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ABSTRACT
RESUMO
Descritores: Telemedicina; Cefaleias Primárias; Enxaqueca; Vídeoconsultas;
Aplicativos de Saúde.
VIEWS AND REVIEWS
Telemedicine in the Management of Primary Headaches:
A Critical Review
Telemedicina no manejo das cefaleias primárias:
uma revisão crítica
Renan Barros Domingues
1
Cassio Batista Lacerda
1
Paulo Diego Santos Silva, MD
1
1
Serviço de Cefaleia, Departamento de
Neurologia, Irmandade da Santa Casa de
Misericórdia de São Paulo.
*Correspondence
Renan Barros Domingues
Rua Vergueiro, 1421 cj 603 Torre Sul, Vila
Mariana, São Paulo, SP, CEP 01504-000
E-mail: contato@renandomingues.med.br
Received: 19 November, 2019.
Accepted: December 5, 2019.
Telemedicine is a modality of health care services delivery with the use of
communication technologies. Its use has grown in several medicine areas. Several
studies evaluated the feasibility, acceptance, efcacy, cost-effectiveness, and
safety of telemedicine in the diagnosis and management of primary headache
disorders. Videoconsultations were shown to be effective, convenient, and safe
for primary headache disorders and migraine follow up. Some mobile health
devices were show to improve adherence favoring better outcomes. Handling
health data is a major concern so that international compliance standards must
be adopted in all telemedicine procedures. The impact in the health system and
increased access to appropriate primary headache treatments with the use of
these technologies has yet to be elucidated.
Keywords: Telemedicine, Primary Headache; Migraine; Videoconsultation;
Mobile Health
A telemedicina é uma modalidade de disponibilização de serviços médicos
com o uso da tecnologia da informação. Seu uso tem crescido enormemente
em várias áreas da medicina. Vários estudos avaliaram a viabilidade, aceitação,
ecácia, custo-efetividade e segurança da telemedicina no diagnóstico e
tratamento das cefaleias primárias. A vídeoconsulta mostrou-se uma forma
ecaz, conveniente e segura no seguimento terapêutico das cefaleias primárias
e da enxaqueca. Alguns aplicativos para dispositivos móveis mostraram
aumento da aderência, favorecendo melhores resultados. A segurança de dados
de saúde é uma preocupação, sendo imprescindível seguir rigorosamente os
protocolos internacionais de conformidade. O impacto no sistema de saúde
e o aumento do acesso a tratamentos adequados proporcionados por estas
tecnologias ainda precisa ser melhor elucidado.
INTRODUCTION
The denition of telemedicine
according to the World Health
Organization is “The delivery of
health care services, where distance
is a critical factor, by all health care
professionals using information and
communication technologies for the
exchange of valid information for
diagnosis, treatment and prevention
of disease and injuries, research and
evaluation, and for the continuing
education of health care providers,
all in the interests of advancing
the health of individuals and their
communities”.
(1,2)
The history of
telemedicine begins in the early 20th
century with the transmission of
eletrocardiographic using telephone
wires.
(3)
Other technologies, such
as closed circuit television, began
to be used in the 1950s and 1960s.
(4,5)
In 1967, the Massachusetts
General Hospital starts to provide
remote health healthcare services
to Boston Logan Airport, being
the rst structured telemedicine
service.
(6)
With the introduction of
World Wide Web (www) in 1990,
the possibility of health information
exchange is greatly expanded, by
replacing analogue processes with
digital ones, increasing enormously
the capacity to store and transmit
data.
(7)
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Domingues RB, et al.
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The delivery of telemedicine services can be made
by four different ways: 1) synchronous – with live video
between patient and provider or non-specialist with
specialist, 2) store and forward - by acquiring medical data
and further transmitting it to a provider or a specialist,
3) remote monitoring - with the use of wearables and
biosensors, and 4) mobile health (mHealth) - which is
the health practice supported by mobile devices.
(8-10)
The use of telemedicine in Neurology is growing due to
the fact that neurological care is still poor around the
world. Telestroke accounts for 65% stroke treatments “in
the USA” - A determiner is probably missing here and
Canada. Several studies have showed potential benets of
telemedicine in the management of Parkinson’s Disease,
Epilepsy, Multiple Sclerosis, Brain and Spinal injury, and
Amytrophic Lateral Sclerosis.
(11,12)
Primary headaches are associated with a signicant
impact.
(13-15)
However, the availability of headache medical
services is poor worldwide and even higher in developing
countries such as Brazil.
(16-21)
Considering the need to
expand access to headache treatment and the high
prevalence of these disorders, telemedicine seems to be
an attractive alternative to provide care for these patients.
In the present review we will critically discuss the current
evidence about this topic.
TELEMEDICINE AND HEADACHE IN
THE LITERATURE
By searching with the words “Telemedicine” and
“Headache” in the PubMed database 53 articles are
found, including several article types, such as clinical
trials, case reports, reviews, and opinion articles. Among
them, twenty are clinical studies or case presentations
evaluating specic telemedicine procedures in the
treatment of headache or specic headache disorders.
The rst scientic paper about the use of communication
technologies in headache care was published in 2004.
Several studies about behavioral interventions on
adherence and outcomes in headache treatment with the
use of mHealth were published between 2004 and 2016,
when the rst well designed, prospective telemedicine
and headache clinical trial article was published.
(22-24)
In
this critical review we took into consideration the most
important articles evaluating synchronous telemedicine
and mobile health (mHealth).
Synchronous telemedine (videoconsultations)
Müller et al. evaluated synchronous telemedicine
and showed high levels of acceptability, feasibility,
as well as cost effectiveness with videoconsutations
when compared to conventional consultations. The
study was carried out in Northern Norway and included
adult patients referred to a neurologist for non-acute
headache treatment by primary care physician. The
patients were randomized for telemedicine consultations
or conventional face-to-face appointments.
Videoconsultations were performed using appropriate
equipment in a telemedicine hospital room, with audio
and video communication between the neurologist
and the patient in the videoconference room. The
same physician carried out the consultations of the
telemedicine group and the conventional consultation
group. Nearly 400 hundred subjects were randomized
for telemedicine or conventional consultations and
were followed for one year and telemedicine was shown
to be feasible.
(25)
In another publication originated from
the same clinical trial the authors compared efcacy of
telemedicine and conventional treatment with visual
analogue scale (VAS) and headache impact test (HIT-
6), showing non-inferiority of telemedicine approach.
(26)
The satisfaction of patients with telemedicine was
also evaluated by the same study group. Telemedicine
patients did not express less satisfaction than those
with traditional consultation.
(27)
The safety of using
telemedicine was also assessed. The ability to identify
secondary headaches over one year of follow up
was not signicantly different between telemedicine
and conventional consultations. The percentage
of neuroimaging exams indication, neuroimaging
abnormalities, as well as the proportions of hospitalized
patients during the follow up period was not signicantly
different between the two groups. It was estimated that
over 20,000 telemedicine consultations are necessary
to miss one secondary headache.
(28)
The feasibility of telemedicine consultations was
also evaluated in children with headache. Vierhile and
cols. conducted a small open study in which children
were evaluated in a spoke site with the presence of a
nurse practitioner. The connection was established
with a hub center with a specialist. Overall, the
headache outcomes were comparable to outcomes
with conventional in ofce consultations. Most of the
parents liked not having to drive to the medical center
and not having to cancel the activities of the children
due to medical consultation.
(29)
Qubty et al. carried out
a prospective pediatric headache telemedicine study
and showed that telemedicine was convenient, cost-
effective, and patient-centered for routine pediatric
headache follow-up visits. Overall patients and family
were satised with telemedicine.
(30)
The efcacy of telemedicine has also been tested
for the management of specic headache types.
Bekkelung and Müller compared video consultations
and traditional consultations in patients with Medication
Overuse Headache (MOH). The group treated with
telemedicine had non-inferior outcomes, including
reduction in the number of headache days and reduction
of analgesic consumption.
(31)
Friedman et al. conducted
a prospective, randomized trial of telemedicine for
migraine management. Patients were evaluated in an
initial in-ofce visit and then randomized for follow-
up with telemedicine consultations or in-ofce visits.
Telemedicine consultations were conducted with specic
software installed on a patient choice computer and
were carried out by the same physician of the traditional
consultations group. The follow-up time was one year. All
the measured outcomes, including efcacy of treatment,
headache impact, and safety, were similar between the
two groups. Physician productivity was higher with
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telemedicine group. The perception of convenience by the
patients was higher in the telemedicine group.
(32)
Mobile health (mHealth)
The use of mHealth has potential advantages as
an auxiliary tool in the management of headaches,
particularly in patient education and life style modication
that are important in the effective treatment of people
with headache disorders. The mHealth devices may be
a good way to record headache-related symptoms and
information such as possible triggers.
Despite the availability of a growing number of
smartphone apps, in particular electronic headache diaries,
there is still little evidence about its efcacy and safety in
handling patient data. Mosadeghi-Nik and cols. carried out
a systematic review with smartphone headache diaries,
which are presumably easier and more practical to use
than paper-based diaries. One reported advantage is
that electronic diaries can be lled in real time. Another
advantage is that assistant physician can have access
patient data through a web portal, also facilitating the
database generation. However, the authors point that the
evidence of effectiveness and safety of these mobile apps
for headache disorders treatment is still limited.
(33)
In a recent
narrative review, Stubberud and Linde sought for clinical
evidence on mHealth based classical behavioral therapies,
such as cognitive behavioral therapy, biofeedback, and
relaxation in patients with migraine; however, evidence is
still missing in this eld.
(34)
In a systematic review, Hundert
et all. also evaluated clinical evidence with the use of
some available headache diary apps. The authors found
38 headache diary apps but only 18% were developed
with headache expertise. Little evidence regarding its
effectiveness was found.
(35)
Concern about privacy with
headache diary smartphone apps was also reported by
Minem et al. that examined 29 apps (14 diary apps and
15 relaxation apps). Only 11/14 headache diaries disclosed
privacy policy and 6 stated that user data were used for
targeted advertisements. Only 11/15 relaxation apps had
disclosed privacy policies.
(36)
One large and controlled study evaluated the efcacy
of a mHealth device in headache management. The value
of electronic monitoring and alerting system was assessed
in the management of MOH in a controlled multicenter
study. In this study, Tassorelli et cols. evaluated the
Comoestas tool which is a diary with an alerting system
that allows remote monitoring of key clinical data. The
system has a headache diary allowing data collection to
a web platform, generating high and low priority alerts.
The system also facilitates electronic communication with
smartphone, e-diary, and E-mail text messages as well
as smartphone calls. A signicantly higher percentage
of patients were overuse-free, there was a lower rate of
subjects lost to follow-up, and higher level of patients
satisfaction were registered in the group treated with the
aid of Comoestas.
(37)
One study compared the use of paper-based diaries
and electronic diaries. Bandarian-Babooch et al. compared
two paper diaries (short and long) and four types of
electronic diaries. The authors found more missing date
and more errors in data lling in the long paper use than
with short paper diary and electronic diaries. Long paper
diaries were found more burdensome and signicantly
less easy to use than electronic diaries and short paper
diaries. The authors concluded that electronic diary is
a potentially useful tool in clinical trials as well as in the
behavioral treatment of headaches.
(38)
DISCUSSION
The available evidence shows that telemedicine is
effective, convenient, and cost-effective in the treatment
of primary headaches. Concern about safety still exists
but available published data shows that using appropriate
screening tools or a rst face-to-face consultation, the
safety level is in identifying secondary headaches is similar
between telemedicine and conventional consultations.
Therefore, there is scientic evidence that telemedicine is
viable for primary headache disorders follow-up, allowing
higher physician productivity, and it is associated with high
level of satisfaction by the patients or caregivers. There
is also some evidence that the use of mHealth devices
may contribute in monitoring headache, potentially
contributing to better outcomes and easier interaction
between patient and assistant physician.
The health system impact of using telemedicine in
headache care still needs to be measured. Considering
that telemedicine is a potentially useful tool in primary
care, it can be used in this setting in the management
of patients with primary headache disorders.
(39)
Potential advantages would be an earlier introduction of
preventive treatments, better orientation for patients in
the management of headache attacks, lifestyle change
orientation, and analgesics overuse prevention. This
would also facilitate the identication of patients requiring
treatment at a specialized tertiary center. Despite these
potential advantages, there is still need for studies
evaluating the clinical and economic impact in health
system and how it can facilitate the access of patients to
adequate treatments.
The use of telemedicine brings concerns about data
security and compliance with local legislations. Most of
the available synchronous telemedicine studies cited in
this review employed validated and safe telemedicine
platforms that allow the storage and inviolability of data,
as well as making it available to the patient or guardian
upon request. There is still concern about some mHealth
devices, particularly electronic diaries, since many of
them do not disclose data security policy. Creating and
maintaining large headache databases has potential
enormous benets, for example, in generating local
and national headache registries that can help to guide
public health policies.
(40)
Handling these databanks
should be done according to all compliance rules to avoid
targeted advertisements. Health Insurance Portability and
Accountability Act (HIPAA) established security standards
for protecting health information in its electronic form.
(41,42)
The procedures established by HIPAA must be adopted
by every app or system dedicated to telemedicine.
Regulatory and legal issues regarding telemedicine have
specicities around world.
(43)
In Brazil, some general
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rules were published in 2002; however, they do not
address technological developments and telemedicine
advances over the last 17 years. There is a new and more
detailed regulation under discussion and it is expected
that this regulation with more specic rules, detailing
of technological requirements, and better specication
procedures will be available until 2020.
In conclusion, the existing evidence favors
telemedicine as an alternative in the treatment of primary
headache disorders. This modality of delivering medical
care may be an option for patients with difculty in
accessing in-ofce consultations. It is possible that, as in
other areas of medicine, telemedicine may increase the
access to available headache treatments. The current
available treatments are not yet widely available because,
among other factors, there are no headache experts in
many regions. The use of telemedicine within ethical and
compliance parameters by qualied professionals may
be incorporated into the treatment of primary headache
disorders. Not as a new treatment, but as an agile and
scalable way to deliver currently available headache
treatments.
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