Delineating headache phenotypes attributed to COVID-19

What we know about headache as a symptom of COVID-19

To lay the groundwork, Dr. Garcia-Azorin stated that he and his colleagues have been analyzing headache as a symptom of COVID-19 since the beginning of the pandemic in early 2020. They recently showed that headache may be an independent predictor of a lower risk of mortality for hospitalized patients with COVID-19.³ In another recent study, they observed that headache “red flags”—which include prior medical history and factors associated with a secondary headache disorder with a higher frequency than expected by chance—were present in most hospital-based patients with COVID-19 who experienced headache as a symptom.⁴ Dr. Garcia-Azorin also shared data yet to be published that the most frequently described headache phenotype for 106 hospitalized patients with COVID-19 was oppressive headache with severe intensity and frontal topography.

In a broader population of patients, headache associated with COVID-19 was experienced early and was frequently bilateral

To gain broader insight into the frequency and phenotypes of headache attributed to COVID-19, Dr. Garcia-Azorin stated that he designed a study—from which data are currently being prepared for publication—to include adults 18 years of age or older with confirmed COVID-19 diagnoses and headache. He noted that patients who were seen in primary care, the emergency department, or admitted to the hospital were all included. Patients were asked by a physician to complete a standardized questionnaire, and data were collected 8 March–11 April 2020 in Spain, according to Dr. Garcia-Azorin.

Dr. Garcia-Azorin reported that the frequency of headache across 2,194 total cases examined was 23.4%. He added that for the subsets of 1,614 patients managed at primary care and the 580 hospitalized patients, the headache frequencies were 23.7% and 22.6%, respectively.

Of the 2,194 cases, 458 patients completed the evaluation and were analyzed for headache phenotypes, according to Dr. Garcia-Azorin. He mentioned that the median age of these patients was 51 years, 72.1% were female, and 48.7% had a prior history of headache (18.1% reported migraine and 21.6% reported tension-type headache or TTH). “Importantly,” Dr. Garcia-Azorin emphasized, “headache was reported as the first symptom for 27.9% of patients, presenting early within the first days of COVID-19 symptom onset. In terms of intensity, 15.6% of patients reported headache as their most bothersome symptom, with a median duration of 7 days.” He added that the reported headache intensity peaked at day 7 after symptom onset, and in 12.9% of patients, headache was persistent one month after initial diagnosis.

“We also analyzed the quality of pain,” Dr. Garcia-Azorin continued, and described that pressing pain was most frequently reported, followed by stabbing and throbbing pain, and noted that some patients reported more than one type. He also presented the frequency of associated symptoms, including that approximately one-third of patients experienced photophobia, phonophobia, and worsening pain by head movement. According to Dr. Garcia-Azorin, the most frequent topography of headache was frontal pain reported by 70.9% of patients, and the majority (80.1%) of patients reported bilateral headache. More than 80% of patients needed acute medication for their headache, and most used analgesics, Dr. Garcia-Azorin stated.

Know the signs and red flags to provide accurate diagnoses for patients with COVID-19 who experience headache

Dr. Garcia-Azorin closed by reiterating that headache is a frequent symptom of COVID-19 that occurs in about a quarter of patients, occurs early over the course of the disease, and most frequently presents as a bilateral, severe, pressing headache with frontal predominance. He stressed that accurate diagnoses of headache symptoms are necessary considering that nearly all patients who experienced headache related to COVID-19 reported “red flags” including those related to prior medical history, headache characteristics, systemic symptoms, and neurologic symptoms.⁴ Nevertheless, he also expressed great hope that the rapidly growing wealth of data will continue to elucidate further details around headache as a symptom of COVID-19.