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Corona headache: first check, then boom

If a post-COVID-19 patient has daily headaches, it is tempting to prescribe painkillers. But there is a vicious circle here. Why a closer look is worthwhile.

Like viruses of the herpes family, SARS-CoV-2 can trigger the development of daily persistent headaches (New Daily Persistent Headache, NDPH). Since normal pain medications generally work well for COVID-19-associated headaches, sufferers risk taking them daily for weeks and months. DGN experts warn of this, because the long-term use of painkillers can in turn trigger headaches and lead to chronification.

Headache and viruses: a well-known couple

Headaches are a common symptom of systemic viral diseases. The IHS classification (ICHD-3) has included this type of headache as a subtype of secondary headaches. One speaks of “headache as a result of a systemic viral infection” when – as the name suggests – a systemic viral disease is present and meningitis and encephalitis have also been ruled out.

Headaches that occur with acute COVID-19 are also part of this clinical picture. However, there is one peculiarity: headaches usually develop as a result of a viral infection parallel to the viral infection. If the clinical status of those affected deteriorates, for example at the beginning of a flu-like infection, the headaches increase and then during the course of the recovery process the headaches subside again. Anyone who has survived the infection is usually free of headaches. Not so with headaches associated with COVID-19.

Corona headache lasts up to half a year

As a review in a journal of the American Headache Society reports, headaches persist in up to 45% of people even after the acute COVID-19 illness. 60 days after the acute viral illness, 16.5% of the people still suffered from headaches, 10.6% after 90 days and 8.4% after six months. “In view of the high number of infections and now more than 30 million people in Germany who have been infected with SARS-CoV-2 so far, the absolute number of people whose lives are impaired in the long term by headaches as a result of COVID-19 is very high” , explains Prof. Hans-Christoph Diener, spokesman for the DGN.

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In addition, the individual suffering is enormous. The authors of the review cite, among other things, a paper showing that 61% of those affected by long-term or post-COVID headaches have daily headaches. Apparently SARS-CoV-2 is a trigger for NDPH. Risk factors for NDPH as a result of COVID-19 appear to be female gender, headache as the first COVID-19 symptom, poor response to pain medication, and pre-existing headache disorders.

COVID-19 makes headaches worse – and triggers them

However, anyone who concludes that COVID-19 aggravates pre-existing headache disorders but does not trigger them again is wrong: In various studies, 47-80% of patients with pre-existing headache disorders stated that the COVID-19-associated headaches differed from the previous ones. They were often bilateral, while migraines typically only cause pain on one side, and were dull, aching, similar to tension headaches. In some of those affected, they were also accompanied by a sensitivity to noise or light or nausea and vomiting, which is otherwise only known from migraines.

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Therapy poses a certain challenge. Conventional, over-the-counter headache medications work relatively well for COVID-19-associated headaches; at least that has been described for the acute phase of viral diseases. However, they are problematic for two reasons: On the one hand, it is known that SARS-CoV-2 also attacks the kidneys directly, which is why one should at least be careful with the substance class of non-steroidal anti-inflammatory drugs (NSAIDs), since these preparations rarely cause damage when taken for a long time can damage the kidneys. The second danger is that with daily headaches over an extended period of time, such as those experienced by many long-/post-COVID sufferers, taking painkillers daily becomes the norm. And headache pills can trigger headaches if they are taken too often – this creates a vicious circle that leads to chronification. A Medication Overuse Headache (MOH) can already be assumed if headaches occur more than 15 days per month and are treated with one or more painkillers over a period of more than three months.

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Instead of NSAIDs: Better a lap around the block

“People with headaches that have lasted for weeks or even months after COVID-19 disease should therefore use headache tablets sparingly in order not to get caught in the ‘hamster wheel’ of drug-induced headaches,” advises Prof. Peter Berlit, DGN Secretary General. “Of course, that’s easier said than done, but it’s definitely worth trying non-drug strategies as well. The portfolio ranges from exercise in the fresh air to relaxation techniques and stress reduction. In severe cases, a neurologist specializing in headaches should be consulted.”

This article is based on a press release from the German Society for Neurology. We have linked the publications mentioned in the text.

Image source: Matteo Badini, Unsplash

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