Many people with migraine have reported an increase in headache frequency and/or severity over the past year owing to the challenges they have faced as a result of the COVID-19 pandemic. A recent online survey explored the real-world impact of COVID-19 on patients with migraine and showed that about 60% of respondents had an increase in migraine frequency, 16% reported a decrease in migraine frequency, and a little over 10% reported converting from episodic migraine to chronic migraine (defined by the International Headache Society as 15 or more headache days a month).
From my own clinical observations, the pandemic has affected people with migraine in the following key areas. There are those whose headaches have been affected after infection with the virus. For patients with migraine who have not been infected, access to medical care has been disrupted because of reluctance to go to medical offices for visits. Drastic changes in daily routines due to lockdown requirements have also played a role, as have mood fluctuations.
Here we review how the virus, as well as the lifestyle alterations and stresses caused by the pandemic, have manifested in patients with migraine.
COVID-19 and Headache
Headache has been reported as the first symptom in 26% of people with COVID-19, and it presented within 24 hours for 62% of people with the virus. One quarter of these patients have a headache that resembles migraine and 54% experience what resembles tension-type headache. Although the pathophysiologic connection between headache and COVID-19 is not totally clear, recent studies suggest that inflammatory mechanisms are the key culprit. A key migraine mechanism is the activation of nociceptive sensory neurons by cytokines and chemokines. The release of cytokines and chemokines by macrophages throughout the course of infection are thought to be a key mechanism in COVID-19, as well. These shared mechanisms make headache a common neurologic symptom in patients with COVID-19 and often worsen headache frequency and severity in patients with an existing diagnosis of migraine.
When patients report to me that their baseline migraine frequency and/or severity has increased after COVID-19 infection, I make sure that there is not a new underlying cause for headaches, such as a stroke or other structural brain lesion, by performing a complete neurologic exam, obtaining an MRI of the brain, and ordering pertinent blood tests. Once a dangerous new cause has been ruled out as the reason for the uptick in headaches, I treat patients on the basis of their primary headache phenotype, which in my clinic is often chronic migraine. I initiate treatments that have been studied for migraine prevention, such as calcitonin gene-related peptide (CGRP) monoclonal antibodies, onabotulinumtoxinA (Botox) injections, seizure medications, antidepressants, or blood pressure medications, in patients with four or more migraine days a month or any migraine day causing them significant disability. I also make sure they have a multistep plan for rescue treatments to limit their day-to-day disability. The plan can include such medications as triptans, of which there are several currently available, including sumatriptan (Imitrex), rizatriptan (Maxalt), zolmitriptan (Zomig), eletriptan (Relpax), or either of two gepants: rimegepant (Nurtec ODT) and ubrogepant (Ubrelvy). Neuromodulation devices such as the Cefaly Dual (Cefaly Technology), Nerivio Migra (Theranica), or gammaCore (electroCore LLC) can also be beneficial. However, cost may be an issue when considering the latter device as it may not be covered by many insurance providers.
Disruptions in Medical Care
Patients have been reluctant to go to medical offices for visits owing to concerns about COVID-19 infection, and many clinics have spaced out office visits to avoid overcrowding in waiting rooms and common areas. As a result, the lines of communication between patients and healthcare providers have become blurry in some cases. Almost 60% of patients report overusing over-the-counter analgesics to acutely treat a migraine attack. I have certainly observed this in my clinic.
As a result of social distancing and a reduced number of in-person visits during the pandemic, appointments for migraine prevention procedures such as onabotulinumtoxinA injections and nerve blocks have been missed or delayed. Consequently, these treatments wear off, which leads to a sudden increase in migraine frequency and severity.
During the past year, medication shortages may have contributed to an increase in headaches and disability for patients with migraine. In recent years, several cutting-edge preventive medications for migraine have been approved, including CGRP monoclonal antibodies, as well as abortive treatments such as rimegepant (Nurtec ODT) and ubrogepant (Ubrelvy). The positive safety and side-effect profiles of these drugs make medication adherence easier for the patient at home. These treatments may be a better fit for each patient's medical comorbidities and lifestyle. Access has not been made easy by insurers, however. For instance, many insurance companies don't cover these specialty drugs because they're more expensive than traditional, nonspecialty therapies, or they may use step therapy, which requires the trial of at least two different nonspecialty agents before allowing for coverage of specialty drugs.
On a positive note, telemedicine visits, which have become more mainstream in the past year, have been a good resource for patients with migraine. Although telemedicine visits can be challenging to set up at first and require a fair bit of technical know-how, research has shown migraine-specific telemedicine visits to be just as good as in-person office visits. Scheduling regular telemedicine visits with patients has made a huge difference in my being able to track the progression of their headaches closely and in making sure that patients are obtaining their medications, staying on track with their treatment plans, and ultimately preventing acute migraine from developing into chronic migraine.
Changes in Daily Routine
Although people across all continents have had their lifestyles disrupted by the COVID-19 pandemic, research shows that patients with migraine are particularly vulnerable to changes to a regular routine. During the pandemic, the triggers that my patients most frequently noted include increased screen time, variability in sleep and wake times, sudden changes in stress levels, variations in caffeine and alcohol intake, and diet.
Fortunately, changes in a patient's daily routine do not always lead to migraine, and the use of coping strategies can significantly help in dealing with sudden lifestyle deviations. When discussing such variables as sleep, screen time, stress, mood changes, skipped meals, and caffeine variability, I help design a plan to combat each of these issues that may trigger migraine attacks. For example, if the patient reports that their sleep is disjointed, I advise adding half an hour to an hour of sleep nightly and recommend that they keep up the same sleep and wake times daily. Maintaining regularity can be a key factor, which complements the mainstream medications I recommend.
I also typically work with a pain psychologist to implement cognitive-behavioral therapy, which has been studied for a range of medical conditions, such as depression, anxiety, insomnia, and chronic pain. Psychologists use cognitive-behavioral therapy to learn to recognize a patient's pattern of thinking that may create barriers to improvement and to teach problem-solving skills to cope with difficult scenarios.
For patients who have been working remotely during the pandemic and spend a significant amount of time in front of a computer screen, which they identify as a migraine trigger, I often recommend glasses with an FL-41 tint, which help with fluorescent light sensitivity and reading.
Managing Mood Shifts
Depression and anxiety are often related to migraine and must be addressed when treating these patients. This pandemic has been especially difficult for those who experience mood disorders owing to social isolation and financial or work-related issues, among other factors. Consequently, I have found that it is critically important to keep a close eye on the mental well-being of my patients, making sure that they have good social networks. It has been useful to refer patients to my psychiatry and psychology colleagues in order to ensure that my patients are well supported.
Antidepressant medications can be used for migraine prevention. Therefore, I may consult with the patient's psychiatrist or psychologist before choosing a drug option to make sure we are using the right medication to address both the pain and mood issues. With the welcome advantages of telemedicine and online counseling services, it is easier than ever to make sure that patients with migraine are being heard and being managed from a holistic point of view.
Although people worldwide have experienced difficulties related to the COVID-19 pandemic, the challenges facing patients with migraine are unique. As physicians, we need to fully engage as patient advocates to ensure that patients with migraine have easy access to mental and social health services, receive adequate preventive migraine treatment, and have a well-formulated plan for acute migraine management.
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Cite this: How Has COVID-19 Affected People With Migraine? - Medscape - May 12, 2021.