arandomizedtrialoftelemedicineefficacy and safety for ...the primaryefficacy endpoint was a change...

Kai I Muumlller MDKarl B Alstadhaug MD

PhDSvein I Bekkelund MD

PhD

Correspondence toDr Muumlllerkaiivarmullerunnno

Supplemental dataat Neurologyorg

A randomized trial of telemedicine efficacyand safety for nonacute headaches

ABSTRACT

Objective To evaluate long-term treatment efficacy and safety of one-time telemedicine consul-tations for nonacute headaches

Methods We randomized allocated and consulted nonacute headache patients via telemedicine(n5200) or in a traditional manner (n5202) in a noninferiority trial Efficacy endpoints assessedby questionnaires at 3 and 12months included change from baseline in Headache Impact Testndash6(HIT-6) (primary endpoint) and pain intensity (visual analogue scale [VAS]) (secondary endpoint)The primary safety endpoint assessed via patient records was presence of secondary headachewithin 12 months after consultation

Results We found no differences between telemedicine and traditional consultations in HIT-6(p 5 084) or VAS (p 5 064) over 3 periods The absolute difference in HIT-6 from baselinewas 03 (95 confidence interval [CI] 2126 to 182 p 5 072) at 3 months and 02 (95 CI2198 to 158 p 5 083) at 12 months The absolute change in VAS was 04 (95 CI 2093to 022 p 5 023) after 3 months and 03 (95 CI 2094 to 029 p 5 030) at 12 monthsWe found one secondary headache in each group at 12 months The estimated number ofconsultations needed to miss one secondary headache with the use of telemedicine was20200

Conclusion Telemedicine consultation for nonacute headache is as efficient and safe as a tradi-tional consultation

ClinicalTrialsgov identifier NCT02270177

Classification of evidence This study provides Class III evidence that a one-time telemedicine con-sultation for nonacute headache is noninferior to a one-time traditional consultation regardinglong-term treatment outcome and safety Neurologyreg 201789153ndash162

GLOSSARYANOVA 5 analysis of variance CI 5 confidence interval FLAIR 5 fluid-attenuated inversion recovery HIT-6 5 HeadacheImpact Testndash6 VAS 5 visual analogue scale

Headaches are widespread and will be experienced by most people1 According to the GlobalBurden of Disease tension-type headache and migraine are the second and fourth most prev-alent disorders in the world Together with medication overuse headache they are the 3 mostprevalent neurologic disorders2 Headaches may seem trivial but many seek health care forheadache-related disability3

The geographic area of Northern Norway is huge and broken up by mountains valleys andfjords into many sparsely populated places (figure e-1 at Neurologyorg) Cumbersome andexpensive travel hampers access to care for many headache sufferers

We evaluated long-term treatment outcomes and safety of telemedicine consultations fornonacute headaches in a secondary neurologic outpatient department The primary hypothesis

From the Department of Clinical Medicine (KIM KBA SIB) UiTndashThe Arctic University of Norway Department of Neurology (KIM SIB)University Hospital of North Norway Tromsoslash and Department of Neurology (KBA) Nordland Hospital Trust Bodoslash Norway

Go to Neurologyorg for full disclosures Funding information and disclosures deemed relevant by the authors if any are provided at the end of the articleThe Article Processing Charge was funded by grants from Helse Nord RHF (The Northern Norway Regional Health Authority)

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 40 (CCBY-NC-ND) which permits downloading and sharing the work provided it is properly cited The work cannot be changed in any way or usedcommercially without permission from the journal

Copyright copy 2017 The Author(s) Published by Wolters Kluwer Health Inc on behalf of the American Academy of Neurology 153

was that telemedicine consultations are nonin-ferior to traditional consultations in treatmentand safety at 12 months

METHODS Trial design We conducted this noninferiority

trial at the department of Neurology in Tromsoslash University

Hospital in Norway (figure e-1)

Power was calculated on the assumption of a normal distribu-

tion of a primary binary satisfaction variable with an inferiority limit

of 15 With an a of 001 in a 98 confidence interval (CI) 127

participants in each group were required to reach a power of 95

In the area of coverage access to all patient records in North-

ern Norway is made possible by a shared database in the

Distributed Information and Patient System for hospitals (DIPS

ASA Bodoslash Norway)4

From September 30 2012 until March 30 2015 we consec-

utively screened and recruited 402 (to ensure applicable 12-

month data) out of 557 headache patients (figure 1) We included

Norwegian-speaking female and male participants aged 16ndash65

years referred from primary care to a neurologist for headache

management with a maximum 4 months waiting time from date

of referral Patients who underwent a neurologic headache con-

sultation within the last 2 years were excluded We defined head-

ache as nonacute and less likely secondary if it started gradually

occurred at least 4 weeks prior to referral and showed no clinical

or radiologic abnormalities56 Findings from the clinical neuro-

logic examination and neuroimaging performed as part of the

Figure 1 Flow of participants through the study

ITT 5 intention-to-treat

154 Neurology 89 July 11 2017

primary clinical evaluation were regarded as sufficient supplemen-

tary information to perform a realistic safety investigation

All participants received written study information and filled

out social and demographic questionnaires Headache Impact

Testndash6 (HIT-6)7 visual analogue pain scale (VAS)8 and consent

forms beforehand At entrance all participants came to the hos-

pital in Tromsoslash and met at the patient reception in the neurologic

department (figure e-1) A nurse controlled the patientrsquos self-

administered forms and the consent and phoned the external

research department at the University Hospital for block random-

ization Randomization was computer-generated by using an Rnd

function in Microsoft (Redmond WA) Access Then the nurse

followed each participant either to a patient examination room at

the department (traditional group) or to a videoconference room

located next to the Department of Neurology (telemedicine

group)

Patients in the traditional group were consulted in-person

face-to-face in the examination room at the Department of

Neurology The neurologists conducted telemedicine visits via

a Cisco (Moorestown NJ) EX60 unit from the examination

rooms where the traditional consultations took place The patient

was then located remotely in the videoconference room The vid-

eoconference room had a Cisco C40 integrator package installed9

providing a 2-way video and audio communication between the

neurologist and the patient The neurologists (KIM and SIB)

checked the inclusion criteria filled in the diagnostic checklist

performed a standardized interview without neurologic examina-

tions and completed the consultation

Both the telemedicine and the traditional in-person consulta-

tion was a one-time consultation of new referred headache pa-

tients In most cases only the neurologist and the patient were

present at consultation but a relative or a friend accompanied

a few

Questionnaires and patient records We sent a structured

questionnaire by patient preference either through an online sur-

vey service (Questback) or by mail at 3 and 12 months with

a reminder after 2 weeks to the nonresponders10

Participants were asked the following

1 To complete the HIT-67

2 For the intensity of headache measured on VAS8

3 To fill in number of headache days and headache attacks per

month for the last 3 months

4 For the subjective change in headache frequency and intensity

ldquoIs the headache better unchanged or worserdquo ldquoIs the head-

ache frequency reduced unchanged or increasedrdquo ldquoIs the

headache intensity reduced unchanged or increasedrdquo

5 For other disability measures including employment sick

leave and other social benefits

6 For the use of medication including frequency of painkillers

and triptans

7 Whether patients underwent brain neuroimaging with CT

MRI or both within 12 months after consultation

8 For recall of the given headache diagnosis compliance with

given treatment and number of general practitioner visits

within the 12 months after the baseline consultation

9 For number of neurologic visits and hospitalizations for head-

aches within the 12 months after the baseline consultation

Outcome variables Demographics were compared between tel-

emedicine and traditional groups of all participants and those

answering the 12-month questionnaire (table 1) Clinical and

headache characteristics including comorbidity and diagnosis ac-

cording to International Classification of Headache Disordersndash211

HIT-6 and VAS of all the participants and those answering the 12-

month questionnaire were recorded (table 1)

Efficacy endpoints and general practitioner follow-up visits

were evaluated through the questionnaires Safety endpoints

neurologic follow-ups and hospitalizations were reported by

the participants in the 12-month questionnaire but also validated

by screening the patientsrsquo hospital records from the year passed

since the baseline consultation

The primary efficacy endpoint was a change in headache bur-

den measured by HIT-6 across 3 periods (at consultation at 3

months and at 12 months) The HIT-6 is a patient-reported

headache outcome measure that assesses the influence of head-

ache on daily life It consists of 6 headache questions relating to

daily activities and work pain fatigue and irritability Every

question has 5 answers (never rarely sometimes very often

and always) and each answer scores 6 8 10 11 or 13 points

respectively A score above 56 has substantial influence on daily

life

The primary safety outcome was incidents of secondary head-

aches revealed within 12 months after the headache specialist

consultation

The main secondary efficacy endpoint was a change in head-

ache intensity measured on VAS across 3 periods (at consultation

at 3 months and at 12 months) The horizontal VAS scale from

0 to 10 0 5 no pain 10 5 worst possible pain is valid and

reliable for assessing headache intensity and many other pain

conditions8 Other secondary efficacy outcome measures were

change in work status sick leave perception of headache head-

ache days per month over the last 3 months frequency of pain-

killers triptans and headache prophylactics in the last month

and diagnostic recall at 12 months The use of painkillers and

triptans were divided into 4 groups 3 days a week 1ndash2 days

a week 1 day a week but every second week and 1 day

every second week

Secondary safety outcomes were assessed by findings of

pathology on brain neuroimaging requisitioned at the specialist

consultation The frequency of headache-related hospitalizations

and specialist headache visits within 12 months after the specialist

consultation were assessed to evaluate the quality and safety of

telemedicine12

Other secondary safety outcomes were compliance with treat-

ment and abnormal CSF analysis demonstrated within 12

months after the specialist headache consultation

Participants were brain scanned in CT or in 15T MRI ma-

chines The CT was performed by a spiral technique with recon-

structions in 3 planes (coronal sagittal and axial) All MRIs had

a HeadSENSE-HeadFlex-L coil and included at least the follow-

ing sequences sagittal 3D fluid-attenuated inversion recovery

(FLAIR) axial T2 turbo spin echo 4 mm axial T2 fast field echo

4 mm axial diffusion 4 mm and sagittal T1 spin echo 55 mm

All neuroimages were evaluated either by experienced radiologists

or with a second opinion from neuroradiologists

Neuroimaging findings were classified as being normal

nonsignificant or significant1314 Normal was defined as no

abnormalities or white matter hyperintensities (T2FLAIR)

corresponding to 1 on the Fazekas scale nonsignificant as

abnormalities not influencing further management or Fazekas

scale 1 and significant if abnormalities needed follow-up

treatment or were categorized as clinically significant neurologic

findings according to given criteria1315

Statistical methods Data were analyzed with SPSS (Armonk

NY) 23 To ascertain normality we inspected continuous variables

by histogram and calculated kurtosis and skewness before performing

independent-samples t tests Categorical variables were compared

Neurology 89 July 11 2017 155

using x2 test and presented as numbers and percentages All tests

were 2-sided Statistical significance was set at p 005

Intention-to-treat analysis was performed by using last observed

value carrying forward for continuous variables together with

cross-tabulation with missing values for categorical variables

Variables not prespecified are labeled in Results We used mixed

betweenndashwithin participants analysis of variance (ANOVA) to

assess whether change in HIT-6 and VAS differed between tel-

emedicine and traditional consultations across 3 time periods

These results were presented as Wilks l partial h2 and F score

Absolute results and numbers needed to treatharm were cal-

culated for the primary and main secondary outcome measures

Consent registration and ethical approval We received oral

and written consent from all participants before data collection The

Norwegian National Committee for Medical and Health Research

Ethics approved the study (20091430REK) and it conforms with

the Helsinki Declaration16 The trial was registered at the Norwegian

Research andManagement database (FAS ID3897HST959-10) and

retrospectively at ClinicalTrialsgov (NCT02270177)17

RESULTS The 3-month questionnaire wasanswered by 348402 (866) and 291402

(724) answered the 12-month questionnaireHIT-6 Cronbach a coefficients were 084 089and 090 at baseline and 3 and 12 monthsrespectively Feasibility outcomes 3-month follow-up data and recommended interventions are pub-lished elsewhere918

Mixed betweenndashwithin participants ANOVAwith a significance level of 005 and 95 CIsshowed no differences in HIT-6 or VAS betweenthe telemedicine and the traditional group over 3periods F1271 5 0043 p 5 084 and F1255 5

022 p 5 064 for HIT-6 and VAS respectively(figure 2)

The absolute changes in HIT-6 were 03 (95CI 2126 to 182 p 5 072) at 3 months and 02(95 CI 2198 to 158 p 5 083) at 12 monthsThe absolute changes in VAS were 04 (95CI 2093 to 022 p 5 023) at 3 months and 03(95 CI 2094 to 029 p 5 030) at 12 monthsFigure 2 compares the decline in HIT-6 and VAS

Table 1 Baseline demographics and clinical characteristics of the randomized groups in patients referred to a specialist for headache

All included patients Patients answering the 12-month questionnaire

Telemedicine (n 5 200) Traditional (n 5 202) p Value Telemedicine (n 5 151) Traditional (n 5 140) p Value

Female n () 148 (740) 153 (757) 077 119 (788) 103 (736) 036

Age y mean (SD) 360 (130) 380 (137) 012 367 (132) 393 (142) 010

Education y mean (SD) 135 (30) 138 (31) 022 135 (29) 138 (31) 052

Employment n () 018 041

Full-time 128 (640) 125 (619) 97 (647) 88 (629)

Part time 18 (90) 12 (59) 13 (87) 10 (71)

Student 28 (140) 24 (119) 22 (147) 16 (114)

Other (not working) 26 (130) 41 (203) 18 (120) 26 (186)

Sick leave due to headache n () 58 (290) 62 (307) 079 42 (278) 40 (286) 099

Body mass index kgm2 mean (SD) 271 (54) 269 (53) 062 271 (54) 275 (54) 051

Obesity (body mass indexpound30) n () 52 (260) 49 (243) 077 42 (278) 39 (279) 100

Without comorbidity n () 115 (575) 106 (525) 036 90 (596) 74 (529) 030

Chronic neck pain n () 89 (445) 99 (490) 042 67 (444) 64 (457) 091

Insomnia n () 61 (305) 65 (322) 080 41 (272) 42 (300) 068

Hypertension n () 14 (70) 22 (109) 023 11 (73) 18 (129) 017

Onset of headache age y mean (SD) 245 (144) 254 (143) 053 244 (146) 266 (152) 020

HIT-6 mean (SD) 641 (61) 640 (61) 082 637 (63) 637 (61) 099

VAS mean (SD) 71 (22) 69 (21) 049 70 (22) 69 (20) 072

Most prominent headache n ()

Migraine 106 (530) 113 (559) 062 79 (523) 77 (550) 073

Tension-type headache 15 (75) 8 (40) 019 12 (79) 5 (36) 018

Medication overuse headache 35 (175) 38 (188) 083 27 (179) 26 (186) 100

Trigeminal autonomic cephalalgiasa 16 (80) 16 (79) 100 12 (79) 11 (79) 100

Abbreviations HIT-6 5 Headache Impact Testndash6 VAS 5 visual analogue scaleThe first 3 columns correspond to all included patients The last 3 columns correspond to those who answered the 12-month questionnairea Cluster headache paroxysmal hemicrania and hemicrania continua


scores between telemedicine and traditional consulta-tions across 3 periods

Table 2 compares treatment efficiency variablesbetween telemedicine and traditional headache con-sultations of patients who answered the 12-monthquestionnaire Table 3 compares quality and safety

variables between the 2 groups within 12 monthsafter the consultation

We identified one secondary headache in eachgroup (table 3) The number of telemedicine con-sultations needed to miss one secondary headachewas 1(1202ndash1200) 5 20200 (95 CI)

Figure 2 Prespecified Headache Impact Testndash6 (HIT-6) and visual analogue scale (VAS) from baseline to 12months after consultation

(A) HIT-6 (p 5 084) and (B) VAS (p 5 064) from baseline to 12 months after consultation


Table 2 Treatment efficiency among patients 12 months after a specialist headache consultationab

Telemedicine(n 5 151)

Traditional(n 5 140)

p Value(95 CI)

Work status n ()

No change 96 (800) 78 (750) 004

Off sick list 18 (150) 11 (106)

On sick list 6 (50) 15 (144)

Subjectively less headache n () 102 (675) 88 (629) 047

Subjectively unchanged n () 36 (238) 34 (243) 100

Subjectively more n () 12 (79) 16 (114) 042

VAS mean (SD) 52 (27) 55 (25) 043 (2036 to 085)

Δ VAS mean (SD)cd 219 (28) 215 (24) 030 (2029 to 094)

HIT-6 mean (SD) 600 (91) 601 (83) 090 (2190 to 215)

Δ HIT-6 mean (SD)ce 2366 (76) 2346 (77) 083 (2198 to 158)

Headache daysmo n () 074

gt15 64 (427) 63 (450)

7ndash15 47 (313) 38 (271)

lt7 39 (260) 39 (279)

Frequency of painkillers use n () 033

gt3 dayswk 32 (232) 43 (328)

1ndash2 dayswk 30 (246) 26 (198)

lt1 daywk but gt every 2 weeks 34 (246) 25 (191)

lt1 day every 2 weeks 42 (304) 37 (282)

Frequency of triptan use n () 071

gt3 dayswk 8 (99) 8 (143)

1ndash2 dayswk 21 (259) 15 (268)



On prophylactic medication n () 56 (371) 53 (379) 099

Recalled diagnosis n () 111 (735) 103 (736) 100

Did you have neuroimaging n ()f 028

MRI 80 (552) 75 (543)

CT 13 (90) 6 (43)

Both 25 (172) 33 (239)

Specialist headache visits n () 19 (134) 22 (168) 054

No of specialist visits mean (SD) 023 (074) 034 (10) 030 (2098 to 032)

GP visits n () 89 (631) 92 (692) 035

No of GP visits mean (SD) 225 (32) 295 (38) 010 (2012 to 154)

Abbreviations CI 5 confidence interval GP 5 general practitioner HIT-6 5 Headache Impact Testndash6 VAS 5 visualanalogue scalea Per protocol analyses of the 12-month questionnairebAll conclusions of intention-to-treat analyses coincided with per protocol analyses p Value of work status in intention-to-treat 5 003c The difference between 12-month follow-up and baseline datad0 5 No pain 10 5 worst possible paineA 6-item patient-related outcome measure where a score above 50 is considered highf Nonprespecified variable All other variables in the table are prespecified


Reasons for hospitalizations due to headache wereas follows

Telemedicine1 Endovascular stenting of an extracranial verte-

bral artery The tension-type headache subsidedafter treatment This was the patient with sec-ondary headache

2 Clips on a middle cerebral artery aneurysm Nochange in cluster headache on 12-month follow-up after neurosurgery

3 A patient with orgasmic headache was admitted toevaluate vasospasms with CT angiography andlumbar puncture She was treated with nifedi-pine CT angiography was normal 3 months later

4 Treatment of postdural puncture headache5 A patient was hospitalized twice for status

migrainosus6 X-rayndashguided lumbar puncture and medication

withdrawal due to medication overuse headache7 Medication withdrawal due to medication over-

use headache

Traditional1 A patient with migraine and medication overuse

headache was hospitalized after a second opin-ion neuroradiologic interpretation of brain MRIsuggesting idiopathic intracranial hypertensionwhich was later confirmed This was the patientwith secondary headache

2 A patient with cluster headache admitted to testinhalation of 100 oxygen as attack-abortingtreatment

3 Treatment of postdural puncture headache4 Neuropsychological testing of a patient with

migraine due to subjective cognitive declineThe test was normal

The significant neuroimaging findings in the teleme-dicine group included a middle cerebral artery aneurysm(1 patient) vasospasms (1 patient) white matter dam-age of suspected prenatal origin (2 patients) 1 Arnold-Chiari malformation type 1 and 1 benign tumor inthe masseter muscle In the traditional group 2 patientshad meningioma and 1 had a Dandy-Walker anomalyNone of the above-mentioned findings was associatedwith the headaches diagnosed at the consultation

All 19 lumbar punctures except in the patientwith idiopathic intracranial hypertension had normalCSF opening pressure and all had normal leucocyteprotein and isoelectric focusing

DISCUSSION With similar conditions in telemedi-cine and traditional headache consultations of newpatients recruited consecutively from our neurologicoutpatient department we found no significant dif-ferences in long-term treatment efficacy measuredrepeatedly with HIT-6 and VAS over 12 months Bythoroughly rereading every participantrsquos hospitalpatient records 1 secondary headache was identifiedin each group within the first year after the headacheconsultation and findings on neuroimaging wereequally distributed between the 2 randomized groupsFurther evaluation after 1 year showed that headachepatients consulted through telemedicine were fol-lowed up in a similar manner as those who underwenttraditional consultations With no significant differ-ences between the 2 methods of consultation tele-medicine is as efficient and safe as traditional visits inlong-term treatment outcome of nonacute headaches

There are a few randomized controlled 2-wayvisual and audio telemedicine trials of neurologic con-ditions beyond stroke19ndash21 Other randomized studiesare based on treatment of already diagnosed condi-tions22ndash24 Still telemedicine is widely used inneurologic departments as well as for headache man-agement122526 Our study shows that after 12 monthsof follow-up headache burden subjective and objec-tive headache change or treatment follow-up

Table 3 Safety of specialist telemedicine consultations for nonacuteheadaches


Traditional(n 5 202) p Value

Secondary headaches n ()a 1 (05) 1 (05) NA

Requisitioned brain imaging n()a

029

Normal 58 (806) 62 (899)

Not significant changes 8 (111) 4 (58)

Significant changes 6 (83) 3 (43)

Abnormal ordered imagings n ()a 14 (194) 7 (101) 019

All abnormal brain imaging n ()a 24 (137) 20 (116) 066

All brain imaging n ()a 067

Normal 151 (863) 153 (884)



Headache visitshospitalizationsmean (SD)bc

019 (055) 021 (063) 076

All hospitalizations n ()b 047

None 182 (910) 174 (861)

1 14 (70) 23 (114)

2 3 (15) 4 (20)

3 1 (05) 1 (05)

Compliance to treatment n ()ad 100 (735) 86 (711) 076

Requisitioned LP n ()a 8 (40) 11 (54) 065

Abbreviations LP 5 lumbar puncture NA 5 not applicablea Nonprespecified analysesb Prespecified frequency at 12 months due to headachec 95 Confidence interval 2013 to 010dNo5 151 in the telemedicine and 140 in the traditional group Compliance with treatmentis from the 12-month questionnaire The other variables are from the electronic patientrecords


outcomes are not statistically in favor of traditionalvisits (figure 2 and table 2) The long-term similaroutcomes of both groups adds to the cost-saving anal-ysis in our previous article9 In a cost-minimizationperspective we now evaluate these results as stronglyindicating cost-effectiveness for telemedicine9 Thisrandomized trial will help to build a base of evidencefor telemedicine consultations for nonacute head-aches and prevent making it less safe than it has to be

The list of differential diagnoses of headaches isone of the longest in medicine but fortunately sec-ondary headaches caused by structural brain disordersare rare27 However some secondary headaches maybe life-threatening and physicians often struggle tosee the forest for the trees6 Some neurologists inNorway require MRI before a patient with nonacuteheadache is referred and this is also the case in theUnited States28 During a headache consultationphysicians should aim at identifying warning signsfor secondary causes of headache6

By excluding secondary headaches from the refer-rals as performed in clinical practice the risk of miss-ing secondary headaches due to misdiagnosis wassmall After 12 months the frequency of secondaryheadaches brain neuroimaging pathology hospitalstays due to misdiagnoses or headache-related treat-ment as well as compliance and lumbar puncture re-sults were comparable between the groups Althoughwe applied the same classification criteria as a popula-tion-based study there were less significant findingson the brain imagings13 One reason may be thatwe initially excluded secondary headaches but pa-tients in our study were also younger The presentstudy documents that telemedicine evaluation ofnonacute headaches without performing clinical neu-rologic examination can be considered safe Con-versely in some geographic areas pathologicfindings on brain CT in patients with nonacute head-aches are reported almost as high as in 50 andpossibly rendering telemedicine less safe29

Generalizability and low risk of selection bias arestrengths of this study since we consecutively re-cruited and consulted referred patients to a daily neu-rologic outpatient department The distances to otherneurologic departments and private practicing neu-rologists are extensive and located outside the rangeof the hospitalrsquos territory Subsequently the risk ofloss to follow-up is negligible Randomization highresponse rate on the questionnaires and thoroughreview of every participantrsquos patient records are otherstrengths that ensure high inclusion rates and fewissues with attrition

Although we consulted all patients inside the hos-pital providing similar group settings the studydesign makes the study conditions less realistic Hold-ing the telemedicine visits within the same hospital as

traditional visits clearly cuts both ways Removingpotential confounding effects of travel location andthe use of different health care personnel strengthensthe internal validity but may also give a false feelingof security from a hospital environment in the teleme-dicine group This and the fact that the patients hadto make a journey may bring value to and build uppatientsrsquo preference and satisfaction of a remote expe-rience Despite potential detraction from this pa-tients were highly satisfied in both groups and thefrequency of satisfied patients in the telemedicinegroup was noninferior to the traditional group18 Lackof a placebo group and blinding are other weaknessesbut would be difficult to implement

Although the efficacy and safety of telemedicineare comparable to traditional headache visits thedecline in HIT-6 and VAS in both groups could becaused by a deviation to the mean30 In line with thisreasoning the efficacy of either consultation type tousual headache care has not been demonstrated Onthe other hand the results are in range of a minimalclinically important difference for HIT-6 and beyondthat of VAS31ndash33 Another uncertainty is that our anal-yses of neuroimaging were based on radiologic de-scriptions from clinical practice comprised of bothCT and MRI and did not differentiate betweenthem On the other hand this reflects a real-life con-text in a neurologic outpatient department

Technologies such as telemedicine are not consid-ered neutral but may have profound influence on his-tory and society and are in various degrees exposed tointerpretations by users34 The positive aspects in thisstudy make telemedicine a compensation for the lackof headache specialists in our area However rules andregulations may hinder use of new technology3536 Thefact that headaches often are underdiagnosed and sub-optimally treated in general practice encourages use oftelemedicine to countervail these circumstances37

In addition to the positive long-term efficacy andsafety results in this study we have previously shownthat telemedicine is an acceptable satisfying and fea-sible consultation form for nonacute headaches918

Still up to 75 of new information and communi-cation technologies turn out to fail38 To becomesuccessful many examples show that such technolo-gies ought to be built through a bottom-up procedurerather than a top-down approach3940 Because thefoundation of our study is not built from scratchbut through a bottom-up procedure using consultingmethods and equipment already incorporated in ourhospital the chance of it becoming successfully incor-porated in clinical practice is high

Telemedicine consultation for nonacute headacheis noninferior to traditional in-person clinic evalua-tion in respect to long-term treatment efficacy andsafety and should be a good alternative for patients


presenting with nonacute headache This study pro-vides Class III evidence that a one-time telemedicineconsultation for patients with nonacute headache isnoninferior to a one-time traditional consultationregarding long-term treatment outcome and safety

AUTHOR CONTRIBUTIONSDrs Muumlller and Bekkelund contributed to the conception and design

acquisition statistical analysis and interpretation of data Dr Alstadhaug

contributed to conception and design and analysis and interpretation of

data All authors revised the article and approved the final version

STUDY FUNDINGThe Northern Norway Regional Health Authority (Helse Nord RHF)

funded this study

DISCLOSUREThe authors report no disclosures relevant to the manuscript Go to

Neurologyorg for full disclosures

Received October 7 2016 Accepted in final form March 16 2017

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ology of headache in a general population a prevalence

study J Clin Epidemiol 1991441147ndash1157

2 Global Burden of Disease Study 2015 (GBD) Seattle Institute

for Health Metrics and Evaluation (IHME) 2015 Available

at ghdxhealthdataorggbd-results-toolparams5querytool-

permalink1e1e0e0f14ead39cf9d234147f456129 Accessed

December 11 2016

3 Bekkelund SI Albretsen C Evaluation of referrals from

general practice to a neurological department Fam Pract

200219297ndash299

4 Christensen B Silsand L Wynn R Ellingsen G The

Biography of Participation Proceedings of the 13th Par-

ticipatory Design Conference Short Papers Industry

Cases Workshop Descriptions Doctoral Consortium Pa-

pers and Keynote abstracts volume 2 Windhoek Nami-

bia ACM 201471ndash74

5 Frishberg BM Rosenberg JH Matchar DB et al Evi-

dence-based guidelines in the primary care setting neuro-

imaging in patients with nonacute headache 2000

Available at httptoolsaancomprofessionalspractice

pdfsgl0088pdf Accessed May 31 2017 (archived by

Webcite at httpwwwwebcitationorg6qs4R5iFK)

6 Detsky ME McDonald DR Baerlocher MO Tomlinson

GA McCrory DC Booth CM Does this patient with

headache have a migraine or need neuroimaging JAMA

20062961274ndash1283

7 Kosinski M Bayliss MS Bjorner JB et al A six-item

short-form survey for measuring headache impact the

HIT-6 Qual Life Res 200312963ndash974

8 Lundqvist C Benth JS Grande RB Aaseth K Russell

MB A vertical VAS is a valid instrument for monitoring

headache pain intensity Cephalalgia 2009291034ndash1041

9 Muumlller KI Alstadhaug KB Bekkelund SI Acceptability

feasibility and cost of telemedicine for nonacute head-

aches a randomized study comparing video and traditional

consultations J Med Internet Res 201618e140

10 Questback Available at questbackcom Accessed April 18

2016 (archived by WebCite at webcitationorg6gr3li1zf)

11 The International Classification of Headache Disorders

2nd ed Cephalalgia 200424(suppl 1)9ndash160

12 Davis LE Coleman J Harnar J King MK Teleneurology

successful delivery of chronic neurologic care to 354 pa-

tients living remotely in a rural state Telemed J E Health

201420473ndash477

13 Honningsvaringg LM Hagen K Haberg A Stovner LJ Linde

M Intracranial abnormalities and headache a population-

based imaging study (HUNTMRI) Cephalalgia 201636

113ndash121

14 Sempere AP Porta-Etessam J Medrano V et al Neuroimag-

ing in the evaluation of patients with non-acute headache

Cephalalgia 20052530ndash35

15 Fazekas F Chawluk JB Alavi A Hurtig HI Zimmerman RA

MR signal abnormalities at 15 T in Alzheimerrsquos dementia and

normal aging AJR Am J Roentgenol 1987149351ndash356

16 World Medical Association World Medical Association

Declaration of Helsinki ethical principles for medical

research involving human subjects 2008 Available at

wmaneten30publications10policiesb3index html

Accessed May 18 2016 (archived by WebCite at

webcitationorg6hb61FDlz)

CommentThe virtual neurologist

In 1999 Levine and Gorman1 introduced telestroke as the first major appli-cation of telemedicine to neurology Today telestroke is standard care globallyNow Muumlller et al2 have conducted one of the largest teleneurology clinical trialsfor nonacute headaches

Despite increasing interest few randomized controlled studies of telemedi-cine have been conducted In this study over 400 nonelderly adults with nonacuteheadaches came to a neurology clinic in Norway and were randomized to eithera traditional in-person clinical evaluation or a one-time video visit with a neurolo-gist The video visit consisted of a clinical history but no neurologic examinationIn this noninferiority trial no significant difference on the Headache Impact Testndash6 a patient-reported outcome was found at 12 months The frequency of safetyissues (less well-defined) appeared similar in both groups

The studyrsquos strengths are its randomized design large sample size clearefficacy measures long follow-up and good but not complete ascertainment ofstudy participants The study however has an artificial design in which patients inboth arms had to travel to a centralized clinic for evaluation In addition unliketelestroke no attempt at a neurologic examination even a screening one wasmade In practice patients are likely to be evaluated at satellite clinics close towhere they live as in the Ontario Telemedicine Network in Canada and in theVeterans Health Administration in the United States3

Current clinical care has a fundamental flaw It asks sick patients to travel tosee healthy neurologists on their terms As telestroke has demonstrated technol-ogy can address this flaw by bringing a virtual neurologist to the patient Futureefforts like those of Muumlller et al ideally will extend the reach of neurologistsso that almost anyone anywhere can receive neurologic care

1 Levine SR Gorman M ldquoTelestrokerdquo the application of telemedicine for strokeStroke 199930464ndash469

2 Muumlller KI Alstadhaug KB Bekkelund SI A randomized trial of telemedicine efficacyand safety for nonacute headaches Neurology 201789153ndash162

3 Wechsler LR Tsao JW Levine SR et al Teleneurology applications report of theTelemedicine Work Group of the American Academy of Neurology Neurology201380670ndash676

E Ray Dorsey MD

From the Department of Neurology and the Center for Health amp Technology University of RochesterMedical Center Rochester NYStudy funding No targeted funding reportedDisclosure Ray Dorsey has received honoraria for speaking at American Academy of Neurology coursescompensation for consulting activities from 23andMe Clintrex GlaxoSmithKline Grand Rounds Lund-beck MC10 MedAvante Medico Legal services the National Institute of Neurological Disorders andStroke Shire Teva and UCB research support from AMC Health Burroughs Wellcome Fund DavisPhinney Foundation Duke University GlaxoSmithKline Great Lakes Neurotechnologies Greater Roches-ter Health Foundation Huntington Study Group Michael J Fox Foundation National Science Founda-tion Patient-Centered Outcomes Research Institute Prana Biotechnology Raptor Pharmaceuticals RocheSafra Foundation and University of California Irvine and stock options from Grand Rounds Go toNeurologyorg for full disclosures


17 The Norwegian Research and Management Database

(FAS) Available at forskningsprosjekterihelsenet

prosjektHST959-10 Accessed April 12 2016 (archived

by WebCite at webcitationorg6giJSsbSY)

18 Muumlller KI Alstadhaug KB Bekkelund SI Telemedicine in

the management of non-acute headaches a prospective

open-labelled non-inferiority randomised clinical trial

Cephalalgia Epub 2016 Jun 14

19 Rubin MN Wellik KE Channer DD Demaerschalk BM

Role of telemedicine in providing tertiary neurological

care Curr Treat Options Neurol 201315567ndash582


Systematic review of teleneurology methodology Front

Neurol 20123156

21 Chua R Craig J Wootton R Patterson V Randomised

controlled trial of telemedicine for new neurological out-

patient referrals J Neurol Neurosurg Psychiatry 200171

63ndash66

22 Dorsey ER Venkataraman V Grana MJ et al Random-

ized controlled clinical trial of ldquovirtual house callsrdquo for

Parkinson disease JAMA Neurol 201370565ndash570

23 Wilkinson JR Spindler M Wood SM et al High patient

satisfaction with telehealth in Parkinson disease a random-

ized controlled study Neurol Clin Pract 20166241ndash251

24 Ahmed SN Mann C Sinclair DB et al Feasibility of

epilepsy follow-up care through telemedicine a pilot study

on the patientrsquos perspective Epilepsia 200849573ndash585

25 George BP Scoglio NJ Reminick JI et al Telemedicine

in leading US neurology departments Neurohospitalist

20122123ndash128

26 Yurkiewicz IR Lappan CM Neely ET et al Outcomes

from a US military neurology and traumatic brain injury

telemedicine program Neurology 2012791237ndash1243


3rd edition (beta version) Cephalalgia 201333629ndash808

28 You JJ Gladstone J Symons S Rotstein D Laupacis A

Bell CM Patterns of care and outcomes after computed

tomography scans for headache Am J Med 201112458ndash

63e51

29 Imarhiagbe FA Ogbeide E Should non acute and recur-

rent headaches have neuroimaging before review by

a Neurologist A review in a Southern Nigerian Tertiary

Hospital Ann Afr Med 201110290ndash293

30 Goldstein LH Seed PT Clark LV Dowson AJ Jenkins

LM Ridsdale L Predictors of outcome in patients consul-

ting their general practitioners for headache a prospective

study Psychol Health 201126751ndash764

31 Coeytaux RR Kaufman JS Chao R Mann JD Devellis

RF Four methods of estimating the minimal important

difference score were compared to establish a clinically

significant change in Headache Impact Test J Clin Epi-

demiol 200659374ndash380

32 Hawker GA Mian S Kendzerska T French M Measures

of adult pain visual analog scale for pain (VAS pain)

Numeric Rating Scale for pain (NRS pain) McGill Pain

Questionnaire (MPQ) Short-Form McGill Pain Ques-

tionnaire (SF-MPQ) Chronic Pain Grade scale (CPGS)

Short Form-36 Bodily pain scale (SF-36 BPS) and

measure of Intermittent and Constant Osteoarthritis

pain (ICOAP) Arthritis Care Res 201163(suppl 11)

S240ndashS252

33 Todd KH Funk KG Funk JP Bonacci R Clinical sig-

nificance of reported changes in pain severity Ann Emerg

Med 199627485ndash489

34 Nicolini D The work to make telemedicine work a social

and articulative view Soc Sci Med 2006622754ndash2767

35 Wechsler LR Tsao JW Levine SR et al Teleneurology

applications report of the telemedicine work group of the

American Academy of Neurology Neurology 201380

670ndash676

36 Thomas L Capistrant G 50-State telemedicine gaps analysis

physician practice standards amp licensure American Teleme-

dicine Association 2017 Available at americantelemedorg

policy-pagestate-telemedicine-gaps-reports Accessed March

4 2017 (archived by WebCitereg at webcitationorg

6ohs7P04m)

37 Lipton RB Scher AI Steiner TJ et al Patterns of health

care utilization for migraine in England and in the United

States Neurology 200360441ndash448

38 Berg M Patient care information systems and health care

work a sociotechnical approach Int J Med Inform 1999

5587ndash101

39 Aanestad M Jensen TB Building nationwide informa-

tion infrastructures in healthcare through modular im-

plementation strategies J Strateg Inf Syst 201120

161ndash176

40 Greenhalgh T Morris L Wyatt JC Thomas G Gunning K

Introducing a nationally shared electronic patient record case

study comparison of Scotland England Wales and Northern

Ireland Int J Med Inform 201382e125ndashe138

Subspecialty Alerts by E-mailCustomize your online journal experience by signing up for e-mail alerts related to your subspecialty orarea of interest Access this free service by visiting Neurologyorgsitesubscriptionsetocxhtml or clickon the ldquoE-mail Alertsrdquo link on the home page An extensive list of subspecialties methods and studydesign choices will be available for you to choose frommdashallowing you priority alerts to cutting-edgeresearch in your field


DOI 101212WNL0000000000004085201789153-162 Published Online before print June 14 2017Neurology

Kai I Muumlller Karl B Alstadhaug and Svein I BekkelundA randomized trial of telemedicine efficacy and safety for nonacute headaches

This information is current as of June 14 2017

ISSN 0028-3878 Online ISSN 1526-632XWolters Kluwer Health Inc on behalf of the American Academy of Neurology All rights reserved Print1951 it is now a weekly with 48 issues per year Copyright Copyright copy 2017 The Author(s) Published by

reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology

ServicesUpdated Information amp

httpnneurologyorgcontent892153fullincluding high resolution figures can be found at

Supplementary Material

085DC2httpnneurologyorgcontentsuppl20170629WNL0000000000004

085DC1httpnneurologyorgcontentsuppl20170614WNL0000000000004Supplementary material can be found at

References httpnneurologyorgcontent892153fullref-list-1

This article cites 32 articles 5 of which you can access for free at

Citations httpnneurologyorgcontent892153fullotherarticles

This article has been cited by 3 HighWire-hosted articles

Subspecialty Collections

httpnneurologyorgcgicollectionpatient__safetyPatient safety

httpnneurologyorgcgicollectionoutcome_researchOutcome research

led_consort_agreementhttpnneurologyorgcgicollectionclinical_trials_randomized_controlClinical trials Randomized controlled (CONSORT agreement)

httpnneurologyorgcgicollectionall_headacheAll Headachefollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwneurologyorgaboutabout_the_journalpermissionsits entirety can be found online atInformation about reproducing this article in parts (figurestables) or in

Reprints

httpnneurologyorgsubscribersadvertiseInformation about ordering reprints can be found online



was that telemedicine consultations are nonin-ferior to traditional consultations in treatmentand safety at 12 months

METHODS Trial design We conducted this noninferiority

trial at the department of Neurology in Tromsoslash University

Hospital in Norway (figure e-1)

Power was calculated on the assumption of a normal distribu-

tion of a primary binary satisfaction variable with an inferiority limit

of 15 With an a of 001 in a 98 confidence interval (CI) 127

participants in each group were required to reach a power of 95

In the area of coverage access to all patient records in North-

ern Norway is made possible by a shared database in the

Distributed Information and Patient System for hospitals (DIPS

ASA Bodoslash Norway)4

From September 30 2012 until March 30 2015 we consec-

utively screened and recruited 402 (to ensure applicable 12-

month data) out of 557 headache patients (figure 1) We included

Norwegian-speaking female and male participants aged 16ndash65

years referred from primary care to a neurologist for headache

management with a maximum 4 months waiting time from date

of referral Patients who underwent a neurologic headache con-

sultation within the last 2 years were excluded We defined head-

ache as nonacute and less likely secondary if it started gradually

occurred at least 4 weeks prior to referral and showed no clinical

or radiologic abnormalities56 Findings from the clinical neuro-

logic examination and neuroimaging performed as part of the

Figure 1 Flow of participants through the study

ITT 5 intention-to-treat

















group)

















a few

















and triptans






























life



consultation













every second week






telemedicine12





















































Female n () 148 (740) 153 (757) 077 119 (788) 103 (736) 036

Age y mean (SD) 360 (130) 380 (137) 012 367 (132) 393 (142) 010



Full-time 128 (640) 125 (619) 97 (647) 88 (629)

Part time 18 (90) 12 (59) 13 (87) 10 (71)

Student 28 (140) 24 (119) 22 (147) 16 (114)







Insomnia n () 61 (305) 65 (322) 080 41 (272) 42 (300) 068

Hypertension n () 14 (70) 22 (109) 023 11 (73) 18 (129) 017


HIT-6 mean (SD) 641 (61) 640 (61) 082 637 (63) 637 (61) 099

VAS mean (SD) 71 (22) 69 (21) 049 70 (22) 69 (20) 072


Migraine 106 (530) 113 (559) 062 79 (523) 77 (550) 073
















p Value(95 CI)

Work status n ()

No change 96 (800) 78 (750) 004

Off sick list 18 (150) 11 (106)

On sick list 6 (50) 15 (144)




VAS mean (SD) 52 (27) 55 (25) 043 (2036 to 085)

Δ VAS mean (SD)cd 219 (28) 215 (24) 030 (2029 to 094)

HIT-6 mean (SD) 600 (91) 601 (83) 090 (2190 to 215)

Δ HIT-6 mean (SD)ce 2366 (76) 2346 (77) 083 (2198 to 158)


gt15 64 (427) 63 (450)

7ndash15 47 (313) 38 (271)

lt7 39 (260) 39 (279)


gt3 dayswk 32 (232) 43 (328)

1ndash2 dayswk 30 (246) 26 (198)




gt3 dayswk 8 (99) 8 (143)

1ndash2 dayswk 21 (259) 15 (268)






MRI 80 (552) 75 (543)

CT 13 (90) 6 (43)

Both 25 (172) 33 (239)



GP visits n () 89 (631) 92 (692) 035












use headache















029

Normal 58 (806) 62 (899)






Normal 151 (863) 153 (884)




019 (055) 021 (063) 076


None 182 (910) 174 (861)

1 14 (70) 23 (114)

2 3 (15) 4 (20)

3 1 (05) 1 (05)























funded this study




REFERENCES








December 11 2016



200219297ndash299
















20062961274ndash1283


















201420473ndash477




113ndash121





















E Ray Dorsey MD
















Neurol 20123156




63ndash66












20122123ndash128









63e51






















S240ndashS252



Med 199627485ndash489






670ndash676






6ohs7P04m)






5587ndash101




161ndash176




























Reprints



















group)

















a few

















and triptans






























life



consultation













every second week






telemedicine12





















































Female n () 148 (740) 153 (757) 077 119 (788) 103 (736) 036

Age y mean (SD) 360 (130) 380 (137) 012 367 (132) 393 (142) 010



Full-time 128 (640) 125 (619) 97 (647) 88 (629)

Part time 18 (90) 12 (59) 13 (87) 10 (71)

Student 28 (140) 24 (119) 22 (147) 16 (114)







Insomnia n () 61 (305) 65 (322) 080 41 (272) 42 (300) 068

Hypertension n () 14 (70) 22 (109) 023 11 (73) 18 (129) 017


HIT-6 mean (SD) 641 (61) 640 (61) 082 637 (63) 637 (61) 099

VAS mean (SD) 71 (22) 69 (21) 049 70 (22) 69 (20) 072


Migraine 106 (530) 113 (559) 062 79 (523) 77 (550) 073
















p Value(95 CI)

Work status n ()

No change 96 (800) 78 (750) 004

Off sick list 18 (150) 11 (106)

On sick list 6 (50) 15 (144)




VAS mean (SD) 52 (27) 55 (25) 043 (2036 to 085)

Δ VAS mean (SD)cd 219 (28) 215 (24) 030 (2029 to 094)

HIT-6 mean (SD) 600 (91) 601 (83) 090 (2190 to 215)

Δ HIT-6 mean (SD)ce 2366 (76) 2346 (77) 083 (2198 to 158)


gt15 64 (427) 63 (450)

7ndash15 47 (313) 38 (271)

lt7 39 (260) 39 (279)


gt3 dayswk 32 (232) 43 (328)

1ndash2 dayswk 30 (246) 26 (198)




gt3 dayswk 8 (99) 8 (143)

1ndash2 dayswk 21 (259) 15 (268)






MRI 80 (552) 75 (543)

CT 13 (90) 6 (43)

Both 25 (172) 33 (239)



GP visits n () 89 (631) 92 (692) 035












use headache















029

Normal 58 (806) 62 (899)






Normal 151 (863) 153 (884)




019 (055) 021 (063) 076


None 182 (910) 174 (861)

1 14 (70) 23 (114)

2 3 (15) 4 (20)

3 1 (05) 1 (05)























funded this study




REFERENCES








December 11 2016



200219297ndash299
















20062961274ndash1283


















201420473ndash477




113ndash121





















E Ray Dorsey MD
















Neurol 20123156




63ndash66












20122123ndash128









63e51






















S240ndashS252



Med 199627485ndash489






670ndash676






6ohs7P04m)






5587ndash101




161ndash176




























Reprints































Female n () 148 (740) 153 (757) 077 119 (788) 103 (736) 036

Age y mean (SD) 360 (130) 380 (137) 012 367 (132) 393 (142) 010



Full-time 128 (640) 125 (619) 97 (647) 88 (629)

Part time 18 (90) 12 (59) 13 (87) 10 (71)

Student 28 (140) 24 (119) 22 (147) 16 (114)







Insomnia n () 61 (305) 65 (322) 080 41 (272) 42 (300) 068

Hypertension n () 14 (70) 22 (109) 023 11 (73) 18 (129) 017


HIT-6 mean (SD) 641 (61) 640 (61) 082 637 (63) 637 (61) 099

VAS mean (SD) 71 (22) 69 (21) 049 70 (22) 69 (20) 072


Migraine 106 (530) 113 (559) 062 79 (523) 77 (550) 073
















p Value(95 CI)

Work status n ()

No change 96 (800) 78 (750) 004

Off sick list 18 (150) 11 (106)

On sick list 6 (50) 15 (144)




VAS mean (SD) 52 (27) 55 (25) 043 (2036 to 085)

Δ VAS mean (SD)cd 219 (28) 215 (24) 030 (2029 to 094)

HIT-6 mean (SD) 600 (91) 601 (83) 090 (2190 to 215)

Δ HIT-6 mean (SD)ce 2366 (76) 2346 (77) 083 (2198 to 158)


gt15 64 (427) 63 (450)

7ndash15 47 (313) 38 (271)

lt7 39 (260) 39 (279)


gt3 dayswk 32 (232) 43 (328)

1ndash2 dayswk 30 (246) 26 (198)




gt3 dayswk 8 (99) 8 (143)

1ndash2 dayswk 21 (259) 15 (268)






MRI 80 (552) 75 (543)

CT 13 (90) 6 (43)

Both 25 (172) 33 (239)



GP visits n () 89 (631) 92 (692) 035












use headache















029

Normal 58 (806) 62 (899)






Normal 151 (863) 153 (884)




019 (055) 021 (063) 076


None 182 (910) 174 (861)

1 14 (70) 23 (114)

2 3 (15) 4 (20)

3 1 (05) 1 (05)























funded this study




REFERENCES








December 11 2016



200219297ndash299
















20062961274ndash1283


















201420473ndash477




113ndash121





















E Ray Dorsey MD
















Neurol 20123156




63ndash66












20122123ndash128









63e51






















S240ndashS252



Med 199627485ndash489






670ndash676






6ohs7P04m)






5587ndash101




161ndash176




























Reprints














p Value(95 CI)

Work status n ()

No change 96 (800) 78 (750) 004

Off sick list 18 (150) 11 (106)

On sick list 6 (50) 15 (144)




VAS mean (SD) 52 (27) 55 (25) 043 (2036 to 085)

Δ VAS mean (SD)cd 219 (28) 215 (24) 030 (2029 to 094)

HIT-6 mean (SD) 600 (91) 601 (83) 090 (2190 to 215)

Δ HIT-6 mean (SD)ce 2366 (76) 2346 (77) 083 (2198 to 158)


gt15 64 (427) 63 (450)

7ndash15 47 (313) 38 (271)

lt7 39 (260) 39 (279)


gt3 dayswk 32 (232) 43 (328)

1ndash2 dayswk 30 (246) 26 (198)




gt3 dayswk 8 (99) 8 (143)

1ndash2 dayswk 21 (259) 15 (268)






MRI 80 (552) 75 (543)

CT 13 (90) 6 (43)

Both 25 (172) 33 (239)



GP visits n () 89 (631) 92 (692) 035












use headache















029

Normal 58 (806) 62 (899)






Normal 151 (863) 153 (884)




019 (055) 021 (063) 076


None 182 (910) 174 (861)

1 14 (70) 23 (114)

2 3 (15) 4 (20)

3 1 (05) 1 (05)























funded this study




REFERENCES








December 11 2016



200219297ndash299
















20062961274ndash1283


















201420473ndash477




113ndash121





















E Ray Dorsey MD
















Neurol 20123156




63ndash66












20122123ndash128









63e51






















S240ndashS252



Med 199627485ndash489






670ndash676






6ohs7P04m)






5587ndash101




161ndash176




























Reprints












use headache















029

Normal 58 (806) 62 (899)






Normal 151 (863) 153 (884)




019 (055) 021 (063) 076


None 182 (910) 174 (861)

1 14 (70) 23 (114)

2 3 (15) 4 (20)

3 1 (05) 1 (05)























funded this study




REFERENCES








December 11 2016



200219297ndash299
















20062961274ndash1283


















201420473ndash477




113ndash121





















E Ray Dorsey MD
















Neurol 20123156




63ndash66












20122123ndash128









63e51






















S240ndashS252



Med 199627485ndash489






670ndash676






6ohs7P04m)






5587ndash101




161ndash176




























Reprints






















funded this study




REFERENCES








December 11 2016



200219297ndash299
















20062961274ndash1283


















201420473ndash477




113ndash121





















E Ray Dorsey MD
















Neurol 20123156




63ndash66












20122123ndash128









63e51






















S240ndashS252



Med 199627485ndash489






670ndash676






6ohs7P04m)






5587ndash101




161ndash176




























Reprints

















Neurol 20123156




63ndash66












20122123ndash128









63e51






















S240ndashS252



Med 199627485ndash489






670ndash676






6ohs7P04m)






5587ndash101




161ndash176




























Reprints

























Reprints




arandomizedtrialoftelemedicineefficacy and safety for ...the primaryefficacy endpoint was a change...

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