Headache care has evolved dramatically during the lifetime of the American Headache Society. Dr. Saper charts the most important developments and recognizes those instrumental in influencing current thought and practice.
Scientific discovery and research achievements are of no value to those who suffer from a chronic disorder such as headache unless the discoveries can be translated and ultimately delivered to those who require the care. The translation and delivery of these discoveries require clinical expertise and wisdom, as well as access to appropriate systems and levels of care, without which discovery finds little target. It is for these reasons that the dramatic evolution and maturation of specialized systems of care, together with a corps of expert and certified specialists to treat headache, are collectively the most important developments in the field of headache during the past 50 years.
The perspective could go back to a time when trephination of the skull, alligators on the painful head, sickening potions or excrement rubbed on the forehead were state-of-the-art care. I choose, however, to stay within the 50-year anniversary perspective of our organization and shall focus on the history from the 1950s forward.
In the early 1950s and 1960s, care beyond routine primary level care was limited to a small group of interested physicians from varying fields of medicine. These were the pioneering clinicians in the field of headache. Many worked in the earliest headache clinics. Among the most notable of these in the late 1960s and early 1970s were Dr. John Graham at Faulkner Hospital in Boston; Dr. Robert Ryan Sr. at the Ryan Headache Clinic in St. Louis; Dr. Arnold Friedman at Montefiore in New York; Dr. Donald Dalessio at Scripps Clinic in LaJolla; Dr. Lee Kudrow in Encino, California; Dr. Seymour Diamond in Chicago; Drs. Leonard Lovshin, Robert Kunkle, and David Rothner at the Cleveland Clinic; and Dr. Ninan Mathew in Houston. These clinics were generally monodisciplinary in nature, principally establishing diagnoses and delivering medications through the efforts of the early pioneers of modern day headache care. Dr. Dalessio worked closely with a well-known behavioral psychologist, Dr. Richard Sternbach (PhD) at the Scripps Clinic, and Dr. Kudrow worked closely in his practice with Dr. Bruce Sutkiss. These 2 clinics, and perhaps a few others, represented the earliest foundation for expanded multidisciplinary care for headache patients.
It is noteworthy that these early leaders and systems of care broke through the barrier of prejudice and bias directed at headache patients. In those days, as is even the case today, many consider the origin of headacheto be an emotional distemper and/or neurotic predisposition. As a young assistant professor of neurology, I personally encountered this prejudice when a scholarly professor in neurology asserted to me that I was compromising a “brilliant career in neurology to treat those nutty patients.” The clinics and clinicians of the 1960s and 1970s were subjected to this prejudice and much more, but they prevailed, and our progress today reflects their success.
It was into this environment that I initially developed a similar, standard headache clinic at the University of Michigan. But in 1978, I left the University of Michigan and founded the Michigan Headache and Neurological Institute (MHNI), which was staffed by a physician (myself), 2 psychologists, and several nurses. What made this development different was that together with my staff, which included Alvin Lake III, PhD and Marge Van Meter, RN, the outpatient concept of headache treatment was advanced by the creation at a nearby community hospital of the first hospital-based dedicated specialty unit for intractable headache patients. Thus, the first coordinated, multidisciplinary, inpatient and outpatient dedicated headache program was established.
A few years later, Dr. Seymour Diamond and his staff visited this program and then developed an inpatient program as part of the Diamond Headache Clinic in Chicago. In 1983, Drs. Sheftell and Rapoport developed the New England Center for Headache, and after visiting MHNI and witnessing the inpatient program, they too developed both inpatient and outpatient programming at the New England Center for Headache. Dr. Mathew, too, expanded his program to include dedicated inpatient care. Dr. Silberstein, initially at Hahnemann University, developed the Jefferson University program in Philadelphia, which also had both inpatient and outpatient care systems.
Another step in the advancement of standards and credentialing for headache programs came in 1986 when MHNI received the first accreditation given to a headache program by the Commission on Accreditation of Rehabilitation Facilities and later by the Joint Commission. Several years later, MHNI hired what was the first interventional anesthesiologist to join a multidisciplinary program, thus advancing the means and the tools to address head and neck pain.
Today, there exists a broad stratification of headache care and delivery systems that provide a spectrum of services from primary, principally physician, therapy to secondary and tertiary specialized services, and quaternary comprehensive programs, which also serve as national and international referral centers. These quaternary programs offer inpatient and outpatient care, and include an array of multidisciplinary professional services, including interventional and implantation care.
These advanced clinics and systems offer expert medical services for headache patients, behavioral therapy and treatment, and nursing care and support. Some offer interventional and surgical services. They are staffed by specialist physicians, experienced psychologists, nurses, physician assistants, nurse practitioners, anesthesiologists, and others.
The needs of many headache patients exceed the services that a monodisciplinary, physician-based program alone can provide in an outpatient setting. Many cases represent complex diagnostic challenges. Many have complex medical and neurological comorbidities. Recognized more and more are the challenges associated with our more complex patients with both complex illness and complex personality features, who require broader and more intense efforts in order to address factors that influence the provocation of headache and response to treatment. The broadened spectrum of care provides a range of expert services to serve this complex group of headache sufferers.
The needs of many headache patients exceed the services that a monodisciplinary, physician-based program alone can provide in an outpatient setting.
From a few interested doctors to certified specialists
As far back as the early 1990s, acting as president of the American Headache Society (AHS), I personally visited the American Board of Neurology and Psychiatry to sample their interest in developing headache specialty certification. They were not interested. As an alternative, AHS developed its “fellow” program, which remains in existence today. It was the earliest effort to recognize accomplishments in the field and identify physicians of advanced knowledge and commitment.
Now, through the endless energy and creativity of Dr. Alan Finkel at the University of North Carolina, together with the support and enormous efforts of Dr. James Couch from the University of Oklahoma, Dr. Stephen Silberstein from Jefferson University, and others, the United Council of Neurological Specialties (UCNS) has accepted the premise of headache specialization. UCNS and a team of exam writing, experienced physicians from AHS developed the first exam and has now offered the first 2 headache certification examinations. At this time, there are approximately 200 formally certified headache specialists in the United States. This movement is also spawning the development of formal headache fellowship training programs throughout the United States. Indeed, the age of headache medicine has matured.
Why is this so important?
Wisdom and experience are requisites both in the laboratory and the clinic. Without experienced and innovative physicians and stratified systems of care, the advancing knowledge and range of available services – diagnostic and therapeutic – will not and cannot be delivered to those who would otherwise benefit. The most brilliant laboratory discovery will have little impact on those who suffer illness unless there are physicians and clinical care systems to translate the discovery into meaningful therapies that can be artfully delivered to those who require it. Moreover, patients who suffer from an illness as subjective and complex as headache require much more than that which is derived from the laboratory or the pharmaceutical industry alone. These are essential but alone are not move sufficient to achieve success in the treatment of many, if not most, who suffer from this illness.
It started with a few dedicated physicians and their small professional society, the American Association for the Study of Headache. It matured into a system of stratified care, coordinated multidisciplinary services, local headache programs, national and international referral systems, and certified specialists. The process has provided teachers to share the knowledge base with postgraduate physicians and to inspire more young physicians to enter this field of practice. The fellowship system will develop formal training opportunities for those who seek a career in this field.
The American Association for the Study of Headache, now the AHS, is in its 50th year. It has played a fundamental and critical role in this process. It has been the foundational sponsor for this progress as well as providing organizational impetus and a forum for the sharing of ideas, and science, the gathering of interested professionals, and the development of sophisticated educational and outreach programs. It has created a platform for the presentation of scientific discovery and new ideas, and for the social mingling of interested professionals from many disciplines and training backgrounds. I am certain that without AHS's effort and the important contribution of its leaders and educators, this evolution would not have occurred, and the care for patients who suffer from headache would have remained locked in prejudice and with limited access to expert care.
Congratulations to the AHS, its leaders past and present, and its members for the profound contribution they have made to human medicine and pioneering educational and scientific initiatives in the field of headache medicine.