Headache as presenting symptoms of COVID-19
Dr KK Aggarwal
In a case series published in the journal Headache, Jyotika Singh, DO, Henry Ford Health System, Department of Neurology, Detroit, Michigan, US, and another colleague, describe 2 instances of women with a history of migraine whose first symptom of coronavirus disease 2019 (COVID-19) was a severe persistent headache.
The first case involves a 31-year-old female, with a history of episodic migraine, whose migraine attacks typically occur once or twice a month, are unilateral, throbbing, moderate-to-severe in intensity, and associated with photophonophobia and nausea. Her headaches generally last from 2-8 hours with treatment.
However, the patient developed a moderate-to-severe daily headache that was characterised as a continuous, pounding, bilateral frontotemporal headache, moderate-to-severe in intensity, and without photophonophobia or nausea. The headache would briefly improve with ibuprofen 400 mg, but recur the next day. One week later, she developed fever, cough, severe myalgias, dyspnea, and diarrhoea, and tested positive for COVID-19.
She switched to paracetamol without improvement, and was advised to take naproxen 440 mg twice daily as needed, as well as tizanidine 4 mg every 8 hours as needed. She decided not to take tizanidine and only took two doses of naproxen, but saw no improvement and discontinued use. Her classical COVID-19 symptoms and headache resolved 4 days after diagnosis and she did not undergo repeat testing for COVID-19.
The second case centres on a 32-year-old female with a history of chronic migraine who is currently on topiramate 50 mg nightly for prophylaxis, and sumatriptan 50 mg for abortive therapy. Her migraines typically occur 2-3 times per week and are bifrontal, throbbing in quality, severe in intensity, and associated with photophonophobia and nausea, with attacks usually lasting more than 24 hours if left untreated.
She developed a severe intractable headache one week prior to the onset of typical COVID-19 symptoms. She said the headache was more intense and persistent than usual, and not responsive to abortive therapy with sumatriptan. She took acetaminophen daily without relief.
One week later, she developed low-grade fever, myalgias, nasal congestion, anosmia, and diarrhoea, and tested positive for COVID-19. After two to three days, these symptoms resolved, but her headache persisted. Her topiramate was increased to 100 mg nightly, her sumatriptan was switched to rizatriptan, and she was started on tizanidine 4 mg every 8 hours as needed for breakthrough pain. Two days after starting this regimen, the patient’s headache resolved. Repeat COVID-19 testing via nasopharyngeal swab was performed and was negative, five weeks after initially testing positive.
The headache preceding typical COVID-19 symptoms was distinct from the patients’ usual migraine, “alluding to the possibility that headache related to COVID-19 is mechanistically different than migraine. It is possible that headache is a manifestation of COVID-19 CNS invasion or cytokine storm, though further data are needed.”
The first patient’s headache resolved with resolution of other COVID-19 symptoms, while the second patient continued to have headaches for two weeks after resolution of typical COVID-19 symptoms. Moreover, the first patient did not have migrainous features with her continuous headache.
