Effi cacy of the Comprehensive Headache Clinic at the Bangkok Hospital: The First 6 Months’ Report

RESULTS: Of the 302 cases, 113 (37.42%) completed a four-week followup. The effi cacy of treatment was analysed by using Paired T-test. The impact of headache symptoms, the severity, and the frequency of headache per week had decreased signifi cantly from a statistical point of view. HIT-6 Score day 0 = 62±5.66, day 28 = 52±7.15 (p < 0.01, t = 2.13), Pain Score day 0 = 7±1.92, day 28 = 3±2.46 (p < 0.01, t = 1.96), Headache frequency per week day 0 = 3±2.68, day 28 = 1±1.87 (p < 0.01, t = 2.58).


H
eadache is the primary symptom that brings the patient to see the neurologist.A survey by the World Health Organization (WHO) in 2007 found that the incidence of headache affected up to 47% of the population worldwide. 1These headaches not only cause annoyance but also infl uence the quality of life.
A survey by David B. Matchar and colleagues 2 found that certain types of headache, such as migraine, could cause inability to work in more than 85% of patients.If calculated in terms of direct, economic loss the sum was estimated to be as much as USD 13 billion annually, and WHO had stated that headache was a health problem affecting 1 in 20 working people in the world. 3e International Headache Society (IHS) has divided headache into three groups, namely, 1) Primary headaches, 2) Secondary headaches and 3) Cranial neuralgias, central and primary facial pain, and other headaches. 4imary headaches are caused by abnormalities of the brain and nervous system itself.No abnormality can be detected by radiological and laboratory tests.Examples of primary headaches include migraine headaches, tension type headache, and trigeminal autonomic cephalalgias (TACs) such as cluster headache, etc.
Secondary headaches are headaches caused by internal or external conditions such as brain tumor, cerebral hemorrhage, cerebral venous thrombosis, head injury, sinusitis, eye disorders, abnormalities of the teeth or temporomandibular joints, infectious diseases, etc.It is necessary for this group to have additional investigations such as Computerized Tomography (CT), Magnetic Resonance Imaging (MRI), and blood tests.
Cranial neuralgias, central and primary facial pain, and other headaches are from other causes.For example, headaches caused by abnormalities of the 5 th or 9 th cranial nerves or an infl ammation of occipital nerves, etc.
Approximately 20% of the patients who visited the Neuroscience Center at Bangkok Hospital presented headaches as a primary symptom.Therefore, the Comprehensive Headache Clinic has been established and initiated a multidisciplinary team made up of headache specialists, nurses, rehabilitation doctors, physical therapists, clinical psychologists, and medical acupuncturists who can provide comprehensive assessment, treatment and headache education in accordance with international standards.
The aims of the Comprehensive Headache Clinic are to reduce the frequency and severity of the symptoms, offer effective treatments according to international standards, decrease the overuse of pain medications, enhance quality of life, and educate patients and their families so that they are able to take care of themselves and manage their headaches appropriately. 5

Acute Treatment
1. Acute pain medications are administrated intravenously or orally as indicated, according to the standard treatment guidelines from the American Academy of Neurology and European Federation of Neurology Society. 6-102. Occipital nerve block, Trigger point injection, and/or Peripheral nerve block are performed as indicated. 11,12ophylactic Treatment 1. Prophylaxis medications are administrated as indicated, according to standard treatment guidelines from the American Academy of Neurology and European Federation of Neurology Society. 6-102. Occipital nerve block or Botulinum toxin injection are performed as indicated. 12,13n-pharmacologic treatments

Materials and Methods
Headache Impact Test TM (HIT-6 TM ), the pain score, and the headache frequency per week were used to evaluate the progression of clinical and therapeutic responses in each patient.
Headache Impact Test TM (HIT-6 TM ) Version 1.1 15 The test was developed to help patients to communicate their feelings about headache especially in terms of the severity of symptoms and the impact on their daily life.There are 6 questions for patients to answer according to how they feel and the scores will be calculated.The symptoms of headache are divided into 3 levels: Mild score of 50-55 (the headache had a minimum impact on daily life and did not require medical attention), Moderate score of 56-59 (the headache had a moderate impact on daily life and required medical attention), Severe score of ≥ 60 (the headache had severe impact on daily life and required urgent treatment). 16HIT-6 TM record form and interpretations are shown in Table 1.

Pain Score
The pain assessment was graded on a numerical rating scale (NRS) with a score of 0-10.There were 4 levels starting from 0 = no pain, 1-3 = mild pain, 4-6 = moderate pain, and 7-10 = severe pain. 17

Headache frequency per week
The number of headache attacks per week was asked.

Statistical analysis
Patient characteristics were described as absolute numbers, percentage, mean, and standard deviation (SD).

Results
Since the opening of the Comprehensive Headache Clinic at Bangkok Hospital on July 2011 there were 302 patients with headaches that were treated in the clinic during the fi rst 6 months (until January 2012).

Population
Of the 302 patients, 237 (78.5%) were Thai, 65 (21.52%) were overseas visitors, 87 (28.81%) being male and 215 (71.19%) being female.Age range between 15  From 302 patients, there were 113 cases (37.42%) who completed a four-week followup period.Those that did not come for followup include 111 cases (36.75%) with mild headache that did not require any further treatment; 63 cases (20.86%) did not keep their appointment and when we called to check how they were, they said that their headaches had improved a lot; 15 cases (4.97%) continued their treatment abroad.

Discussion
From our Comprehensive Headache Clinic, on the fi rst day (Day 0) patients had an average headache score (HIT-6 TM ) of 62 (severe headache impact), average pain score of 7 (severe pain score) and the average headache frequency score was 3 times per week (high frequency).After the 4 weeks treatment of headache, we found that the severity of headache had improved to mild degree and the average headache score (HIT-6 TM ) decreased to 52 (mild headache impact), the average pain score was reduced to 3 (mild pain score), and the average of headache frequency was reduced to once per week (low frequency).As a result, these patients had a signifi cant increase in their quality of life due to reduced suffering from headaches.
Using HIT-6 TM score, pain score, and headache frequency per week for treatment evaluation helps patients to communicate more effectively with their physicians.As a result, treatment can be given more effectively and patients can better notice the progression of treatment.Sauro KM, et al. 18 showed in their trial of the Calgary Headache Assessment and Management Program (CHAMP) that the multidisciplinary team were able to signifi cantly reduce the HIT-6 TM score from 63.6 to 58.2 (p < 0.001) in three months' duration.
We propose that by forming a similar Comprehensive Headache Clinic with a multidisciplinary team helps us to improve assessment and treatment of patients with a holistic approach which will accentuate the effectiveness of treatment.

Conclusion
A multidisciplinary team in the Comprehensive Headache Clinic can improve the patient's quality of life by signifi cantly reducing the severity of headache, the frequency, and the impact of headache symptoms.Headache scores will help the patient and physician to reach a common understanding.
Inferential statistics was used with Paired sample T-test to determine the headache scores before treatment (Day 0) versus after treatment (Day 28).The Bangkok Medical Journal Vol.5; February 2013

Figure 2 :
Figure 2: Graph shows the comparison of the headache score on Day 0 vs. Day 28
≥ 60Severe Your headaches are having a very severe impact on your life.You may be experiencing disabling pain and other symptoms that are more severe than those of other headache sufferers.TM To

score, add points for answers in each column.
Please share your HIT-6 results with your doctor.

To complete, please circle one answer for each question.
This questionnaire was designed to help you describe and communicate the way you feel and what you cannot do because of headaches.

Effi cacy of the Comprehensive Headache Clinic at the Bangkok Hospital: The First 6 Months' ReportTable 2 :
Patient characteristics and Headache subtypes

Table 2 .
and 35 years in 52.32% and over 35 years old in 47.68%.

Table 3 :
Comparison of headache scores on Day 0 vs. Day 28