Paradigm shift in migraine management impacted by COVID-19 pandemic and the role of confounding factors inflicting the change

Objectives:To assess the impact of the COVID-19 pandemic on migraineur’s quality of life and confounding factors.Methods:This is an observational cohort study conducted in Rashid hospital, Dubai Health Authority, UAE. Study was plotted to assess migraine indices in pre-COVID period, pre-pandemic and pandemic periods and to evaluate the pandemic induced paradigm shift in migraine management.Results:Out of 840 migraineurs 201 patients were selected, with an obvious female predominance (78%). Migraine without Aura was found in 70% and Migraine with Aura in 29.9%. Mean MIDAS score during period I, II and II was 22.78, 18.58 and 17.92 respectively indicating certain degree of improvement rather than deterioration during pandemic (p=0.001). Interestingly significant reduction in both migraine frequency and severity from pre-COVID to COVID period was noticed (p=0.01). Parameters like headache days/month, use of abortive therapy and Emergency visits also declined. Chronic migraine (CM) showed more improvement than episodic migraine (EM). Confounding factors like distance working and lack of social/professional stress mainly rendered this change. A modified strategy to handle headache during any pandemic/crisis can ensure quality management of migraine.Conclusion:Migraine patients had a resilient behavior during the COVID pandemic and showed significant improvement of all indices. Confounding factors like distance working played the most favorable role.

Coronavirus disease 2019 (COVID-19) mainly exerts its effect by binding to receptors in the pulmonary epithelium and blood vessels with a special affinity to ACE2 receptors; release of inflammatory cytokines like IL-6 and TNFα; dysregulation of the immune response; dysregulation of the renin–angiotensin–aldosterone system (RAAS); thrombo-inflammation; and direct viral toxicity. ¹ Awareness of its clinical manifestations has developed over couple of years and thousands of researchers have reported their experiences to illuminate the world about this novel disease.A systemic review on neurological manifestations has shown up a wide spectrum of symptoms, including smell disorders (59%), taste disorder (56%), headache (20%), ischemic stroke (5%), encephalopathy (8.8%), intracerebral hemorrhage (0.45%), encephalitis/meningitis (1.4%), myelitis (1.2%), neuropathy (acute like Guillain-Barre-syndrome) (1.2%) and rhabdomyolysis. ² Headaches are encountered mainly in neurology clinics, reportedly these make 33% of neurology clinic visits. ³ With a serious concern, headaches are a major symptom reported during the COVID-19 pandemic. Headache-related issues can be segregated into 2 main categories: (i) already existing headaches that are affected by COVID or (ii) new headaches introduced by the infection itself or protective gadgets. For instance, frontline healthcare workers in all hospitals were mandated to wear personal protective equipment (PPE) while handling COVID-19 patients. Wearing the N95 mask during severe acute respiratory distress syndrome (SARS) epidemic in Singapore (2003) resulted in the occurrence of novel onset face-mask-associated headaches with a prevalence of 37.3%. ⁴ Similarly, amongst medical professionals using the N-95-mask and protective eyewear for an average of 5.7 hours/day, 81% reported de-novo PPE induced headaches and 91% stated aggravation in their pre-existing headaches. However, certain trigger factors, such as sleep deprivation (60.9%), physical stress (29.3%), emotional stress (13.0%), irregular mealtimes (15.2%), and inadequate hydration (39.1%) contributed too. ⁵ Of the primary headaches, migraine is highly prevalent and is the second leading cause of years-lost-to-disability worldwide. ⁶ Pandemic induced changes in the healthcare model impacted considerably on headaches and other chronic disorders. ⁷ Management protocols, patient consultancy, clinic visit frequency, emergency visit criteria, and all other management protocols were modified during the pandemic. Consequentially, individuals’ suffering from migraines intensified. Certain factors, such as stress, infection, fear of catching infection, isolation, limited options of recreation, altered sleep cycle, and wearing PPE, rendered notable changes in the frequency and severity of migraine. However, there were certain factors which positively impacted on migraineurs’ lives.Our objective in this study was to assess the impact of the COVID-19 pandemic on migraineur’s quality of life and confounding factors. Such studies can play a leading role in devising new protocols for migraine management during any crisis in future.