Hospitalization aims to control or to reduce the intractable headache, to restore functionality to the patients by reducing the incapacity, and to treat the associated comorbidities, thus improving the patients' quality of life. While abrupt withdrawal of the medication overused is perhaps the greater unanimity in the management of refractory chronic headaches associated with medication overuse, all the other aspects are open to challenge and debate. Aspects regarding management of analgesics abstinence symptoms and rebound headache, transitional (bridge) therapy, timing and type of prophylaxis are all less clear and amenable to be challenged.(32) The aggressive analgesic/antimigraine approach that we have described probably would not be enough without the concomitant changes in prophylactic therapy. Even the issue of hospitalization is not a consensus.(25) Although it is still possible in Brazil, in many countries it has been substituted by day-hospital approaches, because of lack of acceptance by the insurers. From the scientific standpoint, hospitalization is not associated with better outcomes in the management of chronic headaches regarding withdrawal of the overused drug or adherence to prophylactic therapy.(32) As advantages we list a better monitoring of the drug withdrawal at its first days, earlier rescue therapy for rebound headache and optimal facilities for continuous medication and/or procedures needing to be monitored.(32) Besides, taking the patient away from its environment is an excellent opportunity for reviewing all the aspects exposed above, and it allows a comprehensive approach. Since patients to be hospitalized usually belong to a more complex group of patients, they frequently have associated fibromyalgia, psychiatric symptoms and/or sleep disorders.(25) As posed before, psychiatric consultation, or rheumatologic consultation as well, may enhance patient care as a whole. Saper et al(28) and Freitag et al(25) also share this view in favor of using hospitalization to treat these patients. As there are no rules that fit all patients, each patient must be individually evaluated and his/her physician must weight the decision about how and where to treat him/her. Although the series presented in this paper is merely illustrative and did not aimed to justify the approach, it gives an idea of the profile of the patients that were submitted to this approach at our neurology service. Based in the arguments above-mentioned, the INC staff feels quite well acquainted in using the inpatient approach for treating complex chronic headache and/or intractable headache patients. However, unexpected
pitfalls may impair the INC's approach such as the recent repetitive shortages on the supply of methysergide and the comments about the supplier's discontinuation of the sale of this prophylactic medication.
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