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Based on the latest data by the Centers for Disease Control and Prevention (CDC), approximately 1 in 36 (~2.7%) children in the United States are diagnosed with autism spectrum disorder (ASD).1 Over the last few years, the increase in clinical ASD diagnoses has led some researchers to attribute this rise to mis- and overdiagnoses of the condition,2 and also, to the growing awareness among the general population and scientific community.3

We reached out to clinicians involved in the diagnosis and care of patients with ASD to get further insights on screening for and diagnosing autism in the US and the collaborative efforts that may result in more favorable patient outcomes.

The discussion panel included the following clinicians:

  • Pediatric neurologist Ann Neumeyer, MD, medical director of the Massachusetts General Hospital’s Lurie Center for Autism in Lexington and associate professor of neurology at Harvard Medical School in Boston.
  • Nora D. Friedman, MD, child, adolescent, and adult psychiatrist at Lurie Center for Autism and instructor at Harvard Medical School.
  • Clinical neuropsychologist Suzanne W. Duvall, PhD, ABPP, associate professor of pediatrics and psychiatry, division of psychology, and associate director of clinical training, Clinical Psychology PhD Program, Institute on Development and Disability at Oregon Health & Science University (OHSU).

In 2013, the American Psychiatric Association (APA) developed standardized criteria —according to the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) — to diagnose ASD by combining 4 conditions: autism, Asperger syndrome, childhood disintegrative disorder, and pervasive development disorder not otherwise specified (PDD-NOS).4

Are Diagnostic Criteria for ASD Misleading?

However, in a review, neuropsychologist David Rowland wrote that autism is more of a brain anomaly than a developmental disorder and that the National Institutes of Health (NIH)’s list of signs and symptoms may be too vague to confirm autism.5

Following the revision of the criteria that introduced the concept of a “spectrum,” the diagnosis of autism appears to be based on behaviors shared with other diagnoses of uncertain similarities.3,6 The broad definition of autism and overlapping symptoms with complex conditions have created challenging situations in practice, with false diagnoses — both false positives and negatives — affecting autism assessment.5,7

Based on these scenarios, we asked Drs Neumeyer and Friedman about diagnosing autism in clinical practice.

Q: What are some of the typical and atypical signs of autism that you have come across? What are your clinical pearls in identifying these signs and symptoms? How quickly must they be addressed?

Dr Neumeyer: The young children with language delay are often diagnosed early and the children who don’t have language delay often have delayed diagnosis or misdiagnosis. When I think about diagnosing autism, I think about the DSM-5 criteriafor autism4 that the child has to have: social communication delays, delays in social and emotional reciprocity, nonverbal communication, and maintaining relationships. Many children with autism who are considered “intelligent” have impaired relationships; however, unless you ask parents, they don’t tell you that.

With regard to health outcomes, one of the other things that is really important is that autism in many individuals is associated with sensory function, and patients become really picky about the foods that they eat, which can lead to nutritional deficiencies. Some patients with these nutritional deficiencies have poor bone growth and density, which can lead to osteoporosis.

Dr Friedman: ASD can be defined as deficits in social communication and interaction, as well as restricted and repetitive behaviors. We want to understand how these issues manifest across settings. As part of the diagnostic work-up, it is important to assess for co-occurring conditions, such as anxiety or attention-deficit/hyperactivity disorder (ADHD). We try to think holistically about the individual with ASD, talking with families about therapeutic and behavioral interventions, school and employment supports, and medication management if indicated. In addition, we aim to connect patients with services as quickly as we can. 

Diagnosing Autism in Adulthood

Age at ASD diagnosis is directly related to achieving optimal outcomes, which may be improvements in cognition and language or adaptive behavior, as well as reduced costs for families, society, and the health care system as a whole.8 In recent years, studies have shown an increase in autism assessments among adults, including diagnoses in both adulthood and after the childhood-to-adulthood transition.9

In a 2023 study published in the International Journal of Mental Health Systems,8 the lived experience of patients with an ASD diagnosis in adulthood was noted. Some of the common themes in their ASD diagnostic journeys were observing differences and similarities between themselves and patients with ASD; barriers in diagnosis, such as cost of care and wait times; and emotional health.

Drs Neumeyer and Duvall presented fairly similar views on why autism diagnoses happen later in life, and the outcomes associated with them.

Q: Data from studies have indicated an increase in autism being diagnosed in adulthood, which can lead to poor health outcomes.8 Can you explain the reasons for these diagnostic delays, and how providers can address this?

Dr Neumeyer: Adults who are being diagnosed with autism are typically considered “intelligent” and who have been able to mask their symptoms or that their condition was misdiagnosed, for example, with anxiety, ADHD, or learning disabilities. There is a smaller group of older adults who are not diagnosed early because when they were younger, autism was just defined as very severe repetitive behaviors and lack of language skills.

Dr Duvall: The most common scenario is that individuals with more nuanced symptoms of autism can be missed in childhood and then go on to receive a diagnosis in adulthood, but in retrospect, the same behavior patterns or social communication [delays] were always present. Autism has a genetic component, thus sometimes, when we provide an ASD diagnosis to a child, the parent notes that they were “just like them” when they were a child and may go on to seek evaluation for an ASD diagnosis themselves.

Gaps and Barriers in Autism Evaluation

To identify barriers in receiving autism diagnosis, researchers at Stanford University, California, conducted a study that revealed sparse and uneven distribution of diagnostic resources in the US, which resulted in increased waitlists and travel distance. Specifically, patients from rural communities were less likely to be diagnosed than those from urban communities who lived closer to diagnostic centers, indicating a gap in access to care.10

In addition to this, the important role of pediatric primary care providers — the first point of care during early childhood — in helping access autism services has also been noted in a 2022 study published in Autism Research.11

Dr Neumeyer spoke further about the existence of barriers in the diagnosis of ASD.

Q: In the US, several clinical specialties are facing a shortage of pediatricians due to certain factors — increasing demand, lesser students opting for pediatrics as their specialty, and poor financial incentives — resulting in gaps in access to autism resources.10 Can you describe some of the most common barriers in achieving a timely and accurate autism diagnosis?

Dr Neumeyer: The number of individuals opting for the subspecialty of developmental behavioral pediatrics is very low, with many fellowships not being able to fill their slots.One of the results of that isthat it is the specialty that diagnoses and cares for children with neurodevelopmental disabilitiesand autism. So, we are in desperate need of more developmental behavioral pediatricians.

Every state in the US has different rules according to which it is decided who diagnoses autism; in Massachusetts, any MD or psychologist can make a diagnosis. One of the barriers in Massachusetts is that most pediatricians don’t feel comfortable or have the training to make a diagnosis. The way their practices are run, it is very difficult to make an autism diagnosis because they see patients quickly, and diagnoses require more time spent with patients. So, typically, psychologists, pediatric neurologists, and psychiatrists make a diagnosis in Massachusetts.

The other, more research-based, challenge is the lack of a biomarker for autism, so we can’t diagnose just with a test. There are some online companies that have been good at getting a validated diagnosis for autism, but those are new.  

What’s Needed for Autism Diagnosis? Role of Collaboration Between Specialists

Experts agree that a multidisciplinary team of health care professionals and awareness of “red flags” by parents, families, and teachers can be an optimal diagnostic approach.8

Q: What is the role of each neurologist, psychiatrist, and psychologist in diagnosing autism? In addition, what collaborative efforts must be taken by the specialties to screen for and diagnose autism, and how should providers go about referrals for autism?

Dr Neumeyer: Generally, here, we start with a psychologist for evaluation of autism and the neurologist and psychiatrist work hand-in-hand, especially when there are atypical features or physical findings. It is very important to bring in the neurologist to make sure there’s no genetic involvement or other syndrome causing or associated with the autism. The psychiatrist can be very important when there are behavioral difficulties. The reality is that there are not enough child psychiatrists in the US, and so, many pediatric neurologists and pediatricians also treat the behavioral aspect of children with autism.

Dr Friedman: Ideally, patients undergo a multipronged evaluation. This can include [evaluation of] history, a clinical interview, observation, physical exam and work-up, and cognitive and/or developmental testing. Understanding a patient’s unique profile informs treatment planning. The available resources in a given area will, in part, dictate the specific clinicians whom a family sees, the subsequent referrals that are made, and access to services. Collaboration among team members is essential for optimal care for patients and their families.

Dr Duvall: In our interdisciplinary ASD-specific assessment clinic, 100% of the individuals coming in report that social difficulties are, at least, part of why they presented with this diagnostic question. However, only about 30% to 50% of the older children and teens who present for a comprehensive ASD assessment receive an ASD diagnosis, while rates in children younger than age 4 may be closer to 60% to 80%.

There is high variability across primary care providers and pediatricians around expertise in neurodevelopmental disorders. If caregivers are concerned, they should talk with their primary care provider to complete in office screening, such as questionnaires or behavioral observation, and then ask for a referral to a specialist for evaluation, as early interventions are often the most effective in supporting skill development.

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In the demanding and emotionally-charged field of health care, physicians often find themselves at the forefront of providing care and support to patients and their loved ones. While empathy and compassion are essential qualities in this profession, the constant exposure to suffering and the pressure to deliver optimal care can take a toll on the emotional well-being of health care professionals. These concerns are particularly true in certain environments like palliative care settings.1 In addition, intense workloads and limited resources during the COVID-19 pandemic further highlighted the mental health crisis facing many health care workers.2

A specific form of psychological distress known as compassion fatigue has emerged as an important topic in need of further research and attention. Compassion fatigue is a state of emotional exhaustion that can reduce your capacity for empathy,1 ultimately putting patient care at risk. To remain effective, health care professionals need strategies to identify the signs of compassion fatigue and alleviate its symptoms before the cumulative stress of work takes over.

How to Recognize Compassion Fatigue

Compassion fatigue is a psychological and physical state that occurs when health care professionals become emotionally drained from their efforts to care for patients. It is often a result of prolonged exposure to patients' suffering, traumatic events, or the inability to alleviate their pain. Experts have defined compassion fatigue as a combination of secondary traumatic stress and burnout.1 It may be viewed as, “the phenomenon of stress resulting from exposure to a traumatized individual rather than from exposure to the trauma itself.”3

As physicians experience increased levels of stress and burnout, they may feel emotionally detached and helpless, losing their sense of purpose. Some warning signs you shouldn't ignore include:

  • Apathy and cynicism: A growing sense of pessimism may develop, affecting interactions with patients, colleagues, family, and friends.
  • Decreased job satisfaction: Compassion fatigue often leads to frustration and dissatisfaction with one's profession, increasing absenteeism and making physicians question their career choices.3
  • Emotional withdrawal: Physicians may emotionally detach themselves from patients and colleagues, leading to numbness or indifference towards their work.
  • Physical exhaustion: Feeling constantly tired, irritable, or experiencing sleep disturbances, along with a lack of enthusiasm for work, are signs of compassion fatigue.
  • Reduced empathy: A once empathetic physician may find it challenging to connect with patients emotionally, leading to a decline in the quality of care provided.

Studies suggest that the greatest mental health concerns for health care providers during the pandemic included insomnia, anxiety, depression, post-traumatic stress disorder, and stress.2 Untreated compassion fatigue and mental health issues can lead to unhealthy coping strategies, including drug and alcohol use disorders.3

Physicians need to remember that their well-being matters. No one is immune to the weight of such significant responsibility. Getting lost in caring for others isn't sustainable. In fact, doing so may compromise patient care, resulting in widespread negative consequences both personally and professionally.2

Preventing Compassion Fatigue

Physicians can use proactive strategies to combat compassion fatigue that promote self-care and emotional resilience. Physicians must prioritize self-care by taking regular breaks, engaging in hobbies, maintaining a healthy work-life balance, and setting boundaries to protect their well-being. Practicing mindfulness and meditation techniques can help physicians stay present and grounded.4

The opposite of compassion fatigue, referred to as “compassion satisfaction” describes pleasure experienced from relieving patient suffering and enjoying a positive work environment.1 Perhaps one of the best ways to avoid compassion fatigue is by focusing on the satisfying aspect of work, taking time to document and reflect on the positive effects of your efforts, even if they seem small in the larger context of a patient’s eventual outcomes.

Seeking professional counseling or therapy can be immensely beneficial in processing emotional challenges and building coping mechanisms. Counseling can be an opportunity to share small wins and talk through traumatizing experiences. In addition, open communication and sharing with colleagues can create a supportive environment where physicians can seek guidance and understanding. Hospitals and medical institutions should provide training and education on compassion fatigue to help combat this increasing problem for physicians around the world.5

More experienced physicians who take time for their mental wellness can positively impact the culture of medicine by setting a healthier example for students and residents entering the field. As research, awareness, and resources related to compassion fatigue increase, the stigma of mental health care should continue to decrease.5

Alleviating Compassion Fatigue

Despite best efforts, compassion fatigue in health care can seem unavoidable. Physicians must first acknowledge and accept that they are experiencing compassion fatigue. Denying or ignoring these feelings can exacerbate the problem.

It is crucial to lean on support systems, whether it be friends, family, colleagues, or professional counselors. Supervisors can also be a supportive resource. Talking about emotions and seeking understanding can help reduce the burden.1 In addition, therapy can help physicians understand their boundaries and limitations, including the fact that it’s not always possible to change a patient’s outcome or circumstances.1 To shift the focus to compassion satisfaction, physicians must find ways to see the rewards and accomplishments in their work.1

Long shifts and physical exhaustion often make it harder to weather the demands of working in health care. Therefore, time off to rest is vital. Physicians should not hesitate to use their leave entitlements when needed. Time off is critical to staying engaged and should be viewed as a necessary aspect of the job. It should also be used wisely as an active time to rejuvenate. In addition, activities that promote relaxation and joy, such as physical exercise, fun hobbies, or spending time in nature, can help reduce stress levels so you can bring your best self to work.1

Resources for Physician Self-Care

Many health care providers face unrealistic expectations, traumatic experiences, and a challenging work environment. Fortunately, more institutions and organizations recognize and provide resources to address burnout and compassion fatigue. If you're struggling with compassion fatigue (or simply trying to prevent it), you may want to seek out some of the following resources:

  • Employee assistance programs (EAPs): Many health care facilities offer EAPs that provide confidential counseling and support services for employees facing emotional challenges.
  • Peer support groups: Some medical institutions organize support groups for physicians to share their experiences, struggles, and coping strategies in a safe and understanding environment.
  • Therapy: Many medical societies and organizations provide access to professional counseling services specialized in supporting health care professionals.
  • Wellness workshops and retreats: Hospitals and medical associations often conduct workshops and seminars on stress management and promoting physician well-being.

Helping Yourself to Help Others

Compassion fatigue is a significant challenge faced by health care professionals, particularly physicians, who dedicate their lives to caring for others. By recognizing the signs of compassion fatigue, taking preventive measures, and utilizing available resources, physicians can safeguard their emotional well-being and continue providing exceptional patient care.

Acknowledging and addressing compassion fatigue is not a sign of weakness but a demonstration of strength and dedication to your profession and patients. Unfortunately, despite an increased awareness of physician burnout and compassion fatigue, there’s still no official guidelines for treatment.5 More research into this common phenomenon can help promote the development of more effective interventions.3 By promoting a culture of understanding, and support, health care institutions can contribute to a healthier and more resilient workforce, improving physicians’ lives and patient outcomes.

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What’s the best way to curb vaping, especially among adolescents and young adults?

Despite Food and Drug Administration (FDA) regulation, vaping is flourishing, with a steady stream of e-cigarette products finding their way into stores as well as into the hands, lungs, and bloodstreams of America’s youth. Vaping, it seems, is the new smoking for teenagers and young adults.

“E-cigarettes have taken over the youth tobacco use landscape. They are the most commonly used tobacco product,” said Thomas Carr, Director of National Policy at the American Lung Association (ALA), in an exclusive interview.

Although there is not yet data to show whether vaping is as harmful as cigarette smoking, substantial harms have been documented — enough to show that vaping poses a threat to human health, especially to the lungs and the heart.1

Given that February has been designated by the Centers for Disease Control and Prevention (CDC) as heart health month, this report looks at what is being done — and what could be done — to curb youth vaping.

"
Taxation has worked well at reducing use in every other tobacco product, especially among youth. I feel pretty confident in saying it will reduce vaping rates.

“The [American Lung] Association is committed to reducing and eliminating use of e-cigarettes among youth users,” noted Carr. Moving forward, he added, the ALA is hoping to see:

  • better FDA regulation and enforcement with respect to e-cigarettes;
  • high levels of taxation on e-cigarettes;
  • an end to the sale of flavored e-cigarettes (a measure that has been taken by only 5 states thus far);
  • incorporating vaping into existing state tobacco-control programs;
  • more media campaigns against e-cigarette use; and
  • community education in schools about the dangers of vaping.

The American Heart Association (AHA) is similarly dedicated to curbing youth vaping, said Rose Marie Robertson, MD, AHA Science and Medical Officer, in an exclusive interview. “A comprehensive approach is needed to help reduce vaping among young people,” she said.

“We have heard from young people who recognize the dangers of vaping and their own addiction to these products, but don’t feel like they know the proper strategies to quit or even how to say no to e-cigarettes and other dangerous products to begin with,” said Robertson. “Therefore, our efforts focus on significant investments in research, youth engagement efforts, and support for schools to choose restorative rather than punitive approaches to students who vape,” she noted.

The AHA and the ALA are also united in their desire for better regulation and enforcement of vaping by the FDA and states.

Statistics on Youth Vaping

Although there has been “some decline since 2019” in the use of e-cigarettes, said Carr, “e-cigarettes remain the most commonly used tobacco product.”

CDC’s 2023 National Youth Tobacco Survey confirms that e-cigarettes are the most commonly used tobacco product by youth in the US. The 2023 survey found that 10% of high school students and 4.6% of middle school students used e-cigarettes. Notably:2

  • 25.2% of current youth e-cigarette users used an e-cigarette product every day;
  • 34.7% of youth e-cigarette users surveyed reported using e-cigarettes during at least 20 of the previous 30 days;
  • 89.4% of youth users used flavored e-cigarettes; fruit flavors were most popular, followed by candy, desserts/other sweets, mint, and menthol;
  • 57.9% reported using products with “ice” or “iced” in the branding;
  • the most common e-cigarette devices used were disposables (60.7%) followed by prefilled/refillable pods (16.1%); and
  • the most popular brands included Elf Bar (56.7%), Esco Bars (21.6%), Vuse (20.7%), JUUL (16.5%), and Mr. Fog (13.6%).

Taxation

One under-utilized strategy that may effectively curb the use of e-cigarettes by both youths and adults is heavy taxation — meaning taxation at the same level as cigarettes, said Carr.

Currently, there is no federal tax on e-cigarettes, and only 31 states and the District of Columbia have enacted excise taxes on vaping products.3 The level of taxation varies widely, with some surcharges hardly noticeable, said Carr.

According to the Tax Foundation, a nonprofit organization that researches tax policy in the US and elsewhere, methods used to tax vaping vary. “Authorities tax based on manufacturer, wholesale, or retail price (ad valorem), volume (specific), or with a bifurcated system that has different rates for open and closed tank systems,” noted a Tax Foundation blog on vaping taxes. “Of those that tax wholesale values, Minnesota levies the heaviest tax at 95 percent, followed closely by Vermont at 92 percent. On the other end of the spectrum, Connecticut levies a 10 percent wholesale tax and Wyoming applies a 15 percent wholesale tax.”

Other states levy a per mL tax. The states with the lowest per milliliter (mL) taxations are Delaware, Kansas, North Carolina, and Wisconsin, with a rate of $0.05 per mL. Louisiana has the highest rate per mL, after tripling this rate to $0.15 per mL in 2023, the blog noted.3

“Taxation has worked well at reducing use in every other tobacco product, especially among youth. I feel pretty confident in saying it will reduce vaping rates,” said Carr.  “We’re still sorting through what completely works,” he added.

FDA regulation

The FDA is acutely aware of the dangers that e-cigarettes pose to youth. A focused segment of their Comprehensive Plan for Tobacco and Nicotine Regulation aims to prevent youth from accessing e-cigarettes and other tobacco products. The FDA has claimed that “significant regulatory and research efforts related to access, marketing, and education are already underway.”4

Regulation enforcement for e-cigarettes is a stated FDA priority. As former FDA Commissioner Scott Gottlieb, MD, said in a 2019 press release, “As the number of children using e-cigarettes remains at epidemic levels, our enforcement work has been one cornerstone of our efforts to protect youth from the dangers of tobacco products.” Gottlieb noted that the FDA had been involved in “vigorous enforcement efforts.” These included “a number of actions to combat the illegal sales of e-cigarettes to youth at brick-and-mortar and internet storefronts, as well as steps to target companies engaged in kid-friendly marketing that can increase the appeal of these products to youth,” and other actions “focused on both retailers and manufacturers.”5

In its Guidance for Industry issued in April 2020, the FDA laid out its enforcement priorities, announcing its intent to target any electronic nicotine delivery system (ENDS) product being sold after September 9, 2020, “for which the manufacturer has not submitted a premarket application.”6

FDA’s Guidance for Industry also stated that for products marketed “without FDA authorization, FDA intends to prioritize enforcement against: [1] Any flavored, cartridge-based ENDS product (other than a tobacco- or menthol-flavored ENDS product); [2] All other ENDS products for which the manufacturer has failed to take (or is failing to take) adequate measures to prevent minors’ access; and [3] Any ENDS product that is targeted to minors or whose marketing is likely to promote use of ENDS by minors.”6

ALA, AHA: More Regulation, Better Enforcement Needed

Although the ALA is pleased that the FDA has not approved any flavored tobacco products to date, the FDA hasn’t yet enforced against any of these products, said Carr, who noted that the ALA would like to see a ban on the sale of all flavored tobacco products.7

https://infogram.com/pulm_feature_vapinglawsinfographic-1hxj48m5re8d52v?live

“The Lung Association has been dismayed at the delay with the FDA, although they have been making more progress recently. In some cases, the companies aren’t following the laws at all and selling products without premarket review. A lot of these products come from overseas so they’re hard to interdict — especially flavored disposable varieties,” said Carr.

Dr Robertson of the AHA echoed this sentiment. “While the FDA has fined retailers for continuing to sell unauthorized tobacco products, the agency must be given the proper resources to not only fund additional research on characterizing flavors, but also strengthen enforcement efforts to remove all illegal e-cigarettes from the marketplace,” she said.

“The [AHA] has continued to urge the Food and Drug Administration to complete its review of all e-cigarette product applications and we are working to ensure that state laws align with the federal minimum age for sale of tobacco products, which is 21,” she added.

E-Cigarette Smuggling

The smuggling of e-cigarettes across the border into the US complicates vaping regulation enforcement.7

“The Lung Association was pleased by the FDA announcement in May 2023 that e-cigarette products from several companies — Elf Bar, Esco Bar and Eon Smoke — were added to an FDA import alert red list with CBP [Customs and Border Protection] in order to be detained at the border without conducting a full inspection at the time of entry. Additional e-cigarette products have been added to the list,” stated the ALA’s State of Tobacco Control 2024 Report.7

“However, Elf Bar, the most popular e-cigarette with kids in 2023, was able to avoid enforcement initially by simply changing the name of its product, a disturbing loophole that needs to be closed. A recent US Department of Health and Human Services Inspector General report looked at FDA enforcement against retailers from 2010 to 2020, and found that FDA did not always follow through with more serious penalties such as civil monetary,” the ALA report continued.7

To date, the FDA and Customs and Border Protection have worked together to seize 1.4 million illegal cigarette products at the border, the report noted.7

The Manufacturers Strike Back

Taking a page from the litigation playbook of big tobacco companies, many e-cigarette manufacturers have filed lawsuits against FDA marketing denial orders for flavored e-cigarettes. The ALA has signed more than 20 amicus briefs with coalition partners in 2022 and 2023 asking courts to uphold these orders. To date, 6 of 8 US circuit courts have upheld these FDA marketing denial orders.7

In addition to leveraging litigation to fight to keep flavored e-cigarettes on retail shelves, manufacturers have kept on top of youth trends and interests when marketing their products to ensure sales. “They have proven expert at getting around regulations whenever they can by innovating their products,” Carr lamented.

Dr Robertson of the AHA agreed. “Big Tobacco and the vaping industry continue to foster addiction in younger generations by developing and marketing new tobacco products that appeal to youth and get them addicted.” This, of course, is nothing new, she added. “For decades, the tobacco industry has modified old products and created new ones to hook new users and keep them addicted, leading to tobacco use as a leading cause of preventable disease and death and a major risk factor in the development of heart disease and stroke.”

Second-Hand Vape

An issue of note that has yet to be talked about is the dangers of second-hand vape, said Carr. “Second-hand aerosol isn’t harmless,” he noted. This problem can be addressed by “adding e-cigarettes to smoke-free workplace laws that exist in a number of states … to prevent vaping in restaurants and other public places.”7

Public and Patient Outreach

Public outreach and education are imperative in the battle against rising rates of e-cigarette use in youth, said Carr. This includes efforts by clinicians, community education in schools, peer education on the dangers of tobacco and smoking, and the use of media campaigns.

One such media campaign is #DoTheVapeTalk.8 The American Lung Association (ALA) recently paired with the nonprofit Ad Council to launch this youth vaping awareness campaign, which involves a public service announcement showing how a dad talks to his teen about the dangers of vaping. #DoTheVapeTalk arms parents with the necessary facts to discuss the dangers of vaping with their kids “while they’re still willing to listen,” according to the ALA State of Tobacco Control 2024 report.7 Unfortunately, there is a paucity of youth-cessation resources like #DoTheVapeTalk, Carr noted.

“It’s vital that the harms and consequences of e-cigarettes and other addictive tobacco products be shared by trusted messengers, such as doctors and other health professionals, teachers, coaches and parents,” said the AHA’s Robertson. “But it is just as important that these influencers in young people’s lives specifically encourage them to quit and refer them to the proper resources and care to do so.”

Carr urged clinicians to take an active role in public and patient outreach. In particular:

  • When seeing kids in the office, physicians should ask about tobacco use and vaping, assess their desire to quit, and refer to counseling.
  • Pediatric pulmonologists can share stories about patients and vaping in the form of letters to the editor or community outreach.
  • Clinicians can support public policy efforts.
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Our easy-to-read fact sheets provide clinicians with reliable information to share with patients and their caregivers.

Pain occurring in the back can be a symptom of occipital neuralgia, migraine, or other causes. Pain from occipital neuralgia can cause headaches or migraine as a result of inflamed nerves that go from the top of the head down to the spinal cord. While there are many symptoms that overlap between occipital neuralgia and migraine, the treatments vary.

Occipital Neuralgia

Occipital neuralgia is a condition in which the nerves that run through the scalp are injured or inflamed, resulting in sudden stabbing or shooting pain that can be felt on the back of the head, upper neck, and forehead.1 Occipital neuralgia is a rare cause of severe headaches and can be difficult to treat.2

Pain can be felt on one or both sides of the head.1 In some patients, the scalp becomes extremely sensitive to even the slightest touch, making hair washing or lying on a pillow painful.2 In other patients, there may be numbness to the affected area or pain radiating toward one eye in particular.1 According to the International Headache Society, common triggers for occipital neuralgia include compression of the greater occipital nerve (90% of the time) or the lesser occipital nerve (10% of the time).3

Migraine Headache

A migraine headache, or migraine, is a disabling headache characterized by recurrent throbbing on one or both sides of the head and often associated with nausea and sensitivity to light or sound. Other symptoms can include mood and cognitive changes.4

Triggers for migraines include stress, sleep disturbances, menstrual cycle changes, weather changes, alcohol consumption, and emotional influences.4,5 Migraines are about 3 times more common in women than in men and research suggests that triggers may vary based on sex at birth.6 The most common triggers for women include menstruation, stress, and bright lights; common triggers for men include sleep deprivation, stress, and bright lights.4 There are 4 phases of a migraine:7

  1. Prodromal: Stage where symptoms normally appear. This occurs approximately 24 to 48 hours before the headache starts.
  2. Aura: Approximately 25% of patients with migraine experience aura, which can be present visually (eg, bright lights), through sound (eg, music, noises, tinnitus), through feel (eg, tingling or numbness), or through motor changes (eg, weakness on one side of the face or body).
  3. Headache: A painful throbbing or pulsating on one or both sides of the head with or without nausea or vomiting.
  4. Postdromal: Stage that includes residual headaches and is accompanied by extreme tiredness or exhaustion.

A diagnosis for migraine without aura includes at least 5 migraine attacks that fulfill the below criteria:8

  • lasts at least 4 to 72 hours if untreated;
  • has at least 2 of the following characteristics: unilateral location, pulsating, moderate or severe pain intensity, and aggravated by or leads to avoidance of routine physical activity; and
  • is associated with nausea and/or vomiting, avoidance of light, or avoidance of sound.

A diagnosis for migraine with aura includes at least 2 attacks that fulfill the below criteria:8

  • patient experiences at least 1 fully reversible aura symptom: visual, sensory, speech/language, motor, brainstem, retinal; and
  • has at least 3 of the following characteristics:
    • at least 1 aura symptom spreads gradually over 5 minutes,
    • 2 or more aura symptoms occurring in order
    • at least 1 aura symptom is unilateral,
    • at least 1 aura symptom is positive, and
    • the aura occurs during or within 60 minutes of headache.

Frequently Asked Patient Questions: Occipital Neuralgia vs Migraine

Diagnosis of occipital neuralgia vs migraine?

There isn’t one test to diagnose occipital neuralgia. A magnetic resonance imaging (MRI) test, CT scan, or X-ray allow for the visualization of surrounding soft tissues and can rule out underlying causes of pain. Your doctor may make a diagnosis using a physical examination to find tenderness and may temporarily treat it with an occipital nerve block. Relief from a nerve block may help confirm the diagnosis.2

A diagnosis for migraine with or without aura requires that the patient experience multiple migraine attacks that fulfill the criteria determined by the International Headache Classification Disorders III edition. A summary of the fulfillment criteria is outlined above.

What over-the-counter (OTC) medications can I use to treat my symptoms? 

OTC management options for occipital neuralgia include nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil®) or naproxen (Aleve®). Other treatments may include heating pads or devices that are placed at the location of pain. Physical therapy and massage therapy can also help to relieve pain caused by occipital neuralgia.2 

Migraine can be treated with NSAIDs similar to those used to treat occipital neuralgia. Other medications that can be used to treat migraine include aspirin (Bayer®), caffeine, acetaminophen (Tylenol®), or a combination of all 3 (Excedrin® Extra Strength).8

If OTC medications are not improving my symptoms, what other options are available?

There is no clear consensus on the management of occipital neuralgia. If pain associated with occipital neuralgia continues to persist, your doctor may prescribe tricyclic antidepressants, serotonin reuptake inhibitors, anticonvulsants, or opioids. More invasive options include local anesthetic agent with a steroid, botulinum toxin A, or surgery such as occipital nerve stimulation.2

If migraine continues to persist despite the use of OTC medications, your doctor may prescribe medications such as:8

Doctors may also recommend external trigeminal nerve stimulation, single-pulse transcranial magnetic stimulation (to be administered during aura), non-invasive vagal nerve stimulation, or non-invasive multichannel electrical stimulation of the trigeminal and occipital nerves for adults. 

Click here for PDF

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