130 CMAAO
CORONA FACTS and MYTH BUSTER Headache in COVID
Dr K K Aggarwal
President CMAAO
952: Headache as presenting
symptoms of COVID-19
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.
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