Reply to correspondence "Contributing factors towards progression of migraines during the Covid-19 pandemic".

We read Shafeeq Ahmed's letter about our recent article with interest. Stress is one of the most well-known migraine triggers. Early studies have already revealed that stress significantly affects migraine clinical course during the COVID-19 pandemic. Therefore, we also took into account the stress factor in our study. We tried to assess the influence of the COVID-19 pandemic on the psychological state of our patients using the Beck Depression Inventory and the Beck Anxiety Inventory. Due to the COVID-19 pandemic, personal protective equipment and disinfectants have been used so widely and intensively for the first time. Thus, we thought that evaluating the effect of the COVID-19 pandemic on migraine only through stress would be an inadequate approach. Our study demonstrated that in addition to stress, mask types, number of masks, duration of mask use, and disinfectant exposure might affect migraine attacks. Taking these factors into account, treatment and preventative methods may improve migraine sufferers' quality of life.

To the Editor,

We read Shafeeq Ahmed's letter [1] about our recent article [2] with interest. One of the important well-known triggers of migraine is stress. For this reason, most of the studies examining the relationship between migraine and the coronavirus disease 2019 (COVID-19) have investigated the effects of stress in detail. In these studies, the impact of COVID-19 infection and pandemic restrictions on stress has been discussed in many dimensions. Finally, early studies have already revealed that stress significantly affects migraine clinical course during the COVID-19 pandemic [3], [4], [5], [6], [7]. Thus we took into account the stress factor in our study. Using the Beck Depression Inventory and Beck Anxiety Inventory, we tried to determine the impact of the COVID-19 pandemic on the psychological state of our patients. Then we stated that increased anxiety and depression in our patients were associated with migraine worsening [2].

Over time, the COVID-19 pandemic has turned into a huge multi-faceted problem that deeply affects societies not only in terms of health but also in economic and social terms. In addition, migraine still remains a disease whose pathophysiology has not been fully revealed and is driven by multiple factors. For these reasons, we thought that evaluating the effect of the COVID-19 pandemic on migraine only through stress would be an inadequate approach. Personal protective equipment (PPE) and disinfectants have been used so widely and intensively for the first time outside of healthcare areas. How these factors will affect a disease such as migraine affected by every aspect of daily life has not yet been adequately evaluated. Our study demonstrated that in addition to stress, mask types, number of masks, duration of mask use, and disinfectant exposure might affect migraine attacks [2]. Contrary to Shafeeq Ahmed's claim [1], considering our results and discussion, we did not emphasize anywhere in our article [2] that PPEs were the only or pure factor for migraine worsening.

Shafeeq Ahmed stated that unemployment, comorbid diseases, age, and COVID-19 infection might impact migraine worsening [1]. Undoubtedly, all these factors can affect migraine attacks. However, it should not be overlooked that the groups of migraine worsening and migraine improving were similar in terms of these factors in our study [2].

As a result, during the COVID-19 pandemic, it is important to remember that some factors such as PPE use and excessive disinfectant exposure as well as stress may cause an increase in migraine attacks. Taking these factors into consideration, treatment and preventative methods may improve migraine sufferers' quality of life and reduce their disability.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.