Headache Medicine 2020, 11(2):48-50 ISSN 2178-7468, e-ISSN 2763-6178

ASAA

DOI: 10.48208/HeadacheMed.2020.14

Headache Medicine

Original

Recommendations for the management of headaches during the

COVID-19 pandemic

Yara Dadalti Fragoso

Marcelo Calderaro

Marcio Nattan Portes Souza

Patrick Emanuell Mesquita

Sousa Santos

Eduardo Nogueira

Shuu-Jiun Wang

4,5

Messoud Ashina

Stephen D Silberstein

Mario F P Peres

8,9

Universidade Metropolitana de Santos, Santos, Brazil.

Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil.

Universidade Federal do Delta do Parnaíba, Parnaíba, Brazil.

Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.

Brain Research Center, National Yang-Ming University, Taipei, Taiwan.

Department of Neurology, Copenhagen University, Copenhagen, Denmark.

Je󰀨erson Headache Center, Department of Neurology, Thomas Je󰀨erson University, Philadelphia, USA.

Hospital Israelita Albert Einstein, Sao Paulo, Brazil.

Instituto de Psiquiatria, Hospital das Clínicas da Universidade de São Paulo, Brazil.

Abstract

Background

During the novel coronavirus - COVID-19 pandemic, health care systems are facing one of

its greatest challenges.

Results

Secondary headaches may need urgent care at an emergency department. Primary heada-

ches exacerbations may require intravenous infusion. Treatment optimization is key for a better

outpatient management.

Conclusion

We give recommendations on when a headache patient should go to the hospital despite

the current limited resources, and primary headache management aspects during the ou-

tbreak.

Yara Dadalti Fragoso

yara@bsnet.com.br

Received: April 18, 2020.

Accepted: April 27, 2020.

Edited by

Marcelo Moraes Valença

Keywords:

Headache management

COVID-19

Emergency department

ASAA

Fragoso YD, Calderaro M, Souza MNP, Sousa Santos PEM, Nogueira E, Wang SJ, Ashina M, Silberstein SD, Peres, MFP

Recommendations for the management of headaches during the COVID-19 pandemic

Introduction

ealthcare worldwide is facing one of its greatest crises in

history

. With the fast spread of the novel coronavirus, health-

care systems are collapsing in some countries, with depletion of

resources and crowding of emergency rooms, wards and intensive

care units

Since the World Health Organization’s declaration that a pandemic Since the World Health Organization’s declaration that a pandemic

exists, interruption of non-urgent healthcare has been generating exists, interruption of non-urgent healthcare has been generating

insecurity and helplessness for people with other health problems, insecurity and helplessness for people with other health problems,

including headache disorders. We need strength and compassion including headache disorders. We need strength and compassion

to face up to and overcome this crisis and its imposed difculties. to face up to and overcome this crisis and its imposed difculties.

One important step is to seek reliable information, and to prevent One important step is to seek reliable information, and to prevent

the spread of false news that generate confusion and panic. Here, the spread of false news that generate confusion and panic. Here,

we provide guidelines for the management of headaches during we provide guidelines for the management of headaches during

the COVID-19 pandemic.the COVID-19 pandemic.

Recommendations for the emergency Recommendations for the emergency

care of headache disorders during the care of headache disorders during the

covid-19 pandemiccovid-19 pandemic

With the emergency department (ED) as a potential source of

COVID-19 infection, patients experiencing headaches need advice

on when to seek emergency care.

Patients should avoid ED visits for treatment of their regular

headache, but if they experience a headache with red ags, urgent

care may be needed. Delay in treatment may increase morbidity

and mortality, telemedicine is one key tool for the management of

headaches during the pandemic.

When should headache patients go to the

emergency department?

COVID-19 and its symptoms are an independent determinant COVID-19 and its symptoms are an independent determinant

of ED care especially with breathing difculties. Headache is of ED care especially with breathing difculties. Headache is

reported in patients with COVID-19 from 8 to 34%.reported in patients with COVID-19 from 8 to 34%.

3,43,4

However, However,

headache and mild symptoms alone that patients may think might headache and mild symptoms alone that patients may think might

be a symptom of COVID-19 should not be considered as not be a symptom of COVID-19 should not be considered as not

an indication. The list below shows conditions that accompany an indication. The list below shows conditions that accompany

headache and may indicate that it is a lifethreatening disorder headache and may indicate that it is a lifethreatening disorder

requiring special management requiring special management

1. Headache and Fever1. Headache and Fever A new-onset acute headache that differs A new-onset acute headache that differs

from those that were previously experienced, in association with a from those that were previously experienced, in association with a

documented increase in temperature (>37.8 °C or >100 °F) is a documented increase in temperature (>37.8 °C or >100 °F) is a

sign of ongoing infection. This may be managed by telemedicine sign of ongoing infection. This may be managed by telemedicine

if another symptom such as painful urination suggests the site of if another symptom such as painful urination suggests the site of

infection (urinary, pulmonary, sinus, common cold). Evaluation infection (urinary, pulmonary, sinus, common cold). Evaluation

and treatment can be given by telemedicine with possible referral and treatment can be given by telemedicine with possible referral

to the ED (change in mental status, diplopia, weakness , stiff neck, to the ED (change in mental status, diplopia, weakness , stiff neck,

etc.) and patient monitoring for clinical worsening. If the patient’s etc.) and patient monitoring for clinical worsening. If the patient’s

condition worsens over time, or mental status is declining, this must condition worsens over time, or mental status is declining, this must

be urgently revaluated by the healthcare provider.be urgently revaluated by the healthcare provider.

2. Headache and stiff neck 2. Headache and stiff neck Headaches associated with stiff neck Headaches associated with stiff neck

may be due to meningitis or subarachnoid hemorrhage (SAH). may be due to meningitis or subarachnoid hemorrhage (SAH).

Meningitis evolves over a few days, generally associated with Meningitis evolves over a few days, generally associated with

fever. In SAH, headache usually presents with sudden onset, as fever. In SAH, headache usually presents with sudden onset, as

an abrupt and very severe headache, i.e. thunderclap headache.an abrupt and very severe headache, i.e. thunderclap headache.

3. Headache and change in mental status 3. Headache and change in mental status Headaches associated Headaches associated

with mental confusion, change in behavior, excessive sleepiness orwith mental confusion, change in behavior, excessive sleepiness or

disorientation may originate from a central nervous system (CNS) disorientation may originate from a central nervous system (CNS)

disorder, stroke, neoplasia or infection. Adequate care should disorder, stroke, neoplasia or infection. Adequate care should

be given, otherwise the primary condition may worsen without be given, otherwise the primary condition may worsen without

treatment. treatment.

4. Eye pain, redness and/or vision loss.4. Eye pain, redness and/or vision loss. Headaches occurring in Headaches occurring in

one or both eyes, associated with redness are more likely to be due one or both eyes, associated with redness are more likely to be due

to conjunctivitis. Glaucoma can present with eye pain or redness, to conjunctivitis. Glaucoma can present with eye pain or redness,

but is usually accompanied by peripheral loss of vision. Vision loss but is usually accompanied by peripheral loss of vision. Vision loss

may also occur in migraine auras. If a patient has experienced may also occur in migraine auras. If a patient has experienced

a headache associated with vision loss for the rst time, medical a headache associated with vision loss for the rst time, medical

attention is needed. Acute headaches that are unilateral or attention is needed. Acute headaches that are unilateral or

periorbital and occur in association with vision loss in the elderly periorbital and occur in association with vision loss in the elderly

should give rise to suspicion of temporal arteritis.should give rise to suspicion of temporal arteritis.

5. Headaches associated with physical exertion or fainting5. Headaches associated with physical exertion or fainting Physical Physical

activity can exacerbate migraine pain and is part of the diagnostic activity can exacerbate migraine pain and is part of the diagnostic

criteria for this condition. However, headaches occurring only criteria for this condition. However, headaches occurring only

after or during physical exertion or sexual activity may be a after or during physical exertion or sexual activity may be a

sign of a secondary headache due to aneurysm, arteriovenous sign of a secondary headache due to aneurysm, arteriovenous

malformation, cerebral venous thrombosis or reversible cerebral malformation, cerebral venous thrombosis or reversible cerebral

vasoconstriction syndrome (RCVS). Headache associated with vasoconstriction syndrome (RCVS). Headache associated with

fainting or seizure can be secondary to brain tumors, infections orfainting or seizure can be secondary to brain tumors, infections or

stroke. stroke.

6. Vomiting6. Vomiting Headaches associated with vomiting only need ED Headaches associated with vomiting only need ED

attention if oral uid intake is not possible. Antiemetics should be attention if oral uid intake is not possible. Antiemetics should be

considered in the early phase of a migraine attack with nausea. considered in the early phase of a migraine attack with nausea.

Vomiting is an associated feature of migraine, but may also be a Vomiting is an associated feature of migraine, but may also be a

symptom of intracranial hypertension.symptom of intracranial hypertension.

7. New-onset headaches starting after 50 years of age7. New-onset headaches starting after 50 years of age If this is an If this is an

ongoing problem, telemedicine is appropriate for initial evaluation. ongoing problem, telemedicine is appropriate for initial evaluation.

A visit to the ER should be made if an early onset acute headache A visit to the ER should be made if an early onset acute headache

is present. is present.

8. Sudden-onset, abrupt headaches (Thunderclap Headache) 8. Sudden-onset, abrupt headaches (Thunderclap Headache)

Sudden-onset severe headaches that reach their peak in seconds Sudden-onset severe headaches that reach their peak in seconds

demand immediate evaluation. They can be due to a SAH, cerebraldemand immediate evaluation. They can be due to a SAH, cerebral

venous thrombosis, carotid or vertebral dissection, meningitis, venous thrombosis, carotid or vertebral dissection, meningitis,

pituitary apoplexy, or RCVS. Recurrent thunderclap headache is apituitary apoplexy, or RCVS. Recurrent thunderclap headache is a

ASAA

Fragoso YD, Calderaro M, Souza MNP, Sousa Santos PEM, Nogueira E, Wang SJ, Ashina M, Silberstein SD, Peres, MFP

Recommendations for the management of headaches during the COVID-19 pandemic

hallmark of RCVS until proven otherwise.hallmark of RCVS until proven otherwise.

9. Headaches in chronic non-communicable disorders or 9. Headaches in chronic non-communicable disorders or

immunodeficiencyimmunodeficiency A new-onset headache in patients with ongoing A new-onset headache in patients with ongoing

infection, HIV or cancer, or in those taking immunosuppressants, infection, HIV or cancer, or in those taking immunosuppressants,

needs urgent attention. If headaches started gradually but are needs urgent attention. If headaches started gradually but are

worsening, medical attention is also needed.worsening, medical attention is also needed.

Management of primary headaches during

the covid-19 pandemic

Primary headache patients will need special attention during the Primary headache patients will need special attention during the

COVID-19 pandemic, particularly if social isolation measures have COVID-19 pandemic, particularly if social isolation measures have

been imposed by health authorities.been imposed by health authorities.

Mental health managementMental health management

Mental health can be severely impaired, leading to anxiety, panic or Mental health can be severely impaired, leading to anxiety, panic or

depression. Suicide rates increased in China during connementdepression. Suicide rates increased in China during connement

. .

Primary headache patients may be more susceptible to mental Primary headache patients may be more susceptible to mental

health issues and/or may have more attacks under these conditions. health issues and/or may have more attacks under these conditions.

Lifestyle measures should be reinforced, since food intake, mood Lifestyle measures should be reinforced, since food intake, mood

and physical activity may be affected during the pandemic. Self and physical activity may be affected during the pandemic. Self

help tools are often available on the internet.help tools are often available on the internet.

Acute headache managementAcute headache management

Primary headaches may be exacerbated during the pandemic. Primary headaches may be exacerbated during the pandemic.

Headaches typically account for 1-3% of ER visitsHeadaches typically account for 1-3% of ER visits

. In order to avoid . In order to avoid

delays in the ED, over taxing urgent care, hospitalization, acute delays in the ED, over taxing urgent care, hospitalization, acute

treatment may need optimization. This may include addition of non-treatment may need optimization. This may include addition of non-

parenteral options such as subcutaneous injections [(i.e. sumatriptan parenteral options such as subcutaneous injections [(i.e. sumatriptan

or dihydroergotamine (DHE)] or nasal spray formulations or dihydroergotamine (DHE)] or nasal spray formulations

(sumatriptan or zolmitiptan). Patients are suggested to increase (sumatriptan or zolmitiptan). Patients are suggested to increase

acute treatment toolbox to better self-manage their headache acute treatment toolbox to better self-manage their headache

attacks. This includes the use of prochlorperazine suppositories. attacks. This includes the use of prochlorperazine suppositories.

Patients may be at risk of worsening of their headache in isolation, Patients may be at risk of worsening of their headache in isolation,

consider new preventive methods to mitigate the risk.consider new preventive methods to mitigate the risk.

Avoiding corticosteroidsAvoiding corticosteroids

Cluster headache and other primary headaches are commonly Cluster headache and other primary headaches are commonly

treated with corticosteroids. If possible, this should be avoided, treated with corticosteroids. If possible, this should be avoided,

because immunosuppression is considered to be a risk factor because immunosuppression is considered to be a risk factor

for negative health outcomes among individuals infected with for negative health outcomes among individuals infected with

COVID-19.COVID-19.

Concl usion

Headache patients will need special management during the CO-

VID-19 pandemic. New-onset acute headaches will still need medical

care. Delays in treating other life-threatening conditions caused by

diversion of resources to treat cases of the novel coronavirus may

lead to additional morbidity burdens, or mortality. Primary headache

patients may be at risk of worsening headache control due to the

limited healthcare resources available and because of changes to

lifestyle due to social-distancing connement.

References

1. MacIntyre CR. On a knife’s edge of a COVID-19 pandemic: is

containment still possible? Public Health Res Pract. 2020; 301:

3012000. doi: 10.17061/phrp3012000

2. Panati, K., Narala, V.R. COVID-19 Outbreak: an Update on

Therapeutic Options. SN Compr. Clin. Med. 2020. https://doi.

org/10.1007/s42399-020-00264-6

3. Huang C, Wang Y, Li X, et al. Clinical features of patients infec-

ted with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;

39510223: 497-506. doi: 10.1016/S0140-67362030183-5.

4. Xu XW, Wu XX, Jiang XG, et al. Clinical ndings in a group of

patients infected with the 2019 novel coronavirus (SARSCov-2)

outside of Wuhan, China: retrospective case series. BMJ. 2020;

368: m606. doi: 10.1136/bmj.m606.

5. Do TP, Remmers A, Schytz HW, et al. Red and orange ags

for secondary Neurology. 2019; 923: 134-144. doi: 10.1212/

WNL.0000000000006697.

6. Qiu J, Shen B, Zhao M, et al. A nationwide survey of psycholo-

gical distress among Chinese people in the COVID-19 epidemic:

implications and policy recommendations. Gen Psychiatr. 2020;

332: e100213. doi: 10.1136/gpsych-2020-100213.

7. Munoz-Ceron J, Marin-Careaga V, Peña L, et al. Headache at

the emergency room: Etiologies, diagnostic usefulness of the

ICHD 3 criteria, red and green ags. PLoS One. 2019; 141:

e0208728. doi: 10.1371/journal.pone.0208728.