Safety and efficacy of rimegepant orally disintegrating tablet for the acute treatment of migraine in China and South Korea: a phase 3, double-blind, randomised, placebo-controlled trial.

BACKGROUND: No acute treatments targeting calcitonin gene-related peptide (CGRP) have been approved for use in China or South Korea. We aimed to compare the efficacy and safety of rimegepant-an orally administered small molecule CGRP antagonist-with placebo in the acute treatment of migraine among adults in these countries. METHODS: This double-blind, randomised, placebo-controlled, multicentre phase 3 trial was done at 86 outpatient clinics at hospitals and academic medical centres (73 in China and 13 in South Korea). Participants were adults (≥18 years) with at least a 1-year history of migraine who had two to eight moderate or severe attacks per month and fewer than 15 headache days per month within the 3 months before the screening visit. Participants were randomly assigned (1:1) to 75 mg rimegepant or placebo to treat a single migraine attack of moderate or severe pain intensity. Randomisation was stratified by the use of preventive medication and by country. The allocation sequence was generated and implemented by study personnel using an interactive web-response system accessed online from each study centre. All participants, investigators, and the sponsor were masked to treatment assignment. The coprimary endpoints of freedom from pain and freedom from the most bothersome symptom (nausea, phonophobia, or photophobia) 2 h after dosing were assessed in the modified intention-to-treat (mITT) population (randomly assigned participants who took study medication for a migraine attack of moderate or severe pain intensity, and provided at least one efficacy datapoint after treatment) using Cochran-Mantel Haenszel tests. Safety was assessed in all participants who received rimegepant or placebo. The study is registered with ClinicalTrials.gov, number NCT04574362, and is completed. FINDINGS: 1431 participants were randomly assigned (716 [50%] to rimegepant and 715 [50%] to placebo). 668 (93%) participants in the rimegepant group and 674 (94%) participants in the placebo group received treatment. 1340 participants were included in the mITT analysis (666 [93%] in the rimegepant group and 674 [94%] in the placebo group). 2 h after dosing, rimegepant was superior to placebo for pain freedom (132 [20%] of 666 vs 72 [11%] of 674, risk difference 9·2, 95% CI 5·4-13·0; p<0·0001) and freedom from the most bothersome symptom (336 [50%] of 666 participants vs 241 [36%] of 674 participants, 14·8, 9·6-20·0; p<0·0001). The most common (≥1%) adverse events were protein in urine (8 [1%] of 668 participants in the rimepegant group vs 7 [1%] of 674 participants in the placebo group), nausea (7 [1%] of 668 vs 18 [3%] of 674), and urinary tract infection (5 [1%] of 668 vs 8 [1%] of 674). There were no rimegepant-related serious adverse events. INTERPRETATION: Among adults living in China or South Korea, a single dose of 75 mg rimegepant was effective for the acute treatment of migraine. Safety and tolerability were similar to placebo. Our findings suggest that rimegepant might be a useful new addition to the range of medications for the acute treatment of migraine in China and South Korea, but further studies are needed to support long-term efficacy and safety and to compare rimegepant with other medications for the acute treatment of migraine in this population. FUNDING: BioShin Limited. TRANSLATIONS: For the Chinese and Korean translations of the abstract see Supplementary Materials section.

Vestibular migraine: a manifestation of long COVID syndrome in children.

Long COVID-19 syndrome has been reported among children and adolescents following COVID-19 recovery. Among them, notable symptoms include myalgia, insomnia, loss of smell and headache. Yet, novel manifestations are being discovered daily. Herein, we report two cases of vestibular migraine post-COVID-19 involving two children who presented with vestibular migraine symptoms following COVID-19 infection and their management. Children post-COVID-19 should be thoroughly evaluated for vestibular migraine symptoms so they can be managed promptly. This is the first article to report vestibular migraine as a manifestation of long COVID-19 syndrome.

Reduced frequency of migraine attacks following coronavirus disease 2019: a case report.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 is a virus affecting different organs and causing a wide variety and severity of symptoms. Headache as well as loss of smell and taste are the most frequently reported neurological manifestations of coronavirus disease 2019 induced by severe acute respiratory syndrome coronavirus 2. Here we report on a patient with chronic migraine and medication overuse headache, who experienced remarkable mitigation of migraine following coronavirus disease 2019. CASE PRESENTATION: For many years prior to the severe acute respiratory syndrome coronavirus 2 infection, a 57-year-old Caucasian male suffered from very frequent migraine attacks and for control of headaches he had been taking triptans almost daily. In the 16-month period before the outbreak of coronavirus disease 2019, triptan was taken 98% of the days with only a 21-day prednisolone-supported triptan holiday, which, however, had no longer-lasting consequences on migraine frequency. Upon severe acute respiratory syndrome coronavirus 2 infection, the patient developed only mild symptoms including fever, fatigue, and headache. Directly following recovery from coronavirus disease 2019, the patient surprisingly experienced a period with largely reduced frequency and severity of migraine attacks. Indeed, during 80 days following coronavirus disease 2019, migraine as well as triptan usage were restricted to only 25% of the days, no longer fulfilling criteria of a chronic migraine and medication overuse headache. CONCLUSION: Severe acute respiratory syndrome coronavirus 2 infection might be capable of triggering mitigation of migraine.

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.

Triggers and clinical changes of childhood primary headache characteristics during COVID-19 pandemic lockdown.

OBJECTIVE: Children with primary headache are particularly vulnerable to the negative impacts of the pandemic due to factors like increased social isolation, disruption of sleep and impairment of healthy diet. We aimed to investigate the clinical changes and triggering factors for childhood primary headaches to demonstrate the impact of the pandemic lockdown. METHOD: Children aged between 60 months and 18 years with headache complaint attending the general outpatient clinic between December 2019 and December 2020 were included in the study. Patients were classified according to ICHD-3 regarding clinical and laboratory data. Primary headaches diagnosed before (December 2019-March 2020) and during the pandemic lockdown (April 2020-December 2020) were divided into two groups as migraine and tension-type headache (TTH). Clinical picture and triggering factors were compared between groups to illustrate the effect of the lockdown. RESULTS: The study included 612 subjects, with 463 patients (76%) classified in the primary headache group and 149 (24%) in the secondary headache group. Among the first group, 267 patients (58%) had migraine and 196 patients (42%) had TTH. Comparisons between before and during the pandemic lockdown showed significant increased frequency of TTH, but no difference in the frequency and duration of migraine. Both screen exposure and sleep pattern changes were found to be significantly increased in the TTH group during the pandemic lockdown. DISCUSSION: We found a significant increase in the attack frequency for TTH patients during the pandemic lockdown. Reduction in screen time is an important strategy in preventing primary headache attacks in children.

[Peripheral stimulation of the trigeminal nerve by nasopharyngeal swabbing as a possible trigger of migraine attacks]. / Estimulación periférica del nervio trigémino mediante frotis nasofaríngeo como posible desencadenante de migraña.

INTRODUCTION: The role of the central and peripheral nervous system in the generation of migraine is not well understood. Our aim was to determine whether peripheral trigeminal nerve stimuli, such as nasopharyngeal swabs, could trigger migraine attacks. SUBJECTS AND METHODS: A survey was sent to 658 doctors, nurses and medical students, asking about the presence of headache suggestive of migraine after carrying out a SARS-CoV-2 swab test, their previous history of migraine, and demographic and headache-related characteristics. Those who tested positive or had associated clinical signs and symptoms of COVID were excluded. RESULTS: A total of 377 people were recruited, 309 of whom were included in the sample. Forty-seven (15.2%) reported headache suggestive of migraine after the swab test and 42 (89.4%) of them had a previous history of migraine. The risk of developing migraine was higher in the subgroup of patients with a history of headache suggestive of migraine - odds ratio: 22.6 (95% confidence interval: 8.597-59.397); p < 0.001. No differences were found between the main characteristics of attacks suggestive of migraine before and after the swab test, except for a lower percentage of associated aura afterwards (42.8% vs. 26.1%; p = 0.016). Individuals with previous attacks suggestive of migraine with a frequency of more than two episodes per month had a higher risk of developing a headache suggestive of migraine after the test - odds ratio = 2.353 (95% confidence interval: 1.077-5.145); p = 0.03. CONCLUSIONS: Nasopharyngeal swabbing may trigger migraine attacks, with a greater likelihood in individuals with a higher frequency of previous migraines. This would confirm the idea that peripheral stimuli on the trigeminal nerve can trigger migraine attacks in individuals with migraine, according to their degree of trigeminovascular sensitisation.

TITLE: Estimulación periférica del nervio trigémino mediante frotis nasofaríngeo como posible desencadenante de migraña.Introducción. La implicación del sistema nervioso central y periférico en la generación de la migraña no se conoce bien. Nuestro objetivo fue determinar si estímulos periféricos sobre el nervio trigémino, como el frotis nasofaríngeo, podrían desencadenar ataques de migraña. Sujetos y métodos. Se envió una encuesta a 658 médicos, enfermeras y estudiantes de medicina, preguntando por la presencia de cefalea sugestiva de migraña tras la realización de un frotis para la determinación del SARS-CoV-2, su historia previa de migraña, y sobre características demográficas y relacionadas con la cefalea. Los que tenían resultado positivo o que asociaban sintomatología de COVID fueron excluidos. Resultados. Se reclutó a 377 personas y se incluyó a 309. Cuarenta y siete (15,2%) refirieron cefalea sugestiva de migraña tras la realización del frotis, de las cuales 42 (89,4%) tenían historia previa de migraña. El riesgo de desarrollarla fue mayor en el subgrupo de pacientes con cefalea sugestiva de migraña previa ­razón de probabilidad: 22,6 (intervalo de confianza al 95%: 8,597-59,397); p < 0,001­. No hubo diferencias entre las características principales de los ataques sugestivos de migraña previos y los desencadenados tras la prueba, excepto un porcentaje menor de aura asociada tras el frotis (42,8% frente a 26,1%; p = 0,016). Los individuos con ataques sugestivos de migraña previos con frecuencia superior a dos episodios mensuales presentaron mayor riesgo de desarrollar una cefalea sugestiva de migraña tras el test ­razón de probabilidad = 2,353 (intervalo de confianza al 95%: 1,077-5,145); p = 0,03­. Conclusiones. El frotis nasofaríngeo podría desencadenar ataques de migraña, más probablemente en individuos con mayor frecuencia de migrañas previas. Esto confirmaría que estímulos periféricos sobre el nervio trigémino pueden desencadenar ataques de migraña en individuos con migraña, de acuerdo con su grado de sensibilización trigeminovascular.

Post-COVID Headache: A Literature Review.

PURPOSE OF REVIEW: Post-COVID headache may be unique in presentation and mechanism, often presenting as a new phenotype in patients with a history of a primary headache disorder or resulting in a new headache syndrome in those without history of headache. This review presents a description of the literature published focused on post-COVID headache. Additionally, we discuss potential mechanisms and considerations for treatment of post-COVID headache. RECENT FINDINGS: Headache is one of the most common symptoms of COVID. Common characteristics are revealed when reviewing the phenotypes of headaches that have been described in patients with COVID-19, with most headache phenotypes resembling migraine and new persistent daily headache. Post-COVID headaches are often described as moderate to severe, persistent, and treatment refractory. This review highlights the diversity of presentation of headaches that present as a complication of COVID-19. Treatment of post-COVID headache is challenging, especially in the setting of a pandemic where resources are limited. CLINICAL CASE: A 42-year-old woman with a history of episodic migraine without aura presents over video visit with a new headache type. Her typical headaches are predominantly left sided, throbbing in nature, and associated with photophobia and phonophobia. They are fully relieved by oral sumatriptan 2 h after treatment. She describes this new headache as a constant, pulsating, holocephalic pain with no other migrainous features that have been ongoing for 6 weeks. She notes that the headache has been persistent since that time. She has tried over-the-counter acetaminophen and ibuprofen and her typical migraine abortive therapy without relief. She is debilitated and wonders if there is anything that will take the pain away. She shares that she tested positive for COVID-19 about 2 days prior to headache onset and has associated rhinorrhea, anosmia, and ageusia.

Amitriptyline for post-COVID headache: effectiveness, tolerability, and response predictors.

BACKGROUND: Headache is one of the most frequently reported symptoms in post-COVID patients. The clinical phenotype of COVID-19 headache combines phenotypic features of both tension-type headache (TTH) and migraine. We aimed to assess the effectiveness, side effects and predictors of amitriptyline (AMT) response in a real-world study setting. METHODS: We performed an observational multicentric study with a retrospective cohort. All consecutive patients with confirmed COVID-19 infection who received AMT for post-COVID headache from March 2020 to May 2021 were included. Response was evaluated by the reduction in the number of headache days per month (HDM) between weeks 8 and 12, compared with the baseline. We explored which variables were associated with a higher probability of response to AMT. RESULTS: Forty-eight patients were eligible for the study, 40/48 (83.3%) females, aged 46.85 (SD: 13.59) years. Patients had history of migraine 15/48 (31.3%) or TTH 5/48 (10.4%). The mean reduction of HDM was 9.6 (SD: 10.9; 95% CI 6.5, 12.7) days. Only 2/48 (5%) of patients discontinued AMT due to poor tolerability. History of TTH (10.9, 95% CI 1.3, 20.6) and nausea (- 8.5, 95% CI - 14.6, - 2.5) were associated with AMT response. CONCLUSIONS: This study provides real-world evidence of the potential benefit of AMT in patients with post-COVID-19 headache, especially in patients with history of TTH and without concomitant nausea.

Protracted headache after COVID-19: A case series of 31 patients from a tertiary headache center.

BACKGROUND: Headache can be a prominent feature of Post-Acute Sequelae of SARS-Cov2 infection (PASC) and previous studies have centered around PASC headaches that have resolved within a month of infection. METHODS: We performed a retrospective chart review of 31 adults evaluated at the Stanford Headache Clinic between September 2020 and January 2022 who developed new or worsening headaches after COVID-19 infection that were unresolved at time of evaluation for demographics, medical history, and headache diagnosis. RESULTS: Headache had been present for a mean duration of 7.4±4.8 months after infection. Notably, 25/31 (81%) had a previous history of headache. The specific features of the headache varied considerably, but 23/31 (74%) met International Classification of Headache Disorders, Third Edition (ICHD-3) criteria for migraine, with 20/31 (65%) meeting ICHD-3 criteria for chronic migraine, while only 5/31 (16%) met these criteria before COVID infection. Additionally, full-time employment decreased from 25/31 (81%) to 17/31 (55%). Prior to establishing care at our clinic, 13/18 (72%) of the patients who were started on preventive medications currently indicated for migraine management, reported a decrease in frequency and/or severity of headaches. CONCLUSIONS: Our study presents a group of patients with protracted headache after COVID-19 infection that includes both patients with a previously lower headache burden who largely exhibited chronification from episodic to chronic migraine, as well as patients with no previous history of headache who meet ICHD-3 criteria for headache attributed to a systemic viral illness, mostly with a migrainous phenotype.

Prevalence of migraine headaches and their impact on the academic performance of Sudanese medical students using ID-Migraine test as a screening tool: A cross-sectional study.

BACKGROUND: Migraine-and episodic headache-is one of the most common types of primary headache. Migraine is considered a serious health problem that affects the quality of life. During university life, students often report increased levels of stress, depression, anxiety, and irregular sleep, all of which are associated with migraines. Our aim was to determine the prevalence of migraine headaches among medical campus students at the University of Khartoum, Sudan. Based on available data, migraine is on the rise in both general populations as well as in university students. METHODS: This is a cross-sectional study. The study population was composed of students registered to the Faculty of Medicine, Dentistry, and Pharmacy at Khartoum University in the academic years of 2020-2021. Out of these, 318 of them accepted to participate. Participants who had two or more headaches in the last 3 months formed the headache group. Afterwards, two preliminary questions were applied to the headache group and participants with at least one affirmative response were asked to perform the validated ID-Migraine™ test. RESULTS: The mean age of 318 students participating in the study was 19.23 ± 1.84 (17-39 years), with adolescents:adult ratio being 2.5:1. A total of 1613 students (43.7%) had at least two headaches in the last 3 months. Migraine-type headache was detected in 266 subjects (7.2%) based on the ID-Migraine™ test. Of the migraine group, 72 were male (27.1%) and 194 were female (72.9%). There was no significant difference in migraine prevalence between adolescent and adult age groups. CONCLUSIONS: With prevalence similar to adults, primary care physicians should be aware of the probability of migraine headaches in university students in order to maintain a successful school performance.

Impact of the COVID-19 pandemic on people living with migraine: Results of the MiCOAS qualitative study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic is an ongoing global health crisis that has had a range of impacts on people living with migraine. METHODS: Qualitative interviews performed as part of the Migraine Clinical Outcome Assessment System project, a multi-stage Food and Drug Administration-grant funded program to develop a patient-centered core set of outcome measures for use in migraine clinical trials, offered an opportunity to explore the experience of living with migraine during the pandemic as well as to examine whether migraine treatment priorities, symptoms, and associated disability changed due to the pandemic. Semi-structured interviews were conducted in the United States between the summer and fall of 2020 with 40 individuals with self-reported, medically diagnosed migraine who self-reported that they had not tested positive for or been diagnosed with COVID-19. RESULTS: Seventy percent (n = 28) of the sample reported ≥1 pandemic-related impact on their life with migraine. Fourteen participants reported both positive and negative impacts, twelve reported negative impacts only, and two reported positive impacts only. Among those reporting ≥1 pandemic-related impact, nine participants (32%) reported more frequent and five (17%) reported less frequent migraine attacks. Other negative impacts included interrupted medical care (n = 9; 32%), and greater stress (n = 13; 46%). The most frequent positive impact reported was greater access to health care (n = 8; 29%). Ictal and interictal symptoms were not noted to change due to the pandemic, but some respondents reported less disability due to increased flexibility of schedules and reduced expectations. Treatment priorities did not change due to the pandemic. CONCLUSION: The global COVID-19 pandemic has resulted in both negative and positive impacts for people living with migraine. Lessons to be considered when moving into a post-pandemic world include benefits of and satisfaction with telehealth and the benefits and importance of healthy lifestyle habits and flexibility such as improved sleep, reduced stress, and fewer social expectations.

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.

The unusual course of a migraine attack during COVID-19 infection - Case studies of three patients.

The effect of the coronavirus disease 2019 (COVID-19) on the nervous system remains undefined. Some studies have shown that headache is one of the most common symptoms and often the first neurological symptom in patients with confirmed infection. There are only a few reports concerning the effects of COVID-19 on the course of migraine. This article investigates three female patients with prolonged history of migraine, in which atypical phenomenology and course of migraine attacks were observed during COVID-19 infection.

Migraine Monitoring in the Time of COVID-19: Triggers and Protectors During a Pandemic.

OBJECTIVE: Aim of the present observational study was to assess the impact of coronavirus disease 2019 (COVID-19) quarantine on migraine and evaluate potential influencing factors. Previous studies reported mixed results regarding clinical outcome during quarantine in patients with migraine. In particular, data from areas strongly affected by COVID-19 pandemic are missing. METHODS: One hundred and seventy patients, previously assessed at the Headache Centre-ASST Spedali Civili Brescia, underwent a telephonic interview regarding migraine features and clinical, occupational, and lifestyle variables. RESULTS: Compared to baseline, during quarantine, we found a significant overall reduction in migraine days (14.7 ± 0.6 vs 12.3 ± 0.7, P < .001), with 47.1% patients reporting a clinical improvement. Outdoor living spaces (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.7-3.07, P = .009), a positive attitude throughout quarantine (OR 4.12, 95% CI 2.3-7.1, P = 0.03), working full-time (OR 1.03, 95% CI 0.5-1.9, P < .001) and a baseline diagnosis of chronic migraine (OR 1.4, 95% CI 1.1-2.02, P = 0.002) were associated with an increased chance of migraine improvement. Being single (OR 1.5, 95% CI 1.1-2.01, P = .05) and physical inactivity (OR 1.3, 95% CI 1.1-1.6, P = .02) were associated with an increased risk of worsening. CONCLUSIONS: Quarantine had an overall positive impact on migraine. Based on our results, we hypothesize the reduction of daily hassles and challenges might be the main reason for such improvement.

Effect of lockdown during COVID-19 on migraine: A longitudinal cohort study.

BACKGROUND: The objective of this study was to assess whether migraine-related outcomes changed during intelligent lockdown when compared with the prior period. METHODS: This was a cohort study evaluating the first month of intelligent lockdown in the Netherlands (12 March to 8 April 2020) compared with one baseline month (13 February to 11 March 2020). We identified 870 migraine patients treated at the Leiden Headache Center with headache e-diaries during the period of interest. Adherence to the e-diary had to be ≥80%, yielding 592 enrolled patients. RESULTS: Intelligent lockdown led to a decrease in monthly migraine days (-0.48; 95% CI: -0.78 to -0.18, p = 0.002) and acute medication days (-0.48; 95% CI: -0.76 to -0.20, p < 0.001), and an increase in general well-being (0.11; 95% CI: 0.06 to 0.17, p < 0.001). No differences in non-migrainous headache days and pain coping were observed. Consistent results were found in a subset that was followed for 4 months. CONCLUSIONS: Our findings imply that intelligent lockdown measures can improve migraine disability despite of the potential negative effects of COVID-19 and lockdown. We hypothesise that this effect is a combined result of working from home, scaling down demanding social lives, and freedom to choose how to organise one's time.

Hospital-based headache care during the Covid-19 pandemic in Denmark and Norway.

BACKGROUND: The Covid-19 pandemic is causing changes in delivery of medical care worldwide. It is not known how the management of headache patients was affected by the lockdown during the pandemic. The aim of the present study was to investigate how the initial phase of the Covid-19 pandemic affected the hospital management of headache in Denmark and Norway. METHODS: All neurological departments in Denmark (n = 14) and Norway (n = 18) were invited to a questionnaire survey. The study focused on the lockdown and all questions were answered in regard to the period between March 12th and April 15th, 2020. RESULTS: The responder rate was 91% (29/32). Of the neurological departments 86% changed their headache practice during the lockdown. The most common change was a shift to more telephone consultations (86%). Video consultations were offered by 45%. The number of new headache referrals decreased. Only 36% administered botulinum toxin A treatment according to usual schemes. Sixty% reported that fewer patients were admitted for in-hospital emergency diagnostics and treatment. Among departments conducting headache research 57% had to halt ongoing projects. Overall, 54% reported that the standard of care was worse for headache patients during the pandemic. CONCLUSION: Hospital-based headache care and research was impacted in Denmark and Norway during the initial phase of the Covid-19-pandemic.

Case Series of Headache Characteristics in COVID-19: Headache Can Be an Isolated Symptom.

Headache was reported in up to one-third of the hospitalized patients; yet, the clinical characteristics of headache associated with coronavirus disease 2019 (COVID-19) have not been defined. This observational case study included patients who were consulted to headache unit due to headache and had COVID-19 illness. Headache features in 13 PCR-confirmed COVID-19 patients with mild symptoms were reported. Headache was the isolated symptom of the COVID-19 in 3 patients and emerged as an early symptom during the disease course in all patients. Patients specified severe, rapid onset, unrelenting headache with migraine-like features, as well as unusual sensory symptoms such as anosmia, and gastrointestinal symptoms such as diarrhea and loss of appetite and weight. Headache lasted up to 3 days in 70% of the patients and resolved in all patients within 2 weeks. Despite the fact that most of the patients were female and headache characteristics were suggestive of migraine, majority of patients were not suffering from primary headaches. It was concluded that headache could be an isolated symptom of COVID-19, which might possibly be ignored in asymptomatic patients. Headaches associated with COVID-19 included features resembling migraine and/or atypical symptoms including anosmia and diarrhea.

Headache as the Presenting Symptom in 2 Patients With COVID-19 and a History of Migraine: 2 Case Reports.

The coronavirus disease 2019 (COVID-19) pandemic has now affected more than 5 million people globally. Typical symptoms include fever, cough, and shortness of breath. Patients with underlying medical comorbidities such as cardiovascular disease and diabetes are more likely to become severely ill. To date there is limited information on how COVID-19 affects patients with a history migraine. Here, we present the cases of 2 women with a history of migraine whose first symptom of COVID-19 was a severe persistent headache.

Delay in OnabotulinumtoxinA Treatment During the COVID-19 Pandemic-Perspectives from a Virus Hotspot.

The COVID-19 pandemic has undoubtedly changed our practice of medicine. With our collective resources and attention focused on caring for those afflicted with the disease, other medical conditions have temporarily but understandably faced constraint. For migraine patients who often require in-person visits for infusions and procedures, this has become particularly challenging. Here, we share our experience in navigating this exigency amidst a local surge of COVID-19.