COVID‐19 and Headache Medicine: A Narrative Review of Non‐Steroidal Anti‐Inflammatory Drug (NSAID) and Corticosteroid Use

Abstract

Objective To summarize the current literature on non‐steroidal anti‐inflammatory drug and corticosteroid use during the coronavirus disease 2019 (COVID‐19) pandemic, recognizing that these are commonly used treatments in the field of headache medicine. Background The use of non‐steroidal anti‐inflammatory drugs and corticosteroids in patients during the COVID‐19 pandemic has been a controversial topic within the medical community and international and national health organizations. Lay press and social media outlets have circulated opinions on this topic despite the fact that the evidence for or against the use of these medications is sparse. In the field of headache medicine, these medications are used commonly and both patients and clinicians may have questions or hesitations pertaining to their use during the COVID‐19 pandemic. Methods A detailed search of the scientific and popular literature was performed. Results There is limited literature pertaining to the safety of non‐steroidal anti‐inflammatory drugs and corticosteroids during the COVID‐19 pandemic. To date, there are no clear scientific data that preclude the use of non‐steroidal anti‐inflammatory drugs in the general population who may acquire COVID‐19 or in those acutely infected with the virus. Several health organizations have concluded that treatment with corticosteroids during active infection should be avoided due to concerns of prolonged viral shedding in the respiratory tract and the lack of survival benefit based on the data from past coronaviruses and influenza virus; specific exceptions exist including treatment for underlying asthma or chronic obstructive pulmonary disease, septic shock, and acute respiratory distress syndrome. Conclusion Scientific information regarding the COVID‐19 pandemic is constantly evolving, and limited or contradictory information can lead to confusion for both patients and clinicians. It is recommended that prior to prescribing non‐steroidal anti‐inflammatory drugs and steroids for the treatment of headache, clinicians have open discussions with their patients about the potential risks and benefits of using these medications during the COVID‐19 pandemic. This manuscript summarizes the currently available evidence and understanding about these risks and benefits to help clinicians navigate such discussions.

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

“…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 [ 7 , 8 ]. Impaired access to neurologists may have worsened this situation for many patients.…”

Headache as a Symptom of COVID-19: Narrative Review of 1-Year Research

“…For migraine-like phenotypes triptans and, where available, lasmiditan and gepants may be an option, although it is important to consider all possible contraindications that could be related not only to patients' comorbidities but also to COVID-19 clinical stage and severity at the moment of the prescription. Although concerns had been raised in the use of nonsteroidal anti-inflammatory medications (NSAIDs) during the COVID-19 outbreak, due to the putative risk that they may upregulate ACE2 and therefore facilitates SARS-CoV-2 infection, there are no clear scientific data that preclude their use in the general population who may acquire COVID-19 or in those acutely infected with the virus [67,68]. Corticosteroids, that represent an effective treatment in status migrainosus, seem to be beneficial in severe COVID-19 [69].…”

Virtual Issue: COVID‐19 and headache

“…Frontline workers, and now the general population, wearing personal protective equipment have developed headache (probably attributed to external‐compression headache) 4 . Clinicians have had to change practice, now heavily weighing the safety of previous commonly used headache treatments like non‐steroidal anti‐inflammatory drugs and corticosteroids and utilizing pragmatic at‐home bridging therapies to replace in‐office procedures and acute care visits 5,6 . The need for social distancing has further led to a drastic healthcare system‐wide shift toward telemedicine and other virtual services, 7 which is also providing a renewed interest in more contemporary applications of holistic care, such as smartphone‐based mindfulness and behavioral applications.…”

“…4 Clinicians have had to change practice, now heavily weighing the safety of previous commonly used headache treatments like non-steroidal anti-inflammatory drugs and corticosteroids and utilizing pragmatic at-home bridging therapies to replace in-office procedures and acute care visits. 5,6 The need for social distancing has further led to a drastic healthcare system-wide shift toward telemedicine and other virtual services, 7 which is also providing a renewed interest in more contemporary applications of holistic care, such as smartphone-based mindfulness and behavioral applications. Headache education has required rapid evolution as the majority of neurology residents and fellows, 8 as well as other graduate, undergraduate and continuing medical education training programs, have had their formative experiences in 2020-2021 impacted by the pandemic.…”