Integrated headache care

Abstract

Patients with chronic or difficult to treat headaches are generally under the care of general practictioners or neurologists in private practice. Some are referred to a headache specialist for evaluation and advice. Treatment is often provided by the referring physician. An alternative is a multidisciplinary headache centre, where care is provided by different disciplines (neurology, behavioural psychology, psychiatry, psychosomatic medicine, physical therapy, sport therapy) across sectors of the healthcare system involving out- and inpatient care and treatment. This is called integrated headache care. This review summarizes experiences in integrated headache care settings in Europe and the USA, describes these settings, and reports outcome data.

Introduction

Headaches are common and often difficult to treat. This is particularly true for patients who are classified with chronic migraine or tension-type headache according to ICHD-2 criteria (1, 2) and patients with medication overuse (3, 4). Clinicians specializing in the general area of pain have long recognized that the treatment of chronic pain requires the coordinated action of several disciplines, including pain physicians, behavioural psychologists, psychiatrists, physical therapists, and social workers. All pain centres at academic and large, non-academic hospitals work according to this principle. There are only a few examples of integrated headache care and almost no prospective studies have investigated outcomes and cost effectiveness of integrated care (5–8). The lead author of this review invited headache physicians from three other academic headache centres that employ integrated headache care to report their organizational structure and outcome data.

Essen Headache Centre

In 2005 the headache centre at the Department of Neurology, University Hospital Essen was approached by an insurance company complaining of poor quality of care and high costs for patients with severe, frequent, or chronic headache. Interviews with these patients identified many problems, such as excessive diagnostic testing (repeated imaging), referral to a high number of different medical specialities creating conflicting diagnoses, frequent visits to emergency departments, and frequent hospital admissions. At the same time, the German government had created a new reimbursement system for ‘integrated care’ for chronic diseases. The formal requirements were a multidisciplinary approach and care across the sectors of the healthcare system (integrating specialist clinics at large hospitals and physicians in private practice). We therefore decided to set up a new integrated headache care system in our catchment area. The headache centre increased its staff with neurologists, behavioural psychologists, physical and sports therapists, headache nurses, and consultants from psychosomatic medicine, psychiatry, and dentistry. Neurologists in Germany have a mandatory 1-year period of psychiatric training as part of their residency. Therefore, in the headache centre, diagnosis and treatment of comorbid depression or anxiety disorders can be provided by neurologists. At the same time a network of 60 neurologists in private practice was founded. These neurologists would refer patients and treat them after getting feedback from the headache centre. As part of an ongoing quality control programme these neurologists provide follow-up data after 3 and 12 months to the headache centre. After 1 year many other insurance companies joined the programme and at present about half of the insurance companies in Germany support the programme.

Germany has another unique feature. It is possible to access the databases of insurance companies. In this way patients with chronic headache, medication overuse, or risk factors for chronification (frequent headache, frequent medication use, low income, other chronic pain, psychiatric comorbidity) can be identified (9–11). If such a patient is identified, she or he is approached by a case manager from the insurance company and invited to be seen at the headache centre. No referral or co-payment is required. By this strategy we hope to identify patients at risk for transition from episodic to chronic headache and to prevent chronification.

Diagnosis and treatment at the headache centre are performed in modules. In module 1, patients with uncomplicated infrequent headaches are seen by an experienced headache specialist and referred to a neurologist in the network with advice for treatment of headache episodes and medical and non-medical preventive therapy. In module 2, patients with frequent or chronic headaches and relevant comorbidity are seen by a neurologist, a behavioural psychologist, and physical and sport therapists. In these cases, a more sophisticated treatment plan is elaborated and the neurologist in private practice is asked to implement these proposals. For patients with long-lasting headache and in particular medication overuse, a 36 hour day-care programme is offered including teaching, group and individual psychological care, implementation of relaxation therapy and stress management, and daily exercise. In patients with medication overuse, withdrawal is performed during these 5 days. In selected but rare cases, patients are referred as inpatient. These are patients with overuse of opioids or tranquillizers or severe comorbidity. Reimbursement is higher for the headache centre and the participating neurologists in private practice (about 100% higher). There are no restrictions in prescribing medication or physical therapy.

Diagnosis and follow-up is based on headache diaries and validated questionnaires for burden of disease and quality of life (MIDAS, SF-12) and a structured standardized questionnaire done by telephone or the neurologists of the network, if the patients were followed up there. An additional independent follow-up of patients was performed by insurance companies regarding patient’s satisfaction with treatment.

Outcome

One of the participating insurance companies contacted patients 3 and 12 months after their visit at the headache centre (n = 672): 57% of the patients reported improved headache, 3% deterioration, and 43% unchanged headache. Our own follow-up performed independently from the headache centre by our call centre for clinical trials in 2256 patients followed prospectively for 12 months showed an improvement of headache >50% in 41.5% of the patients, improvement <50% by 29.5%, no change in 15.3%, and deterioration in 13.7%. We also investigated adherence to the recommended therapy prospectively in 362 patients followed for 12 months. Adherence to exercise and sport was reported by 72% of the patients and to relaxation therapy by 61%. Adherence to drug therapy revealed that 7% of the patients never started the recommended prophylaxis, 64% terminated prophylaxis or changed the recommended drug due to side effects. and only 29% continued intake

An independent auditing company analysed the cost effectiveness of the integrated headache care. For this purpose 945 patients were identified in whom the only diagnosis was migraine or tension-type headache. The mean age was 43 years and 80% were female. The control group comprised 68,824 patients with the same diagnosis not participating in integrated care. Annual total costs for health care were calculated (physician, drugs, visits to emergency rooms, hospital admission, admission to rehab centres, and compensation for sick leave). Total annual costs per patient treated in integrated headache care were €2750, €3275, and €3720 for the years 2005, 2006, and 2007, respectively. The total annual costs for patients not participating in integrated headache care were €4437, €4853, and €4473 for the same years. The cost reduction favour of organized care was on average 30%. Cost savings resulted mostly from reduced visits to emergency departments and hospital admissions. As could be expected, costs for drugs were higher in patients in integrated care.

These numbers clearly indicate that integrated headache care is successful and cost effective. Patient satisfaction is high and the improvement of headache significant. Healthcare providers are paid better (including neurologists in private practice) and insurance companies can save up to 30% in annual costs.

Danish Headache Centre

Organization

Following a very long tradition of headache research lead by Professor Jes Olesen in Copenhagen, the Danish Headache Centre (DHC) was inaugurated in 2001 as a tertiary outpatient referral headache centre, organized within the Department of Neurology, Glostrup Hospital (5,12). The main uptake area was Copenhagen County with a population of 600,000. In addition, DHC also functions as the only national referral centre for severely affected headache patients in Denmark (in total 5.5 million inhabitants).

The capacity was initially 700 new patients per year, but due to excessive demand the intake was increased to 1000 patients per year during the following years. In close cooperation with the Clinical Department of Neurology, an inpatient facility with six beds is now available for severely affected patients with medication overuse or in need of specific and planned observation. Acute general neurological service in the emergency room is available, but DHC offers no specific service for patients with acute headache attacks.

The staff in the headache centre consists of six part-time senior headache specialists supplemented by junior doctors on rotation, three physical therapists, three psychologists, three nurses and five secretaries, hereof most part-time associated. Patients must be referred from general practice, practising neurologists, or other neurological departments. A smaller but similar multidisciplinary headache centre for children and adolescents below the age of 18 has also been established at Glostrup Hospital. This centre is directed by paediatricians with specific interest in headache and there is a close collaboration with the neurologists from DHC. All levels of medical consultation are publicly financed in Denmark and free of costs to the patients, whereas medication is only partially reimbursed.

Diagnosis

Before their first visit, all patients receive a diagnostic headache diary (13) and are told to record headache characteristics, including type and amount of medication used, prospectively for at least a 4-week period. They also fill in a standardized questionnaire regarding status of health, impact on work, family, and social life, and prior headache treatment.

A detailed headache history is obtained by means of a standardized procedure at the initial consultation by neurologists or by junior doctors supervised by the neurologists. The history is supplemented by the diagnostic headache diary and the general medical questionnaire. After a complete general physical and neurological examination, all first visit patients are classified according to ICHD-II (14).

A detailed treatment strategy is then planned with the patients, based on optimized medical treatment, self-responsibility, education, and repeated visits in the clinic. Depending on need, patients are referred to physical therapist, psychologist, and/or nurses. During the treatment period, most patients are seen by the neurologist at control visits lasting 20 minutes every 2–4 months and they are encouraged to use a headache calendar recording attack frequency, severity, and medication use during their entire treatment period. When the headache condition is stable and acceptable, patients are referred back to their general practioner with detailed information about further treatment strategy and plan in case of relapse.

Physical therapy

Patients suffering from tension-type headache or combined headaches with significant pericranial muscle tenderness are referred to the physical therapists. The sessions are individual. They consist of a detailed examination of posture and muscular function. Patients are instructed in active exercises and detailed information about identification and avoidance of possible muscular stress factors. Patients are also encouraged to a daily, individualized exercise programme. Passive treatment strategies such as massage or ultrasound are avoided.

Psychological therapy

Patients with stress, anxiety, or suspected psychological trigger factors are referred to the psychologists. They primarily use group sessions (eight patients) and focus on stress management (cognitive and behavioural techniques) and bio-feedback relaxation. All referred patients are interviewed by the psychologists and thereafter included in the appropriate group therapy programme. Only a minority of patients is offered individual psychological guidance or therapy in the centre.

Headache nurses

Patients who fulfil the diagnostic criteria for medication overuse headache are referred to our specialized nurses for treatment which consist of: (a) individual detoxification after detailed information; (b) an outpatient teaching programme (The Headache School) where groups of five or six patients are guided through their detoxification period; or (c) an inpatient programme for 2 weeks (5,12,15,16). The nurse’s main responsibility is as coordinator of the multidisciplinary treatment of medication overuse headache and as a medical co-advisor for headache treatment in general. In medication overuse headache patients, all acute headache medication is discontinued abruptly and patients are kept medication free for 2 months with frequent support from the nurses (15,16).

Other medical specialities

Structured relations to other departments in the hospital are formalized and cooperation with the department of neurosurgery regarding trigeminal neuralgia, idiopathic intracranial hypertension, hydrocephalic conditions, and similar problems is established. Likewise, an efficient collaboration with the department of gynaecology has been developed due to the problems related to menstrual migraine, hormonal treatment, and pregnancy. An experienced anesthesiologist performs the blood patch treatment for the patients with low-pressure headache. If comorbid psychiatric disorder is suspected, a referral to a specific psychiatrist with interest in headache and pain is initiated. A dentist with specific orthodontic experience has also been allocated once a month for a specialized evaluation of selected patients.

Results

During a 2-year period, a total of 1907 new patients was referred and a complete dataset of 1326 treated and discharged patients was analysed (12). All treated patients who had finalized their treatment during this 2-year period were included in the present results. The mean age was 43.7 years ranging from 13 to 92 years and the male/female distribution was 3/7 with 406 males and 920 females. The mean duration of headache was 10.6 years with a wide range from 0 to 76 years. Their mean treatment period was 477 days (median 10 months), 43 (3.2%) patients were only seen once, and 20% were finalized due to administrative reasons such as loss of contact or absence from scheduled appointments. At admission, 55% had chronic headaches 15 days or more per month. The vast majority of patients (63%) suffered from primary headaches (migraines 63%, frequent episodic or chronic tension-type headache 54%, cluster headaches 9%, and combinations hereof). Among the secondary headaches, medication overuse headache was most frequently identified, in 25.5% of all patients (12).

In the total population, the frequency of headache was reduced from 20 days/month on admission to 11 days/month at the end of treatment, with a major variation between diagnoses − migraine having the most prominent reduction, from 7.5 to 2.9 days/month. Among the 49 patients with cluster headache, 31 (63%) became completely headache free, and among the remaining 18 patients, both attack intensity and duration decreased significantly (p < 0.001). Severity and duration of other headaches were also reduced significantly in all groups (12).

Sickness absence from work decreased significantly from 5 days per month initially to 2 days per month after treatment, with a significant reduction in all major headache groups. When a positive outcome was defined as a 50% or more reduction of frequency, the univariate analysis identified female gender, medication overuse, overuse of triptans, and a familial disposition as positive predictive factors. In contrast, a diagnosis of tension-type headache and overuse of simple analgesics predicted a poor outcome.

Conclusion

The DHC experience documents a positive outcome in severely affected, so-called refractory headache patients after a multidisciplinary approach in a tertiary headache centre. Further evaluation of specific treatment strategies and outcome predictors are important for future planning and optimization.

Kiel Headache Centre and German Headache Treatment Network

Development

A first specialized headache centre was established at the Department of Neurology at Kiel University Hospital in 1985 by Prof Dieter Soyka, founding president of the International Headache Society and the German Migraine Society.

The healthcare system, based on separated sectors and universal contracts, contributed to the lingering progression (‘chronification’) and persistence of headache disorders. Due to lack of efficiency, many patients with chronic headache searched for help outside of the professional system. Thus over many years, further progression of headache disorders took place and severe organic and psychiatric complications resulted in more expensive medical treatment requirements.

The German healthcare policies in the 1990s did not allow for an extension of healthcare structures, as funds were already stretched. An exception was made only for particularly innovative treatment concepts. The legal basis for such pilot projects was made in 1995 to subsequently evaluate them for clinical efficacy and cost-saving potential in comparison with conventional care.

Concept

Against this backdrop, the scientific concept of the Kiel Headache and Pain Centre for Neurological and Behavioral Medicine was developed and implemented in 1997. A pilot project was set up for the treatment of patients with headache across sectors and disciplines in the German state of Schleswig-Holstein. The academic staff includes neurologists, psychiatrists, anaesthesiologists, and psychologists trained in special pain therapy. Additional groups include physical therapists, sport therapists, social workers, and specially trained headache nurses. In addition, all conservative and surgical specialties could be consulted at any time from adjacent hospitals. The Kiel Headache Centre provides a multidisciplinary treatment for children, adolescents, and adults. A coordinated pre- and long-term follow-up is provided with the help of practice-based doctors that are part of the treatment network. The centre collaborates with patient support groups, health insurers, and healthcare politicians to further develop treatment structures and processes. Pre- and postgraduate medical healthcare professionals are educated and trained. Online educational facilities for patients, the public, and healthcare professionals are developed and maintained in parallel. Active research includes the initiation and implementation of collaborative national and international research projects and the continued development of coordinated treatment structures. Approximately 80 employees handle 8000 outpatient and 1500 full inpatient attendances per year.

Patients treated include those with refractory headache, as chronic migraine, chronic tension-type headache, severe cluster headaches and other trigeminal autonomic cephalgias, severe secondary headaches, severe medication overuse headache, trigeminal and other cranial neuralgias, headaches with severe physical and/or psychological comorbidities, specific diagnostic problems, and specific treatment complications. Severe and complex comorbidities such as medication intolerances and psychiatric and social complications as well as organ damage are seen. It is particularly these patients who require special coordinated headache care in a cooperation of regional and supra-regional specialized care providers within a coordinated network throughout an entire patient career.

The scientific evaluation of this prototype showed a sustainable clinical improvement of the treated patients and a parallel significant cost reduction compared to conventional care. The results led to the creation of new national legal foundations for the creation of so-called ‘integrated care’. The integrated care of headache disorders, which so far only covered one state, was expanded to the entire Federal Republic of Germany. To do so, contracts were signed with the largest German statutory health insurance companies to develop a nationwide integrated treatment network. A national network of pain therapists seeing outpatients and/or inpatients in practices and hospitals collaborates across all health system sectors. Outpatient, rehabilitative, and full inpatient therapies are adapted and temporally coordinated. The concept encompasses a supra-regional coordinated treatment from regional centres, outpatient pain clinics and hospitals without any limits on types of disciplines and bureaucratic reimbursement structures. The integrated care comprises three phases:

Phase I: Specialized diagnosis, professional screening, selection and realization of treatment paths across sectors, local treatment;

Phase II: Supra-regional neurological behavioural-medicine treatment across sectors;

Phase III: Outpatient follow-up and evaluation, local monitoring of therapy success across sectors, taking place locally.

For the realization, a nationwide network of practices experienced in headache treatment was created. The aim was the establishment of a comprehensive treatment network for all headache forms. More than 450 regional pain therapists as well as inpatient pain specialists collaborate in this way. Treatment quality is permanently improved through continuous scientific evaluation. The lasting cost-effectiveness is confirmed through analysis of direct and indirect costs. Two years after starting, all large statutory health insurance companies in Germany have joined the treatment project. Patients are actively involved via patient support groups. The Kiel Headache Centre serves patients nationwide, who cannot be adequately treated regionally after exhausting available resources in specialized practices and day hospitals. The concept is used extensively and has transformed healthcare provision for headaches nationwide. The referral criteria and provision of pre- and long-term follow-up, as well as reimbursement by the health insurance companies, are contractually agreed.

Outcome

According to legal guidelines, the scientific evaluation and auditing is done by the health insurance companies, independently from the treating doctors (17,18). The evaluation documented the individual treatment paths and analysed the effects of the integrated approach on service utilization, costs, and work and social situation as well as on pain and quality of life. Data items were acquisitioned from individual patient careers over 5 years prospectively. It was based on patient-related, anonymized service data of the health insurance companies across all sectors (hospital acute inpatient and rehabilitative 500,000 data, outpatient consultations 5 million data, drugs 6 million data, benefits in kind and care allowances 800,000 data) as well as individual contributions and patient social background (700,000 data). The service utilization across all sectors was analysed over time and the resulting costs calculated. As controls, patients treated conventionally with identical diagnosis, age, and gender were identified. The integrated care could significantly lower the costs in all healthcare sectors: 21.5% for inpatient services, 31.5% for outpatient services, and 50.6% for rehabilitative services. In the control group, outpatient costs fell by only 6.4%, while inpatient and rehabilitative costs rose by 19.9% and 34.6%, respectively. Therefore, the conventional treatment leads to a significant cost increase, while the integrated care across sectors can achieve a significant cost saving.

Due to the income-dependent health insurance contributions in Germany, it was possible to analyse the development of income of patients with chronic pain disorders and compare this in different groups. Patients with severe headaches are disabled at work and achieve a significantly lower average income. Integrated care, by improving the headaches, allowed a continuous income improvement of 17.9%. Patients were able to resume work, become promoted, and increase their income. The control group’s income fell by 8.1% in the same period. Severe chronic headaches without specific treatment lead to a relative income reduction. The result is a lower standard of living for the individual and less social and tax contributions for society. Integrated headache care can stop and reverse this trend.

Clinical improvement was monitored, amongst others, via SF-36. Before treatment commenced, patients showed a reduction in all domains of quality of life. Despite this marked reduction, integrated care could largely normalize their quality of life in comparison to the rest of the population. This normalization was lasting and could still be observed 2 years after treatment completion. Patient satisfaction with integrated care is very high. More than 85.4% are entirely satisfied; a further 13.9% are largely satisfied. 82.4% of patients would recommend integrated care entirely, a further 13.6% largely.

Modern integrated care contracts are characterized by acceptance of a guarantee for defined treatment success. This is based on the attestable treatment quality and its scientific evaluation. On the basis of this, risk sharing for treatment success can be contractually agreed to act as a motivator for patients, insurers, and care providers. In the nationwide headache treatment network, this is implemented in the form of a merit-rating system which is operationalized via the patient’s capacity to work. The health insurance providers continuously monitor and log days of absence from work, because they need to compensate the employer for these. In the case of lack of efficacy, a malus payment is returned to the insurance company. In case of prolonged capacity to work, the health insurance company pays a bonus premium to the healthcare providers. The evaluation so far shows that risk-sharing is a win−win situation for all participants: in 81.6% of cases, a bonus was paid, a malus only in 18.4%. Treatment success means that long periods of inability to work are replaced by lasting capacity to work. This confirms clinical efficacy for patients and reduces costs for employers and insurers.

The Jefferson Headache Center

Headache is a neglected field in the USA. Very few academic headache centres exist and those that do exist have financial difficulties. Medical schools lack staff with expertise in headache disorders, as opposed to staff with expertise in other neurological disorders. Limited federal (i.e., NIH) funding is available for headache research and no endowed chairs exist. Who will train medical students, residents, and primary care physicians if there are no academic champions? Most medical schools offer students at most a few hours of lectures about headache disorders and little time is dedicated to headache education during residency training.

Structure

The Jefferson Headache Center is a unique medical facility that specializes in treating patients with all types of head pain; provides primary, secondary, and tertiary headache care; and offers headache sufferers the services of a team of neurologists, psychologists, psychiatrists, dentists, and nurses who are sensitive to their individual problems and needs. The Jefferson Headache Center began as the Comprehensive Headache Center at the Germantown Hospital in 1982. The original core personnel, consisting of two neurologists, a psychiatrist, and a nurse, visited established headache centres and then, based on their observations, experience, and research, created their own unique approach to headache management. Each discipline was given the freedom and responsibility to set their own best practice standards, and then, as a team, they assimilated these practices into a comprehensive, multidisciplinary programme. To gain the support and enrichment of a university medical centre setting, the centre moved to Thomas Jefferson University in 1997. The move enabled the centre to continue providing the same skilled headache care and add an effective outreach programme.

The centre’s staff interact with and visit other leading headache centres around the world and has frequent communication with other prominent national and international headache experts. The centre has developed the philosophy that headache patients are best served with a seamlessly integrated system that utilizes the most efficient methods to provide the most appropriate level of care. The centre continually analyses its priorities, programmes, and services in order to provide the highest quality care and obtain the best outcomes in the most cost-efficient manner. In addition to clinical expertise, the centre has a large clinical research department, a basic research division, and fellowship and preceptorship programmes. The centre has developed a customized electronic medical record system that aids the clinical, administrative, and research office practices. The centre evaluates approximately 1000 new patients and performs approximately 11,000 follow-up office visits annually. The outpatient infusion unit handles approximately 850 visits a year and the inpatient unit has approximately 450 admissions annually.

Clinical patient management is essential to the development and implementation of the centre’s comprehensive programme. This includes outpatient and inpatient care. We are one of only a few headache centres in the country with an inpatient programme for our most complicated patients.

The professional staff comprises four full-time neurologists, two full-time nurse practitioners, and four full-time-equivalent registered nurses. The research division comprises clinical researchers and basic researchers. The centre has three clinical fellows during a given year. Also on staff are a part-time dentist with facial pain expertise, as well as a psychiatrist and two psychologists. The centre utilizes Centricity Physician Office EMR (Centricity; formerly Logician), to maintain its patient medical records. The centre’s electronic medical record system captures longitudinal clinical information directly from the clinical visit using customized encounter forms.

Most patients with severe headache disorders can be managed as outpatients. The centre has a well-developed outpatient programme that allows for convenience of care as well as reduced costs compared with inpatient hospitalizations. Other outpatient measures for this population include non-pharmacological interventions, such as relaxation techniques, biofeedback, and supportive counselling. The centre also provides extensive telephone support, which enables us to provide continued outpatient management. Infusion therapy (intravenous medication treatment) is an extension of our outpatient management programme. It is used for patients who have daily or frequently recurring headaches that cannot be effectively managed in a typical outpatient setting or whose disability precludes control in the office setting.

Some patients require hospitalization. All medications that could complicate treatment are adjusted or discontinued. Opioids, analgesics, and barbiturate-containing medications are discontinued. Clonidine and/or methadone are used for narcotic withdrawal management. Phenobarbital is used to prevent seizures and other withdrawal symptoms. Intravenous fluids are given to enhance detoxification and treat dehydration. Patients are started on an aggressive parenteral treatment regimen administered at least three times a day. This is used to control the headaches and/or exacerbations induced by withdrawing the overused drugs. Preventive medications are adjusted or started.

The centre’s basic and clinical research programmes serve multiple purposes, from elucidating the basic pathophysiology of headache to discovering advanced treatment options for headache sufferers.

The centre’s education initiatives play an important role: educating patients through doctor or nurse interactions and handouts and books that it has published; educating medical students, residents, fellows, graduate students; and educating colleagues and other providers (obstetricians and gynaecologists, primary care physicians) through lectures, peer-to-peer interaction, clinical rotations, preceptorships, articles, and books. Continuing education for staff is an essential component of this initiative, ensuring that professionals stay abreast of the latest emerging information on headache pathophysiology, diagnostics, and therapeutics.

The Jefferson Headache Center is one of the premier educational centres for training physicians in headache management.

Medical student education. Students at Jefferson Medical College have their first exposure to headache diagnosis and management during their second year, at which time a lecture on headache is presented by a Jefferson Headache Center attending physician. We also offer first- and second-year medical students a competitive summer preceptorship.

Residency programme. Neurology residents at Jefferson gain experience in headache through two months that they spend on the outpatient and inpatient headache units.

Fellowship programme. The centre runs one of the oldest headache fellowship programmes in the country. Two to three clinical fellows and one or two research fellows per year receive further education in the burgeoning field of headache. We are one of the United Council of Neurologic Specialties (UCNS) approved Headache Medicine Fellowship programme providers.

Preceptorship programme. The centre provides a preceptorship programme to primary care physicians and other professionals involved in providing care to headache sufferers.

Outcomes

Our electronic medical record system has allowed us to do case series and outcomes studies on patients with new daily persistent headache, hemicrania continua, and chronic migraine.

In the past we performed follow-up evaluations on 50 hospitalized patients with medication overuse headache who had became headache-free. Once detoxified, treated, and discharged, most patients did not resume daily analgesic or ergotamine use. Seventy-two percent continued to show significant improvement at 3 months, and 87% continued to show significant improvement after 2 years. This would suggest at least a 70% improvement at 2 years in the initial group (35/50), allowing for patients lost to follow-up. We also created an online Web-based registry to look at the outcome of patients treated in clinical practice with botulinum toxin (19).

Conclusion

The European model of integrated headache care, with cooperation between the government, the insurance companies and the headache centres, has led to improved outcomes and decreased costs. The cost reductions result from decreased diagnostic testing and fewer emergency department visits and inpatient admissions. As expected, drug costs are higher. Crucial to this system is increased reimbursement to the practising physicians and costs coverage for the headache centres.

In contrast, headache care in the USA is fragmented. There are different budgets for drugs, diagnostic testing, emergency department visits, and hospital admissions. Increased neuroimaging has led to preauthorization demands by the insurance companies, which increases unreimbursed physician costs.

The major problem in the USA is that, unlike in Germany and Denmark, there is no increased compensation for difficult patients and no funding for a community of care. Some private centres refuse to take insurance; others (including ours) have long waiting lists and are unable to hire additional staff because of lack of profit to the parent institution. Headache sections and centres are rare in academic neurology in the USA.

The Europeans are ahead of the Americans, who need to catch up. Comprehensive coordinated headache care improves outcomes and reduces healthcare costs. We need more centres of similar design in the world.