His medical history revealed that he suffered from migraine with aura for almost 40 years. The individual attacks typically persisted between 8 and 16 hours and, when left untreated, the pain severely affected the patient’s ability to participate in daily life. While in the early phase of his disease no effective treatment could be established, headache became better controllable after the advent of the triptans [5]. The patient applied sumatriptan in early years and later zolmitriptan (requiring prescription) for very heavy attacks and naratriptan (available as OTC drug in Germany) for less severe migraine. However, while migraine attacks occurred before triptan therapy approximately every 5 days, the frequency increased since triptans were applied finally resulting in almost daily migraine and as a consequence almost daily triptan usage. Approximately since 2003 the patient fulfilled the criteria of medication overuse headache, i.e. (i) headache present on more than 15 days/month, (ii) regular overuse of a symptomatic treatment (> 10 days per month for triptans) for more than three months and (iii) markedly worsened headache during medication overuse [6, 7]. Throughout his adult life, the patient was treated with several prophylactic therapies including beta-blockers, tricyclic antidepressants, topiramate, acupuncture, neural- and psychotherapy as well as dietary changes and relaxation techniques. Out of these measures topiramate was most effective, significantly reducing migraine frequency. However, this outcome was transient and several started therapies always ended with discontinuation of topiramate treatment due to return of daily migraine and triptan usage after a few month or weeks. In combination with topiramate but also with other prophylactic therapies, the patient had - over a period of 13 years - in total seven prednisolone-supported drug holidays from triptans. However, long-lasting effects on migraine frequency and reduction of triptan overuse could never be achieved, particularly not in recent years.
In December 2020, the patient had extended contact to a SARS-CoV-2 positive person, developed COVID-19 symptoms and two positive SARS-CoV-2 PCR tests confirmed the infection. The course of his COVID was mild, with fever, fatigue and headache, as well as weak respiratory symptoms. Headache was bilateral but developed every day into a unilateral migraine attack. However, after approximately 20 days, the patient not only felt as if he had completely recovered from COVID-19 but surprisingly also experienced thereafter 24 days with only three migraine attacks. This was unprecedented and with the exception of periods of high-dose corticosteroid treatment had - according to the patient’s memory and his written migraine diary - not occurred in the previous 15 years. Reduced frequency of migraine attacks and triptan usage compared to the pre-COVID-19 phase persisted for 80 days (Fig. 1). Only 20 migraine attacks and 20 days with triptan usage, respectively, during this period (25% of the days) imply that the patient neither fulfilled the criteria for chronic migraine nor for medication overuse headache during this time. Almost as sudden, as the period with reduced migraine had started it ended with a return to almost daily migraine (Fig. 1).