Understanding COVID-19’s Impact on Existing, New-Onset Migraine and TTH

After contracting COVID-19, patients reported a worsening of primary headache, while headaches related to COVID-19 were severe and presented as a migraine phenotype, according to study results published in The Journal of Headache and Pain.

Although patients infected with SARS-CoV-2—the virus that causes COVID-19— experience a wide range of manifestations that can lead to critical illness in some, approximately 33% of individuals will never develop symptoms, researchers wrote.

Fever, cough, fatigue, and myalgia are some of the more common symptoms of COVID-19. “However, various neurologic manifestations such as headache, dizziness, anosmia, impaired consciousness, and acute cerebrovascular disease have been also reported,” they explained.

Research has also shown a 5-fold increase in headache incidence in regions affected by the pandemic, but little information is known about the characteristics of these headaches.

To address this knowledge gap, investigators assessed the frequencies, features, and course of preexisting primary headaches (migraine and tension-type headache [TTH]) and characteristics of new-onset headache in patients with confirmed cases of COVID-19.

A total of 121 patients, aged 18 to 65 years, were included in the cross-sectional study that took place in Kuwait. Patients were recruited from the country’s only specialized neurology and tertiary hospital and presented to the clinic within 3 months of COVID-19 onset—confirmed via a reverse transcription polymerase chain reaction (RT-PCR) test.

Headache characteristics were ascertained through questionnaires, and stepwise approaches were used to determine preexisting primary headache disorders. The mean (SD) patient age was 35.29 (9.54) years, and the majority (83.5%) were women.

Prior to COVID-19 onset, 78 (64.5%) patients had migraine and 11 (9.1%) experienced TTH. Thirty-two individuals (26.4%) reported de novo headache post COVID-19.

Analyses revealed:

• Patients experienced a significant increase in headache days (11.09 [8.45]) post COVID-19 compared with (8.66 [7.49]) headache days before infection (P < .006).
• Post COVID-19, migraineur usage of analgesics increased significantly (2.31 [1.65] vs 3.05 [2.09]; P = .002) and patients with TTH experienced a statistically significant increase in severity (5.556 [1.86] vs 7 [2.25]; P = .033) and frequency (7 [6.29] vs 12.72 [7.96]; P = .006) of headache attacks.
• Bifrontal and temporal headache were the most reported (40.6% each) headache site among the de novo headache group.
• Patients younger than 40 years had a longer duration of headache attack (18.50 [16.44] vs 5.5 [9.07]; P = .045) post COVID-19.
• Men compared with women (8.66 [1.15] vs 5.93 [2.01]; P = .04) had more severe headaches post COVID-19.
• De novo headache resolved within 1 month in most patients (65.3%).

“The present study showed that COVID-19 has a significant negative impact on patients with pre-existing primary headache disorder, either migraine or TTH. De novo primary headache is frequent post COVID-19,” the researchers wrote. “Occurrence of headache during the symptomatic phase of COVID-19 can be considered as headache attributed to systemic viral infection,” they added.

Among those who reported de novo headache post COVID-19, symptoms resembled those of migraineurs, including photophobia and phonophobia. COVID-19–related stress could also have induced migraine attacks in participants.

“Previous studies found that pre-existing primary headache disorders are usually associated with [an] atypical pain process due to atypical release of pro-inflammatory cytokines and chemokines,” the authors noted. “Such changes lead to sensitization of central and peripheral nociceptive pathways with a subsequent reduction in pain threshold,” which may explain the increased headache intensity reported by the study population.

The negative economic and psychosocial ramifications of the pandemic have also contributed to poor mental health which could in turn lead to increased rates of headache.

Overall, researchers recommend that physicians pay more attention to the neurological symptoms of COVID-19 to avoid chronicization, and consider headache during the course of COVID-19 as a possible prognostic factor for the severity of symptoms.

Future studies are warranted to better understand the impact of COVID-19 on headache and to assess time to headache improvement post COVID-19. The relatively short follow-up period and small sample size mark limitations to the current study.

Reference

Al-Hashel JY, Abokalawa F, Alenzi M, Alroughani R, and Ahmed SF. Coronavirus disease-19 and headache; impact on pre-existing and characteristics of de novo: a cross-sectional study. J Headache Pain. Published online August 21, 2021. doi:10.1186/s10194-021-01314-7