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Telemedicine Found Noninferior to Office Visits for Chronic Headache Disorder

ARTICLE IN BRIEF

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SEVERAL recent papers have reported on the safety and efficacy of telemedicine for headache.

Researchers found no differences in safety and efficacy between telemedicine and traditional visits for acute headache. But independent experts, while supportive of telemedicine for improving access to physicians, particularly in rural areas, cited some limitations and contraindications for using telemedicine.

As measured by years of life lost to disability, headache disorders are the third-highest specific cause of disability worldwide, according to a 2015 study in the Journal of Headache Pain. Many patients with chronic headache disorders find themselves traveling long distances to see specialists — missing work and spending money on travel, parking, and sometimes even local lodging.

But a Norwegian study published in the June 14 online edition of Neurology is the latest in the scientific literature to report that telemedicine can make care more accessible for chronic headache patients, without sacrificing quality.

Kai Ivar Müller, MD, of the department of neurology at University Hospital of North Norway in Tromsø and the study's lead author, described a typical patient. “Imagine Margaret, who lives about 800 km from our secondary neurological clinic. To attend her headache consultation, Margaret has to drive 40 km to the nearest airport, take a plane to Hammerfest, then another flight from Hammerfest to Tromsø, and a taxi from the airport to Tromsø University Hospital,” he said.

“To prevent flight delays or cancellations, for example, caused by weather conditions, Margaret will probably plan her travel to the day prior to the consultation. To have a specialist consultation, rural patients in our area need to spend one to two days away from home.”

STUDY DESIGN, RESULTS

The noninferiority trial randomized 402 nonacute headache patients to a one-time visit via telemedicine (n=200) or in a traditional manner (n=202). Questionnaires at three and 12 months after the visit assessed comparative efficacy based on patients' change from baseline in the Headache Impact Test-6 (HIT-6), the primary endpoint, and pain intensity as measured by the visual analogue scale (VAS), the secondary endpoint.

The researchers found no difference between the telemedicine and traditional visits on either HIT-6 (p=0.84) or VAS (p=0.64). On the study's safety endpoint, presence of secondary headache at 12 months, there was also no difference; one secondary headache was found at 12 months in each group.

EXPERTS COMMENT

“This is a particularly important study for patients with headache who are trying to get access to care in places that are very remote,” said Gretchen Tietjen, MD, professor and chair of neurology at the University of Toledo Medical Center (UTMC) and director of the UTMC Headache Treatment and Research Program, who was not involved with the study. “It's hard to do effective follow-up when your patient lives four or five hours away or more; often, the headache specialist ends up doing a one-time visit, writes down their recommendations, and the patient's subsequent follow-up is only with their primary care provider.”

These findings also echo the conclusions of other recent papers on the safety and efficacy of telemedicine for headache. For example, at the 2015 meeting of the American Headache Society, researchers from Mercy Virtual in St. Louis presented results of a study involving its TeleHeadache program, showing that 77.4 percent of follow-up migraine patients were prescribed or recommended evidence-based acute medication via telemedicine, versus 27.0 percent of those who received care locally.

Nauman Tariq, MD, now a clinical assistant professor in the department of neurology and ophthalmology at Michigan State University and a headache specialist at Michigan Headache and Neurological Institute, led a “virtual headache clinic” ten-patient pilot study while in his fellowship in headache medicine at the Cleveland Clinic from 2014-2015. “As a tertiary care center, a lot of these patients come from great distances, and the burden of traveling for follow-up care can be significant,” he said.

The visits were conducted using Cleveland Clinic's in-house version of a Skype-style video visit app, which could be downloaded to the patient's smartphone or tablet. All were existing patients — and Dr. Tariq stressed the importance of a face-to-face initial visit.

“You need to meet with the patient in person for that first visit, to conduct the physical examination and history, establish rapport, and make sure all the exams are normal. That is essential,” he said. “But after that, once the diagnosis is established, telemedicine visits for headache are very feasible and cost-effective. They save time for both the patient and the doctor, and they save money for the patient as well.”

Because Dr. Tariq's project was a pilot study, patients were not charged for the telemedicine visit and no insurance coverage was used, but patients saved $58 on average in gas, tolls, parking and other expenses. An after-visit survey conducted using a secure online tool found that patients were satisfied with the care and visit, he said.

After Dr. Tariq took his position in Michigan, the program continued at the Cleveland Clinic and continues to be successful, he said. Other programs in the department of neurology at the clinic are also taking advantage of telemedicine.

Robert Wilson, DO, a specialist in autonomic disorders, told Neurology Today that between 20 percent and 30 percent of his follow-up patients in a given week are not within a six- to eight-hour commute. “I have one patient in Florida with an autoimmune neurologic disease, for example,” he said. “She emailed me that she wasn't doing well, so we scheduled a virtual visit for 7:30 the next morning. But it's not always patients who are far away. I did a telemedicine appointment last week with one woman who lives right here in the Cleveland area, but she's a professional who works 50 hours a week and has three kids, and getting to the office is prohibitive.”

Telemedicine solves one of patients' biggest frustrations with the health care system, Dr. Wilson said. “Their biggest frustration is access, and a big frustration for doctors is patients adhering to their care plan. Virtual visits make access easier for the patients and give the doctor the opportunity to reinforce what needs to be done.”

“In some other neurologic subspecialties, you really need to lay hands on the patient at every visit,” said Stewart J. Tepper, MD, professor of neurology at the Geisel School of Medicine at Dartmouth, who was involved with telemedicine while at the New England Center for Headache in Stamford, CT, and during the pilot at the Cleveland Clinic. “But as long as the patient has primary headaches, and as long as the headache pattern is stable — we like it stable for at least six months — telemedicine for headache is very reasonable. The patient can send their patient-reported outcomes and headache diary online or via fax.”

That said, Dr. Tepper cautions that there are some patients who may have contraindications for virtual visits. “If the patient worsens despite your interventions while using telemedicine, you may have to insist they come in. Or if they are prescribed a drug that requires closer monitoring, it may be that telemedicine is not the best fit for that patient.”

Charles E. Argoff, MD, professor of neurology at Albany Medical College and director of the Comprehensive Pain Center at Albany Medical Center, said it would be wrong to conclude from the study, however, that telemedicine is an effective approach for the treatment of headache.

“The study supports that a single specialty consultation in person versus a telemedicine consultation yields the same result,” Dr. Argoff told Neurology Today. The study did not consider whether “optimal care” was delivered equivalently in the two settings, he pointed out.

The study leaves the impression that “a single encounter is all you need for optimal treatment of headache. We know that isn't the case,” Dr. Argoff said. “The optimal care of a person with chronic, intermittent headache would not be one and done.”

He said follow-up appointments are standard to assess how patients are faring on medical or non-medical therapies and whether treatment approaches need adjusting.

Dr. Argoff said another shortcoming of the published report was that it didn't provide details on how the telemedicine assessment was done. He said that during a traditional office visit for headache it is important to do an exam that includes a general medical evaluation as well as evaluating for neurologic deficits and other “red flags” that may indicate a more specific and potentially serious condition underlying the headache disorder.

Experts noted, as well, that the issue of payment and insurance coverage for telemedicine is still evolving. “Many patients self-pay for these visits, with some using health savings accounts to cover the cost. Insurance issues are still being figured out, plan by plan,” Dr. Wilson said.

EXPERTS: ON TELEMEDICINE FOR CHRONIC HEADACHE

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DR. GRETCHEN TIETJEN: “This is a particularly important study for patients with headache who are trying to get access to care in places that are very remote. Its hard to do effective follow-up when your patient lives four or five hours away or more; often, the headache specialist ends up doing a one-time visit, writes down their recommendations, and the patients subsequent follow-up is only with their primary care provider.”

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DR. NAUMAN TARIQ: “You need to meet with the patient in person for that first visit, to conduct the physical examination and history, establish rapport, and make sure all the exams are normal. That is essential. But after that, once the diagnosis is established, telemedicine visits for headache are very feasible and cost-effective.”

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DR. STEWART J. TEPPER: “If the patient worsens despite your interventions while using telemedicine, you may have to insist they come in. Or if they are prescribed a drug that requires closer monitoring, it may be that telemedicine is not the best fit for that patient.”

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DR. CHARLES E. ARGOFF said the study leaves the impression that “a single encounter is all you need for optimal treatment of headache. We know that isnt the case. The optimal care of a person with chronic, intermittent headache would not be one and done.”

LINK UP FOR MORE INFORMATION:

• Müller KI, Alstadhaug KB, Bekkelund SI, et al. A randomized trial of telemedicine efficacy and safety for nonacute headaches http://neurology.org/lookup/doi/10.1212/WNL.0000000000004085. Neurology 2017; Epub 2017 Jun 14.
    • Steiner TK, Birbeck GL, Jensen RH, et al. Headache disorders are third cause of disability worldwide https://thejournalofheadacheandpain.springeropen.com/articles/10.1186/s10194-015-0544-2. J Headache Pain 2015; 16:58.
      • American Headache Society Abstract 2015: Markwell M, et al. TeleMedicine improves migraine care quality: Results of a pilot teleheadache program. http://bit.ly/AHS-pilottelemedicine.