Headache infusion centers: A survey on treatments provided, infusion center operations, and barriers to developing new infusion centers.

BACKGROUND: Infusion therapy refers to the intravenous administration of medicines and fluids for the treatment of status migrainosus, severe persistent headaches, or chronic headache. Headache practices and centers offer this treatment for patients as an alternative to the emergency department (ED) setting. However, little information is available in the literature on understanding the operations of an infusion center. OBJECTIVE: We sought to survey the Inpatient Headache & Emergency Medicine specialty section and the Academic Program Directors listserv of the American Headache Society (AHS) to better understand current practices. METHODS: A survey was advertised and distributed to the listservs of both the Inpatient Headache & Emergency Medicine specialty section and the Academic Program Directors, which combined included both academic and private practices. In addition, the survey was available on laptops at related events at an annual AHS meeting in Scottsdale. RESULTS: Of the 127 members of the combined group of both listservs, 50 responded with an overall survey response rate of 39%. Ten out of fifty were from programs with more than one responder completing the survey, leaving 40 unique headache programs. Academic programs made up the majority of programs (85%, 34/40). The total of 40 participating programs is comparable with the 47 academic headache programs listed on the American Migraine Foundation website at the time of the survey. Of the academic programs surveyed, most were hospital based (n = 23) compared with a satellite location (n = 11). Of all programs surveyed, 68% (27/40) offered infusion therapy. Of those that did not have an infusion practice (n = 13), the most common reason cited was insufficient staffing (n = 8). Key highlights of the survey included the following: The majority of programs offering infusions obtain prior authorization before scheduling (70%, 19/27) and offer patient availability 5 days/week (78%, 21/27) typically only during business hours (81%, 22/27). Programs reported that they typically give three to four medications during each infusion session (72%, 18/25). Treatment paradigms varied between programs. Programs surveyed were concentrated in the Northeast and Midwest regions of the United States. CONCLUSION: The limited number of headache infusion centers overall may contribute to the limited ability of headache infusion centers to prevent ED migraine visits. Headache patients can have unpredictable headache onset, and most of the infusion practices surveyed appeared to adapt to this by offering infusions most days during a work week. However, this need for multiple days per week may also explain the most common reason for not having an infusion practice, which is insufficient staffing. Various treatment paradigms are implemented by different practitioners, and future studies will have to focus on investigation of best practice.

Telehealth as a new care delivery model: The headache provider experience.

OBJECTIVE: To assess telehealth practice for headache visits in the United States. BACKGROUND: The rapid roll out of telehealth during the COVID-19 pandemic impacted headache specialists. METHODS: American Headache Society (AHS) members were emailed an anonymous survey (9/9/20-10/12/20) to complete if they had logged ≥2 months or 50+ headache visits via telehealth. RESULTS: Out of 1348 members, 225 (16.7%) responded. Most were female (59.8%; 113/189). Median age was 47 (interquartile range [IQR] 37-57) (N = 154). The majority were MD/DOs (83.7%; 159/190) or NP/PAs (14.7%; 28/190), and most (65.1%; 123/189) were in academia. Years in practice were 0-3: 28; 4-10: 58; 11-20: 42; 20+: 61. Median number of telehealth visits was 120 (IQR 77.5-250) in the prior 3 months. Respondents were "comfortable/very comfortable" treating via telehealth (a) new patient with a chief complaint of headache (median, IQR 4 [3-5]); (b) follow-up for migraine (median, IQR 5 [5-5]); (c) follow-up for secondary headache (median, IQR 4 [3-4]). About half (51.1%; 97/190) offer urgent telehealth. Beyond being unable to perform procedures, top barriers were conducting parts of the neurologic exam (157/189), absence of vital signs (117/189), and socioeconomic/technologic barriers (91/189). Top positive attributes were patient convenience (185/190), reducing patient travel stress (172/190), patient cost reduction (151/190), flexibility with personal matters (128/190), patient comfort at home (114/190), and patient medications nearby (103/190). Only 21.3% (33/155) of providers said telehealth visit length differed from in-person visits, and 55.3% (105/190) believe that the no-show rate improved. On a 1-5 Likert scale, providers were "interested"/"very interested" in digitally prescribing headache apps (median 4, IQR 3-5) and "interested"/"very interested" in remotely monitoring patient symptoms (median 4, IQR 3-5). CONCLUSIONS: Respondents were comfortable treating patients with migraine via telehealth. They note positive attributes for patients and how access may be improved. Technology innovations (remote vital signs, digitally prescribing headache apps) and remote symptom monitoring are areas of interest and warrant future research.

Neuroscience Education as Therapy for Migraine and Overlapping Pain Conditions: A Scoping Review.

BACKGROUND: Neuroscience education therapy (NET) has been successfully used for numerous overlapping pain conditions, but few studies have investigated NET for migraine. OBJECTIVE: We sought to 1) review the literature on NET used for the treatment of various pain conditions to assess how NET has been studied thus far and 2) recommend considerations for future research of NET for the treatment of migraine. DESIGN/METHODS: Following the PRISMA guideline for scoping reviews, co-author (TR), a medical librarian, searched the MEDLINE, PsychInfo, Embase, and Cochrane Central Clinical Trials Registry databases for peer-reviewed articles describing NET to treat migraine and other chronic pain conditions. Each citation was reviewed by two trained independent reviewers. Conflicts were resolved through consensus. RESULTS: Overall, a NET curriculum consists of the following topics: pain does not equate to injury, pain is generated in the brain, perception, genetics, reward systems, fear, brain plasticity, and placebo/nocebo effects. Delivered through individual, group, or a combination of individual and group sessions, NET treatments often incorporate exercise programs and/or components of other evidence-based behavioral treatments. NET has significantly reduced catastrophizing, kinesiophobia, pain intensity, and disability in overlapping pain conditions. In migraine-specific studies, when implemented together with traditional pharmacological treatments, NET has emerged as a promising therapy by reducing migraine days, pain intensity and duration, and acute medication intake. CONCLUSION: NET is an established treatment for pain conditions, and future research should focus on refining NET for migraine, examining delivery modality, dosage, components of other behavioral therapies to integrate, and migraine-specific NET curricula.

Understanding How to Strengthen the Neurology Pipeline With Insights From Undergraduate Neuroscience Students.

Despite increased neuroscience interest at the undergraduate level, a significant shortage of neurologists in the United States exists. To better understand how to generate more interest in neurology, specifically at the undergraduate level, we conducted an anonymous cross-sectional online survey comprising 1,085 undergraduates in either neuroscience courses or majoring/minoring in neuroscience from across the United States to better understand their clinical neurology experiences and perspectives. The survey quantitatively and qualitatively assessed students' clinical neurology exposure inside and outside of the classroom, research experiences, and career goals. Students were from a broad spectrum of undergraduate institutions (public research university [40.8%], liberal arts college [29.7%], and private research university [29.0%]). Most students (89.9%) were looking to pursue graduate studies; 56.9% reported wanting to be a physician, and 17.8% expressed interest in obtaining an MD/PhD. Of importance, students reported first exposure to neuroscience at age 16 years but felt that they could be exposed to neuroscience as early as 13 years. Half (50.5%) decided to major in neuroscience before college, and a quarter (25.6%) decided to major in their first year of college. Despite high interest in clinical neurology exposure, less than one-third of students had spoken with or shadowed a neurologist, and only 13.6% had interacted with clinical neurology populations. Only 20.8% of students felt volunteer and internship opportunities were sufficiently available. Qualitative results include student perspectives from those who did and did not work with a neurologist, describing how they were or were not able to obtain such opportunities. We discuss translating the survey findings into actionable results with opportunities to target the undergraduate neuroscience interest to improve the neurology pipeline. We describe existing programs that could be integrated into everyday neurology practices and new approaches to learning and training to help leverage the significant undergraduate neuroscience interest. We also raise questions for further research, including exploring (1) how students learn of neurologic conditions/expand their knowledge about additional neurologic conditions, (2) whether qualitative investigation of the experiences of neuroscience undergraduates at specific institutions might provide an additional insight, and (3) systems to maintain interest in neuroscience/neurology as students enter medical school.

The blattodeas.s. (Insecta, dictyoptera) of the Guiana shield.

Here we provide a checklist of cockroach species known from areas within the Guiana Shield based on literature records and new field collection. We give records of sixteen species collected in Guyana, eight of which are new records for Guyana and one of which is a new generic record for the entire Guiana Shield. We also provide a description for a geographically disparate species of Calhypnorna Stal, and the new species Xestoblattaberenbaumae. The complete checklist contains 234 species of Blattodeas.s. currently known in the shield. This checklist shows particularly low richness in Guianan Venezuela, Roraima and Amapa Brazil, but this is likely an artifact due to under-sampling. Indeed, based on previously published data and current fieldwork, we believe that most regions of the Guiana Shield are under-sampled for cockroaches. Despite this, French Guiana (151 spp.) and Suriname (136 spp.) rank as the second and sixth most species dense faunas of cockroaches in the neotropics.