Adaptation of the management of chronic migraine patients with medication overuse to the suspension of treatment protocols during the COVID‐19 pandemic: Lessons from a tertiary headache center in Milan—6‐month results

Abstract

This Research Letter provides followup to our earlier work regarding patients with chronic migraine with medication overuse and the suspension of treatment protocols due to the COVID19 pandemic.1 After a 6month followup, we report updated results. The study was initiated following the imposition of restrictions to control the spread of COVID19 across Milan, Italy in March 2020, that impacted clinical activities at a tertiary headache center also in Milan (Foundation IRCSS Carlo Besta Neurological Institute). Because of the restrictions, treatment efforts were modified to make use of communication by telephone and the internet. This Research Letter reports the results of followup after 6 months. Nineteen patients who had undergone withdrawal per our protocol for medication overuse headache were scheduled for followup that included pharmacological prophylaxis combined with behavioral therapy and mindfulness, generally performed in small group sessions. Due to the pandemic, these visits were converted to weekly provider calls and recorded videos to facilitate home practice. Four patients decided to continue only the pharmacological therapy. One patient dropped out after hospitalization for an unrelated medical issue, leaving 14 patients in the program (3 males/11 females; mean age 45.2 ± 8.9) who completed the 6month protocol. Headache days and medications were recorded daily. Because of the small sample size, a descriptive statistical analysis was performed on the obtained results. At the 6month followup, migraine days were significantly reduced: 20.6 ± 6.04 pretreatment versus 8.7 ± 4.5 at 6 months. Medication intake was significantly reduced from 19.4 ± 5.8 pretreatment versus 7.5 ± 5.0 at 6 months. Questionnaires demonstrated a decrease in disability: MIDAS score from 67.7 ± 52.6 pretreatment versus 35.1 ± 36.5 at 6 months and impact at HIT6 from 66.2 ± 5.3 pretreatment versus 60.0 ± 7.6 at 6 months (Table 1). Although adherence was not measured formally, most patients participated actively in the program and did not miss any sessions or video calls. Patients reported that they were comfortable with engaging in the program and felt they had been followed up carefully using this modality. There are limitations to this study. Due to the pandemic, the treatment program was organized over a short period of time. This prevented, among other things, the randomization of patients, addition of an active treatment comparator, addition of a control group, and adequate group size. Nevertheless, the 6month followup provides useful information about the effectiveness of this program, and a longer followup will be important to confirm the clinical results. In conclusion, among the different services that our headache center makes available for patients with chronic migraine and medication overuse, after withdrawal, is a specific behavioral therapy service with relaxation training and in particular mindfulness. After withdrawal, patients usually combine pharmacological prophylaxis with behavioral support in six weekly 60min small group sessions of five to six patients to reinforce their clinical improvement and to develop pain management strategies without the use of medications. Because of the stayathome order necessitated by the pandemic, patients treated with standard withdrawal and waiting for behavioral treatment could not attend the sessions regularly. This led to both anxiety and a real risk of failure of their withdrawal therapy. Thus, this specific protocol of treatment was organized, using technology for mindfulness sessions and video calls, to meet patients’ needs and to continue the therapeutic process started with the withdrawal treatment. Prior studies have demonstrated the efficacy of telemedicine in various clinical applications, including migraine.2,3 The application of telemedicine has been limited to few reports, but recently, an increase in the application of this modality has been recorded due to travel restrictions, especially for patients on pain medicine.4 Our results, although preliminary and in a restricted group of patients, are encouraging for the application of telemedicine as they indicate good clinical effectiveness combined with high adherence of patients. Thus, this could potentially be the beginning of a new era of patient care alongside the conservation of time and resources for both health systems and patients.