Another recent study looked at total health care costs in families with migraineurs (pharmacy and medical claims data as well as work absenteeism and short- and long-term disability).4 Total healthcare costs were 70% higher in families with migraine sufferers; even more cost was associated with a child that had migraine compared to an adult. However, when both a parent and a child were affected with migraines, the total costs were $2,500 higher each year and both direct and indirect costs were elevated.
Studies have shown that early treatment with migraine-specific agents like sumatriptan is more effective than if the migraine pain is moderate to severe when treated. In one study, a model designed to assess the costs and outcomes per treated migraine attack,8 early treatment with sumatriptan when migraine pain was mild resulted in substantially decreased total costs per treated attack—with decreased time with headache pain, and an increased proportion of migraineurs pain free at four hours without recurrence. Fewer physician and emergency department visits were noted as well.
A number of US-based studies7,9-11,16,17 speak eloquently to the immense national burden of migraines and other headaches on the worker, the employer and society in general. Studies and surveys performed in other countries (Canada, France, Brazil and multinationally2,5,6,12-15) closely replicate the findings from US-based studies regarding the widespread prevalence of migraines and the need for successful treatment strategies to decrease workplace absenteeism and disability.
Similar data also exist abundantly for the cost burden of pain disorders in the workforce.18-25 A recent study sampled health care costs (direct and indirect) for employees with painful conditions and compared them to a random sample of employees. The costs among the former group were 1.5-3.5 times higher annually ($7,088-16,874 compared to $4,849).18 An interesting older incidence study looked at nationwide data for various job categories regarding total cost for medical care, lost productivity and pain and suffering.19 At the top of the list for average cost (cost per worker) were: taxicabs, bituminous coal and lignite mining, logging, crushed stone, oil field services, water transportation services, sand and gravel, and trucking. Industries high on the total-cost list were trucking, eating and drinking places, hospitals, grocery stores, nursing homes, motor vehicles, and department stores.
Musculoskeletal disorders, particularly those with a component of chronic pain, impose a significant direct cost burden on health care systems and have even greater indirect losses of productivity. Occupational back pain is the most common and costly musculoskeletal disorder in the workplace.20 Characteristics associated with prolonged disability among cases of work-related back pain include: employment in high-risk jobs that demand heavy lifting, failure to take advantage of job accommodations and granting of disability benefit payments.
Occupational low back pain is widespread in our society. One study attempted to create a model to calculate the net costs to an employer to put in place ergonomic interventions for employees.21 The study showed that putting in interventions could result in lower costs through better productivity. It was felt the employer should play a more active role to prevent back pain. Another study researched total outpatient costs of four common treatments for low-back pain (LBP) at 18-months follow-up. 681 patients were assigned to 1 of 4 treatment groups—medical care only (MD), medical care with physical therapy (MDPt), chiropractic care only (DC), or chiropractic care with physical modalities (DCPm). DC was found to be 52% more expensive than MD (p22
Arthritic disorders are quite prevalent in the US (16% of the population) and are associated with significant poor quality-of-life issues, particularly in terms of bodily pain and physical functioning, where quality of life is lower than that for gastrointestinal conditions, chronic respiratory diseases, and cardiovascular conditions.23 A study of arthritic disorders in three countries, including the US, documents that these disease states account for up to 1-2.5% of the gross national product of western nations. This burden comprises both the direct costs of treatment and interventions and also indirect costs, such as premature mortality and chronic and short-term disability.