Migraine Care in the Era of COVID‐19: Clinical Pearls and Plea to Insurers

Christina Szperka, MD, MSCE, FAHS

AHSAM 2020 - Oral session
Published on July 17, 2020

7 minute

Key messages

  • To ensure the health and safety of patients during the COVID-19 global pandemic, and prevent the spread of infection, telemedicine has been successfully implemented across headache departments in US hospitals.
  • Real-world strategies for acute and preventative treatments of migraine during the COVID-19 outbreak remain in line with those recommended in the American Headache Society (AHS) published guidelines.
  • Consideration should be given as to whether headache is a symptom of COVID-19 and bridge strategies that could be implemented if necessary.
  • The addition of non-medical strategies could be beneficial for many patients to maintain a sense of normality and boost resilience.
  • Health insurance companies should be relaxing restrictions on treatments to improve patient access during this difficult time.
  • Healthcare providers are encouraged to seek wellness advice and practice self-care.
     

Key messages

  • To ensure the health and safety of patients during the COVID-19 global pandemic, and prevent the spread of infection, telemedicine has been successfully implemented across headache departments in US hospitals.
  • Real-world strategies for acute and preventative treatments of migraine during the COVID-19 outbreak remain in line with those recommended in the American Headache Society (AHS) published guidelines.
  • Consideration should be given as to whether headache is a symptom of COVID-19 and bridge strategies that could be implemented if necessary.
  • The addition of non-medical strategies could be beneficial for many patients to maintain a sense of normality and boost resilience.
  • Health insurance companies should be relaxing restrictions on treatments to improve patient access during this difficult time.
  • Healthcare providers are encouraged to seek wellness advice and practice self-care.
     

Background

  • The COVID-19 pandemic was declared by the World Health Organisation (WHO) on March 11 2020.
  • As of May 26 2020, the Johns Hopkins Coronavirus Resource Center reported over 5.5 million confirmed cases and 347,836 deaths worldwide from COVID-19.1
  • In the US, hospitals were instructed to limit non-essential procedures by March 18 2020.
  • As a result, clinics shifted from in-person visits to telehealth, employing real-time interactive remote audio and video communication between them and their patients.
  • Non-respiratory symptoms of COVID-19 include headache; therefore, consideration has to be given to how patients are managed to maximise their safety, avoid infection of healthcare workers and minimise demands on an already overburdened hospital infrastructure.

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

Real-world strategies for acute treatment of migraine

  • 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.

Real-world strategies for bridge treatment of migraine

  • 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.

Real-world strategies for prevention of migraine

  • 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.

Real-world non-medical strategies for prevention of migraine

  • 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.

Effects surrounding practice: Advocacy and clinical trials

  • 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.

Effects surrounding practice: Self-care

  • 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.

Conclusions

  • Telehealth enables healthcare providers to continue to care for their migraine patient population and help avoid hospital visits that put patients at risk and burden the overwhelmed healthcare system.
  • Real-world strategies for the treatment and prevention of migraine can be implemented where evidence-based medicine is lacking.

This is a highlights summary of an oral session given at the AHSAM 2020 Virtual Annual Scientific Meeting and presented by:

Christina Szperka, MD, MSCE, FAHS
Director, Pediatric Headache Program & Assistant Prof of Neurology & Pediatrics
Children's Hospital of Philadelphia/University of Pennsylvania
Philadelphia, Pennsylvania

The content is produced by Infomedica, the official reporting partner of ASHAM 2020 Virtual Annual Scientific Meeting. The summary text was drafted by Goldcrest Medical Writing, reviewed by Marco Vercellino, MD, an independent external expert, and approved by Jessica Ailani, MD, FAHS and Mark J. Burish, MD, PhD, the scientific editors of the program.

The presenting authors of the original session had no part in the creation of this conference highlights summary.

1. Johns Hopkins Coronavirus Resource Center. COVID-19 Dashboard. Available at: https://coronavirus.jhu.edu/map.html. Accessed June 2020.

2. Qubty W, Patniyot I, Gelfand A. Telemedicine in a pediatric headache clinic: A prospective survey. Neurology 2018;90:e1702‐e1705. https://n.neurology.org/content/90/19/e1702.long

3. Muller KI, Alstadhaug KB, Bekkelund SI. Telemedicine in the management of non‐acute headaches: A prospective, open‐labelled non‐inferiority, randomised clinical trial. Cephalalgia 2017;37:855‐863.

4. Muller KI, Alstadhaug KB, Bekkelund SI. A randomised trial of telemedicine efficacy and safety for nonacute headaches. Neurology 2017;89:153‐162.

5. Rametta SC, Fridinger SE, Gonzalez AK, et al. Analysing 2,589 child neurology telehealth encounters necessitated by the COVID-19 pandemic. Neurology Publish 2020; Ahead of Print DOI: 10.1212/WNL.0000000000010010.

6. Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the American Headache Society evidence assessment of migraine pharmacotherapies. Headache 2015;55:3-20.

7. Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society Neurology 2012;78:1337-1345.

Headache
COVID-19

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