Report
Survey on Headache During COVID-19 Infection in People with Chronic Headache
2023 Volume 6 Issue 2 Pages 62-67
Details
2023 Volume 6 Issue 2 Pages 62-67
A questionnaire survey was conducted to clarify the headache situation in people with chronic headache during the new coronavirus disease 2019 (COVID-19) infection. A questionnaire survey was conducted on the internet. The subjects were 600 women in their 20s to 40s who were infected with the 7th wave of COVID-19 infection from July to October 2022. Subjects (55.7%) had headaches at the time of infection, and most of the infected people were recuperating at home. Other headaches (excluding migraine) accounted for about 60% of existing headaches in both the headache group and the headache-free group, but people with migraine accounted for 30.5% of the headache group, and those without headache accounted for 23.3% of the headache-free group. In the headache group, 40.3% had headaches even at the time of vaccination against COVID-19. In both the migraine group and other headache groups, compared to regular headaches, headaches during COVID-19 infection had a greater impact on daily life. Migraine headaches may have worsened in migraine carriers, as accompanying symptoms of migraine were observed at the time of infection. It is therefore important to note that chronic headache patients may develop severe headaches during COVID-19 infection.
The new coronavirus disease 2019 (COVID-19) is highly contagious and has caused an explosive epidemic worldwide due to droplet infection, contact infection, and aerosol infection. The major difference from conventional viral infections is that there are many asymptomatic patients, and the virus spreads easily by acting without knowing that they are infected. Analysis of HER-SYS data from June 14 to July 18, 2021 showed 73% and 85% fever, 43% and 46% cough, 31% and 32% general malaise, and 22% and 27% headache in alpha and delta strains, respectively.1) In addition, a comparison of symptoms by age group among those who were positive for corona infection and had symptoms showed that 6.6% of those over the age of 65 had headaches, while 23% of those under the age of 65 had headaches.1) The 7th wave of the COVID-19, caused by the omicron strain substrain BA.5, which began in July 2022, had become an epidemic that surpasses the 6th wave in Japan. According to a survey by the French Public Health Agency, the most common clinical symptoms in 288 people infected with the Omicron strain BA.5 in France were general malaise (76%), cough (58%), and fever (58%), headache (52%) and runny nose (50%).2)
Vaccines have been developed with the aim of preventing the onset of COVID-19 infections, reducing the number of deaths and severe cases as much as possible, and preventing the spread of coronavirus infections. In fact, vaccination has been confirmed to be effective in preventing the onset of symptoms,3) and it is thought that symptoms such as fever and headache are reduced because it prevents the aggravation of COVID-19 infection. On the other hand, side effects such as pain in the injection site, fatigue, headache, muscle and joint pain, chills, diarrhea, and fever are known to occur after vaccination. In a female-biased group (hospital nurses), headaches after vaccination against the COVID-19 were more likely to occur as a side effect in those who had pre-existing headaches.4) Therefore, even if infected with the COVID-19, it is likely that female with pre-existing headaches are more likely to have headaches after infection.
In this study, a questionnaire survey was conducted on female infected with the 7th wave of COVID-19 to clarify the headache situation in people with chronic headache during COVID-19 infection.
Among the monitor members of Loyalty Marketing Inc., an Internet research company, the subjects were women in their 20s to 40s who were infected with COVID-19 between July and September 2022. An Internet research company sent questionnaire request emails to registered monitors (107,137 people), and 8,177 people responded to the screening. In this survey, the subjects were 600 women in their 20s to 40s, and the number of women in each age group was set to 100 for each gender. The response request email was sent on October 1, 2022, and the survey was discontinued on October 2, 2022, when the planned number of responses was reached. As a result, 600 samples were collected. The questionnaire was multiple-choice and anonymous to protect the personal information of the respondents. In addition to the basic attributes, the question items were “situation during the 7th wave of COVID-19 infection”, “vaccination status”, “usual headache situation”, and “headache during the 7th wave of COVID-19”. This survey was conducted after obtaining approval from the human subject research ethics committee of Teikyo Heisei University (approval number: 2022-083).
How to Differentiate HeadacheTo select people with migraine, we used the modified ID migraine screener Japanese version,5) which included five items: headache exacerbation during daily activities, nausea, photophobia, osmophobia and phonophobia, covering the past 1 year. Respondents were asked to answer pre-existing headaches, excluding headaches associated with vaccination and headaches due to COVID-19 infection. Based on previous study by Lipton et al.,6) we assessed headache exacerbation during daily activities, nausea, photophobia, osmophobia and phonophobia using the following criteria: “yes” assigned to response of “less than half the time” or “half the time or more”. Participants who answered yes to at least two of five questions were considered to have migraines. Of the people who had headaches in the past 1 year, those who did not meet the criteria of migraine were considered to have other headaches. Moreover, people with migraines who answered yes to the question about aura symptoms (visual symptom) were considered to have migraine with aura. In this way, migraine was evaluated according to the International Classification of Headache Disorders, Third Edition (ICHD-3).7) Usually, migraine screener cover the past 3 months, but in this study, the coverage period was 1 year. Therefore, many people with mild chronic headache were included in the subjects, and it was expected that the rate of chronic headache people would increase.
Statistical AnalysisData are expressed as mean ± standard deviation or number of respondents (%). In this study, the subjects were classified into a “headache group” who developed headache due to the 7th wave of COVID-19 infection, and a “headache-free group” who did not have a headache. Furthermore, the headache group was classified into a migraine group and other headache groups, and analyzed. χ2 test and Fisher’s exact method were used for categorical variables, and p < 0.05 was considered significant. The Fisher's exact test is utilized since the sample size is small with expected frequency less than 5 in one cell. The statistical software used was Excel Statistics ver.3.21 (Social Information Service).
Of the 600 subjects who were infected with the 7th wave of COVID-19, 334 had headaches at the time of infection, and 266 had no headaches (Table 1). In both groups, especially in headache group, many people complained of fever, sore throat, cough and sputum (Table 1). As for the route of infection, household infections accounted for about half of the cases in both groups (Table 1). The next most common was unknown route of infection, which accounted for about one-fourth in both groups (Table 1). Most of the infected people were recuperating at home (Table 1).
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Pre-Existing Headache Situation
In pre-existing headache situation, compared with the headache-free group, the headache group had more accompanying symptoms, such as headache exacerbation during daily activities, nausea, photophobia, osmophobia and phonophobia (p < 0.001), and the degree of disability in daily life was higher (p < 0.001, Table 2). In both the headache group and the headache-free group, the most common type of headache was classified as other headaches, but migraine accounted for 30.5% of the headache group, and 23.3% of the headache-free group had no headaches on a regular basis. (Table 2). People with pre-existing headache were divided into the migraine group (132 people) and the other headache group (377 people), many people in the migraine group had accompanying symptoms (p < 0.001), and the degree of disability in daily life was higher (p < 0.001, Table 2). Migraine with aura accounted for 30.3% of the migraine group (Table 2).
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Vaccination Status Against COVID-19
The number of vaccinations against the COVID-19 before the 7th wave infection was 3 times, accounting for 53.0% in the headache group and 55.6% in the headache-free group (Table 3). Approximately 80% of both the headache group and the headache-free group had received Pfizer's vaccine (Table 3). Fever was the most common adverse reaction after vaccination, which was 66.7% in headache group and 65.3% in no headache group (Table 3). In the headache group, injection site pain (p = 0.024), general malaise (p = 0.029), headache (p < 0.001), muscle pain (p < 0.001), and chills (p = 0.003) were more frequent (Table 3). In the headache-free group, 11.0% had no symptoms (p = 0.022, Table 3). In a comparison of the migraine group and other headache groups, among the side effects of vaccination, injection site pain (p = 0.028) and headache (p = 0.003) were more frequent in the migraine group (Table 3).
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Situation of Headache During the 7th Wave of COVID-19 Infection
Among those with headache during the 7th wave, 24.6% had headaches for 2 days, 23.7% for 3 days, and 13.5% for 5 or more days (Table 4). Regarding the situation at the time of the infection, in the headache group, “headache caused by fever” was 76.0%, “the headache site was the frontal region or the whole head” was 73.7%, and “the headache was pulsatile” was 60.5% (Table 4). Compared to other headache groups, 60.8% (p < 0.001) of the migraine group responded that “I felt noisy with the headache” 58.8% (p < 0.001) said that “The headache was non-pulsatile with a feeling of tightness or heaviness over the head”, 56.9% (p = 0.011) said that “I had trouble sleeping due to headaches”, and 44.1% ((p < 0.001) said that “the headaches were accompanied by nausea and an upset stomach”, 40.2% (p < 0.001) said that “accompanied by a headache, I felt that the light was dazzling to the extent that I usually didn't notice it”, and 35.3% (p < 0.001) said that “accompanying the headache, I felt that the smell was unpleasant”.
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The most common answer for headaches during the 7th wave infection was that they stay in bed (Table 4). Migraine and other headache groups, the degree of disturbance to daily life was greater than usual headaches (Fig. 1, p < 0.001). Approximately half of the headaches associated with infection were managed with prescription drugs (Table 4). Comparing the migraine group and other headache groups, more migraine group responded that they used over-the-counter medications (p = 0.008, Table 4).
Effects of Headache During COVID-19 Infection and Non-Infection on Daily Life.
Migraine and other headache. People with pre-existing headache were divided into the migraine group (132 people) and the other headache group (377 people). Headache during infection was worse than that during non-infection (p < 0.001).
BA.5, one of the omicron strains, was the mainstream of the 7th wave of the COVID-19 in Japan.8) Headache was a common symptom overseas, where the infection spread earlier than in Japan.8) In this study, just like abroad,2) headache was observed in 55.7% (334/600), and other symptoms such as fever, cough/phlegm, sore throat, and malaise were frequently observed. If the oxygen saturation is 96% or more and there are no respiratory symptoms, or if there is only a cough but no dyspnea, it is classified as mild and will be treated at home or in a hotel. If oxygen saturation is less than 96% and dyspnea or pneumonia findings are observed, hospitalization is indicated to prevent aggravation. Since 2022, when the omicron strain became mainstream, the mortality and severity rates have been declining.8) Therefore, it was confirmed that the subjects of this survey are a group that has the characteristics of the 7th wave infected people in Japan.
Usual Headache SituationIn our study, many of subjects had pre-existing headaches. In the migraine group, migraine with aura accounted for 30.3%, which is almost the same value as previous reports in Japan.9) In addition, it was confirmed that the migraine group had a higher degree of disability in daily life than the other headache groups, and had the characteristics of migraine. However, in this study, there is a possibility that people with migraine headaches were included in other headaches because physicians did not conduct interviews or diagnoses.10) Moreover, it cannot be denied that the population is biased, because it was an Internet survey and the subjects were limited to female.
Vaccinations for COVID-19 and HeadachesThere was no difference in the number of vaccinations or the type of vaccines taken between the headache group who had headaches due to the 7th wave infection and the headache-free group who did not have headaches. However, those who had headaches from the 7th wave of COVID-19 infection had headaches, injection site pain, general malaise, myalgia, and chills as side effects of vaccination compared to those who did not have headaches. Sekiguchi et al. also reported that people with pre-existing headaches, such as migraine, were more likely to have headaches after vaccination than people without headaches.4) Furthermore, in our study, when comparing the subjects’ pre-existing headaches, it became clear that the migraine group was more likely to have headaches after vaccination than the other headache groups. On the other hand, in the headache-free group, there were many people who did not usually have a headache, and compared to the headache group, a higher percentage of respondents answered that they had “no symptoms” after vaccination.
Headache During the 7th Wave of COVID-19 InfectionToptan et al. reported that COVID-19-infected people with migraine had different headaches (earlier onset, longer duration, stronger headache) than those without migraine.11) In this study, it was found that in migraine and other headache groups, compared to headaches during normal times, the headaches during the 7th wave COVID-19 infection was highly disabling. In both groups, more than 80% of the respondents said that headache was caused by fever. Therefore, the expansion of cerebral blood vessels due to fever may have caused a migraine. Even in the migraine group, more respondents reported that their headaches were non-pulsatile than in other headache groups. In addition, nausea, photophobia, osmophobia, phonophobia, and sleep deprivation were significantly more common in the migraine group than in the other headache groups, and headaches affect daily life. It was revealed that the migraine group suffered from symptoms other than headache. Thus, migraine headaches may have worsened in people with migraine, as accompanying symptoms of migraine were observed at the time of infection. Because migraine is a stress-associated disease,12) stress due to COVID-19 infection, including movement restrictions and anxiety about infecting someone with COVID-19, might worse migraine. Furthermore, more than half of the respondents in both groups reported using prescription drugs for headache, and it is thought that many of them used NSAIDs. In this study, since many migraine sufferers had exacerbated migraine during COVID-19 infection, it is important to use triptans if headache does not improve with NSAIDs.
The authors would like to thank Medical English Service (https://www.med-english.com/) for the English language review.
Conflict of interestThe authors declare no conflict of interest.
