Why Do You Get Headache Attacks When You’re Sick?

Lindsay Weitzel, PhD
Hello everyone, and welcome to HeadWise, the videocast and podcast of the National Headache Foundation. I’m Doctor Lindsay Weitzel, and I have a history of chronic and daily migraine that began at the age of four.

I am excited to be here today with repeat guest, headache medicine specialist, Doctor Fred Cohen. Hi, Doctor Cohen, how are you doing today?

Fred Cohen, MD
I’m well, thanks for having me back.

Lindsay Weitzel, PhD
Thanks for being here. Doctor Cohen is the director of Headache Intervention in New York City and an assistant professor at the Icahn School of Medicine at Mount Sinai. So today, we have a very common thing that we want to talk about. I think most everyone is going to be able to relate to this. We’re going to talk about flu related headache, headache you get when you’re sick, post-infection headache often it is called.

So we’re going to delve right into this because people are getting sick this time of year. So, let’s start with a simple question. Why does a healthy person who is not normally prone to headache attacks get a headache attack when they have the flu?

Fred Cohen, MD
Having a headache attack when you’re sick is a really common symptom. And the question comes down to, does this keep going afterwards? So, headache in a nutshell, a headache attack is inflammation. The different kind of headache disorders, from migraine to cluster, are different causes of how inflammation is affecting it.

So it’s really common of course to have a headache attack when you’re under the weather, or you have a fever. But sometimes it can stay after. Sometimes it can keep presenting, after you’re done with the viral bout, which we call Post-Infectious Headache.

Lindsay Weitzel, PhD
Okay. So is it different? You just sort of showed us that they might be different. There’s a headache while you’re sick and a headache that stays after you’re sick. Do those two headaches feel different to us? What do they feel like?

Fred Cohen, MD
You know, the feeling doesn’t really matter too much. Let’s say I have migraine disease, for instance, if I had the cold or the flu, that might precipitate having a migraine attack during when I have the flu.

The way I describe it more is how does the headache attack feel? If the headache attack feels like your migraine attack, then you’re having a migraine attack during the flu. If this is just more of a different kind of headache attack and you’re having just the viral bout, or your body’s reaction to it is causing a different kind of headache attack. So when someone’s under the weather, I don’t hone in too much on which one is it.

I’ll say this, if you are a person living with migraine, and you have a cold, or you have Covid, and you get a headache attack that feels like your migraine attack. Use your migraine medication. Again, having that viral illness is making you more prone to having one of your migraine attacks.

If it doesn’t feel like your regular migraine attack, then you could try just taking an over-the-counter medication fever reducer. But if it feels like you’re migraine attack, take your triptan or gepant. Because who says you can’t have a migraine attack when you’re sick.

Lindsay Weitzel, PhD
Yeah, that was going to be one of my questions is, how do we know the difference between some of these headache attacks? For example, do you get sinus-related headache attacks during these viral flus, etc.? And then how do you know which medicine to take?

Fred Cohen, MD
You know, it just comes down to knowing how your migraine attacks are. I’ll give me as an example, if I get sick, and I feel more of a dull headache, and it doesn’t really feel like my migraine attack. I’m just going to take something like if I have a cold, like NyQuil, a fever reducer, Tylenol, or Advil.

But my migraine attack presents, behind one eye, throbbing pain, if I’m feeling that, that’s more of a migraine attack. I want to take my triptan or gepant. Don’t be afraid of taking your migraine medication when you have a cold or the flu. You know, that doesn’t stop you from taking it.

Always use as directed by your provider. But it really just depends on how you’re feeling. If this feels like your regular migraine attack. Yeah. Take your migraine medication.

Lindsay Weitzel, PhD
Okay. What if we are a person that generally does not get migraine attacks and we have the flu, we’re sick and we have a headache, what should we take then?

Fred Cohen, MD
So, if you have no history of migraine and you’re not prescribed any migraine medication and you’re having a headache. First off, migraine as defined by the International Classification of Headache Disorders is you have to have at least five attacks.

So, if you’re someone without a history of migraine disease and you’re having a headache attack that someone tells you is a migraine attack, hold up, this is too acute. Meaning I’m not diagnosing you with migraine during this. You’re sick with a headache.

Does it have migraine-like features? Okay, it can happen, someone might get one migraine attack in their life. But if this becomes recurrent or what we call post-infectious headache, meaning that let’s say you have the cold for a week, it goes away, but this headache remains. That’s a bit different.

So, you know, to summarize and to answer your question, if you don’t have a history of migraine disease, and you get a headache attack during this, take fever reducers. If this becomes recurrent, that’s the time to see a provider. You could see a diagnosis of migraine disease after having a viral bout.

Lindsay Weitzel, PhD
So your answers are making me change my questions a little bit. So you talked about this post-viral headache that can last for a long time.

So if you are someone that got the flu, got Covid and you end up with a headache for a long time, what are the options there? How do you know if it’s a sinus headache? How do you know if you develop some post-viral problem or if it’s migraine disease? This could be very confusing if you weren’t someone that went into this with a headache disorder.

Fred Cohen, MD
So post-infectious headache can happen from any viral bout. We see it a lot from the flu, Covid, it can even happen from the common cold and the way we diagnose it is by its definition that you have headache attacks weeks after the viral bout is over, but the headache hasn’t gone away.

So I’ll start with the why. The why we don’t fully know. We don’t have technology to look in and see why the nerve is going off. When your immune system is fighting a virus, unfortunately in the process, through inflammation and other pathways, it’s turned on one of the pain circuits, and that pain circuit hasn’t turned off.

Usually these do go away over time. I have seen them go away after a month, a year or multiple years. Sometimes it does linger for a while. It’s different for everyone. The most common way we treat it, if someone comes to me is a short course of steroids to see if we can calm down the immune system.

But it also comes down to how the headache is presenting. A lot of the time people are diagnosed with migraine disease, meaning it’s a post-infectious headache that’s given migraine disease features. And unfortunately, again, this bout of inflammation has, led to it.

And the other part of your question was how do you get diagnosed. Generally, if this is new to you, you’re seeing your primary care doctor. If it’s a sinus thing, you would see an ENT, they’ll be able to look up the nose with their scopes and visualize if there’s inflammation and whatnot. And they might prescribe antibiotics.

We start getting concerned about post-infection headache when those measures have failed. Antibiotics haven’t helped. You’re not having signs of inflammation in the nose. That’s when people come to see me, and I give a diagnosis of post-infectious headache. We see if there’s something we can do. A lot of times we treat it similar to migraine disease, if they have migrainous features.

Lindsay Weitzel, PhD
Does this often come with other things like fatigue that people talk about Post-virally, or can the headache attack just come by itself?

Fred Cohen, MD
It can be with either. I usually do see fatigue with this. That is common, but this is a pain condition. Pain is subjective. Pain can affect people in any different way. For instance, if you don’t have fatigue, it doesn’t mean I’m going to say it’s not post-infection.

The most important thing is the temporal relation. How soon after did this start from when you had a viral bout? Also, I want to point out, this can happen after vaccines. I don’t want to say this is a reason not to get vaccinated, but it has been seen because it’s not that the vaccine did it, it’s that your immune system revved up and did it.

It would have probably happened if you caught the virus that the vaccine targeted. We don’t have that information. We can’t prove that. And I want to stress that’s not a reason to not get a vaccine. If your provider has recommended it, it’s quite rare. But again, when you get a vaccine, your body’s creating an immune response, a better controlled one versus getting the virus out in the open. And that could turn on pain circuits.

Lindsay Weitzel, PhD
Okay. So if we could just circle back to the start. So, a person that doesn’t have a migraine history and just gets the flu or Covid and has a headache during that time, that isn’t sinus related, that is also normal. It’s just an inflammatory response; how would you treat that one?

Fred Cohen, MD
Over the counter. If this is new, over the counter, ibuprofen, acetaminophen. You could take Excedrin, one of the liquid combinations, NyQuil, DayQuil. If it becomes a reoccurring thing, again, migraine disease is defined as more than five episodes or at least five episodes. Then that’s when you might consider a migraine specific medication. But if this is new to them, it might just be this might be how their headache attack is presenting. And if they do well with over the counter, that’s the goal of those.

Lindsay Weitzel, PhD
Okay. Is there anything you can add to this subject before we go today.

Fred Cohen, MD
For anyone listening if this is something you’ve noticed, the biggest thing is the timing of recovery. Because there are people that on average, usually it’s six months to a year, but it could be longer. Never compare your headache to someone else’s. I’ve met patients that within a month or two, we got them under control. I have a patient that took a year and a half. We got them under control, but it took much longer. Every case is different. Everyone’s brain responds differently.

Lindsay Weitzel, PhD
Okay, well, thank you so much for joining us today, Doctor Cohen. And thank you everyone for listening. And please tune in to the next episode of HeadWise. Bye bye.

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