Physicians Collaborate to Treat Acute and Chronic Headache Disorders

Cleveland Clinic’s Department of Pain Management includes several specialists with expertise in headache and facial pain. They can assist the referring physician with diagnosis and formulation of a treatment plan. Cleveland Clinic collaborates to provide a multidisciplinary approach and treats a wide variety of painful conditions, such as refractory migraine, cluster headache, cervicogenic headache, trigeminal neuralgia, occipital neuralgia, medication overuse headache and post-dural puncture headache.

Collaborative Expertise: Neurology and Intervetional Pain Management

“We provide a number of percutaneous interventions to give patients long-term relief from headache pain they may have suffered with for years,” says Benjamin Abraham, MD, a member of the Department of Pain Management.

Those interventions can include:

• Specialized nerve blockade (diagnostic or therapeutic)
• Neurostimulator implantation
• Injection of botulinum toxin (Botox®)\
• Radiofrequency ablation (RFA)
• Epidural blood patch
• Transcutaneous electrical nerve stimulation for migraine prevention and treatment (TENS, Cefaly®)

Depending on the source and type of headache, the patient may benefit from blockade of the cervical medial branches, atlanto-axial (C1-2 nerves), sphenopalatine ganglion (SPG) or occipital nerves. These procedures can alleviate headaches for six months or more in many cases.

Some patients may be candidates for radiofrequency ablation (RFA) of the nerves causing the headache. Pain relief in response to diagnostic nerve blockade often predicts long-term success when RFA is used, or helps to identify good candidates for nerve stimulator placement.

Collaborative Care with a Team of Headache Experts

Dr. Abraham and his colleagues work closely with the neurologists in the Headache and Facial Pain Clinic. Stewart Tepper, MD is one of the nation’s most respected headache specialists. “There’s a lot of consultation and collaboration between the neurologists in our headache clinic and the Department of Pain Management,” he says. While Dr. Tepper and his colleagues provide evaluation, diagnostic and medical management services for headache patients, they often refer patients to Dr. Abraham for interventional procedures, or for diagnostic support in especially challenging cases.

One example: the continuous, unilateral headache can sometimes be a sign of cervicogenic headache, according to Dr. Tepper. “The best way to diagnose cervicogenic headache is to perform a blockade of the C1-2 nerves,” he says. “So I may refer a patient with unilateral headache for a diagnostic block of these nerves. If the headache is immediately stopped, but then returns when the local anesthetic wears off in a predictable, repeatable pattern, we can then confidently diagnose cervicogenic headache and manage it accordingly.”

Specialization Matters

This type of close cooperation between headache specialists and pain specialists is not possible at many institutions. “We’re fortunate to have the Headache and Facial Pain Clinic,” says Dr. Abraham. “Many hospitals don’t have a department solely dedicated to headache medicine, so oftentimes headache patients are seen by their family doctor or general neurologist alone. Having board-certified headache specialists can make a big difference for patients by allowing for more comprehensive and specialized care. Dr. Tepper and his colleagues see headache patients exclusively.”

Dr. Tepper likewise notes that many pain medicine physicians do not provide the headache interventions that the Department of Pain Management does, because of the technical expertise and advanced training required. “Beyond that,” he adds, “headache patients who are not candidates for medication changes, nerve blockade, neurostimulation, or other interventions, there is a smorgasbord of other options at Cleveland Clinic.” These options include:

• The IMATCH (Interdisciplinary Method for the Assessment and Treatment of Chronic Headache) Program, a three-week day-hospital program in which patients receive IV infusions and are seen by neurologists, psychologists, internists and physical therapists. “The aim is to wean patients off any overused headache medications and take care of the “whole person” by addressing comorbid psychiatric or medical issues along with the headache,” Dr. Tepper explains. “We offer one of the two existing day-hospital programs of its kind in the United States.”
• The Chronic Pain Rehabilitation Program, a two- or five-week day-hospital program that focuses on physical rehabilitation, detoxification from harmful medications, and mobilization. “There are very few intensive outpatient pain rehab programs like this in the country,” Dr. Tepper says.
• The Alcohol and Drug Recovery Center (ADRC) is offered for patients whose headaches may have a component of substance abuse or addiction.
• The Center for Neurological Restoration, which offers deep brain stimulation or other devices requiring neurosurgery expertise.

“We refer patients and solicit opinions across these various areas all the time,” says Dr. Tepper. “There is a lot of cross-fertilization.”

More Options Than Many Realize

This wide variety of available treatment options is something Dr. Abraham hopes physicians become more aware of. “Not all referring doctors are familiar with the many interventional approaches that can be effective for headache,” he says. “Patients with chronic headache can benefit from many options that might not be available in their local community.”