Matthew Robbins, MD on the State of Headache Medicine During COVID-19

In this podcast, Dr Robbins discusses how the ongoing pandemic has impacted headache medicine thus far, key areas of future research going forward, and what neurologists should keep in mind as the pandemic wears on. He recently gave a talk about this topic at the American Headache Society Virtual Annual Scientific Meeting.

Additional Resource:
Robbins M. Headache medicine in the era of COVID-19. Talk presented at: American Headache Society Virtual Annual Scientific Meeting; June 2020. Virtual. https://americanheadachesociety.org/education-training/virtual-meeting-platform/

For more podcasts like this, visit Neurology Consultant.

Matthew Robbins, MD, is an associate professor of neurology at Weill Cornell Medicine in New York, and the Neurology Residency Program director at New York Presbyterian Hospital.

TRANSCRIPT:

Christina Vogt: Hello everyone, and welcome back to another podcast. I’m Christina Vogt, associate editor of the Consultant360 Specialty Network. Today, I’m joined by Dr Matthew Robbins, who is an associate professor of neurology at Weill Cornell Medicine in New York, and the Neurology Residency Program director at New York Presbyterian Hospital. Thank you for joining me today, Dr Robbins.

Dr Robbins: Thank you for having me.

Christina Vogt: Today, we will be discussing the state of headache medicine during the COVID-19 pandemic. He recently discussed this topic at the American Headache Society Virtual Annual Scientific Meeting. So first, could you discuss how the COVID-19 pandemic has impacted headache medicine thus far? What are some difficulties you have encountered in your own practice, and how are you addressing these difficulties?

Dr Robbins: Thanks, Christina. I think that's a great question, and you could tackle it from a lot of different angles. First, the way in which we practice medicine, including for patients with headache disorders, has been totally transformed by this need to develop practice in telemedicine, and that took on a very immediate need as soon as COVID-19 hit New York City, which became really rapid and robust and led to immediate shutdowns of any elective visits or most routine office visits with a few exceptions, when there was really an urgent need to keep people out of the emergency department or urgent care visits. So, the rapid adaption of telemedicine was a major impact during that time, and I think will be forever with us, for which I think is for the better in the long run.

And then, the other aspect is how our patients fared, I think patients with existing headache disorders or new headache disorders surrounding COVID-19 have had a variety of different trajectories that certainly we can discuss further.

Christina Vogt: As the COVID-19 pandemic wears on, what are some key considerations neurologists should keep in mind in the field of headache medicine?

Dr Robbins: Well, I think when we think about COVID-19 and headache, I think there's just, like all headache disorders, we can group them into two different categories. There’s secondary headache, where headache is symptomatic of something like COVID-19, or there's primary headache, where a disorder like migraine or tension-type headache or other headaches can be either induced or triggered or made worse by COVID-19 itself.

So, for secondary headache, there's a lot of different ways in which COVID-19 can induce headache COVID-19 as a viral syndrome that can affect a person systemically can induce headache, and that's an accepted cause of headache that we've seen with other viral illnesses–Epstein-Barr virus, influenza, and so on. Then with COVID-19, we see that there's this particular cytokine released syndrome that is this inflammatory response that happens after the initial systemic infection takes place, which is the inflammatory response of the body to the infection, which seems extreme, and there, we often see headache manifest in that sort of second phase of the infectious process.

And then the third secondary headache consideration for patients with COVID-19 is that there can be scarier causes of headache that can be associated with it, such as vascular causes including stroke or venous stroke. There could be something called posterior reversible encephalopathy syndrome, where there's a disorder of cerebral autoregulation in the setting of COVID-19. There could be COVID-inducing such severe cough, or because of it being an antecedent viral illness itself, leading to cervical artery dissection and headache too. So, these are just some examples of secondary headaches that we've seen with COVID-19 and things for neurologists to keep in mind.

And then there's primary headache. So certainly, people with migraine have very clearly reported that having a COVID-19 infection has induced or triggered a severe migraine attack in such patients. And then, there's also the psychological aspects where having sort of a stressful situation or even more adjustment after the stress of having COVID-19 or having a family situation with such, or city or regional situation of such, can sort of lead to stress letdown, and then as a migraine trigger can happen there after. And then, certainly, because it can be such a severely impactful event with quarantining and severe illness, there could be a post-traumatic stress disorder that comes with it that can serve as a migraine-inciting factor to evolve from someone who has infrequent migraine or episodic migraine attack to chronic migraine.

And then finally, what we've also been seeing is that sort of a de novo headache disorder that can be continuous from onset could be triggered by COVID-19 itself, even in the absence of any other causes, which we label as new daily persistent headaches in syndrome, and that's–when that was originally reported in the 1980s was described as a post–Epstein-Barr virus syndrome, but certainly we've been seeing that in the aftermath of COVID-19 as well.

Christina Vogt: What are some key areas of research that are needed going forward when it comes to headache medicine and COVID-19?

Dr Robbins: I think what we need to know is how to treat our patients symptomatically well during this time, because COVID-19 is a virus that causes severe inflammation, but it also seems to lead to hypercoagulability, and we've seen a lot of patients in the hospital who've developed arterial or venous thromboembolic events, including stroke, including deep vein thrombosis, pulmonary embolism, or rim ischemia with this. And, although our patients who are being triaged or managed on the outpatient side might not have such as severe inflammatory syndrome, we don't know whether a lot of the medications that we use for migraine, for example, are safe to use in such patients in the midst of their infection, which could include perhaps even triptans, which can cause basic constriction, or gotamine, which can certainly cause arterial and venoconstriction, as well as some of the newer medications that target this calcitonin gene-related peptide.

The counter to that is that CGRP has actually been looked at as a target for treatment for COVID-related inflammation, including a clinical trial of intranasal zavegepant, which is an investigational drug, to see if that helps to reduce this inflammatory syndrome associated with COVID-19. So, there's much that we still need to learn, including also how to manage our patients with severe headache attacks that are tough to break with their routine medication. A recent study that has come out of the UK is shown the dexamethasone, a steroid, might help reduce the inflammatory course of COVID in severely impacted patients, and that's a medication we frequently used to treat status migrainosus, both in emergency departments and then also as in outpatients using a course of oral medication over a number of days. So, these are these are things that we still need to be open-minded about and consider.

Christina Vogt: And then lastly, what key takeaways do you hope to leave with neurologists on this topic, especially when it comes to patients who may be at risk for COVID-19 or who have already had it?

Dr Robbins: Well, I think people need to be, and neurologists need to be open-minded about complications about seeing the impact of this illness in the balance–you know, what is really specific to the virus vs what is just more typical of someone having a severe inflammatory syndrome with a viral illness. And, I think being open-minded about it would be useful. I think appreciating any comparative data to see whether what we observe in case series or case reports or observations in real-time really are borne out over time, because certainly there can be a lot of bias in clinical studies that don't have an active comparator. So, I think erring on the side of safety is always the best approach, I believe, in this situation.

Christina Vogt: Thanks again for joining me today, Dr Robbins.

Dr Robbins: Thanks so much.

Christina Vogt: For more podcasts like this, visit Consultant360.com.

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