Co-Evaluation and
Interdisciplinary Management
of Headache
Kathryn Giblin, MD
Neurology, Interventional Pain
Boston Headache Institute,Boston PainCare Center
Jordan Backstrom, M.Div, Psy.D
Clinical Psychology
Boston Headache Institute, Boston PainCare Center
Tufts School of Dental Medicine
•  Neitherpresenterhasanyrelevant
disclosures
•  Par5cipantswillbeabletodescribethe
principlesandmethodologyofbiopsychosocial
assessmentofheadachepa5ents.
•  Par5cipantswillbeabletonameatleast3
tangiblebenefitsofheadacheco-assessment.
•  Par5cipantswillbeabletorecommend
appropriateinterven5onsforpersistent
headache.
•  OverviewoftheBiopsychosocialModel
•  Dis5nc5onbetweenMul5-Disciplinary
andInterdisciplinaryCare
•  OverviewofInterdisciplinaryHeadache
Assessment
–  Neurological/BiomedicalFactors
–  PsychosocialFactors
•  CaseExamples
•  GenerallyaMributedtoGeorgeEngel
–  RoyGrinkeractuallypredatedEngel’swork
•  Ini5allyaresponsetothebiomedicalvs.
psychologicalargumentinpsychiatry
•  Cri5cizedboththereduc&onistandexclusionist
conceptualiza5onsofdisease
•  Suggestedthatbiochemicalabnormali5esare
necessarybutnotsufficientfortheoccurrenceof
thehumanexperienceofdisease
(Ghaemi,2009;Engel,1977)
•  “Disease”–Referstoanobjec5vebodilyevent
thatinvolvesdisrup5onofspecificbodystructures
ororgansystemscausedbypathological,
anatomical,orphysiologicalchanges
•  “Illness”–Referstoasubjec5veexperienceor
self-aMribu5onthatadiseaseispresent,resul5ng
inphysicaldiscomfort,emo5onaldistress,
behaviorallimita5ons,andpsychosocialdisrup5on
•  Collabora5vecareimprovesoutcomesincondi5ons
thatrequiresselfmanagement,mostespecially
chronicpainandchronicheadache
•  Collabora5vecareispar5cularlyeffec5vewhen
condi5onsareaccompaniedbycomorbid
psychopathology
Kroenke,2014;McGregorM,etal.JAmbulCareManage.
2011;34:152-162.
•  Termsareoienincorrectlyused
interchangeably
•  “Mul5disciplinary”simplymeans
numerousdisciplines
•  “Interdisciplinary”meansthatthey’re
actuallyworkingtogether
(GatchelRJ,etal.AmPsychol.2014;69:119-130)
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ProviderLoca5on
Finances,lackofreimbursement
ScheduleCoordina5on
Pa5entResistance
ClinicianAnxiety
Personality
•  Innova5veModelwheremul5pleproviders
assesspa5entsimultaneously
•  Effec5velyaddressesbarriers:
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ProviderLoca5on
ScheduleCoordina5on
Pa5entResistance
ClinicianAnxiety
•  Evalua5onofheadacheinaddi5ontogeneralhistory
–  NeurologicandMedical“RedFlags”
–  1ormoreheadachetypes
•  Physicalexamina5onandmedicalrecordreview
•  PsychosocialEvalua5on(includinghowpainis
impac5ngrela5onshipsandfamily,signsof
depression,anxiety,suicidalthoughts)
•  PMPReview
•  ScreeningTools
–  PHQ-9,GAD-7,MIDAS,Headache
Diary,ISI
•  UrineToxicologywhen
appropriate
•  RiskAssessment
•  IndividualizedwriMentreatmentplan
includingfunc5onalgoals.
–  Specific,Measurable,Achievable,Realis5c,and
Time-boundGoals
•  Consulta5onwithaddi5onalspecialistswhen
indicated(e.g.,sleepspecialist,physical
therapy,dental,psychiatry,optho)
•  Whyisitsoimportantforheadachepa5ents
specifically?
–  Headacheisanongoingillnessandnotsimplya
disease.
•  Forexample…
•  AMackfrequency
•  Stressfullifeeventsandpsychiatric
comorbidity
•  Effectsofchildhoodmaltreatment;physical,
sexual,emo5onalabuse
•  Medica5onandcaffeineoveruse
•  Obesity
•  Snoringandsleepapnea
Smitherman,Maizels,&Penzien,2008
•  Assessmentofcogni5vefactors
•  Pa5entinterestinmedicaltreatment
-beliefs/artudesaboutillness/treatment
•  Monitoringandmanagingtriggers
•  TreatmentAdherence
–  50%-70%ofpa5entsfailtoop5mallyusemedica5ons
•  Poten5alroleforadjunc5vebehavioral
treatment(e.g.,biofeedback,relaxa5on,CBT)
–  TensionType&Migraine
(Nicholson,2010)
•  Presenceofpsychiatricco-morbidity
•  Difficul5escopingwithheadache
•  SleepProblems
•  ManagingStressandReducingArousal
•  Medica5onOveruse/Misuse
•  HistoryofTrauma/Abuse
•  WorkLossandDisability
(Andrasik,Buse,&Grazzi,2009)
(Baskin,2017;Goulart,A,Santos,I,etal.Headache2014;54:1310-1319)
(Baskin,2017;GuiderV,GalliFetal:Cephalalgia1998;18:455-462)
•  55yearoldmanwithhxsignificantfor
hypertensionandGERD,presen5ngwith
dailyheadachesforthelast20years.
•  Headachewasholocephalic,noassociated
symptoms,worseinthemorning
•  Onreviewofsymptoms,endorsedday5me
sleepiness/napping
•  Ques5onnaires:
•  PHQ-9:WNL
•  GAD-7:WNL
•  ISI:ALARMING
•  RelevantPhysicalExam
Findings:
–  NeurologicalExamWNL
–  Priorneuroimaging
reassuring
–  Mallampa5IV
Onfurtherques5oning:
distantdxofOSA,non-adherentwithCPAP
….Diagnosis?
•  Diagnosis:
–  headachesecondarytosleepapnea
•  ImmediateInterven5onandPOC
–  BriefCBT-Iinterven5onfocusedonsleephygiene
–  Referraltosleepspecialist
•  RecommendedCPAPadherence
•  Poten5aloralsplinttherapy
–  4weekneurologicalandpsychologicalfollowup
•  48yearoldwomanwithhxsignificantforgastric
bypass,PTSD,anxiety,depression,“migraines,”
presen5ngwithdailyheadachepain.
•  Headachesstartedinadolescence,ini5ally
catamenial,+phono/photo/N/V.
•  ManagedbyPCPswithfioricet,Tylenolwith
codeine
•  Age35,HAbecame“constant.”
•  Now1-2EDvisitspermonth(IVF,opiates,mag)
–  Taking2-3tabsFioricetdaily,Tylenolwithcodeine1
tabQHS.AlsotakeslorazepamQHSforsleep.
•  Ques5onnaires:
•  PHQ-9:ModeratelyDepressed
•  GAD-7:HighlyAnxious
•  ISI:Moderate
•  MIDAS:21+,MIDASGradeIV,Severedisability
–  Missingmul5pleworkdays(5+)andfamilyac5vi5esdueto
headache
•  Physicalexamwithtaut,tenderbandsover
cervicothoracicmusculature,butnormalcervical
ROM,neurologicalexamina5on
•  Neuroimagingreassuring
•  Addi5onalInforma5on:
–  PCPnolongerwillingtoprescribeTylenolw/
CodeineandFioricet
•  Diagnosis:
–  HxofMigraine,nowwithMedica5onOveruse
Headache,r/orebound
–  DualDiagnosis:PolysubstanceUseDisorder,
Depression/Anxiety,ChronicPTSD
•  Recommenda5onsandPOC:
–  Inpa5entvs.outpa5entmedica5onweanwith
subsequentoutpa5entSubstanceAbuse
Treatment/CBTforMood
–  MOHtreatment:steroidpulse,ini5a5onof
migraineprophylac5c(topiramate);sumatriptan
SQforabor5vemedica5ononceHAbecame
episodic
–  Ongoingfollowup(MOHrelapse10%annually)
THANK YOU!
Kathryn Giblin, MD
[email protected]
Jordan Backstrom, M.Div, Psy.D
[email protected]
Questions?
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Andrasik,F.,Buse,D.C.,&Grazzi,L.(2009).Behavioralmedicineformigraineandmedica5onoveruseheadache.Current
PainandHeadacheReports,13(3),241–248.
Baskin,S.(2017,April).BehavioralMedicineTherapy.PresentedattheThe27thAnnualStoweHeadacheSymposium
“HeadacheMedicine–WhereAreWeGoing,”Stowe.
Engel,G.L.(1977).Theneedforanewmedicalmodel:achallengeforbiomedicine.Science(NewYork,N.Y.),196(4286),
129–136.
Gatchel,R.J.,McGeary,D.D.,McGeary,C.A.,&Lippe,B.(2014).Interdisciplinarychronicpainmanagement:past,present,
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Ghaemi,S.N.(2009).TheRiseandFalloftheBiopsychosocialModel:ReconcilingArtandScienceinPsychiatry(1edi5on).
Bal5more:JohnsHopkinsUniversityPress.
Guider,V.,Galli,F.,Fabrizi,P.,Giannantoni,A.S.,Napoli,L.,Bruni,O.,&Trillo,S.(1998).Headacheandpsychiatric
comorbidity:clinicalaspectsandoutcomeinan8-yearfollow-upstudy.Cephalalgia:AnInterna&onalJournalofHeadache,
18(7),455–462.hMps://doi.org/10.1111/j.1468-2982.1998.1807455.x
Goulart,A.C.,Santos,I.S.,Brunoni,A.R.,Nunes,M.A.,Passos,V.M.,Griep,R.H.,…Benseñor,I.M.(2014).Migraine
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