Researchers report a case of a young male patient who came in with a headache to an emergency room. He had increased intracranial pressure and tested positive for SARS-CoV-2, suggesting new headaches during the pandemic should not be ignored.
The causative pathogen of coronavirus disease (2019) – severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) – mainly affects the respiratory system causing symptoms such as a dry cough, loss of taste and smell, and shortness of breath. However, there are increasing reports that COVID-19 also causes neurological effects like encephalitis and stroke.
Headache has been reported in patients with COVID-19, sometimes along with neurological symptoms. It is the most common neurological manifestation and needs to be evaluated further.
In a study published in the journal Headache, researchers from the Institute of Human Behavior and Allied Sciences in India report a case study of a 15-year old boy who came into an emergency room with a headache. The throbbing headache started abruptly and came every 5–10 minutes. The boy was also vomiting and was sensitive to light. The patient reported that it was worse when he awoke in the morning and increased when bending forward. Although the boy had a low fever five days before the onset of headache, there were no respiratory symptoms like cough, sore throat, or loss of smell.
Headache with COVID-19
When doctors examined the patient, they found no fever. Though he was agitated, he responded to commands at intervals. Eye examination and a brain MRI did not reveal any abnormalities. Routine blood tests were also normal.
They found increased pressure of 30 cm of water when they examined the cerebrospinal fluid. Test for viral pathogens like mumps, varicella, and enterovirus were negative.
Doctors started the patient on intravenous fluids, acyclovir, and paracetamol. After five days of treatment, the boy was conscious and had no behavioral symptoms, but his headache did not improve and did not respond to painkillers.
Because of the ongoing COVID-19 pandemic, the patient’s nasal and throat swabs were sent for SARS-CoV-2 testing, and they came back positive. But, the cerebrospinal fluid was negative for the virus. A repeat test of the cerebrospinal fluid still showed increased pressure of 28 cm of water, with two cells, both lymphocytes.
The doctors performed a second lumbar puncture, which dramatically reduced the patient’s headache. He was given dexamethasone, mannitol, acetazolamide, and topiramate for two weeks during his stay in hospital. After three weeks, the patient was doing fine with no reports of headache, requiring no further medication.
New headaches during pandemic should not be ignored
There have been reports on COVID-19 cases that describe and emphasize headaches in patients and their nature. Literature reports show about 11–14% of COVID-19 patients have reported headaches. Studies of patients in Beijing, China, showed headache to be a common symptom in about 6.5% patients.
There may be different mechanisms for the appearance of headache in COVID-19 patients. One could be an infection of the trigeminal nerve endings in the nasal cavity. SARS-CoV-2 infects host cells by binding to the human angiotensin-converting enzyme 2 (ACE2). ACE2 expression in the brain is mainly seen in neurons and glial tissues, and the expression of ACE2 in the endothelial cells could affect trigeminovascular activation and headache.
The authors think the headache is likely the result of the body’s immune response to SARS-CoV-2, with changes in cerebrospinal fluid production and resorption, resulting in increased intracranial pressure, which can lead to cerebral edema because of cytokines or infection of the endothelium.
The headache in the case reported was relieved by a second lumbar puncture. There are only isolated cases reported so far of COVID-19 with increased intracranial pressure. In another case, a young male patient with COVID-19 encephalitis had increased pressure with seizures and altered senses; they required ventilation due to the severity of their infection. In contrast, the patient in this study’s only major symptom has a headache and abnormal behavior, suggesting a probable case of COVID-19 related encephalitis.
“We already know that SARS-CoV-2 has neurotrophic potential, so in the current pandemic headache as a complaint should not be ignored especially any new-onset headache,” write the authors.
They suggest people with any changes in chronic headaches should be tested for COVID-19. Further studies should be performed to understand the complications due to headache in COVID-19 patients, along with exploring the need for intracranial pressure monitoring in patients with COVID-19 related encephalopathy.
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