Covid-19 is the most frightening viral illness to strike the world and has infected millions. It is a disorder with many presentations; most commonly cough, loss of taste and smell, sore throat, pneumonia, fever, disorders of clotting, and headache. A third of those with COVID-19 develop neurological symptoms which include headache in about 8%.

The issues of migraine and COVID are similar to those that occur when migraine accompanies other illnesses. It is important to understand that migraine is a disorder with many causes. Genetics play an important role and many genetic factors have been identified as risk factors for the development of migraine. If you are diagnosed with migraine, that diagnosis does not explain how you developed the condition.

I think of migraine as a condition of the brain with a low threshold for the development of headache. You should be able to get through a period, become dehydrated, miss a meal, or under sleep without developing a bad headache. If you can’t, you probably have migraine. Anyone drinking a quart of Chianti can develop a headache, but one with migraine might get a headache from one glass. It all depends on your threshold for headaches.

The same is true for structural problems. We all think of brain tumors as an important cause of headache, although in reality, that is rare. It’s the person with migraine who is more likely to develop headaches from a tumor, and the features of that headache are similar to their usual migraines, although often more severe and of longer duration.

People with migraine commonly develop prominent headaches when they get a significant viral illness, and it is not surprising that this is a COVID symptom. Many of the most serious COVID symptoms stem from the fact that COVID can induce a dramatic inflammatory response. Although many issues can occur with migraine, inflammation in blood vessels and around the brain is an important one. Many viruses can enter the nervous system through nerve endings, as seen with Shingles, and COVID-19 does that as well. It primarily enters through the nose and the “olfactory” nerves. In severe cases, it can cause the brain to swell. Once a virus has spread to the brain, it is in a protected region and difficult for the body to remove it. A dramatic worsening of a headache should trigger a medical visit.

Many with COVID have “silent hypoxia” where they may have impaired oxygenation, yet not struggle to breathe. Other conditions with impaired oxygenation, like sleep- apnea syndrome, also cause headache.

Less dramatic are headaches secondary to being “locked down.” Remember that those with migraine have brains which don’t do well with environmental changes. These can include oversleeping or undersleeping, changes in the timing of caffeine, and the stress, anxiety, panic, and depression that this situation has caused. Many instances of suicides and abusive behavior have been reported. More than the general population, migraineurs tend to overuse acute medication and drink alcohol. Health care workers with migraine often do poorly as the personal protective equipment, long shifts, missing meals, and dehydration are all problematic. Sanitizers have been widely employed, and those with strong odors should be avoided.

The treatment of migraine in association with COVID is likely not different from attacks with other triggers. Early on there were concerns over the safety of ibuprofen in those with COVID. However, this concern does not appear to be justified. Stress reduction techniques are particularly important. Most providers and patients are unhappy that most of the care is through “virtual” visits. The positive news is that the most important feature of a headache diagnosis is the description of attacks, including frequency and severity, and most cases can be managed with non-face-to-face visits. However, if headache is severe or progressive, patients should be seen in person by their provider.

Mark W. Green MD, FAAN
Director of Headache and Pain Medicine
Professor of Neurology, Anesthesiology, and Rehabilitation Medicine
Vice-Chair of Neurology for Professional Development and Alumni Relations
Icahn School of Medicine at Mt Sinai