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Patient impact and management tips for physicians
The COVID-19 pandemic is an unprecedented public health crisis that has disrupted millions of lives globally.
This “new normal,” in which people’s homes have become their office, gym, school and more, has impacted everyone differently. Some, perhaps, were already telecommuting to work or home schooling their children; however, for others, this transition has been difficult.
Take patients with migraines, for example. When asked how the COVID-19 pandemic has impacted her migraine patients, says Susan Hutchinson, M.D., a headache specialist, family physician and founder of the Orange County Migraine & Headache Center in Irvine, California, “For about one-third of my migraine patients, their migraines are better, one-third are worse and one-third are about the same.”
Increased stress may be part of the problem
To further understand just how much the pandemic is affecting adults in the United States, the American Psychological Association (APA) adapted its annual Stress in America poll into a monthly analysis of stressors and stress levels. The online survey was conducted from April 24-May 4, 2020, by the Harris Poll on behalf of the APA and included 3,013 U.S. adults ages 18 and older.
The findings showed that the average reported stress level for U.S. adults related to the COVID-19 pandemic was 5.9 on a scale of 1-10 (1 meaning “little or no stress” and 10 meaning “a great deal of stress”). Regarding stress level in general, the average reported stress level was 5.4, which marks the first significant increase in average reported stress among U.S. adults since the survey started in 2007, according to the APA.
These rising stress levels are particularly concerning for patients with migraines, for whom stress is a common trigger. According to the American Headache Society, 4 out of 5 patients with migraines report stress as a trigger.
When asked how her migraine patients were managing during the pandemic, says Linda Davis, M.D., a family physician with Kolvita Family Medical Group in Mission Viejo, California.“I do think (COVID-19) had a negative impact and (that) they’re probably suffering from more (migraines) because of the stress.”
One source of stress for patients with migraines could be tension in the household related to home offices and remote learning. Such changes may have forced some adult patients with migraines to telecommute for work and/or home-school their children and younger migraine patients to switch from in-school learning to home schooling.
Millions of families are affected
Education Week, an independent news organization that provides comprehensive coverage on K-12 education, tracked pandemic-related U.S. school closures. From March 6-May 15, 2020, school closures impacted as many as 55.1 million students in 124,000 public and private schools nationwide at the pandemic’s peak.
In addition, a significant number of adults switched from working at the office to telecommuting if their job permitted. According to a Gallup poll conducted from March 30-April 2, 2020, 62% of employed Americans said they’ve been working from home during the pandemic (double the number working from home in mid-March).
Although working from home offers some benefits, including increased flexibility and time spent with loved ones, for some, that extra family quality time may be a source of stress. “There’s a lot of tension in some households with kids home, Mom and Dad home,” Hutchinson says.
For example, a 12-year-old migraine patient of Hutchinson’s presented with headaches that had transformed into a refractory pattern. “After further discussion with the mother, she said the husband, because he’s stuck at home all day with the daughter, (is) angry,” explains Hutchinson. “He’s angry at the slow internet speed. He’s just angry at the world, and I think he makes his 12-year-old daughter feel like she’s somewhat responsible.”
The patient was also missing her friends from school, so Hutchinson told the patient’s mother, “I’m going to do what I can with medication, but all the medication in the world isn’t going to be able to get your daughter back to an infrequent episodic pattern.” Hutchinson advised that they look at the family dynamics at home to relieve some of the patient’s stress.
Davis shares a similar example of a patient who was doing well with her maintenance medications for some time, but she developed a migraine recently that would not break and came into the office for an injection.
“We were talking about it, and she said that what’s been hard for her is normally when she gets in these cycles of migraines that she can’t break, there’s a reprieve at home. Home is ... her safe place (where) she can go lie down, she can relax,” says Davis. “But right now, she’s working from home, her husband’s working from home, the kids are being home-schooled. So suddenly, her stress environment is her home.”
Davis adds that the patient had to get in her car and take a drive to find some peace. “It was kind of an eye opener. … I think maybe in the beginning, the migraines (were) a little bit less, but as time goes on, I think this (new normal) is becoming a trigger for (patients with migraines),” she says.
Pandemic impacts women and men differently
Female patients with migraines are a group of particular concern during the pandemic. Women have migraines three times as often as men, and migraine is also one of the leading serious health issues affecting women.
“I think the women probably are faring worse than men because women have children to take care of now who maybe had been going to school,” notes Hutchinson about her female migraine patients. “So all of a sudden, they have the school responsibilities. Many of them also have careers and jobs so they also have work responsibilities.”
A Kaiser Family Foundation Health Tracking Poll conducted March 25-30, 2020, included 1,226 U.S. adults age 18 and older and found a widening gap between men and women in self-reported negative mental health impact from COVID-19. Overall, 53% of women said worry or stress related to the COVID-19 pandemic has had a negative impact on their mental health vs 37% of men, and this gap widened more among parents of children under age 18 — with 57% of mothers vs 32% of fathers reporting their mental health has gotten worse during the pandemic.
“There have been a lot of articles in the medical literature, sort of opinion articles, that (the pandemic) is going to set women back quite a bit in general because what’s going to happen is when the fall comes and their kids are not going back to school, somebody’s going to have to stay home. And usually it ends up being the woman,” says Davis. “It’s going to be a vicious cascade across the board because more of the home responsibilities are already still on the women.”
COVID-19 impact on care for migraine patients
Physician practices across the country have had to change the way they deliver care to ensure patient safety in response to the COVID-19 crisis.
An April 2020 survey of 842 U.S. physicians conducted by the physician search firm Merritt Hawkins, in collaboration with The Physicians Foundation, found that 48% of physicians are treating patients through telemedicine. This is a significant increase since 2018, when only 18% of physicians reported using telemedicine.
Peter McAllister, M.D., medical director at the New England Institute for Neurology and Headache and chief medical officer for the New England Institute for Clinical Research and Ki Clinical Research in Stanford, Connecticut, explains how being near the epicenter of COVID-19 cases drastically changed how he delivered care to his migraine patients. “The short answer is, it’s been profound,” he says. “Clearly with New York City being the epicenter of the number of cases and number of deaths — (and) we are just up the road in Connecticut. There were a lot of people being quite afraid to go out, understandably and quite reasonably.
“We had to make some big decisions at our practice. Some practices, neurological practices, closed their doors completely and have gone to a full telemedicine thing. My perspective was that we could probably thread the needle and do it safely to be at least partially opened.”
As now mandated by the Centers for Disease Control and Prevention for patient safety, McAllister and colleagues call all patients the day before an appointment to complete a questionnaire on potential COVID-19 exposure or infection; the questions are repeated upon arrival at the office, and temperature is checked. Patients and staff are required to wear a mask or other face covering.
McAllister and his staff also get tested for COVID-19 on a weekly basis; half the staff is assigned to work from home, and then they rotate.
“It’s decreased the actual number of people, our footprint of people, here. So it’s actually a bit quiet, but I wasn’t going to stop seeing patients because I felt that wasn’t the right thing to do,” says McAllister.
Hutchinson has made similar changes to care delivery for migraine patients.
“We’re encouraging everyone to do a virtual follow-up,” says Hutchinson. “We do allow people to come in ... if they’re not doing well, and some people come in for a nerve block. ... We also still have patients that come in every 12 weeks for Botox for their chronic migraine.”
Communication with migraine patients is also important in delivering quality care during the pandemic. At Kolvita Family Medical Group, Davis and her staff send out weekly emails with COVID-19 updates to patients.
“We get a nice response when we send out our emails because they’re pretty objective and informative. We’ll get responses saying, ‘Thank you. It’s always so calming to hear from you guys and get some real information,’ even though we’re very clear that we don’t have all of the answers and that the testing is not as accurate as we would hope it would be,” Davis says.
The continued uncertainty around when the pandemic will come to an “end” can be particularly difficult for migraine patients who like structure.
“It’s going to be a process though, right? There’s still going to be a little stress as things open up because you have that uneasiness of, ‘Is it safe?’ It’s the new normal, so I think it’ll be gradual, but yes, some people’s migraines will get better as they feel more comfortable getting back to some degree of normalcy,” says Hutchinson.
Until then, communicating with migraine patients is important. The pandemic continues to evolve, and new information is released nearly every day — but there is also a lot of misinformation that can make it for hard for patients to decipher fact from fiction.
“Our weekly emails have been huge,” says Davis. “Sometimes it’s hard to be super proactive, but that persistent reminder that they need to not disregard other aspects of their health care is very important. The persistent reminder that we’re still here, even if it’s not physically in the office, we have access by phone and technology. That constant ‘Please reach out to us if you have questions and concerns on any of your health care issues’ is hugely important.”
If the only communication to the patient base is telling them about the office’s COVID-19 protocols, patients may get the impression that their physician is only focusing on COVID-19 and not on other important health concerns, including migraine.
Says Davis: “I think (if you have) some method (to communicate) — whether it’s on your website or if you have a social media platform that your patients look at or you have the ability to mass message them — (you) should.”