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.
BYTARA HAELLE

PUBLISHED SEPTEMBER 23, 2022

• 10 MIN READ

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 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 hospitalized 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 recognize 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 recognized 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 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.”