S2 E9: Covid-19

A National Migraine Centre Heads Up Podcast transcript


Series 2, episode 9

Heads Up is the award-winning podcast series on all things headache, brought to you by the National Migraine Centre.  Produced by leading headache doctors, it’s the trusted source of information and support for all those affected by migraine and headache.

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[00:00:00] Did you know 50% of people with migraine have found their condition had worsened due to the recent COVID 19 lockdown. Change in routine can have a detrimental impact on migraine. Welcome to the Head’s Up podcast brought to you by the National Migraine Centre, the only UK charity treating migraine and headache.


Dr Katy Munro [00:00:28] Welcome to our latest episode of Head’s Up podcast. I’m Dr. Katy Munro and I am virtually looking at Dr. Jessica Briscoe.


Dr Jessica Briscoe [00:00:39] Hello.


Dr Katy Munro [00:00:39] So today’s episode is of course, inevitably about the coronavirus, COVID 19, which has changed all of our lives and which we are kind of beginning to work around some of the things that it’s affected. We at National Migraine Centre have certainly really changed everything we’re doing in terms of how we see patients. We’re still going, aren’t we, Jess.


Dr Jessica Briscoe [00:01:03] Yes we are, we are. We’re still sort of going along. I’m going to apologise now because we’re recording at home. You might occasionally hear the odd background bit of noise. We’ve tried to keep it as quiet as possible. But occasionally, if you hear a little of a door, that’s just either my neighbours or my sister who I live with. So apologies. Okay. So yeah, it really has changed the way that we’re living and working. So I think maybe if we just start off by talking about what we know a little bit about coronavirus, cause I’m sure you’re all saturated with information and you’re aware about what it is and about how it’s changed the way that we work and the way that you might have your headaches treated or managed, actually. So the coronavirus is a new- it’s a novel virus, which means it’s a slightly changed virus. There are other types of respiratory virus around, but this one is very infective and passes between people very rapidly, which is why it’s caused this global pandemic. Now, the symptoms are very varied, so you can have respiratory symptoms, so particularly dry cough, fever, stomach symptoms, all sorts of skin symptoms and people might not have symptoms at all. But I think the things that we’re often interested in are the headache symptoms, because lots of people who don’t usually get headache have started to probably understand a little bit of what it’s like to suffer with migraine if you get lots of pain. And there have been- I’ve definitely heard of people saying they’ve never felt pain like it before. And personally, I had the headache with the coronavirus and it wasn’t as bad as my migraine pain. But that’s the point, it’s very variable from person to person.


Dr Katy Munro [00:02:46] So the headache could mimic your migraine do you think Jess? Do you think it’s more likely to trigger migraines if you’re having coronavirus?


Dr Jessica Briscoe [00:02:54] I think the headache that you get with the actual virus isn’t quite the same as it wasn’t the same type of pain. It wasn’t in the same area. It was a much more generalised pain for me. But as we all know, migraine pain is very specific from person to person. But I certainly think it could trigger more migraines. It’s like any infection. One of those big triggers we talk about, anything that puts stress on your body, it certainly could make people more prone to having bouts of migraine attack.


Dr Katy Munro [00:03:23] And I think it’s quite common, isn’t it, to get a headache if you’re getting a temperature from any cause. So keeping the temperature under control may be a way of trying to reduce the headache that is linked with the COVID-19 virus.


Dr Jessica Briscoe [00:03:38] Absolutely. And actually, I found that paracetamol worked well for the headache and other people have said the same. Paracetamol doesn’t usually touch my migraine headache. So that’s a big, big difference between that type of headache and my migraine.


Dr Katy Munro [00:03:51] So I was going to say there are other sort of neurological things that we’ve heard about as well, that are sometimes the secondary effects of having a COVID-19 infection, aren’t there?


Dr Jessica Briscoe [00:04:01] Absolutely. I think the things that we tend to think about are the sort of complications such as stroke. I think we have seen there’s been a few reports of it now. It’s not something I particularly want to worry people about, but I think it’s important to say that if you have suffered with symptoms of coronavirus and your migraine is different, so more prolonged, prolonged aura, just doesn’t go in its usual pattern, it is worth seeking medical advice about it just to make sure. It’s the same advice we tend to give to people with migraine anyway, but it’s just something to keep at the back of your mind I think.


Dr Katy Munro [00:04:37] The one thing that has really changed is the way that healthcare systems in the UK and worldwide are functioning at the moment. And I think there’s been a bit of concern that people with symptoms that they may not think of COVID-19 but symptoms of other illnesses may be holding back from contacting physicians and going to emergency centres or phoning NHS 111 because they feel partly that they don’t want to bother the healthcare professionals who are so busy with the COVID 19 and partly because they’re scared of going to healthcare facilities. So we would urge people, if you have a concerning symptom you’re not sure about, the healthcare systems are still there for you. You must get it checked out.


Dr Jessica Briscoe [00:05:22] Absolutely.


Dr Katy Munro [00:05:23] If there’s anything new or different in adults or children then do seek advice, the systems are still running to give you good quality advice and help you. But of course, some of the clinics that we would normally send our patients to aren’t running in the same way. And this has had quite an impact on the patients that we’re still seeing, hasn’t it Jess.


Dr Jessica Briscoe [00:05:45] Yeah, I think that’s really true. So I think we will probably start off by talking about what’s happened to headache clinics in the Coronavirus. It’s very similar to what’s happened to most clinics. So because of the pressure that’s been put on health care systems and because of the social distancing rules that have been put in place, most clinics have had to really change their function. So people who work in clinics so the doctors have been redeployed. Doctors or nurses or physiotherapists may have been moved to work in other parts of the hospital to help with the crisis. There’s also been quite a lot of illness amongst staff as well so then the numbers may be down, which means that, you know, the clinics can’t function. There’s also concerns about how the clinics are run. So can people go into the hospital physically to the headache clinic, or will it have to be a virtual consultation? And of course, that has implications on procedures. So lots of people require regular procedures to keep their headaches or their headache disorders at bay, and that’s been disrupted quite significantly, which has been really worrying for people.


Dr Katy Munro [00:06:57] We’ve really understood that because procedures in headache clinics tend to be injections into the face or the back of the head. Then of course, that means very close physical contact from the doctor or the specialist nurse who’s doing these procedures. And that’s why there is a particular reduction of those kind of services. And most of the places that are doing Botox or greater occipital nerve blocks that we know about through the NHS have stopped doing them completely because the risk to the staff and to the patients for doing these kind of close face to face procedures is really high.


Dr Jessica Briscoe [00:07:38] Yeah, particularly actually for Botox because you do the injections at the front. That’s a high risk. We know that clinicians and nurses who work in areas of the ear, nose and throat or around the eyes have actually had higher numbers of transmitting COVID or catching COVID. That’s really why they’ve tried to stop people having Botox during this time- whether the virus is rife in the community.


Dr Katy Munro [00:08:08] So we do Botox at the National Migraine Centre and we’ve also, of course, closed our doors and haven’t seen anybody physically face to face. But we have managed to keep our clinics running. In fact, we’ve had some more clinics than usual because doctors weren’t able to go on their holiday. So we’ve just got back to work. So that’s sort of bad news/good news in a way.


Dr Jessica Briscoe [00:08:31] Yeah, I mean, probably been a good thing. It’s forced us to move with the times a bit and start doing more telemedicine consultations and get all the infrastructure set up properly. But I think that’s been important as well because it is a scary time and people’s migraines- we’ll go on to rates of migraines in a bit. But people have been struggling and I think being able to sort of have some form of consultation and advice has been really important.


Dr Katy Munro [00:08:59] So we’ve been doing video consultations as well as telephone consultations. And how do you find it? I quite like it I have to say, Jess, I think from the point of view of a migraine patient, especially because we’re a national centre, that people travel from such a long way away sometimes to see us. People are really loving it because, you know, they don’t have to get on a train or climb into their cars. They can just speak to us. Obviously, some things are different. We can’t do neurological examinations. We can’t look in the back of people’s eyes. How are you getting around that? What do you feel about that?


Dr Jessica Briscoe [00:09:37] So as long as people have had an opticians review, because opticians are very good at looking in the backs of eyes. Obviously a lot of opticians- ophthalmoscopy, which is that looking at the back of eyes, is one of the banned examinations at the moment anyway because it’s high risk. But if people have had that fairly recently, then that for me it’s something I note down. But I think the way to get around is that we’ll have to make sure that people have had someone look in the back of their eye at some point once the restrictions have lifted, and that doesn’t have to be a specialist, that could be a GP or an optician. Well, opticians are specialists. Doesn’t have to be a headache specialist?


Dr Katy Munro [00:10:18] Somebody who’s confident that using an ophthalmoscope and has the right conditions to check out- because what we’re looking for is the optic nerves at the back of the eye to make sure those are healthly because with migraine, they’re healthy. But if we see that there’s something not quite right, then it can be a sign of an underlying different cause for migraine. So it’s very reassuring when we have a normal fundocopy.


Dr Jessica Briscoe [00:10:40] But I think it’s also important to say that any neurological examination is something we’re all taught at medical school, but any examination should just back up the clinical history. And I think that’s true. I’ve never done an examination and suddenly found something I wasn’t expecting. So actually I think a lot of the time if the story is reassuring, then actually not having to do it, not being able to an examination straightaway shouldn’t be worrying. If there’s something that’s worrying in the story that’s a different matter and we would actually treat that differently anyway. So I don’t think anything’s changed from that point of view.


Dr Katy Munro [00:11:16] No, I agree with you there. I think the other thing is, because of the nature of our clinic, quite a lot of the patients that we see have also been to see GP’s or neurologists or even some headache specialists in the past. So they may have had a long history of clearly migraine, you know, that they’re still struggling with and they may have had neurological examinations or even scans before they get to see us. That doesn’t apply to everybody. And if somebody hasn’t, and we really felt that they needed a neurological examination, then we would advise them to contact their GP and go and have a consultation and that is still possible to do that.


Dr Jessica Briscoe [00:11:55] So GP’s are still doing consultations. It’s just that like us they’re usually looking at risk and actually brings us on to other things that have changed about headache clinics because some of our medications actually need monitoring. Particularly one that I think we’re using more. And well I’m certainly using it more and more, candesartan, which we use quite a lot. That one often requires a blood test as you’re starting the medication and increasing the dose just to check for- it can unmask a kidney condition. That’s why we usually do that blood test and also blood pressure checking for that and propranolol as well which is another blood pressure medication whilst you’re starting it. Have you found that that’s been a problem for you?


Dr Katy Munro [00:12:37] Yes. One or two people I’ve suggested that may want to start Candesartan. And then we do have to bear in mind, you know, it may sometimes make the difference between choosing one preventative and another won’t it really. And of course, the other group that need monitoring are our cluster headache patients if they’re going to start on verapamil because you know they do need to start having an ECG and with every dose change having an ECG. So that’s been a tricky one as well. Definitely some difficulties with certain things that we kind of took for granted before.


Dr Jessica Briscoe [00:13:09] I think if you’re already on that medication and you’re due to have your annual blood tests, because most people have a yearly blood tests when they’re on that, that can be delayed. And that’s the same with managing blood pressure. We’ve sort of said that it’s safe to wait until the restrictions are lifted. It’s just if you’re starting the medication, it can be a problem. So I think next, we’re going to talk more specifically about migraine and we are going to talk a bit about cluster headache later as well, because I feel sometimes cluster headache people feel they’re forgotten a bit. But we’re talking about both today. We did a poll, didn’t we, Katy.


Dr Katy Munro [00:13:44] Yes, we did. Because we’d had a lot of wondering about whether being at home and all the changes would actually help some people’s migraine or whether it would make it worse because of the tension anxiety. So we did a poll. And the results of the poll were very interesting, actually. We went across Facebook and all our social media’s, Instagram and Twitter. And so we had quite a number of responses. And in general, all of those social media platform results agreed with each other. So some people said that the migraine had improved. I think it was about 30% of people felt that theirs had improved. Some people, about another 30% said, oh, there was no change. And then between I think it was between about 40 and 50%, depending on the poll, said that theirs were worse. So that’s a shame. But what did people say made the difference? We had some interesting comments, Jessica, didn’t we?


Dr Jessica Briscoe [00:14:44] Really interesting comments. Actually what I thought was interesting was the people that have improved because things like not having to commute to work, can actually make a difference, a bit of less stress of going to work and coming back might have made a bit better. Some people have improved their routine a little bit or been able to exercise more, but I actually think that change in routine as well has made things worse. So if you’re not having to commute to work, there is a bit more of a blur in your day. So you can suddenly ‘oh, I’ll quickly just check that email or I’ll send that offer. I’ll check that figure’. You’ve got much less of a distinction between the beginning and the end of the day. So you don’t have that usual routine. You might be homeschooling, which has been a really big issue for people.


Dr Katy Munro [00:15:41] Oh my goodness.


Dr Jessica Briscoe [00:15:41] I mean, I had someone the other day who said that they don’t see their husband, them and their husband are like ships that pass in the night because one looks after their children at the beginning of the day, the other looks after their children at the end of the day and then they’re working in between, they just don’t see each other. Must be stressful.


Dr Katy Munro [00:15:56]  I think it must be incredibly difficult when children are normally at school and, you know, you’re going off to work and, you know, completely separate. But to have everybody in the same place and still be trying to do whatever your usual job is, most likely as we are on teleconferencing calls, which are actually quite stressful in themselves and quite tiring.


Dr Jessica Briscoe [00:16:19] Really tiring.


Dr Katy Munro [00:16:22] They also involve a certain amount of concentration to pick up cues from the other person. Because I was reading an article by a psychologist the other day and she was saying that, you know, when we’re having a conversation, we often pick up nonverbal cues from the other person, and that makes us understand what they’re feeling without them having to say it. Whereas when we’re doing a video thing and I even find it doing this podcast with you as we normally very well in tune with each other, and it just takes an extra bit of concentration to be looking at the screen again and listening and concentrating sometimes there’s crackling on the line.


Dr Jessica Briscoe [00:16:58] Or delays.


Dr Katy Munro [00:16:58] And all sorts of things that make it- yeah, or the line goes down. So, yes, it can be stressful. Going back to our basic principles of what migraine is caused by, we know that the genes that cause migraine, it’s a genetic condition inherited and the genes cause your brain to be always a bit more sensitive to change. And so anything like the kind of changes that we’ve all had to make over the last few weeks, it’s kind of not surprising in a way that our brains have kicked off a bit in some cases. So, change in routine, as you were saying, the structure may be very different. Sometimes work is leaching into other parts of the day when it shouldn’t do. There’s no going home time because you’re already there. You may not be moving around in your working day.


Dr Jessica Briscoe [00:17:48] And I was just thinking things like the commute. So I was also reading another article about the effects of not being able to switch your brain off. So because you’re not commuting or you don’t have those blank spaces in the day where you might be walking to your car or driving. When you’re not actually thinking about very much, it gives your brain a bit of time to rest. Actually, when you’re socially isolating or social distancing, you don’t have that rest time. Your brain’s much more active as well. So that can be a big issue for anxiety and also problems with sleep as well that can affect your sleep pattern, too. So, as you said, little activity levels, not getting up in between, not popping out to the coffee shop or popping out to get your lunch or, you know, going for your little walk to clear your head and things like that make a big difference.


Dr Katy Munro [00:18:37] Yes, I’m very fortunate because we have a garden. And so I do find that just going outside for a while, just to look at the flowers or, you know, listen to the birds has been helpful. And I think a lot of people are trying to get out and go for a walk once a day or exercise in some way. Of course then other people have gone mad on exercising and started leaping around in their sitting rooms where they wouldn’t normally do that. So what do you think about those kind of sudden high impact regimes that we can all tune into now?


Dr Jessica Briscoe [00:19:07] As you know, Katy, this is one of my hobby horses. I’m a big fan of exercise. I think it’s very good. I think it’s something people have to be very, very careful about. So you have to gradually increase. High intensity exercise is known to increase your cortisol level and cortisol is the stress hormone. So a big change in something again. You have to be a bit careful. Activities like running, doing these these very high aerobic exercise classes, which there are lots of on the Internet, there’s lots and lots of free classes that people can join. But if you’re not used to doing that, that change in cortisol level, that change in energy, so depletion in energy level, that change in hydration level, that can trigger migraines sort of 12 hours later. And so I think it’s important also to make sure people have rest as well from these exercises, because I think the temptation when you’re like, ‘well, I’m not moving, so I’ll do a really high, intense class every day or I’ll go for a run every day’. You need to rest your body. Having those changes in cortisol levels every day is not good for the body and certainly not good for a migrainey brain.


Dr Katy Munro [00:20:16] Yeah. There was a study on exercise and migraine a while ago now and it was advocating that 30 minutes of exercise three times a week regularly was probably the best way of reducing your migraine and and keeping yourself fit. So I think if you’re pacing it like that, then you’ll probably be alright.


Dr Jessica Briscoe [00:20:34] Also just remember that things like, as you said, going for a walk counts. You don’t have to be running around. It’s moving, if you want to do a bit of dancing instead, that’s okay. Doesn’t have to be structured. That’s fine.


Dr Katy Munro [00:20:47] I did a bit mowing the lawn earlier on.


Dr Jessica Briscoe [00:20:49] I cleaned the house, that felt like exercise.


Dr Katy Munro [00:20:53] That counts. Hoovering counts. I don’t do that every day, I have to confess. And the other thing, talking about physical things, is posture. So I definitely had somebody the other day who was saying that her migraines had got really much worse in the two weeks since she’d been sitting at home working on her laptop. And of course, a laptop is often lower. You’re much more head forward. You may be having your chin on your chest, looking down to the keyboard for quite prolonged periods of time. So it’s really worth looking up desk exercises or what the best position is for your workstation. Check it out at home. You should be basically looking almost horizontally at your screen, not having to bend forward and be round shouldered. And so sitting on your bed or on a sofa with your laptop on your lap is actually really quite bad posture for your head and neck. And we know that that can aggravate by putting tension into the muscles and that sending signals in to trigger off a migraine attack. So sit up straight, put your shoulders back.


Dr Jessica Briscoe [00:22:01] Your eyeline should be in the top two thirds of your screen, basically. And the problem is, I mean, people aren’t using desks as much. People might be using a kitchen table and chairs that aren’t adjustable and things like that, things that we take for granted at work.


Dr Katy Munro [00:22:16] Or sitting on the bed or, you know, sitting on the sofa.


Dr Jessica Briscoe [00:22:20]  Lying down.


Dr Katy Munro [00:22:22] Yeah. So all sorts of postures which you probably wouldn’t have even thought about. And when you go to work, usually employers have thought a little bit more about, you know, setting up your workstation, hopefully. They should do anyway.


Dr Jessica Briscoe [00:22:36] And then eating I think is the next thing I want to talk about.


Dr Katy Munro [00:22:40] Oh yes, eating.


Dr Jessica Briscoe [00:22:42] So, there are all sorts things in the pandemic that have changed our eating habits. So the fact that people are going out a lot less to shop, so you might only go out for your, you know- if you’re only allowed to go out once a day if you’ve forgotten something, that’s it. You can’t get anything else that day. So I think what people are buying, their shopping habits have changed. At the beginning of the pandemic, there were all sorts of runs on different items. There’s still not much flour in the shops. You know, people might be a bit limited to what you can actually cook. The fact that you’re at home means it’s much easier-  Katy can see I’m right next to my kitchen. It’s much easier for me to go and grab a snack in the middle of the day. And it may be a biscuit, it may be something more healthy. So what you’re eating changes and then baking.


Dr Katy Munro [00:23:32] Oh, baking. Have you had that craving for cake?


Dr Jessica Briscoe [00:23:35] Oh, yes.


Dr Katy Munro [00:23:36] I have had that craving for cake. Oh, my goodness. It’s a comfort thing, isn’t it? We think, well, I deserve something nice because I’m having a hard time at the moment. And I’ve certainly reached for a biscuit, a chocolate biscuit or a slice of cake more often than I usually do. Not good for migraine.


Dr Jessica Briscoe [00:23:50] Yeah, mini eggs were my thing because this also coincides with Easter. So mini eggs were the thing. I’ve had to stop buying them.


Dr Katy Munro [00:23:59] Well, that is one answer isn’t it.


Dr Jessica Briscoe [00:24:01] Yes. Don’t buy them. But baking. I think a lot of people have been baking during this time because if you’ve got lots of time, if you’re not able to work, if you’re furloughed or if you’ve actually got children to entertain, baking is quite a nice thing to all do together and then you can all enjoy the things. But if it’s sugary, that can be a problem. We talk about this all the time, sugar, big changes in blood sugar level being irritating for the migraine brain.


Dr Katy Munro [00:24:27] Yeah, we do advise generally to have the more protein and fat based snacks rather than carbohydrates, keep the carbohydrates as the lower proportion of the snacks or the meals that you’re having. Because by having protein and fat, you get a slower energy release and your brain likes a nice, sustained, even blood sugar. It doesn’t like fluctuations, but one plus about baking thought, Jess, don’t you think? If you’re having to knead the dough, you can get all your frustrations out by hammering that bread dough.


Dr Jessica Briscoe [00:25:01] But my oven is not even


Dr Katy Munro [00:25:02] And mine is a bread maker so.


Dr Jessica Briscoe [00:25:05] My oven is not even so my frustration comes back again when I put something in the oven. And then I think other food related things. Caffeine and alcohol. They’re are the other things where  I’ve noticed people have changed their habits for both of them during this time. Either some people stopped drinking caffeine because that’ll be their habit, where they go to a coffee shop as their break or on their way to work. Other people will be nearer the kitchen so just grab another coffee or, you know, if you’re making one, I’ll have one, too. It might increase the amount of caffeine they’re having. And certainly alcohol as it is one of the essential items apparently, it has been deemed an essential item.


Dr Katy Munro [00:25:48] Oh really!


Dr Jessica Briscoe [00:25:48] I think people are increasing their alcohol consumption a fair bit because of not having much else to do, maybe being anxious or low, you know, worried about situation. People drink more.


Dr Katy Munro [00:25:59] I did a little one of our video Thursday tips on caffeine and alcohol the other day, which is out on our social media if you catch that. Interesting about caffeine, isn’t it? Because if you suddenly stopped having caffeine- and some people do this when we’ve had a chat to them about their migraine, they just stopped drinking their three cups of coffee a day and then they get withdrawal headaches. Whereas if you are going to change your caffeine, I just say to people, do it gently. Your brain doesn’t like change, so bring it gently to the morning, avoid caffeine in the afternoon. And if you’re going to reduce it, just reduce it slowly and gently so your body gets used to it. Some people really do benefit from cutting out caffeine, but do it gently. And then alcohol, just a quick word. So we think that alcohol has two effects on migraine triggering. One can be immediate and one can be a kind of delayed reaction. So sometimes you might have a couple of glasses of wine and not feel the headache until the next morning. And so watch out for alcohol. I think increasingly when I’m asking patients, do you drink much alcohol? Almost invariably they say, well, no, it’s just not worth it because it is such a trigger.


Dr Jessica Briscoe [00:27:12] Disproportionate hangovers. That’s my phrase.


Dr Katy Munro [00:27:14] Yes, yes, that’s right. Just be really careful with that in this lockdown and in the future, basically. Sometimes people drink to get themselves off to sleep and of course, that doesn’t work because although you might zonk yourself out initially, it really lightens the quality of your sleep so you don’t get that restorative sleep, which is so important for the brain in general.


Dr Jessica Briscoe [00:27:39] Absolutely. And I think the last thing we’ve touched on a little bit through all of the themes is anxiety and mood. The situation as a whole, we’re in, the phrase we’ve used most, unprecedented times. And so there is a lot of anxiety out there, not just about the virus itself or worrying about family and friends, but also change in routine. People are worried about their jobs, whether they will still have jobs to go back to and incomes. About actually education of their children, you know, how to keep children entertained. Not seeing friends and family generally, working from home, the stresses of that. Internet going down. And then also fear of migraine. If you find your migraines getting worse, that fear of migraine attack is a thing I see a lot and that can make things worse.


Dr Katy Munro [00:28:33] I think people are very worried about other people as well. There’s that ‘I’m all right, but I’m worried about my elderly mother in law or my, you know, my children who are further away and, you know, other elderly relatives we’re particularly concerned about’. But I think with the change from the lockdown to the transition period of us coming out, I’m slightly concerned that worry is going to be heightened because, you know, at least when you’re safe, locked down in your house, you know you personally aren’t in contact with the virus, but it’s the more that we’re going out and possibly being in contact. So anxiety is a big one.


Dr Jessica Briscoe [00:29:12] It really is.


Dr Katy Munro [00:29:13] And of course, depression, you know, if people are feeling isolated, they may be stuck in somewhere on their own. And a lot of people with pre-existing anxiety and depression have found that that’s been really hard for them to cope with.


Dr Jessica Briscoe [00:29:26] Absolutely. And, I mean, there are some things that people can do to help. So we’re both big fans of mindfulness.


Dr Katy Munro [00:29:34] Yes.


Dr Jessica Briscoe [00:29:34] So there are different books, apps, courses, all sorts of things that can help with that. So it’s worth looking into that if you haven’t tried it before. Also looking into exercise. Some people find yoga quite helpful to guide their meditation because lots of breathing exercises can be helpful. CBT counselling, cognitive behavioural therapy. They’ve been working really hard to keep counselling services going during this time. And some of them you can self-refer to and people are doing remote consultations. You can speak to your GP as well because, as we said, normal GP services are running. You’re not wasting anybody’s time. If anxiety is an issue, it’s really important to reach out and speak to someone about it. Actually, some corporations, also, some some workplaces have wellness schemes or wellbeing schemes. So it is worth seeing whether there is a helpline that you can speak to via work. They are usually confidential and not linked to your employer. It’s just a service that your employer sets up. So that could be another source of getting help, support or counselling for that. And occupational health as well. It’s worth saying whether there is an occupational health department at work, if you are having problems with desk set ups or screen issues when working from home or stress or any issues at all, problems juggling home schooling and work as well. It’s worth speaking to your manager and saying about occupational health and whether they can help too.


Dr Katy Munro [00:31:04] One of the other things which is very troubling is, of course, some people are reporting that the level of domestic violence is raised. And if you’re worried or affected by that, there are some very good national helplines which are doing their best to be there for anybody who’s affected by domestic violence and social services are also there for any vulnerable children. And so, you know, I think if things are becoming desperate, remember that those kind of helplines are still there. People may be feeling suicidal sometimes. The Samaritans are still taking calls, Childline is still open, and we’ll put some links in the blurb of helplines that might be useful for people.


Dr Jessica Briscoe [00:31:50] So I think we’ll move on to management actually now. We’ve talked loads about reasons that, you know, migraines may be worse, but can you do anything to help them in this time? Because there’s been loads of stuff about what medications are safe. Can you take ibuprofen? Can you take your aspirin? Do I have to just take my paracetamol? What are your thoughts on that, Katy?


Dr Katy Munro [00:32:11] So I think there’s a difference between somebody who’s actually got COVID-19 infection and somebody who hasn’t. So there was a big thing at the beginning of this lockdown, about whether or not it was safe to take ibuprofen or the family of drugs that it belongs to called the non-steroidal anti-inflammatory drugs, which includes naproxen, diclofenac and aspirin. And there was some evidence at the time, although it seemed to be slightly weak, that this may aggravate things. But I think the general consensus that we’ve come to from studying various health authorities which have put out guidance, is if you are actively suffering from COVID 19, stick with paracetamol. So we’re not 100% sure whether there is a big risk and people who take ibuprofen for other conditions such as rheumatoid arthritis, they have to take it regularly have been advised to keep going with it because the evidence is weak, but it’s more of a sort of being careful and a security thing, isn’t it really?


Dr Jessica Briscoe [00:33:18] What about triptans? Can I take my triptans?


Dr Katy Munro [00:33:22] I don’t think there’s any concern about triptans at all. If you have an attack of migraine, whether you have COVID 19 infection actively or not, it is perfectly fine to take your triptans. It’s also perfectly fine to take your anti-nausea tablets. The antiemetics that we often prescribe are domperidone or metoclopramide that help enhance the absorption of paracetamol, make it work more effectively. So paracetamol on its own may not be very good for migraine soluble paracetamol may be better. And if you combine it with an anti-nausea tablet like metoclopramide, then that can be even more effective. So that’s what I’m advising people to do.


Dr Jessica Briscoe [00:34:04] And obviously I’m just going to throw in the avoid codeine tag.


Dr Katy Munro [00:34:09] Oh, please avoid codeine.


Dr Jessica Briscoe [00:34:10] Please avoid codeine.


Dr Katy Munro [00:34:12]  It’s just the worst thing to take if you migraine sufferer, even if you take it for other conditions, it can very rapidly aggravate your migraine. So avoid avoid!


Dr Jessica Briscoe [00:34:22] And just be a bit mindful about cold and flu remedies if you are taking them for coronavirus symptoms, just have a look at what they contain and be mindful of medication overuse. I mean, if you’re just taking them for a short period of time, it’s usually okay. But I always just like to point that out.


Dr Katy Munro [00:34:38] I think read the small print because a lot of combination medications some of them sneak some codeine in and some of them have caffeine in. So just be very careful about what you’re taking.


Dr Jessica Briscoe [00:34:51] Preventative treatments as well. That’s something that I think it’s worth covering. So I don’t think there’s been any evidence that any of the preventatives are particularly unsafe to use in the pandemic. At the beginning there was a bit of a worry about Candesartan.


Dr Katy Munro [00:35:09] Yeah, but that’s-


Dr Jessica Briscoe [00:35:12] That was to do with the ACE inhibitor things. So ramipril which is a blood pressure medication or other ‘pril’ medications and candesartan, which is a related drug, because they were worried that it increased your susceptibility to getting coronavirus. But actually most of that’s been refuted now. And I’ve actually seen a few papers that have shown that some people do better with it.


Dr Katy Munro [00:35:34] Quite a few reassuring.


Dr Jessica Briscoe [00:35:34] But it’s very early evidence. They’re very reassuring. So if you’re taking that, keep taking it is the message.


Dr Katy Munro [00:35:42] Keep taking it. I mean, the one preventive that’s really been impacted and we’ve seen a lot of patients who struggle because of this is the Botox injections. We’re very lucky at the National Migraine Centre because we are able to prescribe the new anti CGRP monoclonal antibody medications. These are the injections that you inject yourself once a month because they’re self-administered, then access to those through the clinic is still available. Now one of them has been approved on the NHS, Ajovy. It was due to be rolled out on the 15th of April, but sadly due to the lockdown, the procedures that need to be implemented to enable that to be rolled out to NHS clinics have been put on hold. So we are waiting to hear how quickly that will be implemented in fact. Because a lot of people who were on Botox can and are quite suitable to switch over to Ajovy. But of course, if they want to do that, we are very happy to do that for them but we do have to charge because we’re a charity and we do rely on this kind of thing for income and we can’t afford to be providing it.


Dr Jessica Briscoe [00:37:03] I think it’s important point to just say there is no evidence and we have said this before in other podcasts, but I’d like to make it really clear there’s no evidence that being on a monoclonal antibody affects your immune system. So there’s no need to stop it during this time at all. So the guidance is to continue with any injectable or oral medication, because the risk of relapsing to your condition is higher than getting coronavirus. But yes as Katy said, Botox has really been impacted and nerve blocks as well. And we will talk about this a bit more maybe when we talk about cluster headache. We do use nerve blocks for migraine, but nerve blocks are much more use for cluster headache. So maybe we’ll discuss that in the cluster headache section below. What about devices as an alternative? So Cefaly.


Dr Katy Munro [00:37:59] Yes. The Cefaly and the sTMS mini devices. These are the Neuromodulation devices. They’re still available through our clinic. They’re quite hard to get hold of on the NHS at the best of times, aren’t they? But you can buy the Cefaly device over the internet I think from online shops and they’re a possibility. I think they can be helpful, I don’t think they’re a miracle for most people. We’re going to be doing an episode on them soon.


Dr Jessica Briscoe [00:38:35] I was going to say it’s probably more of a just thinking about things. If you are unable to get a monoclonal antibody in while you’re waiting for the clinics reopen, things that might ease things a little bit. And the other thing is supplements if you’ve not taken them. You’re inside a lot so vitamin D supplements are a must for everybody whether or not you get migraine. But there is evidence that links migraine and low vitamin D, but also the usual magnesium, B2 and coenzyme Q10 as well is worth just adding in if you’re struggling.


Dr Katy Munro [00:39:06] Our fact sheets on the website gives all the doses of those. Have a look on our website for fact sheets for more detail about any of these kind of things.


Dr Jessica Briscoe [00:39:16] I think this is a good point to just interrupt the podcast and have a little plea about donations. So we are a charity. Obviously, we run headache clinics and we provide information for people on our website and also via these podcasts. Now, because we’re a charity, we are incredibly reliant on donations to keep running. So we’d be really grateful if you’ve enjoyed the podcast and learn things from it, if you could actually visit Virgin Money Giving Page and we’ll pop the link in our blurb and just donate something to keep us going, because it’s been invaluable in making sure that our clinics have kept running, particularly through this pandemic crisis.


Dr Katy Munro [00:40:00] Cluster headache. Let’s come on to cluster headache. A rarer kind of primary headache. Not to be confused with migraine. Completely different and we always emphasise don’t use the term cluster migraine because there’s no such thing. So I still want to emphasise that because I still have patients saying, oh, I was told I have cluster migraine. No, you either have cluster headache or you have migraine or sadly some people develop both, but it’s two separate conditions. So there were concerns at the beginning of the coronavirus outbreak that cluster headache sufferers, who are very reliant on oxygen for the acute treatment of their attacks. It’s amazing how helpful it can be in an attack. And there were some concerns that they either wouldn’t be able to get their usual oxygen supply or that they would have to return some of their oxygen because of COVID 19 patients. Are you aware of that happening?


Dr Jessica Briscoe [00:41:00] I haven’t actually spoken to any patients who’ve had problems with that, actually, but I’ve seen concerns about it on various social media, particularly Twitter. I’ve seen people mention that. Have you come across anyone who’s had problems with that?


Dr Katy Munro [00:41:13] I follow a Facebook group about cluster headache and certainly one or two of the sufferers there who had standby oxygen for when their next episode started had been asked to return oxygen that they weren’t using, which did heighten their anxiety.


Dr Jessica Briscoe [00:41:30] Of course. Especially being spring as well. This did happen in Spring.


Dr Katy Munro [00:41:32] Yes.


Dr Jessica Briscoe [00:41:33] Which, if you listen to one of our earlier episodes, you can learn more about cluster headache. But spring and autumn tend to be times where people are more likely to get a cluster. Sumatriptan injections are another invaluable treatment, as with the oral triptans completely safe to use. So it’s worth making sure- I mean, there was a bit of a concern about people hoarding medication. Obviously if you get cluster headaches, you’re probably used to making sure that you’ve got stuff ready before your attack. It’s worth actually just double checking. You’re not hoarding medication if you get them available beforehand because you will be using them. It’s not quite the same thing and your GP should be able to provide them for you. I’m not aware that there’s a shortage, but there could just be a bit of a delay in getting your normal medication. So it’s worth just making sure you request it early. What about oral steroids? Because some people find they use tablet steroids, don’t they, to stop a bout when it first hits.


Dr Katy Munro [00:42:31] Yes. It’s not very frequently used. It’s an option, isn’t it? That we do occasionally prescribe, of course. But I think there’s a bit of concern if you actually have the COVID 19 infection that the use of oral steroids, it should be avoided. So I think we would be even more careful about prescribing them than we usually are. This is where the greater occipital nerve blocks are so useful because they can really help if you get in there quickly at the beginning of a cluster bout they can often help people. But of course at the moment we can’t do that. So that has caused some difficulties.


Dr Jessica Briscoe [00:43:12] No. So we can’t do it at the clinic. The advice from the British Association for the Study of Headaches is that each case should be discussed with cluster headache on a case by case basis with your consultant. So it is one of the situations that if you are having severe difficulties, they may consider doing a nerve block if they have the capability to do it. One of the problems is it’s also using a steroid, isn’t it? So for cluster headache particularly, it’s a mixture of steroid and local anaesthetic. Now, there isn’t actually- so the Faculty of Pain Medicine have released a document. So they talk about all the different types of nerve blocks, you can do them all, it’s not just at the back of the head. Lots of people have nerve blocks elsewhere. And also for cluster headache, people have multiple nerve blocks, too. Now they’ve said that it should that nerve block should not be used if someone has suspected or known coronavirus. But if the risk of the problem- if the risk of the condition of treating is very high in which cluster headache is a severe pain condition, you can consider doing it. So if you are struggling, then please do speak to your consultant about it and see whether or not there is a case for you having it. But there’s definitely no guarantees at this time.


Dr Katy Munro [00:44:43] I think it is very difficult and I think it’s worth reiterating that cluster headache is not just a headache. It is one of the most severely painful conditions known to humans, and it has sometimes in the past been called a suicide headache. So when we are assessing patients for cluster headache and for the severity of their condition, I would urge anybody who’s caring for people with Cluster to remember that this is really not just- I think sometimes the word headache makes people go, ‘oh, well, you know, it’s just a normal headache, isn’t it?’ And of course, it really isn’t. Chronic migraine is the same, it’s so severe. The impact on people’s lives is absolutely massive.


Dr Jessica Briscoe [00:45:26] And you mentioned Verapamil at the beginning, actually.


Dr Katy Munro [00:45:30] Yes. A very good preventor. But the difficulty is, of course, if you’re changing the doses of Verapamil, then ECG monitoring is strongly advised because of the risk of cardiac problems with it. So it can cause rhythm disturbances. And so it’s very important to do that. And it may well be that GP’s have got facilities ability to do ECGs. So it doesn’t mean it’s not possible, it just means it may be slightly more tricky to arrange.


Dr Jessica Briscoe [00:46:00] And then what about-


Dr Katy Munro [00:46:00] What about the GammaCore?


Dr Jessica Briscoe [00:46:01]  You read my mind! So this is another device that. Its held to your neck and it stimulates the vagus nerve and there is evidence it’s helpful in cluster headache. Is it available on the NHS now? I can ever remember.


Dr Katy Munro [00:46:18] I think it is but I think it’s quite tricky and it’s very regional. It depends on local guidance. But it may be that if you’re speaking to your cluster headache consultant specialist it might be something that they would suggest to you. It would just depend on the local guidelines of what’s available but GammaCore, it’s a very, very safe neuromodulation device. You use it to stimulate the vagus nerve, as Jess has said, and you need to use it regularly to try and reduce the impact of cluster. And some people find that very helpful.


Dr Jessica Briscoe [00:46:53] Absolutely. And don’t forget, OUCH, the Organisation for the Understanding of Cluster Headache, are around and available to help advocate. They also run a support line. We will put their details in the blurb as well, but they’re always a great source of information about what is available and what isn’t and what the state of play is nationally. So please do get in touch with them.


Dr Katy Munro [00:47:17] So yeah, to summarise.


Dr Jessica Briscoe [00:47:19] Yes, to summarise.


Dr Katy Munro [00:47:20] So Coronavirus pandemic restrictions have changed life as we know it and who knows what will result from here. But certainly headache services have been impacted and may take a lot of time to go back to normal because we know certainly in certain areas of the country, a waiting list to see a neurologist was already very long. So catching up with that, it may take a long, long time for people to get sorted. On the plus side, we’ve all had to reinvent how we do things. And so telemedicine may mean that we can crack on through and waiting lists may be shortened by putting in remote consultations by NHS. This is conjecture. I’m just wondering because we certainly, I don’t think, will be going back to all just face to face consultations. We’ve certainly found that this has been a very great benefit to lots of patients.


Dr Jessica Briscoe [00:48:14] Absolutely.


Dr Katy Munro [00:48:15] So we’d urge you, if you have any kind of headache problems and you can’t get through to your NHS providers, by all means, book in for an appointment with one of our headache specialist doctors at the National Migraine Centre. We’ve got lots of clinics available, lots of slots available and we’re even looking at doing some flexible, out-of-hours and Saturdays if there was a demand.


Dr Jessica Briscoe [00:48:37] Yeah for people that are working mainly so that you know, you don’t have to miss work to speak to a headache specialist.


Dr Katy Munro [00:48:44] Yes. Because even if you are working from home, sometimes it’s quite difficult to be not working from home during the day on the Monday to Friday. Try and manage your triggers, particularly during this time. Regular routine, reduce change as much as possible. So keep your mealtimes regular, your bedtime, your waking time as regular as possible and try keeping your exercise as we’ve discussed, little and often.


Dr Jessica Briscoe [00:49:15] Yes. Don’t forget that most migraine treatment is safe, but there are issues with providing injection services at present. So think about alternatives that might ease your symptoms such as devices or supplements that have evidence for their use. And if you are having a bout of cluster headache and you’re struggling, speak to your headache specialist as soon as possible and contact OUCH or us for more advice on management.


Dr Katy Munro [00:49:42] Thanks for listening to this episode and we’ll hopefully be joining you in a couple of weeks with our next episode, which is going to be about devices for migraine and cluster headache.


Dr Jessica Briscoe [00:49:54] Perfect. Stay safe, everyone.


[00:49:59] You’ve been listening to the Heads Up podcast. If you want more information or have any comments, email us on info@NationalMigraineCentre.org.uk. Till next time.

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This transcript is based on a past episode of the Heads Up podcast and reflects information available at the time of broadcast – some facts may have changed or new treatments become available since.

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