Executive Functions, Anxiety, Social Participation and Quality of Life in Children with Migraine During COVID-19 (preprint)

Objective: To compare executive functions (EF), anxiety, social participation, and quality of life (QoL) between children with migraine and healthy controls during the COVID-19 pandemic, and to examine these parameters in children in each group who did vs. did not contract COVID-19. Background: Migraine is among the most prevalent headache disorders in children, especially in adolescents. Migraine is exacerbated by stress, and it holds potential to affect patients’ emotional and cognitive state and, by extension, their functioning and wellbeing – parameters that were also affected by the COVID-19 pandemic. Materials and Methods: A prospective cohort study. The patient group comprised children seen in our pediatric neurology clinic for migraine, and the control group was composed of aged-matched healthy children with no neurological findings or developmental disorders. Participants’ parents completed a health and demographic questionnaire, BRIEF (child/adolescent version), PedsQL, the State-Trait Anxiety Inventory for Children (STAIC) and CASP. Participants or their parents furnished information on whether the participant had contracted COVID-19. Results: 84 children and adolescents aged 6–17.5 participated in the study: 33 with migraine (17 boys, 16 girls); 51 healthy controls (28 boys, 23 girls). Children with migraine showed significantly lower EF due to reduced behavioral regulation, higher trait anxiety, and lower physical, emotional, and school related QoL. Reduced EFs correlated with intensity of migraine attacks, higher anxiety, reduced social participation, and reduced QoL. Lower social participation correlated with reduced QoL and predicted emotional and social QoL. The BRIEF metacognition scale predicted school-related QoL. Healthy children who contracted COVID-19 showed significantly lower EF than children with migraine in the inhibition (56.66±10.56 vs 45.71±7.12-, p=.013) and initiation (60.01±11.89 vs 46.01±6.54, p=.005) BRIEF scales, and in the general metacognition index (65.83±14.48 vs 46.75±9.19, p=.003). Healthy children who contracted COVID-19 had significantly worse initiation and working memory compared to those who did not contract COVID-19 (initiation: 60.01±11.89 vs 46.81±8.89, p=.007), working memory: 61.16±15.48 vs 47.21±11.06, p=.021). Conclusion: Migraine has a significant negative impact on executive functions in children and adolescents, even more than contracting COVID-19. Executive dysfunction influences their emotional state, participation in social activities, and quality of life. The COVID-19 pandemic had a less deleterious effect on migraine patients compared to the healthy control group. Further research on pediatric migraine is warranted.

Antibiotic Utilisation Patterns in Tanzania: A Retrospective Longitudinal Study Comparing Pre- and Post-COVID-19 Pandemic Using Tanzania Medicines and Medical Devices Authority Data (preprint)

SynopsisO_ST_ABSBackgroundC_ST_ABSAntimicrobial resistance (AMR) is a growing public health concern globally, and misuse of antibiotics is a major contributor. ObjectiveThis study investigated antibiotic utilisation patterns before and after the COVID-19 pandemic in Tanzania using data from the Tanzania Medicines and Medical Devices Authority (TMDA). MethodsThis retrospective longitudinal study analysed secondary data. The study compared antibiotics consumption in defined daily doses (DDD) per 1000 inhabitants per day (DID) in two distinct eras: 2018-2019 as the pre-COVID-19 era and 2020-2021 as the post-COVID-19 era. Data was reorganised using Microsoft Power BI, and statistical analysis was conducted using SPSS software. ResultsThe study analysed 10,614 records and found an overall increase in antibiotics consumption from 2018 to 2021. When we divided the consumption of antibiotics into a pre- and post-COVID time period, with the pre-COVID period being 2018 and 2019 and the post-COVID period being 2020 and 2021, we found that the consumption was 61.24 DID in the post-COVID era and 50.32 DID in the pre-COVID era. Levofloxacin had the highest percentage increase in use, with a 700% increase in DID after the pandemic. Azithromycin had a 163.79% increase, while cefotaxime had a 600% increase. In contrast, some antibiotics exhibited a decrease in usage after the pandemic, such as nalidixic acid, which had a 100% decrease, and cefpodoxime, 66.67% decrease. ConclusionThe increase in antibiotic consumption during the COVID-19 pandemic highlights the importance of implementing effective antimicrobial stewardship strategies to prevent AMR, especially during pandemics.

Several Mathematical Aspects on Daily Number of COVID-19 Infection Cases in Eight Southeast Asian Places (preprint)

The number of daily confirmed infected cases is a key parameter to determine emergency management actions to take. The mathematical characteristics of the daily infection number should be explored for working out appropriate control scheme. Several mathematical aspects on the daily number of infected cases will be discussed in 8 Southeastern Asian places using the confirmed daily infection numbers available in public websites. Phase space diagrams of plotting the daily infection rate estimated numerically against daily infection number on those tests are presented first. Modeling parameters including the Farr's Law are also discussed. A parameter is proposed to describe the extent of infection by estimating the transient daily infection number divided by the time.

The increasing role of electronic media in headache.

Most individuals with access to the internet use social media platforms. These platforms represent an excellent opportunity to disseminate knowledge about management and treatment to the benefit of patients. The International Headache Society, The European Headache Federation, and The American Headache Society have electronic media committees to promote and highlight the organizations' expertise and disseminate research findings. A growing mistrust in science has made dealing with infodemics (i.e., sudden access to excessive unvetted information) an increasing part of clinical management. An increasing role of these committees will be to address this challenge. As an example, recent studies have demonstrated that the most popular online content on migraine management is not evidence-based and is disseminated by for-profit organizations. As healthcare professionals and members of professional headache organizations, we are obliged to prioritize knowledge dissemination. A progressive social media strategy is associated not only with increased online visibility and outreach, but also with a higher scientific interest. To identify gaps and barriers, future research should assess the range of available information on headache disorders in electronic media, characterize direct and indirect consequences on clinical management, and recognize best practice and strategies to improve our communication on internet-based communication platforms. In turn, these efforts will reduce the burden of headache disorders by facilitating improved education of both patients and providers.

Cross-sectional, hospital-based analysis of headache types using ICHD-3 criteria in the Middle East, Asia, and Africa: the Head-MENAA study.

BACKGROUND: Headaches are frequent neurological disorders that are yet to be unveiled and treated comprehensively worldwide. Bearing in mind that the distribution of headache subtypes in neurology clinics (NC) is essential for planning appropriate diagnostic and therapeutic approaches, the primary goals of this multi-centric study are to carry out inter-regional comparisons by using current diagnostic criteria with evaluations of neurologists to delineate headache burden. METHODS: A cross-sectional study between April 1 and May 16, 2022 was conducted with the participation of 13 countries from the Middle East, Asia, and Africa. Patients were included in the study on a specific day each week during five consecutive weeks. All volunteers over the age of 18 and whose primary cause for admission was headache were examined. The patients admitted to NC or referred from emergency services/other services were evaluated by neurologists by means of the International Classification of Headache Disorders (ICHD-3) criteria. RESULTS: Among the 13,794 patients encountered in NC, headache was the primary complaint in 30.04%. The headache patients' mean age was 42.85 ± 14.89 (18-95 years), and 74.3% were female. According to the ICHD-3 criteria, 86.7% of the main group had primary headache disorders, 33.5% had secondary headaches, 4% had painful cranial neuropathies along with other facial and headaches, and 5.2% had headaches included in the appendix part showing some overlapping conditions. While the most common primary headache was migraine without aura (36.8%), the most common secondary headache was medication-overuse headache (MOH) (9.8%). Headaches attributed to COVID-19, its secondary complications, or vaccines continue to occur at rates of 1.2%-3.5% in current neurology practice. Pain severity was significantly lower in Ivory Coast and Sudan than in Türkiye, Turkish Republic of Northern Cyprus, Iran, Egypt, Senegal, Tatarstan, and Azerbaijan (p < 0.001). CONCLUSIONS: The study showed that migraine is still the most common motive for admissions to NC in different regions. Furthermore, MOH, an avoidable disorder, is the most common secondary headache type and appears to be a significant problem in all regions. Remarkably, pain perception differs between regions, and pain intensity is lower in Africa than in other regions.

Left- vs right-sided migraine: a scoping review.

BACKGROUND: Migraine is a historically unilateral head pain condition, the cause of which is not currently known. A growing body of literature suggests individuals who experience migraine with left-sided headache ("left-sided migraine") may be distinguished from those who experience migraine with right-sided headache ("right-sided migraine"). OBJECTIVE: In this scoping review, we explore migraine unilaterality by summarizing what is currently known about left- and right-sided migraine. METHODS: Two senior medical librarians worked with the lead authors to construct and refine a set of search terms to identify studies of subjects with left- or right-sided migraine published between 1988, which is the year of publication of the first edition of the International Classification of Headache Disorders (ICHD), and December 8, 2021 (the date the searches were conducted). The following databases were searched: Medline, Embase, PsycINFO, PubMed, Cochrane Library, and Web of Science. Abstracts were loaded into Covidence review software, deduplicated, then screened by two authors to determine study eligibility. Eligible studies were those involving subjects diagnosed with migraine (according to ICHD criteria) in which the authors either: a) compared left- to right-sided migraine; or b) described (with analysis) a characteristic that differentiated the two. Data were extracted by the lead author, including ICHD version, the definition of unilateral migraine used by the authors, sample size, whether the findings were collected during or between attacks, and their key findings. The key findings were grouped into the following themes: handedness, symptoms, psychiatric assessments, cognitive testing, autonomic function, and imaging. RESULTS: After deduplication, the search yielded 5428 abstracts for screening. Of these, 179 met eligibility criteria and underwent full text review. 26 articles were included in the final analysis. All of the studies were observational. One study was performed during attack, nineteen between attacks, and six both during and between attacks. Left- and right-sided migraine were found to differ across multiple domains. In several cases, reciprocal findings were reported in left- and right-migraine. For example, both left- and right-sided migraine were associated with ipsilateral handedness, tinnitus, onset of first Parkinson's symptoms, changes in blood flow across the face, white matter hyperintensities on MRI, activation of the dorsal pons, hippocampal sclerosis, and thalamic NAA/Cho and NAA/Cr concentrations. In other cases, however, the findings were specific to one migraine laterality. For example, left-sided migraine was associated with worse quality of life, anxiety, bipolar disorder, PTSD, lower sympathetic activity, and higher parasympathetic activity. Whereas right-sided migraine was associated with poorer performance on multiple cognitive tests, a greater degree of anisocoria, changes in skin temperature, higher diastolic blood pressure, changes in blood flow through the middle cerebral and basilar arteries, and changes on EEG. CONCLUSION: Left- and right-sided migraine differed across a wide range of domains, raising the possibility that the pathophysiology of left- and right-migraine may not be identical.

School-based online survey on chronic headache, migraine, and medication-overuse headache prevalence among children and adolescents in Japanese one city - Itoigawa Benizuwaigani study.

BACKGROUND: We investigated the prevalence of headache, migraine, and medication-overuse headache (MOH) among children and adolescents through a school-based online questionnaire. We also investigated the triggers for migraine among them and the effect of the COVID-19 pandemic on headache frequency. METHODS: Children and adolescents aged 6-17 y.o. completed an online questionnaire. Migraine, MOH was defined as The International Classification of Headache Disorders Third edition. Factor and clustering analyses were performed for migraine triggers. The effect of the coronavirus disease 2019 (COVID-19) pandemic on headache frequency was also asked. RESULTS: Of the 2489 respondents, the prevalence of headache, migraine, and MOH were 36.44%, 9.48%, and 0.44%, respectively. Up to 70% of the respondents with headaches complained of the disturbance to daily life, but about 30% consulted doctors. The migraine triggers were grouped into 5 factors by factor analysis. The sensitivities of the migraineurs against the factors were divided into 3 clusters. Cluster 1 had stronger sensitivity for several triggers. Cluster 2 was sensitive to weather, smartphones, and video games. Cluster 3 had less sensitivity for triggers. Cluster 2 less consulted doctors even though the burden of migraine was enormous. During the COVID-19 pandemic, 10.25% of respondents increased headache attacks, while 3.97% decreased. CONCLUSIONS: This is the first detailed study on headache prevalence in Japanese students from elementary school to high school in one region. The burden of headaches is large among children and adolescents, and the unmet needs of its clinical practice should be corrected.

Refractory Headaches.

Medication overuse headache (MOH), new daily persistent headache (NDPH), and persistent refractory headache attributed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection represent a significant burden in terms of disability and quality of life, and a challenge in terms of definition, pathophysiology, and treatment. Regarding MOH, prevention without withdrawal is not inferior to prevention with withdrawal. Preventive medications like topiramate, onabotulinumtoxinA, and calcitonin gene-related peptide (CGRP) monoclonal antibodies improve chronic migraine with MOH regardless of withdrawal. The differential diagnosis of NDPH is broad and should be carefully examined. There are no guidelines for the treatment of NDPH, but options include a short course of steroids, nerve blocks, topiramate, nortriptyline, gabapentin, CGRP monoclonal antibodies, and onabotulinumtoxinA. The persistence of headache 3 months after SARS-CoV2 infection is a predictor of poor prognosis.

Pediatric Headache Experience During the COVID-19 Pandemic.

OBJECTIVE: Headache disorders are exceedingly common in children and adolescents. The association between headaches, emotional stress, and disruptions in daily routines are well established. The goal of this study is to compare the experiences of patients with a preexisting diagnosis of a primary headache disorder in terms of headache frequency and severity, lifestyle techniques for headache prevention, screen use, and mood from before and after the onset of the COVID-19 pandemic. METHODS: Patients evaluated by the Headache Clinic at Children's National Hospital between Summer 2020 and Winter 2021 were enrolled in a patient registry. Patients completed a questionnaire examining changes in headache characteristics and lifestyle factors since the onset of the COVID-19 pandemic. RESULTS: A total of 107 patients completed the survey. Since the pandemic's onset, patients reported decreased physical activity (n = 59, 55%), increased frequency of chronic headaches from 40% (N = 42) to 50% (N = 54), and increased constant daily headaches from 22% (n = 24) to 36% (n = 38). Patients reported worsened anxiety (n = 58, 54%), mood (n = 50, 47%), and workload (n = 49, 46%). Sixty-one percent (n = 65) of patients reported using screens for school for more than 6 hours per day. The majority (n = 67, 63%) of patients indicated that they would prefer attending in-person school, with 14% (n = 15) responding that they preferred online school. CONCLUSION: Since the COVID-19 pandemic's onset, pediatric headache patients have experienced increasing headache frequency, worsening anxiety and mood, decreased physical activity, and increased screen usage. Although this study is limited by sample size and observational design, future population-based studies will further elucidate the impact of this pandemic on pediatric headache.

Headache related to personal protective equipment in healthcare workers during COVID-19 pandemic in Mexico: baseline and 6-month follow-up.

BACKGROUND AND AIM: Headaches related to the use of personal protective equipment (PPE) could affect performance at work in healthcare personnel. Our aim was to describe the prevalence and risk factors for headaches related to PPE, in the personnel of a specialized coronavirus disease 2019 (COVID-19) tertiary hospital. METHODS: In this cross-sectional survey study, we invited healthcare workers from COVID-19 referral center in Mexico (May 22-June 19, 2020) to answer a standardized structure questionnaire on characteristics of new-onset PPE-related headache or exacerbation of primary headache disorder. Participants were invited regardless of whether they had a current headache to avoid selection bias. This is the primary analysis of these data. RESULTS: Two hundred and sixty-eight subjects were analyzed, 181/268 (67.5%) women, 177/268 (66%) nurses, mean age 28 years. The prevalence of PPE-related headache was 210/268 (78.4%). Independent risk factors were occupation other than physician (OR 1.59, 95% CI 1.20-2.10), age > 30 years (OR 2.54, 95% CI 1.25-5.14), and female sex (OR 3.58, 95% CI 1.86-6.87). In the 6-month follow-up, 13.1% of subjects evolve to chronic headache, with stress as predictive risk factor. CONCLUSION: The frequency of PPE-associated headache is high, and a subgroup could evolve to chronic headache. More studies are necessary to improve the knowledge about this condition.

Severe Intractable Headache as a Presentation of COVID-19 in a 23-Year-Old.

Severe acute respiratory syndrome coronavirus type 2 is a novel betacoronavirus with a new genome sequence that causes coronavirus disease 2019 (COVID-19), which primarily affects the lungs, thus causing pneumonia which can progress to severe acute respiratory distress syndrome. New emerging cases of extrapulmonary manifestations of COVID-19 include gastrointestinal, cardiac, renal, and/or central nervous system involvement. Although an ischemic stroke converting to a hemorrhagic stroke is more commonly seen, spontaneous intracranial hemorrhage (ICH) in hospitalized COVID-19 patients is on the rise. This case report describes a 23-year-old female who tested positive (via a polymerase chain reaction test) for COVID-19 and presented with new onset of severe intractable headache. The investigation suggested COVID-19 as the most probable cause of this patients' spontaneous ICH. This case emphasizes the importance of adding COVID-19 to the differential diagnosis of hemorrhagic cerebrovascular accidents in patients with a spontaneous ICH of unclear etiology and, in the process, performing COVID testing.

Probable New Daily Persistent Headache After COVID-19 in Children and Adolescents.

INTRODUCTION: Headache has been cited as both a primary symptom and a sequela of infection with the novel coronavirus. Cases of long coronavirus disease (COVID) headache have already been documented in adults, but literature on similar cases in children and adolescents is scant. CASE REPORT: We present three cases of persistent headache after infection with COVID-19 in pediatric patients presenting to a tertiary headache center. CONCLUSION: Infection has been suggested as a trigger for chronic headaches, specifically those of the new daily persistent headache type. Although the association between new daily persistent headache and COVID-19 remains unclear, these cases highlight the importance of awareness of the neurological sequelae of novel coronavirus infection in children and adolescents.

Post COVID-19 1st Dose Vaccination Common Symptoms among SE Asia College Students (preprint)

In the second year of the COVID-19 epidemic in the Southeast Asia (SE) regions, there is a plan to reopen the school, including the campus. Among students in Indonesia, college students have a population of almost 8.3 million. Considering the massive numbers of college students, school reopening should be supported by adequate COVID-19 vaccination. As a result, the first dose of the inactivated virus COVID-19 vaccine has been administered, including to college students aged over 18 years old. While COVID-19 vaccination is widely available, there is still a scarcity of information on post-vaccination symptoms. As reported from other locations, post vaccination has been reported. Then, this study aims to assess the common symptoms of COVID-19 1st dose vaccinations among the following groups: gender (male and female college students), age, body weight, and height. The observed symptoms include sore arms, fatigue, headache, fever with a body temperature above 38 oC, nausea, shivering, and muscle joint pain. Participants in this study were students at the university. They were considered eligible for this study if they were currently enrolled at university, were at least 19 years of age, and provided informed consent. The data was recorded using a standardized online questionnaire. The answers were collected in an online database. At the beginning of the questionnaire, subjects or students were informed that data would be collected anonymously. Based on the results, the symptoms were different between female and male students. In fact, female students have experienced more symptoms than male students. While male students only suffered sore arms (68%) followed by headache symptoms (32%). Similar to male students, sore arms are the most common symptom observed among female students. Among female students, from the most to the least common symptoms observed from 20 years of age in this study are sore arms at site reaction > headache > fatigue > fever > muscle joint pain > shivering > nausea. A higher risk of presenting fatigue and headache symptoms was found in those with a non-overweight status with weight ranges of 50-60 kg.

Echinacea purpurea for the Long-term Prevention of Viral Respiratory Tract Infections during COVID-19 Pandemic: A Randomized, Open, Controlled, Exploratory Clinical Study (preprint)

Introduction SARS-CoV-2 vaccination is effective in preventing severe COVID-19, but efficacy in reducing viral load and transmission wanes over time. In addition, the emergence of novel SARS-CoV-2 variants increases the threat of uncontrolled dissemination and additional antiviral therapies are urgently needed for effective containment. In previous in vitro studies Echinacea purpurea demonstrated strong antiviral activity against enveloped viruses, including SARS-CoV-2. In this study, we examined the potential of Echinacea purpurea in preventing and treating respiratory tract infections (RTIs) and in particular, SARS-CoV-2 infections. Methods 120 healthy volunteers (m,f, 18 – 75 years) were randomly assigned to Echinacea prevention or control group without any intervention. After a run-in week, participants went through 3 prevention cycles of 2, 2 and 1 months with daily 2’400mg Echinacea purpurea extract (Echinaforce®, EF). The prevention cycles were interrupted by breaks of 1 week. Acute respiratory symptoms were treated with 4’000 mg EF for up to 10 days, and their severity assessed via a diary. Naso/oropharyngeal swabs and venous blood samples were routinely collected every month and during acute illnesses for detection and identification of respiratory viruses, including SARS-CoV-2 via RT-qPCR and serology. Results Summarized over all phases of prevention, 21 and 29 samples tested positive for any virus in the EF and control group, of which 5 and 14 samples tested SARS-CoV-2 positive (RR=0.37, Chi-square test, p=0.03). Overall, 10 and 14 symptomatic episodes occurred, of which 5 and 8 were COVID-19 (RR=0.70, Chi-square test, p>0.05). EF treatment when applied during acute episodes significantly reduced the overall virus load by at least 2.12 log 10 or approx. 99% (t-test, p<0.05), the time to virus clearance by 8.0 days for all viruses (Wilcoxon test, p=0.02) and by 4.8 days for SARS-CoV-2 (p>0.05) in comparison to control. Finally, EF treatment significantly reduced fever days (1 day vs 11 days, Chi-square test, p=0.003) but not the overall symptom severity. There were fewer COVID-19 related hospitalizations in the EF treatment group (N=0 vs N=2). Discussion/Conclusion EF exhibited antiviral effects and reduced the risk of viral RTIs, including SARS-CoV-2. By substantially reducing virus loads in infected subjects, EF offers a supportive addition to existing mandated treatments like vaccinations. Future confirmatory studies are warranted. Clinical Trials registration Nr NCT05002179

Patient and public involvement in a UK National Institute for Health Research Programme Grant for Applied Research: experiences from the Chronic Headache Education and Self-management Study (CHESS).

BACKGROUND: Patient and public involvement (PPI) plays a crucial role in ensuring research is carried out in conjunction with the people that it will impact upon. In this article, we present our experiences and reflections from working collaboratively with patients and public through the lifetime of an National Institute for Health Research (NIHR) programme grant; the Chronic Headache Education and Self-management Study (CHESS) which took place between 2015 and 2020. PPI OVER THE COURSE OF CHESS: We worked closely with three leading UK migraine charities and a lay advisory group throughout the programme. We followed NIHR standards and used the Guidance for Reporting Involvement of Patients and the Public checklist. We consulted our PPI contacts using a variety of methods depending on the phase of the study and the nature of the request. This included emails, discussions, and face-to-face contact.PPI members contributed throughout the study in the programme development, in the grant application, ethics documentation, and trial oversight. During the feasibility study; in supporting the development of a classification interview for chronic headache by participating in a headache classification conference, assessing the relevance, and acceptability of patient-reported outcome measures by helping to analyse cognitive interview data, and testing the smartphone application making suggestions on how best to present the summary of data collected for participants. Due to PPI contribution, the content and duration of the study intervention were adapted and a Delphi study with consensus meeting developed a core outcome set for migraine studies. CONCLUSIONS: The involvement of the public and patients in CHESS has allowed us to shape its overall design, intervention development, and establish a core outcome set for future migraine studies. We have reflected on many learning points for the future application of PPI.

A Patient-Focused Questionnaire Designed to Support Headache Diagnosis in General Practice (preprint)

Background: There is an unmet need for the correct diagnosis of primary headache disorders, such as migraine, in primary care. Misdiagnosis is associated with suboptimal management of patients, and it is now widely accepted internationally that better diagnostic support is needed for general practitioners (GPs). In this study, we describe the development of a short, patient-directed questionnaire and supporting documents that aim to help with the diagnosis of headache disorders in primary care. We have also prepared patient feedback material and collected preliminary input from patients, but the main aim of this report is to invite comment and debate on the use of the questionnaire in real-life clinical practice. Methods: : This questionnaire was developed over 18 months using the clinical experience of the authors, current literature review and the International Classification of Headache Disorders (ICHD), 3 rd edition, for migraine, tension-type headache, cluster headache and medication-overuse headache. The questionnaire and two supporting documents will hopefully assist the GP to make a correct diagnosis. A patient survey was used to gather feedback from a small number of patients, and based on these comments, the questionnaire and the supporting documents were modified and updated. Results: : Feedback gathering was attempted in Austria, Germany, Switzerland, Ireland and Spain, but was only possible in Austria due to the COVID-19 pandemic restrictions. From the 18 patients who participated, 17 responded about how easy or difficult the questionnaire was to complete, with 14/17 (82%) being able to complete the questionnaire easily on their own. Overall, the patients found the questionnaire averagely helpful in reminding them of and communicating their headache triggers, symptoms and behaviour changes; on a scale of 1–5, with 1 being very helpful and 5 being not helpful at all, the mean scores were 2.8 and 2.7 (n=18), respectively. Conclusions: : This questionnaire and associated documents were developed with a view to helping GPs to make an accurate headache diagnosis quickly in primary care. Following feedback from patients, updates have been made, including changes to reduce the time it takes to complete the questionnaire. Next steps include wider validation and feedback from primary care physicians.

Telehealth as a new care delivery model: The headache provider experience.

OBJECTIVE: To assess telehealth practice for headache visits in the United States. BACKGROUND: The rapid roll out of telehealth during the COVID-19 pandemic impacted headache specialists. METHODS: American Headache Society (AHS) members were emailed an anonymous survey (9/9/20-10/12/20) to complete if they had logged ≥2 months or 50+ headache visits via telehealth. RESULTS: Out of 1348 members, 225 (16.7%) responded. Most were female (59.8%; 113/189). Median age was 47 (interquartile range [IQR] 37-57) (N = 154). The majority were MD/DOs (83.7%; 159/190) or NP/PAs (14.7%; 28/190), and most (65.1%; 123/189) were in academia. Years in practice were 0-3: 28; 4-10: 58; 11-20: 42; 20+: 61. Median number of telehealth visits was 120 (IQR 77.5-250) in the prior 3 months. Respondents were "comfortable/very comfortable" treating via telehealth (a) new patient with a chief complaint of headache (median, IQR 4 [3-5]); (b) follow-up for migraine (median, IQR 5 [5-5]); (c) follow-up for secondary headache (median, IQR 4 [3-4]). About half (51.1%; 97/190) offer urgent telehealth. Beyond being unable to perform procedures, top barriers were conducting parts of the neurologic exam (157/189), absence of vital signs (117/189), and socioeconomic/technologic barriers (91/189). Top positive attributes were patient convenience (185/190), reducing patient travel stress (172/190), patient cost reduction (151/190), flexibility with personal matters (128/190), patient comfort at home (114/190), and patient medications nearby (103/190). Only 21.3% (33/155) of providers said telehealth visit length differed from in-person visits, and 55.3% (105/190) believe that the no-show rate improved. On a 1-5 Likert scale, providers were "interested"/"very interested" in digitally prescribing headache apps (median 4, IQR 3-5) and "interested"/"very interested" in remotely monitoring patient symptoms (median 4, IQR 3-5). CONCLUSIONS: Respondents were comfortable treating patients with migraine via telehealth. They note positive attributes for patients and how access may be improved. Technology innovations (remote vital signs, digitally prescribing headache apps) and remote symptom monitoring are areas of interest and warrant future research.

New daily persistent headache after SARS-CoV-2 infection: a report of two cases.

BACKGROUND: The 2019 Coronavirus (SARS-CoV-2) is a novel respiratory virus which causes Coronavirus Disease19 (COVID-19). Although the predominant clinical picture of COVID-19 is represented by respiratory symptoms, neurological manifestations are being increasingly recognized. Headache, in particular migraine-like and tension types, has been largely reported in patients suffering from COVID-19 both in the acute and the healing phase of the infection. New daily persistent headache (NDPH) is a primary headache characterized by persistent and daily painful symptoms, with pain becoming continuous and non-remitting within 24 h, and lasting more than 3 months. Even though an increasing number of reports describe patients who develop a persistent headache, diagnosis of NPDH has been rarely explored in the context of COVID-19. METHODS: Two patients with persistent headache and Sars-CoV-2 infection were identified. Both underwent a full clinical and neuroradiological evaluation. Blood sample with inflammatory biomarkers search was also performed. RESULTS: According to International Classifications of Headache Disorders diagnosis of probable new daily persistent headache was made. The treatment with high doses of steroids was associated with relief of symptoms. CONCLUSIONS: Our report described two cases of probable NDPH due to SARS-CoV-2 infection. Clinical evaluation of COVID-19 patients presenting with persistent headache should take into consideration NDPH. Given the supposed major role for neuroinflammation in the genesis of Sars-CoV-2-driven NDPH, immunomodulatory therapy should be promptly started. In line with this hypothesis, we obtained a good therapeutic response to short-term high dose of corticosteroids.