Content summary

Telehealth in headache care

Telemedicine for headache has been available for several years, is a cost-effective and convenient approach to patient management, with similar satisfaction rates and outcomes.^2-4
Previous reimbursement and licensing barriers to the use of telemedicine in the US have been lifted due to the COVID-19 pandemic, enabling healthcare professionals to bill for telehealth visits.
Switching to telehealth requires planning and preparation prior to installation but also for each patient visit.
Despite the initial challenges with initiating telemedicine, there are examples where it has been successfully implemented such as The CHOP child neurology outpatient center.⁵

The main goal of health care providers is to ensure the health and safety of their patients.
The AHS guideline for acute treatment of migraine published in 2015, recommends non-steroidal anti-inflammatory drugs (NSAIDs), triptans and anti-emetics for acute treatment, which still represent the mainstay of therapy, and may be used in combination.⁶
WHO raised initial concern that NSAIDs may exacerbate COVID-19 symptoms, but the FDA issued an advisory stating it was not aware of scientific evidence connecting the use of NSAIDs with worsening COVID-19 symptoms.
New treatment options include gepants, ditans, and some devices.

The health and safety of patients is still the primary goal of treatment and avoidance of in-patient hospital visits.
Consideration should be given as to whether the headache is a symptom of COVID-19 and bridge strategies that could be implemented.

To prevent patients from visiting the hospital, treatments such as injections of onabotulinum toxin A injections and calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) have been deferred.
In such cases, other preventative treatments should be considered as outlined in the 2012 AHS/ American Academy of Neurology guideline on pharmacologic treatment for episodic migraine prevention in adults.⁷
Procedure-only clinics could be feasible if they can be carried out safely with little risk of infection.

The addition of non-medical strategies could be beneficial for many patients, such as promoting consistent sleep patterns, meals, exercise and stress management, to help maintain normalcy, and boost resilience.
Virtual ‘mindfulness’ sessions have been implemented in some clinics and been well attended by patients.

In light of COVID-19, some health insurance companies in the US have relaxed restrictions on treatments, such as ‘fail first’ requirements and prohibitions on simultaneous coverage; however, many still require a case by case review.
There have been no changes to national legislation in the US that would increase treatment coverage for migraine patients.
On a local level, many coverage decisions are based on the Drug Utilisation Review Board, so engagement with these boards is encouraged.
COVID-19 has impacted clinical trials across the globe, with many ongoing trials suspended or slowed and numerous new trials postponed.
The FDA issued non-binding recommendations in March 2020 to ensure the safety of clinical trial participants.
The recommendations included changes to trial recruitment, the continuation of investigational products and patient monitoring.

Burnout and exhaustion were prevalent in healthcare providers before the emergence of COVID-19, but the additional daily stressors brought by the pandemic have added new burdens.
Healthcare providers are encouraged to seek wellness advice and practice self-care.