Headache Medicine 2021, 12(2) p-ISSN 2178-7468, e-ISSN 2763-6178

ASAA

DOI: 10.48208/HeadacheMed.2021.17

Headache Medicine

Review

COVID-19 pandemic impact on headache in healthcare workers:

a narrative review

João Gabriel de Azevedo José Romero

, Franklin Teixeira de Salles-Neto

, Juliana Stuginski-Barbosa

Paulo César Rodrigues Conti

, Camila Megale Almeida-Leite

Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil;

Universidade de São Paulo, Bauru, São Paulo, Brazil

Abstract

Background

Pandemic of COVID-19, the potentially fatal disease caused by SARS-CoV-2, had caused

intangible consequences on global health systems, economy, daily life, education, travel,

leisure, work, and mental health. Its impact on mental and physical health, especially in health

professionals, has been described.

Objective

This study aimed to review and discuss the published evidence regarding the presence of

headache on COVID-19 healthcare workers.

Methods

In this review, we searched for all articles published in various databases including PubMed/

Medline, Scopus, and Web of Science and all original research studies, letters to editor,

case reports, commentaries and reviews published in English, Portuguese or Spanish were

searched. Two researchers independently analyzed published articles in order to include/

exclude based on inclusion or exclusion criteria.

Results

Thirteen articles were included. All studies included in this review were observational; eleven

were cross-sectional studies, one was a prospective/cohort and one was a retrospective. Two

studies evaluated psychological outcomes, mental health disorders and associated factors, one

study investigated symptoms and causes of somatic symptom disorder and all other studies

evaluated headaches associated with personal protective equipment.

Conclusions

The present review shows that COVID-19 pandemic has negative impact on physical and

mental health in healthcare workers and headache has been associated with psychological

stress and work overload during pandemic. Further studies are necessary to better investigate

COVID-19 pandemic effects on headaches and other neurological conditions.

Camila Megale Almeida-Leite

Laboratório de neurobiologia

Conceição Machado/O3-245

Departamento de Morfologia,

Instituto de Ciências Biológicas

(ICB), Universidade Federal

de Minas Gerais (UFMG), Av.

Antônio Carlos, 6627 - Pampulha

- 31290-701

Belo Horizonte/MG - Brazil

camila@icb.ufmg.br

Edited by:

Marcelo Moraes Valença

Keywords:

Coronavirus infections

Headache

COVID-19

Healthcare workers

Personal protective equipment

Received: August 12, 2021

Accepted: September 30, 2021

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Romero JGAJ, Salles-Neto FT, Stuginski-Barbosa J, Conti PCR, Almeida-Leite CM

COVID-19 pandemic impact on headache in healthcare workers: a narrative review

Introduction

n December 2019, several cases of pneumonia of unknown

etiology in Wuhan, China, had been announced and a

new-type of coronavirus, named SARS-CoV-2, was conrmed

as the cause of the outbreak.

COVID-19, the potentially fatal

disease caused by SARS-CoV-2, had become an emergency

of international concern.

Transmission occurs from human

to human, mainly by direct contact or droplets spread by

cough or sneeze of an infected person.

Social isolation

to prevent COVID-19 spread and the disease itself have

caused intangible consequences on global health systems,

economy, daily life, education, travel, leisure, work, and

mental health.

3-5

COVID-19 pandemic has had a massive impact on

frontline healthcare workers due to heavy workload with

increased hours, increased number of patients to treat,

including those with risk of death, a higher possibility of

exposure to the virus, associated with a scarcity of health

supplies and resources, especially in poor and developing

countries. In addition, frequent deaths of patients and co-

workers and a high level of concern about exposing family

members to the disease are contributing factors to this

scenario. It is well known that stressors at workplace affect

employee’s physical and mental health and symptoms may

arise.

6,7

In addition, an increased drive towards the use

of personal protective equipment (PPE) to reduce infection

is an additional factor that negatively impact healthcare

professionals during COVID-19 pandemic.

Based on this fact, different manifestations of health-related

problems are expected in this population, including

physical, somatic and behavioral diseases. Headache is

commonly related to stress, depression, anxiety and other

mental disorders. Psychiatric comorbidities have been

commonly observed in patients with primary headaches

as migraine and the tension-type headache (TTH).

9-11

The

relationship between migraine and psychiatric disorders

such as depression and anxiety is well established and

bidirectional.

12-14

People with migraine are more likely

to suffer from depression or anxiety and patients with

depression or anxiety are more likely to have migraine.

12,15

Similarly, concomitant presence of psychiatric disorders in

patients with migraine or TTH is associated with increased

headache frequency, acute medication overuse, progression

to chronicity, and poor prognosis.

13,16

Moreover, it has

been shown that the excessive usage of respiratory (masks)

and eye (glasses) protection tools may also increase the

risk of headaches.

17-21

Hence, it is expected that during the

COVID-19 pandemic, the association of psychiatric issues,

such as moderate to very-severe depression, anxiety,

and stress, with physical factors, as the use of protective

equipment, create a perfect scenario for the increased

frequency of headache in healthcare workers.

Symptoms

of dyspnea, chest discomfort and palpitation, headache,

and fatigue have also been described.

Given the importance of this recent issue, the present

study aimed to review and discuss the published evidence

regarding the presence of headache on COVID-19

healthcare workers.

Methods

Study design

This is a narrative review designed to collect and discuss

published literature on COVID-19 pandemic effects on

headache in healthcare workers. The following steps were

followed to conduct the study: (1) identication of a clear

research objective and search strategies, (2) identication

and selection of relevant research articles, (3) extraction

and charting of data, and (4) summary, discussion, and

report of results.

Literature search strategies

In this review, we searched for all articles published in

various databases including PubMed/Medline, Scopus,

and Web of Science, using keywords “covid 19”, “SARS-

CoV-2”, “pain”, “facial pain”, “headache”, “healthcare

workers”, “dentists”, “physicians”, and “nurses”. All

original research studies, letters to editor, case reports,

commentaries and reviews published in English, Portuguese

or Spanish were searched without time limit.

Identification and selection of relevant studies

Two researchers (FTSN and JGAJR) independently analyzed

title and abstract of all published articles. Disagreements

regarding inclusion or exclusion of articles were solved

through discussion. Duplicate articles were eliminated.

Data extraction from included studies and summary

of the findings

After selection of the articles, full text was obtained for all

articles and were read by the two reviewers, who extracted

all potentially relevant data. All ndings were arranged in

a data summary table. The data chart included author(s),

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Romero JGAJ, Salles-Neto FT, Stuginski-Barbosa J, Conti PCR, Almeida-Leite CM

COVID-19 pandemic impact on headache in healthcare workers: a narrative review

year of publication, study location, intervention type/study

type, comparator (if any), duration of the intervention,

study populations, aims of the study, methodology,

outcome measures, important results. Based on the main

research objective, collected information was summarized,

discussed and reported.

Results

Characteristics of included studies

Thirteen studies were included in this review. All studies were

observational; eleven were cross-sectional studies

6,8,17-25

one was a prospective/cohort study

and one was a

retrospective study.

Of those, two cross-sectional studies

evaluated psychological outcomes, mental health disorders

and associated factors among healthcare workers. One

cross-sectional study investigated symptoms and causes of

somatic symptom disorder (SSD) in Chinese nurses and

all the other studies evaluated headaches associated with

Personal Protective Equipment (PPE). Characteristics of

included studies are presented on Table 1.

Table 1. Studies included in the review.

Authors Study Location Study type Aims of the study Important results

Chew et al.,

Singapore

and India

Observational/

Cross-sectional

study

To associate psychological outcomes and

physical symptoms among healthcare

workers.

Depression (p=0.001), anxiety (p=0.001), stress (p=0.13), and PTSD

(p=0.023) were signicantly associated with the presence of physical

symptoms. Most common physical symptom.

Yifan et al.,

China

Observational /

Cross-sectional

study

To investigate symptoms and causes of

SSD of ICU nurses treating COVID-19

pneumonia.

The 5 most severe symptoms were dyspnea, chest discomfort and

palpitation, headache, fatigue, and xerostomia.

Ong et al.,

Singapore

Observational /

Cross-sectional

study

To determine risk factors associated with

the development of de novo PPE-associated

headaches and the perceived impact of

these headaches on personal health and

work performance in healthcare workers.

Participants with a pre-existing primary headache diagnosis (p=0.013)

and combined PPE usage for >4 hours per day (p=0.012) were more

likely to develop de novo PPE-associated headaches.

Tabah et al.,

Many

Countries

Observational /

Cross-sectional

study

To describe current reported practices,

availability, training, condence in use and

adverse effects due to the prolonged use of

PPE by healthcare professionals around the

world caring for COVID19.

2,711 participants: 1,797 doctors (67%), 744 nurses (27%), 170 other

professionals (6%). Use of PPE: 1557 (58%) uses FFP2 / N95 masks,

1574 (62%) wears face shield, 2245 (83%) received adequate training

in the use of PPE. Adverse effects: reported by 80% of participants:

1,266 (51%) heat, thirst (1174, 47%), pressure areas (1088, 44%),

headaches (696, 28%), inability to use the bathroom (661, 27%) and

extreme exhaustion (492, 20%).

Sharif et al.,

Many

Countries

Observational /

Cross-sectional

study

To assess stressors as a result of the

pandemic; determine the prevalence

and factors associated with anxiety and

depression; determine the frequency of

depression during the pandemic.

375 questionnaires answered : 52 countries; 34% with increased tension,

32.5% unhappy, 25% with insomnia, 20% with headache and 5%

with suicidal ideation; 14% of participants had scores consistent with

depression; probability of depression was greater in professionals who

did not receive adequate guidance on the use of PPE.

Bharatenduet

et al.,

Singapore

Observational /

Cross-sectional

study

To evaluate cerebral hemodynamics during

the placement of the N95 respiratory mask

alone, as well as in conjunction with PAPR.

154 health professionals: migraine headache was the most common

comorbidity 38 professionals (25%); 123 (80%) developed headache

due to the use of the N95 mask; N95 and N95 + PAPR masks leads to

changes in cerebral hemodynamics.

Ramirez-

Moreno et

al.,

Spain

Observational /

Cross-sectional

study

To demonstrate whether there is an

association between the appearance of

“new” headache with the type of mask and

its duration of use, as well as the impact of

this headache.

306 health professionals participated: Surgical mask used by 208

(79.7%), lter mask (N95 or FFP2) used by 53 (20.3%) of the

professionals; 158 (51.6%) reported the appearance of a new

headache, of which 65 (41.1%) already had a headache (migraine or

tension), 103 (33.7%) did not report a new headache.

Hajjij et al.,

Marocco

Observational /

Cross-sectional

study

To describe headache subtypes among

frontline health professionals using PPE;

determine correlations between PPE-related

headaches, working conditions and trends

in PPE use.

155 professionals answered the questionnaire: 81 (52.3%) had previous

chronic headache and migraine was the most prevalent type in 47

(30.3%); 96 (62%) health professionals reported headache induced by

the use of PPE; 41(32.9%) headache as “new” headache and 45 (29%)

considered it as already experienced but worsened by the use of PPE.

Swaminathan

et al.,

United

Kingdom

Observational /

Cross-sectional

study

To describe the impact of PPE and the effects

on the physical and mental well-being of

health professionals.

72 questionnaires were answered: 70.8% reported exhaustion when

using PPE, 61.7% reported headache, 90.3% reported difculty in

communication, 47.3% reported negative impact on performance, 27.8%

reported anxiety, 19.5% depression.

Zaheer et al.,

Pakistan

Observational /

Cross-sectional

study

To determine the association of the use of

PPE with headache of recent onset and

exacerbation of pre-existing headache

disorders.

241 health professionals: 68 (28.2%) reported headaches again; Of the

68 with recent onset headaches, 16 (23.5%) the pain started more than

2 hours after PPE placement; while 19 (27.9%) stated that the headache

ended within 1-2 hours after removing the PPE .

Choudhury et

al.,

India

Prospective and

observational

To evaluate the physiological effects and

the tolerability of the PPE kit together with

the N95 respirator in health professionals in

their daily routine activities in the ICU.

75 health professionals: Signicant difference in post-exchange

physiological parameters compared to baseline values: frequency

cardiac (p<0.001); oxygen saturation (p<0.001); PI (p<0.001). RPE

showed greater discomfort with the continuous use of N95 FFR. However,

the effort has increased only marginally. Adverse effects: fogging,

headache, tiredness, difculty in breathing and imbibition of the mask.

Rapisarda et

al.,

Italy

Observational /

Cross-sectional

study

To examine headache variations related

to the intensive use of facial masks in

healthcare professionals in a low to medium

risk scenario of exposure to SARS-CoV-2.

400 questionnaires: 383 validated: Of the 166 headache-free

individuals, 44 (26.5%) developed headache again; 217 reported

previous diagnosis of primary headache: 137 migraine and 80 tension-

type headache; 31.3% of those with primary headache experienced an

aggravation due to the frequency and average duration of the attack.

Shubhanshu

and Singh,

India Retrospective

To evaluate the adverse effects of the use of

protective masks.

423 participants: 283 (67%) wore the N95 / 140 mask (33%) wore the

surgical mask; Main complaints: 23% headache / 22% nasal dryness /

19% eye dryness / 12% acne Other complaints: 5% skin lesions / 5%

impaired cognition / 5% epistaxis.

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Romero JGAJ, Salles-Neto FT, Stuginski-Barbosa J, Conti PCR, Almeida-Leite CM

COVID-19 pandemic impact on headache in healthcare workers: a narrative review

Analysis of the results

A cross-sectional study at hospitals in Singapure and

India was conducted to evaluate the association between

psychological outcomes and physical symptoms among

healthcare workers. The Depression, Anxiety and Stress

Scale (DASS-21) was used to assess depression and anxiety

and Impact of Events Scale-Revised (IES-R) was used for

post-traumatic stress disorder (PTSD). It has been shown

that out of the 906 healthcare workers who participated

in the survey, 22.6% had previous comorbidities and

the most frequent was migraine (9.6%). A large number

of participants (33.4%) reported more than four physical

symptoms, and the most frequent was headache (31.9%).

Regarding psychological outcomes, 5.3% screened

positive for moderate to very-severe depression, 8.7% for

moderate to extremely-severe anxiety, 2.2% for moderate

to extremely-severe stress, and 3.8% for moderate to severe

levels of psychological distress. Depression, anxiety, stress,

and PTSD were signicantly associated with the presence

of physical symptoms.

A cross-sectional study assessed factors associated

with anxiety/depression and determined prevalence of

these disorders and the frequency of depression during

the pandemic among neurosurgeons. Eight hundred

neurosurgeons worldwide were recruited to respond online

version of WHO Self-Reporting Questionnaire-20 that

evaluated depression and anxiety. Out of 375 respondents

from 52 countries, majority were from Asia (n=181, 48.5%),

consultants (79%) or from low to middle-income countries

(66%). Almost 14% showed anxiety/depression, 34% felt

tension, 33% reported unhappiness, 25% had insomnia,

and almost 20% reported headaches. Moreover, 14% had

depression according to questionnaire scores. Anxiety and

depression were more likely in those who did not receive

guidance about self-protection from their institutions, did

not feel safe with provided PPE, were exposed to a COVID-

19-positive colleague or whose families considered their

workplace unsafe.

Another cross-sectional study investigated symptoms and

causes of somatic symptom disorder (SSD) in 140 nurses

aged 20-50 years that worked at COVID-19 pneumonia

intensive care units (ICU) in China. A questionnaire

of symptoms was designed based on the International

Classication of Functioning, Disability and Health (ICF) and

16 symptoms were evaluated. A questionnaire to evaluate

possible risk factors was also designed and applied.

Analysis was performed to cluster the symptoms and to nd

its risk factors. In 140 nurses, ve major symptoms were chest

discomfort and palpitation (31.4%), dyspnea (30.7%),

nausea (21.4%), headache (19.3%), and dizziness

(17.9%). Symptoms were classied into three clusters:

cluster A of breathing and sleep disturbances (dizziness,

sleepiness, and dyspnea); cluster B of gastrointestinal

complaints and pain (nausea and headache), and cluster

C of general symptoms (xerostomia, fatigue, as well as

chest discomfort and palpitation). Gender, sputum splash,

urine/feces splash, and urine/feces clearance were risk

factors for the occurrence of symptom clusters (p<0.05). In

cluster A, urine/feces splash, gender, and sputum splash

were related to symptoms; fall of protective glasses and

urine/feces splash were related to cluster B; and urine/

feces splash and urine/feces clearance were related to

symptoms of cluster C.

Among 10 studies that evaluated headaches associated

with PPE, physiological and adverse effects, tolerability

of PPE usage, presence of PPE-headaches and associated

factors, impacts of headache on personal health (both

physical and mental health) and work performance were

evaluated, as well as headache subtypes, appearance

of “new headache”, and exacerbation of pre-existing

headache disorders.

8,17,18,20,21,23-27

Most were conducted in

one country from Europe, North America, Africa or Asia

and sample ranged from 72 to 2,711 participants. One

was a cohort

, one was retrospective

, and all the others

were cross-sectional studies.

8,17,18,20,21,23-25

A work with small sample studied physiological effects and

tolerability of PPE and N95 masks in healthcare workers.

Signicant differences in physiological parameters such

as cardiac frequency, oxygen saturation, and pulsatility

index were observed after PPE exchange in comparison

to baseline values. Among adverse effects, headache was

an important one.

The largest study was conducted in over 90 countries of

Europe, North America, and Asia and enrolled 2,711

participants. Headache was one of the reported adverse

effects in 28% of respondents.

Similarly, Shubhanshu and

Singh

reported that headache was the most prevalent

adverse effect of PPE in 423 healthcare professionals and

frequency of this symptom was 23%.

Ong et al. (2020) evaluated 158 healthcare workers in

Singapore. Of those, 29.1% had a pre-existing primary

headache diagnosis and 81.0% developed ‘de novo’ PPE-

associated headaches. Headache was bilateral in location

and 87.5% described pain as pressure type. Over 70%

classied pain as mild and 23.4% described associated

symptoms as nausea and/or vomiting, photophobia,

phonophobia, neck discomfort, and movement sensitivity.

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COVID-19 pandemic impact on headache in healthcare workers: a narrative review

More than half of subjects (52.3%) attributed usage of PPE

as the cause for their headaches. Participants with a pre-

existing primary headache diagnosis and those working

in the emergency department were more likely to develop

‘de novo’ PPE-associated headaches. Regarding impact

of headaches, 91.3% of participants with pre-existing

headache reported that PPE usage compromised control of

their background headaches, which affected their level of

work performance.

Ramirez-Moreno and others (2020) evaluated 306 health

professionals and 51.6% of those reported appearance

of a new headache and 41.1% already had a headache

(migraine or tension), which was modied in location,

frequency, intensity and response to habitual analgesics

in 83.1% subjects. In this study, occurrence of headache

was associated with the use of a lter mask (FFP2 or

KN95) and being a health worker or a nurse. Regarding

self-perceived work stress, professionals with ‘de novo’

headache signicantly had worse scores than those without

headache.

The study of Hajjij

et al.

(2020) reported that 52.3% out

of 155 professionals that participated in the survey had

previous chronic headache and 62% had headache

induced by the use of PPE. Headache was considered

as “de novo” by 32.9% and 29% reported worsening of

previous headache by the use of PPE. Headache induced

by PPE occurred less or more than twice a week for 62.5%

and 37.5%, respectively. Frontal (58.3%) and bi-temporal

(40.8%) areas were the most prevalent sites of headache.

Working more than eight hours per shift during pandemic

was correlated to ‘de novo’ headache and the profession of

doctor was correlated to PPE aggravated headache. Type

of mask was not correlated to ‘de novo’ headache neither

to PPE aggravated headache occurrence. Respondents

reported an impact on work-related quality of life due to

PPE use during pandemic and experienced and 66.9%

considered that their professional performance reduced.

Among 241 health professionals evaluated in Pakistan,

21.1% had pre-existing headache, 28.2% showed recent

onset headache and 28.2% reported ‘de novo’ headache.

Most headaches were bilateral in location (69%), with

pressure/heaviness quality (45.5%) and moderate intensity

(66%). Among participants, 41.2% believed that combined

use of respiratory and eye protection was causing the

‘de novo’ headaches, while 22.4% attributed them to

sleep deprivation. Presence of pre-existing headaches

was associated with more susceptibility to PPE-induced

headaches and age and department of activity may be

additional risk factors.

Rapisarda and others (2021) evaluated 383 healthcare

providers in Italy. At baseline, 43.3% did not have

headache, but 26.5% of those developed headache

after 4 months. Out of 56.7% who reported pre-existing

headaches, being migraine and tension-type headache

the most frequent types, had worse symptoms mainly

regarding frequency and duration of migraine attacks.

One study evaluated cerebral hemodynamics during

usage of N95 respirator mask alone or together with

powered air-purifying respirators (PAPR) among 154

frontline healthcare workers. N95 mask was associated

with headache in 80% of participants and N95 and

N95 + PAPR lead to changes in cerebral hemodynamics.

N95 masks caused a decrease in pulsatility index but

its association to PAPR favors intracranial physiology as

compared to N95 respirator mask alone.

Swaminathan

et al.

(2020) studied the impacts of PPE on

physical and mental well-being of 72 health professionals.

Over 70% reported exhaustion when using PPE and

61.7% had headaches. Almost half of the participants

(47.3%) informed that PPE usage and its effects had

negatively interfered with their performance. Moreover,

27.8% reported anxiety and 19.5% depression.

Discussion

This review aimed to discuss evidence regarding COVID-19

pandemic effects on headache in healthcare workers. The

thirteen included studies described physical symptoms and

psychosocial impacts in healthcare workers during COVID-19

pandemic. Headache was one of the most frequent symptoms

reported by the participants.

COVID-19 pandemic has had a huge impact on health

systems all over the world. Frontline healthcare workers have

been submitted to extremely stressful situations as previously

described, which has led to the onset or worsening of physical

and mental health symptoms.

6,7,17,22,28-31

All studies included in this review agree that the majority of

healthcare workers develop some symptomatology related

to the COVID-19 pandemic. The most common physical

symptom was headache

6,17-26

, especially those symptoms

related to the PPE-usage.

8,17,18,20,21,23-27

Moreover, greater psychological and physical fatigue,

and sleep disturbances are also reported by individuals

exposed to high workload. Psychological disorders, such as

depression and insomnia are signicantly associated with

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Romero JGAJ, Salles-Neto FT, Stuginski-Barbosa J, Conti PCR, Almeida-Leite CM

COVID-19 pandemic impact on headache in healthcare workers: a narrative review

occupational stress.

32-34

Although psychological reactions

to stressful situations depend on individual vulnerability and

neural mechanisms to stress response, coping strategies, and

intolerance to uncertainty

, many studies have shown that

COVID-19 pandemic has undoubtedly caused increased

levels of psychological disorders.

Among healthcare workers,

psychological symptoms of distress, depression, anxiety, and

insomnia commit 44 to 71% of individuals.

29,30

Moreover,

presence of anxiety and depressive symptoms were associated

with epidemiological issues, material and human resources,

and personal factors.

Different studies included in this review

have shown that anxiety, depression, stress, and psychological

distress are present in healthcare workers

8,19,22

and those

psychological factors were associated with appearance of

“new headache” and exacerbation of pre-existing headache

disorders.

8,17,18,20-27

The physical and homeostasis’ effects of using the PPE may

also have inuenced the presence of headache. Facemask

and eye protection could exert mechanical forces and induce

irritation of supercial sensory neurons at cranial and cervical

regions.

Ong

et al.

2020 described the PPE-associated

headache as a subtype of external-pressure headache. The

prolonged mechanical force generates peripheral sensitization

and activation of trigeminal cervical complex, which triggers

headache attacks. This fact could not only explain the

exacerbation of pre-existing primary headache, but also the

‘de novo’ PPE-associated headache. Moreover, this could

lead and maintain central sensitization process, generating

hyperalgesia and allodynia.

The pathogenesis of PPE-associated headache could also

involve hypoxemia and hypercapnia. A recent study showed

that prolonged use of FFP2 mask led to a decrease in oxygen

saturation of hemoglobin, an increase in heart rate and in

facial temperature, which may lead health professionals

to stress, fatigue, and headaches.

High levels of carbon

dioxide in the blood can also contribute to side effects such as

dizziness, shortness of breath, and headaches.

As headache was associated with increased duration of PPE,

15 minutes breaks every two hours of PPE usage have been

suggested to lessen the deleterious effects.

Spontaneous

headache resolution within 60 minutes after removing PPE

was reported.

Although not within the scope of the studies at this stage,

category of headaches deserves a discussion. It is possible

that workers with previous history of a primary headache,

especially migraine, suffer a strong impact of both, behavioral

(sleep deprivation, stress, etc.) and physical stimulation

(head and face pressure caused by the PPE), contributing

to a signicant worsening in the frequency and severity of

migraine crises.

On the other hand, the increased muscle tension, possibly

related to activation of masticatory muscles (teeth clenching

and bruxism) may also stimulate new episoldes of pain in the

head named Temporomandibular Disorders (TMD), which

can have an overlap to the diagnostic classication of tension-

type headache. These statements, however, lack for evidence

and deserve future investigations.

It is well known that headaches are associated with

psychological stress, anxiety, depression, and sleep

disorders.

11,39

The studies reviewed here have shown that

physical overload by pandemic excessive workload have

impacted the high prevalence of headache as a physical

symptom as a consequence of stress, anxiety and PPE usage

in healthcare professionals during COVID-19 pandemic.

6,17,22

This has a huge impact on their well-being and work

performance and on health system assistance. Institutional

planning committees need to provide measures to minimize the

negative impacts of work overload and PPE on their personnel.

Healthcare administrators, policymakers, governments, and

industry should raise efforts to address these issues.

8,18

Conclusion

The present review shows that COVID-19 pandemic has a

signicant negative impact on physical and mental health

in healthcare workers. Headache has been associated with

psychological stress, work overload, and PPE use during

pandemic. Further studies are necessary to better investigate

COVID-19 pandemic effects on the onset of different headache

categories and other neurological conditions.

Conflict of Interest: The authors declare no conict of interest.

Authors' Contributions: JGAJR and FTSN performed data

collection and formal analysis, discussed the results, and wrote

the original manuscript. JSB and PCC conceived the idea of

the study, discussed the results, performed supervision, and

commented on the manuscript. CMAL conceived the idea for

the study, collected and analyzed data, supervised the study,

wrote and reviewed manuscript.

João Gabriel de Azevedo José Romero

https://orcid.org/0000-0002-3891-8648

Franklin Teixeira de Salles-Neto

https://orcid.org/0000-0001-5288-7203

Juliana Stuginski-Barbosa

https://orcid.org/0000-0002-7805-5672

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Romero JGAJ, Salles-Neto FT, Stuginski-Barbosa J, Conti PCR, Almeida-Leite CM

COVID-19 pandemic impact on headache in healthcare workers: a narrative review

Paulo César Rodrigues Conti

https://orcid.org/0000-0003-0413-4658

Camila Megale Almeida-Leite

https://orcid.org/0000-0003-2694-8521

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