Post-COVID-19 Syndrome? New daily persistent headache in the aftermath of COVID-19

Síndrome Pós-COVID-19? Nova cefaleia diária persistente após COVID-19

Dear Editor,

We read with great interest the systematic review article entitled “Neurological complications in patients with SARS-CoV-2 infection: a systematic review” by Munhoz et al¹, published in this journal in May 2020. We want to congratulate the authors for this successful article and add our own contributions.

Recently, we noticed frequent clinical visits (General Neurology Outpatient Clinic and a Radiology Clinic) with complaints suggestive of New Daily Persistent Headache (NDPH) following recovery from SARS-CoV2 infection, which is characterized by a clear and distinct onset, persistent headache. It is known that extracranial viral infections are the main triggering factor of NDPH, in addition to stressful life events and invasive procedures such as intubation².

Headache is a frequent symptom associated with ongoing SARS-CoV2 infection, as reported by Munhoz et al. (up to 34%); however, headache persistence has been observed even weeks after recovery³, and as described in case reports and in the authors’ experience, enough to fulfill International Classification of Headache Disorders, 3rd edition (ICHD-3), diagnostic criteria for NDPH. To our knowledge, there is still no comprehensive review of remote morbidities following recovery.

In our experience, the following patterns were agreed upon: they had mild or moderate respiratory symptoms, treated on an outpatient basis, mainly without a diagnosis of pre-existing primary headache, had characteristics of holocranial, pressure-like pain starting within 2 weeks after recovery of respiratory symptoms, no pathological causal findings have been observed in contrasted imaging studies (excluding cerebral venous thrombosis, a known neurological complication of SARS-COV2 infection).

The pathophysiology of NDPH is largely unknown, some studies believe that the pain may be due to the production of cytokines and persistent glial activation that arise in response to precipitating events⁴, which is also one of the hypotheses for CNS involvement by COVID-19, thus occurring synergy between pathophysiological mechanisms.

In clinical practice, most headache specialists treat NDPH based on the main headache phenotype, whether it is migraine or tension-type. No medication has shown to be advantageous in the studies conducted to date. As such, prophylactic treatment was used mostly with a tricyclic antidepressant or anticonvulsant (namely, amitriptyline and topiramate), with varying success^4,5.

In our opinion, as we follow an increasing number of patients recovered after SARS-CoV-2 infection, a better understanding of the pathophysiology and course of the disease (and therefore the best treatment approach) is certainly warranted.

References

• ¹
  Munhoz RP, Pedroso JL, Nascimento FA, Almeida SM de, Barsottini OGP, Cardoso FEC, et al. Neurological complications in patients with SARS-CoV-2 infection: a systematic review. Arq Neuropsiquiatr. 2020 May;78(5):290-300. https://doi.org/10.1590/0004-282x20200051
  » https://doi.org/10.1590/0004-282x20200051
• ²
  Li D, Rozen TD. The clinical characteristics of new daily persistent headache. Cephalalgia. 2002 Feb 1;22(1):66–9. https://doi.org/10.1046/j.1468-2982.2002.00326.x
  » https://doi.org/10.1046/j.1468-2982.2002.00326.x
• ³
  Sampaio Rocha‐Filho PA, Voss L. Persistent headache and persistent anosmia associated with COVID-19. Headache. 2020 Aug;60(8):1797-9. https://doi.org/10.1111/head.13941
  » https://doi.org/10.1111/head.13941
• ⁴
  Yamani N, Olesen J. New daily persistent headache: a systematic review on an enigmatic disorder. J Headache Pain. 2019 Jul 15;20(1):80. https://doi.org/10.1186/s10194-019-1022-z
  » https://doi.org/10.1186/s10194-019-1022-z
• ⁵
  Rozen TD. New daily persistent headache. Curr Pain Headache Rep. 2003 May;7(3):218-23. https://doi.org/10.1007/s11916-003-0076-3
  » https://doi.org/10.1007/s11916-003-0076-3

Reply

Resposta

Authorship SCIMAGO INSTITUTIONS RANKINGS

We thank Dr. Liu and colleagues for their comments and citation of our systematic review¹ apropos of their insightful clinical observation presented in the letter entitled Post-COVID-19 Syndrome? New daily persistent headache in the aftermath of COVID-19².

This description of a potentially new late complication of SARS-CoV-2 infection confirms a previous similar observation³ and provides a reasonable pathophysiological rationale as well as a treatment approach. We congratulate the authors for their astute clinical observation, which may serve as guidance and advice for the clinician involved in the care of these patients.

References

• ¹
  Munhoz RP, Pedroso JL, Nascimento FA, Almeida SM de, Barsottini OGP, Cardoso FEC, et al. Neurological complications in patients with SARS-CoV-2 infection: a systematic review. Arq Neuropsiquiatr. 2020 May;78(5):290-300. https://doi.org/10.1590/0004-282x20200051
  » https://doi.org/10.1590/0004-282x20200051
• ²
  Liu JWTW, De Luca RD, Mello Neto HO, Barcellos I. Post-COVID-19 Syndrome? New daily persistent headache in the aftermath of COVID-19. Arq. Neuropsiquiatr. 2020. In Press.
• ³
  Sampaio Rocha‐Filho PA, Voss L. Persistent headache and persistent anosmia associated with COVID-19. Headache. 2020 Aug;60(8):1797-9. https://doi.org/10.1111/head.13941
  » https://doi.org/10.1111/head.13941

Publication Dates

• Publication in this collection
  14 Dec 2020
• Date of issue
  Nov 2020

History

• Received
  30 Sept 2020
• Reviewed
  12 Nov 2020
• Accepted
  01 Oct 2020