COVID-19 Headache: Patterns, Causes, and Clinical Insights

Headache is a common symptom of COVID-19, often appearing early in the course of infection. Unlike typical headaches, those associated with COVID-19 can be more persistent and severe, sometimes resembling migraines or tension-type headaches. Understanding these headaches is crucial for diagnosis and management, as they may offer insight into the virus’s neurological effects.

Research suggests that COVID-19-related headaches stem from inflammation, vascular dysfunction, and direct viral effects on the nervous system. Identifying their characteristics can help clinicians differentiate them from other headache disorders and improve patient care.

Frequency In Clinical Observations

COVID-19-related headaches have been widely documented, with prevalence estimates ranging from 13% to 34% of symptomatic cases. A meta-analysis in The Journal of Headache and Pain reviewed over 100 studies and found that nearly one-third of hospitalized patients experienced headaches, with even higher rates among non-hospitalized individuals with mild to moderate illness. This suggests headaches may be an early indicator of infection, sometimes appearing before respiratory symptoms.

Demographic and clinical factors influence headache frequency. Younger adults, particularly those under 50, report headaches more often than older individuals, possibly due to differences in immune response or pre-existing headache disorders. A study in Cephalalgia found that patients with a history of migraines or tension-type headaches were more likely to experience severe and prolonged headaches during COVID-19. Additionally, healthcare workers and individuals under high stress reported a greater incidence, likely due to both viral effects and external stressors exacerbating headache susceptibility.

Hospital-based research indicates that headache presentation varies with disease severity. In mild cases, headaches are often moderate to severe, bilateral, and pressure-like, resembling tension-type headaches. In contrast, critically ill patients report headaches less frequently, possibly due to the overwhelming systemic effects of severe infection or the use of sedatives and analgesics in intensive care. A retrospective study in Neurology found that among ICU patients, headaches were documented in fewer than 10% of cases, whereas in outpatient settings, they were a leading complaint.

Phenotypic Traits

COVID-19 headaches exhibit distinct characteristics. Patients frequently describe them as diffuse, moderate to severe, and affecting the entire head rather than one side. Unlike typical tension headaches, which present as a dull, band-like pressure, COVID-19 headaches may have a pulsating or pressing quality, resembling migraines in some individuals.

One distinguishing feature is their persistence. While viral infection-related headaches typically resolve within days, those linked to SARS-CoV-2 can last for weeks, even after other symptoms subside. A study in Headache: The Journal of Head and Face Pain found that nearly 20% of patients experienced headaches for over a month, with some reporting lingering pain for up to three months. This prolonged duration raises concerns about post-viral neurological effects, particularly in the context of long COVID.

Many COVID-19 patients find typical analgesics ineffective. Over-the-counter pain relievers, such as acetaminophen and ibuprofen, often provide minimal relief. A Cephalalgia study noted that nearly 70% of patients required stronger medications, such as triptans or prescription anti-inflammatories, to manage symptoms. This suggests that underlying mechanisms differ from those of primary headache disorders, potentially involving neuroinflammation or vascular dysfunction.

Additional symptoms further distinguish COVID-19 headaches. Many patients experience photophobia, phonophobia, and nausea, similar to migraines. Others report cranial pressure exacerbated by physical activity, resembling exertional headaches. The presence of these neurological symptoms suggests SARS-CoV-2 may influence central pain processing pathways, heightening sensitivity to external stimuli.

Classification Of Patterns

COVID-19-related headaches manifest in distinct patterns, resembling known headache disorders. Some individuals experience a diffuse, pressure-like sensation akin to tension-type headaches, while others report symptoms more characteristic of migraines. Certain cases exhibit atypical features that do not fit conventional classifications. Recognizing these variations can aid diagnosis and treatment.

Tension Type

A significant proportion of COVID-19 headaches resemble tension-type headaches, characterized by a bilateral, pressing, or tightening sensation. Patients often describe a constant, moderate-intensity pain lacking the throbbing quality of migraines. However, COVID-19-related tension headaches tend to be more severe and persistent, sometimes lasting for weeks.

A study in The Journal of Headache and Pain found that nearly 40% of COVID-19 patients with headaches reported pressure-like discomfort that worsened with prolonged screen time or stress. Muscle tension in the neck and shoulders has also been frequently observed, possibly due to prolonged bed rest or increased stress levels. While these headaches typically do not involve nausea or sensitivity to light and sound, some patients report mild photophobia, indicating potential viral effects on central pain processing.

Migraine Like

For some individuals, COVID-19 triggers headaches resembling migraines, featuring unilateral or bilateral throbbing pain, nausea, and heightened sensitivity to light and sound. These headaches often intensify with physical activity and may be accompanied by dizziness or nasal congestion.

A study in Cephalalgia found that among COVID-19 patients with pre-existing migraines, nearly 60% experienced an exacerbation of their usual headache pattern, with increased frequency and severity. Even in those without prior migraines, COVID-19-related headaches sometimes present with aura-like symptoms, such as visual disturbances or tingling sensations. The strong resemblance to migraines suggests SARS-CoV-2 may influence trigeminovascular pathways, which play a central role in migraine pathophysiology. Additionally, the poor response to common analgesics further supports a migraine-like mechanism, often requiring triptans or other targeted treatments for relief.

Other Presentations

Some COVID-19 headaches exhibit atypical features that do not conform to standard classifications. These include stabbing or ice-pick headaches—brief but intensely painful episodes occurring multiple times a day. Others report a burning or electric-shock sensation, suggesting possible involvement of neuropathic pain pathways.

A case series in Neurology described COVID-19 patients developing cluster-like headaches, characterized by severe, unilateral pain around the eye, accompanied by tearing and nasal congestion. While true cluster headaches are rare, their occurrence raises questions about the virus’s impact on the autonomic nervous system. Additionally, some individuals experience headaches fluctuating in intensity throughout the day, potentially linked to inflammatory responses or vascular changes. These diverse presentations highlight the complexity of COVID-19’s neurological effects and the need for tailored treatment approaches.

Proposed Neurobiological Mechanisms

The mechanisms underlying COVID-19-related headaches likely involve multiple neurological pathways. SARS-CoV-2 can enter the central nervous system through routes such as retrograde axonal transport via the olfactory nerve and blood-brain barrier disruption. Autopsy studies have detected viral RNA and proteins in brain tissue, suggesting direct effects on neurons and glial cells. This could explain the persistence and severity of headaches in some patients, as viral invasion may trigger localized neuroinflammation and heightened pain sensitivity.

Changes in vascular function may also contribute, particularly in migraine-like cases. SARS-CoV-2 has been linked to endothelial dysfunction, which can alter cerebral blood flow and increase vascular permeability. Dysregulation of the trigeminovascular system may contribute to the throbbing nature of COVID-19 headaches. Elevated levels of vasoactive substances such as calcitonin gene-related peptide (CGRP) and nitric oxide have been observed in infected individuals, both known to promote headache symptoms by inducing vasodilation and neurogenic inflammation.

Overlap With Other Neurological Symptoms

COVID-19 headaches often occur alongside other neurological symptoms, such as dizziness, anosmia, dysgeusia, and brain fog. These symptoms suggest shared underlying mechanisms, particularly involving neuroinflammation and autonomic dysregulation.

A study in JAMA Neurology found that patients with persistent headaches were also more likely to experience cognitive difficulties and sensory disturbances, indicating widespread neural dysfunction rather than a localized pain response. Some individuals continue to experience headaches alongside cognitive impairment and fatigue for months after infection, a phenomenon linked to long COVID. Functional MRI studies have shown altered connectivity in pain-processing regions of the brain in post-COVID patients, reinforcing the idea that prolonged symptoms may result from lingering neuroinflammation or dysregulated neurotransmitter function.

Variation Across Different Populations

COVID-19 headache presentation and frequency vary across demographic groups, influenced by age, sex, genetic predisposition, and pre-existing conditions. Younger adults tend to report headaches more frequently than older individuals, possibly due to differences in immune response or neurovascular sensitivity. A multinational study in The Lancet Neurology found that individuals under 50 were significantly more likely to experience severe headaches, whereas older adults had a higher prevalence of delirium and confusion.

Women report COVID-19-related headaches at higher rates than men, consistent with broader trends in primary headache disorders such as migraines. Genetic factors may also play a role, as certain cytokine-related gene polymorphisms are associated with increased headache susceptibility in viral infections. Individuals with a history of migraines or tension-type headaches appear more prone to severe and prolonged headaches during COVID-19, likely due to pre-existing sensitization of pain pathways. Recognizing these trends can help tailor treatment approaches and improve symptom management.