COVID-19 and Migraine: How Does The SARS-CoV-2 Coronavirus Affect Chronic Migraine Sufferers?

Besides anosmia (losing the sense of smell), headache pain is one of the most prominent symptoms of Coronavirus Disease 2019 (COVID-19). For people living with chronic migraine, it may be hard to tell if a migraine episode is brought on by COVID-19 or not, especially if they are not longtime migraine warriors. 

It is, therefore, not surprising that most headache sufferers share the same concern: Is my headache COVID-19? 

Many long-term migraineurs might not be able to tell the difference when the symptoms start, even if a headache brought on by COVID-19 presents differently than a migraine. Don’t worry! The Migraine Buddy community is here to help shed light on this topic.

Keep reading to find out how to evaluate your headache symptoms and determine if you are dealing with COVID-19, migraine episode, or other headache types.

You will also learn if migraineurs are at an increased risk of COVID-19, and how the pandemic affects migraine management. Finally, we will be sharing relevant medical information concerning vaccine recommendations for people living with migraines. 

Armed with all this knowledge, we hope you will be in a better position to go through the COVID-19 pandemic. So, let’s start!

Getting COVID-19: SARS-CoV-2 Impact on Migraine

This section aims to answer numerous questions that trouble migraineurs, such as how to tell if a symptom is due to migraine-related headaches or those caused by SARS-CoV-2, and how the pandemic influences headaches in general.

What type of headache does COVID-19 cause, and how does it compare to migraine?

Before we start exploring how COVID-19 affects migraine warriors, it is helpful to distinguish a headache pain caused by SARS-CoV-2 from those caused by migraine. The main difference is the types of symptoms that accompany headache pain. If your headache comes with fever, trouble with breathing, persistent coughing, and a squeezing sensation in your head, that could be signs that you could be dealing with COVID-19. 

Based on the current public health information, there are various mechanisms that cause headache in COVID-19. The stinging sensation we mentioned is usually a result of your immune system fending off the SARS-CoV-2 virus by releasing chemicals called cytokines. In turn, cytokines cause inflammation that can be perceived as pain signals in the cerebral cortex of the brain.

Persistent headaches in patients with COVID-19 can also be caused by the infection of the central nervous system (brain, spinal cord). These could result in aseptic meningitis, a severe illness that requires immediate medical care.

Headaches experienced by COVID-19 patients can be brought on by coughing as well, especially during the first days of the disease. 

In addition, SARS-CoV-2 can trigger a headache via the trigeminal nerves in two different ways:

• direct infection of trigeminal nerve endings
• damage to blood vessels that stimulates trigeminal nerve endings, systemic inflammation, and loss of the sense of smell and taste

Over time, SARS-CoV-2 infection may cause lung damage that can reduce oxygen levels sent to the central nervous system, which causes new headaches. 

Of course, it will take more time and research to fully understand all the mechanisms underlying headache due to SARS-CoV-2. From the published research, we know that the prevalence of headaches was examined in two different studies examining health care workers diagnosed with COVID-19 in China and the Netherlands. In China, 53.33% (16/30 patients) reported experiencing a headache, with similar results in the Netherlands – 71.1% (64/90 patients).

While there are a few studies on the prevalence of headache among COVID-19 patients, data regarding headache characteristics is limited. In a cross‐sectional study of 112 healthcare professionals diagnosed with COVID-19 and headache, 46% of patients reported having hemicranial pain (pain in one side of the head), 42.5% had holocranial pain (pain can be felt around the head), and 17.7% of patients reported occipital headaches (pain in the back of the head). In this study, most patients (80.4%) described their headache as having a pressing quality, 10.7% of patients experienced stabbing pain, and 7.1% reported pulsating sensation. 

What about migraine headaches? 

Migraine episodes share some symptoms as headaches caused by COVID-19, including:

1. Pain frequently affecting only one side of the head
2. Pulsating or throbbing pain that can be moderate or severe
3. Sensitivity to light and noise
4. Vomitting

In addition to these symptoms, many patients may experience a migraine hangover (also called postdrome), where the pain lasts from eight to fourteen hours, with brain fog or cognitive clouding after the pain has resolved.

Other symptoms that can linger are:

1. lethargy (lack of energy)
2. feeling irritable
3. light sensitivity 
4. nausea

It can take a few days for the episode to finally end, even with the proper treatment.  The whole process and symptom management can put a lot of stress on migraineurs and their family members. 

We still do not know everything about the underlying mechanisms, but it is generally believed that severe migraines involve the nerves and blood vessels of the brain. These headaches have long been considered to be a vascular disorder, mostly due to the throbbing nature of the pain.

Still, only about a third of patients experience throbbing pain and thus vascular changes cannot be considered as the underlying mechanisms for all migraine headaches. The pathophysiology of migraines is much more complex.  

Do migraine headaches occur more frequently or become worse since the COVID-19 pandemic began? 

If you answered Yes, you are not alone. Numerous adult patients suffering from frequent migraine attacks have complained of getting more migraine headaches since the pandemic started.

Migraineurs found that the current COVID-19 situation has not only increased their headache frequency, but also made it more challenging to manage migraines. In a CNN report, Dr. Rachel Colman, Director of the Low-Pressure Headache Program at Mount Sinai in New York, revealed that his patients are complaining of getting more headaches during the COVID-19 pandemic. 

What triggers these migraine attacks?

Dr. Colman explains that migraine headaches are mostly triggered by people being worried and stressed. Dr. Seymour Diamond, President and Managing Director of Chicago’s Diamond Headache Clinic, agrees and believes that the reason for more frequent attacks lies in the fact that the difference between our home and workplace is blurred. 

Working from home prevents people from switching off their work mode, and people who live with migraines are more sensitive to such lifestyle alterations, since their nervous system is already sensitized to abrupt changes.

Unfortunately, the pandemic places many restrictions on the things we are used to doing. We lack normal physical activity, hydration, and do not have enough sleep – any of these can trigger migraine and make managing migraine more difficult. A healthy lifestyle has become secondary to COVID-19 prevention. Increased stress levels only add fuel to the fire. 

Migraine Buddy Research: Survey Results

Peer-Reviewed Publication

To help better understand how COVID-19 has impacted migraine managment, the Migraine Buddy community has generously helped with our real-world research. We have conducted two surveys and collected valuable data from our users.

Survey One – Impact of COVID-19 on Migraine Symptoms

Healint sent out a survey to help us understand whether COVID-19 had an impact on managing migraine headaches. Questionnaires were sent to users and we had enough respondents in just three week to start data analysis. A whooping 3,264 users responded to the survey, with 91.1%  of them being women. 68.1% of the respondents are from the USA while half of them (52.3%) were in the 35-54 age range.

What does the results reveal?

Overall, 28.9% of respondents declared that SARS-CoV-2 infection worsened their migraine episodes. This effect lingered for up to six months after the diagnosis or first symptoms manifested. 

87.3% of respondents experienced more frequent attacks, while 49.3% noticed increased pain intensity. Half of the respondents also reported other symptoms of migraine.

These result are in sync with two registry study publications published this April in the Lancet Psychiatry and  PLoS One journals. 

The first study reported that unlike patients with common influenza, COVID-19 patients experienced worsening of a number of psychiatric and neurological conditions, especially over time. The authors of the second paper concluded that SARSCoV2 can induce neurological complications, even in patients without a preexisting condition.

Now, all studies have some limitations, although the fact that the results share many similarities provide strong justification to the concerns regarding the consequences of COVID-19 on migraine patients.

The prevailing opinion supported by research institutions suggests that vaccination should be conducted as soon as possible. This would reduce the number of infection and thus benefit public health, but it would also help resume many clinical studies in the CNS field that have been put on hold.

Fears of COVID-19 vaccines

Long-term control of the COVID-19 pandemic depends on comprehensive preventive vaccination. Sadly, some refuse vaccines due to concerns over their safety and efficiency.  Reluctance to getting vaccinated against COVID-19 is a problem many countries share. 

What about our respondents?

At the time of survey collection, 45.1% of our respondents have not yet been vaccinated. The majority of them (70%) stated that they have not had the opportunity to do it yet. 18.9% considered that they needed more data to reach the decision. Some refuse to take the COVID-19 vaccine, while others have medical reasons, or are pregnant, or breastfeeding. 

So how can vaccine hesitancy be best addressed?

Evidence-based communication with reluctant patients is the best way to foster vaccine confidence and overcome this issue. We will discuss this in a moment, as soon as we analyze the results of the second survey we have conducted, so keep on reading.

Survey Two – COVID-19 Impact on Migraine Management

The second survey that Migraine Buddy conducted is a qualitative survey about stress and how the pandemic affects migraine symptoms management. We had 1,975 responses!

37% of respondents found it more difficult to maintain a migraine-friendly diet during the COVID-19 pandemic, while 26% of them could not access medical care or even emergency department when needed. 

About a third of respondents were forced to cancel their appointments, and 20.7% of them felt they had decreased access to medications.

30% of surveyed people (30%) also noticed that the number of migraine days has increased significantly. 

What is the main source of stress during the COVID-19 pandemic?

From the respondents:

• 55% of them chose social isolation
• 48% of respondents thought they had been exposed to information overdose
• 43% stated their stress was linked to financial concerns
• 41% of respondents found it difficult to access essentials

COVID-19 Vaccine: Recommendations for Migraineurs

We can finally look forward to a brighter future thanks to the vaccines. As COVID-19 vaccination work advances all over the globe, we can slowly regain control over our lives. 

As we have already concluded, chronic migraine sufferers found the pandemic extra challenging. The added stress and uncertainty have only worsened their painful condition.

The COVID-19 pandemic has raised questions about whether vaccines have an effect on managing migraines and other types of headaches. The main concerns are:

• Will migraine treatment interfere with the efficacy or safety of the COVID-19 vaccine?
• Will the COVID-19 vaccine reduce the effectiveness of migraine treatments?

The American Headache Society suggests that the importance of preventing COVID-19 is imperative. There are too many COVID-19 related risk factors to delay vaccination. Besides, migraine prevention therapy is highly efficient and there is no point to avoid COVID-19 vaccine for the sake of it.

Should you continue your migraine treatment?

There is no risk of contraindications if you continue using NSAIDs or acetaminophen after the vaccine. On the other hand, the CDC recommends that you should not use NSAIDs or acetaminophen routinely before the COVID-19 vaccination, especially if you use them as prevention.

As always, you should discussed your decision in detail with a healthcare professional.

What about the OnabotulinumtoxinA (Botox) injections and monoclonal antibodies to prevent migraine?

There is no evidence that OnabotulinumtoxinA reduces your immune response to any of the COVID-19 vaccines.

Similarly, clinical trials conducted thus far do not indicate that the monoclonal antibodies (Aimovig, Ajovy, Emgality, Vyepti) are either immunosuppressive or myelosuppressive. Thus, there is no reason to think that they would reduce your immune response to COVID-19 vaccines.

The same goes for the COVID-19 vaccines affecting the effectiveness of migraine preventives – nothing suggests that antibodies generated by the vaccines would eliminate onabotulinumtoxinA or antibodies to CGRP or its receptor. Therefore, there is no need to alter the timing of your treatments if you worry the vaccine would impair their effectiveness.

FAQ: COVID-19 and Migraine

Q: Do chronic migraineurs need to consult a doctor before the COVID-19 vaccination?

A: Yes, everyone should discuss the COVID-19 vaccine with their doctor. In most cases, the risk factors related to COVID-19 infection outweigh the potential risks of the vaccine. Still, it would be wise to discuss your vaccination with the migraine specialist or neurologist.

Q: Will the COVID-19 vaccines interact with monoclonal antibody treatments? 

A: No, even though not all the vaccines were specifically studied, the trials conducted so far (Pfizer, Moderna) shows that there are no adverse interactions with monoclonal antibody treatments. If you or your doctor have some concerns, you can discuss pausing the migraine monoclonal antibody treatment for three weeks while you get vaccinated.

Q: Will the COVID-19 vaccines interact with OnabotulinumtoxinA (Botox)?

A: There is no medical evidence that would suggest the patients using the Botox treatments are at higher risk of adverse reactions to the COVID-19 vaccine.

Q: Are people who are suspectible to migraines have a higher risk of having new headaches as a side effect of the COVID-19 vaccine? 

A: The most prominent side effects of the COVID-19 vaccine usually occur during the first 36 hours after vaccination. Chronic migraineurs are likely to experience new headaches during this period, too. 

Q: Can you use pain relievers after COVID-19 vaccination?

A: It depends on what pain relievers you use. Tylenol or NSAIDs, such as ibuprofen or naproxen, should be avoided since they could hinder the immune response required for generating antibodies from the vaccine. If you use Triptans, you are safe.

References

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675458/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7513457/
https://americanheadachesociety.org/wp-content/uploads/2018/05/NAP_for_Web_-_Pathophysiology_of_Migraine.pdf
https://edition.cnn.com/2020/06/22/health/migraines-covid-19-headache-wellness/index.html
https://americanheadachesociety.org/news/research-summary-migraine-treatment-and-covid-19-vaccines-no-cause-for-concern/
https://americanmigrainefoundation.org/resource-library/questions-about-the-covid-19-vaccines-for-people-living-with-migraine/
https://www.healthcarevaluehub.org/advocate-resources/publications/telemedicine-decreasing-barriers-and-increasing-access-healthcare