Headache Clinic Workflows During the COVID-19 Pandemic

Telemedicine and precaution can provide relief safely, according to Nina Riggins, MD, Ph.D, and Rashmi Halker Singh, MD, FAHS, FAAN

The COVID-19 pandemic has fundamentally altered how clinicians are able to see and treat their patients, and headache specialists are no different. Faced with an unprecedented situation, physicians are turning to each other to determine the best practices for COVID-19 workflows to help their patients while also protecting themselves.

Rashmi Halker Singh, MD, FAHS, FAAN, a headache medicine neurologist at Mayo Clinic, has found insight from neurology groups that she belongs to on social media. “People are saying ‘This is what’s happening at my clinic; what are you guys doing?’ The conversations grow from there and one person’s ideas will spark somebody else’s ideas.” She and her colleagues discuss how to provide rescue treatment for patients while reducing their risk of exposure to COVID by keeping them out of busy  EDs, infusions centers, and procedure clinics. Doctors like her are pressed to become inventive. 

“We need to continue to take all appropriate actions to help protect the safety and health of our headache community. But we also need to ensure that we continue to provide care for all our patients during this pandemic,” says Nina Riggins, MD, a neurologist at UCSF Health. Dr. Riggins proposes the following two workflows for headache specialists to treat patients safely during the pandemic.  

Workflow #1: Telemedicine Whenever Possible

Dr. Riggins recommends using telemedicine for all non-urgent patient clinic visits, including new patients, follow-up patients, and in place of procedure visits. Mayo Clinic followed this route, delaying all non-urgent face to face office visits and procedures for eight weeks. “Due to the severity of this outbreak, the ability of the virus to spread undetected, and lack of testing and personal protective equipment, in-person appointments are not the safest option and should not be done unless medically urgent,” says Dr. Riggins.

“One of the biggest factors that is impacting the whole situation is that we don’t have enough personal protective equipment,” says Dr. Halker Singh. “It’s a novel virus, which means nobody is immune to it, and it’s spreading very quickly. The last thing any of us wants is to be a vector and transmit it from one patient to another person.”

Research has shown that telemedicine is a good, often preferable option for patients, which Dr. Riggins says specialists should make use of. “While the coronavirus pandemic is active, headache specialists must maintain patient continuity and care using telemedicine or over the phone visits whenever possible. There must be no in-person visits, unless there is a medically urgent reason,” says Dr. Riggins.

Additionally, clinicians should help patients find alternative, self-administered treatments to prevent them from going to outpatient clinics for face to face visits. “When we’re talking about migraine prevention at a time like this,” says Dr. Halker Singh, “instead of using onabotulinumtoxinA, maybe we reach for CGRP monoclonal antibodies.” It’s also possible, virtually, to teach patients to self-administer injections, or to coach them through integrating FDA-cleared neuromodulation devices for migraine and cluster headache.

Workflow #2: Open and Safe Clinics

Some headache patients still require in-person treatment, however, in which case Dr. Riggins proposes a clinic workflow during the pandemic, which includes:

• Prevention: Clinics should send a message and place a phone call to each clinic patient the day before their scheduled appointments, asking that they not come to the headache clinic if they have fever, cough or other symptoms of cold/infection. “In case of symptoms, we provide resources and plan for the way forward—such as a specific call-in number for what to do next,” says Dr. Riggins.
• A front desk triage: “If, after phone screening, a patient comes in for a visit, and the patient is high-risk or has symptoms, instruct the patient to put on a mask that you provide and place the patient in isolation,” recommends Dr. Riggins. “Put personal protective equipment on yourself and conduct the patient visit only if you are satisfied with the safety precautions. If you are not, conduct the visit over the phone while the patient is in an isolation room.
• Social distancing: It’s not unusual for headache patients to come to a clinic with family members, but it’s best to ask patients to come in alone for the time being.
• Model and encourage handwashing: Doctors should wash their hands in front of the patients, show them the World Health Organization 20-second hand washing method and encourage patients to do the same.

Tips for Implementation

There are some methods for implementing these two workflows to make them effective for patients whose headache attacks don’t stop during a pandemic.

With regards to telemedicine, Dr. Riggins explains, clear communication about the plan of action and next steps is essential. “I offer follow up video appointments, and I also make sure that I include a comprehensive after-visit summary to the patients.” She sends this to the patients directly as well as including it in their chart and electronic records.

This is also a good time to remind patients about non pharmacologic treatment options including  lifestyle modification, and reminders that regular sleep and hydration can help avoid headache triggers and exacerbation. Coaching patients on how to manage the stress, especially if it’s triggered by current events, can be helpful. “It’s a very stressful time for everyone, and we all know that this is a big migraine trigger,” says Dr. Halker Singh. We want to make sure that they’re taken care of and that their headache disorder is under the best control possible so that they don’t need to go into the ER, which is not a safe place at this point for patients with migraine,” says Dr. Halker Singh.

A Team Effort

Dr. Halker Singh wants clinicians to utilize their networks and lean on each other during this stressful time. “I think it’s been a very difficult time for a lot of clinicians. Many people who I’ve spoken to have told me that they feel a little bit alone or maybe that they’re not sure that their concerns are being heard. They need to remember to continue to speak up.” She explains that a doctor’s first duty is to do no harm. “We have to be safe, we’ve got to take care of our patients and we have to take care of ourselves. We have a community. If clinicians don’t know what to do, there are other colleagues who are in the same situation and they can always reach out.” 

She suggests doctors reach out to one another through the different means that they might be comfortable using. This could include social media, and if they aren’t on social media, by calling or texting a colleague. Dr. Halker Singh says, “Because chances are they’re experiencing the same thing you are. My experience over the last week is that a lot of people have ideas that I haven’t even thought of. We’re all in this together.”