2025+AHS立场声明：远程医疗对头痛疾病患者的临床管理安全有效

Correspondence

Andrew Charles, MD, UCLA Goldberg Program, Los Angeles,CA, USA.Email: acharles@ucla.edu

Abstract

Objectives/Background: This study was undertaken to review the published litera-ture and provide a position statement from the American Headache Society regarding the safety,efficacy,and impact on access to care of telemedicine for the clinical man-agement of patients with headache disorders. Access to specialized care in headache medicine is severely limited in the United States and worldwide. Telemedicine has been used as an approach to care delivery in headache medicine for more than a dec-ade,with accelerated adoption during the COVID-19 pandemic. There is now uncer-tainty regarding the extent to which telemedicine will be accepted by health systems and reimbursed by payers moving forward. The purpose of this position statement is to summarize evidence and clinical experience supporting the utility of telemedicine in headache medicine.

Methods: Evidence regarding the safety and efficacy of telemedicine, and patient and clinician satisfaction with the use of telemedicine for headache specialty care, was gathered from a variety of sources, including PubMed, Google Scholar, and ClinicalTr ials.gov.The results and conclusions based upon these results were reviewed and dis-cussed by the authors and the Board of Directors of the American Headache Society to confirm consistency with clinical experience and to achieve consensus.

Results: Several randomized clinical trials and observational studies have been performed to compare telemedicine with in-person visits in the management of patients with headache disorders. These studies showed consistently that tele-medicine is noninferior to in-person care based upon multiple outcome measures,including disability measures, patient satisfaction, and clinician satisfaction. In ad-dition, these studies found that telemedicine rarely leads to a missed diagnosis of secondary headache or mismanagement of primary headache. Telemedicine has

# Abbreviation: AHS, American Headache Society

Deborah I. Friedman and Andrew Charles are joint last authors.

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substantial advantages for patients, including improved access to care and reduced costs associated with obtaining care. Studies evaluating health care utilization in-dicate no significant differences between patients evaluated and treated virtually versus in person. Obvious limitations of telemedicine include the inability to per-form an in-person physical exam or to perform injections.For a substantial number of patients, however, these limitations are outweighed by its advantages.The ex-perience with telemedicine reported in the literature is consistent with the experi-ence of the Board of Directors of the American Headache Society, who endorse its use for patients when feasible and appropriate.

Conclusion: Telemedicine has significantly advanced the care of patients with head-ache disorders. Its further development and deployment should be supported and reimbursed.

Plain Language Summary: Telemedicine was used widely during the COVID-19 pan-demic to ensure that patients with headache disorders could continue to receive care,but ongoing support for this approach is uncertain. Here we review the published literature regarding the usefulness of telemedicine in headache medicine and provide a position statement that reflects a summary of this literature as well as experience of the Board of Directors of the American Headache Society. We conclude that tel-emedicine is effective, safe, and well accepted by both clinicians and patients and that it is an important tool for improving access to specialized care for the management of headache disorders.

KEYWORDS access,migraine,telehealth,Telemedicine,virtual

INTRODUCTION

Because of the paucity of clinicians with specialized training and experience in headache medicine relative to the high prevalence of headache disorders, access to specialized care historically has been severely limited.1 The development of telemedicine approaches,which was accelerated during the COVID-19 pandemic, created new opportunities to deliver such specialized care. Broadly speak-ing,telemedicine refers to delivery of medical care remotely rather than in person. Telemedicine can take a variety of forms, including"video visits," audio only visits, and"electronic consultations," which involve written rather than spoken communication. Telemedicine approaches were widely reimbursed by public and private health insurers during the pandemic. Currently, however, the future of sup-port and reimbursement for telemedicine in headache medicine is uncertain.

Telemedicine has significant advantages for both patients and clinicians in headache medicine.2-4 For patients, the primary benefit is access to care. One important element of access is the time and expense of travel to a clinical visit. This is an obvious issue for those who do not live in close proximity to a headache specialist. Even for those who do, significant time may be required to account for traffic, parking, and time spent during check-in and in the waiting

room. Apart from travel expenses, the cost of lost work, school, or childcare may be substantial.These costs may be a particular burden on economically disadvantaged individuals.

For health care professionals, advantages include the ability to see patients more efficiently and the ability to do brief follow-up vis-its with reduced office infrastructure. Further, telemedicine enables headache specialists to offer care more easily to individuals outside of their typical catchment areas, where access to specialty care may be more limited.

One obvious limitation of telemedicine is the inability to do an in-person examination. A key reason to do an examination, particularly for a new patient, is to rule out secondary causes of headache. On the other hand, the overwhelming majority of patients presenting with headache have a normal neurological examination.5 Secondary causes of headache can commonly be identified based upon the clinical history.6.7 Significant aspects of neurological function can be evaluated remotely, such as elements of cognitive function, cra-nial nerve function, motor strength, coordination, and gait. Other aspects of an examination such as vital signs, tenderness, or range of motion can be assessed by patients themselves, with or without assistance from someone accompanying them. Cranial autonomic signs can often be observed by video or subjectively reported. One key component of the examination of patients with headache, the

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fundoscopic exam, is difficult to do remotely.This is a good example,however, of a component of the examination that could be done by a collaborating local eye care professional in lieu of having it done by the headache specialist.

During the pandemic, multiple restrictions regarding the use of telehealth were relaxed or rescinded, and reimbursement was increased. Over the past 1-2 years, however, a number of these restrictions have been reinstated, and the future of reimburse-ment for telehealth is uncertain. During this period of transition, it is important to consider evidence regarding the benefits vs. risks of continuing to develop and reimburse telephone in headache medicine.

METHODS

After a series of discussions at Board of Directors meetings and an Emerging Leaders Project that was developed and presented in June 2024, a task force of authors working on behalf of the American Headache Society(AHS) was identified by the Executive Committee. A literature search including PubMed, Google Scholar,and ClinicalTrials.gov was performed with the following search terms: telemedicine,telehealth,remote,virtual,electronic,head-ache,migraine,cluster,neurology.Evidence regarding telemedi-cine was gathered from the published literature, including primary and secondary endpoints from randomized controlled clinical trials and prospective and retrospective observational studies.These data were summarized in a draft version of this paper, which was then circulated to the AHS Board of Directors to determine whether the published data represented an accurate reflection of experience and whether there were other points to be made based upon the experience of specialists in headache medicine. This re-sulted in refinement of the paper and some additional points of emphasis.

RESULTS

Randomized controlled trials

A group in Norway has investigated the utility of telemedicine in the care of headache patients extensively with multiple prospective studies.8-12 In one large, randomized trial comparing telemedicine with traditional in-person consultations, they found that telemedi-cine is a well-accepted, feasible alternative to traditional specialist consultations for nonacute headache disorders. Telemedicine was associated with significantly reduced cost, time savings, and high levels of patient satisfaction. They also performed a randomized trial that provided class III evidence that a one-time telemedicine consultation for nonacute headache is noninferior to a one-time tra-ditional consultation with respect to long-term treatment outcome and safety.11 In addition, they performed a randomized, controlled study, which showed that video consultations were noninferior to

traditional consultations in managing patients with medication-overuse headache.8 It is important to note that these studies were all performed before the COVID-19 pandemic, which itself, out of necessity, drove significant advances in the technology and capacity to do telemedicine.

A smaller randomized clinical trial in the United States compared video visits with in-person visits for the follow-up management of migraine with outcome measures including Migraine Disability Assessment,headache days,and average severity at 1 year.13 No dif-ferences were identified in these parameters, and those in the tele-health group reported greater convenience and shorter visit times.

Observational studies

A prospective survey of patients and families in a pediatric head-ache population found that compared with a clinic visit, telemedi-cine was universally reported to be more convenient, less disruptive,less time-consuming, and associated with remarkable cost savings(average$486/patient in 2018). Satisfaction was high, and 51 of 51 patients and families reported that they would choose to do telemedicine visits again.14 A study in the Veterans Administration system showed that those receiving care for headache disorders via telemedicine found it to be acceptable and effective, although tech-nological barriers were found to be an obstacle for some.15 A study based at a telehealth headache center found that a comprehensive virtual headache-care model significantly decreased migraine fre-quency, severity, and disability as well as emergency department or urgent care visits.16 One concern that has been voiced regard-ing telemedicine is that it could lead to overutilization of health care resources. However, a study in an urban academic medical center found that"e-consult" use was not associated with significantly in-creased odds of having subsequent ambulatory headache encoun-ters compared with in-person referrals.17 Although there are no similar data for virtual patient visits, this study with e-consults indi-cates that remote evaluation of headache patients does not lead to increased health care utilization. An American Migraine Foundation survey to assess patient experience of telemedicine during the COVID-19 pandemic found a high patient satisfaction rate, with 528 of 638(82.8%) surveyed reporting their experience as“good”or"very good." Additionally, 573 of 638(89.8%) of respondents indi-cated that they would like to continue to use telemedicine for their ongoing headache care.2

Although the practice of headache medicine varies considerably in different countries around the world, it is highly informative to evaluate observational evidence regarding experience with tele-medicine in international locations. A large prospective study in the Netherlands found that video consultations in combination with val-idated electronic diaries were a good alternative to in-person vis-its, according to a substantial majority of patients and clinicians.18 Studies in Lithuania,Italy,China, and other countries all found tele-medicine consultations to be feasible and valuable for the manage-ment of patients with headache.19-21

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A number of studies evaluating the experience with telemed-icine in general neurology practice have been conducted, with headache being the most common condition evaluated in these studies. Results of these studies are similar to those examining headache specifically, as it was found that telemedicine is an ef-fective and efficient alternative to in-person visits and acceptable to patients.22,23

In addition to medical management, telemedicine has been shown to be effective for the delivery of behavioral and integrative care for patients with headache disorders.24-26 This is particularly important given the severely limited access of patients to these types of treatment approaches.

The American Academy of Neurology published a position statement in 2021 endorsing the use of telehealth approaches for delivery of care for neurological disorders.27 The World Health Organization and other international organizations have also made a case for the use of telemedicine as a means to increase access to high-quality care for those with headache disorders, particularly in underserved regions.28,29

DISCUSSION

Multiple controlled and observational studies from around the world have found that telemedicine is a valuable approach to the care of patients with headache disorders, and that it is effective, safe, and well accepted by both patients and clinicians. These data are cor-roborated by extensive unpublished experience of clinicians world-wide,including the Board of Directors of the AHS. Access to care is a highly significant issue in headache medicine given the scarcity of clinicians who are qualified to provide specialized care for headache disorders. Expanded use of telemedicine directly addresses this critical need.

Safety concerns

Concerns remain regarding the safety of telemedicine for evaluat-ing new patients due to limitations in the physical and neurologic exam, particularly the fundoscopic exam. If a fundoscopic exam is deemed necessary at a virtual visit, the patient can see a local ophthalmologist or optometrist for an eye exam or have a timely in-person follow-up examination. It is important for clinicians to establish mechanisms for urgent or semiurgent referrals for in-person visits should there be concerns about secondary headache or if parenteral therapies are required. Most of the studies cited were focused on nonacute headache. In-person visits may be more appropriate for evaluation and management of acute head-ache. On the other hand, a telemedicine visit may be reasonable to triage patients with acute headache to determine whether urgent referral for an in-person visit is warranted. This is an important consideration given that the occurrence of acute headache may prevent individuals from attending an in-person visit.

Patient selection

One straightforward approach to patient selection is for new consul-tations to be performed in person, at which time appropriate patients may be selected for virtual follow-up visits; this approach is required in some states. There may be circumstances, however, in which it is appropriate to do an initial evaluation by video visit or by review of medical records, with subsequent determination of whether an in-person visit with the specialist is required. Alternatively, an in-depth examination could be done by a local collaborating clinician. Patient preference may also come into play; whereas some patients strongly prefer virtual visits, others may find that in-person communication is more effective.

Technological and other practical issues

Technology requirements for telemedicine are a significant poten-tial barrier, which may be compounded by socioeconomic status,age, and rural environments.The availability of high-speed internet may be variable, the software used for visits may be challenging to use, and the hardware(computer or phone) may be expensive. On the other hand, those who experience these technological barriers are among those who are in most need of better access to specialty care, such that ongoing development of the infrastructure to allow telemedicine for these patients is well worth the investment.Some individuals may have difficulty with the technology required for telemedicine, even if this technology is readily available.These individu-als may need the assistance of family members or other caregivers to carry out virtual visits. It is worth noting that these may often be the same individuals who require assistance with in-person visits, such that family members and/or caregivers may experience some of the same expense and inconvenience that patients themselves face with in-person visits. Other issues that arise with telemedicine include lack of ability to see others besides the patient who may be present during the visit, which may affect the content of communication,the possibility of unwanted visualization of the patient's home environ-ment, and safety/privacy concerns if the patient attempts to carry out the visit while driving or in public. These can be addressed by inquiring about the presence of others, and verification that the visit is taking place in a private, safe, and secure environment. Finally,given that light sensitivity is a common feature of headache disor ders,sensitivity to viewing digital screens may need to be addressed with accommodations such as filters or the use of small screens.

Reimbursement and licensing

The future of reimbursement by public and private health insurers for care delivered by telemedicine is uncertain.In addition, the abil-ity of clinicians to perform out-of-state virtual visits-which was of great practical benefit during the pandemic-is now challenged by the resumption of state licensure requirements that discourage this

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practice. These requirements limit the ability to offer telemedicine across state lines only to those who undertake the time and expense to obtain licenses from multiple states. Because some states have few if any available headache specialists, these requirements rep-resent a significant obstacle to accessing specialty care in a timely manner. Several states have enacted legislation that allows for spe-cialty care to be provided across state lines under special circum-stances, with some of these states having such processes in place since even before the pandemic. Nationwide adoption of similar policies would address the huge management gap we currently face in headache medicine.

SUMMARY

The basis for this focused AHS position statement is:

1. Significant evidence and extensive experience have shown tele-medicine to be effective, safe, and well accepted by patients with headache disorders.

2. Telemedicine markedly increases access to care and mark-edly reduces costs associated with obtaining care for headache disorders.

3. For clinicians in headache medicine, telemedicine is an efficient means of care delivery that is widely seen as an important tool in the care of patients.

4. There is no evidence that telemedicine increases health care utili-zation for headache disorders, and to the contrary, it may reduce urgent care and emergency department visits by increasing ac-cess to care.

5. Resumption of the ability to perform telemedicine visits across state lines would increase access to headache specialists.

AUTHOR CONTRIBUTIONS

Karissa N. Arca: Conceptualization; writing- review and editing;investigation. Allyson B. Bazarsky: Conceptualization; investiga-tion;writing-review and editing.Derek Y.Yuan: Conceptualization;investigation; writing- review and editing. Raissa Villanueva:Conceptualization; investigation; writing- review and editing.

CONFLICT OF INTEREST STATEMENT

Andrew Charles has served as a compensated consultant for AbbVie,Aspeya,Eli Lilly,Pfizer,and Lundbeck.He receives royalties from Oxford University Press. He is the immediate Past President of the American Headache Society. Derek Y. Yuan has received honoraria as a speaker for AbbVie and Pfizer. Raissa Villanueva has received speaking honoraria for the AHS and AAN. Deborah I. Friedman has served as consultant for Allergan/AbbVie, Axome, Eli Lilly,Impel,Lundbeck,Pfizer, Satsuma,Scilex, Theranica, and Tonix. She serves on a speaker bureau for AbbVie and Scilex and on medical advisory

boards for Healthy Women, Spinal CSF Leak Foundation, and Migraine Meanderings. She is on the editorial board of Neurology Review and Journal of Neuro-ophthalmology and is a contributing au-thor for Medlink Neurology. Karissa N.Arca and Allyson B.Bazarsky declare no conflicts of interest. The AHS is a nonprofit organization that receives support from industry for educational programming and for research and advocacy. This includes support from multiple companies that are involved in the development, distribution, and marketing of therapies for headache disorders. These companies had no direct or indirect involvement in the development and writ-ing of this consensus statement. The members of the AHS Board of Directors and their disclosures are listed on the AHS website.

DISCLAIMER

This consensus statement published by the AHS is an assessment of current scientific and clinical information that is provided as an edu-cational service.The information should not be considered inclusive of all appropriate treatments. New evidence may develop between the time this statement is submitted and when it is published or read.This statement addresses only the question that is specifically iden-tified. It does not mandate any particular course of medical care, and is not intended to substitute for the independent professional judg-ment of the treating clinician. The AHS assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.

ORCID

Andrew Charles https://orcid.org/0000-0003-3379-054X

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How to cite this article: Arca KN, Bazarsky AB,Yuan DY,Villanueva R,Friedman DI,Charles A,.Telemedicine is effective and safe for clinical management of patients with headache disorders:An American Headache Society position statement. Headache.2025;00:1-6. doi:10.1111/head.15084