“The COVID-19 pandemic has led to extremely unusual circumstances, altering people’s behavior, including that of patients with migraine,” explains Gisela M. Terwindt, MD, PhD. “Genetic predisposition to migraine and hormonal influences contribute to a lower internal threshold for neuronal excitability, while external trigger factors may cause patients with migraine to tip over this threshold, and therefore, precipitate an attack. The course of migraine attacks may, therefore, be modified by lifestyle and behavioral factors, especially during lockdown.”

For a paper published in Cephalalgia, Dr. Terwindt, Iris E. Verhagen, MD, and colleagues assessed whether migraine-related outcomes changed during “intelligent lockdown” when compared with the period prior to the pandemic. An intelligent, or targeted, lockdown, she explains, seeks to mitigate social, economic, and psychological costs of social isolation and make the eventual return to normality more manageable. “The Netherlands adopted an intelligent lockdown in March 2020, which included schools, sports clubs, restaurants, and businesses dependent on physical contact,” she says. “Our team recently developed a headache e-diary, which enabled us to observe whether these lockdown measures influenced migraine in patients.”

Lockdown Positively Impacts Migraine-Specific Outcomes

The researchers identified 870 patients with migraine being treated at a headache center who kept time-locked headache e-diaries during from March 12, 2020, to April 8, 2020. Adherence of 80% or greater to the e-diary yielded 592 patients. “An automatic algorithm based on the International Classification of Headache Disorders (ICHD-3) criteria calculated for each day whether it was a headache or a migraine day,” Dr. Verhagen says. “We used the e-diary data to examine the change between baseline and lockdown in number of monthly migraine days and headache days, pain coping, and general well-being.”

The study team’s findings indicate that intelligent lockdowns positively impact migraine-specific outcome measures and general well-being, according to Dr. Terwindt. “We assume that this is a combined result of working from home, scaling down demanding social lives, and freedom to choose how to organize one’s time,” she explains. “Under less stressful circumstances, these benefits may be even greater.” In looking at migraine-related outcomes for 56 days prior to baseline and 56 days after lockdown, observed differences were modest. “However, the results we discovered in this extended analysis were consistent with the results from our primary analysis,” says Dr. Terwindt (Table). “Despite some of these treatment measures having negative impacts at first—such as withdrawal of acute medication overuse or tapering down prophylactic treatment before starting other prophylactics—we were still able to show an overall positive effect of lockdown.”

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More Freedom to Organize Time

Dr. Terwindt presumes that patients with migraine could benefit from more freedom to organize their time, even post-pandemic. “Headache e-diaries are a useful telemedicine tool that can be used by physicians in clinical practice to help monitor the course of their patients’ disease,” she says. “Registering headache symptoms may also lead to recognition of lifestyle habits that have a negative effect on migraine.”

With the lockdowns coming unexpectedly, the researchers were not able to assess the presence of each possible contributing factor. “The lockdown has led to multiple changes,” says Dr. Verhagen. “Some of those changes may possibly decrease the susceptibility to a migraine attack, and some may increase it. For many patients, lockdown may increase feelings of stress, anxiety, and insecurity about health, employment, or one’s financial situation. In addition, closing of sports clubs and limiting outdoor activities could induce weight gain and have a negative impact on mood. In the long term, these factors may worsen migraine. “

Drs. Verhagen and colleagues express the need for future research addressing which individual factors are responsible for the overall positive results of lockdown on migraine they observed, and to what extent lifestyle changes can impact migraine in more ideal circumstances.