Sparking Interest in Headache Medicine: A Conversation with Mia Minen

By Isabel Reyes | May 9, 2024 | Posted in

“Increasing the number of headache providers is an extremely important area and a great passion of mine. In addition to increasing headache knowledge among all kinds of providers – emergency department physicians, primary care providers, OB/GYNs, ENTs – I’ve conducted research on how to increase the number of headache specialists and help early-career individuals establish the pathways that would be most fulfilling for them and helpful to patients with headache disorders.” – Mia Minen

Mia Minen, MD, is an associate professor in the Department of Neurology and in the Department of Population Health, and chief of headache research at New York University (NYU) Langone Health, New York, US. She is both a clinician and a researcher, with a strong interest in behavioral treatments for headache disorders, headache education, and advocacy.

In this MSC interview, Minen speaks with Isabel Reyes, a research technician at the NYU Grossman School of Medicine, to discuss her journey to headache medicine, her educational efforts to increase the number of headache providers, and some of her work on behavioral therapies for migraine. The interview has been edited for clarity and length.

What motivated you to become a headache specialist? Did mentorship influence your decision?

Chance, connections, and mentorship got me into the field of headache medicine. When I was a medical student rotating in neurology, it just so happened that my attending physician, Dr. William B. Young, was a headache specialist at Jefferson Medical College. Dr. Young offered me the opportunity to join his clinic to observe outpatient neurology; I was deciding between psychiatry, internal medicine, and neurology. I joined his clinic and realized neurologists have long-term relationships with and counsel their patients. In headache medicine, we can provide extensive counseling and see how patients change over time with the various treatment modalities offered to them.

Although there have been initiatives to spark interest in headache medicine, how can we further address the shortage of headache specialists?

Increasing the number of headache providers is an extremely important area and a great passion of mine. In addition to increasing headache knowledge among all kinds of providers – emergency department physicians, primary care providers, OB/GYNs, ENTs – I’ve conducted research on how to increase the number of headache specialists and help early-career individuals establish the pathways that would be most fulfilling for them and helpful to patients with headache disorders.

Additionally, I teach medical students a session during their neurology clerkship called Headache Vignettes, where we review patient cases. I provide insight into the work I do and how to personalize it based on the patient, exposing medical students to headache medicine early in their careers. I also offer medical students the opportunity to join my clinic and observe what I do.

Mia Minen

Mia Minen

I also take residents as part of an ambulatory care rotation, and a headache medicine elective is also available. Given the high prevalence and burden of headache disorders, there should be required headache rotations across all neurology residency programs. We’re not there yet, but I think that’s a goal of many headache specialists.

There are also opportunities to bring headache fellows together to learn from each other’s experiences and training and observe how providers practice. When I became an attending physician, I visited various headache centers around the country, and colleagues were nice in including me and showing me their systems. When I came to NYU to build a headache center, I had ideas of what had worked and what required effort to help guide me in building a program.

Tell me more about what you are doing at NYU Langone.

When I began at NYU, I selected one college student to perform research. Subsequently, I continued selecting one student per year until I realized the headache research program was growing so much that we needed more and more students. I discovered I have a real passion for mentoring college students and exposing them to headache medicine. Over time, I have mentored over 40 college students and ultimately decided to formalize a mentorship program.

Realizing that there’s a shortage of neurologists – not just headache specialists – we decided to develop the Building Research Aspirations in Neurology (BRAIN) program and successfully obtained NIH funding to run this R25 program to provide clinical research training to college students. It is a summer-intensive experience to obtain hands-on work in a laboratory setting, didactics, and training in responsible conduct of research. The students interact with other students in internship programs across NYU.

I realized that there’s only so much one can accomplish over the summer, so we have the program continue throughout the academic year so that the students can continue working on their projects, present abstracts or posters at national meetings, and be co-authors on publications.

What other initiatives are out there?

There is an ever-extending role for advanced practice providers [APPs], given that there is such a shortage of headache medicine doctors. The American Headache Society [AHS] and American Academy of Neurology have had great initiatives bringing together APPs interested in headache medicine, offering courses and programs, and making them feel included in the societies.

I am heavily involved in the American Headache Society’s First Contact Committee program and was part of the initial advisory board that developed initiatives to improve headache knowledge among primary care providers. Recently, I’ve worked on a project analyzing the metrics of what the AHS First Contact program has been able to accomplish over the past few years to help lead us in future directions and continue the expansion of headache knowledge amongst primary care providers.

You have also developed an art program to help increase knowledge of migraine. Can you tell me about that?

Migraine affects over 47 million Americans and is the second most disabling condition in terms of disability-adjusted life years. For this reason, I developed the program Headache and Arts, where we teach high school students about the brain, vision, perception, migraine, and concussion through the visual arts. Students learn to identify the signs of migraine or concussion and depict the neurologic symptoms via art. Students then create artwork depicting either migraine or concussion symptoms for exhibition.

A public health advocacy component is modeled after the American Academy of Neurology Palatucci Advocacy Leadership Forum in which students learn how to deliver an elevator pitch, write a letter to the editor, and other public health advocacy skills so that they can advocate for headache and migraine causes. Subsequently, they develop the skills to advocate for any cause they find important in the future.

Let’s switch gears and talk about behavioral treatments for migraine and your research in this area. Could you give us an overview of these therapies?

There are Grade A evidence-based behavioral therapies for migraine prevention that include cognitive behavioral therapy [CBT], biofeedback, and relaxation.

Cognitive behavioral therapy is more well known since it’s used to manage depression, anxiety, and insomnia. Providers already trained in CBT but not familiar with the migraine protocol can learn the protocol and provide therapy. Functional neuroimaging studies of patients pre- and post-CBT tailored for migraine prevention demonstrate changes in neurocircuitry.

During biofeedback, individuals are connected to sensors to detect heart rate, skin temperature, and muscle tension. Patients learn how to tense and relax individual muscles and change their breathing to reduce their heart rate or galvanic skin response. Biofeedback is essentially giving feedback to individuals on how they can change their body’s physiologic processes to help with the migraine.

Lastly, progressive muscle relaxation [PMR] is where individuals learn to tense and relax individual muscle groups so that they are more relaxed over time, and it has Grade A evidence for migraine prevention.

Given that there are significant issues in patients being able to pursue these behavioral therapies due to difficulty finding providers, insurance reimbursement, or having a lack of time, I wanted to develop more scalable and accessible forms of these behavioral therapies.

How did you do that?

Progressive muscle relaxation appeared the easiest to integrate into a smartphone application that patients could access and use to practice on their own. Therefore, I developed the RELAXaHEAD application to offer treatment to patients. We’ve studied it successfully in the neurology setting, emergency department, and primary care in patients with migraine or multiple sclerosis, and now insomnia. I recently received an NIH R01 award to do a Phase 3 clinical trial of PMR in primary care settings.

What about mindfulness?

Mindfulness is one of the emerging treatments being studied for migraine prevention. Traditionally, we were looking at a 50% reduction in headache days as the primary outcome in headache or migraine trials. So far, mindfulness hasn’t necessarily hit that outcome measure, but it is helping to improve migraine-related disability and quality of life, which are now considered clinically important outcomes.

There is great research being done on mindfulness-based stress reduction [MBSR] and mindfulness-based cognitive therapies. It is exciting that MBSR is more accessible than one-on-one CBT for migraine. However, at this point, these are still emerging treatments, and there’s research that needs to be done.

As more individuals enroll in studies of behavioral therapies and wearables, how do you envision future behavioral research and treatment for migraine?

It’s a really exciting time in headache medicine, with many individuals enrolling in smartphone-based studies and studies with wearables. However, many are downloading applications or using wearables that have not been studied, and we don’t know their efficacy.

Therefore, I encourage patients to enroll in research studies; that way we can learn whether such interventions can be helpful. Over time, we can deliver progressive muscle relaxation, cognitive behavioral therapy, and biofeedback using mobile health technology.

Isabel Reyes is a research technician at the NYU Grossman School of Medicine.

Image credit: 123RF Stock Photo.

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