COVID-19 and Headache: The New York Experience

Matthew S. Robbins, MD, FAHS

AHSAM 2020 - Oral session
Published on July 17, 2020


Key messages

  • New York has emerged as an epicentre of the COVID-19 pandemic, which has led to an operational shift in headache and neurological care in New York hospitals.
  • A number of primary and secondary headache disorders may be encountered in association with COVID-19, triggered either directly or indirectly, to biological or psychological mechanisms.
  • Clinicians face challenges with regards to headache disorders diagnostics and therapies, which they must overcome in their daily practice.

Key messages

  • New York has emerged as an epicentre of the COVID-19 pandemic, which has led to an operational shift in headache and neurological care in New York hospitals.
  • A number of primary and secondary headache disorders may be encountered in association with COVID-19, triggered either directly or indirectly, to biological or psychological mechanisms.
  • Clinicians face challenges with regards to headache disorders diagnostics and therapies, which they must overcome in their daily practice.

Background

  • New York state has been severely affected by COVID-19 with 364,745 cases and 28,900 deaths reported as of May 24 2020.
  • At the Weill Cornell Hospital, during the peak of the outbreak in April, 477 patients had been admitted with COVID-19, 230 patients were in intensive care.
  • Several papers have been published on the New York clinical experience of COVID-19, including details of patient characteristics and neurological impact.1,2

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.

Emerging clinical phenomenology of headache and COVID-19

  • 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.

Headache care

  • 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 surrounding COVID-19

  • 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.

Headache therapy challenges in 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.

Conclusions

  • COVID-19 has impacted headache and neurological care in New York in a variety of ways, including a shift in staffing, educational strategies, and an abrupt transformation to telemedicine.
  • A number of primary and secondary headache disorders may be encountered in association with COVID-19.
  • Migraine may be triggered by COVID-19 either directly or indirectly, related to biological or psychological mechanisms.
  • Clinicians face a number of therapy challenges such as patient fear to frequent hospitals and concerns regarding the use of migraine medicine.

This is a highlights summary of an oral session given at the AHSAM 2020 Virtual Annual Scientific Meeting and presented by:

Matthew S. Robbins, MD, FAHS
Associate Professor of Neurology, Neurology Residency Program Director
Weill Cornell Medicine
New York, New York

The content is produced by Infomedica, the official reporting partner of ASHAM 2020 Virtual Annual Scientific Meeting. The summary text was drafted by Goldcrest Medical Writing, reviewed by Marco Vercellino, MD, an independent external expert, and approved by Jessica Ailani, MD, FAHS and Mark J. Burish, MD, PhD, the scientific editors of the program.

The presenting authors of the original session had no part in the creation of this conference highlights summary.

1. Parag Goyal, Justin J. Choi, Laura C. Pinheiro, et al. Clinical Characteristics of Covid-19 in New York City. N Engl J Med 2020;382:2372-2374.

2. David A. Berlin, Roy M. Gulick and Fernando J. Martinez. Severe COVID-19. N Engl J Med 2020; DOI: 10.1056/NEJMcp2009575.



Headache
COVID-19


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