952:  Headache as presenting symptom 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 two cases of women with a history of migraine whose first symptom of COVID-19 was a severe persistent headache.

The first case was that of a 31-year-old female, with a history of episodic migraine. Her 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.

The patient developed a moderate-to-severe daily headache, characterised as a continuous, pounding, bilateral frontotemporal headache, moderate-to-severe in intensity, without photophonophobia or nausea. The headache would briefly improve with ibuprofen 400 mg, but recur the next day. A week afterwards, she developed fever, cough, severe myalgias, dyspnea, and diarrhea, 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 required. She decided not to take tizanidine and only took two doses of naproxen, but there was no improvement and thus discontinued use. Her COVID-19 symptoms and headache resolved 4 days after diagnosis and she did not undergo repeat testing for COVID-19.

The second case was that of a 32-year-old female with a history of chronic migraine, currently on topiramate 50 mg nightly for prophylaxis, and sumatriptan 50 mg for abortive therapy. Her migraines usually occur 2-3 times per week and are bifrontal, throbbing, severe, and associated with photophonophobia and nausea, with attacks usually lasting >24 hours if untreated.

She developed a severe intractable headache one week before the onset of typical COVID-19 symptoms. 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 diarrhea, and tested positive for COVID-19. After two to three days, these symptoms resolved, but her headache persisted. Topiramate was increased to 100 mg nightly, sumatriptan was switched to rizatriptan, and she was started on tizanidine 4 mg every 8 hours as needed for breakthrough pain. Two days later, her headache resolved. Repeat COVID-19 testing was negative, five weeks after initially testing positive.

The headache preceding typical COVID-19 symptoms was found to be distinct from the patients usual migraine, implying 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; however, further data are needed.

The first patients 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. The first patient did not report migrainous features with continuous headache.

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Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA