How COVID-19 headaches are different from others—and how to manage them

Experts say three types of headaches can occur with coronavirus infection. Figuring out which one someone has is key to finding the right treatment.

By Tara Haelle
Published 23 Sept 2022, 20:30 BST
An angiogram done at the University of Virginia Medical Center reveals a patient's cerebral vasculature. Headaches related to SARS-CoV-2 infection may result from microvascular injury involving the trigeminal nerve.
Photograph by Joe Mcnally, Getty Images

As a survivor of a traumatic brain injury that happened a little more than a decade ago, Heather Schroeder is no stranger to headaches. She’s controlled her intermittent migraines with medication and Botox injections since a horse-riding accident. But when she caught COVID-19 in July 2021, the headaches she suffered were “living hell,” she says.

“Unlike a migraine related to my TBI, this one descended like a blanket being thrown over my head. It wasn't a process of getting a headache. I suddenly had a headache, and it was excruciating,” says Schroeder, a 52-year-old from Knoxville, Tennessee. “A normal migraine for me can be an eight or nine out of 10, with vomiting, light sensitivity, and post-migraine malaise. This headache was a 20 out of 10.”

Neither Tylenol [paracetamol] nor migraine rescue medications reduced the pain, she says. The headache persisted for two weeks and deprived her of sleep—allowing her only 15 to 45 minutes at a time. “A lot of people I know spent their COVID quarantine watching television or reading,” Schroeder says. “I spent it with a cold pack on my head trying to endure the pain of the headache.”

Schroeder is far from alone. In a recent review of the research, approximately half of all people with an acute COVID infection developed a headache, and it was the first symptom in about a quarter of people. Despite COVID’s classification as a respiratory disease, about one in five patients with moderate to severe COVID report that it was the neurological symptoms—including headache, brain fog, and loss of taste and smell—that bothered them the most.

Those percentages are likely an underestimate. “The reporting of headache varies depending on whether it’s assessed inpatient or outpatient,” says Mia Tova Minen, chief of headache research and a neurologist at New York University Langone Health. “It’s likely underreported by hospitalised patients in part because there’s so many other symptoms that might be the focus of those patients.”

Types of COVID-19 headaches 

A headache is usually an early COVID symptom and typically bilateral—occurring on both sides of the head, or the “whole head,” as some have described it. The pain varies from moderate to severe, but several people told National Geographic that the pain was far worse than with previous headaches; others rated the pain as on par with past migraines. But between 47 and 80 percent of people with a history of headaches described their COVID headache as different from past ones—with pain that was both sudden and intense.

Schroeder, for example, says her migraines used to begin slowly, giving her time to reduce light exposure and take medicine. But her COVID headache came on in an instant, and her migraines since her infection aren’t the same. “My migraines are far less controllable, and in the fall and early spring they were far more frequent than ever before,” she says.

Her husband, Jesse Trucks, also sustained a TBI from sports injuries and, like his wife, had been vaccinated four months before getting COVID-19. He also developed a headache, which he described as distinct from those resulting from his brain injury. “The pain of the COVID headache was like when the dentist’s drill hits a nerve,” he says. While his headaches typically form a band around the front of his head, his COVID headache instead parked itself at the base of his neck and the back of his head, lasting for 10 days.

The headaches reported by people with acute COVID fall into three main categories, according to Jennifer Frontera, a neurologist at New York University’s Grossman School of Medicine: migraine-like, tension-type, and daily persistent headaches. Each of these correspond to types of headache diagnoses that already exist.

Some people with COVID describe a migraine-like headache, with throbbing on one side of the head, often accompanied by nausea, vomiting, and light and sound sensitivity. Multiple studies, however, have identified the most common characteristics of COVID headaches as symptoms similar to those in tension-type headaches, which occur across both sides and have a more “rubber band-like restriction across your head,” Frontera says. Between 70 and 80 percent of people say they occur on both sides and the front of their head and describe them as having a “pressing” or “tightening” quality. Light or sound sensitivity and nausea or vomiting, on the other hand, occur in less than half of those with a COVID headache.

But some of these COVID-triggered tension-type headaches have another quality that warrants the third category: they last for days, weeks, or even months. These resemble “new daily persistent headaches,” a diagnosis for a headache which just doesn’t go away and is often triggered by a viral infection, a medical procedure, a stressful life event, or even a plane ride, Minen says. Although only formally diagnosed as a new daily persistent headache after lasting 90 days, Minen says doctors typically recognise these headaches and may begin treating earlier.

New daily persistent headaches may be less responsive to the standard headache treatments for migraine or traditional tension-type headaches, which has led many headache specialists to link them to the ongoing headaches people describe during a bout of COVID, Minen says.

In one study of more than 900 COVID patients, their headache lasted a median 14 days, but one in five patients still had it three months later; one in six patients had it nine months later. The worse the headache was during acute infection, the longer people were likely to have it.

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 issues with the endothelial cells that form the inner layer of blood vessels. None of these, however, explain all COVID headaches.

“There’s probably slightly different mechanisms at play,” Frontera says. “The most compelling pathological data pertains to microvascular injury,” she says. The negative effects of COVID-19 on blood vessels are well recognised and may affect the trigeminal nerve, the largest cranial nerve and the one responsible for facial sensations and motor activities, such as chewing and swallowing. Located near the temple in front of the ears on either side of the head, each trigeminal ganglion—a group of nerves—has three branches along the top, middle, and bottom parts of the face.

“There’s an association between headache and loss of sense of smell and taste, so one potential mechanism could be that there’s some sort of damage in that olfactory pathway,” Minen says. “It could be that COVID is entering through the nose, and there’s inflammation in the nasal cavity. That then activates the trigeminal nerve branches, which can cause headaches.”

Laura Johansen, a public health clinical researcher in Charlotte, North Carolina, noticed that the headache she developed when she suffered from COVID-19 in October 2020 “aligned almost perfectly with starting to lose my sense of taste and smell, and worsened together in tandem,” a common association in the research. Like most with COVID headaches, hers was concentrated at the top and front of her head.

“It felt like a sinus headache met a migraine,” Johansen says. “It lasted for about four days, and once it set in, it was solidly parked—no ebbs and flows, just continuous ache.” Though she took acetaminophen, she said it didn’t do much.

Acetaminophen – known as paracetamol in the UK – is one of the most common treatments doctors offer, as well as non-steroidal anti-inflammatory drugs, metamizole, triptans, or a combination of these, but only a quarter of people report complete relief; only half reported getting any relief from these medications. Minen says headache specialists will often treat tension-type headaches or persistent daily headaches with gabapentin, a medication that’s also used to treat seizures and nerve pain.

“Certainly, if you’re not responding to basic over-the-counter pain medications, it’s probably reasonable to make an appointment with a headache specialist,” Frontera says. “One, to make sure there’s not something else going on, and then to define what type of headache you are having.” Treatments are different for migraine-like headaches versus tension-type or daily persistent headaches, she says.

Long COVID headaches

Though COVID-related headaches subside with other symptoms in most people, up to 45 percent of people continue to suffer from the headache after other symptoms wane.

Travis Littlechilds, a systems analyst who lives in London, has had his COVID headache most days for the past four months. His headache during active infection was similar to a migraine, he says, “but extra sensitive to pressure.” Bending over or coughing was particularly painful. Though his headaches have become less severe, their quality is roughly the same: strong pressure directly in the back of his head that feels worse with movement.

Others with long COVID have similarly reported that the headache they developed during the infection never left. In a meta-analysis of 36 studies involving more than 28,000 people, the headache lasted up to two months for one in six people and up to three months for one in 10. For 8 percent of patients, the headache lasted at least six months. Most research on COVID headaches doesn’t address whether symptoms differ for vaccinated or unvaccinated people, but at least one recent study found that for those who were vaccinated or boosted, headaches were among the less severe symptoms.

Those most likely to develop a long COVID headache are people who had a history of headaches, who experienced a headache as their first symptom, whose COVID headache lasted longer than the rest of their COVID symptoms or whose headache didn’t respond to pain medications. Those with post-COVID headaches tend to respond well to the migraine medications amitriptyline and nortriptyline, Frontera says.

Schroeder, whose illness was primarily her headache and fatigue without any chest tightness or sniffles, was fortunate not to develop a long COVID headache, and she and her husband continue to take precautions to avoid another infection.

“I never ever want to have a headache like that again,” she says. “I look back and wonder how I survived the experience. Oddly, I don't remember the days well at all … but I can remember the pain perfectly.”


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