Headache Associated With COVID-19

Epidemiology, Characteristics, Pathophysiology, and Management

Pedro Augusto Sampaio Rocha-Filho MD, PhD


Headache. 2022;62(6):650-656. 

In This Article

Secondary Headache Associated With Complications of COVID-19

Several neurological complications for which a headache may be a symptom have also been linked to COVID-19. Among these, arterial and venous cerebrovascular diseases, encephalitis, and acute disseminated encephalomyelitis are the most outstanding.[35,36]

A systematic review reported an incidence of cerebral venous thrombosis of 0.8 cases per 1000 hospitalized patients. In 19% of cases, there were other risk factors for cerebral venous thrombosis in addition to COVID-19. In 7% of cases, symptoms of cerebral venous thrombosis preceded respiratory symptoms and in 1.8%, headache was the only symptom presented.[37]

A case series involving 25 patients with COVID-19 who underwent cerebrospinal fluid (CSF) examination for refractory headache drew attention to the possibility of the presence of intracranial hypertension. Five patients presented with a CSF opening pressure greater than 250 mm CSF; four of these were women and four had no papilledema. These patients presented no other CSF changes and their brain magnetic resonance imaging (MRI) had normal findings.[38]

We previously described a case of meningitis associated with SARS-CoV-2. The patient had a fever in the first 7 days of symptoms, but when the headache began, she no longer presented this symptom. She had no meningeal signs. She had a continuous headache that lasted 7 days.[39]

Patients with a COVID-19 headache present a high frequency of red-flag symptoms.[16,17] This is not surprising because a COVID-19–associated headache is a secondary headache. Among the traditional red flags, the most clinically significant are sudden headache, headache triggered by Valsalva maneuver, progressive headache, headache associated with abnormal neurological examination (except anosmia and myalgia), treatment-resistant headache, and headache associated with epileptic seizures. The ability of red flags to identify a complication of COVID-19 has yet to be assessed.

Thus, when there is a case of suspected neurological complications from COVID-19 based on the patient's history and physical examination, MRI of the brain, a cerebral magnetic resonance angiogram, and CSF examination should be requested.