COVID-19 and Migraine: Portraits of Patient Impact

July 8, 2020
Sydney Jennings

Associate Editor of Patient Care Online

How has the COVID-19 pandemic impacted migraine patients? We asked 3 migraine specialists that question and more.

The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented public health crisis that has disrupted millions of lives globally. Since the World Health Organization declared the COVID-19 outbreak as a “pandemic” on March 11, 2020, the number of confirmed cases worldwide has surpassed 10 million, and continues to increase despite social isolation efforts.

This “new normal,” where people’s homes have become their office, gym, school, and more, has impacted everyone differently. Some, perhaps, were already telecommuting to work or homeschooling their children; however, for others, this transition has been difficult.

Migraine patients, for example, have not been untouched. When asked how the COVID-19 pandemic has impacted her migraine patients, Susan Hutchinson, MD, headache specialist, board-certified family physician, and director of the Orange County Migraine and Headache Center in Irvine, California, told Patient Care Online: “I would say so far…for about one-third of my migraine patients their migraines are better, one-third worse, and one-third about the same.”

Increased stress could be part of the problem

To further understand just how much the pandemic is affecting US adults, the American Psychological Association (APA) adapted its annual Stress in America poll into a monthly analysis of stressors and stress levels due to COVID-19.

The online survey was conducted by the Harris Poll on behalf of the APA and included 3013 US adults aged ≥18 years between April 24 to May 4, 2020.

The survey found that the average reported stress level for US adults related to the COVID-19 pandemic was 5.9 on a scale of 1-10, where 1 means “little or no stress” and 10 means “a great deal of stress.” When asked to rate their stress level in general, the average reported stress was 5.4. This current average level of 5.4 also marks the first significant increase in average reported stress among US adults since the survey started in 2007, according to the APA.

These rising stress levels are particularly concerning for migraine patients for whom stress is a common trigger. According to the American Headache Society, 4 out of every 5 patients with migraine report stress as a trigger.

When asked how her migraine patients were managing during the pandemic, Linda Davis, MD, board certified family physician with a specialty in migraine headaches from the Kolvita Family Medical Group in Mission Viejo, CA, told Patient Care Online: “I do think it’s [COVID-19] had a negative impact and I do think they’re probably suffering from more of them [migraine headaches] because of the stress.”

One source of stress for migraine patients could be tension in the household related to corporate offices and schools switching to online commerce and remote learning. This change in schedule may have forced adult patients to telecommute for work and/or homeschool their children; younger migraine patients may have had to also make the switch from in-school learning to homeschooling.

Millions of families have been affected

EducationWeek.org, an independent news organization that provides comprehensive coverage on K-12 education, tracked pandemic-related US school closures. Between March 6 and May 15, 2020, school closures impacted as many as 55.1 million students in 124 000 public and private schools nationwide at the peak.

A significant number of adults also had to switch from in-office work to telecommuting if their job permitted. According to a recent Gallup poll conducted March 30-April 2, 2020, 62% of employed Americans say they have worked from home during the pandemic, a number that has doubled since mid-March.

There are benefits to working from home, including increased flexibility and being able to spend time with loved ones, but for some, that family quality time may be a source of stress. “There’s a lot of tension in some households with kids home, Mom and Dad home,” Hutchinson told Patient Care Online.

For example, a 12-year-old migraine patient of Hutchinson’s presented with headaches that had transformed into a refractory pattern. “After further discussion with the mother, she said the husband, because he’s stuck at home all day with the daughter, he’s angry,” explained Hutchinson. “He’s angry at the slow internet speed. He’s just angry at the world and I think he makes his 12-year-old daughter feel like she’s somewhat responsible.”

The patient was also missing her friends from school, so Hutchinson told the patient’s mother, “I’m going to do what I can with medication, but all the medication in the world isn’t going to be able to get your daughter back to an infrequent episodic pattern.” Instead, Hutchinson continued, they needed to look at the family dynamics at home to relieve some of the patient’s stress.

Davis shared a similar example of a patient who was doing well with her maintenance medications for some time but developed a migraine recently that would not break, so the patient came into the office for an injection.

“We were talking about it and she said that what’s been hard for her is normally when she gets in these cycles of migraines that she can’t break, there’s a reprieve at home. Home is like more her safety place and she can go lie down, she can relax,” said Davis. “But right now, she’s working from home, her husband’s working from home, the kids are being homeschooled. So suddenly, her stress environment is her home.”

The patient even had to get in her car and take a drive to find some peace, added Davis. “It was kind of an eye opener…so I think maybe in the beginning, the migraines might have been a little bit less, but as time goes on, I think this is becoming a trigger for them,” said Davis.

Pandemic impact on gender gap

Women with migraine are a group of particular concern during the pandemic. Women suffer from migraine 3-times as often as men and migraine is also one of the leading serious health issues affecting women.

“I think the women probably are faring worse than men because women have children to take care of now that maybe had been going to school,” said Hutchinson of female migraine patients. “So, all of a sudden, they have the school responsibilities. Many of them also have careers and jobs so they also have work responsibilities.”

A Kaiser Family Foundation Health Tracking Poll conducted March 25 to March 30, 2020, among 1226 US adults aged ≥18 years, found a widening gender gap in self-reported negative mental health impact from COVID-19.

Overall, 53% of women said worry or stress related to the COVID-19 pandemic has had a negative impact on their mental health vs 37% of men, and this gap widened more among parents of children under age 18. The gender gap between parents was a striking 25 percentage points with 57% of mothers vs 32% of fathers who reported their mental health has gotten worse because of the pandemic.

“There's been a lot of articles in the medical literature, sort of opinion articles, that this [the pandemic] is going to set women back quite a bit in general, because what's going to happen is when the fall comes and their kids are not going back to school, somebody's going to have to stay home and usually it ends up being the woman,” said Davis. “It's going to be a vicious cascade across the board because more of the home responsibilities are already still on the women.”

COVID-19 impact on care for migraine patients

Physician practices across the country have had to change the way they deliver care to ensure patient safety in response to the COVID-19 crisis.

A recent survey of 842 US physicians conducted by the physician search firm Merritt Hawkins, in collaboration with The Physicians Foundation, found that 48% of physicians are treating patients through telemedicine. This is a significant increase since 2018 when 18% of physicians reported using telemedicine.

Peter McAllister, MD, medical director at the New England Institute for Neurology and Headache and chief medical officer for the New England Institute for Clinical Research and Ki Clinical Research, all in Stamford, Connecticut, told Patient Care Online how being near the epicenter of COVID-19 cases drastically changed how he delivered care to his migraine patients:

“The short answer is it’s been profound.”

“Clearly with New York City being the epicenter of the number of cases and number of deaths – we are just up the road in Connecticut. There were a lot of people being quite afraid to go out, understandably and quite reasonably,” McAllister explained. “And we had to make some big decisions at our practice. Some practices, neurological practices, closed their doors completely and have gone to a full telemedicine thing. My perspective was that we could probably thread the needle and do it safely to be at least partially opened.”

As now mandated by the CDC for patient safety, McAllister and colleagues call all patients the day before an appointment to complete a questionnaire on potential COVID-19 exposure or infection; the questions are repeated upon arrival at the office and temperature is checked. Patients and staff are required to wear a mask or other face covering.

McAllister and his staff also get tested for COVID-19 on a weekly basis and half of the staff is assigned to work from home and then they rotate.

“It’s decreased the actual number of people, our footprint of people here. So it’s actually a bit quiet, but I wasn’t going to stop seeing patients because I felt that wasn’t the right thing to do,” said McAllister.

Hutchinson has made similar changes to care delivery for migraine patients.

“We’re encouraging everyone to do a virtual follow-up,” said Hutchinson, “We do allow people to come in . . . if they’re not doing well, and some people come in for a nerve block . . . We also still have patients that come in every 12 weeks for Botox for their chronic migraine.”

Keep communications open

Communication with migraine patients is also important in delivering quality care during the pandemic. At Kolvita Family Medical Group, Davis and her staff send out weekly emails to patients with COVID-19 updates.

“We get a nice response when we send out our emails because they’re pretty objective and informative. We’ll get responses saying ‘thank you, it’s always so calming to hear from you guys and get some real information,’ even though we’re very clear that we don’t have all of the answers and the testing is not as accurate as we would hope it would be,” said Davis.

A vaccine against COVID-19 has yet to be approved and it is still unclear when the pandemic will come to an “end.” This uncertainty can be particularly difficult for migraine patients who like structure.

“It’s going to be a process though, right?” Hutchinson told Patient Care Online. “There’s still going to be a little stress as things open up because you have that uneasiness of ‘is it safe?’ It’s the new normal, so I think it’ll be gradual, but yes, some people’s migraines will get better as they feel more comfortable getting back to some degree of normalcy.”

Until then, communicating with migraine patients is important. The pandemic is still evolving, and new information is released nearly every day but there is also a lot of misinformation that can make it for hard for patients to decipher fact from fiction.

“Our weekly emails have been huge,” said Davis. “Sometimes it’s hard to be super proactive, but that persistent reminder that they need to not disregard other aspects of their health care is very important. The persistent reminder that we’re still here, even if it’s not physically in the office, we have access by phone and technology. That constant ‘please reach out to us if you have questions and concerns on any of your health care issues’ is hugely important.”

If the only communication to the patient base is telling them about the office’s COVID-19 protocols, patients may get the impression that their physician is only focusing on COVID-19 and not on other important health concerns including migraine.

“I think having some method, whether it’s on your website, or if you have a social media platform that your patients look at, or you have the ability to mass message them, I think they [physicians] should,” said Davis.