Migraine Care Gaps: The Physician Shortage and Therapeutic Needs

Deena Kuruvilla, MD

This is the second of a 2-part interview. Click here for Part 1.

Currently, a major challenge for neurologists and specialists in neurology is the lack of physicians available to treat an increasing demand for care from an ever-growing, ever-aging population. A recent report from the American Academy of Neurology noted that a “large mismatch” exists between the number of patients who require neurologic services and the neurologists available to meet this need in the United States.¹

Part of this appears to be driven by the identification of effective therapies for conditions previously lacking them—such as migraine—which, in turn, has increased referrals to specialists, as data has shown that patients who see disease-specific specialists often have better outcomes than those who solely see a primary care provider. For the migraine specialists, this mismatch is all the starker. It is estimated that 40 million individuals with migraine live in the United States.

To find out more about how the field and its related organizations might address this challenge, and what other efforts are ongoing and needed in migraine care, NeurologyLive spoke with Deena Kuruvilla, MD, director, Westport Headache Institute.

NeurologyLive: With the ongoing neurologist shortage and a limited number of headache specialists, but 40 million Americans with migraine, is there a solution to the issue of migraine treatment education?

The first kind of key thing that we could do to help the shortage is getting more physicians interested in treating headache medicine. Headache medicine is composed of neurologists; primary care providers; ear, nose, and throat physicians; otolaryngologists; and different family medicine physicians—but there are so many different physicians who can become headache specialists. If we can increase that interest in people who are going into those fields, I think that's really the big way to do it. The biggest way to tackle that might be calling on the national societies who run the meetings for these different specialties to really make a focus on headache, and to really emphasize the burden of migraine and try to target that population and increase that interest.

The second way that I think that we could combat this is by increasing education among primary care providers at these national conferences, doing more lectures, and telling them—all of these different physicians or providers—what the benefits of treating migraine are and why should they care about it. We can simplify the visit with a migraine patient, so it's not draining all their time. Providers are so busy. They're seeing so many patients each day, and sometimes they just don't have enough time to delve into all these different questions that need to be asked. But we could provide more education on key questions that can be asked to streamline that process. Definitely, providing more education by speaking at national meetings, doing webinars, webcasts, producing more research—those are the key ways to address this.

What is the mindset that you're seeing from your patients?

I am surprised that when I see patients, they, number one, don't have the mindset that there isn't a lot of hope for treatment or there aren't many things to offer. The first thing I do once I've ruled out dangerous causes for headache is reassure the patients when I know it's migraine. I say, “Look, this is treatable, you are going to get better if we can get you on an effective preventive treatment for migraine and if we can get you on an acute treatment for migraine.” And then we can also talk about some natural options that you can add on to help the process along. I target those 3 areas and tell the patient there's hope. I have seen higher success rates with that power of suggestion, with just giving them a little hope and reducing their anxiety related to migraine as their disease.

Is there anything in the pipeline or that’s recently become available that you’re keeping an eye on in terms of its potential effect for care?

Certainly, gepants are on the market and you have the preventive CGRPs medications. But one thing I would love to highlight is that, just recently, we have our first medication approved for the acute treatment of migraine and the preventive treatment of migraine, rimegepant. That has been a very interesting conversation with patients because previously we've divided between acute treatments and preventive treatments. Now, we're kind of discussing that we have 1 option that patients can kind of decide if they want to end up using it as acute treatment, or if they want to use it for mini-prevention or a short course around when they anticipate having a migraine—such as when you have your menstruation or when you're going to be traveling and have that high altitude triggered migraine attack. That's a whole different conversation that that 1 treatment has opened which has been really cool.

There are multiple medications that are in clinical trials right now and being studied shortly in a couple of months, there may be a medication that is now developed for prevention only, an oral gepant that's been approved in Europe: atogepant. It’s being developed for the prevention of migraine and we're seeing that might be in the US pipeline in the coming months. There are multiple different oral treatments that are currently being studied such as rizatriptan and meloxicam—taking that existing rizatriptan medication and combining it with a nonsteroidal anti-inflammatory to see what the use is for the abortive treatment of migraine.

There is also a new formulation for dihydroergotamine—one of our oldest acute migraine treatments—that may be delivered in a new device called the Trudesa device. Then, there's an acute subcutaneous gepant that's being studied for the acute treatment of migraine, and, excitingly, there is the Relivion device. I conducted the clinical trial for the Relivion device when I was at Yale, and it is the first device that will specifically stimulate not only the nerves of the forehead, the supraorbital and supratrochlear nerves, but also the occipital nerves. So it's like a full-around headband that has FDA approval for the acute treatment of migraine. It's not available to patients yet, but that might be a game-changer for some patients who have occipital neuralgia in addition to pain and other regions of the head.

There are so many exciting things on the horizon, but really have to bolster them and get these treatments out there and let people know about them so patients can start getting the newer ones.

What are the unmet needs and challenges that still need to be addressed?

We need more disease-specific targets for treatment. We do have CGRP medications, of course, which is wonderful and fabulous. We have serotonin-targeting acute treatments, but we need to look at other migraine pathways because the CGRP pathway may not be the final common pathway for every patient. It's a game-changer and I'm appreciative for the patients who have a slam dunk response to it. But there are other targets that have been studied and still need more studies, such as PACAP, pituitary adenylate cyclase, that need to have more research so that we can find other mechanisms that might be interesting to target for migraine.

We need more providers that are interested in treating headache, and get that special focus on headaches so we can provide treatment. We need more patient advocacy. Patient advocacy is going to be a key factor in fighting the stigma that that migraine has attached to it. We've seen that with patients with multiple sclerosis, that advocacy makes a big difference. We've seen it with our patients with HIV. I think that if more people rally around migraine, we can really reduce the stigma surrounding it.

Transcript edited for clarity. You can hear the entire conversation with Deena Kuruvilla, MD, on episode 46 of the Mind Moments podcast.

REFERENCE
1. Majersik JJ, Ahmed A, Chen IA, et al. A shortage of neurologists – we must act now: A report from the AAN 2019 transforming leaders program. Neurology. Published online April 30, 2021. doi:10.1212/WNL.0000000000012111