Primary headaches during the COVID-19 lockdown in Germany: analysis of data from 2325 patients using an electronic headache diary

DOI: https://doi.org/10.1186/s10194- 021- 01273- z

Abstract-Summary We aimed to assess changes in primary headache characteristics and lifestyle factors during the COVID-19 lockdown in Germany using digital documentation in the mobile application (app) M-sense.

We analyzed data of smartphone users, who entered daily data in the app in the 28-day period before lockdown (baseline) and in the first 28 days of lockdown (observation period).

This analysis included the change of monthly headache days (MHD) in the

observation period compared to baseline.

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We also assessed changes in monthly migraine days (MMD), the use of acute

medication, and pain intensity.

They reported 7.01 ± SD 5.64 MHD during baseline and 6.89 ± 5.47 MHD dur-

ing lockdown without significant changes (p > 0.999).

The app users reported reduced stress levels, longer sleep duration, reduced activity levels, along with a better mood, and an improved energy level during the first lockdown month (p ≤ 0.001).

In an extension analysis of users who continued to use M-sense every day for 3 months after initiation of lockdown, we compared the baseline and the subsequent months using repeated-measures ANOVA.

In these 539 users, headache frequency did not change significantly neither (6.11 ± 5.10 MHD before lockdown vs. 6.07 ± 5.17 MHD in the third lockdown month, p = 0.688 in the ANOVA).

Despite slight changes in factors that contribute to the generation of headache, COVID-19-related lockdown measures did not seem to be associated with primary headache frequency and intensity over the course of 3 months.

Extended: We aimed to assess changes in headache characteristics before and during the COVID-19 lockdown period in Germany using a smartphone-based headache diary.

We also assessed changes of several predefined factors including sleep duration (in 15-min intervals), self-assessed sleep quality (on a NRS 0–10), energy level (0–10), mood (0–4), stress (0–10), and level of activity (0–10).

Introduction Patients with primary headache disorders perceive external factors such as stress, sleep, and changes of everyday routine as common trigger of their headache attacks [386].

Also patients with other primary headache disorders such as tension-type head- ache (TTH) usually report one or more precipitating factors, most commonly related to changes in stress levels or sleep patterns [386].

Lockdown measures due to the coronavirus disease 2019 (COVID-19), which changed daily life dramatically, could have an influence on the course of primary headaches.

Patients with chronic diseases, including headache disorders, had to face cancel- lations of doctor’s appointments and delay of therapies, resulting in emotional stress [387].

The implications of COVID-19 restrictions on the course of primary headache

disorders remain largely unknown.

We aimed to assess changes in headache characteristics before and during the COVID-19 lockdown period in Germany using a smartphone-based headache diary.

Methods The app developers provided us with aggregated data from all M-sense users, who entered headache-related data in this app in the four-week periods before March 22 (baseline) and after March 22 (first month of lockdown) every day.

Primary outcome of this retrospective analysis was the change in monthly head-

ache days (MHD) between baseline and the first lockdown month.

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Tele-Medicine

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Our analysis also included changes in monthly migraine days (MMD), monthly days with use of acute headache medication (AMD), mean headache and migraine intensity (on a numeric rating scale—NRS 0–10).

A migraine day was defined as each calendar day at which the user experienced

a headache attack classified as migraine by M-sense.

We then performed an extension analysis of M-sense users who continued to use

the app for at least 3 months after lockdown begin.

Results Headache frequency did not show any statistical difference, with 7.01 ± 5.64 MHD during baseline and 6.89 ± 5.47 MHD in the first lockdown month (95%-CI −0.03 to 0.27, p = 0.999).

AMD decreased slightly from 4.50 ± 3.88 before lockdown to 4.27 ± 3.81 in the

first lockdown month (95%-CI 0.19–0.35, p < 0.001, d = 0.060).

In the extension analysis, we included 539 M-sense users with daily data up to

the third lockdown month.

They reported 6.11 ± 5.10 MHD during baseline and 6.07 ± 5.17 MHD in the

third lockdown month (p = 0.688 in the ANOVA between all months).

Discussion In a large cohort of users of a German headache app, we observed slightly reduced self-reported stress levels during the first month of the COVID-19-related lockdown. Headache frequency and intensity remained unchanged with a small reduction of

acute headache medication days in the first lockdown month.

An extension analysis up to the third lockdown month revealed no significant

changes in headache characteristics or lifestyle factors.

This is the first study to assess changes in headache frequency longitudinally before and after lockdown implementation using daily data from a commercial headache app.

A larger Italian telephone survey also revealed a mild improvement of headache frequency and intensity as well as days with acute medication intake in 433 patients with migraine during the first lockdown month [251].

A cohort study from the Netherlands, using a time-locked e-diary, showed a sig- nificant decrease in monthly migraine days and acute medication days during the first month of lockdown [250].

Conclusion We did not observe a change in headache frequency and intensity in patients suffer- ing from migraine and/or TTH during the first 3 months of the lockdown in Germany. A small stress reduction in the first lockdown month was not associated with an

improvement in these primary headache disorders.

Acknowledgement A machine generated summary based on the work of Raffaelli, Bianca; Mecklenburg, Jasper; Scholler, Simon; Overeem, Lucas Hendrik; Oliveira Gonçalves, Ana Sofia; Reuter, Uwe; Neeb, Lars 2021 in The Journal of Headache and Pain.

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