From Pharmacy to Neurology, the Art of Headache Medicine, and the Importance of Mentorship: A Chat with Shivang Joshi

“Think of the patient as a person with a neurological condition, not just as a disease. It’s really important to take a detailed and analytical approach, and to look at all the available information – their primary care notes, their admission records, their labs. You really want to approach them as a whole, because disease – especially migraine – doesn’t exist by itself. There are always other factors that contribute to the development of disease.”

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

Shivang Joshi, MD, MPH, RPh, FAHS, is a neurologist with clinical interests in trigeminal autonomic cephalgias such as cluster headache and migraine with aura in women. After initially receiving his pharmacy degree and license at St. John’s University College of Pharmacy and Allied Health Professions in New York City, he completed an MD and master’s degree in public health at St. George’s University School of Medicine, Grenada, West Indies. He completed his neurology residency at the Beth Israel Medical Center, New York City, US, before joining the John R. Graham Headache Center at the Brigham and Women’s Hospital in Boston, US, for a fellowship in headache medicine.

Joshi recently spoke with Lincoln Tracy, a research fellow and freelance writer from Melbourne, Australia, about his path from pharmacology to neurology, the art of headache medicine, his passion for educating and mentoring the next generation of neurologists and headache specialists, and much more. This interview has been edited for clarity and length.

What was your path to becoming a neurologist?

My path to neurology started at a very young age, when I took part in the Westinghouse Science Talent Search, which was then called the Intel Science Talent Search, during my time at Brooklyn Technical High School in New York City. I was linked up with the Center for Neurosciences at Columbia University when I was 17 or 18 and worked in a lab that identified the underlying mechanisms of how memories are consolidated in the brain. Although I didn’t realize it at the time, I was working with people who wrote the textbook, Principles of Neural Science, used by all neurologists and neuroscientists – people like Eric Kandel and James Schwartz. That really piqued my interest in neurology and the neurosciences.

After that, I decided to pursue a degree in pharmacy and pharmacology at St. John’s University, where I eventually obtained my pharmacist license. After pharmacy school I briefly worked in industry while applying to medical school. My time in medical school was fantastic. I did a combined master’s in public health and MD program. As part of the public health component, I was able to do an epidemiological research project relating to the anthrax letters [see below].

Shivang Joshi

After medical school I applied for a neurology residency. Part of that program is to do a year of internal medicine, which I completed at Elmhurst Hospital. Elmhurst is in an incredibly diverse part of New York City – you can walk out of the hospital and eat Burmese food, Ethiopian food, and everything in between. It was a wonderful experience and an enjoyable place to learn medicine during that first year. I then went on to complete my neurology residency.

Your work on the anthrax letters sounds fascinating. Can you tell me more about it?

During my master’s I had to complete a capstone, which is almost the equivalent of a thesis, so you get to work on research projects. My project was with Tyler Cymet, a physician out of Johns Hopkins. The US had recently gone through a bioterrorism event where congressional offices had been sent letters containing anthrax spores. We felt there would have been health-related issues in the postal employees who handled the letters, but for whatever reason this was something that wasn’t being explored. Many of the affected people were minoritized or had other difficulties in communicating their experience.

So, I identified all the postal employees who were exposed and went knocking on doors, talking to family members, obtaining autopsy reports, and so on. We found that it was more than just a couple of postal workers who were affected, and that there were other illnesses that may have occurred because of this event. These data were presented to the Institute of Medicine [now called the National Academy of Medicine] and ended up being referenced in the Institute’s manual it published on decontaminating the postal facilities. I’m very proud to have been involved in this work.

How did you develop an interest in headache medicine?

During my residency I got the opportunity to complete an elective in headache medicine under some of the foremost people in the field – Richard Lipton, Brian Grosberg, Sarah Vollbracht, Dawn Buse, Juline Bryson, and Joshua Cohen. All of these people contributed to my initial interest in headache medicine. I also completed another elective at a headache center with Larry Newman, which was the first time I was really exposed to a migraine population. There had been limited opportunities for exposure to this group of patients before then.

I liked working with this patient population, as I felt I could truly make a difference in their neurological condition. It seemed like an area where I could use all my training to impact their course of disease by looking at the multidimensional aspects of how we treat migraine. I could use my pharmacy training to look at their comorbid conditions and medications to help reduce polypharmacy and select the optimal medications. And my public health background helped my approach to treating these patients – a population-based approach to help determine what their needs were.

But I think the thing that solidified my desire to go into headache medicine was getting to attend the Scottsdale Headache Symposium. I loved the camaraderie of the physicians who practice headache medicine. Some of the most famous and accomplished people were still so humble. You could just walk up to them, and they would be so willing to help guide you. I could tell they really cared about the patients they treated. It was such a great, family-like atmosphere.

Much of your previous research has focused on cluster headache. Why is it important to focus on this type of headache disorder?

Cluster headaches are still very difficult to manage and treat. Even though there have been some advances, it is still one of, if not the, most painful conditions known to humankind. There is still a lot of room to help these patients, which is why I have a particular interest in it. I also find the potential underlying hypotheses and mechanisms to be particularly fascinating.

We know the brain plays a role, involving how light is transmitted from the eyeball. But it’s not just an immediate process. There’s also a circadian process, involving the suprachiasmatic nucleus, where there are day-to-day changes as well as seasonal changes. There is some evidence that calcitonin gene-related peptide plays a role in cluster headache, as well as another receptor called PACAP, which is also being studied.

Focusing on cluster headaches is also important because it’s challenging to get the right diagnosis. Sometimes cluster headaches are misdiagnosed as sinus-related headaches or something similar, so patients get placed on steroids, or see a dentist or an ENT specialist instead. It’s also challenging to get these patients into clinical trials due to the nature of the attacks. They only last for 30 minutes, or maybe an hour at certain times of the year, so how do we get these patients in for analysis?

You have a strong passion for educating and mentoring the next generation of clinicians and researchers. How did this interest develop?

I feel very lucky to be where I am, as I’ve been supported and mentored by so many people, in different ways, after arriving to the US from India as a young child. When I first got here, I didn’t speak any English at all. I got a lot of assistance from teachers in those early years, and a few years later I was getting perfect or near-perfect scores in reading and math. So, a lot of credit must go to them, but also to my high school teachers, my mentors at Columbia, and then all the colleagues and mentors I’ve encountered in headache medicine. It was very much a collective thing, and I’m very keen to pay that back by helping the next generation.

I feel it comes naturally to me. My dad was a university professor in chemistry back in India, so maybe it’s genetic [laughs].

What’s one aspect of your mentoring that you are proud of?

Probably speed mentoring, which is one of the initiatives I came up with for the American Headache Society. I wanted to create an opportunity for mentees to interact with mentors in a way that would maximize the mentee’s time, and to make use of all the accomplished physicians, clinicians, and statisticians working in headache medicine who are all very willing to share their time.

I had an idea where mentees had to come up with an idea for a project they had in mind, like a clinical research study. Then, they would get five or 10 minutes with each mentor to present the project and get feedback. So, for example, you would get an epidemiological perspective from Richard Lipton or Peter Goadsby, or you could get clinical trial design feedback from Stewart Tepper, or publishing advice from Andrew Charles and Elizabeth Loder. We ran the program in person for two years before going virtual because of COVID.

The program turned out to be really effective. We’ve heard that some mentees had obtained grants and started their projects, which is a great accomplishment. But just the overall feedback from both the mentees and mentors was pleasing, as everyone found this initiative very rewarding.

Is there a common theme to the advice you give to the up-and-coming researchers and clinicians you work with?

One of the things I really try to emphasize is having a comprehensive approach and thinking about the patient walking through the door. Think of the patient as a person with a neurological condition, not just as a disease. It’s really important to take a detailed and analytical approach, and to look at all the available information – their primary care notes, their admission records, their labs. You really want to approach them as a whole, because disease – especially migraine – doesn’t exist by itself. There are always other factors that contribute to the development of disease.

How did you initially get involved with the Association of Migraine Disorders and the Migraine Science Collaborative?

I’ve had the pleasure of knowing [AMD Founder] Frederick [Rick] Godley for quite some time now. When I was last working in Massachusetts, I saw there was an opportunity to work with AMD in really expanding education and knowledge of migraine. This organization had a terrific vision that I was keen to be a part of. Being part of the MSC editorial board also allows me to keep in touch with what is going on in the headache community from a clinical and research perspective. It’s been a pleasure and honor to be able to serve in this space.

Finally, if you could host a dinner party for anyone from history, dead or alive, who would you want at your table and why?

Well, this might change by the time this interview is published, but I’d have to say Leonardo da Vinci. When I was studying abroad in Italy, I worked on a project trying to figure out why he left his paintings unfinished. I really admire da Vinci for his remarkable ability to do both science and art, so I’d love to ask him about the real reason why he left his paintings unfinished. It would also be great to explore his mind and see what we can learn from it.

I like to think we try and practice the art of headache medicine. In fact, one symposium we had for the Great Lakes Regional Headache Society was at the Cleveland Museum of Art. The theme was the history of art and headache medicine, so I mandated that each speaker had to incorporate one work of art into their talk. It goes back to how I feel that we should really individualize what you want to do for the patient.

Lincoln Tracy, PhD, is a researcher and freelance writer based in Melbourne, Australia. Follow him on Twitter @lincolntracy.