This study aimed to register the most common triggers of migraine during COVID-19 lock down. It included patients who are registered at headache clinic in Ibn Sina hospital in Kuwait. The results showed that most patients 85% had multiple triggers for their migraine attacks. The most frequent trigger factors for migraine were smell of strong odors, certain food items, sleep disturbance, emotional or mental stress and caffeine. Our result is supported by the finding of Chabriat H et al.  who reported that sleep disturbance and food or drinks are the most frequently reported migraine headache precipitants.
Strong odors such as Arabic perfumes, incense smoke, and different odors were reported as the most triggering factors for migraine attacks in 63% of our cohort. Kuwaiti population are also used to consumes a lot of Perfume especially Arabic perfume. One of traditional habits in Kuwait is smelling incense which is steam of nice volatile substance. Incense is a bioaromatic substance that releases aromatic smoke upon burning . A lot of people in the Arab Gulf region believe that incense smoke can kill germs and microbes in the air. Incense smoke consumption has increased during the lockdown.
Staying at home increased exposure to incense smoke. Previous study about odorant triggered migraines showed the association of perfume odors within other factors, such as cleaning, cooking, beauty products, and foul odors .
Lifestyle may be changed during quarantine, with the consequent modification in sleeping and eating habits. These changes may worse migraine during COVID-19 pandemic. Staying at home and consumption of preservative food, due to the restriction in grocery shopping may play a role in precipitating migraine during lockdown COVID-12 pandemic.
Sleep disturbance, and stress were frequent trigger factors in this study and this in line with previous studies [7, 15, 16]. Sleep disturbances were reported to be 3–17 times more likely to be triggers for migraines in a population-based study. Sleep deprivation results in fatigue which activates the sympathetic outflow to boost metabolic process for availability of energy. The sympathetic activation thought to precipitate migraine .
Our result showed that stress was a common trigger for migraine in 24% which is similar to result of Uygun who reported that stress was triggers for headache in up to 30% of the participants . Hearing or reading continuously about the COVID-19 from media can be stressful. Stress also increased due to job loss that affected many people due to the COVID-19 and many small projects went bankruptcy, all these factors resulted in more stress to many people. Stress precipitate migraine. Also, stress may lead patients to toward overeating of certain food that can precipitate migraine attacks.
Caffeine was triggers for migraine in 34% of the cohort. Kuwait population consume a lot of Arabic coffee which is pure and rich in caffeine.
Sun light exposure was triggers of migraine in 12%. This study was run in April. During this month and the sun light is bright with high temperature in Kuwait. The lock down was staring at 5 pm until 5 am next day. The subjects showed finish their necessary shopping, or necessary issues during day time. Ultraviolet radiation in the sunlight alters calcitonin gene related peptide and nitric oxide release by intraepidermal sensory nerve fibers in the skin . This condition may trigger migraine attack through vasodilatation. In addition to brightness of sunlight, high temperature may be considered as another triggering factor. High temperatures may stimulate cutaneous thermoreceptors, that may precipitate migraine attacks .
COVID-19 pandemic had a negative impact on patients with migraine in Kuwait. Majority of migraine patients experienced increase in migraine frequency and severity in addition to overuse of analgesics during and pandemic . This negative impact can be explained by the change of life habits and presence of more migraine triggers. The lockdown has caused many changes in people daily life routine. Sleep pattern may have altered with the change to working from home and with schools being closed. Anxiety, and low mood may contribute to sleep disturbance. Mealtimes may also have changed with the temptation to snack, cravings for comfort food and the simplicity of takeaways leading to a change in the balance of carbohydrates, fat and protein. Smoking and caffeine intake may have increased. Some people may have exercises more than usual where others may be finding their lives are more sedentary. So, all these changes can trigger migraine.
The study had some limitations. First, we did not compare between migraine triggers before COVID-19 quarantine and during lockdown. Second, we did not assess associations between the trigger factors and the migraine frequency and severity. Third, all the analyzed datas were collected through a questionnaire, thus they were less verifiable than data issued from clinical interview.
Strength of our study is the first study describe triggers of migraine during quarantine. To our knowledge, this study was one of the first studies to investigate the impact of the COVID-19 lockdown on migraine triggers.