What do neurology residents and attendings think of headache medicine?

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ghost dog

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As a Canadian chronic pain physician, I wonder about this from time to time. I have no idea if the headache fellowships are difficult to get into in the U.S. , and what value is placed upon them.

Any thoughts?

What do you think about this field of medicine?

Is this considered a "soft field"?

Is Saper wasting his time?

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Well, as a person who suffers headaches a lot, I would certainly appreciate such a field...
 
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you arent getting much response because most dont know much about it.
They are certainly well respected. not sure how difficult it is to get fellowships.
Most institutions I have come across, if they dont have a headache specialist they "would like to find one"
sorry i cant tell you more
 
you arent getting much response because most dont know much about it.
They are certainly well respected. not sure how difficult it is to get fellowships.
Most institutions I have come across, if they dont have a headache specialist they "would like to find one"
sorry i cant tell you more

You're right about that one. The Mayo clinic has a headache fellowship; it's so popular 3 (yes three!) have completed it.

http://www.mayo.edu/msgme/neuro-headache-sct.html

GD.
 
In an orchestra, you have musicians playing different instruments. Headache patients are quite difficult for neurologists. Emotionally, they can be very taxing. Me and other neurologists love to have other collegues taking care of those patients. Unfortunately for headache (or behavioral) neurology, you spend your time seeing only patients in clinic with essentially no procedures (botox injections, perhaps). To make a dent on the care of your intractable headache patients (the bread and butter of headache docs), you need to take throughly detailed histories, seeing/billing for few patients. Thus, headache (and behavioral) neurology are not as well paid as Neuromuscular or Epilepsy because the number of RVU generation. Headache science is also consider by many as a soft science. There is a lack of animal models to understand pathophysiological events and few objective abnormalities in humans. That plus the great placebo effect (~30% in randomized controlled trials) contribute to that soft perception.

You should do whatever you feel passion for. To an extent, this is an opportunity as you have little competition. Good luck!

Even in academia,
 
In an orchestra, you have musicians playing different instruments. Headache patients are quite difficult for neurologists. Emotionally, they can be very taxing. Me and other neurologists love to have other collegues taking care of those patients. Unfortunately for headache (or behavioral) neurology, you spend your time seeing only patients in clinic with essentially no procedures (botox injections, perhaps). To make a dent on the care of your intractable headache patients (the bread and butter of headache docs), you need to take throughly detailed histories, seeing/billing for few patients. Thus, headache (and behavioral) neurology are not as well paid as Neuromuscular or Epilepsy because the number of RVU generation. Headache science is also consider by many as a soft science. There is a lack of animal models to understand pathophysiological events and few objective abnormalities in humans. That plus the great placebo effect (~30% in randomized controlled trials) contribute to that soft perception.

You should do whatever you feel passion for. To an extent, this is an opportunity as you have little competition. Good luck!

Even in academia,


There are some significant financial compensations out there in the form of inpatient admission for the treatment of truly intractable head pain. This is extremely expensive for the patient; it can cost up to $30,000. I'm sure a portion goes to the headache doc.

GD.
 
I have no idea if the headache fellowships are difficult to get into in the U.S.

I don't think so.

, and what value is placed upon them.

Academic value? Some
Financial value? Not much. No more than a general neurologist. Unless you're running some private pay headache clinic for wealthy somatisizers.

Any thoughts? What do you think about this field of medicine?

Any field of medicine that takes chronic pain out of my clinic so I can do real neurology is OK with me.

Is this considered a "soft field"?

Not sure what you mean by "soft." If you mean "lots of talking to patients and no procedures," the answer is yes.

If you mean not well developed scientifically or academically, I'd say no. Headache research and literature is quite extensive.


Is Saper wasting his time?

Not if he likes what he's doing.
 
Financial value? Not much. No more than a general neurologist. Unless you're running some private pay headache clinic for wealthy somatisizers.


I see. Do you consider chronic migraine and chronic cluster headache somatization?

You need to go back to medical school if you think that is the case. These patients can (and sometimes do) commit suicide due to the severity of their daily headaches.

Inpatient headache clinics are not targeted at "the wealthy somatisizers" as you put it. They are for people in pain. I have seen patients mortgage their houses in an attempt to ease their head pain.
 
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These patients can (and sometimes do) commit suicide due to the severity of their daily headaches.

To me, that suggests that psychiatric problems have gone unrecognized and/or untreated because the focus has been on the unrealistic goal of "making the pain go away" rather than educating the patient how to live with it and manage it within reason.

Inpatient headache clinics are not targeted at "the wealthy somatisizers" as you put it. They are for people in pain. I have seen patients mortgage their houses in an attempt to ease their head pain.

And what's been the outcome? Maybe if you can withdraw them from from the 20 butalbital tablets they've been taking every day you can make some progress, but again, by the time a patient is heading for an inpatient headache clinic there is so much psychologic/psychiatric overlay that the pain is really not the biggest issue any more.
 
To me, that suggests that psychiatric problems have gone unrecognized and/or untreated because the focus has been on the unrealistic goal of "making the pain go away" rather than educating the patient how to live with it and manage it within reason.



And what's been the outcome? Maybe if you can withdraw them from from the 20 butalbital tablets they've been taking every day you can make some progress, but again, by the time a patient is heading for an inpatient headache clinic there is so much psychologic/psychiatric overlay that the pain is really not the biggest issue any more.

quote=ghost dog;7228787] You might want to tell the neurosurgeons who perform brain surgery on intractable chronic cluster headache patients that they're really treating a psych patient. Yes, these patients do become secondarily depressed from their severe pain; and yes, they do commit suicide as a result of this severe pain. It doesn't take a psychiatrist to figure that one out.

Medication withdrawal is one of the many protocols performed at an inpatient headache clinic. It is uninformed to say that this is their sole purpose.

I find it very interesting that you state that a patient with intractable head pain has more psychiatric "overlay" that needs to be addressed rather than their "real pain". Psychogenic head pain (which I think is what you are implying here) is RARE , and attributing a patient's pain to this does your patient a great disservice. This is usually the result of lazy physician, rather than an exhaustive differential diagnosis. This type of diagnosis is best arrived at in conjunction with a psychatrist or psychologist who has experience in chronic pain (which is rarely done). Thus the rationale for an inpatient admission, where a patient can be observed closely - both physically and psychologically. The multidisciplinary team can co-ordinate all aspects of their care in this setting.
 
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quote=ghost dog;7228787] You might want to tell the neurosurgeons who perform brain surgery on intractable chronic cluster headache patients that they're really treating a psych patient. Yes, these patients do become secondarily depressed from their severe pain; and yes, they do commit suicide as a result of this severe pain. It doesn't take a psychiatrist to figure that one out.

Medication withdrawal is one of the many protocols performed at an inpatient headache clinic. It is uninformed to say that this is their sole purpose.

I find it very interesting that you state that a patient with intractable head pain has more psychiatric "overlay" that needs to be addressed rather than their "real pain". Psychogenic head pain (which I think is what you are implying here) is RARE , and attributing a patient's pain to this does your patient a great disservice. This is usually the result of lazy physician, rather than an exhaustive differential diagnosis. This type of diagnosis is best arrived at in conjunction with a psychatrist or psychologist who has experience in chronic pain (which is rarely done). Thus the rationale for an inpatient admission, where a patient can be observed closely - both physically and psychologically. The multidisciplinary team can co-ordinate all aspects of their care in this setting.


I think you're missing the point of what "Neurologist" was intended to imply when he stated "wealthy somatasizers".

There are certainly people who have "real" headaches and deserve treatment. But this is a challenge, obviously, hence why most here have already stated that they would gladly refer their patients to a headache specialist.

But consider this, who can afford the expensive sometimes unproven or little medically based evidence cash only treatments? (botox, acupuncture, massage therapy, aroma therapy, herbal, etc). The wealthy somatisizers!! A vial of 100 units of botox cost about $600 alone.

I myself went to an osteopathic medical school. I will never forget that I had an OMT professor who bragged that he made about 400K per year doing nothing but alternative medicine and OMT and stole business from all of the chronic pain people in his area. I once visited his office. Guess what he sells convienently behind his counter? All of the alternative herbals he recommends. Hmmm, who pays for these and how much commision does he make from selling them to patients? Certainly not some poor headache sufferer's health insurance policy.
 
I think you're missing the point of what "Neurologist" was intended to imply when he stated "wealthy somatasizers".

There are certainly people who have "real" headaches and deserve treatment. But this is a challenge, obviously, hence why most here have already stated that they would gladly refer their patients to a headache specialist.

But consider this, who can afford the expensive sometimes unproven or little medically based evidence cash only treatments? (botox, acupuncture, massage therapy, aroma therapy, herbal, etc). The wealthy somatisizers!! A vial of 100 units of botox cost about $600 alone.

I myself went to an osteopathic medical school. I will never forget that I had an OMT professor who bragged that he made about 400K per year doing nothing but alternative medicine and OMT and stole business from all of the chronic pain people in his area. I once visited his office. Guess what he sells convienently behind his counter? All of the alternative herbals he recommends. Hmmm, who pays for these and how much commision does he make from selling them to patients? Certainly not some poor headache sufferer's health insurance policy.

There are 2 issues I have with your statement and that of "neurologist":

1. Do you really put Botox on par with herbal medications and aroma therapy ?

2. Many doctors (including "blue" neurologist - as evidenced from his statements) - seem to view chronic daily headache as PRIMARILY a psychiatric issue. This will not serve your headache patient well. Viewing a headache from a purely psychogenic viewpoint moves the patient away from potential physical treatments that may potentially provide significant benefit, such as inpatient admission. Indeed, some headache populations have shown very significant clinical benefit from this therapeutic modality.

GD.
 
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There are 2 issues I have with your statement and that of "neurologist":

1. Do you really put Botox on par with herbal medications and aroma therapy ?

2. Many doctors (including "blue" neurologist - as evidenced from his statements) - seem to view chronic daily headache as PRIMARILY a psychiatric issue. This will not serve your headache patient well. Viewing a headache from a purely psychogenic viewpoint moves the patient away from potential physical treatments that may potentially provide significant benefit, such as inpatient admission. Indeed, some headache populations have shown very significant clinical benefit from this therapeutic modality.

GD.


Did I say that botox is on par with herbal therapy? I will put botox, herbal therapy, aroma therapy, massage therapy, and a whole bunch of other stuff into one big category;

STUFF THAT MOST HEALTH INSURANCE COMPANIES DO NOT PAY FOR.

I am not here to argue which is most effective and blah blah blah, but only to point out that there is a lot of stuff out there that is expensive and yet the headache sufferer will not have the opportunity to utilize these therapies.

I think it is incorrect to assume that most neurologist feel that headache is a primary psychiatric disorder. I am sure that there are plenty of non-neurologist who feel this way (know some unfortunately). Certainly some psychiatric overlay in some cases, but certainly not a psychiatric disorder alone.

Lets all get up on our high horses and talk about how patients so greatly benefit from inpatient therapy. But who pays for this? Did you know that at the Diamond Clinic in Chicago they have people around the clock who spend their entire work day on the phone with health insurance companies trying to get things like inpatient admissions approved? Do you have that kind of staff? Do you spend that much time on the phone yourself as a physician? Unfortunately, most are offered inpatient admission only to discover that they cannot afford it. Others actually become irrate when they do have say an inpatient admission for DHE and then get stuck with a bill. They blame it on the doc.

You make an excellent point that I do not think anybody would disagree with. There are treatments that help these people, there are things that need to be done. But as I have pointed out by using the diamond clinic as an example, this is why the specialist are needed. So that they can devote the time, effort, energy to help these patients. In addition pursue research.

So to answer your original question, no saper is not wasting his time.
 
Did I say that botox is on par with herbal therapy? I will put botox, herbal therapy, aroma therapy, massage therapy, and a whole bunch of other stuff into one big category;

STUFF THAT MOST HEALTH INSURANCE COMPANIES DO NOT PAY FOR.

I am not here to argue which is most effective and blah blah blah, but only to point out that there is a lot of stuff out there that is expensive and yet the headache sufferer will not have the opportunity to utilize these therapies.

I think it is incorrect to assume that most neurologist feel that headache is a primary psychiatric disorder. I am sure that there are plenty of non-neurologist who feel this way (know some unfortunately). Certainly some psychiatric overlay in some cases, but certainly not a psychiatric disorder alone.

Lets all get up on our high horses and talk about how patients so greatly benefit from inpatient therapy. But who pays for this? Did you know that at the Diamond Clinic in Chicago they have people around the clock who spend their entire work day on the phone with health insurance companies trying to get things like inpatient admissions approved? Do you have that kind of staff? Do you spend that much time on the phone yourself as a physician? Unfortunately, most are offered inpatient admission only to discover that they cannot afford it. Others actually become irrate when they do have say an inpatient admission for DHE and then get stuck with a bill. They blame it on the doc.

You make an excellent point that I do not think anybody would disagree with. There are treatments that help these people, there are things that need to be done. But as I have pointed out by using the diamond clinic as an example, this is why the specialist are needed. So that they can devote the time, effort, energy to help these patients. In addition pursue research.

So to answer your original question, no saper is not wasting his time.


As blue neurologist says, " by the time a patient is heading for an inpatient headache clinic there is so much psychologic/psychiatric overlay that the pain is really not the biggest issue any more." I am using a NEUROLOGIST as an example of the incorrect thinking out there that can lead headache patients in the wrong therapeutic direction.

As for your logic behind the cost for an inpatient assessment: in the end, this is more cost effective than the repeated usage of outpatient and ER visits (in addition to the fact that these repeated visits are not effective for the treatment for intractable chronic daily headache). Your inefficient American bureaucratic medical model doesn't work. As a Canadian physician, I don't have to spend "days on the phone" to apply for an inpatient admission; simply filling out one OHIP form is sufficient.
 
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