COVID-19 Symptoms: Study Warns That Sudden Headaches That Were Never Common In An Individual Before May Be A Symptom Of COVID-19
: Doctors from the Institute of Human Behaviour and Allied Sciences, Delhi-India report a report a case of a young male patient who came in with a headache to an emergency room. He had increased intracranial pressure and tested positive for SARS-CoV-2, suggesting new headaches during the pandemic should not be ignored.
The case report and study findings were published the peer reviewed journal: Headache, a journal of the American Headache Society. https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.14006
The SARS-CoV-2 coronavirus, the causative pathogen of the COVID-19 disease mainly affects the respiratory system causing symptoms such as a dry cough, loss of taste and smell, and shortness of breath. However, there are increasing reports that COVID-19 also causes neurological effects like encephalitis and stroke.
However headaches have been reported in patients with COVID-19, sometimes along with neurological symptoms. It is the most common neurological manifestation and needs to be evaluated further.
The report a case study of a 15-year old boy who came into an emergency room with a headache. The throbbing headache started abruptly and came every 5–10 minutes. The boy was also vomiting and was sensitive to light. The patient reported that it was worse when he awoke in the morning and increased when bending forward. Although the boy had a low fever five days before the onset of headache, there were no respiratory symptoms like cough, sore throat, or loss of smell.
Also when the physicians examined the patient, they found no fever. Though he was agitated, he responded to commands at intervals. Eye examination and a brain MRI did not reveal any abnormalities. Routine blood tests were also normal.
The study team found increased pressure of 30 cm of water when they examined the cerebrospinal fluid. Test for viral pathogens like mumps, varicella, and enterovirus were negative.
The study team found that the cerebrospinal fluid examination revealed 12 cells with 60% lymphocytes and 40% neutrophils with normal sugar, protein, and chloride levels with markedly increased pressure of 30 cm of water in the left lateral decubitus position. Tests for viral pathogens (herpes simplex virus 1 and 2, mumps virus, varicella zoster virus, enterovirus, parechovirus) in the CSF by real‐time PCR were negative. The tuberculosis bacilli were not detected in the CSF by PCR.
The physicians started the patient on intravenous fluids, acyclovir, and paracetamol. After five days of treatment, the boy was conscious and had no behavioral symptoms, but his headache did not improve and did not respond to painkillers.
However due to the ongoing COVID-19 pandemic, the patient’s nasal and throat swabs were sent for SARS-CoV-2 testing, and they surprisingly came back positive.
But, the cerebrospinal fluid was negative for the virus. A repeat test of the cerebrospinal fluid still showed increased pressure of 28 cm of water, with two cells, both lymphocytes.
The physicians performed a second lumbar puncture, which dramatically reduced the patient’s headache. He was gi
ven dexamethasone, mannitol, acetazolamide, and topiramate for two weeks during his stay in hospital.
After three weeks, the patient was doing fine with no reports of headache, requiring no further medication.
To date, there have been reports on COVID-19 cases that describe and emphasize headaches in patients and their nature. Literature reports show about 11–14% of COVID-19 patients have reported headaches. Studies of patients in Beijing, China, showed headache to be a common symptom in about 6.5% patients. https://pubmed.ncbi.nlm.nih.gov/32235486/
However it must be noted that there may be different mechanisms for the appearance of headache in COVID-19 patients. One could be an infection of the trigeminal nerve endings in the nasal cavity. SARS-CoV-2 infects host cells by binding to the human angiotensin-converting enzyme 2 (ACE2). ACE2 expression in the brain is mainly seen in neurons and glial tissues, and the expression of ACE2 in the endothelial cells could affect trigeminovascular activation and headache.
The study team thinks the headache is likely the result of the body’s immune response to SARS-CoV-2, with changes in cerebrospinal fluid production and resorption, resulting in increased intracranial pressure, which can lead to cerebral edema because of cytokines or infection of the endothelium.
In this case, the headache reported was relieved by a second lumbar puncture. There are only isolated cases reported so far of COVID-19 with increased intracranial pressure. In another case, a young male patient with COVID-19 encephalitis had increased pressure with seizures and altered senses; they required ventilation due to the severity of their infection. In contrast, the patient in this study’s only major symptom has a headache and abnormal behavior, suggesting a probable case of COVID-19 related encephalitis.
The study team said, “We already know that SARS-CoV-2 has neurotrophic potential, so in the current pandemic headache as a complaint should not be ignored especially any new-onset headache.”
The study team suggests individuals with any changes in chronic headaches should be tested for COVID-19.
Further studies are needed in patients of COVID‐19 for studying and substantiating the characteristic pattern and severity of headache and its possible complications. The need for intracranial pressure monitoring in patients developing acute encephalopathy following COVID‐19 also needs to be explored with further research.
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