Collaboration addresses barriers to care.
- Managing migraine in underserved populations presents unique challenges in an urban outpatient neurology clinic.
- Barriers to care include psychiatric comorbidities, sleep disorders, financial hardship, poor health literacy, lack of transportation, and homelessness
- Interprofessional care, including physicians, nurse practitioners, and neuropharmacists, can help meet patient needs.
Migraine is a neurologic disorder that affects approximately 1 billion people worldwide, mostly females. The Global Burden of Disease Study 2016 identified migraine as the second leading cause of disability, accounting for more disability than all other neurologic disorders combined. The World Health Organization reports that 1.7% to 4% of the world’s adult population experiences 15 or more headache days per month. (See About migraine.)
Barriers to care
Clinicians treating patients with migraine in medically underserved areas face several challenges, including psychiatric comorbidities, sleep disorders, financial hardship, poor health literacy, lack of transportation, and homelessness. A headache physician, nurse practitioner, and neuropharmacist in an urban outpatient clinic work collaboratively to provide the best treatment possible despite these barriers to care.
Baskin notes that psychiatric comorbidities such as depression, anxiety, bipolar disorder, schizoaffective disorder, and post-traumatic stress disorder contribute to the challenge of effective migraine treatment. Comorbidities and stress increase the chances of episodic migraine progressing to chronic migraine. They also may complicate differentiating true migraine from other headache disorders and interfere with pharmacologic and nonpharmacologic treatment adherence.
In a systematic review, Dresler and colleagues found that migraineurs are over 2.5 times more likely to suffer from depression compared with non-migraineurs. The relationship between depression and migraine appears to be bidirectional.
More than half of patients with migraine will meet the criteria for at least one anxiety disorder in their lifetime. Anxiety disorders are two to five times more prevalent in patients with migraine than in the general population, up to two times more common in patients with migraine than in patients with depression, and more common in patients with chronic migraine compared with episodic migraine. Treating and controlling anxiety in patients with migraine generally is associated with improved adherence to, and effectiveness of, treatment plans and improved quality of life.
We implement various interventions—including deep breathing exercises, relaxation techniques, pharmacologic treatment, and psychiatric referrals—to address anxiety and other psychiatric disorders during patient visits. However, time constraints during an outpatient neurology visit limit our ability to maximize these interventions, and outside resources are limited, especially for underserved populations. In addition, the stigma associated with mental health treatment prevents some patients from seeking treatment.
Sleep disorders (including sleep apnea, restless leg syndrome, and insomnia) and migraine have a bidirectional association. To determine if a patient’s migraines are associated with a sleep disorder, ask about the timing of migraines. For example, patients who wake with a migraine, snore, or report gasping for air should raise suspicion for sleep apnea. Sleep disturbances (including irregular sleep, lack of sleep, or too much sleep) can trigger a migraine. Conversely, having a migraine headache can interfere with good sleep.
Ideally, patients should be screened for obstructive sleep apnea and insomnia and referred to a sleep specialist. However, a sleep study may have up-front costs that create a barrier to comprehensive migraine headache treatment. In our clinic, we review good sleep hygiene techniques with patients, but many underserved patients don’t have control over their sleep environments, particularly those who are homeless.
Approximately 30% of our patients are insured by Medicaid and 30% by Medicare Part D; 25% are uninsured. Assistance programs for certain medications are available for patients whose income is 400% below the federal poverty level, but many face the possibility of running out of medication or have limited treatment options. Psychiatric co-morbidities can limit pharmacologic treatment options. Many first-line migraine treatments are psychiatric medications, which limit the ability to titrate and make changes. Behavioral interventions—such as bio-feedback, mindfulness training, and cognitive behavioral therapy—frequently are unavailable to this patient population due to lack of insurance and financial resources. Some insurance doesn’t cover neuromodulation devices, which are used alone or in conjunction with pharmacologic treatment to change the activity of nerve pathways in the brain to stop a migraine. In addition, patient assistance programs aren’t available for the uninsured.
Health literacy and computer access
Functioning within the complex healthcare environment requires certain skills, including health literacy (the ability to find, understand, and use information and services to make personal health decisions). For example, patients must be able to read medication bottles, understand how to implement pharmacologic and nonpharmacologic interventions, and provide documentation in a timely manner to receive approval for financial assistance. In many cases, receiving health information requires that patients have a working phone number, computer access to communicate with healthcare providers, and access to phone or computer apps to manage a headache diary.
Approximately 80 million American adults require assistance with health literacy. Our clinic witnesses the challenges that can arise in patients with low health literacy, especially with medications requiring titration such as topiramate and lamotrigine. Our neuropharmacist—who has their own schedule for patient visits in the neurology clinic—helps address poor health literacy by assisting with completing forms to receive free or reduced-fee medications, creating color-coded medication systems, reviewing the use of pill boxes, and performing medication reconciliation. We use the teach-back method to assess a patient’s ability to read instructions.
Lack of transportation
Getting to appointments can be difficult without a car. Patients may rely on others for transportation and may miss or be late to appointments. Even when patients have a car, they may not be able to afford the cost of parking. Although our clinic is located near train and bus lines, services can be unreliable and inaccessible for some. We’re providing telehealth to patients during the pandemic, and discussions are underway with hospital administration to continue these practices to ensure continuity of care.
Patients who lack safe and secure housing may lack access to electricity, which means they may not have appropriate lighting to read medication instructions or refrigerators for storage. They’re at risk of having medications stolen, a problem frequently reported by our patient population. Without a permanent address, these patients can’t take advantage of receiving medications through the mail. During the pandemic, this has been another barrier to patients receiving medications consistently. To overcome this hurdle, we sometimes request that medications be mailed to a liaison in the pharmacy department who then gives them to the patient or a family member who might be willing to receive the medication and pass it along to the patient. However, many of these patients hesitate to go to pharmacies and have limited community support to have others pick up medications for them.
Migraine treatment begins with a thorough patient history, including screening for comorbidities using tools such as the Patient Health Questionnaire for depression, the Generalized Anxiety Disorder Scale, and the Epworth Sleepiness Scale to evaluate for sleep apnea. Identifying comorbidities helps the provider choose an effective migraine treatment that also addresses the comorbidity.
Treatment options for migraine headaches include both preventive and abortive medications. Some are available over-the-counter, but most are prescribed. Routes of administration include oral tablets, oral dissolving tablets, intranasal sprays, intramuscular injections, subcutaneous injections with Botox or the new calcitonin gene-related peptide (CGRP) medications, and I.V. infusions. The full scale of treatment options exceeds the scope of this article.
Preventive medications include tricyclic antidepressants (amitriptyline) and serotonin-norepinephrine reuptake inhibitors (venlafaxine). They can be prescribed for patients with psychiatric comorbidities such as anxiety and depression, as well as sleep disorders. A beta blocker such as propranolol, another preventive medication, may be appropriate for patients with hypertension, anxiety, and migraine. However, the provider should monitor for worsening depression. Providers may prescribe anticonvulsants for chronic migraine treatment, but they require caution in women of child-bearing age due to the risk of fetal anomalies.
The nurse practitioner performs Botox injections every 12 weeks in our clinic. After training by the neuropharmacist, patients can administer monthly CGRP injections at home. This relatively new medication class was developed specifically to provide preventive and abortive treatment. It’s a good option for patients who prefer an alternative to daily medication, for those who’ve had treatment failures, or those who are already taking several other medications. Some patients receive a combination of daily oral preventive treatment as well as injections. (See Preventive treatment options.)
Abortive migraine medications, such as triptans, can be used for episodic or chronic migraine treatment. Limitations include comorbidities such as uncontrolled hypertension and stroke history. Some patients can’t tolerate triptans and report chest pain. The potential for a medication overuse headache limits the amount of abortive medication a patient can take. Patient education, addressed at each visit, can help prevent this adverse reaction. (See Abortive treatment options.)
Other treatment options
Migraine treatment goals include decreasing headache frequency, intensity, and duration. This can be accomplished with a combination of preventive and abortive medications, lifestyle changes, and comorbidity management. Other treatment options include vitamins (such as magnesium and riboflavin), essential oils, and over-the-counter medications.
Identifying migraine triggers—such as certain foods, alcohol, dehydration, and stress—can help prevent headaches. However, patients without housing may not be able to avoid triggers, and the stress of food and shelter insecurity may prompt a migraine.
Our clinic’s nursing team interacts with patients in various ways. Certified nursing assistants perform the initial clinic triage and vital sign assessment. They provide reports of patient headache pain and other concerns. The nurse practitioner completes the evaluation and assessment and develops treatment strategies. Although the patient may be coming to a clinic visit because of migraine headaches, the holistic nursing model allows for the complete assessment of other issues (sleep disorders, mental health issues, health literacy) that may impact successful treatment. Clinic nurses check out patients at the end of the visit and are instrumental in ensuring prescriptions have been sent to the correct pharmacy, educating patients about the treatment plan, and scheduling follow-up visits.
A collaborative approach
Headache management in underserved populations is a global and local healthcare burden. Our headache clinic works to provide migraine treatment with a combined approach of provider treatment, neuropharmacist education, and referrals to specialists. This collaborative approach allows us to better meet the needs of this unique patient population. Additional questions for future research include examining differences in migraine prevalence between urban and rural populations.
Amy Perez is an adult nurse practitioner in the outpatient neurology clinic at Grady Health System in Atlanta, Georgia. Roger P. Simon, MD, is a neurologist at Grady Neurology Clinic in Atlanta, Georgia. Alexandria May, PharmD, BCPS, is a clinical pharmacist specialist at Grady Health System in Atlanta, Georgia.
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