Pearls for Managing Migraine via Telemedicine During COVID-19

In this video, Stephanie Nahas, MD, MSEd, offers strategies that could help improve the telemedicine experience for both patients and providers when caring for patients with migraine during the ongoing pandemic.

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Stephanie J. Nahas, MD, MSEd, is an Associate Professor of Neurology, and Director of the Headache Medicine Fellowship Program at Thomas Jefferson University in Philadelphia, Pennsylvania.

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Stephanie Nahas, MD: I'm Dr Stephanie Nahas. I am a neurologist and a headache specialist working at Thomas Jefferson University at the Jefferson Headache Center in Philadelphia, Pennsylvania.


I might offer a few pearls of advice to my colleagues in this era in trying to provide the best telemedicine experience for yourselves and for your patients alike. Number one is to be prepared. Preparedness is the key to a lot of things that we do in life, and this is no exception. Making sure that you understand the technology and how it works on your end, but as well as what the person or the patient on the other end is seeing.

The experience that they have to go through in order to be able to connect to the video platform and to be able to interact with the electronic medical record for their aspects of it, filling out their questionnaires, for example, online beforehand. Making sure that they know how to access the video call.

Always having some kind of backup means of being able to set up that 2-way audiovisual communication. Sometimes, the systems that are in place, set up by our EMR and our IT departments, they don't always work out for one reason or another, so having 1 or 2 backup plans to still conduct that visit is important.

It's also challenging to do the physical exam over a video connection, but there are lots of things that can be done. We already do a lot just by casual observation. You may think that doing a full neuro exam or even a physical exam over video is impossible.

Yes, that is true, but there's more that one can do than one may realize, especially if that patient has somebody else there to help you do the physical exam. You can have a patient get very close to the camera to do a pupillary exam.

You can have them, or a friend, or a family member grab a flashlight or even just their cell phone with the light on the cell phone to illuminate the pupil to examine for pupillary constriction. You can have them get close to the camera to examine their eye movements.

You can have them step far away from the camera to get a full-body view and have them do various motor tasks for coordination, for their gait, for their balance, even checking the Romberg sign, etc. There's little tricks and nuances for how you have to learn how to leverage the technology in a different way to examine the patient in the way that you need.

Of course, you can't feel if they've got muscular tension, but you can assess their range of motion quite easily, having them perform those sorts of maneuvers. Ask them, are they feeling pain anywhere when they're doing that range of motion exercise? Ask them to palpate areas for themselves and tell you if they identify any areas of tenderness and exactly where they are.

They may be able to identify for you that, "It's tender in the back of the head." You can say, "Well, do you feel is that tenderness right where there's a little bit of a notch in the back of your head?” Because that's where the occipital nerve is. If they've got exquisite tenderness right there, you've got a problem that you can address.

Of course, you'll have to bring them into the office in order to address that neuralgiform pain in the occipital nerve, but it can be done. You can get at that very quickly. If your patient has somebody else who's in the room who can maybe even do some sensory testing for you, have them get an ice cube from the freezer to test temperature sensation.

They probably don't have a tuning fork to test vibratory sensation. Although, they might be able to set up, again, their cell phone with a buzzer and apply it to certain areas on the skin. It's not perfect. It's not the same way that we do it in the office, but it is a way to get at whether they're having any kind of sensory dysfunction.

There's all kinds of little tricks like this that you can learn, and there are various resources online and other podcasts that go through this. I'd encourage you to look into them.