Covid-19 headache, coronavirus headache, Covid headache and Covid19 headache are all terms for the same headaches which have been on the rise thanks to Coronavirus (Covid-19). This has been happening in patients who have gotten infected with Covid-19, including the Covid delta variant, Covid omicron variant, and all the others. We’ll be discussing that in much greater detail further down, as well as how to treat Covid-19 headache. Headache from the Covid-19 vaccine is also being reported for high proportion of patients, and this is also discussed further down.
Interestingly though, migraines and headache have been worsening in patients who have not been infected at all as well. So how is Covid-19 worsening headaches in patients who haven’t been infected? This phenomenon on worsening headaches related to Covid-19 in patients who haven’t been infected is predominantly occurring in patients with migraine. Let me tell you the reasons why.
Why Are My Migraines Worse Since Covid-19 And How Are They Treated?
We look at migraine as an electrical neurological event. It is no longer considered a “vascular headache”, which older terminology suggested. People with migraine have a hypersensitive, or hyperactive, neurological system. So when they encounter triggers, their migraine circuitry switch turns on easier, compared to someone without a migraine history. Basically, they have a lower threshold to trigger a migraine compared to someone without migraine.
Stress is a major, major migraine trigger, and one of the top triggers. Did I mention it is a MAJOR migraine trigger? Ok, you get the point. In addition to stress, there are a wide spectrum of triggers ranging from weather changes, hormones, foods, food additives, too little sleep, excess sleep, and a whole array of others. However, let’s talk about Covid-19 stress.
Unless you’ve been living in isolation in a doom’s day bunker deep in the remote countryside, the Covid-19 pandemic has been very stressful on everyone. So not surprisingly, migraine has also been much worse in general for patients with migraine given these increased stress levels. Everyone’s world has been turned upside down with Covid-19. Our routines and life as we’ve known it were abruptly changed. Parents suddenly became teachers at home, despite no knowledge or ability of knowing how to teach. Screen time skyrocketed (which is often a migraine trigger) from virtual teaching, virtual school, Zoom meetings, and a whole spectrum of other nightmarish virtual work meetings. The frequent crashing of these virtual platforms for many people is also very stress inducing, and likely led to some broken computer screens followed by unanticipated repair costs, and ok, you get the point here. People became socially isolated, which worsened mood for many people, and this often correlates with migraines worsening as well. Spouses and family members found themselves in quarantines and spending way more time together than they were used to or liked to, and that can also be stress inducing for many couples. Kids were home constantly, needing entertainment for their perpetual “I’m bored” complaints, basically just never letting parents get a break, and there were many reports of children actually turning into demons at home. Ok, maybe not, but I think you get the picture. The bottom line is that there have been many changes in our normal routines which were often very intrusive, disruptive, and stress inducing.
In addition to stress, quarantining and working from home have introduced many other variables into day to day life which are common migraine triggers such as changes in eating habits, changes in sleep patterns, types of foods and snacks eaten (which means consumption of more migraine triggering food additives, sugars, etc.), and for some, weight gain (by the way, obesity is associated with a 5x increased risk of chronic migraine (15-30 days of headache with 8 or more days being migrainous).
Treatment of the increased migraine frequency during Covid-19 (or any other time of increase) consists of typical management strategies. Conservative measures including mindfulness techniques such as yoga and medication, diet, hydration, proper sleep and exercise certainly play a role. You'll want to ensure you have a consistently effective well tolerated abortive/acute (as needed) migraine specific treatment such as the new gepant (Nurtec and Ubrelvy) or ditan (Reyvow) options, triptans, neuromodulatory device, or other abortive option. If frequency remains high, then preventive treatment should be considered for a few months until migraines improve. Having 4 or more migraines per month is a general guideline of when a preventive treatment is often considered. Preventive treatments include natural therapies, supplements and nutraceuticals, daily medications, CGRP monoclonal antibody therapy (Aimovig, Ajovy, Emgality, Vyepti), Botox, and neuromodulatory devices.
What is Coronavirus (Covid-19) Headache?
First of all, the International Classification of Headache Disorders 3rd Edition (ICHD-3) accounts for Headache attributed to systemic viral infection, which is common with many nonspecific infections including viral infections such as the common cold or other upper respiratory viral infections. So headache is certainly not specific only to Coronavirus, but it is common with many common viral infections. These types of nonspecific headaches are diagnosed with the following criteria:
- Headache of any duration fulfilling criterion C
- Both of the following:
- systemic viral infection has been diagnosed
- no evidence of meningitic or encephalitic involvement
- Evidence of causation demonstrated by at least two of the following:
- headache has developed in temporal relation to onset of the systemic viral infection
- headache has significantly worsened in parallel with worsening of the systemic viral infection
- headache has significantly improved or resolved in parallel with improvement in or resolution of the systemic viral infection
- headache has either or both of the following characteristics: a) diffuse pain, b) moderate or severe intensity
4. Not better accounted for by another ICHD-3 diagnosis
Coronavirus (Covid-19) headache refers to headaches that have been triggered in direct relation to becoming infected with Covid-19, which is also associated with a variety of other symptoms and a positive Covid-19 test. First of all, if you already have migraine, you will generally be much more likely to have an increase in headaches since your internal electrical wiring already predisposes you to having headaches easier when the body is under any stress (emotional, physical, infection, stress, etc.), as discussed above. So if you get infected with Covid-19, you may have an increase in your baseline migraines for this reason, similar to what often happens with other types of infections (including the common cold). However, headache is a common (and often early) Covid-19 symptom in patients who do not have a migraine or headache either, similar to headaches which can be caused by many other types of infections as well.
The Covid-19 associated headache is often daily and commonly has migraine characteristics (throbbing, pounding, nausea, sensitivity to light and sound), or it can have tension type headache character (dull achy pressure throughout head), or a combination of both. Tension type headache is also discussed further here. One small study reported that Covid-19 associated headaches also had some unusual features, including new rapid onset unrelenting pain (including a thunderclap headache presentation), higher intensity, and association with anosmia/ageusia (loss of smell/taste), diarrhea, reduced appetite, and weight loss.
Coronavirus headache may also present with a story which fits well with New Daily Persistent Headache (NDPH). This is a headache that begins as a daily headache and persists as daily for more than 3 months, without any other known cause. Classically, patients with NDPH often will come into the office and tell you the specific date the headache began and that it has never gone away since. It may fluctuate in the severity levels, but it never fully goes away. It often has an overlapping mixture of migraine characteristics (throbbing, pounding, nausea, sensitivity to light and sound), and tension type headache characteristics (dull achy pressure throughout head). NDPH most often occurs without a clear reason. However, notably one of the most common associations if there is one is a nonspecific viral infection such as a cold or upper respiratory infection that precedes the headache. Covid-19 is simply another type of virus which can be associated with this form of headache.
Covid headache may also be associated with a variety of Covid-19 neurological symptoms. Patients with COVID-19 headache (or without headache) include loss of taste and/or smell, dizziness, muscle weakness, sensory disturbances such as tingling or numbness in the hands and feet, confusion, delirium, persistent neurocognitive symptoms (memory, concentration, attention, etc.), stroke (seen in many young patients as well as older), and seizures.
Headaches From Covid-19 Vaccine
Now that the Covid-19 vaccine is available, Covid-19 vaccine side effects are reported in some patients, including headaches. The Covid-19 vaccine headaches have ranged from mild and a temporary side effect to more severe and extended. So further observation will be useful. Some early data has reported that headaches occur in 35.4% of patients receiving the first Moderna Covid-19 vaccine injection, and 62.8% of patients after receiving the second injection. For the Pfizer Covid-19 vaccine, 41% of patients reported headaches after the first injection, and 51.7% of patients got a headache after the second injection. The Covid-19 vaccine side effects of headaches are typically associated with other common transient side effects of some vaccinations (fevers, chills, body aches, fatigue, exhaustion, soreness at injection site), which are just a sign of your body mounting an immune response in preparation for potential Covid-19 exposure and infection. Regardless, Covid-19 vaccination headache, if present, is milder and of shorter duration than Covid headache from the direct infection itself.
How Long Does Covid-19 Headache Last?
A study looked at the correlation between headache and Covid-19 infection. It found that headache was a very common symptom of Covid-19 infection, but that it was also a predictor of a shorter Covid-19 clinical course. Headache evolution was followed in 74 patients who had Covid-19. After 6 weeks, only 37.8% of them (28/74) still had headache (so most had resolved). The average duration of headache in the patients in whom headaches stopped was approximately 15 days. Of those patients who continued to have headache after 6 week, 50% (14/28) of them had never had prior recurrent headache disorders (such as migraine), and 60.7% (17/28) had daily continuous headache.
Can I Still Get Botox With The Covid-19 Vaccine?
Can I Still Use My CGRP Monoclonal Antibody Treatment (Aimovig, Ajovy, Emgality, Vyepti) With The Covid-19 Vaccine?
The short answer is that we need to gather more data on this, so check back periodically for updates. However, this hasn't been a reported issue thus far. There is no current evidence for an interaction between the Covid-19 vaccine and CGRP mAbs or Botox injections, the same as any other vaccine. This has also been stated by the American Migraine Foundation. Patients receiving Botox or CGRP monoclonal antibodies (Aimovig, Ajovy, Emgality, Vyepti) were not excluded from the Covid-19 vaccine trials. There is no evidence at this time that these treatments cannot be used along with receiving Covid-19 vaccination, nor do they need to be delayed or timed any differently in relation to receiving Covid-19 vaccination. Most physicians feel that there should theoretically be no interaction or contraindication to receiving either of these treatments in relation to Covid-19 vaccination because they are entirely different proteins with different mechanisms of action. The Covid-19 vaccine stimulates the immune system to form antibodies against the virus, should you encounter it. However, neither Botox nor the CGRP mAbs have any significant influence on the immune system (they do not cause immunosuppression, etc.). Rarely, the immune system of some patients can form neutralizing antibodies against Botox and the CGRP mAbs, and this can weaken the effectiveness of these treatments in their ability to decrease migraine frequency and severity. However, this rarity really has nothing to do with the mechanism and how the Covid-19 vaccine works. So, it is not felt that the Covid-19 vaccine will lessen the effectiveness of these treatments, nor will these treatments lessen the effectiveness of the Covid-19 vaccine.
Notably, there have been just a few isolated reports of dermal fillers used in dermatology causing some facial swelling in association with Covid-19 vaccination, but not with Botox. These reports were with the Moderna Covid vaccine and resolved with steroids and/or antihistamines.
How Is Coronavirus (Covid-19) Headache Treated?
Treatment of Covid-19 itself should follow current guidelines as directed by your regular doctor as well as the CDC (Centers for Disease Control) and WHO (World Health Organization) guidelines. For many patients, treatment of Covid-19 headache and the infection itself revolves around symptomatic treatment such as rest, hydration, over the counter common cold and virus type medications (analgesics, decongestants, etc.), and vitamins such as vitamin C, zinc, and vitamin D. Symptomatic treatment basically means you are treating the symptoms rather than the virus itself, as is the case with the majority of viral infections (such as common cold viruses) besides treatable ones such as herpes simplex virus (HSV) and varicella zoster virus (VZV).
However, treatment may also include intravenous medications such as steroids (typically dexamethasone), Remdesivir, and supplemental oxygen, especially for more serious infections. Intravenous antibiotics may also be necessary if the Covid-19 infection progresses to pneumonia, in which bacterial infections begin within the inflamed and injured lung tissue from the Covid-19 infection. There have also been conflicting reports of Covid-19 treatment success with Hydroxychloroquine and Ivermectin (the human version, definitely NOT the veterinary/animal version), However, these are not currently listed in the standard treatment guidelines, and there is not enough supporting clinical evidence for their use. Any Covid-19 infection should be evaluated and managed by your doctor to ensure you are optimizing your treatment strategy to prevent progression to pneumonia or other Covid-19 complications. Your treatment may vary depending on the infection severity, your medical history and risk factors for more severe disease, guidelines, and your doctor's treatment preferences and experience. So, you should see your doctor or local emergency department if you have any symptoms or concern for Covid-19 infection because early treatment is crucial.
If the headaches have migraine features, they can be treated as migraine, tension-type headache, or NDPH with acute/abortive options as detailed above, and preventive daily treatment options, also as detailed above, if the frequency of headaches remains high and is not improving.
Covid-19 vaccination is recommended in order to prevent Covid-19 infection including from the delta variant, as well as prevention of Covid headache and Covid neurologic symptoms such as Long Covid Syndrome, or Post-Covid Syndrome.
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