Recommendations for the management of headaches during the COVID-19 pandemic

Background During the novel coronavirus COVID-19 pandemic, health care systems are facing one of its greatest challenges. Results Secondary headaches may need urgent care at an emergency department. Primary headaches exacerbations may require intravenous infusion. Treatment optimization is key for a better outpatient management. Conclusion We give recommendations on when a headache patient should go to the hospital despite the current limited resources, and primary headache management aspects during the outbreak. Yara Dadalti Fragoso yara@bsnet.com.br Received: April 18, 2020. Accepted: April 27, 2020. Edited by Marcelo Moraes Valença


Introduction
H ealthcare worldwide is facing one of its greatest crises in history 1 . With the fast spread of the novel coronavirus, healthcare systems are collapsing in some countries, with depletion of resources and crowding of emergency rooms, wards and intensive care units 2 .
Since the World Health Organization's declaration that a pandemic Since the World Health Organization's declaration that a pandemic exists, interruption of non-urgent healthcare has been generating exists, interruption of non-urgent healthcare has been generating insecurity and helplessness for people with other health problems, insecurity and helplessness for people with other health problems, including headache disorders. We need strength and compassion including headache disorders. We need strength and compassion to face up to and overcome this crisis and its imposed difficulties. to face up to and overcome this crisis and its imposed difficulties.
One important step is to seek reliable information, and to prevent One important step is to seek reliable information, and to prevent the spread of false news that generate confusion and panic. Here, the spread of false news that generate confusion and panic. Here, we provide guidelines for the management of headaches during we provide guidelines for the management of headaches during the COVID-19 pandemic. the COVID-19 pandemic. When should headache patients go to the emergency department? COVID-19 and its symptoms are an independent determinant COVID-19 and its symptoms are an independent determinant of ED care especially with breathing difficulties. Headache is of ED care especially with breathing difficulties. Headache is reported in patients with COVID-19 from 8 to 34%. reported in patients with COVID-19 from 8 to 34%. 3,4 3,4 However, However, headache and mild symptoms alone that patients may think might headache and mild symptoms alone that patients may think might be a symptom of COVID-19 should not be considered as not be a symptom of COVID-19 should not be considered as not an indication. The list below shows conditions that accompany an indication. The list below shows conditions that accompany headache and may indicate that it is a lifethreatening disorder headache and may indicate that it is a lifethreatening disorder requiring special management requiring special management 5 5 : :  should give rise to suspicion of temporal arteritis.

5.
Headaches associated with physical exertion or fainting 5. Headaches associated with physical exertion or fainting Physical Physical activity can exacerbate migraine pain and is part of the diagnostic activity can exacerbate migraine pain and is part of the diagnostic criteria for this condition. However, headaches occurring only criteria for this condition. However, headaches occurring only after or during physical exertion or sexual activity may be a after or during physical exertion or sexual activity may be a sign of a secondary headache due to aneurysm, arteriovenous sign of a secondary headache due to aneurysm, arteriovenous malformation, cerebral venous thrombosis or reversible cerebral malformation, cerebral venous thrombosis or reversible cerebral vasoconstriction syndrome (RCVS). Headache associated with vasoconstriction syndrome (RCVS). Headache associated with fainting or seizure can be secondary to brain tumors, infections or fainting or seizure can be secondary to brain tumors, infections or stroke. stroke. Vomiting is an associated feature of migraine, but may also be a Vomiting is an associated feature of migraine, but may also be a symptom of intracranial hypertension. symptom of intracranial hypertension. 9. Headaches in chronic non-communicable disorders or 9. Headaches in chronic non-communicable disorders or immunodeficiency immunodeficiency A new-onset headache in patients with ongoing A new-onset headache in patients with ongoing infection, HIV or cancer, or in those taking immunosuppressants, infection, HIV or cancer, or in those taking immunosuppressants, needs urgent attention. If headaches started gradually but are needs urgent attention. If headaches started gradually but are worsening, medical attention is also needed. worsening, medical attention is also needed.
Management of primary headaches during the covid-19 pandemic Primary headache patients will need special attention during the Primary headache patients will need special attention during the COVID-19 pandemic, particularly if social isolation measures have COVID-19 pandemic, particularly if social isolation measures have been imposed by health authorities. been imposed by health authorities.

Mental health management Mental health management
Mental health can be severely impaired, leading to anxiety, panic or Mental health can be severely impaired, leading to anxiety, panic or depression. Suicide rates increased in China during confinement depression. Suicide rates increased in China during confinement 6 6 . . Primary headache patients may be more susceptible to mental Primary headache patients may be more susceptible to mental health issues and/or may have more attacks under these conditions. health issues and/or may have more attacks under these conditions. Lifestyle measures should be reinforced, since food intake, mood Lifestyle measures should be reinforced, since food intake, mood and physical activity may be affected during the pandemic. Self and physical activity may be affected during the pandemic. Self help tools are often available on the internet. help tools are often available on the internet.
Acute headache management Acute headache management Primary headaches may be exacerbated during the pandemic. Primary headaches may be exacerbated during the pandemic. Headaches typically account for 1-3% of ER visits Headaches typically account for 1-3% of ER visits 7 7 . In order to avoid . In order to avoid delays in the ED, over taxing urgent care, hospitalization, acute delays in the ED, over taxing urgent care, hospitalization, acute treatment may need optimization. This may include addition of non-treatment may need optimization. This may include addition of nonparenteral options such as subcutaneous injections [(i.e. sumatriptan parenteral options such as subcutaneous injections [(i.e. sumatriptan or dihydroergotamine (DHE)] or nasal spray formulations or dihydroergotamine (DHE)] or nasal spray formulations (sumatriptan or zolmitiptan). Patients are suggested to increase (sumatriptan or zolmitiptan). Patients are suggested to increase acute treatment toolbox to better self-manage their headache acute treatment toolbox to better self-manage their headache attacks. This includes the use of prochlorperazine suppositories. attacks. This includes the use of prochlorperazine suppositories. Patients may be at risk of worsening of their headache in isolation, Patients may be at risk of worsening of their headache in isolation, consider new preventive methods to mitigate the risk. consider new preventive methods to mitigate the risk.

Avoiding corticosteroids Avoiding corticosteroids
Cluster headache and other primary headaches are commonly Cluster headache and other primary headaches are commonly treated with corticosteroids. If possible, this should be avoided, treated with corticosteroids. If possible, this should be avoided, because immunosuppression is considered to be a risk factor because immunosuppression is considered to be a risk factor for negative health outcomes among individuals infected with for negative health outcomes among individuals infected with COVID-19. COVID-19.

Conclusion
Headache patients will need special management during the CO-VID-19 pandemic. New-onset acute headaches will still need medical care. Delays in treating other life-threatening conditions caused by diversion of resources to treat cases of the novel coronavirus may lead to additional morbidity burdens, or mortality. Primary headache patients may be at risk of worsening headache control due to the limited healthcare resources available and because of changes to lifestyle due to social-distancing confinement.