Headache as a feature of Covid-19

Headache is common in patients with Covid-19. Headache is of course a common feature of most viral infections, though the pathophysiology of this remains

obscure. In some cases headache can be the presenting, or even the sole symptom. In other cases, it can come on after some of the other cardinal features (such as cough or fever), but then persist beyond the resolution of other symptoms. Further phenotyping of headaches associated with SARS-Cov-2 infection, as well as fuller headache histories in these patients, would go a long way to improving our understanding of the reason behind the high prevalence of headache in Covid-19.

Concerns about headache medication and Covid-19

In the early stages of the pandemic in Europe, there was speculation that certain drugs that are commonly taken by patients with headache, notably ibuprofen, could worsen symptoms in COVID-19. SARS-CoV2 host cell infection is mediated by the binding to angiotensin-converting enzyme 2 (ACE2). In a letter to the journal Lancet Respiratory Medicine, researchers hypothesized that diabetes and hypertension treatment with drugs that increase the expression of ACE2 (such as lisinopril or candesartan) might increase the risk of developing severe COVID-19, and that other drugs, including ibuprofen might exacerbate this. Against this, however, are the potential positive effects of blocking ACE2 receptors in disabling viral entry into the heart and lungs, and decreasing inflammation. At present there is no convincing evidence that these drugs are deleterious in Covid-19, and pretty much all the major national and international cardiology societies continue to recommend their use.

Patients with certain headache disorders (most usually episodic cluster headache) may occasionally take short course of steroids to abort or ameliorate their headaches. The use of steroids has in the past been associated with increased mortality in influenza infections, and decreased viral clearance in Middle Eastern Respiratory Syndrome (MERS). Reports from China suggest that the latter may be the case in patients with Covid-19, but not the former. The use of steroids should therefore be minimized, but not avoided altogether. Doses and treatment duration may need to be reduced to minimize the potential risk of exacerbating underlying SARS-Cov-2 infection.

Whilst CGRP is widely distributed in body tissues, and may play as yet incompletely understood roles in the immune modulation (particularly in mucosal defenses, such as in the lungs), the use of treatments (including triptans, CGRP monoclonal antibodies and (where available) gepants) that impact CGRP mechanisms in the body do not cause immune suppression, and are not linked to increased severity of infection. Indeed, as I reported in a previous blog, vazegepant, an intranasal CGRP antagonist in development, is being used in clinical trials in the United States to ascertain whether it will reduce lung injury in Covid-19.

Challenging Times at Home

Migraine likes people to be a bit boring. Many patients with migraine find that disruptions to their normal routine will trigger attacks. Lockdown brings new schedules, pressures and challenges when it comes to maintaining physical and psychological well being. The approach to managing these challenges is no different now from before: getting up at the same time every day, structuring the day with regular breaks, minimizing distractions, stopping for lunch, getting fresh air and exercise, avoiding prolonged periods of immobility (especially if it involves a phone, tablet, or laptop), keeping well-hydrated, and practicing good sleep hygiene. It’s important to avoid the temptation to increase alcohol consumption, and to rely on ready-made meals that contain additives such as MSG. Relaxation techniques, such as breathing exercises, meditation, mindfulness, and so on, may be helpful for some people.

In conditions of social isolation, depression and anxiety may worsen. This can adversely affect headache disorders, and lead to medication overuse. Stress and anxiety can often be managed by focussing on those things that are within one’s control (such as hand washing, staying at home, and ensuring a sufficient supply of acute and preventive medications), and avoiding the barrage of social media updates and news reports about the pandemic. If this is not enough, it’s important to have a low threshold for reaching out for support, picking up the phone, staying in touch with friends and family, or actively seeking professional support.

Solutions and Opportunities

It seems clear that there will be an exponential increase in the use of telemedicine for headache management. If our experiences in lockdown have taught us anything, it is how to use Zoom, or Teams, or Skype, or any of the other widely available videoconferencing platforms. Previous research on telemedicine for headache care has shown that patients find it convenient with similar satisfaction rates and outcomes to traditional face-to-face consultations. Factors that have until now prevented more widespread use – including technological limitations, concerns about privacy and confidentiality, and inertia – have been rapidly swept aside in the era of COVID‐19, given the need for significant social distancing precautions.

Many media commentators and life coaches are encouraging us to take the opportunity of lockdown to learn new skills, or to get involved in new activities.

References

  1. Mao L, Jin H, Wang M, et al. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol 2020. Published online April 10, 2020. doi:10.1001/jamaneurol.2020.1127

  2. Zhu J, Ji P, Pang J, et al. Clinical characteristics of 3,062 COVID-19 patients: a meta-analysis. J Med Virol2020. Published online April 15, 2020. doi: 10.1002/jmv.25884

  3. Borges do Nascimento I, Cacic N, Abdulazeem H, et al. Novel Coronavirus Infection (COVID-19) in Humans: A Scoping Review and Meta-Analysis. J Clin Med 2020 Mar 30;9(4). pii: E941. doi: 10.3390/jcm9040941

  4. Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med 2020. Published online, 11 Marc, 2020. doi.org/10.1016/PII

  5. Rico-Mesa J, White A, Anderson A. Outcomes in Patients with COVID-19 Infection Taking ACEI/ARB. Curr Cardiol Rep 2020. 22(5):31. doi: 10.1007/s11886-020-01291-4

  6. Maassen Van Den Brink A, de Vries T, Danser A. Headache medication and the COVID-19 pandemic. J Headache Pain 2020. https://doi.org/10.1186/s10194-020-01106-5

  7. Sytsma T, Greenlund L, Greenlund L. Joint corticosteroid injection associated with increased influenza risk. Mayo Clinic Proceedings Innovations, Quality And Outcomes 2018; 2: 194–8

  8. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020. 395: 497-506

  9. Martelletti, P. An unexpected and suspended time. J Headache Pain 212020. https://doi.org/10.1186/s10194-020-01112-7

  10. Qubty W, Patniyot I, Gelfand A. Telemedicine in a pediatric headache clinic: A prospective survey. Neurology 2018; 90: e1702‐ e1705

  11. Muller KI, Alstadhaug KB, Bekkelund SI. Telemedicine in the management of non‐acute headaches: A prospective, open‐labelled non‐inferiority, randomised clinical trial. Cephalalgia 2017; 37: 855‐ 863

  12. Silvestro M,Tessitore A,Tedeschi G, Russo A. Migraine in the Time of COVID‐19. Headache 2020. Published online, 8th April, 2020. https://doi.org/10.1111/head.13803