key: cord-0704485-i7q2oxjs
authors: Gelfand, Amy A.; Poland, Gregory
title: Migraine treatment and COVID‐19 vaccines: No cause for concern
date: 2021-03-23
journal: Headache
DOI: 10.1111/head.14086
sha: 08b3701cdeec2dd0be1ec43cec7bd02727973393
doc_id: 704485
cord_uid: i7q2oxjs

The advent and availability of COVID-19 vaccines has led patients to pose a number of questions to their headache healthcare providers. In retrospect, it is perhaps surprising that these questions did not come earlier-for example around annual flu shot campaigns. However, COVID-19 has brought into focus questions about whether vaccines have an impact on the management of migraine and other headache disorders.

The advent and availability of coronavirus disease 2019 vaccines has led patients to pose a number of questions to their headache healthcare providers. In retrospect, it is perhaps surprising that these questions did not come earlier, for example, around annual 

Some patients may wonder whether onabotulinumtoxinA is con- 

With regard to the four mAbs to CGRP or its receptor, there is no immunological or clinical reason to think that these would impair the body's immunologic response to any COVID-19 vaccine. While there are CGRP receptors on lymphocytes, macrophages, and mast cells, and CGRP may have a role in pro-and anti-inflammatory actions, 2 clinical trial evidence with these mAbs has not suggested that they are immunosuppressive or myelosuppressive-nor would they be expected to be given the molecular engineering they have undergone. 3 While upper respiratory tract infection-like symptomatology and urinary tract infections were reported as adverse events in the adult CGRP clinical trials, rates of these were not higher than what occurred in the placebo groups. 4, 5 Moreover, the nature of mAbs is that they have very narrow specificity limited to their defined target, and not broad specificity that might allow non-specific binding to other proteins. A frequent question that arises is whether to defer monthly or quarterly CGRP pathway mAb treatment by 2 weeks from the vaccine. At this point, there are no data to suggest that such treatments would in any way interfere with COVID-19 vaccine immunogenicity, safety, or efficacy.

The three CGRP pathway mAbs that are given by subcutaneous injection can cause local injection site reactions-typically redness or soreness at the site. This could be confused with a local vaccine reaction if the patient administered their CRGP pathway mAb in the same arm in which they recently received a COVID vaccine. However, many patients administer their injections to the abdomen or thigh, and those who do use the arm could simply be advised to inject in the opposite arm to the one in which the vaccine was given.

In some studies, antipyretic use has been associated with decreased laboratory measured antibody response to vaccination in infants. 6 However, the clinical significance of this is unclear, and the effect was seen with primary vaccination and not with boosters. 6 

On the question of whether antibody production in response to the COVID-19 vaccine would make these migraine preventive treatments less effective, there is no reason to think that antibodies to the spike protein of the SARS-CoV-2 virus would neutralize onabotulinumtoxinA, or antibodies to CGRP or its receptor, given that COVID-19 vaccines induce antibody only to the spike protein of SARS-CoV-2. While it is remotely possible that the body could produce an antibody that would neutralize these treatments, there is no more reason to think that the COVID-19 vaccine would lead to production of such an antibody than any other vaccine, or any other infection. Therefore, there is no apparent rationale to retime these treatments out of concern for impairing their efficacy.

As always, individual patients should make treatment decisions in concert with their treating healthcare professionals, taking into account their individual circumstances. We are aware of no evidence that preventive treatment with CGRP pathway mAbs or onabotuli-numtoxinA injections needs to be delayed or retimed with regard to timing of administration of a COVID-19 vaccine. Similarly, no evidence exists that the timing of COVID-19 vaccine administration should impact concurrent treatment with these migraine preventives. The established risks of COVID-19 infection, and the proven efficacy of migraine preventive therapies, further underscore the importance of not delaying either of these interventions. Those patients who administer CGRP pathway mAbs in the upper arm may wish to administer in the opposite arm to the one in which they received the COVID vaccine to avoid confusion as to cause if a local injection site reaction develops. While routine use of NSAIDs or acetaminophen before a vaccine is not recommended, if symptoms develop after the vaccine (e.g., fever or headache), the use of these treatments is not contraindicated and would be considered first-line treatment.

We thank headache healthcare professionals and others on Twitter who provided input in response to the questions, "Headache providers: What questions are your patients asking you about the COVID vaccine? What information do you wish you had to be able to counsel them better?", sent by @aagelfand on Wednesday, January 13, 2021. 

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Migraine treatment and COVID-19 vaccines: No cause for concern Headache