Managing Chronic Headache During the COVID-19 Pandemic: A Q&A

In light of the coronavirus disease 2019 (COVID-19) pandemic, neurologists have had to change their practices to care for patients with chronic headache and migraine.

Recently, Matthew Robbins, MD, and his colleague, Sarah M. Bobker, published a paper in Headache that outlined the effects of the pandemic on patients with headaches disorders.

We reached out to Dr Robbins to learn more about how care has changed for patients with chronic headaches in the midst of the COVID-19 pandemic.

Dr Robbins is an associate professor of neurology at Weill Cornell Medicine in New York, New York, where he focuses on patients with migraine, cluster headache, new daily persistent headache, and other headache disorders. His research interests include headache in pregnancy and the elderly, cluster headache, new daily-persistent headache, unusual primary and secondary headache disorders, and unusual forms of migraine aura.

How has care for patients with chronic migraine or headache changed during COVID-19?

Care has been changed in a number of ways. Most importantly, there was a rapid conversion of practice to telemedicine, with in-person visits being curtailed and prioritized for procedures (such as botulinum toxin injections or nerve blocks) for patients who may otherwise have a risk for decompensation, be severely disabled, and could be at risk of requiring care in the emergency department or an urgent care center.

Initial warnings of COVID-19 susceptibility for nonsteroidal anti-inflammatory drugs (NSAIDs), angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers, and medications for migraine led to the cessation or avoidance of these treatments. When presented with a choice of treatments requiring in-office or at-home therapies, at-home therapies have largely been pursued, such as CGRP [calcitonin gene-related peptide]-targeting monoclonal antibodies vs botulinum toxin injections.

Do you have any practical tips for managing migraine or chronic headache care via telemedicine? 

Much of the management strategies remain the same using telemedicine instead of in-person visits. Clear communication and compassionate care prevail. We are fortunate to have a lot of great treatment options for headache disorders right now.

Have you had any experience with patients expressing that their chronic headaches are worsening during the pandemic? If so, how are you differentiating their symptoms from a potential COVID-19 infection?

Yes, many patients have had migraine exacerbations when infected with COVID-19. In some, these seem to happen early, but in my experience more patients have attacks later on in the course. Certainly the presence of other symptoms aside from headache is key to elevating the suspicion for COVID-19, particularly lack of smell, muscle aches, fever, and respiratory symptoms.

Have you encountered patients presenting with new-onset headaches who are concerned that their symptoms may be COVID-related?

Yes, though most patients in such situations are now able to get tested for clarity; however, the sensitivity of the swab is far less than 100%, so it is important to follow-up with such patients for the development of other symptoms, or if they are unwell, to provide quarantine guidance.

In your recent article, “COVID19 and Headache: A Primer for Trainees,” you mention that some patients develop headaches later in their course of COVID-19 and that may be related to cytokine release storm. What are your suggestions on how to best capture the effects of headache with the timing of the disease course?

Observational studies focusing on the timing of neurologic symptoms, including headache, are needed to truly understand which ones are related to the viral infection itself and which are manifestations of the inflammatory response that may follow.

Reference

Bobker SM, Robbins MS. COVID19 and headache: a primer for trainees [published online June 10, 2020]. Headache. doi:10.1111/head.13884