Making a Difference in Neurology and Headache Medicine with an Integrated Approach: An Interview with Deena Kuruvilla

By Lincoln Tracy

Editor's note: This is the fifth in a series of interviews with Migraine Science Collaborative editorial board members.

Deena Kuruvilla, MD, is a board-certified neurologist, headache specialist, and director of the Westport Headache Institute. She has served as an assistant professor and associate program director for the headache fellowship at the Yale School of Medicine and is a medical advisor for Healthline.?

Kuruvilla completed her medical internship at the Mount Sinai School of Medicine in New York. Subsequently, she completed her neurology residency at Brown University in Rhode Island, where she was chief resident. She went on to complete a fellowship in headache and facial pain at the Montefiore Headache Center and the Albert Einstein College of Medicine. She is also the former chair of the Complementary and Integrative Medicine Special Interest Section and current chair of the Women's Health Special Interest Section of the American Headache Society.

Kuruvilla has conducted research studies on medical devices, complementary and integrative medicine, and procedural approaches for the treatment of headache disorders.?Here, she speaks with Lincoln Tracy, a Melbourne-based freelance writer and research fellow, to discuss her journey to headache medicine, how her research interests have evolved over time, the benefits of non-pharmacological approaches for migraine management, and more. This interview has been edited for clarity and length.

What was your path to neurology and headache medicine?

At the start of my career, I was planning to become an internal medicine physician and possibly go on to be a gastrointestinal physician. But in the first or second month of my internal medicine residency, I had a neurology rotation and fell in love with the complex nature of the brain and spinal cord, and with learning about the different neuroanatomy pieces and how they connect to different functions of a person.

Immediately after doing that rotation, I decided to jump ship to neurology, and I've never looked back. It's a beautiful field that has a lot of research opportunities. It's a field that is very underserved; there are certainly not enough neurologists and headache specialists to cover all the patients who need to see a specialist in this area. This was one of the key drivers behind my decision to pursue a headache and facial pain fellowship.

The second reason is that migraine is a very treatable condition within neurology. There are other conditions where we let patients down a lot because we don't have enough research for treatments, or we don't have many options for treating their disease. And patients end up with quite a bit of disability with many neurological diagnoses. But migraine is a space where I found I was able to make the biggest difference in a person's life.

Why is there a shortage of people working in this field?

There are so many different factors that contribute to this. But first and foremost, there is a lot of stigma among physicians towards pain specialties – they view patients who seek help for pain diseases as difficult or challenging. During my neurology residency I was repeatedly told things like, “Why would you want to specialize in migraine? There are so many other more fun specialties you could go into,” or “Migraine is not real. It's really a person who's hysterical” – even from chairs of departments.

I wrote a letter to the editor, for the journal Pain Medicine, about the stigma of migraine within a neurology department. Parts of that survey did reveal stigma from the point of view of the neurology provider in providing care for patients with migraine. But we know that migraine is a real thing, especially with the advent of so many new therapies.

Another part of the shortage has to do with our training. When people decide to go into neurology, we are mainly exposed to things like stroke and epilepsy, so that’s where most people end up going. There are so many programs out there that don't even have a headache specialist, or the residents don't get time with a headache specialist. So I don't think every program exposes residents equally to this field. Education for migraine and for headache disorders in general should start in med school, to capture people and gain their interest in headache. But I just don't think that happens enough.

What is the overall goal of your research?

When I first started working on research with some of my colleagues at the Montefiore Headache Center, I focused more on the procedural side of headache medicine. I am still very interested in that area, but over time my interests have evolved based on attending different meetings within the American Headache Society [AHS].

I was the chairperson of the Complementary and Integrative Medicine Special Interest Section of the American Headache Society and completed research under that umbrella. I'm very interested in integrative medicine. I'm hoping, fingers crossed, that this year I will find an acupuncture program and can get certified in that area. I've had that on my to-do list for years because there is mounting evidence to support acupuncture, and I've even written about this in my papers.

More recently, I've been writing about women's health, the use of integrative medicine therapies, nonpharmacological therapies, the safety and efficacy of neurostimulation devices during pregnancy, and the postpartum period. I’ve also performed clinical trials of devices as a nonpharmacological approach for migraine management. Specifically, I’ve done a lot of work looking at nerve stimulation devices.

What was your time as chair of the Complementary and Integrative Medicine Special Interest Section of the AHS like?

When I took over this section six or seven years ago, there was a stigma towards integrative medicine – that those therapies do not have the evidence to back them up. I don't think it was a very respected section, to be honest with you. When I organized my first meeting, most people who attended were trying to push certain oils, herbs, or other products they had developed, with varying degrees of evidence. Some approaches were not cleared by the FDA or hadn’t been studied in the context of migraine. So I had my work cut out for me.

But, over time, it stopped being a sales platform for approaches without an evidence base and turned into an evidence-based group, which was wonderful to see. We put out papers about evidence-based complementary and integrative medicine [for example, see here]. We even conducted a couple of different courses at American Headache Society meetings, such as mindfulness meditation, with attendees. It took a lot of effort over four years, but it was a lot of fun to promote an evidence-based approach to integrative medicine and not promote things that could be harmful to patients and that hadn't been studied in patients.

Earlier you mentioned your work on nerve stimulation devices. How did your research into external trigeminal nerve stimulation (e-TNS) for migraine start?

It started in 2014 when I was at Yale and involved in a pilot study with Columbia University. The pilot study showed a significant reduction in migraine pain when e-TNS was used for the acute treatment of migraine [20 minutes a day]. After that, CEFALY Technology, the company that was developing the technology and was based in Belgium at the time but is now closer to me here in Connecticut, asked me if I would help to write a larger study for the use of e-TNS as an acute treatment. I absolutely jumped at the chance.

Being able to construct a randomized clinical trial was very exciting and a huge point in my career. We found that patients had a statistically significant increase in pain freedom at two hours compared to placebo when the e-TNS device was used as needed. We've also found that a significant number of patients had freedom from their most bothersome symptom at two hours. In addition to the benefits participants experienced at the two-hour mark, they also reported sustained pain freedom and pain relief at the 24-hour mark [see related MSC news story].

It's really refreshing to know that patients have a complementary option to supplement traditional pharmacological treatments. I was often asked by patients, “Can I use e-TNS as needed because I’m not getting enough from my as-needed treatments?” So using these devices is something I routinely recommend for patients.

You also mentioned you are writing about migraine experienced by patients during pregnancy. What are the challenges in treating migraine during that time?

The biggest challenge in managing migraine during pregnancy is being on the same page as the patient and their obstetrician as to what medications we're all able to accept. Obstetricians may have different recommendations than neurologists or headache specialists do. And some neurologists and headache specialists are more conservative with treatment options during pregnancy than others are.

I tend to be on the conservative side for my patients who are pregnant because we don't have enough evidence for many of the migraine treatments we can use during pregnancy. For example, propranolol, which is a preventive medication we frequently use for migraine, could cause placental hypoperfusion [reduced blow flow to the placenta]. There are cases out there, but we don't have large enough studies to say it’s well tolerated in most people and that it’s not going to cause an issue.

Within the field of migraine research or clinical practice, what don’t we currently know that you hope we will have an answer for in five to 10 years?

We need more data about the long-term effects of CGRP [calcitonin gene-related peptide] antagonism within the migraine population. We have three- to five-year long-term data about the use of CGRP monoclonal antibodies for the prevention of migraine in patients, but we don't have enough further long-term data. We're all excited about the treatments; I recommend them all the time because they really are a game changer for patients. We have CGRP super responders who do really well, but how long can we keep these patients on these treatments?

I also hope we expand research into migraine treatments during pregnancy and perimenopause. And I hope that we start doing studies on patients who are going through in vitro fertilization and having migraine. And I suppose within the transgender population, there's more research coming out now about that transition, and the hormonal therapy that's used and migraine management in those folks. That's another big area for research going forward.

How and why did you get involved with the Association of Migraine Disorders, which is the parent organization of the Migraine Science Collaborative?

The AMD is a unique organization. It’s the first time I've seen patients targeted for education, advocacy, and getting involved. I really love the way they set up the AMD Migraine Symposium with its two tracks – one for patients and one for providers. I also love that the AMD Research Advisory Committee has MDs and PhD researchers who meet quarterly and really discuss research concepts.

For a person like me, who's in private practice, I may not have had that opportunity because I'm no longer at an academic institution. The Research Advisory Committee gives me an opportunity to stay involved in research and learn about new ideas that are out there, contribute my scientific ideas, and collaborate with people I would otherwise never collaborate with at other institutions.

Lincoln Tracy is a freelance writer and researcher based in Melbourne, Australia. You can follow him on Twitter @lincolntracy.

This article originally appeared on the Migraine Science Collaborative.