Management of Post-Viral Headache
Post-viral headache should be treated primarily with supportive care including regular multimodal analgesia (acetaminophen 1000 mg plus NSAIDs such as naproxen 500-825 mg or ibuprofen 400-800 mg), adequate hydration, and strict limitation of acute medications to no more than 2 days per week to prevent medication-overuse headache. 1, 2
Initial Assessment and Red Flag Exclusion
Rule out secondary causes by screening for thunderclap onset, progressive worsening, fever with neck stiffness, altered consciousness, focal neurological deficits, or new headache after age 50—any of these mandate urgent neuroimaging (MRI preferred) before treating as post-viral headache. 3
In patients with normal neurologic examination and no red flags, neuroimaging is not warranted. 3
Post-viral headache typically presents as moderate-to-severe, persistent, bilateral pain resembling tension-type or migraine patterns, often refractory to standard analgesics. 4, 5
Acute Symptomatic Treatment
First-line therapy consists of acetaminophen 1000 mg plus an NSAID (naproxen sodium 500-825 mg or ibuprofen 400-800 mg) taken at headache onset. 2
For moderate-to-severe attacks unresponsive to NSAIDs after 2-3 episodes, escalate to triptan therapy (sumatriptan 50-100 mg, rizatriptan 10 mg, or eletriptan 40 mg). 2
Indomethacin 25-50 mg three times daily has demonstrated efficacy specifically for refractory COVID-related and post-COVID headache when standard analgesics fail, with >50% pain relief reported by the third day in 97% of patients. 6
Add an antiemetic (metoclopramide 10 mg or prochlorperazine 25 mg) 20-30 minutes before analgesics if nausea is present, as this provides synergistic analgesia beyond antiemetic effects alone. 2
For severe attacks with significant nausea or vomiting, consider non-oral routes: subcutaneous sumatriptan 6 mg (59% pain-free at 2 hours) or intranasal sumatriptan 5-20 mg. 2
Critical Medication-Overuse Prevention
Strictly limit all acute headache medications to ≤2 days per week (≤10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1, 2
If acute treatment is required more than twice weekly, immediately initiate preventive therapy rather than increasing acute medication frequency. 3, 2
Supportive Measures
Maintain adequate hydration with oral fluids; use intravenous fluids only when oral intake cannot be maintained. 1
Evidence does not support routine use of abdominal binders or aromatherapy. 1
Caffeine may be offered in the first 24 hours of symptoms with a maximum dose of 900 mg per day (200-300 mg if breastfeeding), avoiding multiple sources to prevent adverse effects. 1
Indications for Preventive Therapy
Initiate preventive therapy when headaches persist beyond 4 weeks post-infection, occur ≥2 times per month causing disability ≥3 days, or require acute medication use more than twice weekly. 3, 2
First-line preventive options include propranolol 80-160 mg daily (long-acting), metoprolol 50-100 mg twice daily, or candesartan 16-32 mg daily. 3
Beta-blockers are contraindicated in patients with asthma, cardiac failure, atrioventricular block, or depression. 3
Evaluate preventive therapy effectiveness at 2-3 months, as oral agents require this duration to demonstrate efficacy. 3
Emerging Evidence for Post-COVID Headache
Post-COVID headache may represent a distinct phenotype, often presenting as new persistent daily headache or chronification of pre-existing primary headache disorders. 4, 5
The pathophysiology likely involves activation of the trigeminovascular system through innate immune response, with interferons, IL-1β, IL-6, and TNF facilitating headache generation. 7
CGRP monoclonal antibodies (erenumab 70-140 mg monthly, fremanezumab 225 mg monthly) should be considered for refractory post-viral headache persisting beyond 3 months when oral preventives fail, with efficacy assessed after 3-6 months. 3, 8
Medications to Avoid
Opioids (codeine, hydromorphone, tramadol) are absolutely contraindicated for post-viral headache due to questionable efficacy, high risk of dependence, rebound headaches, and worsening of overall headache outcomes. 2
Butalbital-containing compounds should be avoided due to high risk of medication-overuse headache. 2
Evidence does not support routine use of hydrocortisone, theophylline, triptans as preventive agents, adrenocorticotropic hormone, or gabapentin in post-viral headache management. 1
Follow-Up and Monitoring
Re-evaluate within 2-3 months to assess headache frequency (days per month), severity, migraine-related disability, adverse events from medications, and adherence to treatment plan. 3
Use headache calendars to track symptomatic days and acute medication use. 3
Refer to neurology or headache specialist if headaches persist beyond 3 months despite optimized therapy, diagnosis is uncertain, or complications arise. 3