Integrating Integrative Medicine

Background

To create an integrative model of care for headache treatment at Scripps, several key collaborations have taken place over time (click here). Currently, patients are evaluated at the Donald J. Dalessio Headache Center, under the direction of neurologist Christy Jackson, with medical, interventional, and preventive approaches initiated after appropriate diagnosis and discussion. Subsequently, the patient is evaluated by me or another physician at the Scripps Center for Integrative Medicine, and appropriate in-house therapies such as acupuncture, biofeedback, dietary supplements, and yoga are prescribed. Services such as physical therapy are offered at another Scripps location. When non-Scripps services such as chiropractic and psycho-behavioral counseling are deemed medically appropriate, referrals are made to reputable practitioners in the community. The patient is followed by the neurologist and the integrative pain specialist at both centers (click here) on a regular basis to determine the benefit of therapies and the appropriate introduction or tapering of therapies.

The above model of care for headache treatment was developed for several reasons, including the high burden of disease with unmet needs, high utilization of CAM (often fragmented), as well as clinical and economic analysis of the efficacy of particular therapies within an integrative model.

Headache has been found to be one of the top 10 disabling medical conditions with migraine sufferers experiencing more pain and restrictions in their daily activities than people with other diseases, including osteoarthritis, diabetes and depression (1,2). Additionally, surveys of headache sufferers have often noted that they are satisfied or very satisfied with current care options less than 25 percent of the time (3). Co-morbidities and triggers (such as stress and muscle tension) are present in 75 percent or more of patients (click here) and are often not relieved with conventional care. Thus it is not surprising to see a summary of the situation as below:

“These patients have significant problems with headache management, disability, pain, worry, and dissatisfaction with care. .we observed across the sites a consistent need for improvement in headache management (4).”

Based on the current state of satisfaction, it is not surprising that headache sufferers look to CAM as “potentially beneficial for headache” as the most common reason (47.7 percent) for attempted use. This is true for at least 30–40 percent of headache suffers who go on to attempt a CAM modality with a similar percentage finding the therapies helpful. Unfortunately these therapies are often done in isolation from conventional care or even each other with 60 percent of CAM users not informing their medical doctors of CAM use (5).

Based on unmet need and the potential benefit of particular CAM therapies for difficult to treat aspect of headache (i.e. stress, muscle tension, obesity, and sleep disruption) particular therapies have undergone trials to examine their singular and synergistic effect in the setting of headache. Before utilization, therapies with evidence for efficacy in the setting of headache, typically migraine, were evaluated and selectively incorporated at the clinic in an attempt to decrease headache burden. Additionally, therapies (particularly mind-body therapies) that provide synergistic benefit when added to conventional care and appear to work best in an integrative environment were also incorporated (6). The therapies currently employed include an individualized incorporation of those noted in part one.

Next Steps

The United States Headache Consortium (an expert multidisciplinary panel) pointed out that nonpharmacologic (NP) and behavioral treatments might be particularly well suited for certain headache patients. Additionally, the goals for such therapy should be clearly defined by clinician and patient. Of note, the “enhanced personal control of migraine,” is a typically pertinent and empowering aspect of this type of treatment. The Consortium overview is provided in part one 6 (7). With these guidelines in mind, particular evidence-based therapies can be incorporated with point-of-care resources as noted in table 1 of this article.

Conclusion

Integrative medicine, as optimally defined and delivered, is a care model which is well-suited to provide a whole person approach to disease management. Headache is a chronic disease that requires an integrative approach for satisfactory care. When appropriately prescribed, an integrative treatment approach can be clinically successful in decreasing the severity and frequency of headaches while empowering the patient. The physician plays a key role in openly discussing and providing guidance in the appropriate incorporation of integrative options to optimize care.

References:

1. Stovner LJ, Hagen K, Jensen R, Katsarava Z, Lipton R, Scher AI et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 2007;27:193-210.
2. Dahlof CG, Solomon GD. The burden of migraine to the individual sufferer: A review. Eur J Neurol. 1998;5:525-533.
3. Lake AE. Psychological impact: the personal burden of migraine. Am J Man Care 1999; 5: S11
4. Harpole LH et al. Headache. Burden of illness and satisfaction with care among patients with headache seen in a primary care setting. 2005 Sep;45(8):1048-55.
5. Rossi P et al. Prevalence, pattern and predictors of use of (CAM) in migraine patients attending a headache clinic in Italy. cephalgia. 2005 Jul;25(7):493-506.
6. Lemstra M, et al. Effectiveness of multidisciplinary intervention in the treatment of migraine: a randomized clinical trial. Headache. 2002;42:845-854.
7. Campbell JK, Penzien DB, Wall EM. Evidence-based guidelines for migraine headache: behavioral and physical treatments. U.S. Headache Consortium 2000.