HEADACHES AND HEALTH CARE UTILIZATION – INSIGHTS FROM A CHIROPRACTIC CASE REPORT

INTRODUCTION

Neurological disorders are the eighth leading cause of health care spend in the United States.¹ Of these, headache disorders are the third leading cause of disability worldwide² and the most common disabling neurological disorder in children.³ Furthermore, the national prevalence and incidence of these conditions has increased in both adults and adolescents.^4,5 As these conditions become more prevalent, they continue to have significant economic impact and result in higher health care utilization by patients.^6–8

The economic impact of headache disorders comes from direct costs (i.e., utilization of health care services: inpatient/outpatient visits, procedures, and medications), indirect costs (i.e., lost productivity), and intangible costs (i.e., costs of suffering and reduced quality of life).⁹ Annual direct costs of migraines have been estimated to be $9.2 billion⁷ and even higher at $12 billion for indirect costs.¹⁰ Both adult and pediatric patients with migraines have been shown to have higher annual direct and indirect health care costs than matched individuals without migraines.^6,8 Increased direct costs have been attributed to increased costs associated with hospital use,^11,12 increasing utilization of imaging,¹³ and inappropriate use of imaging.¹⁴ Other factors associated with increased costs include having lower health related quality of life scores, more chronic health conditions, use of acute relief medications (i.e., opioids and triptans), more hospital visits, and visiting with a neurologist.^15,16 Unfortunately, most of the research on headache disorder costs and health care utilization is on primary headaches (i.e., migraines and tension-type headaches) and there is insufficient data on cervicogenic headaches.

Annually, 11% of the population uses chiropractic care.¹⁷ Among patients who receive chiropractic care, 6% seek care for headache.^18,19 These rates of utilization and reasons for attending chiropractic care are similar amongst pediatric populations.¹⁹ Current chiropractic guidelines recommend the use of spinal manipulation for cervicogenic headaches and migraines, and low load craniocervical mobilization for tension-type headaches.^20–22 Additionally, recent data suggest that various treatment modalities often utilized by chiropractors have an additive effect when combined to treat cervicogenic headache.^19,23

Despite chiropractic care having ample evidence to support its use for treating headache disorders and being a common specialty for individuals with headaches to consider^20–27 primary care guidelines published in American Family Physician do not make mention of these viable treatment options.^28,29 Unlike these headache guidelines, primary care guidelines for low back pain published by the American College of Physicians recommend the use of spinal manipulation and other modalities commonly used by chiropractors.³⁰ Based on the best available evidence guidelines provide recommendations for best practices and a summary of alternative care options that influence clinical decision-making and referral pathways for patients. Current evidence demonstrates that there is a reduction in health care utilization for patients with low back complaints who initiate care with chiropractors or physical therapists and when added to usual medical care, chiropractic care improves outcomes for patients with low back pain.^31–33 However, we were only able to identify a single study assessing the impact of chiropractic care on health care utilization and costs for headache disorders.³⁴ This study was limited to using claims data obtained from 2 sources in North Carolina, but they did find that costs were significantly less for headache patients who received chiropractic care.

There is insufficient evidence on health care utilization and costs when initiating care with chiropractors or combining chiropractic care with usual medical care for headache disorders. This case highlights the care pathway of an adolescent patient with cervicogenic headaches, the resulting health care utilization, and cost associated with chiropractic care. With this case we aim to encourage discussion about filling this gap within the chiropractic literature for headaches and health care utilization.

CASE REPORT

Patient Presentation

A 15-year-old female with an uninterrupted headache that wrapped around both sides of the head over the previous 2-months with associated subjective complaints of visual disturbances, nausea, and dizziness was referred for chiropractic care by a pediatric headache specialist. The symptoms were aggravated by coughing, transitioning from a flexed to upright posture, and golfing. There were no identifiable alleviating factors. The initial pain rating was 6/10 on an 11-point numerical pain rating scale (NPRS). On the Department of Defense/Veterans Affairs Pain Supplemental Questionnaire (DoD/VA PSQ), a biopsychosocial questionnaire, she had a score of 13/40.

Examination and Diagnosis

Physical examination demonstrated the presence of bilateral suboccipital active trigger points via manual palpation that concordantly replicated the patient’s complaint. Manual palpation further revealed bilateral joint restrictions of the upper cervical spine segments (C₁-C₃). Orthopedic testing elicited a positive spurling’s test, cervical compression test, and valsalva maneuver that each concordantly replicated the chief complaint. Cervical distraction testing was negative. A diagnosis of cervicogenic headaches was made.

Therapeutic Intervention

Treatment was guided by the physical examination findings and consisted of myofascial release via pin-and-stretch of the suboccipital muscle and spinal manipulation of the upper cervical spine segments (C­₁-C₃). At the end of treatment, she reported having a 10% reduction in pain. A daily home exercise plan consisting of suboccipital muscle stretching to be completed daily was also recommended.

Over 2 more visits at 1-week intervals, the 11-point NPRS scores decreased from 6/10 to 0/10 and the DoD/VA PSQ scores from 13/40 to 0/40. She had a full return to golfing without aggravation of symptoms. She returned 3 weeks later for a wellness follow-up symptom free. Over a 2-year follow-up period, 4 episodes of headaches occurred. The first and second flare-ups were reported at 1- and 2-months post discharge, respectively. The third flare-up occurred 9-months after the second and the fourth flare-up occurred 11-months after the third. Flare-ups 1, 2, and 4 were resolved with a single treatment session, and 2 treatment sessions were required to resolve the third flare-up. Each flare-up treatment was consistent with the initial treatment plan.

Pre-Chiropractic Health Care Utilization

A chart review was conducted to identify the patient’s health care utilization patterns for this headache. In our review, we assessed each encounter within the electronic health record associated with this complaint from the initial encounter to the most recent, including follow-ups for reoccurrence. To avoid redundancy, we have labeled the non-chiropractic physical examinations as a standard medical physical examination. A standard medical physical examination consisted of an assessment of the patient’s general appearance, skin, eyes/vision, ears, nose, throat, lungs, heart, abdomen, and nervous system (cranial nerves 2-12, cerebellar testing).

The chart review process revealed that she entered the healthcare system for the headache complaint via an urgent care center within our hospital system. She presented with a headache that wrapped around both sides of her head and associated subjective symptoms of nausea, dizziness, and sensitivity to light and sound. A standard physical medical examination resulted in no pertinent findings. She was provided with 6mg of subcutaneous Imitrex with no symptomatic improvement and a prescription for 400 mg of Ibuprofen to be taken as needed. A referral to a pediatrician was also made. Care was continued with a pediatrician the next day.

Upon visiting the pediatrician, her complaint symptomology was consistent with the previous day. There again were no pertinent findings identified during a standard medical examination. However, concerned about the potential of a migraine headache, a referral was made to a pediatric anesthesiologist who specializes in pediatric headaches. During the consultation with the pediatric headache specialist, her symptomology had remained stable, and the standard medical examination did not identify any pertinent findings. Subsequently, referrals to an ophthalmologist for a dilated eye examination and a psychiatrist for a psychotherapy assessment were made. An order for a brain MRI with and without contrast was also placed. The examinations and imaging failed to demonstrate any relevant contributors to the headache. Therefore, the headache specialist recommended that chiropractic care or acupuncture may be beneficial.

During this chart review, we did note that despite a thorough standard medical examination being completed by each contacted provider to screen for red flag conditions and serious pathology, a musculoskeletal examination of the cervical spine and musculature was never conducted.

Health Care Costs

We found it noteworthy that this patient saw 5 different providers and received advanced imaging within a 2-month period prior to receiving conservative musculoskeletal care. To assess the financial impact of the health care utilization patterns associated with this headache episode, we collected billing data.

We found that care with the headache specialist and psychiatrist occurred outside of our institution. Due to this we were unable to identify the full extent of the cost incurred by the patient. Nonetheless, we were able to identify that the amount of medical services billed prior to receiving chiropractic care within our healthcare institution was $3,618. The services included are the visits with the urgent care center ($671), pediatrician ($513), ophthalmologist ($634), and the brain MRI ($1,800). The total billed for chiropractic services for the initial headache episode was $1,064. Chiropractic services billed for the wellness follow-up were $117 and the entirety of the 2-year follow-up period for the 4 headache flare-ups was $930. The combined cost of these chiropractic services was substantially less than the portion of billed medical services that we were able to collect, $2,111 and $3,618 respectively.

DISCUSSION

We found it noteworthy that this patient used a substantial amount of health care services prior to establishing chiropractic care. Unsurprisingly, as utilization of health care services increased so did the costs. This is consistent with previous research which demonstrated adult and pediatric patients with migraines incur more annual direct and indirect health care costs than matched individuals without migraines.^6,8 Furthermore, through collecting billing data that was available within our healthcare system, it was found that the billed services for chiropractic care was substantially less than the billed services prior to establishing chiropractic care for this headache episode. Of the billed services that were obtained, nearly half of the total cost resulted from a single brain MRI ($1,800).

The American College of Radiology states that it is inappropriate to use imaging in patients with primary headache disorders (migraine and tension-type headaches) who have normal neurological examinations and no red flags.^35,36 Despite this, MRI use for headaches is increasing in both adult and pediatric population.^13,37 Additionally, up to 30% of imaging studies done on pediatric patients with headaches could be considered inappropriate.³⁸ When compared to the American College of Radiology appropriateness criteria,³⁵ the use of MRI in this case would be considered inappropriate.

It was noted during our chart review, that the patient never received a musculoskeletal examination of the cervical spine or musculature in the encounters with the 5 different providers. This is important as nearly one-third of patients with headache disorders are inaccurately diagnosed.² This is in part due to the fact that proper diagnosis of headaches can be challenging, and patients can have multiple diagnoses at the same time.³⁹ However, prior research suggests that cervicogenic headaches clearly differ from migraines and tension-type headaches, and that diagnostic criteria can adequately distinguish between them.⁴⁰

The International Headache Society (IHS) states that the diagnosis of cervicogenic headaches can be made clinically when the following criteria are met.³⁹

1. Any headache fulfilling criterion C.
2. Clinical, laboratory and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck, known to be able to cause headaches.
3. Evidence of causation demonstrated by at least two of the following:
   1. Headache has developed in temporal relation to the onset of the cervical disorder or appearance of the lesion.
   2. Headache has significantly improved or resolved in parallel with improvement in or resolution of the cervical disorder or lesion.
   3. Cervical range of motion is reduced and headache is made significantly worse by provocative maneuvers.
   4. Headache is abolished following diagnostic blockade of a cervical structure or its nerve supply.
4. Not better accounted for by another ICHD-3 diagnosis.

The IHS also reports that having pain which occurs predominately on one side, experiencing headache provocation with digital pressure on the cervical musculature or by head movement, and having a posterior-to-anterior radiation of pain are signs and symptoms of cervicogenic headaches that can help differentiate them from migraines and tension-type headaches.³⁹ Additionally, migrainous features such as nausea, vomiting, and photo/phonophobia can occur in cervicogenic headaches and can further help differentiate them from tension-type headaches.³⁹ Many of these differentiators would require a musculoskeletal physical examination that assesses range of motion and utilizes palpation and provocative testing to be identified. This approach to a physical examination is consistent with best practice recommendations within chiropractic guidelines and guided the diagnosis of cervicogenic headaches being made in this case.²²

The current health care environment has put primary care providers (PCPs) in a position where they are overburdened with insufficient time to provide guideline-concordant care.⁴¹ Chiropractors are portal of entry providers for neuromusculoskeletal conditions and more access to chiropractic care has been shown to lessen the burden placed on PCPs for spinal complaints.^42,43 It is unknown if chiropractors have a similar impact on headache disorders but considering that a musculoskeletal physical examination helps differentiate common headache disorders, chiropractors can play an important role on the healthcare team in making an early proper diagnosis. This could result in a more effective utilization of health care services, reduce burden on the healthcare system, and decrease the amount of medical spend incurred by patients.

CONCLUSION

This case demonstrates the potential for reducing health care utilization and spending by establishing chiropractic care early in the management pathway for headaches. Further investigation of a large cohort of patients to identify associations between initiating care with chiropractors or combining chiropractic care with usual medical care and reductions in subsequent health care utilization and medical spend for headaches is warranted.