What Does a Headache Specialist’s Job Look Like?

Session 31

Dr. Kristen Sahler is a community-based Neurologist who specializes in headache medicine. She has been practicing for four years outside of her fellowship and she shares with us what drew her to it and her advice if you’re interested in it.

[01:28] Her Path to Headache Medicine

Kristen knew she was going to be a neurologist when she was fourteen years old having been motivated by having a family member with Tourette’s syndrome so very early on, she was learning about it and about the brain and got fascinated by all of it. She then hyper-focused on that pathway and never gave up on it.

As for getting into headache medicine, it wasn’t on her radar until her third or fourth year of medical school on her neurology rotation where she was sent to see a headache consult. She became fascinated by the patient’s story and thought her interesting visual aura was cool and learned about migraine. By the end of medical school, Kristen has already carved out that headache was the field for her which was confirmed as she went through residency every step of the way.

What she likes about the field is how interesting it is having all these strange phenomenon and visual disturbances. But essentially, she has always been interested in the central nervous system and in neurotransmitter systems which hearkens back to his brother with Tourette’s syndrome. With migraine, it’s predominantly common with the serotonergic system which she’s interested in.

Additionally, she was interested in Parkinson’s disease being a neurotransmitter-based disease but she didn’t feel as much excitement seeing the inevitable decline of patients experiencing it since you can’t change the course of their disease. Whereas a lot of the other primary headache disorders have disorders that can change people’s lives taking them from being completely disabled an in pain everyday to nearly pain-free.

[04:37] Traits that Lead to Being a Good Headache Specialist

Kristen cites patience as the one skill she uses the most day-to-day considering how headache patients don’t give the greatest history. You don’t always know how to describe they’re feeling so you need to guide them through it to get the information out of them that you need.

Another trait is liking the detective work because there are so many things that can cause a headache and not each one is a migraine or whatnot so you need to be able to fuss out what the underlying causes are.

Lastly, you need to okay with psychiatry because there’s a lot of overlap between headache disorders and psychiatric disorders. In particular, migraine is comorbid with anxiety, depression, and bipolar so she sees a lot of people with psychiatric co-morbidities which she’s not managing but she needs to be able to be patient with them ad help them cope through these things.

Alternatively, if you’re really interested in psychiatry, you could choose to manage both issues. In neurology, they study a good amount of psychiatry so you could choose to be a headache specialist and also manage their anxiety or depression and just choose to do both. Kristen though doesn’t like to manage the psychiatric issues because she feels she’s not up-to-date on the management side of it but she’s comfortable seeing patients with those diseases.

Kristen says she never thought of any other specialty pulling her from her path to neurology. Although she was interested in some fields but she never once thought they were the right field for her. She thought psychiatry was interesting but when she looked to the day-to day of what a psychiatrist does, she knew it wasn’t for her. She thought internal medicine is the best field because for her the most impressive people went into internal medicine. She practically thought of them as rock stars but she knew still that it wasn’t the field for her. She wanted to be that person who was going to dig her hole really dip and narrow and just do headache but do it really, really well.

[08:03] A Typical Day in the Life of a Headache Specialist

Kristen is doing outpatient for majority of the day. She takes some calls at a local community hospital but not very often. She’s usually in the office for seven hours seeing office patients, new consults, or follow-up visits for patients she’s already seen. She predominantly does headache so she is a 75% headache specialist and the other 25% is being a general neurologist dealing with a variety of issues including dementia, epilepsy, Parkinson’s multiple sclerosis. The reason being is that she’s in a multi-specialty group so her referral days is a group of primary doctors, OB/GYN’s, pediatricians who want to have somebody with general neurology skills. She also likes to have a little bit of general neurology since some days, she feels like she’s seen so many really complicated headache patients back-to-back which can be emotionally and cognitively exhausting so having someone coming in with, say, a carpal tunnel syndrome is nice break for her.

If you’re in a headache specialty center as a headache specialist and you’re only doing headache and you’re not going to be doing any general neurology at all. But her typical day is just seeing patients in the office, managing callbacks, medications, and emails that may come in. Patients may call in complaining about a bad migraine so she spends about an hour everyday speaking with them on the phone and helping them through it.

[09:55] Types of Procedures

She does procedures for patients too. This is another trait she wants to point out if you want to be a good headache specialist is that you should like procedures. Kristen does simple procedures such as nerve blocks, trigger point injections (focused on muscles, neck, head, and shoulders) as well as another type of nerve block called the sphenopalatine ganglion block which is a catheter that goes up through the nose to block the nerve cluster behind the sinuses and she also does Botox for chronic migraines They’re all relatively simple procedures which you can do in the office. They are quick and easy and they relieve pain very effectively and they’re pretty lucrative, relatively speaking for the amount of time it takes to do them.

Not to mention, these are very low-risk procedures and the complication rates are pretty much next to nothing. They’re very low-stressed procedures but they can help the patients a lot. Another procedure she does are lumbar punctures but if you don’t want to do them, you’re going to need to refer them out to get them done somewhere else.

[11:38] Taking Calls and Work/Life Balance

Kristen works at a stroke center and they don’t have any other support. They have a neuro hospitalist who’s in the hospital from 9-5 Mon-Fri so she’s never torn away to the hospital and she can just focus on her office these times. But every once every two weeks, she will have a shift from 5pm – 9am where she’s on call for any hospital issues. Generally, they get an acute stroke code around every other day so it all comes down to luck. For example, she got a stroke code at midnight and had to get out of bed, go to the hospital to see the patient, give them TPA, admit to ICU, and go back to bed.

That is unfortunately the reality of taking call at a stroke hospital but most headache doctors don’t do the stroke call coverage. Again, this is because Kristen still does a bit of neurology so she’s involved in a general neurology coverage group that she’s doing these calls.

Kristen says she has a fantastic work/life balance which is partly her own choosing because she had chosen to only schedule patients 32 hours a week. She split her days up, some days longer while others shorter but she only schedules patients for 32 hours a week, doing an extra hour a day doing phone calls and messages which adds up to about 36 hours a week of clinical work which she thinks is a perfect number for her considering she has two young kids so she still has to take care of family and she wants to have the time to do this with them and not rush the time. With headache, you have that freedom over your schedule. If you’re at a surgical center, you can just set your office hours and decide what works for you.

[14:25] Residency Training and Competitiveness

The road to residency training includes doing an intern preliminary year although Kristen thinks you can’t do a transitional year for neurology. it has to be a preliminary year then do a neurology residency for three years and then one year in headache fellowship.

Kristen did her fellowship at St. Luke’s Roosevelt in New York City. After finishing your headache fellowship, you have to take the board certification for headache medicine. If you didn’t take the boards, you could still call yourself a headache specialist, just without that additional board certification. Also, you have to do the neurology board certification after your neurology residency.

Kristen thinks Headache Fellowship was competitive when she applied for it only because there were fewer headache fellowship spots. But now, the number of spots available in the last four or five years has nearly double so it has become less competitive now than before. Because it’s becoming a popular field and people are knowing more about it, more schools are now starting their headache fellowships. She adds that if you want to be a headache specialist, you will be able to get into that position and find that role.

Additionally, Kristen says a lot of neurologists get really turned off by headaches since they feel like patients are demanding and crazy although she feels otherwise seeing that her patients are in a lot of pain, are suffering, and they have some anxiety and depression who are the patients that need the most help. So she never got turned off by it. Alternatively, the majority of neurologists pursue neuromuscular. Kristen says that more often than not, you’re going to end up being the only person in your class of neurology residency that wants to do headache.

[17:50] How to be Competitive for Headache Fellowship

Kristen recommends getting involved in either headache research or in the Move Against Migraine Campaign by the American Migraine Foundation which is a political campaign and also a social awareness campaign.

The campaign seeks to educate people on how common it is and how debilitating it is and help getting more research money to go to migraines so they can get more treatments for people. Kristen is involved in helping spread the word for such campaign. And if you just start offering your help, this would be very impressive to anybody in the headache world.

[19:13] DO’s, Subspecialty, Primary Care, and Other Specialties

Kristen doesn’t see any negative bias towards DO and nobody couldn’t even tell who was a DO in their residency because nobody cared. Moreover, Kristen explains there are no further subspecialty within headache. But she has colleagues that focus more on one type of headache which is easier to do for migraine. There are some headache specialists known as the “migraine guru” as well as those known for being the go-to specialist if you need in-patient management. So you can essentially carve out a niche for yourself.

In terms of working with primary care providers, she would want them or anyone referring any patients to her to not give them any opioids or any Butalbital medications. A lot of patients come to headache specialists who have been managed by primary care for a period of time and they’re given Butalbital-caffeine combination medicine, for example, just to help them get to the neurologist and help their pain until they see a neurologist. Unfortunately, those types of medications worsen migraines and a lot of headaches. Not to mention, that they can develop dependency on them.

Kristen recommends that if you’re worried the patient has to wait a certain amount of time and you worry about their pain, don’t give them a pain pill. She prefers for them to call her and talk to her to ask to get them in sooner rather than have to see them in three to four weeks and have to not only manage their headaches but help them detoxify from such medications since headache specialists don’t use those kinds of medicines in headache. Nevertheless, Kristen welcomes any type of headache issue primary care providers would send in her way. Aside from primary care, other specialties she works the closest with include internal medicine, OB/GYN, pediatricians, psychologists, and psychiatrists for co-morbidities.

[23:25] What She Wished She Knew About Headache Medicine

Kristen would have wanted to learn early on how to cope with failure. As a headache specialist, she is often the third neurologist they’ve seen or the third headache specialist they’ve seen and they’ve already tried everything in her toolbox but you can’t cure all people. This was hard for her when she first started.

It took Kristen a little bit of time to process that and learn how to not take it as a personal failure but to learn how to conceptualize it and move past it although this might be one of the skills that you just have to learn as you go.

[24:35] Most and Least Liked Things About Headache Medicine

Kristen likes the ability to help to people and seeing that huge impact they can have in someone’s life, helping them get back to work, get them functioning, and be a better mother or spouse, and basically get them back to their lives and feel good about their themselves.

What she likes the least is the failure part since you’re going to see the toughest cases so you’re not going to always have those wins. She really dislikes the stroke call she takes but again, for most headache specialists, it’s not going to be part of the deal. She also would have hated the different psychiatric co-morbidities if she was asked four years ago, but she has now adapted to it and understands it so much better now alongside her skill sets that have already expanded.

[26:15] The Future of Headache Medicine

Kristen mentions a new and exciting class of drugs coming into the market soon called the CGRP antagonists which are monoclonal antibodies targeting the one of the main neuropeptides that transmits migraine pain signals which is probably going to hit the market in 2018 to early 2019. This is the first preventative medication for migraine specifically targeted just for migraine which she sees as a very exciting new treatment and revolutionary in terms of migraine management. She thinks this is going to spur a lot of new research since they will definitely expand off of this and look at other pain neuropeptides and develop other monoclonal antibodies to them.

[27:15] Last Words of Wisdom

If she had to do it all over again, she would have chosen the same being a very big fan of headache medicine. She thinks it’s one of the most interesting parts of neurology and one of the most rewarding parts. On the flip side, it could also be one of the most difficult parts but she likes the combination.

Finally, Kristen’s advice to those interested in this field is to make sure you’re interested in the information. Make sure you like reading about the central nervous system or neurotransmitters and that you don’t hate psychiatry and that you can find the passion in the information since you’re going to need to really delve nitty-gritty into these systems and if you hate all that stuff then that’s telling you something. So make sure you like what you’re reading or the process of learning about the brain and just go from there.

Links:

MedEd Media Network

Move Against Migraine Campaign by the American Migraine Foundation

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