Headache & COVID-19: A Short-term Challenge with Long-term Insights

Patricia Pozo-Rosich, MD, PhD

AHSAM 2020 - Oral session
Published on July 17, 2020

6 minute

Key messages

  • Headache is a key symptom that is indicative of the different clinical evolution of COVID-19.
  • Headache may manifest during the asymptomatic or symptomatic period of the disease and have migraine-like or tension-type features.
  • Patients who present with headache experience a typically shorter duration of disease and those with a headache plus anosmia are hospitalised for a shorter duration.
  • A subgroup of patients suffers from headache following COVID-19 symptom resolution.
  • Understanding the pathophysiology of headache associated with COVID-19 may add to the current understanding of migraine and headache in a wider context.

Key messages

  • Headache is a key symptom that is indicative of the different clinical evolution of COVID-19.
  • Headache may manifest during the asymptomatic or symptomatic period of the disease and have migraine-like or tension-type features.
  • Patients who present with headache experience a typically shorter duration of disease and those with a headache plus anosmia are hospitalised for a shorter duration.
  • A subgroup of patients suffers from headache following COVID-19 symptom resolution.
  • Understanding the pathophysiology of headache associated with COVID-19 may add to the current understanding of migraine and headache in a wider context.

Background

  • The COVID-19 pandemic was declared at the end of December 2019 in Wuhan, China.
  • As of 22 April 2020, the World Health Organisation reported 2.4 million cases of COVID-19 globally, with 165,310 deaths associated with the disease.
  • Spain is one of the most affected countries.

Content summary

How is headache associated with COVID-19?

  • COVID-19 is the disease caused by the SARS-2 virus.
  • People with COVID-19 have reported a wide range of symptoms, ranging from mild to severe.
  • Symptoms typically appear 2 to 14 days after exposure to the virus and patients may present with a cough, shortness of breath or difficulty breathing alongside a fever, chills, muscle pains, sore throat, new loss of smell or taste, or headache.
  • Headache is one of the main clinical characteristics of patients with COVID-19, with an estimated prevalence of 74.4% in patients administered to the Vall d-Hebron hospital in Barcelona, Spain.
  • The characteristics of headache associated with COVID-19 differ according to time of onset during the evolution of the disease, showing more migraine-like symptoms at the asymptomatic stage.

Why is headache a symptom of COVID-19?

  • The SARS-2 virus infects the body via the angiotensin-converting enzyme 2 (ACE2) receptor, which is present throughout the human body.
  • The virus enters the body through the nasal cavity and causes initial neuroinflammation.
  • It can then travel into the lungs, causing pneumonia before entering the bloodstream causing systemic inflammation through a cytokine storm.
  • When the patient develops acute respiratory syndrome, it leads to increased permeability of the blood-brain barrier leading to direct infection of the microglia and endothelialitis.
  • The virus may then directly infect the central nervous system (CNS), attacking the trigeminal and olfactory nerve, triggering activation of the trigeminal vascular system. This potentiates the neuroinflammation at a localised level in the CNS.
  • Levels of interleukin 6 (IL-6), that is a known pro-inflammatory cytokine released during migraine attacks, were lower and more stable in COVID-19 patients with headaches than those without.

How does headache evolve in COVID-19?

  • There are potentially four pathways through which COVID-19 evolves; (i) 30% of patients present with no symptoms and acquire immunity, (ii) 55% of patients have mild symptoms and then go on to develop immunity, (iii) 10% develop severe symptoms which require hospitalisation, and (iv) 5% require admission to ICU.
  • The type of headache patients experience depends on when in the disease timeline symptoms first present.
  • Up to a third of patients develop a reoccurring, difficult-to-treat, ongoing headache which appears to be a new persistent daily headache.
  • Headache is a predictive symptom of COVID-19 evolution—patients with a headache generally experience shorter disease duration by approximately seven days, and those patients with a headache plus anosmia are hospitalised for a shorter duration (minus seven days).

How can we treat headache associated with COVID-19?

  • Ibuprofen is safe for patients to take during the COVID-19 pandemic.
  • There was initial clinician concern regarding the use of candesartan, but this is an ACE-1 inhibitor, not ACE-2.
  • Calcitonin gene-related peptide (CGRP)-monoclonal antibodies are also currently considered safe to use during this time as they do not suppress the immune system.
  • CGRP is one of the main neuroinflammatory molecules, and there is a clinical trial underway evaluating the efficacy of vazegepant for hospitalised patients with COVID-19.

Conclusions

  • Headache is a key symptom that is indicative of the different clinical evolutions of COVID-19.
  • Improved understanding of headache and COVID-19 leads to more effective treatment and improved patient outcomes.
  • The role of headache is underestimated and it requires more focus and understanding across wider medicine.

This is a highlights summary of an oral session given at the AHSAM 2020 Virtual Annual Scientific Meeting and presented by:

Patricia Pozo-Rosich, MD, PhD
Vall Hebron Hospital
Barcelona, Catalonia, Spain

The content is produced by Infomedica, the official reporting partner of ASHAM 2020 Virtual Annual Scientific Meeting. The summary text was drafted by Goldcrest Medical Writing, reviewed by Marco Vercellino, MD, an independent external expert, and approved by Jessica Ailani, MD, FAHS and Mark J. Burish, MD, PhD, the scientific editors of the program.

The presenting authors of the original session had no part in the creation of this conference highlights summary.



Headache
COVID-19


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