A working patient with recurring migraine. Elise was a 50 year old married mother of 2 who worked in the software industry. She was a project manager who had headaches. She began with migraines when she was a teenager. While her problem had stabilized after the birth of her first child when she reached the age of menopause the headaches increased from once a month to almost weekly. Her primary doctor had given her Vicodin which she took in frequently until a two years ago when headaches increased. A visit with the neurologist had started a regimen of Imitrex and other medications so that now she was receiving over 5 medicines almost daily to control what had become nearly daily headaches. These were causing her to leave work on an increasing basis. While she had a good job with an understanding boss she realized that to keep things stable she needed HELP.

The Evaluation: Creating Elise's clinical path.

The evaluation team realized that Elise's primary problem was managing the impact of her headaches. She already knew what migraine was and in the 35 years that she had been experiencing headaches she had learned not to be afraid of them. Her use of medications had become a more regular problem. She had increased her use of Violin to the point that she was now experiencing opioid rebound headaches. Now that her body was accustomed to the opioid there would be a physiological change whenever she was without the drug. That change would induce a migraine. This vicious cycle had to be stopped and new techniques had to be introduced. Elise did not want to have to leave work. She was hopeful that we could treat her remotely. With that goal in mind we constructed a clinical pathway for her that would include only a single part day program for orientation to the remote care and from there on we would provide her training via phone, and internet contact with infrequent direct physician visits.

Elise's first event was the remote orientation.

She learned that HELP remote care is based on productivity and function as the primary measures of successful pain management. She was taught about the 5 stages of remote care which provide the general structure of the goals that patients wish to achieve. At orientation she went through the initial qualifying steps for remote opioid compliance and began the weekly goal setting and activity monitoring.

The next event on Elise's clinical pathway: Opioid detoxification.

This step requires that the HELP medical team educate Elise about gradual opioid tapering. We started with the core education about opioids and extended into a discussion of using a pain cocktail for gradual opioid reduction. This training was completed using the online video education materials and written information. Elise asked questions of the care coach during their regular calls and when she described being ready to start the tapering we prescribed the pain cocktail remotely.

The medication optimization ensued.

As weeks passed the goals of increasing time at work, less absenteeism, and reduced medication use were slowly achieved. By the time Elise had stopped using the cocktail six weeks had passed and she was down to a frequency of headaches that were only once a week. She was missing only one day a month from work due to headache. Even with this improvement she wanted more. She had learned about managing without medication using psychological techniques. She wanted to learn these skills.

Psychological management skills attainment.

Using remote lessons over the phone delivered by the care coach, group broadcast of remote lessons with other patients and other recommended reading Elise began learning visual imagery, selective muscle relaxation and meditation. When she developed a headache at work that was threatening her work she would employ these techniques. When the techniques did not work well enough on her own she would call HELP and see if the care coach could talk her through these strategies. Gradually she became a competent manager of her headaches using no medications.