The Impact of Natural Disasters on Migraine

Recent research shows that victims of the 2018 Japan Floods were more likely to receive newly prescribed migraine treatment, compared to non-victims. A separate study reveals how COVID-19 can affect migraine – sometimes in surprising ways.

Malcolm Turnbull, the former prime minister of Australia, once said, “[W]e learn from every natural disaster. Whether it is a fire or a flood, we learn something from it so that we can respond to the next one, better.”

Unfortunately, the world has seen many natural disasters and other catastrophic events recently – extreme weather and COVID-19 immediately come to mind – so there is much to learn from. People living with chronic disease, including migraine, may be at particular risk of their condition worsening because of the disruption and stress these events can cause. To test that hypothesis, new research examines the impact of two recent events on the symptoms, severity, and treatment of migraine.

In one study, researchers from Kitahiroshimacho Yahata Clinic, Hiroshima University and Jichi Medical University in Japan found that victims of the 2018 Japan Floods, which caused widespread flooding and mudflows in the western part of the country, were more likely to receive newly prescribed acute treatment after the disaster, compared to non-victims. The study also reported an increase in the number of tablets for victims.

“The current study demonstrates that natural disaster preparedness is an important part of migraine management, and that we need to consider it as clinicians and counsel our patients regarding how to prepare,” wrote Amy Gelfand, University of California San Francisco, US; Rashmi Halker Singh, Mayo Clinic, Scottsdale, US; and Matthew Robbins, Weill Cornell Medicine, New York, US, in an accompanying guest editorial.

“Patients may enter our practice upon settling in a new area after displacement by a natural disaster. Cognizance of the patient experience impacting their migraine pattern, and the amount of treatment needed, can guide clinical decision-making,” they continued.

In the second study, investigators from Albert Einstein College of Medicine and Montefiore Medical Center in New York undertook a qualitative study using semi-structured interviews. These interviews asked people with migraine about their experience of living with the condition during the COVID-19 pandemic.

The study reported that many people with migraine experienced interrupted medical care, leading to increased severity and frequency of migraine. In contrast, other study subjects said that more flexible schedules actually decreased the frequency of migraine attacks. Increased access to healthcare, thanks to telemedicine, was also a positive impact of the pandemic.

The Japan Floods study and accompanying guest editorial appeared in the June 2022 issue of Headache. The qualitative COVID-19 study was published in the March 2022 issue of the same journal.

More new prescriptions
The 2018 Japan Floods, known in the country as Heisei san-jū-nen shichi-gatsu gōu, laid waste to much of western Japan. Those who survived the floods had to manage the incredible damage and destruction left behind.

After publishing a study earlier this year showing that benzodiazepine prescriptions increased after the floods – a trend that persisted for an entire year – first author Yuji Okazaki, a physician at the Kitahiroshimacho Yahata Clinic, and colleagues wondered if psychological stress from the floods would hasten the onset of, or exacerbate migraine.

“We found an association between this natural disaster and psychological stress in the benzodiazepine study,” he wrote to MSC in an email. “We wanted to know what the relationship between the stress of the floods would be with migraines, which have a high prevalence.”

The researchers conducted a retrospective longitudinal cohort study using data from Japan’s National Database of Health Insurance Claims to examine whether prescriptions for triptans and ergotamine increased after the floods. The team focused on areas of the country that experienced the most severe damage and looked at the claims of people who received a special government code designating them as victims of the disaster.

The investigators found that victims of the floods were significantly more likely to receive new prescriptions for acute migraine treatment than non-victims. Specifically, 0.7% of victims received newly prescribed treatment, compared to 0.43% of non-victims. This translated to new prescriptions for acute treatment being 1.68 times more likely to occur in victims than in non-victims. (These results applied to people who had not had acute treatment before the disaster).

Victims were also more likely to receive a higher number of tablets during the post-disaster period. This was true both for people who had previously received acute treatment and for those who previously received both acute and preventive treatment before the disaster.

Interestingly, there was a delayed effect, with the cumulative incidence of new prescriptions for acute treatment beginning to diverge between victims and non-victims only about two months after the flood.

“Although the direct cause of the increase of migraine attacks, and acute migraine treatment, is unclear, we believe it is stress related,” according to Okazaki. “We believe that the deaths of family members and loss of homes that cause this kind of stress is immeasurable. Living in a shelter is probably also a source of stress. And while we were surprised the prescriptions for triptans did not increase immediately after the disaster, we think this may be consistent with studies showing that migraine attacks are not triggered by the stress itself but rather when stress levels drop.”

Gretchen Tietjen, University of Toledo, Ohio, US, who was not involved with the research, said the study is important and innovative. But she is curious to see what the results would be if the work had been expanded to include other drugs, such as non-steroidal anti-inflammatory drugs (NSAIDs).

“It would be hard to capture these drugs in their database since they aren’t specific for migraine, but it would have been interesting to see,” she said. “And while there were many psychological stressors involved with the increase in these prescriptions, there could be other physical stressors involved, too. There may be changes to the water or to air quality after an event like this. But, regardless, these findings are important and show that, in times of natural disaster, physicians should be prepared for headache symptoms to increase.”

Understanding the cons – and surprisingly, some pros – of a pandemic for people with migraine
When the COVID-19 pandemic struck, Dawn Buse, Albert Einstein College of Medicine; Richard Lipton, also from Einstein and Montefiore Medical Center; and colleagues were working on a qualitative study for the US Food and Drug Administration (FDA) Migraine Clinical Outcome Assessment System (MiCOAS). The goal was to better develop meaningful outcome measures for clinical trials of migraine treatments.

“We were working on this project to help the FDA find the outcomes that matter most to patients for use in migraine trials,” said Lipton. “It involved interviewing people who live with migraine to determine how the illness impacts their lives, what they like and don’t like about the treatments they are getting, and what they want from an ideal treatment. It’s a starting point to develop new metrics to use in clinical trials. But by the time we were ready to start, the COVID-19 pandemic was at its peak. We worried that COVID-19 might change the way people experience migraine and migraine treatment in ways that might render our qualitative work invalid, so we added questions about COVID-19 and migraine.”

The MiCOAS team used semi-structured interviews with 40 patients with self-reported, medically diagnosed migraine who said they had not tested positive for or been diagnosed with COVID-19. When it came to migraine treatment, the team discovered that 70% of the study sample said the pandemic had changed their experience of life with migraine. About one-third reported more frequent attacks, as well as interrupted medical migraine care. Thirteen of the 40 respondents said their stress levels had increased, too.

Yet, some participants said their condition had improved with the pandemic. Twenty-nine percent said they had improved access to healthcare thanks to telehealth options. Others pointed to less disability, having more flexible work and school schedules, and reduced social expectations as benefits.

Buse said the research team was not surprised by the negative impacts of the pandemic, especially the challenges due to interruptions to care. Yet, she was somewhat surprised by the positive impacts.

“At that point, there were some data suggesting that having COVID-19 could trigger or exacerbate headache. And it was logical to assume that even for someone who did not contract COVID-19, if they regularly received a preventative migraine treatment such as onabotulinumtoxinA [Botox] and their medical office was closed and they could not receive their treatment, then that would negatively impact them,” she said.

“But participants also reported what I like to think of as ‘silver lining’ benefits to the early public health response to the pandemic including work and school closures followed by virtual options. People liked having greater flexibility and control over their schedules,” Buse continued. “They were sleeping more and slowing down when they needed to. For decades we’ve been talking about the importance of these healthy lifestyle habits in managing migraine. But now we had this real-life experience that showed what happens when you give people more control over their sleep schedules and their work lives. A fair number of interview participants reported that they felt better and thought that their migraine improved as a result.”

Leon Moskatel, a headache specialist at Stanford University School of Medicine who does research on headache after COVID-19 but was not involved with the MiCOAS study, said the current results support the idea that lifestyle factors are an integral part of managing migraine.

“It would be helpful to expand a study like this – to look specifically at interruptions to treatment and how those patients were affected by it,” he said. “But it’s important that we, as clinicians, are more cognizant of all the ways that events outside of a patient’s control can worsen with migraine and be ready with the right tools to help them weather these changes, whether it’s a pandemic, a natural disaster, or just a major life change.”

A let-down from stress?
Lipton said that anecdotal evidence and published studies are now showing that many people experience an increase in the frequency or severity of migraine after a natural disaster. Like Okazaki, he said that the likely culprit is the “let-down” from stress.

“We did a diary study that was published in Neurology a number of years ago where we measured stress and the occurrence of headache every day,” he said. “We found a phenomenon called ‘let-down headache.’ Headaches didn’t come on from stress. Rather, they were more likely after the stress was over. The stress itself wasn’t the most potent trigger. It was the relaxation after the stress when the headache happened.”

He hypothesizes that the body releases cortisol in response to major stressors – part of the “fight-or-flight response.” But when cortisol levels go down, headaches tend to come on. So, it may be that falling cortisol is a migraine trigger.

As for Okazaki and colleagues, “We believe there are two things that physicians need to understand,” he wrote to MSC. “First, because migraine attacks may increase after a natural disaster, it’s important to educate patients about this in advance to increase their understanding of health maintenance. Second, it is important that we use proper prophylaxis for migraine attacks. This may be effective in preventing migraine attacks resulting from the psychological stress of a natural disaster.”

Tietjen added that the studies demonstrate the need for more research.

“These two studies both point out that so much more research needs to be done because, when it comes down to it, we need to figure out ways to address these different issues so we can help our patients who are experiencing these disasters,” she said. “There are a lot of challenges in doing work like this. But more research can only help us in coming up with solutions that will help us and our patients better manage their migraines.”

Kayt Sukel is a freelance writer based outside Houston, Texas.

References:

Impact of the 2018 Japan Floods on prescriptions for migraine: A longitudinal analysis using the National Database of Health Insurance Claims. Okazaki et al. Headache. 2022 Jun;62(6):657-667.

Worsening migraine: Another casualty of natural disasters. Gelfand et al. Headache. 2022 Jun;62(6):645-647.

Impact of the COVID-19 pandemic on people living with migraine: Results of the MiCOAS qualitative study. Buse et al. Headache. 2022 Mar;62(3):284-293.