In the present study, we reported a clear increase in the proportion of stress-related migraine as the COVID-19 crisis deteriorated. We chose this metric to illustrate the changing patterns in migraine, as the number of recorded migraine attacks is affected by the number of active users in Migraine Buddy. In our questionnaire survey, 57.5% of respondents reported an increase in migraine frequency and 41.8% indicated worse severity during pandemic period. Hence, we argue that the COVID-19 pandemic has not only increased the proportion of stress-related migraine but also the migraine frequency and severity. Similar to our findings, an online survey conducted in Kuwait demonstrated that the majority of respondents had reported increase in migraine frequency and severity during pandemic period [4].
Stress is known as the most common trigger of migraine attacks [5]. COVID-19 pandemic, as a global health crisis, is perceived as a major stressful event. In a recent study from Spain, 41% of participants reported feeling moderate to severe stress and depressive symptoms during the pandemic, and 25% experiecned mild to severe levels of anxiety [6]. Young women, who consisted the majority of respondents in our study, felt the strongest negative impact [6]. COVID Stress Scales [7], which are scales measuring COVID-related stress and anxiety symptoms, may offer promise as tools for better understanding patients with COVID stress-related migraine.
Next, information overdose was reported as the second most common source of stress during pandemic in our questionnaire survey, with another study demonstrating that attention paid to COVID-19 media coverage as a risk factor for psychological distress in migraineurs [8]. This suggests that migraineurs could avoid paying too much attention on the media coverage of the pandemic.
Most respondents experienced significant life changes during a short period of time. In the light of questionnaire survey, respondents had difficulty maintaining migraine-friendly diets, scheduling doctor consultations, and accessing health/emergency services. A recent study reported that disturbance of eating habits was one of the factors affecting increase migraine frequency and severity [4]. A recent survey of 155 countries conducted by the World Health Organization found that nearly half of the patients with noncommunicable diseases failed to receive their regular medical care and medications since COVID-19 pandemic began [9]. With the various lockdown measures and shifts in healthcare systems towards COVID-19, it is plausible that this has resulted in a shift in patient behaviour towards self-management and may have exacerbated migraine.
From our questionnaire, 13.5% of respondents reported in migraine frequency and 11.2% of respondents reported improvement of migraine severity during pandemic period. This could be explained by the reduction in work-related pressure as workplaces shift towards a working from home arrangement, and echoed by our observation that migraine records tend to decrease over the weekend. This is similar to a recent study from Italy that reported fewer migraine attacks and lesser pain [10]. The authors attributed the findings to a reduction of trigger as a result of less work. Another recent study of Italian working women revealed that most of the additional housework and childcare associated with the COVID-19 pandemic were managed on not their partners but women [11]. Therefore, less office work attributed to COVID-19 pandemic may also be another trigger of migraine for women.
Interestingly, the ratio of stress-related migraine showed inverse correlation with the DJIA index. Rising fears and global economic shutdown due to the COVID-19 pandemic are believed to be main causes of the stock market crash [12]. During the study observation period, we observed that the bottom of the DJIA index overlaps with the peak of the ration stress-related migraine, suggestive that the stock market performance has an impact on stress-related migraine.
The ongoing threat of COVD-19, or other future pandemics, will require strategies for patients to better manage their migraine. The solutions identified by the survey respondents include coaching programs, medication home delivery and telemedicine consultation. Thus, it is a positive sign that organisations such as the American Migraine Foundation remain dedicated to providing support, education and comfort to those with migraine [13]. These resources will be benefits for patients managing migraine during these difficult times. Headache specialists should also consider taking steps to rapidly develop remote teleconsultation services. There is an urgent need to identify clinicians who are trained in telemedicine, expand existing remote consultation technologies with community hospitals and emergency departments and offer medication home delivery.
There are known limitations inherent to these real-world studies that rely on self-reported data from a smartphone app. First, there is potential bias as the study analyzed data reported by users, and no physician diagnosis is available to confirm a migraine diagnosis. However, the majority of respondents have reported the use of common migraine medication within the Migraine Buddy app.
Secondly, selection bias may arise owing to the requirement to have access to a mobile smartphone and comfort level in operating digital apps and, therefore, the population may not be entirely representative of the migraine population. Our respondents were unbalanced for sex and age, as the population to be young females. However, migraine is known to be more common in females, with the highest prevalence in the 20–50 age groups. Also, younger population usually constitutes the majority of smartphone app users.
Thirdly, being an observational study conducted via a smartphone app, the establishment of a direct causal relationship between migraine and COVID-19 pandemic can be difficult. Our goal is to present findings that can be representative of the real-world impact of COVID-19 on patients with migraine, given the rather large sample size. This will help increase the understanding of patients’ needs, and help with the planning and executive of mitigating strategies.
During COVID-19 pandemic, the clinical management of migraine as well as mental health should not be neglected. The stress-related psychosocial impact of the pandemic is evident and complex. Migraine attacks can be associated with a decline in perceived stress [14]. It is plausible to experience an increase in migraine cases once the COVID-19 pandemic situation has stabilized. Long-term follow-up data are necessary and smartphone apps like the Migraine Buddy can play a big role in monitoring changes in migraine managemnet. In future, the analysis of information about the body, collected via wearables, together with self-reported data entered into the migraine diary, can be performed by artificial intelligence to provide migraine patients with feedback to optimize their migraine management.