A meta-analysis found that migraine is more common in those with low, or very high, BMI (but not high BMI), suggesting this may be epiphenomenal rather than causal. A UK study found migraine was most common in white women, without correlations with education or income and a global review found headache disorders did not follow sociodemographic indices. Prevalence of migraine in younger women militates against two of these risk factors. COVID-19 mortality associates with cardiac and pulmonary diseases, diabetes, older age, male gender, obesity, Asian and black ethnicities and deprivation. Extrapolation suggests people with migraine are at average, or lower risk, of severe acute COVID-19. There are little specific data on migraine as a risk factor for COVID. A World Health Organization (WHO) survey of 155 countries found that almost half of patients with chronic diseases missed their regular medical care and medications since COVID-19 pandemic began. Pro-active management of long-term conditions, such as migraine and epilepsy, is essential to prevent suffering, secondary morbidity, particularly mental health problems, and avoidable emergency attendances. Challenges for health practitioners and physicians and neurologists include protection of vulnerable patients, and tackling neurological complications of COVID-19. The COVID-19 (coronavirus, severe acute respiratory syndrome coronavirus 2, SARS-COV-2) pandemic creates unprecedented challenges and new working patterns for clinicians. Most management occurs outside of secondary care-only 100,000 (4%) of 2.5 million primary care headache consultations in the United Kingdom (UK) are referred to specialists, but headache is the fourth most common emergency department presentation, 90% of which are migraine. Migraine has an annual cost of €95 billion in Europe (93% due to lowered productivity), causing 9.5% of years lived with disability in 15–49-year-olds. Treating migraine, a sequel of COVID, potentially reduces the impact of long COVID. Migraine and other long-term conditions need adequate resourcing to prevent personal, social and economic suffering. Secondary effects of COVID-19, including long COVID and its economic impact, are probably equal or greater in people with migraine. Close contact procedures (botulinum toxin, acupuncture and steroid injections) are avoided in lockdown or in the vulnerable. Most migraine treatments can start or continue in acute COVID-19, with care to avoid drug interactions. Telemedicine is effective for migraine follow-up, and needs ongoing evaluation. Many risk factors for severe COVID-19-older age, male gender, cardiac and respiratory diseases, diabetes, obesity, and immunosuppression-are less frequent in migraineurs. This article examines the impact of COVID-19 on migraine, and changing aspects of migraine care during and after the pandemic. Migraine hits people particularly in their early and middle years, potentially reduces quality of life and productivity, and remains a common emergency presentation. The worldwide treatment gap for migraine before COVID-19 inevitably widens as attention focuses on an international emergency.
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