The “Silver Linings” of the Pandemic for Patients With Migraine

In this video, Stephanie J. Nahas, MD, MSEd, discusses how the ongoing pandemic has affected symptoms, management, and treatment among patients with migraine.

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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.

When I think about how the pandemic has affected my patients and the patients in our practice with respect to their migraine symptoms, their other headache symptoms, and their overall general health, there's a lot to be said.

For one thing, this is one of those silver linings that we look for in these situations. The pandemic has forced all of us to retreat to our homes more than we would like. For many people with chronic migraine, this is their every day. They feel less stigmatized now that everybody is staying home more often. Everybody is turning down social activities, social events.

Everybody is having to get things delivered to their home for health reasons. Not just because they've made poor life decisions, or because they have a mental health problem, or because they just don't like other people.

These are the kinds of things that are thought about people with chronic migraine who have to restrict their day‑to‑day activities and live in their own virtual world.

They're becoming less stigmatized and better understood for what's going on around the world, and how we have to consider our health and the health of the people around us when we're making decisions about our day‑to‑day lives.

Of course, seeking care in the era of the COVID pandemic is challenging. Again, we don't want to venture out of our homes and expose ourselves to people unnecessarily, but people need health care. Especially when it comes to migraine, there's a lot that has to be done that's hands‑on and that's face‑to‑face.

For people with chronic migraine especially, they may rely on treatments that have to be rendered in the office–for example, injections, intravenous infusions as an injection of medication used to treat acute symptoms of migraine, and other headache injections of anesthetic into painful trigger points in the musculature or to block nerves around the scalp, again to relieve migraine symptoms.

For some people, they rely on this primarily rather than taking medication every day to get injections like this on a routine basis to help keep their symptoms under control.

Another injection treatment is onabotulinum toxin A, which is FDA-approved for the treatment and management of chronic migraine specifically. That's not something that can be done at home. You have to come into the office every 12 weeks to get that treatment.

We've had many patients, even though we've made the effort to keep our office open for these essential types of procedures, even if we can't see everybody face‑to‑face, many patients who rely on these treatments were simply too afraid to come into the office to get that treatment.

When they finally realize that things have gotten so out of control, they have to come back, they're way overdue for their treatment, we have a lot of ground to catch up on. Because oftentimes, when you resume these treatments, it takes a little while for them to pick back up and to get control again.

It may not be a matter of “I'm 3 months late for my injections. I'm going to come in and everything is going to be fine later today.” No, it may take some more time to regain that lost ground, and that's a major challenge that we face.

Again, though, on the upside with the advent of telemedicine, or I shouldn't say the advent of telemedicine, it's been around for a long time. With the massive uptake of telemedicine out of necessity, this in some ways has enhanced the care that we can provide, because a lot of headache medicine is just talking to somebody, and learning about their symptoms and how they affect their day‑to‑day lives, and what you can do to help them manage.

For a lot of what we do, you don't necessarily have to be face‑to‑face and hands‑on. It's more of a one‑on‑one direct connection cerebrally and intellectually and emotionally, and that's not perfect over an audio visual connection, but there is a lot that you can do.

Obviously, there are limitations to telemedicine. You can't be there face‑to‑face, but there are certain advantages as well. I may not have to leave my home, my patient doesn't have to leave their home or their office. We take out all of the stress and issues of having to travel both on my side and the patient’s side, particularly for the patient’s side.

Coming to downtown Philadelphia is a major undertaking for many of our patients, who may live a long distance, and they have to drive several hours or maybe even drive down the night before, stay in a hotel just to have their appointment and then drive home or take the train, and then parking, gas. There's a lot of costs that add up and that can be very stressful. That can trigger an attack or an exacerbation of symptoms.

Many of our patients will tell us they know they need to come in, but it takes their whole day and it takes a major toll on them. Being able to just sit in the comfort of their own home and connect via video, and talk to their doctor and get advice–it's much more comfortable and much lower stress. In fact, many of our patients have been telling us how wonderful this is and they hope that it will continue. I certainly hope that it will continue, because there's definitely a time and place for telemedicine and all of medicine, but particularly for headache medicine.

Now, we can't do everything over a video call. We can't do a hands‑on physical exam. There are certain elements, particularly if there are neurologic exams which are very important in assessing a new patient with headache that we can't do over video. Most of what we do anyway is our history, and that is easy to do over a video call. When we're concerned, we can always express that concern and urge our patients to get to be seen in‑person either locally or to come into our office. Thankfully that hasn't happened too much.

On the whole, having the ability to provide telemedicine care for our patients has been a major plus.