Key Clinical Message:
Headache is not the focus of published papers about COVID‐19 and seems
to be underestimated in prevalence and characteristics. The
classification of headache based upon position, quality, timing, and
associations appears to be insufficient and challenging to clinical
application in times of crisis.
To the Editor,
I’m a final year MD candidate in Al-Azhar Medical School, Al-Hussein
University Hospital, Cairo, Egypt. Recently, I have been exposed without
PPEs to a contact person of two positive COVID-19 patients, 2 days
later: the contact deteriorated and tested positive. Due to limited
resources and high-flow severe cases, health authorities protocol didn’t
qualify my case for a PCR or a radiological assessment. I self-isolated
my self at home and followed up on my signs and symptoms over days. The
first day after midnight, I felt dizzy and lightheaded, vital signs were
normal and no other symptoms were present. After 6 hours of sleep, I
woke up on sever excruciating headache, the temperature reached 38.5 C,
but the HR ranged from 70 - 75 BPM, BP was 120/78 mmHg, RR was 10-12 BPM
-deep vesicular regular abdomino-thoracic, no other neurological
manifestations, no orbital involvement, no congestion, no rhinorrhea, no
cough, no expectoration, no dyspnea, no GIT associations, no urine
disturbance, no abnormalities in chest auscultation and percussion. Over
the next three days, no more symptoms evolved: the headache didn’t
regress, didn’t respond to 1000 mg acetaminophen -even after combined
with an NSAID, HR ranged from 80-85 BPM, BP was 110/75 mmHg-but no
water-hammer pulse and no systolic nor diastolic murmurs, the
temperature reached 39.5 C RR was 10-12 BPM, no other manifestations,
and the assessments were repeated at least two times daily. Blood
investigations revealed no abnormalities; no anemia of any kind, no
platelet dysfunction, no lymphocytopenia, no leukocytopenia, no
thrombocytopenia, the parameters of CRP, LDH, D-dimer, and Ferritin were
normal. On palpation and percussion: the liver and the spleen were
completely on average, the lung was clear; normal TVF, no crepitations
no rhonchi, no rub, no extra resonance nor dullness, and no skin nor
mucosal discolorations. This further weakened the hypothesis of COVID-19
infection. Still, the headache severity was correlated with the
temperature and presented chronologically with the exposure. Meanwhile,
I have no personal or family history of any type of migraine and I have
not experienced this headache before -even with the most severe
infections that I have been through. I have followed the criteria of the
ICHD-III: the closest headache in quality was the type 9.2.2.1 of Acute
headache attributed to systemic viral infection, I had a diffuse pain,
severe in intensity, and related to fever(1). Still, it was not similar
to that of common viruses such as influenza, and it had a bad response
to acetaminophen. Tension-type, cluster, trauma, substance, migraine,
trigeminal, occipital, and ocular headaches were excluded. There was no
unilateral orbital/supraorbital or temporal pain, no recent
psychological distress, no facial pain, no conjunctival injection, no
lacrimation, no eyelid edema, no forehead/facial sweating, no ptosis nor
miosis, no CO intoxication, no alcohol, no paroxysmal attacks, no
sensation of shooting or stabbing or lightning strike, no trauma, no
tenderness, no more worsening with day progression, and no association
with stress or tension or aggravation by eye movement. Sinusitis, otitis
media, acute closed-angle glaucoma, raised intracranial pressure,
encephalitis, meningitis, giant cell arteritis, intracranial and
subarachnoid hemorrhage were all excluded. There were no mucopurulent
nasal discharge, no tenderness over sinuses, no tinnitus, no hearing
loss, no prostrating attacks, no painful ear, no vertigo nor nystagmus,
no red eyes, no haloes, no corneal clouding, no pupil abnormality, no
worsening on waking and no aggravation by cough, sneezing, or bending;
no papilloedema, no photophobia, no neck stiffness, no vomiting, no
Kernig’s sign, no petechial or purpuric rash, no focal neurological
signs, no dysphagia, no speech problem, no amnesia, no scalp tenderness,
no jaw claudication, no loss of temporal arterial pulsation, no sudden
loss of vision, no dysarthria, no faint, and no variable degree of
consciousness. In fact, I tried playing chess, solving clinical
scenarios, and even performing my usual workout -attempting to compare
my mental and physical status. The headache responded positively to hand
pressure, articulation, distraction -through reading with recitation and
metacognition thinking process, but badly to sleeping and rest. I have
had incredible challenges every time I want to sleep and even more after
waking up, but noticeably no bad or heavy dreams have been experienced.
On the fourth and fifth day: the headache still the same, while I was
eating my lunch I suddenly felt an episodic burning sensation in my
nose. I started feeling like smelling warm dust, no breathing problem no
mouth breathing; just the smell with an annoying sensation of close
vomiting. An hour later, I could smell nothing; even the strongest
smells started to decay. Whenever I tried to smell more the dusty
burning sensation aggravated and the headache worsens.
This is an atypical case of headache in susceptible COVID-19 contact.
In a recent meta‐analysis of 40,000 patients: Headache seems to be the
5th most common symptom after fever, cough, fatigue, and dyspnea (2).
Headache is not the focus of published papers about COVID‐19.
Nonetheless, headache seems to be underestimated in prevalence and
characteristics; for the majority of the literature concerned with the
pulmonary and intensive care features of COVID‐19, they do not analyze
headache -only reporting it in generic descriptions (3). They didn’t
specify its attribution whether to tension or infection, cough induced,
or hypoxic. Neither did they define at which point the headache
developed or whether the patients had a previous history of headaches.
Meanwhile, the classification of headache based upon position, quality,
timing, and associations appears to be insufficient and challenging to
clinical application in times of crisis. Extra parameters such as
headache response to pressure, posture, potent analgesics, distraction,
and articulation should be eligible for discussion in a future tailored
algorithm.
List of abbreviations : HR ; Heart Rate, RR ;
Respiratory Rate, BP ; Blood Pressure, BPM ; Beat/Breath
Per Minute.