While loss of taste and smell are among the most publicized symptoms of COVID-19, headaches are also among the early symptoms. Often, those headache effects can linger.

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Dr. Megan Donnelly

Dr. Megan Donnelly, a women’s neurologist and board-certified headache specialist at Novant Health Neurology and Headache - SouthPark in Charlotte, answers questions about COVID-19 headaches, neurological effects of the virus, and migraines in the time of a pandemic.

What is the connection between COVID-19 and headache?

From a headache perspective, this is one of the presenting symptoms of COVID-19.

This virus is behaving very differently than a lot of other viruses in the past. It appears that one of the first symptoms that people have, before they develop cough, is they will get anosmia, which is lack of sense of smell. They can get really bad headache at that time. Sometimes cough doesn't come until another couple of days later. There is a theory that this anosmia is actually due to the virus crossing over and invading the cribriform plate (near the nasal cavity) into their brain, causing a viral meningitis like picture.

What are other serious neurologic conditions might COVID-19 cause?

There are several. The more ominous things are encephalitis, seizures, increased risk of stroke and blood clot in the brain and hemorrhagic encephalitis.

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We’ve seen things like brain and spinal cord inflammation, a condition called ADEM (acute disseminated encephalomyelitis) and another that looks like a multiple sclerosis attack, which can include tingling, numbness, fatigue, cramps, tightness and dizziness, altered mental status, and seizure.

What type of headache does COVID-19 cause, and how does it compare to a migraine?

I'm seeing patients while they're actively sick and also in follow-up, sometimes even months later, after they've recovered from COVID-19, but they're still having post-COVID-19 headache. In some patients, the severe headache of COVID-19 only lasts a few days, while in others, it can last up to months.

It is presenting mostly as a whole-head, severe-pressure pain. It's different than migraine, which by definition is unilateral throbbing with sensitivity to light or sound, or nausea. This is more of a whole-head pressure presentation.

What else do you have to be aware of?

I make sure I'm not missing one of the more ominous conditions. I often have to order imaging on these patients and they'll get an MRI to make sure we're not seeing stroke or encephalitis. I check venous imaging to make sure I'm not missing a clot in the veins. The reason for that is COVID-19 patients have a tendency for blood clots. There's a recommendation by the American Society of Hematology to add aspirin (81 mg) on a daily basis to anyone who is actively infected, to help decrease the risk of clots.

There hasn’t been enough time to conduct large, in-depth medical studies, because COVID-19 is new. You, in essence, are forced to do battlefield research, rather than, say, a five-year study.

Correct. We've had a couple of months. We don't have any randomized control trials. What we have is on-the-ground, in-the-battlefield advice that the drug gabapentin nightly (300 to 900 milligrams) has looked helpful for these patients who have post-COVID-19 lingering headache, who we know have normal resolved brains, where we’re not seeing strokes encephalitis, clots or anything. There isn't anything randomized controlled about it. It's the same way we're having to do everything with COVID-19, which is by the seat of our pants.

How are you treating patients in this uncertain time?

Patients are doing video visits with me while actively infected in the first 14 days, then are able to follow up with me in office if they want after that. Being able to offer video visits has been a wonderful resource for these patients to have while they're sick and at home. They can still receive acute and adequate, quality neurologic recommendation and care. They’re not told `Oh, you're sick right now, nobody can see you.’

For someone whose migraines are triggered by stress, how do they deal with that during the unsettling times of a pandemic?

We're all weathering the storm and each person's weathering it differently in terms of the degree of stress they're facing. It could be a family member’s illness, or themselves, financial stressors, etc. There’s a lot on people's plates. Managing stress levels and focusing on mindfulness can be extremely important in that setting. In the beginning of this in March, I personally was very, very stressed about the pandemic itself. I have several family members very important to me, who are immune compromised. So, my profound level of worry was beyond a normal stressor, I recognized that was a toxic stress level. I started doing more practice of yoga and of mindfulness, meditation, deep breathing, because I knew that I needed to do that.

Sometimes that's not enough. Although I think that's an important first mainstay of treatment, we need to recognize when we need to treat patients with medication and with psychotherapy to help. If the stressors are the biggest cause of the uptick of headache, addressing stress and mental health, rather than just throwing more medications at the headache, is going to be extremely important. As with any health condition, treating the underlying cause of uptick is more important than putting a bandage on it.

Any general tips for someone concerned about headaches in this age of COVID-19, whether they’ve dealt with migraine or fear it developing?

Continuing a healthy lifestyle is always going to be one of my top pieces of advice. Make sure you are getting enough sleep, that you're keeping a routine with your sleep. With the loss of many regular life activities, making sure you maintain a modicum of routine schedule is extremely important. Even if you’re at home, I recommend getting up at the same time that you used to, get dressed, eat meals, exercise and go to sleep at the regular times. We should not have loss of routine and loss of schedule due to these COVID-19 changes. Do not work from bed, in your pajamas. That’s not an OK option. Also, in this time of more social isolation, I recommend staying connected with friends and family through telephone and video technology, because we can get through this better together.

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