TRANSCRIPT

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Molly O’Brien: Welcome to Spotlight On Migraine, hosted by the Association of Migraine Disorders. In this episode, we learn about inpatient migraine treatment. What is it, and who is a candidate? Dr. Merle Diamond describes the various treatment approaches used in an inpatient setting, where it’s available, and what happens after inpatient treatment. Hello, and welcome to Spotlight On Migraine. I’m your host, Molly O’Brien. Today we’re discussing inpatient treatment options. 

I’d like to introduce and welcome our guest, Dr. Merle Diamond. Dr. Diamond is president and medical director of all Diamond Headache Clinic locations, including Ascension Saint Joseph – Chicago Diamond Headache Clinic Inpatient Unit. She is board certified in internal medicine. Dr. Diamond, thanks so much for being here.

Merle Diamond, MD, AQH: Thank you for having me. I’m excited to do this, so let’s go.

O’Brien: Let’s hop right into it. We really appreciate you taking the time to chat with us today. So just to give people an idea of what we’re talking about here, can you please explain? Give us an introduction on what inpatient treatment for migraine is.

Diamond: You know, for that 5 to 7% of patients who suffer with migraine, who are chronic, patients who perhaps have been put on the wrong medications at certain times, patients who are unable to function, there’s a set of criteria we use for admission. But basically, to make it sort of simple, I’d say high disability, not functioning, nothing working to help. Those are patients who may end up being in an inpatient unit for the treatment of their headaches. And this has been done for decades. So it’s not new. There are challenges with how medicine is done these days, so that sometimes it’s hard to get admitted for your headache, but the goal is, particularly with severe migraine, we want to restore functional capacity. And so for a patient who’s bedridden and unable to kind of do any of their daily activities, it’s an important aspect to have in their care.

O’Brien: Absolutely. That helps us give a baseline understanding. Can you talk to us about where inpatient treatment for migraine is available? Can people seek inpatient treatment at their regular hospital, or do you have to visit a specialized center? Where do you go?

Diamond: So, inpatient headache has been done for many decades. My father, a guy named Joel Saper, who’s in Michigan and then at Philadelphia, they also have a program there at Jefferson. There used to be many, many inpatient programs. And we’re sort of the dinosaurs. We’re still left over. But I think patients can be hospitalized locally. I think some of the challenges in that is they’ll use a certain protocol…and I’m just going to use the example of the Raskin protocol, which is IV dihydroergotamine, or D.H.E. 45. And the Raskin protocol is supposed to be over a 3-day period of time. You may have to put medicines in between if stuff isn’t working. 

And if you’re not quite familiar with it or you don’t do it very often, it may or may not help the patient because you may need to supplement other medications in there. Sometimes the patient will get better in 48 hours, but they just immediately discharge the patient from the hospital, and the headache recurs. So it’s really, really important to make sure the headache is actually broken. And at least in most inpatient programs that still exist, it’s not just about the medicine. It’s also about teaching patients about what the medicines are and what to expect. It’s also about what are the other therapies that we want to mesh in? Because it’s not always about drugs sometimes. 

And then, how do we get somebody who’s been bedridden back to work, and what are the appropriate time frames over what that can occur? So I think every patient would rather do this in their neighborhood, at a hospital they feel comfortable at, but it may or may not be accessible to them.

O’Brien: That’s so true on so many points. And I find it interesting too that it’s not just inpatient treatment when you’re looking at it. It’s about breaking the cycle. It’s about breaking that attack. But also you want people to learn how to have an overall lifestyle and strategies and treatment options that will work for them. So it’s not just, oh, you’re going to be back here next week or next month.

Diamond: Yeah, that’s the whole goal. And in the old days, if I wanted somebody to go do biofeedback, or I wanted somebody to go have acupuncture, if I wanted them to have vestibular PT, or PT, or massage, or whatever, it could take a few days to get that organized. Today, when I add those things as an outpatient, it may be months and months before patients may have access to care. So it’s hard. 

The other issue, and part of the reason education is so important, is because there are only 640 or 650 headache specialists, boarded headache specialists, in the United States. And as the patient, you may be the most educated person in your community. And so not that you have to come and take in clinic patients or whatever, but it’s important for you to be able to advocate for yourself. So that’s important too.

O’Brien: What are the admission criteria for inpatient treatment for migraine? So that’s one section. And then let’s talk about at what point should a person with migraine actually consider seeking inpatient treatment. They’re a little bit different.

Diamond: Right. They are.

O’Brien: Because you might hit all the list, but you might still be functioning and doing the best you can. 

Diamond: Correct. So criteria…so it depends who you talk to. If you’re talking to an insurance company or you’re talking to us.

O’Brien: Let’s talk to you.

Diamond: [crosstalk] who are advocating for you. If you’re talking to us, patients who cannot perform daily activities; patients who need fluids because they can’t catch up because their migraine is so bad; patients who have unrelenting headaches, unresponsive to multiple attempts at breaking the cycle at home; patients who are having adverse reactions to medications, obviously. And then another one that’s a really big one is that patient who has a lot of comorbidities – which I hate even that word – but patients who have severe depression, anxiety, bipolar disease, or even more important, things that complicate outpatient therapies. Because there’s certain medicines some people can use and some people can’t use, right? And so looking at all that stuff is important. 

So, if I have a patient who has terrible heart disease and difficult diabetes, and they get very dehydrated with their migraines, that might be a patient because of their comorbidities or coexisting other conditions that need to be in an established environment, right? And I think last but not least is having – and I don’t use the word patient fail – having our medications having not worked well enough so that we’ve been able to manage that patient as an outpatient. Now, insurance companies may or may not recognize that, and it’s really, really important. And we fight this battle quite frequently. Sometimes insurance companies will use this old MMBR…anyway, this old criteria where, basically, you have to be bleeding in your head, have meningitis, and a brain tumor to get admitted for a headache. They don’t separate it from migraine. 

O’Brien: Oh, interesting. 

Diamond: We don’t see it as much anymore because we try to shame them into understanding that that’s like in the 70s, and we know a lot more, and we know that migraine…to me, the worst part of migraine for many of my patients…obviously, the pain is important, but it’s the inability to be counted on. It’s the level of disability it causes. And that doesn’t just impact the patient, although they are the center of it. It’s the whole family. And one of the most important things I like to see if we’re successful and, more importantly, if the patient is successful, that they get to go back and live their lives.

O’Brien: Let’s take me, for example. I have had chronic migraines since my twenties. I was episodic when I diagnosed when I was 4. And I’ve been in these cycles where like I can’t break it. I am stuck. 

Diamond: You’ve done everything you know how.

O’Brien: Everything. Every treatment, every everything. So, at what point would a patient – me, whoever – say, okay, I need to do this. I should consider this. I know it’s an option. Do I want to take that step?

Diamond: And again, I think it’s patient to patient, obviously. I think that important things are, are you able to get to work? Do you have a quality of life outside of work? Because what a lot of patients do is they function, function, function, but then they miss the rest of their lives because they’re in bed, right? Those aren’t things that insurance companies are particularly interested in, but I am. I know they are, right? Having the ability to make changes in the medicine, and when they’ve had to do it in the past, they crash and burn. 

I think we saw a lot of women after pregnancy, at one time, because shouldn’t take anything in pregnancy or whatever. And so by the time they have their babies, they’re not in good shape. And I hate having to put somebody who’s just had a baby in the hospital, but there are conditions, and I’m just using that as an example, right? Or a patient who everything has been working, but they’ve developed a condition that forces us to change that family of medications and go in a different direction. And thankfully, with babies, we have lots of options these days, thank God, but it can take a little while, yeah.

O’Brien: While we’re on that subject, and I’m skipping ahead from my original line of questioning, but I want to talk about pregnancy and postpartum because there’s not a ton out there for people who are pregnant, and a lot of times you’ll hear, well your attacks will probably just get better during pregnancy. Well that’s not the case for everyone, and I [cuts out] that. And postpartum is another time where one, you’re in bad shape because of pregnancy, and two, you’re dealing with a lot of extra stress, life changes…

Diamond: Right, and the hormonal changes, lack of sleep, all of that stuff.

O’Brien: All of that. So what are the options? Are there options for while you are pregnant and postpartum? 

Diamond: Yeah. So the old story was 60% of women during pregnancy don’t have headaches anymore. So there was actually a lovely woman, Dawn Marcus…who passed away a few years ago. She was wonderful…and she did a study, albeit a very small study, in patients with migraine. And the terms in that study are wrong because she talked chronic daily headache instead of chronic migraine. But what they found was that patients with episodic migraine, whose headaches are centered around their menstrual cycles, often do get better with pregnancy. Chronic migraineurs, maybe not. 

And so for a long time…and I’ve sat on panels where I wanted to punch the man sitting next to me because he never had a baby. He doesn’t know what’s going on. You know, “I would tell her that she could only use Tylenol.” And I’m like, okay, my patients would kill me. So there are options available. Like today, I feel very comfortable using onabotulinum in pregnancy. And so that is a great option for women who are using it prepregnancy and during pregnancy. If you feel like you don’t want to do that, you could get a dose leading in. And many women, once they’re through their first trimester, may be fine after that period of time. 

There are other prevention that is safe in pregnancy. Beta-blockers have been studied extensively. And there was a wonderful kind of review article in one of the British journals beta-blockers are safe in pregnancy. So it’s not like we have every tool in our toolkit, but we got a lot of them, right, and a lot more than we used to. And there are abortive drugs we can use in pregnancy too. So I’m just going to use sumatriptan as my example. You know, the sumatriptan pregnancy registry had about 600 babies in it by the end, a little bit more. And it’s clearly safe, but you need about 1,100 to say so. But there’s a Danish registry that looks very similar, and there’s a Swedish registry. Are we allowed to add them up scientifically? Absolutely not. But it’s reasonable. And there are other medicines we can use as well. 

So occasionally do I admit someone who’s pregnant? Yeah, if they’re refractory, they’re vomiting, they have hyperemesis…which I’d love to say doesn’t happen a lot in migraine, but it actually does. You know that thing where you just vomit, vomit, vomit all the time. But there are options available that are safe, and so I don’t ever just tell my pregnant patients get a grip. You’re going to be okay.

O’Brien: Thank goodness. Thank goodness. That’s really great to know. And thanks for expanding on that topic because I do think it’s definitely needed. And for people who are postpartum as well. 

Diamond: Right. Exactly. And there are medicines that are safe postpartum. And there’s actually an app where you can look stuff up. So it’s more if your provider kind of looks at you blankly or says whatever, there’s actually a reasonable list of medicines you can use postpartum that are safe for you and the baby.

O’Brien: What is the approach and strategy for treating migraine in inpatient settings?

Diamond: I’m pretty proud of our center. I mean, we don’t do it perfect, I promise. But the nice thing in our center is that we, hopefully, can look at you individually to make a treatment plan that will work for you. But to not get into medications, goal number one is to break whatever cycle you’re in as quickly as possible. Goal number two is to attend to whatever type of lab abnormalities might have occurred because you can’t eat, or you can’t drink efficiently. Scanning. It’s unusual for people not to come with their scans, but if something’s different or new, making sure you can get that. 

And I like to think that our inpatient unit is modeled not in terms of what we do there, but modeled in the way that a rehab would be modeled, in the sense of…so we’re not talking about bad drugs here, we’re talking about what are the other things that we can do to alter your environment or alter how you do your environment, that might be tools that you could use at home. So, for example, using neuromodulatory devices. Vestibular therapy can be very, very helpful. All of those kinds of things are really worthwhile to look at. Acupuncture. If you look at the overall statistics for acupuncture, it doesn’t look very promising. But when you have providers that know about headache, and sleep disturbances, and migraine, all of a sudden you have good providers that can really help our patients. 

And not everybody lives in Chicago, so the important thing is that they can write out a treatment plan of what works for you, so you can carry it with you. Vestibular therapy is really important. Dizzy is such a common piece of migraine for so many patients, and different patients have had different experiences with vestibular therapy. So it’s very important. It’s something you have to work on when you leave. It doesn’t…you know, I did it, and I’m done. Right? Sometimes with patients who are very bedridden, we have to work on you have to start to be active. And it’s part of that activity is attending classes. Part of that activity is working with our physical therapy people who help make sure your balance is okay and all that good stuff, but then also gives you a regimen to kind of reenter life. Because you can’t go from being bedridden to going to work at your job for 8 hours a day, right? 

And then we also add psychology in there. Sadly, about 80% of our patients have some significant trauma, be it physical, emotional, or sexual, and we need to pay attention to it. And in the old days, people get really mad. “You just think this is all psychiatric.” I go, no, but it all fits together. And even if you haven’t had trauma, the trauma where you’re living right now, in terms of your pain, is significant. It’s really, really important, the things you’ve given up, the things you’d like to get back. So it’s pretty comprehensive. 

We also have a dog. Dog had to go away during COVID, but he’s back, actually two dogs. And I do think that helps. Pet therapy is really useful for people. So we’ve got a lot of different options and opportunities. We have a PharmD on the floor, a pharmacy doctorate, who actually, first of all, keeps us out of trouble, making sure we’re using medicines correctly, and second of all, they do a lot of teaching on the unit for patients. So, for example, many years ago – and I’m going to be a little specific – we used to use…we still do use DHE. And the way it’s described in the Raskin protocol when we’re using it to break a headache is push that DHE in. Well, that’s cruel and unusual punishment. And so between an anesthesiologist I used to work with and our PharmD, we give it in a much more humane way. We drip it over a long period of time so that patients can tolerate it. It’s not supposed to be torturous. 

And so all of us work together to try to make sure that the patient has a good overall experience. The rooms are private. You can have a companion. They’re double blackout shades. I mean, we try to make it as good an environment as possible. It’s a scent-free floor, for the most part. Occasionally, somebody in the kitchen sometimes doesn’t pay attention to the rules, but in general. So we’ve tried to adapt that. And the other thing is, we’re very open to like if something’s not working for you, like, let us know. Let’s see what we can do to adapt. Because it’s not about me, it’s about the patient and what the patient needs. And it’s kind of rare these days, but we try to put the patient in the middle so that they get to be in charge.

O’Brien: Well, that’s incredible, and it sounds like everything was really thought of with the patient and their well-being and their best interest in mind. So we appreciate that. You did give some examples, but I want to talk, and it can just be briefly, on what some of the treatment options are for breaking the attack versus as-needed medication. And then maybe what type of treatments you take when you leave. Can you give us just a couple examples? And probably everybody’s different, right?

Diamond: So I’m going to start with DHE, which has been sort of our standard bearer for many, many decades. I still sometimes see patients who need to be admitted to the hospital who have never had DHE, and so it’s an important complement. We don’t use it in elderly patients who could have heart disease, or we have them see the cardiologist, to make sure it’s safe. The protocol is 9 doses over 3 days. Sometimes we repeat it for patients who’ve been just in status for a long, long period of time, or it takes that long for them to respond. Some patients aren’t candidates for DHE. They can’t tolerate it. It’s an improper drug for them. And so we might use IV valproic acid, which is Depakote but IV. And, no, you won’t gain weight or lose your hair with it IV. Orally, it’s a different story. 

We use IV levetiracetam, which is Keppra. We use IV. Sometimes we’ll use something called a triple shot, which has an antidopaminergic agent. So Thorazine, Compazine, something like that with some Benadryl and a relaxer in there. It varies for different patients. We do use IV magnesium. We’ve got lots and lots of different options. So we try to tailor it to the patient themselves.

O’Brien: And my next question was, how does treatment approach or strategy differ depend on migraine status? So not only is everyone coming at you with a different unique situation, but people have different statuses as well. Some people might be chronic, some people might be intractable. Does it make a difference?

Diamond: Well, I think it does, to a certain extent. So, for example, sometimes I have somebody in who has a drastic change in their lifestyle. So they’re traveling all the time, they’re doing international traveling or whatever, and there’s timescale switches. And they may not be intractable, but they’re certainly either frequent, episodic, or chronic. And what we’re trying to do is find a plan for them with good, abortive medicines and also teach them a lot about their disease and what their triggers are. Like, should I be napping? 

So something I – true story – something I’ve been telling patients forever when they travel in the East, like Japan or what – I think it’s in the East – but anyway, where the time stuff changes dramatically. Like I’ve always…and this funny. My dad started the clinic many years ago, but he used to tell people, when you do that, and you’ve got to flip a day, don’t nap all day. Do a 2-hour nap when you get home, do another hour nap a couple hours later, and then one more hour nap, and then go to sleep like you normally would. And I’ve been telling patients that for years because that’s what he told me. I actually went to Japan this year, and it worked 100%, and I didn’t get a headache. 

O’Brien: No way.

Diamond: So it’s also telling people how to adapt to their situation. Do you know what I mean? For example, police, firemen, ambulance people, they work shifts, and they might do 24 to 36 hours at a time. How do we compensate for that, and what tools can we give them? So it’s very individualized, and it’s also focused on function if it can be. 

O’Brien: Okay, I have to say that is the most solid, useful, best piece of advice on how to take a nap to travel. Because some people are traveling and then just feel miserable. But some people don’t travel because they know it’s going to trigger an attack or make their current situation even worse. So that is genius and thank you.

Diamond: Well, it’s funny, because I used to ask my dad…so he was one of the first headache doctors, and my question was, well, why? And he would go, in his true, Seymour Diamond fashion, “Just do it.” And I’m like, okay. Because they didn’t know back then, right? But they knew what worked, and he listened to patients. Yeah, he was pretty amazing.

O’Brien: Well, thank you to him, and thank you to you for continuing this great information forward. I want to talk a little bit about – and we don’t have to go into too much depth – but what about kids? Is inpatient treatment for kids an option? And if so, how do you handle it, and how do you know when to handle it?

Diamond: Yeah, so there’s a couple. I think Cincinnati has an inpatient or has access to an inpatient program. We do admit kids. I know that Lurie is down the street from us, which is a children’s hospital here in Chicago, one of the children’s hospitals, will sometimes admit kids. I would say our typical adolescent is probably between 13 and 17 or 18. I have seen kids much, much younger. I saw a little girl, who I took care of her dad. Talk about feeling old. And my dad took care of his dad. So it was like, oh, okay. And she just started to have headaches, and she didn’t need to be admitted. 

But nonfunctional, really, really important, DHE can be adapted for children if it needs to be. The one clue I have is like don’t wait till school starts. If they have trouble in the spring, get them in during the summertime, so that – and again, sometimes headaches are better in the summer, whatever – but let’s get tools together for the fall so that that child can have a good experience in school. And so yeah, we do admit kids. We don’t do a ton of it, but yeah, we do it.

O’Brien: How do you define success after inpatient treatment? And how can a patient define success? Because it could be two totally different things.

Diamond: Absolutely. So, success is if you’re frequenting the ER, no ER visits. I mean, so here’s the thing: You have to set expectations, right? Like I’ll see somebody who’s completely disabled, terrible, difficult to manage anxiety or depression, which, of course, because you’re having headaches all the time, and I have to set like what do we want first? What we want first is for you to be able to function at home. And hopefully, we have enough time, and they’ve got a good enough job coverage that they can take that time to recover. It’s a stepwise thing, right? So occasionally, I have patients who can have 6 days and then they’ve got to run back to work on their shift work and whatever. That’s hard to manage, right? 

So if I can protect them – and I also do this for kids, right? – protect them to put them on like when you go back to work, start at 3 days a week, 4 or 5 hours a day, just to make sure. Because if anything pops up, we want to be able to handle it quickly, so they don’t fall back into more and more headache over time. So we always do a 2-week follow-up call. We started this a few years ago with patients, either inpatient or outpatient. And one of the reasons we do that is because today you may not get your medicines right on time.

O’Brien: Yeah. 

Diamond: So one of the things that we’ve adapted in the past 2 years, and it’s not perfect by any means, is when we know what medicines you’re going home with, we call it into your pharmacy or whoever your insurer is, make sure, number one, it’s covered, and number two, that they have it because sometimes we use some weird stuff and may or may not have it. But we want to make sure, and we want to make sure it’s affordable. Like I had a gentleman, 82-year-old gentleman, post head trauma that I’ve taken care of for 25 years. And literally, I just saw him, and he’s on a small dose of a muscle relaxant that his head trauma insurance, or whatever, his work insurance doesn’t want to pay for. And they wanted, if they’re going to send it to him, it’s going to be $300. He can’t pay for that, and it’s generic. 

But I was able to find it on GoodRx, and his son’s going to take him to pick it up. And he said, “Well, I should have this covered.” And I go, “I know you should, but it’s not going to break the bank for you, and you’ll at least have it, right?” We have to think outside the box because that’s a huge issue for patients is access to care.

O’Brien: So frustrating, but that’s good to know that there is help out there. 

Diamond: Right. And we just have to be creative sometimes, and we have to figure out…I mean, this was not part of my education in medical school and residency, but it’s where we are today, and so I have to act as a helper for my patients to have access to their care.

O’Brien: Okay, great. So kind of along those lines, access can be extremely difficult for folks, and it can also be very expensive. And a hospital stay could be very expensive. Now, it depends on treatment options that are used and whether or not insurance is going to cover things, but do you have like a ballpark idea of how much an inpatient stay might cost for patient?

Diamond: Oh, actually, we find that out. So we have an intake thing that we do, and our new-patient person actually can tell the patient, number one, because we have a screener on there, you might need to be admitted. Number two, you could do it now, or you could do it in the future, but you look like you might qualify. She’s not a doctor, but she knows kind of the criteria. And then she’ll check hospital benefits so nobody’s surprised at the end. Because hospitals are way too expensive, and you could fix somebody’s headache, but put them into bankruptcy. That’s not the goal. The goal is that you get treated, and you get treated appropriately. 

So sometimes I’ll see somebody who maybe has a post armed services disability related to head trauma or traumatic brain injury. They often won’t admit somebody right away, and I have to write them a treatment plan, and then we can put that into place and go with it, right? So that’s what we’re doing. And again, follow up. If patients are out of town and it’s very expensive to take a day to drive to Chicago or fly to Chicago, we do a lot of Zoom appointments, which means we have to kind of be licensed in all these states now, but we do that. And again, some people have great primary people who are taking care of them at home, but they need an inpatient stay. So I feel very comfortable to send a young lady home to Kentucky today. I know who her primary neurologist is. He does a great job. She’ll follow up with him, and she’s comfortable with that, right?

O’Brien: So interesting to learn so much about this topic. Dr. Diamond, thank you so much for taking the time today to be a guest. I know you’ve given us some excellent advice, some excellent insight. So knowledgeable and so easy to chat with you. I could chat with you all day.

Diamond: Nice. Good. I like chatting with you, too. I think the important thing, and my dad always said this, like headache patients are the most maltreated patients in medicine because it’s invisible, it’s a headache, you look okay, whatever. And I learned very early on in my career like compassion, empathy, do the best you can, right? And I think today…and it makes me nervous to retire. I’m not retiring yet, but like I want to see a doctor who like talks to me.

O’Brien: Well, thank you so much for taking the time. Really appreciate all of your insight.

Diamond: It’s great talking to you. We’ll talk again. How’s that?

O’Brien: Yes, we will talk again soon. And that wraps up this episode of Spotlight on Migraine. I’m Molly O’Brien with the Association of Migraine Disorders. Thank you so much for joining us, and we’ll see you next time.

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