How has COVID-19 affected migraine sufferers?

Many migraine sufferers have reported an increase in the frequency and/or severity of headaches over the past year due to the challenges they have faced as a result of the COVID-19 pandemic. A recent online survey explored the real impact of COVID-19 on migraine patients and showed that approximately 60% of respondents had an increase in migraine frequency, 16% reported a decrease in migraine frequency. migraines and just over 10% reported converting. from episodic migraine to chronic migraine (defined by the International Headache Society as 15 or more headache days per month).

From my own clinical observations, the pandemic has affected migraine sufferers in the following key areas. There are those whose headaches have been affected after infection with the virus. For migraine patients who have not been infected, access to medical care has been disrupted due to reluctance to come to doctors’ offices for visits. Drastic changes in daily routines due to confinement requirements also played a role, as did mood swings.

Here we look at how the virus, along with the lifestyle changes and stresses caused by the pandemic, manifested in migraine patients.

COVID-19 and headaches

Headache was 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. A quarter of these patients have a migraine-like headache and 54% experience what feels like a tension headache. Although the pathophysiological link between headaches and COVID-19 is not entirely clear, recent studies suggest that inflammatory mechanisms are the main culprit. A key mechanism of migraine is the activation of nociceptive sensory neurons by cytokines and chemokines. The release of cytokines and chemokines from macrophages throughout infection is also thought to be a key mechanism of COVID-19. These shared mechanisms make headache a common neurological symptom in patients with COVID-19 and often worsen the frequency and severity of headaches in patients previously diagnosed with migraine.

When patients report to me that their baseline migraine frequency and/or severity has increased after COVID-19 infection, I ensure there is no new underlying cause of headaches , such as a stroke or other structural brain injury, performing a comprehensive neurological exam, obtaining an MRI of the brain, and ordering relevant blood tests. Once a dangerous new cause has been ruled out as the reason for the increase in headaches, I treat patients based on 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, anticonvulsants, antidepressants, or antihypertensives , in patients with four or more migraine days per month or any migraine day that causes them significant disability. I also make sure they have a multi-step rescue treatment plan to limit their day-to-day disability. The plan may include medications such as triptans, several of which are currently available, including sumatriptan (Imitrex), rizatriptan (Maxalt), zolmitriptan (Zomig), eletriptan (Relpax), or one 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) may also be beneficial. However, cost can be an issue when considering this latest device as it may not be covered by many insurers.

Disruptions to medical care

Patients have been reluctant to come to doctor’s offices for visits due to concerns about COVID-19 infection, and many clinics have spaced out office visits to avoid overcrowding in waiting rooms and clinics. common areas. As a result, lines of communication between patients and healthcare providers have become blurred in some cases. Nearly 60% of patients report abusing over-the-counter pain relievers to acutely treat a migraine attack. I have certainly observed this in my clinic.

Due to social distancing and fewer in-person visits during the pandemic, appointments for migraine prevention procedures such as onabotulinumtoxinA injections and nerve blocks have been missed or delayed. As a result, these treatments fade, leading to a sudden increase in the frequency and severity of migraines.

Over the past year, drug shortages may have contributed to an increase in headaches and disability among migraine patients. In recent years, several cutting-edge migraine preventative drugs 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 medications facilitate adherence to therapy for the patient at home. These treatments can be better tailored to each patient’s medical comorbidities and lifestyle. However, access was not facilitated by insurers. For example, many insurance companies do not cover these specialty drugs because they are more expensive than traditional non-specialty therapies, or they may use step therapy, which requires the trial of at least two agents non-specialty medications before authorizing specialty drug coverage. .

On a positive note, telemedicine visits, which have become more common over the past year, have been a good resource for migraine patients. Although telemedicine visits can be difficult to set up at first and require some technical know-how, research has shown that migraine-specific telemedicine visits are just as effective as in-office visits. Scheduling regular telemedicine visits with patients has made a huge difference in my ability to closely monitor the progression of their headaches and ensure patients get their medications, stay on track with their treatment and ultimately prevent acute migraine from developing into chronic migraine.

Changes in daily routine

Although people on all continents have seen their lifestyles disrupted by the COVID-19 pandemic, research shows that migraine patients are particularly vulnerable to changes in a regular routine. During the pandemic, the triggers my patients have most often noted include increased screen time, variability in sleeping and waking times, sudden changes in stress levels, variations in caffeine intake, and alcohol 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 cope with sudden lifestyle deviations. When I discuss variables such as sleep, screen time, stress, mood swings, skipped meals, and caffeine variability, I help design a plan to tackle each of these likely issues. trigger migraine attacks. For example, if the patient reports that his sleep is inconsistent, I advise him to add half an hour to an hour of sleep per night and recommend that he keep the same sleeping and waking times every day. Maintaining regularity can be a key factor, which complements the traditional 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 thought pattern that may create barriers to improvement and to teach problem-solving skills to deal with difficult scenarios.

For patients who have worked remotely during the pandemic and are spending a lot 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 helps with sensitivity to fluorescent light and reading.

Manage mood swings

Depression and anxiety are often linked to migraine and should be considered when treating these patients. This pandemic has been especially difficult for those who suffer from mood disorders due to social isolation and financial or work-related issues, among other factors. Therefore, I have found it extremely important to closely monitor the mental well-being of my patients, making sure they have good social networks. It has been useful for me to refer patients to my psychiatrist and psychologist colleagues in order to ensure that my patients are well supported.

Antidepressant drugs can be used for migraine prevention. Therefore, I may consult with the patient’s psychiatrist or psychologist before choosing a medication option to ensure that we are using the correct medication to address both pain and mood issues. With the welcome benefits of telemedicine and online counseling services, it is easier than ever to ensure migraine patients are heard and cared for from a holistic perspective.

Although people around the world have experienced difficulties related to the COVID-19 pandemic, the challenges faced by migraine patients are unique. As physicians, we must be fully engaged as patient advocates to ensure that patients with migraine have easy access to mental and social health services, receive adequate migraine preventive treatment, and have a well-formulated plan for the management of acute migraine.

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