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This COVID-19 Practice: How Those Migraine Procedures Are Resuming

Whether onabotulinumtoxinA (Botox) to treat migraine is considered an elective procedure varies from one state, health system, and neurologist to the next. "This has been a huge controversy within the headache world," said Deena Kuruvilla, MD, assistant professor of neurology at Yale School of Medicine. "Half of the community says it's not elective because if somebody misses their Botox, the treatment wears off and the patient will end up in the emergency room. And half of the community is saying we can get on video and give them equally effective options for treatment."

Depending on where they stand on the issue, neurology practices are facing a huge backlog of patients needing botulinum toxin treatments when their communities come out of lockdown—or simply working in a few extra appointments that were missed.

As COVID-19 bore down on New York City, Mount Sinai Health System stopped all elective procedures, includingbotulinum toxin treatments for patients with migraine. "We have a lot of people crying on the phone about that," said Mark W. Green, MD, FAAN, professor of neurology, anesthesiology and rehabilitation medicine at Icahn School of Medicine at Mount Sinai. 

Neurologists at Mount Sinai decided to switch patients, if possible, to a calcitonin gene-related peptide (CGRP) monoclonal antibody, which patients can administer on their own. Some insurance companies have been reluctant to pay for a CGRP inhibitor if a patient had already been approved for botulinum toxin, however, forcing Dr. Green and his colleagues to push back.

For one thing, allowing patients to be treated in the clinic would violate the city's stay-at-home order; for another, doing so would require personal protective equipment (PPE) needed in the health system's emergency department and intensive care units. "We can't take it away from them," Dr. Green said in an interview on May 7.

The Miami-Dade County area has also been a COVID-19 hotspot, but neurologists in the University of Miami Health System have more flexibility. Patients who use botulinum toxin to treat migraine are asked to schedule telehealth visits to assess whether the treatment can be postponed, and non-pharmaceutical options—trigger management, stress and relaxation techniques and others—are encouraged.

Teshamae Monteith, MD, FAAN, chief of the headache division at University of Miami's Miller School of Medicine, continued to provide botulinum toxin injections for many patients throughout the two-month lockdown. "I was seeing the majority of my patients because migraine is one of the most disabling conditions worldwide," she said.

Dr. Monteith, associate professor of neurology, found it difficult to implement the American Migraine Foundation's recommendation, issued on March 21, that patients consider postponing and rescheduling all non-emergent procedures for at least the next eight weeks. These injections are scheduled at three-month intervals and, for some patients, the treatment's effectiveness starts wearing off before the next injection is due.

"If they're having severe migraine attacks two weeks prior to their (scheduled) visit and you delay it eight weeks, they're going to be in very bad shape," Dr. Monteith said. "That's evidence that that patient cannot go without treatment."

She stratified patients based on their history with the treatment and other factors:

·      Patients who have a history of emergency department visits and/or overuse of medication when botulinum toxin wears off received injections on their regular schedule.

·      Patients who have a partial benefit to botulinum toxin, sufficient that it reduces the level of disability, received injections on their regular schedule.

·      Patients who have been successfully treated with regular botulinum injections for many years were postponed on the possibility that they would not need treatment until the shutdown ended.

·      Older patients and those with comorbidities who were at high risk of severe illness if they contracted Covid-19 were postponed if possible.

·      Patients who had possible COVID-19 symptoms or exposure to the virus were required to be tested—and shown negative— before botulinum toxin would be given.

Altogether, Dr. Monteith estimated that she treated about 70 percent of her patients during the lockdown.

When COVID-19 first emerged in Connecticut, Dr. Kuruvilla found many of her patients treated with botulinum toxin did not want to risk infection by coming to the clinic; she used telehealth visits to suggest alternatives.

"But as time went by, more of my patients were calling me, literally begging for me to do their injection," she said. "So I went through my own schedule and looked for anybody who was due that had been delayed and I added on extra injection days so that folks wouldn't land in the emergency room with severe migraine."

Dr. Kuruvilla also practices at the VA Connecticut Healthcare System, which took a different approach. "The VA has been converting its Botox patients to CGRP inhibitors and this has been working well," she said. "They do not want their patients coming into the clinic for the procedures while social distancing measures are in place."

Children's Mercy Hospital in Kansas City has not yet experienced a COVID-19 surge, but it did stop offering elective procedures, including botulinum toxin, for several weeks. In mid-April, based on the COVID-19 numbers in the community, the hospital began slowly opening for treatments.

"We tried to limit to more emergent needs, the kids who were almost debilitated to the point they were bedridden and couldn't function normally without Botox," said Gina L. Jones, DO, director of the hospital's neurology clinic. "It was maybe one or two a week."

In May, the clinic re-opened but was not overrun by pent-up demand, said Dr. Jones, clinical associate professor of pediatrics at the University of Missouri-Kansas City School of Medicine. Some parents chose to postpone their child's appointment rather than risk exposure to the virus. "In the earlier weeks (of the pandemic), we were just canceling without having a plan so some of those parents are calling for more emergent Botox, and those are the kids we are working in now," she said.

The hospital temporarily added two acute-procedure clinics a week to treat children who needed acupuncture or nerve blocks to relieve suffering.