Expert Perspective

Headache and COVID-19: Key questions answered

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Although coronavirus 19 disease (COVID-19), caused by severe acute respiratory coronavirus 2, is characterized by symptoms that primarily impact the respiratory system, many patients experience neurological manifestations, with headache among leading complaints. Moreover, headache symptoms, including migraine-like headache, can last long after patients recover from COVID-19.

Last November, in an interview with 60 Minutes, Sadie Nagamootoo described her experience. “There are days when I do nothing and cannot get out of bed. The migraines are 10 times worse than a flu headache.”

To help individuals like Nagamootoo and others who experience headache as a result of COVID-19, it is important to understand the data that are emerging and how to incorporate them into practice. Following are answers to important questions that can guide front-line neurologists and other clinicians who are practicing during the pandemic.

Why is headache a symptom of COVID-19? It should come as no surprise that patients with COVID-19 can experience headache. Peng reminds us, in a November 2020 editorial in Cephalalgia, that headache is a common symptom in individuals with acute respiratory disease, representing a physiological response to acute infection. Headache is often the primary reason patients seek treatment.

How is headache associated with COVID-19? It is too early to know with certainty the mechanisms underlying COVID-19 headache, but a possible explanation—according to Uygun and colleagues, writing in the The Journal of Headache and Pain —is that the virus directly invades trigeminal nerve endings in the nasal and oral cavities.

How does headache tend to present in COVID-19? Patricia Pozo-Rosich, MD, PhD, presented on this topic at the American Headache Society’s 2020 Virtual Annual Scientific Meeting in June. In a recent interview with Neurology Reviews, Dr. Pozo-Rosich, head of the Headache & Craniofacial Pain Unit at Vall d’Hebron University Hospital, Barcelona, Spain, noted that “headache seems to have 2 different presentations: 1) migraine-like characteristics that are severe, disabling, and usually start before other COVID symptoms and 2) tension-type headache characteristics, which usually start together with the rest of COVID symptoms.”

Are there symptoms that tend to occur more frequently in patients with COVID-19 and headache? Caronna and colleagues recently published an analysis in Cephalalgia of 130 individuals with COVID-19, showing that loss of smell and/or taste occurred in more than half of patients with headache, compared with fewer than 20% of those without headache. This finding is notable because it has been frequently reported in case reports of patients with COVID-19 and headache.

What does the presence of headache indicate about COVID-19 prognosis? The good news for individuals with COVID-19 who experience headache is that the duration of their COVID-19 illness might very well be shorter. In the Caronna study, COVID-19 duration in individuals with headache was, on average, 1 week shorter (24 days) than in those without headache symptoms (31 days). “We don’t know why,” said Dr. Pozo-Rosich, who is one of the study’s authors. She hypothesizes that it is because of a balance between neuroinflammation and systemic inflammation. “Having an extraordinary initial reaction at the nasal cavity might protect us from having greater systemic inflammation.”

What is the cause of headache from COVID-19? Bolay and colleagues reported in Headache in Spring 2020 that patients developed new-onset, moderate-to-severe, bilateral pulsating or pressing headache toward the frontal area and forehead during the viral phase of disease. The virus activates peripheral trigeminal nerve endings directly or through vasculopathy and/or increased circulating pro-inflammatory cytokines.

What else is important to be aware of regarding headache evolution in individuals with COVID-19? The bad news for many of these individuals is that, although their COVID-19 illness might dissipate more quickly, headaches could linger. Moreover, many will be experiencing chronic headache for the first time in their life. Caronna reported that that one third of follow-up patients who reported headache were experiencing persistent disabling headache daily after 6 weeks, and more than half had no history of recurrent headache.

What is the recommended treatment for headache associated with COVID-19? Dr. Pozo-Rosich recommends starting with a nonsteroidal anti-inflammatory medication. Eventually, steroids might be indicated, “especially if the disease progresses.”

It is important for neurologists to be aware of new-onset headache associated with anosmia early in the disease. Test for the virus in such a patient; hopefully, their course will be shorter, milder, and non-respiratory.

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