Severe acute respiratory syndrome coronavirus 2 (SARS-C0V-2) is a novel coronavirus, responsible for the coronavirus disease (COVID 19) that emerged in China at the end of 2019 causing the current global pandemic. In our Headache clinic we have seen a number of referrals of ongoing headaches and migraines post COVID infection. A similar observation has been noted by Headache and Migraine clinics around the world and this was explored further in a recent case series published in the American Headache Society’s, Headache the Journal of Head and Face Pain (May 2021)

In this blog we will summarise these 3 cases, and similar presentations have been observed in our patient cohort.

Patient 1: Migraine Chronification
A 56 year old woman with a history of low frequency migraine reported a mild COVID 19 infection associated with symptoms of headache, lack of smell, and malaise. Headache was the first symptom of the infection, starting a couple of days prior to the other symptoms. She reported it was different from her usual migraine in that the pain since onset was constant. The relentless nature of the pain was associated with the patient starting to overuse acute medication. In addition the patient started to notice tenderness (allodynia) while combing her hair. At the headache clinic she complained additionally of fatigue and insomnia. Given the combined headache and sleep disturbance complaint Amitriptyline was commenced. This resulted in improved sleep quality, however she continued to experience almost daily headaches. OnabotulinumtoxinA was added to her treatment regimen, with a reduction in headache frequency and a return in character to her usual migraine.  

Patient 2: Long Lasting COVID Headache
A 55 year old woman with no personal or family history of migraine experienced a mild case of COVID 19 infection. Her initial symptoms were that of loss of smell and taste, cough, shortness of breath, feeling systemically unwell, and diarrhoea. A persistent headache started a few days after the appearance of her other symptoms. She presented to the clinic with this ongoing headache as well as with symptoms of fatigue, and insomnia. Combination treatment was commenced with amitriptyline and onabotulinumtoxinA. After 3 months of treatment she reported improved sleep quality and her headache severity and frequency was reduced by 50-75%. Ongoing symptom control was reported over subsequent treatment cycles.

Patient 3: Delayed onset COVID Headache
A 44 year old man with no history of migraine had a mild COVID 19 infection associated with cough, shortness of breath and malaise. As his respiratory symptoms began to improve after 2 months, he started to report daily, constant headaches, at times the events were associated with migrainous features of throbbing pain, sensitivity to light and sound, nausea, and worsening of pain with movement. On his presentation to the headache clinic he complained additionally of fatigue and insomnia, and his blood pressure was found to be elevated at 140/90. He was commenced on Amitriptylline for his poor sleep, and Candesartan for his high blood pressure. On the follow up visit his blood pressure was controlled, and sleep quality had partially improved, though no changes to his headaches were reported. Subsequently OnabotulinumtoxinA was added, as well as Rizatriptan for acute events, however these were not effective. On his most recent visit changes in mood and memory were reported with antidepressant therapy commenced, he reported continuing to experience disabling, daily, and constant headache, and had not returned to work or his usual activities.

These cases are instructive, and we have seen cases similar within our own Headache clinic. Patient 1 suggests that COVID 19 is a risk factor in the worsening of an underlying headache disorder, in this case, triggering the development of chronic migraine. Patients 2 and 3 were without a personal migraine history, though infection with COVID seems to have been associated with the development of migraine like features, suggesting acquired activation of the trigeminovascular system by the infection. In patient 3 persistent headaches emerged despite not having experienced headache in the acute infection phase. Case 3 in particular was noted for Headache in association with other symptoms (insomnia, memory loss, dizziness, fatigue), that may identify as ‘post COVID 19 syndrome’. The presence of these co-morbid conditions could point to the involvement of different pathophysiological pathways , such as the brainstem and neurotransmitter depletion in neuropsychiatric symptoms.

Treatments for post COVID Headache
Many patients with a history of migraine report that the headaches associated with COVID are different, either more severe, or long lasting. At this stage it is too early to recommend treatments for headache associated with COVID. In general however, when patients describe migraine like headache after COVID infection, migraine therapies are recommended, and patient 1 and 2 reported improvement following OnabotulinumtoxinA. In addition, if other symptoms are reported such as poor sleep, then medications that address these issues, as well as migraines, can be chosen.

Toward a better understanding of persistent headache after mild COVID 19: Three migraine like yet ;distinct scenarios; Edoardo Caronna, MD,  Alicia Alpuente MD, Marta Torres-Ferrus MD, and Patricia Pozo-Rosich MD, Headache 2021 Sep; 61(8): 1277–1280.

Migraine and Post COVID Headache; American Headache Foundation, Published; February 17, 2022