Should We Adapt the Prescription Criteria for Specific Treatments for Migraine Due to the COVID‐19 Pandemic?

We have read with great interest the article by Ali et al regarding the delay in Onabotulinumtoxin (OBT) during the COVID‐19 pandemic in 3 patients published in Headache. ¹ During the pandemic, Headache units have had to adapt by replacing face‐to‐face care with phone calls or visits using electronic means. Unfortunately, in many cases this has led to a deterioration in patient treatment. ² As discussed in the article by Ali et al, many patients understand the situation, but as the spread of COVID‐19 and associated lockdown extend over time, their viewpoint is prone to shift. ¹ For neurologists, the situation is not easy because we often now see how the therapeutic effort that we have made for months or years is lost and the patient returns to relive a previous situation, which, in turn, increases anxiety and nervousness. In addition, the discontinuation of therapies may be associated with extra cost for health systems and patients after the pandemic because of the need to improve pain in patients that were previously stable.

To understand the scope of this situation, we have analyzed the situation of migraine patients treated with OBT and pericranial nerve blocks (PNB) during the pandemic. We have taken into account whether they have presented a perceived deterioration or have increased emergency room visits to receive rescue treatment. All patients analyzed came from a telephone consultation in March 2020 during the pandemic and have received a follow‐up call in the 1st week of May. At this moment, the total confirmed cases in the Region of Madrid accounted for 60,765 people. We have selected 20 consecutive patients treated with OBT. The mean age was 48.7 ± 8.12, 14 of them (70%) were treated with OBT, 5 (25%) with PNB, and 1 (70%) receive both treatments at the same time. In March, the mean frequency of headache of these patients was 9.5 ± 5.11 headache days by month. Seven patients (35%) considered that they need the treatment for further improvement, but most of them were prepared to wait to re‐apply the treatment due to the risk of SARS‐CoV‐2 contagion. In May, after a month without treatment, the mean frequency of headache was 17.95 ± 8.94 days and 15 patients (75%) were unsatisfied, considered that they were worse and that they needed an effective solution to the difficulties in the administration of OBT as soon as possible. This situation was especially more evident in patients who continued with 10 or more days of pain per month between March and May.

Our analysis shows a reality of those patients with chronic migraines that, for several reasons, discontinued treatment with OBT with a consequent worsening of the frequency of headache. This increase in frequency leads to deterioration in the quality of life and, thus, causes the perception of the situation to change. It seems that having 10 crises or more a month changes the perception of migraine, something that is in line with previous studies on the disability caused by migraines. ³ Patients with chronic refractory migraine who after having seen that with OBT they have greatly improved and can lead a normal life, due to the current circumstances are again in a situation of high disability

According to our findings, we believe that we should consider a change in the protocols of management of headache patients. On the one hand, it is worthy to assess the implementation of appropriate safety measures to apply OBT to patients. In this regard, some neurological societies, including the Headache Working group of the Spanish Neurology Society have already presented several recommendations. ⁴ In addition, the fact that the patients do not go to the emergency room during acute treatment‐refractory crises makes headaches more intense and lasting, and the risk of contagion in these circumstances may be greater than OBT application using safety protocols. Its application should also be evaluated in those patients that continue to present 8‐10 crises or more despite having already started treatment with OBT and having presented improvement. On the other hand, is a re‐evaluation of the criteria for the indication of monoclonal antibodies against calcitonin gene‐related peptide (MAC) or its receptor, since they are effective treatments and now, during a pandemic, they prevent the patient from going to the hospital since it can be applied at home. ⁵ , ⁶ In fact, in our center these drugs are sent home for treatment with an explanation on how to apply it. Therefore, we believe the requirement that OMB failure is mandatory to prescribe these drugs ⁷ should be eliminated in the current circumstances. Accordingly, during the pandemic, chronic migraine patients should try to maintain a treatment that has shown efficacy within safety measures or be selected if they want to be treated with MAC, even if OBT was effective.