COVID-19-associated headache

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahimeh Shojaei, M.D. Syed Musadiq Ali M.B.B.S.[2]

Synonyms and keywords:

Overview

The association between COVID-19 and headache was made in 2020. COVID-19 associated headache may be caused by the SARS-CoV-2 virus. There is no established system for the classification of COVID-19 associated headache. The exact pathogenesis of headache in COVID-19 patients is not fully understood. It is thought that headache is the result of cytokine release, direct invasion, metabolic disturbances, inflammation, dehydration, and hypoxia. COVID-19-associated headache must be differentiated from other diseases that cause headache, such as migraine, tension-type headache, cluster headache, seizure, meningitis, encephalitis, neurosyphilis, SAH, subdural hematoma, brain tumor, hypertensive encephalopathy, brain abscess, multiple sclerosis, hemorrhagic stroke, Wernickes encephalopathy, and drug toxicity. A positive history of fever and cough in addition to headache is suggestive of COVID-19-associated headache.

Historical Perspective

• The association between COVID-19 and headache was made in December, 2019 during the SARS-CoV-2 outbreak initiated in Wuhan, Hubei Province, China.

Classification

• There is no established system for the classification of COVID-19 associated headache.

Pathophysiology

• The exact pathogenesis of headache in COVID 19 patients is not fully understood.
• It is thought that headache is the result of:
  • Cytokine release
    • There is higher concentration on IL-6 and INF-gamma in patients infected with SARS/ CoV2.
    • Cytokines can disrupt blood brain barrier and cause tissue injury and cerebral edema.
  • Direct invasion
  • Metabolic disturbances
  • Inflammation
  • Dehydration
  • Hypoxia

By Fahimeh Shojaei, M.D. / https://en.wikipedia.org/wiki/File:Migraine.jpg

Causes

• COVID-19 associated headache may be caused by SARS-CoV-2 virus.

Differentiating COVID-19-associated headache from other Diseases

• For further information about the differential diagnosis, click here.
• To view the differential diagnosis of COVID-19, click here.

Epidemiology and Demographics

Incidence / Prevalence

• WHO reported that more than 462,801 people have been infected worldwide, more than 380,723 of which are outside of China.
• The incidence/prevalence of COVID-19-associated headache is still unknown.
• Guan et al. recently reported 13 percent of COVID-19-associated headache among 1099 laboratory-confirmed cases.

Age

• There is insufficient information regarding age-specific prevalence or incidence of COVID-19-associated headache.

Gender

• There is insufficient information regarding gender-specific prevalence or incidence of COVID-19-associated headache.

Race

• There is insufficient information regarding race-specific prevalence or incidence of COVID-19-associated headache.

Risk Factors

• There are no established risk factors for COVID-19-associated headache.

Screening

• There is insufficient evidence to recommend routine screening for COVID-19 associated headache.

Natural History, Complications, and Prognosis

Natural History

• At this point, the natural history of COVID-19-associated headache is unknown.
• Further studies are needed to better understand the COVID-19-associated headache.

Complication

• Patients with a history migraine may experience headache as their first symptom, and these patients experience more severe headache and are more disabled by the infection compared with age‐matched cohorts.
• Further studies are needed to better understand complications.
• Larger retrospective studies are needed for evaluating the experience of COVID‐19 in patients with a history of a primary headache disorder.

Diagnosis

Diagnostic Study of Choice

• The diagnosis of COVID-19-associated headache is based on the clinical presentation.

• There are no established criteria for the diagnosis of COVID-19-associated headache.

History and Symptoms

• The hallmark of COVID-19-associated headache is headache.

• A positive history of fever and cough in addition to headache is suggestive of COVID-19-associated headache.

Common Symptoms

• Common symptoms of COVID-19-associated headache are:
  • Fever
  • Shortness of breath
  • Cognitive impairment
  • Cough
  • Fatigue

Less Common Symptoms

• Less common symptoms of COVID-19-associated headache are:
  • Facial droop
  • Myoclonus
  • Dysarthria
  • Seizures
  • Paralysis
  • Dizziness
  • Sedation
  • Coma

Physical Examination

• Patients with COVID-19-associated headache usually appear normal.
• Physical examination of patients with COVID-19-associated headache is usually remarkable for fever, cough, and malaise.

Laboratory Findings

• Additional diagnostic tests like blood chemistry and urine analysis may be needed to rule out other medical conditions.

• There are no diagnostic laboratory findings associated with COVID-19-associated headache.

Electrocardiogram

• There are no ECG findings associated with COVID-19-associated headache.

X-ray

• There are no x-ray findings associated with COVID-19-associated headache.

Echocardiography or Ultrasound

• There are no echocardiography/ultrasound findings associated with COVID-19-associated headache.

CT scan

• There are no CT scan findings associated with COVID-19-associated headache.

MRI

• There are no MRI findings associated with COVID-19-associated headache.

Other Imaging Findings

• There are no other imaging findings associated with COVID-19-associated headache.

Other Diagnostic Studies

• There are no other diagnostic studies associated with COVID-19-associated headache.

Treatment

Medical Therapy

• Medical therapy for COVID-assocaited-headache is still controversial.
• The use of NSAIDs, who received treatment early in the disease causes worsening of COVID-19 symptoms according to some anecdotal evidences.
• In March 11, 2020, Fang et al. reported the hypothesis that ibuprofen (40 mg/kg/dose) can increase the risk of developing severe and fatal COVID-19 since ibuprofen is known to upregulate ACE2 receptors.
• In March 23, 2020, US FDA announced that it is not aware of any evidence that NSAIDs such as ibuprofen could worsen COVID-19.
• The European Medicines Agency and World Health Organization (WHO) have not yet recommended that NSAIDs be avoided.
• Despite this recommendation, as a precautionary measure many providers are avoiding NSAIDs in patients with COVID-19.
• In practice, the decision to continue or stop NSAIDs in patients with COVID-19 is made in collaboration between the treating physician and the patient, after a brief discussion on the limited available evidence.
• More data are needed before broad recommendations are made.

Surgery

• Surgical intervention is not recommended for the management of COVID-19-associated headache.

Primary Prevention

• There are no established measures for the primary prevention of COVID-19 associated headache.

Secondary Prevention

• There are no established measures for the secondary prevention of COVID-19-associated headache.

References

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