Primary Viewpoints Episode 1: COVID-19 Impact on Migraine Management

Sydney Jennings: Hello, and welcome to Primary Viewpoints from Patient Care Online, a monthly podcast that features informative conversations with healthcare experts, opinion leaders and practicing physicians about what impacts primary care medicine today. My name is Sydney Jennings and I am the associate editor at Patient Care Online and in our first episode Grace Halsey, senior editor of Patient Care Online, talks with Peter McAlister, MD, medical director at the New England Institute of Neurology and Headache and chief medical officer for the New England Institute for Clinical Research, both in Stamford, Connecticut, about the impact of COVID-19 on migraine patients.

Grace Halsey: So your practice is in the tri-state area, Stamford, Connecticut, so in the New York, New Jersey, Connecticut area, could you describe the impact of COVID-19 on health care in the area and healthcare delivery in general, and then more specifically on your practice?

Peter McAllister, MD: The short answer is it's been profound. Clearly with New York City being the epicenter of the number of cases and number of deaths. We are just up the road in Connecticut, a suburb of New York City, so there were a lot of cases. There was a lot of people being quite afraid to go out understandably and quite reasonably. And we had to make some big decisions at our practice. Some practices, neurological practices, closed their doors completely and have gone to a full telemedicine thing. My perspective was that we could probably thread the needle and do it safely to be at least partially open. And my thinking was that if somebody had severe headache requiring shots or intravenous medications, for example, if I wasn't open, they would go to the emergency room which is about the last place you want somebody to go. Certainly my general neurology patients, my MS patients, etc., they need some interventional procedures that we offer here. So what we've done is the following: we will ask the day before a questionnaire for each new patient and each follow-up patient coming in based on exposures and whether they've had it etc. We will take their temperature on the way in, we require they wear a mask, we have masks to provide them if they don't have one. Our staff all wears masks, we do testing on our staff, had been doing it on a weekly basis. And we've also taken half of our staff and assigned them to home and then they rotate, so they spend 2 days in the office and 2 days at home and they split Fridays. What that's done, is it's decreased the actual number of people, our footprint of people here. So it's actually a bit quiet, but I wasn't going to stop seeing patients because I felt that wasn't the right thing to do.

Grace Halsey: Also, one of my follow-up questions was going to be about how you handle patients on an acute basis who need a shot or an infusion for a headache or for some other medical problem, as well as Botox treatments which can't easily be done elsewhere.

Peter McAllister, MD: Right, and I'm on a bunch of listservs of headache specialists around the country, and most headache specialists come down solidly on the most profoundly impacted migraine patients (those who were having 25-30 plus headache days) to take away their Botox would again either send them to the ER or make them nonfunctional. So that was a decision. Certainly, we have markedly curtailed our so-called elective procedures and we're doing more FaceTime and Zoom visits, particularly in our older folks who we'd rather not bring out here. But if somebody wants to come out here for their Botox and feels it's very important to their overall neurological care, they're going to come here and get it. We will be masked, we'll take appropriate precautions.

Grace Halsey: Would you do telehealth visits or a phone visit for an initial visit with new patients and then move forward from there?

Peter McAllister, MD: Some of my colleagues prefer not to do consults by telehealth. My approach to telehealth, is that it's the most minimally effective way to get ideas across in medicine. In other words, I'm not a big fan of it. It turns out, it's even more reinforced in me that the human interaction—to be able to listen carefully to someone's stories, to be able to examine them, etc—is really critically important. I'm glad we have telehealth, I'm glad insurers are covering it to variable extent, but it is just a bare bones minimum. So, I will do a consult over telehealth, but I would also have people come in here. I had a woman who was 47 [years old] who her neurologist just closed the office completely. And she travelled the distance, she called up and said, "Are you seeing live patients?" Our response was "Yes", she came in and actually had a brain disorder called CNS vasculitis. She had had multiple tiny strokes and she was a young woman. She was admitted to the hospital and got a stat workup. I think she would have been in really bad shape had she not come in someplace and gotten examined. I have another guy who has something called Guillain-Barré syndrome, diagnosed just last week, probably related to COVID-19 because he had COVID-19 4 weeks ago. So neurology doesn't go away in the midst of a pandemic, unfortunately.

Grace Halsey: Headache has been discussed as one of the primary symptoms for some people who've been affected by COVID-19. Have you found any relationship at all among your migraine patients? First of all, have you had anybody who has contracted COVID-19?

Peter McAllister, MD: Yes, again, because I'm in the tri-state area, I've been getting increasingly a collection of people who have gotten through COVID-19 and have come in now completely asymptomatic, afebrile, and telling me their story. I've got just anecdotal stories, but a number of patients who are really bad migraine sufferers, told me that yes, they had a headache from COVID-19 that was markedly different from their migraines. Not as severe, involving the entire head, moderate severity, nonthrobbing, and their migraines kind of went away during COVID-19, particularly when it was at its worst. When they got better, they knew they were kind of out of the woods when their migrianes came back. And that's something that we see in very sick individuals, migraines take a backseat and once someone is out of the woods, migraines represent themselves. Although most headache specialists are familiar with that concept, we have no idea why.

Grace Halsey: Do you feel that going forward the fear of the virus is going to continue to keep people from coming in when they need you?

Peter McAllister, MD: It may to some extent, but I hope not. We all need to be very careful. We need to wash our hands. It's been shown fairly conclusively that face masks eliminate or decrease the ability of transmission. If you don't have multiple risk factors, you have to make a personal decision. Is it worth going to your doctor? When we hear these stories about kids not getting their normal routine vaccines because the parents are afraid to go out, when people are having chest pain and aren't telling their doctor, or go into an emergency room. I think net, that's a really bad idea. So I would encourage patients to be thoughtful and be careful, but if you need to go to your neurologist or any specialist you should consider doing so.

Thank you for listening to this episode of Primary Viewpoint. To hear more episodes on a variety of clinical practice topics, visit www.patientcareonline.com. Click on “media” and then “expert interviews."