Hospital-based headache care during the Covid-19 pandemic in Denmark and Norway

DOI: https://doi.org/10.1186/s10194- 020- 01195- 2

Abstract-Summary The Covid-19 pandemic is causing changes in delivery of medical care worldwide. It is not known how the management of headache patients was affected by the

lockdown during the pandemic.

The aim of the present study was to investigate how the initial phase of the Covid-19 pandemic affected the hospital management of headache in Denmark and Norway.

Of the neurological departments 86% changed their headache practice during the

lockdown.

Among departments conducting headache research 57% had to halt ongoing

projects.

Fifty-four percent reported that the standard of care was worse for headache

patients during the pandemic.

Hospital-based headache care and research was impacted in Denmark and

Norway during the initial phase of the Covid-19-pandemic.

Extended: The aim of this “Neurology during a pandemic (NeuroPan) study” was to examine how the lockdown due to the Covid-19 pandemic affected the spe- cialized hospital-based treatment of headache patients in Denmark and Norway.

Background To many patients such a change provided continuous access to care despite infec- tion control measures, but for new-onset headache and complex chronic headache cases, this could result in suboptimal consultations without the possibility of a proper clinical examination or injection treatments [303].

A number of widely used migraine treatments such as nonsteroidal anti- inflammatory drugs (NSAIDs), angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs) and calcitonin gene-related peptide (CGRP) monoclonal antibodies were all scrutinized for potentially worsening the Covid-19 disease in the initial phase of the pandemic, creating uncertainty among patients and physicians [304, 305].

During the pandemic, anecdotal reports emerged describing a considerable drop in the number of headache patients seen in the emergency department and patients treated with injections such as greater occipital nerve block (GON) and botulinum toxin A (BTX) [306, 307].

The aim of this “Neurology during a pandemic (NeuroPan) study” was to exam- ine how the lockdown due to the Covid-19 pandemic affected the specialized hospital- based treatment of headache patients in Denmark and Norway.

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Materials and Methods There are 14 and 18 hospitals with a department of neurology in Denmark and Norway respectively, varying from smaller district hospitals to larger university hospitals.

All neurological departments in Norway may prescribe the new CGRP-antibodies for migraine prevention, but only the departments with certified headache clinics (n = 6) are allowed to use the treatment in Denmark.

The structured questionnaire about headache treatment was distributed to the Head of headache services at all neurological departments in Denmark and Norway. The design of the questionnaire was based on the authors’ clinical experience from the first week of the pandemic lockdown, in addition to their general knowl- edge and experience in headache medicine and neurology.

Groups were compared using the t-test (continuous data) or the χ2 test (categori-

cal data).

Statistical significance was defined by p < 0.05, using a two-sided test.

Results More hospitals in Denmark (42%) than in Norway (13%) focused on follow-up rather than newly referred patients.

In Norway, 29% of the hospitals reported shifting more patients than normal from BTX to CGRP antibody treatment, whereas no Danish hospitals reported this. In Norway, hospitals were twice as likely to start patients on CGRP antibodies rather than BTX as the new preventive treatment for chronic migraine (41%) com- pared to Denmark (17%).

Eleven out of 29 hospitals (38%) reported that headache patients received the

same follow-up as before the lockdown.

Fifty-four percent reported that the standard of care was worse for headache

patients during the pandemic.

Discussion The present study shows the same pattern for headache patients, as almost 70% of the hospitals reported a decrease in admission rates of severe migraine and 60% reported fewer evaluations for acute headache, normally considered a red flag in headache care [65].

BTX is one of the few available and effective treatments for a large group of headache sufferers with chronic migraine in Denmark and Norway, and the lack of access to care thus negatively affected the most vulnerable headache patients [306, 308].

The fact that hospitals were severely affected by the lockdown underscore that most headache patients can and should be managed in primary care in close collabo- ration with specialist health care.

In health care systems where all headache patients are referred or treated by headache specialist at hospitals, a lockdown such as the period in the spring of 2020 will have decisive influence on the possibility of obtaining an effective diagnosis of headache and the continuation of treatment.

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COVID-19 and SARS-COV2 Vaccines

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Conclusion Hospital-based headache care and research was impacted in Denmark and Norway during the initial phase of the Covid-19-pandemic.

More research on implementing telemedicine in headache care, institutional and governmental strategies and priorities for headache patients, and headache patients’ overall well-being and prognosis during the long-term lockdown is warranted.

Acknowledgement A machine generated summary based on the work of Kristoffersen, Espen Saxhaug; Faiz, Kashif Waqar; Sandset, Else Charlotte; Storstein, Anette Margrethe; Stefansen, Simon; Winsvold, Bendik Slagsvold; Hansen, Jakob Møller 2020 in The Journal of Headache and Pain.

Impact of the COVID-19 pandemic on migraine in Japan: a multicentre cross- sectional study