This is the first study that evaluated COVID-19 phobia in migraine patients during the lockdown period of the pandemic. We found significantly lower COVID-19 phobia score in migraine patients compared to the healthy controls. In accordance with the total test score, all subgroup scores of the COVID-19 phobia scale were found to be lower in patients with migraine. Reduced PTSD PCL-5 scale scores in migraine patients were consistent with COVID-19 phobia results. In parallel to these data, migraine attack frequency was found to be decreased or not changed in 67% of the patients during the lockdown period. We interpreted the data that acute stress response in migraine patients to an extraordinary condition during COVID-19 pandemic may not be as exaggerated as healthy controls.
Comorbid psychiatric disorders including anxiety and mood disorders were reported in 23.1% of patients with migraine headache (22) and life-time social phobia frequency was found in 4% of migraine patients (22). Specific phobia was found to be higher in patients with migraine headache compared to the control group (9). However, we found that specific COVID-19 phobia was unexpectedly lower during the alarming, extraordinary conditions of lockdown period. It was also notable that the physiological, psychosomatic, economic, and social subscales of COVID-19 phobia test were also significantly different in migraine patients.
COVID-19 phobia scale, applied to the migraine patients for the first time detected lower scores than the control group. Though, specific phobia and post-traumatic stress disorder have been reported more frequently in patients with migraine under normal life conditions, we suggest that migraine headache patients might be more resilient to unpredicted, panicking events.
Regarding the treatment, 13 migraine patients were taking duloxetine or amitriptyline. The latter two drugs have been given at a low dose to benefit from its sedative effect, and the antidepressant efficacy was not expected at this lowest dose. Still, we evaluated whether the lower scores in migraine patients were related to the antidepressants used for migraine prevention. Yet, phobia and PCL-5 scale scores were not different between migraine patients using duloxetine or amitriptyline and those patients without on these drugs. This finding showed that COVID-19 phobia was not related to antidepressant use in the present study. In addition, the application of all these questionnaires by two headache professionals and the correlation between PTSD and COVID-19 phobia scale scores increase the reliability of the study results.
Studies on stress adaptation in migraine patients are limited, yet perceived stress was reported to be higher in migraine patients with increased frequency of attacks (23). No significant difference was found in the 'Upset because of something that happened unexpectedly' subgroup in the perceived stress scale when patients with migraine were compared with the control group, while other subgroup scores were significantly higher in migraineurs (23). These results are in line with our data and support that the reaction to extraordinary, unexpected, and alarming stress could be different in migraine patients. It may also imply that migraine patients can be resistant to stress in extraordinary circumstances.
Reaction to lockdown stress during pandemic has not been reported in adults, yet two studies evaluated stress response and anxious symptoms during COVID-19 to the lockdown period, in children and adolescents with migraine. Frequency of migraine attacks and anxiety symptoms were found to be decreased or not changed in most patients during the lockdown period. It was related to the reduced environmental challenges and stress (20). In a multi-center study in children aged 5–18 years, pain characteristics and COVID-19 anxiety, general anxiety and depression were evaluated in patients with migraine with or without aura and tension type headache (20). Headache frequency and severity of attacks were reduced, and authors emphasized that reduced school effort and anxiety were the most important factors to explain headache improvement (20). Likewise, it has been established that lifestyle change is the main factor affecting headache (21).
During lockdown period in our country, strict quarantine rules were applied, and many places have high risk of contamination such as schools, shopping malls, cafes, restaurants, hotels, hairdressers, and beauty salons were suspended. Curfew restrictions were imposed especially on weekends and some public holidays. As a result of all these measures, the great majority of the people in the country had to spend most of the day at home. Also, many people limited their social activities and relationships due to contagion concerns.
Conventional hospital services were the most affected area. Admission to hospitals decreased significantly due to both the limitation of outpatient clinic in most hospitals and the patients seeing the hospital as a dirty area. In this environment where face-to-face meeting could not be as comfortable as it used to be, telemedicine applications gained importance as a new communication method for the medical field.
As an important trigger for migraine, we can see the impact of stress and life-style changes on the migraine attack frequency. Work stress, insomnia, some food and drinks and lighting systems increase attacks in patients with migraine (19). In our patients, decrease in work stress and intensity, less exposure to external stressor factors (factors such as shopping mall lights, crowded environment, noise), more regular and healthy meals (homemade food, reduced fast food consumption, less skipping meals) attention to water consumption might be important modulating factors on migraine attacks.
Migraine attack frequency was reduced or not changed in 67% of the patients. In parallel, analgesic intake was significantly lower in 38% and not changed in 23% of migraine patients. Therefore, we think that reduced stress and relaxing factors such as regular living, flexible working schedule played a role in these patients. No new treatment was prescribed in any of the patients, and all majority continued their current treatment. New easy prescription policy that abortive and preventive medications were delivered to the patients without visiting hospital could contributed to that result. On the other hand, increased attack frequency was detected in 33% of migraine patients in whom the stressors were more prominent.
Health care facilities/health coverage is free for citizens in Turkey. During lockdown period, all COVID-19 patients had free access to hospitals and even private hospitals provided treatment without any charge. In addition, economic support has been given to unemployed and rent payments were delayed by the government. Our subjects on the study group continued to get their basic monthly salary during the lockdown period. All of these have been effective in alleviating some economic concerns.
The relatively late entry of COVID-19 to our country provided valuable short time to take measures for preparation and informing community compared to countries that encountered the virus earlier. In addition to later emergence of the pandemic, lower total number of COVID-19 infections and particularly deaths in Turkey (24) could take part in low phobia associated with COVID-19. Therefore, the public might show less panic reaction and anxiety. Nonetheless these factors were inadequate to explain why migraine patients had lower PTSD and phobia scores than healthy controls.
The COVID-19 pandemic and social isolation had positive impact on the attack frequency and severity in our migraine patients who were trying to adapt to the new world regulations. The attack frequency did not increase in most of the patients. As a result of the factors such as being isolated in a safe home environment, having healthy and regular nutrition, decreased stress related to work and socialization, the frequency and severity of attacks decreased in patients and consequently, the use of analgesics reduced.
COVID-19 phobia was evaluated for the first time in migraine patients along with PCL-5 scale during lockdown period of COVID-19 pandemic. Other strenght of the study is that two headache experts completed the phone interview with migraine patients. Also, enrolled patients were previously registered to our headache clinic and their clinical features were well known.
One of the limitations of the study is that the sample size of the study was not sufficient for subgroup analysis. The socioeconomic status, lifestyle and environmental factors were not similar in migraine patients during the lockdown period. The duration was not adequate to obtain follow-up data. Considering the country specific differences in economic, sociocultural dynamics and management of the pandemic, COVID-19 phobia results of migraine patient could be unique this study and cannot be generalized globally.