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The Primary Viewpoints podcast features informative conversations with health care experts, opinion leaders, and practicing physicians, about what impacts primary care medicine today.

In episode 14, headache specialist Dr Peter McAllister discusses the first FDA-approved migraine-specific oral preventive treatments in the gepant class and the role these medications may play in treatment of migraine in primary care settings.

 is medical director of the New England Institute for Neurology and Headache and chief medical officer of the Chief Medical Officer, New England Institute for Clinical Research, both located in Stamford, CT.

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"Primary Viewpoints," a podcast from Patient Care Online, brings you an exclusive interview with headache specialist Peter McAllister, MD. 

Gepants for Migraine Prevention: A Perfect Fit for Primary Care

Hello, and welcome to Primary Viewpoints from Patient Care Online, a monthly podcast that features informative conversations with healthcare experts, opinion leaders and practicing physicians about what impacts primary care medicine today. My name is Sydney Jennings and I am the associate editor at Patient Care Online and in our first episode Grace Halsey, senior editor of Patient Care Online, talks with Peter McAlister, MD, medical director at the New England Institute of Neurology and Headache and chief medical officer for the New England Institute for Clinical Research, both in Stamford, Connecticut, about the impact of COVID-19 on migraine patients.

So your practice is in the tri-state area, Stamford, Connecticut, so in the New York, New Jersey, Connecticut area, could you describe the impact of COVID-19 on health care in the area and healthcare delivery in general, and then more specifically on your practice?

The short answer is it's been profound. Clearly with New York City being the epicenter of the number of cases and number of deaths. We are just up the road in Connecticut, a suburb of New York City, so there were a lot of cases. There was a lot of people being quite afraid to go out understandably and quite reasonably. And we had to make some big decisions at our practice. Some practices, neurological practices, closed their doors completely and have gone to a full telemedicine thing. My perspective was that we could probably thread the needle and do it safely to be at least partially open. And my thinking was that if somebody had severe headache requiring shots or intravenous medications, for example, if I wasn't open, they would go to the emergency room which is about the last place you want somebody to go. Certainly my general neurology patients, my MS patients, etc., they need some interventional procedures that we offer here. So what we've done is the following: we will ask the day before a questionnaire for each new patient and each follow-up patient coming in based on exposures and whether they've had it etc. We will take their temperature on the way in, we require they wear a mask, we have masks to provide them if they don't have one. Our staff all wears masks, we do testing on our staff, had been doing it on a weekly basis. And we've also taken half of our staff and assigned them to home and then they rotate, so they spend 2 days in the office and 2 days at home and they split Fridays. What that's done, is it's decreased the actual number of people, our footprint of people here. So it's actually a bit quiet, but I wasn't going to stop seeing patients because I felt that wasn't the right thing to do.

Also, one of my follow-up questions was going to be about how you handle patients on an acute basis who need a shot or an infusion for a headache or for some other medical problem, as well as Botox treatments which can't easily be done elsewhere.

Right, and I'm on a bunch of listservs of headache specialists around the country, and most headache specialists come down solidly on the most profoundly impacted migraine patients (those who were having 25-30 plus headache days) to take away their Botox would again either send them to the ER or make them nonfunctional. So that was a decision. Certainly, we have markedly curtailed our so-called elective procedures and we're doing more FaceTime and Zoom visits, particularly in our older folks who we'd rather not bring out here. But if somebody wants to come out here for their Botox and feels it's very important to their overall neurological care, they're going to come here and get it. We will be masked, we'll take appropriate precautions.

Would you do telehealth visits or a phone visit for an initial visit with new patients and then move forward from there?

Some of my colleagues prefer not to do consults by telehealth. My approach to telehealth, is that it's the most minimally effective way to get ideas across in medicine. In other words, I'm not a big fan of it. It turns out, it's even more reinforced in me that the human interaction—to be able to listen carefully to someone's stories, to be able to examine them, etc—is really critically important. I'm glad we have telehealth, I'm glad insurers are covering it to variable extent, but it is just a bare bones minimum. So, I will do a consult over telehealth, but I would also have people come in here. I had a woman who was 47 [years old] who her neurologist just closed the office completely. And she travelled the distance, she called up and said, "Are you seeing live patients?" Our response was "Yes", she came in and actually had a brain disorder called CNS vasculitis. She had had multiple tiny strokes and she was a young woman. She was admitted to the hospital and got a stat workup. I think she would have been in really bad shape had she not come in someplace and gotten examined. I have another guy who has something called Guillain-Barré syndrome, diagnosed just last week, probably related to COVID-19 because he had COVID-19 4 weeks ago. So neurology doesn't go away in the midst of a pandemic, unfortunately.

Headache has been discussed as one of the primary symptoms for some people who've been affected by COVID-19. Have you found any relationship at all among your migraine patients? First of all, have you had anybody who has contracted COVID-19?

Yes, again, because I'm in the tri-state area, I've been getting increasingly a collection of people who have gotten through COVID-19 and have come in now completely asymptomatic, afebrile, and telling me their story. I've got just anecdotal stories, but a number of patients who are really bad migraine sufferers, told me that yes, they had a headache from COVID-19 that was markedly different from their migraines. Not as severe, involving the entire head, moderate severity, nonthrobbing, and their migraines kind of went away during COVID-19, particularly when it was at its worst. When they got better, they knew they were kind of out of the woods when their migrianes came back. And that's something that we see in very sick individuals, migraines take a backseat and once someone is out of the woods, migraines represent themselves. Although most headache specialists are familiar with that concept, we have no idea why.

Do you feel that going forward the fear of the virus is going to continue to keep people from coming in when they need you?

It may to some extent, but I hope not. We all need to be very careful. We need to wash our hands. It's been shown fairly conclusively that face masks eliminate or decrease the ability of transmission. If you don't have multiple risk factors, you have to make a personal decision. Is it worth going to your doctor? When we hear these stories about kids not getting their normal routine vaccines because the parents are afraid to go out, when people are having chest pain and aren't telling their doctor, or go into an emergency room. I think net, that's a really bad idea. So I would encourage patients to be thoughtful and be careful, but if you need to go to your neurologist or any specialist you should consider doing so.

Thank you for listening to this episode of Primary Viewpoint. To hear more episodes on a variety of clinical practice topics, visit 

. Click on “media” and then “expert interviews."

In episode 1 of Primary Viewpoints, migraine specialist Peter McAllister, MD, discusses how the COVID-19 pandemic has impacted his migraine patients.

Primary Viewpoints Episode 1: COVID-19 Impact on Migraine Management

Your daily dose of the clinical news you may have missed.

Atogepant Safe, Effective in Treatment-Resistant Episodic Migraine: Daily Dose

Atogepant once daily reduced mean monthly headache days in adults for whom up to 4 classes of oral migraine preventives were ineffective. 

Atogepant Safe and Effective in Treatment-Resistant Episodic Migraine: ELEVATE Phase 3b Trial

Migraine-Related Stigma Impacts Quality of Life: Daily Dose

Reports of migraine-related stigma were common in a recent population-based study, with nearly one-third reporting the experience often/very often. 

Migraine-related Stigma is Common and Impacts Level of Disability, Quality of Life 

Older adults with a history of migraine, in contrast, were at no greater risk of an automotive crash than those without prevalent migraine, according to new study results. 

Older Adults with New Onset Migraine 3 Times More Likely to Have Motor Vehicle Accident 

"Migraine is a tremendously rewarding disease to treat,"

was the start of headache specialist Christopher Gottschalk, MD's answer to our request for clinical pearls about treating migraine in primary care. 

In the same vein he emphasized the relief clincians can offer to patients with migraine, a treatment outcome often different from what is possible in "many other chronic diseases where the best you can hope for is stabilization or slowing the rate of decline." 

Yale headache specialist Christopher Gottschalk, MD, talks about the opportunities to make a marked difference in the quality of patients' lives. 

"Migraine is a Tremendously Rewarding Disease to Treat"

Headache and Migraine

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