Content summary

Operational impact of COVID-19

COVID-19 had a considerable impact on residency programmes within New York City due to nearly half of all residences testing positive for COVID-19 and 16.8% undergoing quarantine in the first month.
All fellowship programmes were disrupted, converting to video-precepting while the members underwent redeployment to other functions outside headache medicine.
Activities in all three aspects of the neurology department—clinical care, research and education—had to shift to accommodate the demands on the hospital by COVID-19.
For example, morning reports were carried out seven days a week, were more operational focused, involved a broader cross-section of departments and utilised Zoom technology.
Neurology residents performed a vital role in patient care during the peak of COVID-19 admissions.

Cases of secondary headache disorders associated with COVID-19 have been reported, including several cases with ophthalmoparesis reported in patients with critical illnesses.
One patient with COVID-19 reported a severe persistent cough that may have triggered an internal carotid artery dissection and another case resulted in cerebral venous thrombosis.
Cranial neuropathies have also been reported that typically feature ophthalmoparesis to varying degrees, alongside imagery that suggests viral inflammation is present.
COVID-19 has exposed care disparities across the region—NYC Department Of Health reported a higher incidence of COVID-19 infection but lower drug accessibility in communities of ethnic minorities.
In particular, these regions had limited access to migraine therapies.

The implementation of telemedicine using ‘Epic’ and ‘Doximity’ has worked successfully and enabled patient follow-up to continue.
Secondary headache evaluations have been challenging because patients have been hesitant to travel to the hospital due to risk of infection.
Swab procedures are now in place when patients come to the hospital for neuroimaging, lumbar puncture or CT myelography.
Studies demonstrate the benefits of using telemedicine in migraine management and highlight patients rate convenience highly.
Telemedicine results in shorter average visit times, which is of particular benefit in New York where people have to travel relatively far to visit a healthcare provider.

Headache associated with COVID-19 can be categorised into secondary and primary.
Secondary headache is comprised of headache attributed to systemic viral infection (ICHD-3), headache that appears later following infection and attributed to cytokine release syndrome, and headache due to other causes such as vascular, non-vascular.
Primary headache includes migraine triggered by COVID-19 itself, or by stress ‘let-down’ or a stressful life event that could lead to post-traumatic stress disorder (PTSD, and de novo headache disorder, such as new daily persistent headache emerging due to COVID-19.

Patients remain afraid to visit the hospital for appointments.
Questions have arisen regarding the use of acute treatments, such as triptans, ergotamines, and gepants, that could induce hypercoagulability in patients who have had COVID-19 quite recently.
Initial concerns were raised regarding non-steroidal anti-inflammatory drugs (NSAIDs) increasing the risk of severe COVID-19 infection, which were later confirmed as unfounded.
The feasibility of onabotulinumtox A injections has been a problem due to the viability of office visits.
Concerns about the use of angiotensin-converting enzyme (ACE) inhibitors /angiotensin receptor blockers (ARB) for hypertension or migraine increasing the risk of contracting COVID-19 were initially raised.
Hypercoagulability in relation to calcitonin gene-related peptide (CGRP)-targeting monoclonal antibodies (mAbs) has been questioned but the roll-out of eptinezumab treatment for migraine disorders has been impacted.
Those patients with status migrainosus who are taking steroids have been instructed to remain quarantined and reduce COVID-19 susceptibility.