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

The Persistence of Headache After the Acute Phase of COVID-19

For between 6% and 45% of those who complain of headache in the acute phase of COVID-19, the headache persists beyond the symptomatic phase.[6,13,16,18–20,25,34]

Caronna et al.[18] compared those who no longer presented with headache and those who still reported headache 6 weeks after the acute stage. The group with a persistent headache contained significantly more women, with more previous headaches, more persistent symptoms, more headache as a first symptom, and they were less responsive to acute pain management. In 61% of patients with persistent headache, the headache was daily and constant.[18]

A systematic review that included 36 articles on post-COVID symptoms observed that headache may persist for up to 60 days in 16.5%, for 90 days in 10.6%, and for more than 180 days from symptom onset to discharge in 8.4% of patients. Thus, there is a decrease in the prevalence of headache over time.[21]

A post hoc secondary analysis of six Spanish studies that included 905 adults with headache in the acute phase of COVID-19 also reported a decrease in the prevalence of headache over time (1 month: 31%; 3 months: 19%, 6 months: 16.8%, and 9 months: 16%). A more severe headache in the acute phase was associated with greater persistence of headache after 9 months of follow-up.[51]

In another study, which assessed patients who had been discharged from the hospital after a mean period of 7 months, the diagnosis of previous migraine was not associated with the persistence of headache.[52] However, previous primary headaches may become worse after COVID-19.[23,34]

Although it is already known that headaches may persist after the acute phase of COVID-19, little is known about the frequency of the attacks of this headache and its impact. Viral infections may be a trigger for developing new daily persistent headache (NDPH). Reports already exist of this type of headache after COVID-19.[53–55]

Secondary headaches should always be ruled out in those with NDPH. Treatment should consist of assessing the pattern of this headache (migraine phenotype vs. tension-type headache phenotype) and managing according to this pattern. In cases in which this headache is triggered by a viral infection, pulse corticosteroid therapy may also be used.[56,57]

We have previously described a case of NDPH with a migraine phenotype.[53] After the publication of that case, the patient was treated with venlafaxine with good results.

Caronna et al.[55] described three cases of NDPH with migraine features, two of which improved after using amitriptyline and onabotulinumtoxinA. The third patient did not improve after treatment. This patient had no previous primary headache, and his headache started late when respiratory symptoms were improving. In addition to the headache, the patient also had complaints of insomnia, fatigue, and cognitive and memory impairment, which are suggestive of the "post–COVID-19 syndrome." The authors suggested that the headache pathophysiology of this patient was different from the other two.[55]

Dono et al.[54] described a case of NDPH that improved after pulse methylprednisolone therapy (1 g intravenously per day for 3 days) followed by oral prednisone (25 mg for 7 days).[54]