The Connection Between Migraine and COVID-19/Long-COVID

Written by: Kylie Petrarca RN, BSN

Medically reviewed by: Dr. Deena Kuruvilla

Edited by: Melissa Calise and Leigh Serth

What is COVID-19?

SARS-CoV-2 is a type of coronavirus, more commonly called COVID-19. It has affected millions of people worldwide and has caused more than 5.6 million deaths as of February 2022.¹  This infectious virus usually causes mild symptoms which may include: cough, headache, fever, chills, congestion, muscle and/or body aches as well as loss of taste and/or smell. Some people experience severe complications such as respiratory failure, systemic inflammatory response syndrome (SIRS) and death. According to Dr. Clayton Cowl who was interviewed by Vivien Williams at the Mayo Clinic, “Dr. Cowl says that SARS-CoV-2 is likely more contagious than the viruses that cause influenza and common cold because it is new to humans. Humans have no way to prepare for it, and their immune systems are not ready to fight it. This results in the virus causing more cellular damage and producing more inflammatory cells.”² 

What is Long-Haul COVID?

Symptoms may occur during the active infection of the virus or in the post-recovery phase. After having COVID-19, some people return back to their baseline health status while others continue to have symptoms from the viral infection. Long-haul COVID or Long-COVID describes a condition where people have new, returning or ongoing symptoms that persist for more than four weeks after COVID-19 infection.³ Some common symptoms of Long-COVID are shortness of breath, loss of taste or smell, fast heart rate, chest pain, brain fog, headache, cough, fatigue and more. If Long-COVID limits one or more of daily activities such as eating, working, walking, etc. then it may be considered a disability. Learn more about Long-COVID and disability here. 

Similarities and Differences Between COVID-19 Headache and Migraine

Migraine is considered a primary headache because it is not caused by another condition, while COVID-19 headache is considered a secondary headache due to the virus being the underlying cause. COVID-19 headache has a higher incidence in males and the pain is reported as moderate to severe and bilateral.⁴ Migraine more commonly impacts females and the pain is often unilateral. Migraine is commonly associated with light and/or sound sensitivity, nausea and/or vomiting. In addition to headaches, people with long-haul COVID-19 may also frequently experience loss of taste and/or smell as well as GI symptoms (nausea, diarrhea, upset stomach).⁴ COVID-19 headache has been reported as pulsating or pressing with increased pain while bending over or with activity.^4,5 Migraine is also commonly described as a pulsating pain and aggravated by exercise. COVID-19 headache has been reported as constant for weeks or months after the initial onset of infection while migraine attacks most commonly last 4-72 hours and vary in frequency. Aura has not been reported among those with COVID-19 headache compared to those with migraine who may or may not have an aura prior to migraine attack. 

Comparison Chart

It may be difficult to tell the difference between migraine attacks and COVID-19 headaches. It is also possible to experience more than one headache type. This chart may help you determine what type of headache you are living with. Keep in mind these are just the typical presentations of each condition, other variations are possible.⁶

How does COVID-19 Cause a Headache?

Headache is one of the most common neurological symptoms among those infected with COVID-19. The pathophysiology of COVID-19 headache is currently unknown however, there are a few proposed theories how COVID-19 affects the trigeminal nerve and thereby provokes a headache: 

1. COVID-19 virus invades the trigeminal nerve endings in the nasal cavity.⁵ 
2. Angiotensin converting enzyme-2 antigen (ACE2) facilitates the entry of the COVID-19 virus into the cell.⁵ This antigen has been found in the endothelium of the blood vessels.⁵ It is proposed that ACE2 in the endothelial cells could activate the trigeminovascular system and trigger a migraine.⁵ 
3. During the COVID infection, pro-inflammatory mediators and cytokines are released which could trigger the perivascular trigeminal nerve endings and activate the trigeminovascular system.⁵ 

We know that people with migraine have a hypersensitive nervous system, therefore, it is possible that these activations may contribute to the development or worsening of migraine disease. 

Post COVID and Migraine

A survey of those who developed COVID-19 found approximately one third of COVID-19 associated headaches occurred in those who had a previous history of migraine and 63.4% of them had worsening of their headaches during the infection period.⁷

Impact of the COVID-19 Pandemic on Migraine Patients 

A survey assessed the impact of the COVID-19 pandemic on those with migraine and reported an increase in attack severity, analgesic use and frequency of attack days.⁸ Transformation from episodic to chronic migraine occurred in approximately 10.3% of participants which is significantly higher than the typical chronification rate of 2.5-4% a year.⁷ Sleep disturbances and symptoms of anxiety and/or depression were reported in 78.1% and 79.5% of respondents, respectively.⁷ 

New Daily Persistent Headache (NDPH) and COVID-19

New Daily Persistent Headache is an abrupt onset of a new headache that occurs daily and results in constant head pain. Usually people can identify the month or date when the headaches began. It is commonly caused by a viral infection (ex. COVID-19), a stressful event or a surgical procedure. “The pathophysiology of NDPH is largely unknown, some studies believe that the pain may be due to the production of cytokines and persistent glial activation that arise in response to precipitating events, which is also one of the hypotheses for CNS involvement by COVID-19, thus occurring synergy between pathophysiological mechanisms.”⁹ Some people may experience migraine type features; photophobia, phonophobia and nausea while others may experience tension type features such as “feeling a tight band around the head”, absence of photophobia/phonophobia and bilateral head pain. Treatment with high-dose corticosteroids for probable NDPH due to COVID-19 was shown to be effective in two case studies.¹⁰ Otherwise, preventive therapies such as antidepressants or anticonvulsants are other options used for NDPH. 

What are the Recommended Treatments for COVID-19 Headache?

More research is needed on post-COVID headache and there are no medication guidelines and/or randomized controlled trials recommending a specific treatment. Currently, COVID-19 headaches are best treated by their symptom profiles: migraine or tension type. Those who were diagnosed with migraine prior to COVID infection and are having more frequent headaches should discuss a treatment plan with their health care provider. This may include increasing the dose of preventive medications or adding an additional therapy. For those who do not have a history of headaches, supplements and vitamins may be an appropriate first step in managing the condition. If there is no relief, over-the-counter options or prescription abortive medications such as triptans or gepants should be discussed with a healthcare provider. Preventive medications such as an antidepressant or anti-seizure medication may also be considered. All headache patients should practice lifestyle modifications such as limiting caffeine intake, regular exercise, adequate water intake and a regular sleep schedule. 

What Type of Doctor Should I See for COVID-19 Headache and Migraine?

If you or someone you know is experiencing COVID-19 headache and/or migraine it is imperative to follow up with a clinician that specializes in headache medicine. 

De Novo PPE Associated Headaches Among Healthcare Workers

Another headache type that has reemerged during the pandemic is called de novo PPE associated headache. This is a new headache that occurs in close relation to the use of personal protective equipment (PPE). 

Read the blog about de novo PPE associated headache here.

A Note to Patients and Providers 

It is evident that some people previously diagnosed with migraine can have an increased number of headache days and migraine severity after contracting COVID-19. Clinicians should be screening for medication adaptation headache as studies are reporting an increase of medication usage for headache and migraine management. Many patients report that their headaches are “different” than they previously were, therefore physicians should assess the new type of headache the patient is experiencing. For those who have an onset of new daily persistent headache, tension type headache or migraine should make an appointment with a clinician that specializes in headache medicine. If one is not available nearby, then a neurologist should be consulted. 

New information about COVID-19 is published almost daily, therefore routinely checking for peer reviewed articles may disclose new information about this condition. 

*This is what we know as of February 2022 regarding the connection between COVID-19 headache and migraine. COVID-19 studies are released frequently and this information may change. Please consult with your doctor.

Resources 

1. Join the Long-COVID Alliance
2. Long COVID Support Group and Mental Health Resources
3. Events and Webinars on Long COVID

References 

1. https://covid19.who.int/
2. https://newsnetwork.mayoclinic.org/discussion/how-the-virus-that-causes-covid-19-differs-from-other-coronaviruses/
3. https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html
4. https://journals.sagepub.com/doi/full/10.1177/0333102420966770
5. https://headachejournal.onlinelibrary.wiley.com/doi/full/10.1111/head.13856
6. https://link.springer.com/article/10.1186/s10194-020-01188-1
7. https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-020-01183-6#auth-Jasem_Y_-Al_Hashel
8. https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-021-01314-7
9. https://www.scielo.br/j/anp/a/Z6MB6ckBRr5bDyRn77yCW4w/?lang=en
10. https://pubmed.ncbi.nlm.nih.gov/34264414/

Thank you to our sponsor Axsome Therapeutics!

*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.