What does a post‑COVID‑19 headache feel like?

What Does a Post-COVID Headache Feel Like?

Post-COVID headaches are typically described as moderate to severe, persistent, throbbing or pulsating pain that is often holocephalic (affecting the entire head) and frequently resembles migraine, with associated photophobia, phonophobia, and worsening with physical activity. 1, 2

Primary Characteristics

Pain Quality and Location

• The headache is most commonly described as throbbing or pulsating in nature, rather than pressure-like or stabbing 1
• Pain is typically diffuse and holocephalic (affecting the whole head), though it can occasionally be unilateral 1, 2
• Intensity ranges from moderate to severe, with many patients reporting debilitating pain that interferes with daily function 2, 3

Associated Symptoms

• Photophobia (light sensitivity) and phonophobia (sound sensitivity) are present in the majority of cases, giving the headache a migraine-like quality 1
• Worsening with physical exercise or exertion is a characteristic feature that distinguishes it from tension-type headaches 1
• Cognitive dysfunction ("brain fog") accompanies the headache in approximately 30% of patients 4
• Dizziness occurs in about 33% of cases 5

Temporal Pattern

Duration and Persistence

• Post-COVID headaches are defined as those persisting ≥4 weeks after acute infection by CDC criteria, though some definitions require ≥12 weeks 4
• The mean duration at presentation to headache specialists is 7.4 months after initial infection 3
• 50% of patients report persistent headaches 12-15 months after their COVID-19 infection 6
• The headache is typically constant and unremitting, rather than episodic 2

Evolution Over Time

• Headache intensity during the acute COVID phase is the strongest predictor of prolonged duration 1
• Most cases show a decreased prevalence over time: 47% at onset, dropping to 10% at 30 days, 16.5% at 60 days, 10.6% at 90 days, and 8.4% at ≥180 days 7

Clinical Phenotypes

Migraine-Like Presentation (Most Common)

• 74% of patients with protracted post-COVID headache meet ICHD-3 criteria for migraine 3
• 65% specifically meet criteria for chronic migraine (≥15 headache days per month), compared to only 16% who had chronic migraine before COVID infection 3
• This represents a chronification from episodic to chronic migraine in many patients with prior headache history 3

New Daily Persistent Headache Pattern

• Some patients develop a new persistent daily headache phenotype, particularly those without prior headache history 2
• The headache begins within days of COVID infection and becomes constant from onset 2

Treatment Response

Medication Resistance

• Post-COVID headaches are often described as treatment-refractory, not responding to typical over-the-counter analgesics (acetaminophen, ibuprofen) 2
• Even typical migraine abortive therapies (such as triptans) may fail to provide relief 2
• However, 72% of patients started on migraine preventive medications (such as topiramate, propranolol, or CGRP antagonists) report decreased frequency and/or severity 3

Structural Correlates

Brain Imaging Findings

• White matter lesions are significantly more frequent (50% vs 20% in controls) in patients with persistent post-COVID headache 5
• These structural changes may explain the persistent, treatment-resistant nature of the headache 5
• Standard imaging is typically normal in most cases, as post-COVID headache is primarily a functional disorder 4

Red Flags Requiring Urgent Evaluation

Warning Signs

• New worsening or unresponsive headache with confusion or altered mental status may indicate cerebrovascular complications 6, 1
• Progressive headache over days evolving into seizures or status epilepticus has been reported 6
• New onset of focal neurological signs (weakness, vision changes, speech difficulty) requires immediate imaging to exclude stroke or cerebral venous thrombosis 1

When to Image Urgently

• Any patient presenting with severe headache plus altered consciousness, seizures, or focal deficits needs emergent brain MRI or CT 6
• Elevated intracranial pressure (opening pressure >25 cm H₂O on lumbar puncture) has been documented in severe cases 6

Impact on Function

Disability Burden

• Full-time employment decreased from 81% to 55% among patients with protracted post-COVID headache 3
• The headache is frequently debilitating, preventing normal activities of daily living 2
• 57% of patients with symptoms persisting beyond 12 weeks report decreased quality of life 4

Clinical Pitfalls to Avoid

• Do not dismiss persistent headache as "just fatigue"—it may represent ongoing neuroinflammation or structural brain changes requiring specific treatment 6
• Do not assume normal imaging excludes post-COVID headache—most cases have normal structural imaging despite severe symptoms 4
• Do not prescribe standard exercise programs for patients with post-COVID headache and post-exertional malaise, as 75% worsen with physical activity 8
• Do not delay migraine preventive therapy—early initiation shows benefit in 72% of patients 3