Klein, Brad C

Abstract Objectives Discuss the current status of advanced practice providers (APPs) onboarding to headache medicine (HM) practices in the United States and present recommendations of the American Headache Society (AHS) APP Work Group to improve the onboarding process. Background A high demand for care, national shortage of specialists, and multiple advancements in HM have led to an increasing interest and presence of APPs of various backgrounds in the field, currently without a unifying onboarding process. Efforts to standardize and optimize the onboarding process for APPs in HM practices are necessary, to ensure high standards in quality of care. Methods The APP Work Group of the AHS Practice Management Committee developed comprehensive recommendations through literature review, survey of AHS members, and expert consensus. A modified Delphi protocol was used to establish key onboarding goals, definitions, and best practice recommendations. Results Recommendations are made regarding duration of onboarding, appropriate supervision, formal education and procedural skills, scope of practice, grading and documentation of competence, and reciprocal feedback. Conclusion Currently, there are no standard onboarding and training guidelines for APPs in the field of HM. We provide recommendations for a more systematic approach to help develop qualified providers and enhance their retention in HM practices.

Objective To outline strategies for the treatment of migraine which do not require in‐person visits to clinic or the emergency department, and to describe ways that health insurance companies can remove barriers to quality care for migraine. Background COVID‐19 is a global pandemic causing widespread infections and death. To control the spread of infection we are called to observe “social distancing” and we have been asked to postpone any procedures which are not essential. Since procedural therapies are a mainstay of headache care, the inability to do procedures could negatively affect our patients with migraine. In this manuscript we review alternative therapies, with particular attention to those which may be contra‐indicated in the setting of COVID‐19 infection. Design/Results The manuscript reviews the use of telemedicine visits and acute, bridge, and preventive therapies for migraine. We focus on evidence‐based treatment where possible, but also describe “real world” strategies which may be tried. In each section we call out areas where changes to rules from commercial health insurance companies would facilitate better migraine care. Conclusions Our common goal as health care providers is to maximize the health and safety of our patients. Successful management of migraine with avoidance of in‐person clinic and emergency department visits further benefits the current urgent societal goal of maintaining social distance to contain the COVID‐19 pandemic.

Objective To describe a standardized methodology for the performance of peripheral nerve blocks ( PNB s) in the treatment of headache disorders. Background PNBs have long been employed in the management of headache disorders, but a wide variety of techniques are utilized in literature reports and clinical practice. Methods The A merican H eadache S ociety S pecial I nterest S ection for PNBs and other I nterventional P rocedures convened meetings during 2010‐2011 featuring formal discussions and agreements about the procedural details for occipital and trigeminal PNBs . A subcommittee then generated a narrative review detailing the methodology. Results PNB indications may include select primary headache disorders, secondary headache disorders, and cranial neuralgias. Special procedural considerations may be necessary in certain patient populations, including pregnancy, the elderly, anesthetic allergy, prior vasovagal attacks, an open skull defect, antiplatelet/anticoagulant use, and cosmetic concerns. PNBs described include greater occipital, lesser occipital, supratrochlear, supraorbital, and auriculotemporal injections. Technical success of the PNB should result in cutaneous anesthesia. Targeted clinical outcomes depend on the indication, and include relief of an acute headache attack, terminating a headache cycle, and transitioning out of a medication‐overuse pattern. Reinjection frequency is variable, depending on the indications and agents used, and the addition of corticosteroids may be most appropriate when treating cluster headache. Conclusions These recommendations from the A merican H eadache S ociety S pecial I nterest S ection for PNBs and other I nterventional P rocedures members for PNB methodology in headache disorder treatment are derived from the available literature and expert consensus. With the exception of cluster headache, there is a paucity of evidence, and further research may result in the revision of these recommendations to improve the outcome and safety of these interventions.