Protracted Headache After COVID-19

A Case Series of 31 Patients From a Tertiary Headache Center

Leon S. Moskatel MD; Liza Smirnoff MD


Headache. 2022;62(7):903-907. 

In This Article

Abstract and Introduction


Background: Headache can be a prominent feature of Post-Acute Sequelae of SARS-Cov2 infection (PASC) and previous studies have centered around PASC headaches that have resolved within a month of infection.

Methods: We performed a retrospective chart review of 31 adults evaluated at the Stanford Headache Clinic between September 2020 and January 2022 who developed new or worsening headaches after COVID-19 infection that were unresolved at time of evaluation for demographics, medical history, and headache diagnosis.

Results: Headache had been present for a mean duration of 7.4±4.8 months after infection. Notably, 25/31 (81%) had a previous history of headache. The specific features of the headache varied considerably, but 23/31 (74%) met International Classification of Headache Disorders, Third Edition (ICHD-3) criteria for migraine, with 20/31 (65%) meeting ICHD-3 criteria for chronic migraine, while only 5/31 (16%) met these criteria before COVID infection. Additionally, full-time employment decreased from 25/31 (81%) to 17/31 (55%). Prior to establishing care at our clinic, 13/18 (72%) of the patients who were started on preventive medications currently indicated for migraine management, reported a decrease in frequency and/or severity of headaches.

Conclusions: Our study presents a group of patients with protracted headache after COVID-19 infection that includes both patients with a previously lower headache burden who largely exhibited chronification from episodic to chronic migraine, as well as patients with no previous history of headache who meet ICHD-3 criteria for headache attributed to a systemic viral illness, mostly with a migrainous phenotype.


Headache remains a common initial symptom of coronavirus disease 2019 (COVID-19) infection and is present in up to 49% of patients.[1] It typically presents on the first day of symptoms, can be the first sign of infection, and has a higher prevalence in persons with a previous history of migraine.[2–4] These headaches are described as holocephalic or bilateral, "oppressive" or pulsatile, and with migrainous features.[2] The presence of headaches has also been associated with less common COVID-19 symptoms including anosmia, ageusia, dizziness, and gastrointestinal complaints, but not with increased rates of pneumonia or hospitalization.[2,5–7]

Headache after COVID-19 has been found to last a median of 14 days (6–39) and extends after 3 months in 19% and after 9 months in 16%.[8] These persistent headaches are associated with a prior history of headache, female sex, and long-term symptoms such as fatigue.[5,9] Previous studies noted a holocranial or bitemporal pain pattern and case reports indicate potential improvement with typical migraine therapies.[1,5]

While previous studies have sought to characterize overall headache after COVID-19, we present a dedicated group of patients with unresolved, protracted headache after COVID-19 who mainly converted from episodic to chronic migraine, as well as a smaller subgroup who developed a new persistent headache.