A survivor of a traumatic brain injury just over a decade ago, Heather Schroeder is no stranger to headaches. Since a horse riding accident, she’s had her intermittent migraines under control with medication and botox injections. But when she contracted COVID-19 in July 2021, the headaches she suffered were “hell on earth,” she says.
“Unlike a migraine associated with my TBI, this one came down like a blanket thrown over my head. It was not a process to get a headache. I suddenly had a headache and it was unbearable,” says Schroeder, a 52-year-old from Knoxville, Tennessee. “A normal migraine for me can be an eight or nine out of ten, with vomiting, photosensitivity, and post-migraine discomfort. This headache was 20 out of 10.”
Neither Tylenol nor migraine relief medication reduced the pain, she says. The headaches lasted for two weeks, robbing her of sleep — giving her only 15 to 45 minutes at a time. “A lot of people I know spent their COVID quarantine watching TV or reading,” says Schroeder. “I spent it with a cold pack on my head trying to endure the pain of the headache.”
Schröder is far from alone. In a recent review of research, about half of all people with acute COVID infection developed a headache, and in about a quarter of people it was the first symptom. Despite classifying COVID as a respiratory disease, about one in five patients with moderate to severe COVID reports that it was the neurological symptoms — including headaches, brain fog, and loss of taste and smell — that bothered them the most.
These percentages are probably an underestimate. “The reporting of headaches varies depending on whether they are evaluated in an inpatient or outpatient setting,” says Mia Tova Minen, director of headache research and neurologist at New York University Langone Health. “It’s probably underreported by hospitalized patients in part because there are so many other symptoms that could be the focus of those patients.”
Types of COVID-19 headaches
Headaches are usually an early COVID symptom and are typically bilateral — occurring on either side of the head, or “whole head” as some have described it. The pain varies from moderate to severe, but several people have said it National Geographic that the pain was much worse than previous headaches; others rated the pain as comparable to previous migraines. But between 47 and 80 percent of people with a history of headaches described their COVID headaches as different than previous ones — with pain that was both sudden and intense.
For example, Schroeder says her migraines used to start slowly, which gave her time to reduce exposure to light and take medication. But her COVID headaches kicked in right away and her migraines haven’t been the same since she was infected. “My migraines are a lot less controllable, and in the fall and early spring they were a lot more common than ever,” she says.
Her husband, Jesse Trucks, also suffered a TBI from sports injuries and, like his wife, had been vaccinated four months before contracting COVID-19. He also developed headaches, which he described as different from those resulting from his brain injury. “The pain of the COVID headache was like the dentist’s drill hitting a nerve,” he says. While his headaches usually form a band around the front of his head, his COVID headaches instead parked at his neck and the back of his head and lasted 10 days.
Headaches reported by people with acute COVID fall into three main categories: migraine-type, tension-type, and daily headaches, according to Jennifer Frontera, a neurologist at New York University’s Grossman School of Medicine. Each of these corresponds to existing types of headache diagnoses.
Some people with COVID describe a migraine-like headache with throbbing on one side of the head, often accompanied by nausea, vomiting, and sensitivity to light and sound. However, several studies have identified the most common features of COVID headaches as symptoms similar to those of tension headaches, occurring on both sides and presenting more of a “rubber-band-like restriction over your head,” Frontera says. Between 70 and 80 percent of people say they appear on both sides and the front of their heads, describing them as “pressing” or “exciting.” Sensitivity to light or sound and nausea or vomiting, on the other hand, occurs in less than half of patients with COVID headaches.
However, some of these COVID-triggered tension headaches have another quality that justifies the third category: they last for days, weeks, or even months. These are similar to “new daily persistent headaches,” a diagnosis for a headache that just won’t go away and is often triggered by a viral infection, a medical procedure, a stressful life event, or even a plane trip, Minen says. Although it wasn’t officially diagnosed as a new daily persistent headache until 90 days, Minen says doctors can usually spot these headaches and start treatment sooner.
New daily persistent headaches may be less responsive to standard migraine headache treatments or traditional tension-type headaches, which has led many headache specialists to associate them with the persistent headaches people describe during a COVID attack, Minen says.
In a study of more than 900 COVID patients, their headaches lasted an average of 14 days, but one in five patients still had them three months later; one in six patients had it nine months later. The worse the headache was during an acute infection, the longer it was likely to be.
Causes of the COVID-19 headache
Researchers are still learning about the specific mechanisms of a COVID-19 headache, but some possibilities include direct injury from the virus, a response to inflammation as the body fights the infection, less oxygen in the blood, dehydration, problems with blood clotting or problems with the endothelial cells, which form the inner lining of blood vessels. However, none of these explain all the COVID headaches.
“There are probably slightly different mechanisms at play,” says Frontera. “The most compelling pathological data relates to microvascular injury,” she says. The negative effects of COVID-19 on blood vessels are well known and can affect the trigeminal nerve, the largest cranial nerve responsible for facial sensation and motor activities such as chewing and swallowing. Each trigeminal ganglion — a group of nerves — is located near the temples in front of the ears on either side of the head and has three branches along the top, middle, and bottom of the face.
“There’s a link between headaches and loss of smell and taste, so one possible mechanism could be that this olfactory pathway is damaged,” says Minen. “It could be that COVID enters through the nose and there is inflammation in the nasal cavity. This then activates the branches of the trigeminal nerve, which can cause headaches.”
Laura Johansen, a public health clinical researcher in Charlotte, North Carolina, noted that the headaches she developed while suffering from COVID-19 in October 2020 “matched almost perfectly with the onset of losing my sense of taste and smell and simultaneously worsened”, a common association in research. Like most with COVID headaches, hers were focused on the top and front of her head.
“It felt like a sinus headache meets a migraine,” says Johansen. “It lasted about four days, and when it kicked in, it was firmly parked — no ebb and flow, just constant pain.” Although she took acetaminophen, she said it didn’t help much.
Acetaminophen is one of the most common treatments doctors offer, as are nonsteroidal anti-inflammatory drugs, metamizole, triptans, or a combination thereof, but only a quarter of people report complete relief; only half reported relief from these drugs. Minen says headache specialists often treat tension-type headaches, or persistent daily headaches, with gabapentin, a drug also used to treat seizures and nerve pain.
“If you’re not responding to simple over-the-counter pain relievers, it certainly makes sense to make an appointment with a headache specialist,” says Frontera. “First, to make sure nothing else is happening, and then to define what type of headache you’re having.” Treatments for migraine-like headaches are different from tension-type headaches or daily headaches, she says.
Long COVID headache
Although COVID-related headaches subside in most people with other symptoms, up to 45 percent of people continue to have the headache after other symptoms resolve.
Travis Littlechilds, a systems analyst based in London, has had his COVID headaches most days for the past four months. His headaches during the active infection were similar to a migraine, he says, “but particularly sensitive to pressure.” Bending down or coughing was particularly painful. Although his headache has lessened, its quality is about the same: intense pressure right in the back of his head that feels worse with movement.
Others with long had COVID similar reported that the headaches they developed during the infection never went away. In a meta-analysis of 36 studies involving more than 28,000 people, headaches lasted up to two months in one in six people and up to three months in one in ten. In 8 percent of the patients, the headaches lasted at least six months. Most research on COVID headaches doesn’t address whether symptoms differ in vaccinated or unvaccinated individuals, but at least one recent study found that headaches were among the less severe symptoms in vaccinated or boosted individuals.
Those most likely to develop a long COVID headache are people who have had a history of headaches, who had headaches as the first symptom, whose COVID headaches lasted longer than the rest of their COVID symptoms, or whose headaches were unresponsive to painkillers. Those with post-COVID headaches typically respond well to the migraine drugs amitriptyline and nortriptyline, according to Frontera.
Schroeder, whose illness was primarily her headache and fatigue with no chest tightness or runny nose, was fortunate not to develop a long-lasting COVID headache and she and her husband continue to take precautions to avoid further infection.
“I never want to have a headache like that ever again,” she says. “I look back and wonder how I survived that experience. Oddly, I don’t remember the days well at all…but I remember the pain perfectly.”