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COVID-19 and Headache Disorders
Headache is the most common neurological symptom presenting in patients infected with COVID-19. In large retrospective studies of international populations, the incidence of headache is greater than 70%. Understanding, diagnosing, and treating these patients remain a challenge.
Epidemiology
Headache is the fifth most common COVID-19 symptom after fever, cough, myalgia/fatigue, and dyspnea, and the most frequent neurological manifestation. The prevalence of headache in COVID-19 patients is reported highest in the young (< age 50) and in female patients with mild-to-moderate disease—in both hospitalized and nonhospitalized patients. Studies show that headache appears to be the presenting symptom for 6%–10% of patients globally with or without other signs of systemic involvement. This prevalence is markedly lower than that in SARS in which headache was recorded as a symptom in 20%–56% of infected individuals, but similar to MERS in which it appeared in 11% of patients. Interestingly, health-care professionals also had a high incidence (> 80%) of self-reported headaches during the COVID-19 pandemic, which is thought to be related to high stress work environments and long hours of PPE use. In one study, the presence of headache was associated with, and predictive of, a shorter clinical course of COVID-19 (23.9 days for those with headache vs 31.2 days for those without headache). Risk factors associated with the incidence of headaches include a history of primary headache disorders, comorbidities, fever, and dehydration.
Clinical Syndromes
Several phenotypes of headaches are found in patients with COVID-19 and the nature and type of headache may evolve during the course of the illness in affected individuals. In one study reporting on the characteristics of headaches in 172 patients with COVID-19, the majority of headaches were holocephalic (52.9%) and pressure-type (40.7%). Fever but also anosmia and ageusia were frequently associated with more severe headaches. While the pressure type seems to be the predominant phenotype, migrainous features were more frequent in patients with a prior history of migraines. When headaches are prodromal, i.e., when they happen as the first COVID-19 manifestation, before the emergence of respiratory symptoms, they tend to be more severe than those who arise later in the course of the disease. This characteristic is important as these prodromal headaches heralded a protracted course of cephalalgia, lingering for up to 6 weeks in a third of the cases in one series.
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