Did You Develop Headaches from PPE? You Are Not Alone

Health care workers have been our heroes caring for patients throughout the COVID-19 pandemic, but research shows they may be at risk for personal protective equipment (PPE) related headaches. Prior to entering a room with a COVID-19 patient, a health care worker must apply personal protective equipment (PPE). This includes an N95 mask, a gown, gloves and eye protection such as goggles or a face shield. It is a repetitive and tedious task, but necessary for protection. Multiple studies have found that many health care workers may be suffering from de novo PPE-associated headaches as a result of PPE use. 

What is De Novo PPE-Associated Headache? 

De novo PPE-associated headache is a new headache that occurs in close relation to the use of PPE. The headache may have characteristics of a primary headache disorder such as migraine or tension. De novo PPE-associated headache also appears to present very similarly to an external compression headache (ECH) where an object such as an N95 mask or eye protection puts continuous pressure on the forehead or scalp. With ECH, the headache is typically resolved when removing the object, or in this case the PPE, but it seems some people are still having de novo PPE-associated headaches after removal of PPE. 

The Journal of Headache and Face Pain published a study of 158 health care workers in Singapore and found 81% of participants reported de novo PPE-associated headaches when wearing an N95 mask, with or without protective eyewear.¹ The study also found that of those 81%, all of them experienced bilateral headaches. Additionally, those who used PPE greater than 4 hours per day had a higher chance of developing headaches. Most health care workers had an onset of headaches within 60 minutes of using an N95 mask or protective eyewear that resolved within 30 minutes after removal of the PPE. The respondents were asked to shade in the areas where pain, pressure or compression was felt from PPE as shown in the picture below. Out of the 158 health care workers, 46 people had a pre-existing primary headache disorder and 93.5% of those experienced de novo PPE associated headaches. Most participants had episodic type headaches and were not on preventive medications. 

Graphic sourced from: Headache: The Journal of Head and Face Pain, Volume: 60, Issue: 5, Pages: 864-877, First published: 30 March 2020, DOI: (10.1111/head.13811)

Another study published in Occupation and Environmental Medicine surveyed 306 health care workers and 158 (51.6%) of the participants reported the appearance of a new headache while 65 (41.1%) participants previously had headaches.² In those with a previous headache disorder, the majority had changes in their headaches (characteristics, location, frequency, intensity and response to analgesics).² 

Why Does It Occur? 

It is unclear how de novo PPE-associated headaches occur but there are a few hypotheses:¹ 

1. Hypoxemia (low level of blood oxygen) or hypercarbia (too much carbon dioxide) may play a role. 
2. The PPE equipment, especially the straps, may put pressure on the sensory nerves that innervate the face thereby sending signals to the trigeminal nerve. 
3. Application of and the additional weight from PPE may cause neck strain and activate the trigeminocervical complex. 
4. Anxiety and/or stress may be contributing to de novo headaches. 

Headache Prevention and Management 

The priority is to keep medical professionals safe with proper use of PPE when they are in contact with COVID-19 or other contagious patients. The N95 mask should be properly fitted and refitted annually or if they get cosmetic surgery or dentures or have a significant weight change. Powered air-purifying respirators (PAPR’s) may be hard to find in some hospitals due to high demand but they help reduce the accumulation of CO2. This may be an alternative option for someone who is experiencing de novo PPE-associated headaches. 

While it’s easier said than done, frequent breaks should be given to allow time without PPE. Eating foods high in magnesium such as leafy greens, nuts and legumes may help reduce headaches. Typical headache prevention modalities include: stress reduction, staying hydrated, and regular sleep and exercise. 

Where To Go From Here 

Some medical facilities are encouraging their staff to wear full PPE (N95 mask, gown, goggles and gloves) for the entire shift. If staff members are suffering from de novo PPE-associated headaches, a discussion with management may be necessary to find a solution. It may be more beneficial for staff to wear PPE as needed rather than for an entire shift. If de novo PPE-associated headaches are new, it is important to find a clinician who specializes in headache medicine. De novo PPE-associated headaches frequently occur in those with a previous headache disorder and may require additional management from a headache specialist. 

For more information on migraine treatments visit: https://www.migrainedisorders.org/migraine-disorders/migraine-treatments/

References

1. https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.13811
2. Image: Headache: The Journal of Head and Face Pain, Volume: 60, Issue: 5, Pages: 864-877, First published: 30 March 2020, DOI: (10.1111/head.13811)
3. https://oem.bmj.com/content/78/8/548.info

*The contents of this blog are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The writer does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.

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