Jessica Ailani, MD, FAHS

There is little doubt that 2020 will be a year that lives in infamy. Unique to it has been the distinct politicization of medicine unfortunately to the disservice of the greater good. With political divide,
civil unrest, and the awakening of our country to discussions about inequality in regard to race, gender, and financial means, telemedicine landed at the forefront of a global pandemic as a way to forge through all barriers and provide care to patients. As quickly as telehealth was accepted by governing agencies that had put limits to its use in the past, barriers to providing patient care using this platform were made clear to practicing clinicians.

Telemedicine is an effective way to provide care to patients who cannot be present in the clinic or office,

 thus it is important that we continue to improve this offering so we can provide safe and effective care to all patients.

Current challenges and considerations for telemedicine include the following:

Barriers to internet and device use must be recognized.

Studies show that elderly patients, those with physical or mental disabilities, Black or Latinx patients, and those with lower socioeconomic status are less likely to have access to a reliable, secure internet source or a device capable of connecting to a video platform or the ability to use these resources on their own without a third party.

 To provide the best care to all patients, limits to internet and device use must be recognized and considerations should be made on how to provide telehealth services to patients with limited access. One possibility would be to have telehealth hubs centered in local communities where patients could book an appointment to connect via a telehealth platform. These hubs could be located in pharmacies and grocery stores or even local libraries. Privacy considerations would have to be taken into account, as would a way to continue to service and run these stations either by public or private grants.

Initial and annual physicals need to be conducted in person.

At this time, telemedicine exams cannot replace in-person exams. Although there are available devices that can connect to telehealth platforms to assist with collecting vital signs and performing EKGs and limited eye assessments, their cost and questionable security will likely continue to limit their use to those who can afford it. Ultimately, nothing will replace a physical exam that evaluates for nodules, lumps, edema, reflexes, papilledema, motor strength, and so on.

Patient education on telehealth platforms is vital.

If a patient is interested in using telehealth, they need to be educated on using the telehealth platform and how to prepare for a visit. Telemedicine leaves a lot for the patient to coordinate and if they are not prepared for this, it can make the visit less efficient and lead to higher rates of dissatisfaction and lower rates of adherence.

Use of ancillary staff provides a sustainable infrastructure.

In clinical practice, we rely on staff to create a smooth visit flow; this is no different with telemedicine. Using a medical assistant to start the visit and update the record can improve practice efficiency and allow clinicians to see a greater volume of patients.

Clinician training on telehealth platforms and conducting telehealth visits is essential.

We were not trained in medical school to stare at the eye of the camera rather than the image on the screen in front of us; on how 

to speak with warmth to a computer screen; and on how to provide compassion without a gentle touch. It takes a unique skill set to translate warmth and humanity over a televisit and without this, virtual visits can lead to decreased adherence to medication regimens, decreased patient satisfaction, and ultimately, difficulty in building long-lasting, trusting relationships. Telehealth skill training should be a required module for all clinicians who implement telehealth into their practice.

"Ultimately, the lessons learned from the rapid uptake of telemedicine should help us build a stronger, more sustainable future for the platform."

Telehealth platforms must be HIPAA compliant.

There is no substitute for a secure, private interaction between a clinician and their patient. Security for both parties should be a priority regardless of the nature of the visit, therefore standardized HIPAA-compliant safety measures should always be employed across telehealth platforms.

Ultimately, the lessons learned from the rapid uptake of telemedicine should help us build a stronger, more sustainable future for the platform.

1. Almathami HKY, Win KT, Vlahu-Gjorgievska E. Barriers and facilitators that influence telemedi- cine-based, real-time, online consultation at patients’ homes: systematic literature review. J Med Internet Res. 2020;22(2):e16407. doi:10.2196/16407

2. Bloem BR, Dorsey ER, Okun MS. The coronavirus disease 2019 crisis as catalyst for telemedicine for chronic neurological disorders. JAMA Neurol. 2020;77(8):927-928. doi:10.1001/jamaneurol.2020.1452

3. Lam K, Lu AD, Shi Y. Assessing telemedicine unreadiness among older adults in the United States during the COVID-19 pandemic. JAMA Intern Med. Published online August 3, 2020. doi:10.1001/ jamainternmed.2020.2671

4. Pearlstein J. Access to telemedicine is the hardest for those who need it most. Wired website. September 3, 2020. Accessed September 4, 2020. https://www.wired.com/story/ access-telemedicine-is-hardest-those-who-need-it-most/

Articles

Guest editor in chief Jessica Ailani, MD, FAHS, FAAN, provides an overview of the challenges and benefits associated with telemedicine. 

Telemedicine: An Opportunity to Bring Better Care to All

“I’m pretty sure telemedicine is going to be around to stay…It’s a movement that has been underway since I was a resident a long time back, we just constantly struggled with payments.”

As did many other organizations, the American Headache Society (AHS) scientific committee needed to make a big adjustment ahead of its anticipated 

 when the pandemic hit. In addition to the latest safety updates and longer-term post-marketing data on newly approved therapeutics, some recognition of how the field has been affected by the novel coronavirus was required.

One of the members of that committee, Jessica Ailani, MD, FAHS, shared her insight into the meeting plans with 

, including a highlight of the 3 plenary talks which sought to inform the headache community about the approach to headache treatment amid a pandemic on several levels. One of the major impacts, however, has been the push toward telemedicine.

In this interview, Ailani offered her insight into how this has provided what some have considered a large push in the right direction for telemedicine, which has long offered patients a way to avoid long travel and other challenges for short visits but has been marred by challenges with insurance coverage.

Videos

The director of MedStar Georgetown Headache Center and associate professor of neurology at MedStar Georgetown University Hospital discussed how this year has proved that telemedicine is likely here to stay.

Jessica Ailani, MD, FAHS: The Staying Power of Telemedicine in Headache

Migraine has a cumulative lifetime incidence of 43% in women and 18% in men,

 is ranked seventh in global disease burden,

 and is the top cause of disability in people aged 15 to 49 years.

 Migraine peaks during reproductive years, so understanding the link between the condition and hormones and how to treat migraine throughout pregnancy, lactation, perimenopause, and menopause is essential for medical providers. 

Migraine occurs more frequently in women than in men because of the effects of female sex hormones on migraine pathophysiology.

 In children, the prevalence of migraine is similar in boys and girls, with an increase occurring in women only after puberty and peaking in the fourth decade.

 Changes in estrogen levels have a direct effect on migraine, with menstrual migraine triggered by falling levels of estrogen in the late luteal phase of the menstrual cycle. This fall in estrogen can also cause migraine with use of oral contraceptives with a hormone-free (placebo) interval. During pregnancy, with a rise in estrogen levels, many women with migraine experience an improvement in migraine severity and frequency.

 They will feel this improvement, if it occurs, by the second trimester. During lactation, some notice continued protection from migraine because of the stability of female hormones. However, women may see an increase in migraines during perimenopause because of hormone irregularity,

 and in menopause, many will have a reduction of migraine severity and frequency because of lower levels of female sex hormones.

Unlike migraine without aura, migraine with aura may increase or occur for the first time in pregnancy, as aura can increase with a rise in estrogen.

 Migraine with aura does not generally change during menopause, and historically, aura symptoms become more predominant with age.

 Migraine with aura may also respond differently to exogenous hormones, occasionally being triggered by higher levels of estrogen seen in older formulations of oral contraceptive hormones. 

Addressing Migraine Throughout Pregnancy 

The treatment of migraine during vulnerable time periods, such as pregnancy and lactation, requires an important tool set. Treatment considerations are especially important because medications used for migraine may need to be stopped or changed when the patient becomes pregnant and may need to change again when the patient is lactating. A discussion about pregnancy and lactation and migraine treatment is best prior to a patient’s desire to become pregnant so the physician can put a treatment plan in place for this time. 

The safest treatment of migraine in pregnancy and lactation is with lifestyle modifications and behavioral therapy.

 Mild to moderate daily exercise and yoga have been shown to reduce the frequency of migraine attacks. Biofeedback, meditation, and mindfulness all have evidence supporting the prevention of migraine and are safe to learn and use during pregnancy. A discussion on adequate nutrition, hydration, and sleep hygiene during pregnancy is also encouraged prepregnancy. 

Lifestyle changes and biofeedback may not be enough to treat an acute migraine attack, so a discussion about acute options is necessary prepregnancy and during lactation. Clinicians need to balance consideration of the use of acetaminophen, metoclopramide, ibuprofen (during lactation), and sumatriptan (or eletriptan in lactation) with potential risks. Newer data indicate that magnesium and compounds containing butalbital may not be safe to use during pregnancy.

Clinicians may consider neuromodulation devices, particularly the transcutaneous supraorbital stimulator, for both acute treatment and prevention of migraine during pregnancy. While there are no studies of safety in pregnancy for these devices, the relative risk to the fetus is theoretically low. 

A small case series is evaluating the safety of peripheral nerve blocks with lidocaine only as treatment of migraine in pregnancy.

 In the 13 cases reported, no adverse outcomes of pregnancy were observed. Clinicians may consider greater occipital block with lidocaine only to treat migraine during pregnancy.

Preventive medications are generally stopped prior to pregnancy for patients with migraine because, as with most medications, the potential risk of continuing them may outweigh the benefit. In general, women should wait 5.5 half-lives after cessation of medication to become pregnant. If a patient is considering continuing her preventive medication during pregnancy or needs to be started on preventive medication during pregnancy, she should consider a maternal fetal medicine consult for a complete review of safety of medication use throughout pregnancy. 

Although migraine can improve in menopause for many women, it may worsen during perimenopause. With rapid fluctuations in hormones during this time, patients may see a rise in the frequency and severity of migraine attacks. Many patients are started on preventive treatments at this time to attempt to reduce migraine frequency. Because hormone irregularity is the cause of more frequent attacks, stabilizing hormones may help migraines. If menses are irregular, use of continuous combined hormonal contraceptives is an option, depending on the patient’s health and smoking status.

 If menses are regular, patients may consider perimenstrual estrogen supplementation. 

Hormone replacement therapy (HRT) in patients with migraine may potentially worsen migraine, though study results are inconsistent.

 The goal post menopause in women who have worsening migraine or who need to be on HRT for other reasons is to stabilize estrogen; this lessens the risk of migraine from HRT. For patients who decide to use HRT, nonoral routes of estradiol are less likely to have a negative impact on migraine.

Migraines throughout a woman’s life can vary and present different challenges in treatment. An ongoing dialogue with your patients throughout life’s stages can help ensure that their needs and concerns are met and addressed. 

Jessica Ailani, MD, FAHS, is the director of the MedStar Georgetown Headache Center, and an associate professor of neurology at MedStar Georgetown University Hospital. 

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2. GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1211-1259. doi: 10.1016/S0140-6736(17)32154-2. 

3. Steiner TW, Stovner LJ, Vos T, Jensen R, Katsarava Z. Migraine is first cause of disability in under 50s: will health politicians now take notice? J Headache Pain. 2018;19(1):17. doi: 10.1186/s10194-018-0846-2. 

4. MacGregor AE. Migraine, menopause and hormone replacement therapy. Post Reprod Health. 2018;24(1):11-18. doi: 10.1177/2053369117731172. 

5. Vetvik KG, MacGregor AE. Sex differences in the epidemiology, clinical features, and pathophysiology of migraine. Lancet Neurol. 2017:16(1):76-87. doi: 10.1016/S1474-4422(16)30293-9. 

6. Calhoun AH. Migraine treatment in pregnancy and lactation. Curr Pain Headache Rep. 2017;21(11):46. doi: 10.1007/s11916-017-0646-4. 

7. Martin VT, Pavlovic J, Fanning KM, Buse DC, Reed ML, Lipton RB. Perimenopause and menopause are associated with high frequency headache in women with migraine: results of the American Migraine Prevalence and Prevention Study. Headache. 2016;56(2):292-305. doi: 10.1111/head.12763. 

8. Matika K, Inagaki M, Kitamura S, Tatsuoka Y. Changes in migraine before and after menopause in Japanese climacteric women. Cephalalgia. 2017;37(11):1088-1092. doi: 10.1177/0333102416653234. 

9. Wells RE, Turner DP, Lee M, Bishop L, Strauss L. Managing migraine during pregnancy and lactation. Curr Neurol Neurosci Rep. 2016;16(4):40. doi: 10.1007/s11910-016-0634-9. 

10. Govindappagarti S, Grossman TB, Dayal AK, Grosberg BM, Vollbracht S, Robbins MS. Peripheral nerve blocks in the treatment of migraine in pregnancy. Obstet and Gynecol. 2014;124(6):1169-1174. doi: 10.1097/AOG.0000000000000555. 

Reproductive considerations and hormonal fluctuations throughout a woman’s life require careful consideration when treating migraine.

Jessica Ailani, MD, FAHS

Articles

Telemedicine: An Opportunity to Bring Better Care to All

Jessica Ailani, MD, FAHS: The Staying Power of Telemedicine in Headache

Managing Migraine in Women