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Episodic and Chronic Migraine Treatment during the COVID-19 Pandemic

COVID-19 has made it necessary for clinicians to adapt how they diagnose, treat, and manage patients with chronic diseases, including migraine. With lockdowns and patients concerns about leaving their homes, telemedicine and the availability of efficacious self-administered therapies, such as subcutaneous prophylactic CGRPs, have facilitated the continued care of migraineurs.

Initiation of prophylactic CGRPs is typically prescribed for migraineurs with 4+ migraine days per month who have failed 2+ oral therapies However, since the COVID-19 pandemic, migraine treatment decisions have likely changed due to Botox injection cancellations, potential SARS-CoV-2 infections, increased anxiety or headache triggers, and putative links between the use of certain drugs, such as angiotensin‐converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), and increased COVID-19 infection risk1. (I would delete this portion because it relates to hospitalized COVID-19 patients)

How has the COVID-19 pandemic impacted your prescribing decisions regarding the initiation of prophylactic CGRP therapy in episodic and chronic migraine patients? What are the factors that contribute to treatment selection during the pandemic?

1 https://www.acc.org/latest-in-cardiology/articles/2020/03/17/08/59/hfsa-acc-aha-statement-addresses-concerns-re-using-raas-antagonists-in-covid-19

 

  • April 01, 2021
    I have switched to doing much more telehealth and it has been a positive step as many patients find that they are much happier with the less commute time and trying to find parking, etc. I think that it works just as well as an in person appt for most patients.
  • April 01, 2021
    I have switched to doing much more telehealth and it has been a positive step as many patients find that they are much happier with the less commute time and trying to find parking, etc. I think that it works just as well as an in person appt for most patients.
  • April 01, 2021
    I have switched to doing much more telehealth and it has been a positive step as many patients find that they are much happier with the less commute time and trying to find parking, etc. I think that it works just as well as an in person appt for most patients.
  • March 30, 2021
    Unlike other centers, we did not stop Botox during the pandemic (even with limited PPE initially) because it was felt to be more important to keep patients with migraine out of the ED. Although some patients cancelled their Botox appts and tried switching to CGRP mab, most got much worse and restarted Botox
  • March 30, 2021
    Unlike other centers, we did not stop Botox during the pandemic (even with limited PPE initially) because it was felt to be more important to keep patients with migraine out of the ED. Although some patients cancelled their Botox appts and tried switching to CGRP mab, most got much worse and restarted Botox
  • March 30, 2021
    Unlike other centers, we did not stop Botox during the pandemic (even with limited PPE initially) because it was felt to be more important to keep patients with migraine out of the ED. Although some patients cancelled their Botox appts and tried switching to CGRP mab, most got much worse and restarted Botox
  • March 14, 2021
    I was one of those who initially felt ‘uncomfortable’ treating headaches without seeing a patient in-person; however, now I embrace it. Reduced in-person patient loads have given me the opportunity to have extra time to spend with my patients virtually. Rather than a rushed in-person visit, patients feel they are getting a higher quality visit (longer ‘face-to –face’ time via video or phone). I agree that certain conditions require an in-person physical exam, but migraine headaches can be diagnosed and managed virtually by obtaining a good history. A quick virtual neurological exam can be done by asking the patient to follow certain maneuvers (ex cranial nerve exam). If there are any red flags, then the patient can be instructed to seek an in-person evaluation.
    Since the pandemic, I have had less patients calling and requesting to come in for a shot of Toradol or Imitrex. I did not prescribe CGRP inhibitors before the pandemic, but have incorporated them in my treatment plan since they are easily done by the patient at home. Each CGRP inhibitor drug has ‘how to inject’ video instructions on their website.
  • March 14, 2021
    I was one of those who initially felt ‘uncomfortable’ treating headaches without seeing a patient in-person; however, now I embrace it. Reduced in-person patient loads have given me the opportunity to have extra time to spend with my patients virtually. Rather than a rushed in-person visit, patients feel they are getting a higher quality visit (longer ‘face-to –face’ time via video or phone). I agree that certain conditions require an in-person physical exam, but migraine headaches can be diagnosed and managed virtually by obtaining a good history. A quick virtual neurological exam can be done by asking the patient to follow certain maneuvers (ex cranial nerve exam). If there are any red flags, then the patient can be instructed to seek an in-person evaluation.
    Since the pandemic, I have had less patients calling and requesting to come in for a shot of Toradol or Imitrex. I did not prescribe CGRP inhibitors before the pandemic, but have incorporated them in my treatment plan since they are easily done by the patient at home. Each CGRP inhibitor drug has ‘how to inject’ video instructions on their website.
  • March 14, 2021
    I was one of those who initially felt ‘uncomfortable’ treating headaches without seeing a patient in-person; however, now I embrace it. Reduced in-person patient loads have given me the opportunity to have extra time to spend with my patients virtually. Rather than a rushed in-person visit, patients feel they are getting a higher quality visit (longer ‘face-to –face’ time via video or phone). I agree that certain conditions require an in-person physical exam, but migraine headaches can be diagnosed and managed virtually by obtaining a good history. A quick virtual neurological exam can be done by asking the patient to follow certain maneuvers (ex cranial nerve exam). If there are any red flags, then the patient can be instructed to seek an in-person evaluation.
    Since the pandemic, I have had less patients calling and requesting to come in for a shot of Toradol or Imitrex. I did not prescribe CGRP inhibitors before the pandemic, but have incorporated them in my treatment plan since they are easily done by the patient at home. Each CGRP inhibitor drug has ‘how to inject’ video instructions on their website.
  • March 14, 2021
    I still see patients in person as well as via telehealth and the pandemic has not impacted my use of the monoclonal antibodies. We have learned to get all the information needed to get the PA approval where appropriate
  • March 14, 2021
    I still see patients in person as well as via telehealth and the pandemic has not impacted my use of the monoclonal antibodies. We have learned to get all the information needed to get the PA approval where appropriate
  • March 14, 2021
    I still see patients in person as well as via telehealth and the pandemic has not impacted my use of the monoclonal antibodies. We have learned to get all the information needed to get the PA approval where appropriate
  • February 25, 2021
    I have not noticed a significant increase in the amount of migraines headaches my patients reported during the pandemic
  • February 25, 2021
    I have not noticed a significant increase in the amount of migraines headaches my patients reported during the pandemic
  • February 25, 2021
    I have not noticed a significant increase in the amount of migraines headaches my patients reported during the pandemic
  • February 16, 2021
    I am prescribing CGRP inhibitors , pandemic has not effected my decision, preauthorisation process is the one that takes time..
  • February 16, 2021
    I am prescribing CGRP inhibitors , pandemic has not effected my decision, preauthorisation process is the one that takes time..
  • February 16, 2021
    I am prescribing CGRP inhibitors , pandemic has not effected my decision, preauthorisation process is the one that takes time..
  • February 16, 2021
    Some of the factors that contribute to treatment selection would be the patients history of using previous medications for migraines, effectiveness of switching to a new medication, and mode of administration to comply with social distancing.
  • February 16, 2021
    Some of the factors that contribute to treatment selection would be the patients history of using previous medications for migraines, effectiveness of switching to a new medication, and mode of administration to comply with social distancing.
  • February 16, 2021
    Some of the factors that contribute to treatment selection would be the patients history of using previous medications for migraines, effectiveness of switching to a new medication, and mode of administration to comply with social distancing.
  • February 16, 2021
    While it is a bit uncomfortable to prescribe such medications without the typical "hands-on" of an office visit, the criteria for therapy initiation remain the same. After a lengthy discussion with the patient involving risks, side-effects, precautions, dasnger signs, etc., I will proceed with therapy.
  • February 16, 2021
    While it is a bit uncomfortable to prescribe such medications without the typical "hands-on" of an office visit, the criteria for therapy initiation remain the same. After a lengthy discussion with the patient involving risks, side-effects, precautions, dasnger signs, etc., I will proceed with therapy.
  • February 16, 2021
    While it is a bit uncomfortable to prescribe such medications without the typical "hands-on" of an office visit, the criteria for therapy initiation remain the same. After a lengthy discussion with the patient involving risks, side-effects, precautions, dasnger signs, etc., I will proceed with therapy.
  • February 16, 2021
    The same increase in prescriptions number applies for acute treatment with anti-CGRP meds as well as chronic tx.
  • February 16, 2021
    The same increase in prescriptions number applies for acute treatment with anti-CGRP meds as well as chronic tx.
  • February 16, 2021
    The same increase in prescriptions number applies for acute treatment with anti-CGRP meds as well as chronic tx.
  • February 16, 2021
    Anti-CGRP meds are great for most of the patients with chronic migraine, so the prescriptions number has increased during the covid19 pandemic, along with more migraine due to increased stress, job uncertainty, and headache as one of the first signs of covid infection.
  • February 16, 2021
    Anti-CGRP meds are great for most of the patients with chronic migraine, so the prescriptions number has increased during the covid19 pandemic, along with more migraine due to increased stress, job uncertainty, and headache as one of the first signs of covid infection.
  • February 16, 2021
    Anti-CGRP meds are great for most of the patients with chronic migraine, so the prescriptions number has increased during the covid19 pandemic, along with more migraine due to increased stress, job uncertainty, and headache as one of the first signs of covid infection.
  • February 16, 2021
    Since the COVID-19 pandemic, I have utilized telemedicine more. I have prescribed more prophylactic CGRPs especially during this time of increased anxiety.
  • February 16, 2021
    Since the COVID-19 pandemic, I have utilized telemedicine more. I have prescribed more prophylactic CGRPs especially during this time of increased anxiety.
  • February 16, 2021
    Since the COVID-19 pandemic, I have utilized telemedicine more. I have prescribed more prophylactic CGRPs especially during this time of increased anxiety.
  • February 16, 2021
    I am seen the migraine patients in the office, prescribing the prophylactic CGRP meds, triptans, and some injectables for the chronic migraine prevention
  • February 16, 2021
    I am seen the migraine patients in the office, prescribing the prophylactic CGRP meds, triptans, and some injectables for the chronic migraine prevention
  • February 16, 2021
    I am seen the migraine patients in the office, prescribing the prophylactic CGRP meds, triptans, and some injectables for the chronic migraine prevention
  • February 16, 2021
    I arose patients in the office and have prescribed this class with very effective results
  • February 16, 2021
    I arose patients in the office and have prescribed this class with very effective results
  • February 16, 2021
    I arose patients in the office and have prescribed this class with very effective results
  • January 23, 2021
    I have done a lot more telehealth since the pandemic started and thinking earlier about cGRP inhibitors since botox and other procedures in the office are more difficult to do.
  • January 23, 2021
    I have done a lot more telehealth since the pandemic started and thinking earlier about cGRP inhibitors since botox and other procedures in the office are more difficult to do.
  • January 23, 2021
    I have done a lot more telehealth since the pandemic started and thinking earlier about cGRP inhibitors since botox and other procedures in the office are more difficult to do.
  • January 17, 2021
    More telemedicine but I’m still prescribing these medications
  • January 17, 2021
    More telemedicine but I’m still prescribing these medications
  • January 17, 2021
    More telemedicine but I’m still prescribing these medications
  • January 17, 2021
    The epidemic has not affected my ability to prescribe CGRP inhibitors. When deemed necessary, there is a fairly involved preapproval process required to get these meds covered by insurance which is the major time limiting factor in prescribing the class. The process is generally done on the phone and online and has not changed with COVID-19.
  • January 17, 2021
    The epidemic has not affected my ability to prescribe CGRP inhibitors. When deemed necessary, there is a fairly involved preapproval process required to get these meds covered by insurance which is the major time limiting factor in prescribing the class. The process is generally done on the phone and online and has not changed with COVID-19.
  • January 17, 2021
    The epidemic has not affected my ability to prescribe CGRP inhibitors. When deemed necessary, there is a fairly involved preapproval process required to get these meds covered by insurance which is the major time limiting factor in prescribing the class. The process is generally done on the phone and online and has not changed with COVID-19.