16th European Headache Congress

Suggesting a Mechanism for "Long COVID-19" Associated Headaches (Fascial Armoring as a Chronic Compartment-Like Syndrome of the Whole Body)

COVID and headache

Tension type headache

Abstract text (incl. figure legends and references) Objective: The Coronavirus pandemic has impact on our community far beyond the acute phase, Long COVID-19 is recognized as a new medical entity and resembles fibromyalgia which, likewise, lacks a clear mechanism. Headaches and myofascial pain are common manifestations of COVID-19 and its post-acute sequalae. This work suggests a theoretical model with an organic mechanical mechanism to help explain long COVID-19 headaches and the headaches of functional psychosomatic syndromes such as fibromyalgia, based on cross-disciplinary empirical studies. Methods: Systematically searched multiple keywords in MEDLINE, EMBASE, COCHRANE, PEDro, and medRxiv, inclusion/exclusion based on title and abstract, then full-text inspection. Additional literature added on relevant side topics. Results: 831 records included. The theory of "facial-armoring&quot; suggests long COVID-19 and fibromyalgia-like entities may be a disease of connective-tissue driven by myofibroblast-generated-biotensegrity-tension. This mechanism may explain fibromyalgia's pain, distribution of pain, close association with primary headache disorders, decreased pressure-pain threshold, tender spots, fatigue, autonomic abnormalities, absence of clear inflammation, silent imaging investigations, and other phenomena. "Long-COVID-19" is predicted by the model to involve fascial armoring, whereby headaches may arise in part due to a disorder of myofascial tissue, at least in a subset of patients. Conclusions: long COVID-19 and fibromyalgia-like syndromes resemble a chronic-compartment-like-syndrome-of-the-whole-body and can lead to headaches due to a network of contractile fascial myofibroblasts. Treatments focusing on lifestyle modification and non-pharmacological modalities may be more beneficial in the long term. The body and the mind are one being. Reference: Plaut S. Scoping review and interpretation of myofascial pain/fibromyalgia syndrome: An attempt to assemble a medical puzzle. PLoS One. 2022;17(2):e0263087.

ePoster

Postcovid Headache after the First Wave of the Covid-19 in a Tertiary Care Headache Outpatient Clinic in Spain

Abstract text (incl. figure legends and references) Question To describe the clinical characteristics of headache, that persists after acute SARS-Cov-2 infection in a sample that belongs to a tertiary outpatient clinic in Spain Methods This is a cross-sectional descriptive study. The study population were patients who had been diagnosed with COVID-19, either by PCR or by serology in the first wave. Demographic variables, history of previous headaches, pain characteristics, symptomatic and preventive treatment, COVID and post-COVID symptoms, and psychiatric comorbidity were collected. Results Twenty patients were included, 90% were women and the mean age was 48.5 years. 60% of the patients had a previous history of headache, being episodic migraine the most prevalent (35%). The accompanying symptoms that stood out during the acute phase were: anosmia/hyposmia 45% and pneumonia 45%. The pain that appeared during the postcovid headache was daily (60%) moderate (70%), bilateral (60%), frontal (30%) and oppressive (50%). The patients associated photophobia 90%, phonophobia 85%, osmophobia 35%. The most used preventive treatment was amitriptyline (55%) . Greater occipital nerve block with anesthetics was beneficial in 50% of the sample. 15% of the patients were treated with corticotherapy. The most reported post-COVID symptoms were anosmia (25%) and cognitive alterations (20%) and fatigue 20%. Four patients met clinical ICHD criteria for NDPH, and these patients had higher scores on the Hamilton anxiety scale, especially in somatic anxiety 13/28 in patients with NDPH vs 8/28 (mean of the rest of the patients). 85% of patients were responders to preventive treatment. Conclusion: Patients who meet the NDPH criteria showed higher levels of anxiety compared to the rest of the patients. Anxiety and other psychiatric comorbidities related to the pandemic may help perpetuate the pain. Although most patients improve over time, in our sample 15% remain with persistent headache

Clinical manifestations and impact of SARS-CoV-2 infections and vaccines in patients with migraine

Migraine

Abstract text (incl. figure legends and references) Objective: To evaluate the clinical manifestations and the impact of (1) the infection caused by different SARS-CoV-2 variants and (2) different SARS-CoV-2 vaccines in patients with migraine. Methods: Cross-sectional study of a cohort of patients with migraine, followed up in a Spanish Headache Unit. Through a digital questionnaire, we collected data on the characteristics of SARS-CoV-2 infection, clinical manifestations associated with vaccination against SARs-CoV-2, and their impact on migraine. We compared participants according to (1) SARs-CoV-2 variant (native strain, Alpha, Delta, Omicron) (2) type of vaccine (Pfizer, AstraZeneca, Moderna). Results: 428 participants. COVID-19: 43.69% (187/428) had at least one infection. 83.42% (156/187) reported headache, being severe in 51.18% (81/187). The native strain and the Alpha variant were associated with a longer duration of headache compared to Delta and Omicron (15.17, 13.11, 9.16 and 6.84 days, respectively, p=0.0003). 9% (17/187) had a reinfection, all due to Omicron, and 75% (9/12) reported headache, less intense than the one of the first infection. In 28.20% (44/156) of patients their migraine got worse since COVID-19. Vaccination: 79.43% (340/428) were vaccinated, 51.47% (175/340) reported headache. There were no differences in the proportion of patients experiencing headache between different vaccines. More severe headache was observed with AstraZeneca (p=0.0041). 21.14% (37/175) of patients reported worsening of their migraine since the vaccination. Conclusions: SARS-CoV-2 infection and vaccines are a frequent cause of headache in people with migraine, however reinfections (with or without previous vaccination), new variants and mRNA vaccines are associated with more benign forms. SARS-CoV-2 infection and vaccines are also factors responsible for migraine worsening.

Prof.

Neuralgic pain after Mucormycosis infection

Trigeminal neuralgia

Abstract text (incl. figure legends and references) We present the case of a previously healthy 53 year old man who presented in the emergency department with drooping of the upper eyelid and difficulty seeing clearly. These symptoms started 5 days ago. The patient has diabetes type 2 and was started on steroids because he was diagnosed with COVID 2 weeks before. On examination there was proptosis of the right eye, the pupil was not reactive to light and there was ophthalmoplegia of 3rd and 6th cranial nerves. The patient also feels paresthesias and a neuralgic pain in the V1 and V2 territory. On visual testing he can only see shadows with the right eye. The rest of the physical exam was normal. On blood work, except for a HbA1C at 9.5 % and HSV1 IgG (+) and VZV IgG (+), other results were within the normal range. The imaging studies revealed no vascular lesions on CT angiography and brain MRI showed retroorbital inflammation on the right side, no signal restriction and the venous system appeared normal, ruling out venous sinus thrombosis. Tissue biopsy confirmed the diagnosis of mucormycosis and treatment with Amphotericin B for 5 days followed by fluconazole. The inflammation seemed to subside, the patient still had some limitations in eye movement and the vision got better but he developed neuralgic pain that was stabbing in character in the V1 and V2 territories. We discharged the patient and started outpatient Carbamazepine therapy for a month which was unsuccessful and then switched to Pregabaline 150 mg/daily. We followed up in 3 months and then in 6 months and the patient is doing better and Pregabalin was slowly tapered.

Case report: Headache and COVID-19

Abstract text (incl. figure legends and references) Introduction: Neurological complications are not rare in patients who survived COVID-19 .On the other hand, ophthalmologists say that ocular manifestations should not be neglected. Case report: We report the case of a 45- year-old male patient COVID-19 positive one month ago, without any other comorbidities, who presents in the Emergency Room in a stuporous state and bilateral midriasis after a tonic bilateral epileptic seizure. Two hours later he was lucid and oriented, without any focal neurological deficit but bilateral midriasis persisted. The patient complained severe, holocranial throbbing headache with dizziness, nausea and significant visual blurring. Ophthalmological examination reveals bilateral optic disc oedema, peripapillary hemorrhagic petechiae and venous tortuosity. Brain MRI , Angio- MRI and EEG resulted normal. The patient is treated with a high-dose of corticosteroids for three days and acetazolamide. After treatment he has no other complaints and the headache is less severe. We scheduled a follow-up with fundoscopy, after being treated with acetazolamide for 10 days. Discussion: Headache is one of the frequent neurological symptoms associated with COVID-19. In the absence of evidence of infectious or vascular disease, pseudotumor cerebri should be considered. Several studies suggest that patients with COVID-19 have vascular retinal lesions ,including flame shaped haemorrhages, peripapillary petechie and acute retinal ischaemia. Conclusion : Further research is needed for COVID-19 and the possible neurological or ocular complications.It is important to consider pseudotumor cerebri in a patient with severe headache after COVID-19 and to perform a fundoscopy if indicated.

Amitriptyline in the preventive treatment of persistent COVID-19 related headache: 50% responder rate and response predictors in a series of 66 patients

Secondary headaches

Abstract text (incl. figure legends and references) Background Headache is a frequent symptom of coronavirus disease 2019 (COVID-19). In most cases, it is transient, but in an 8-16% it adopts a chronic pattern. Herein we describe our experience in a real-world setting with amitriptyline (AMT) and we explore the possible response predictors. Methods Patients with confirmed COVID-19 that were referred due to headache were included. The 50% responder rate of AMT was determined as the proportion of patients who presented a 50% reduction in the number of headache days per month between weeks 8-12 of treatment, compared to the month prior to the AMT onset. We conducted a regression model to evaluate which variables were associated with a higher probability of response. Results Sixty-six patients had used AMT, 92.4% female, aged 48.11 (standard deviation (SD): 11.5) years, 34.8% with prior history of migraine and 15.2% with prior history of tension-type headache. Patients had prior history of anxiety (43.9%), depression (28.8%), sleep disorders (37.9%), and other painful conditions (27.3%). Median time between the COVID-19 infection and the AMT use was 6.1 (inter-quartile range (IQR): 4.1-9.6) months. The median monthly frequency of headache at the moment of AMT use was 30 (IQR: 28-30). AMT was the first preventive treatment in 80.3%. The 50% responder rate between weeks 8-12 of AMT use was 45.5%. The variables that remained associated with a 50% responder rate in the multivariate analysis were prior history of other painful conditions (odds ratio (OR): 0.142; 95% confidence interval (CI): 0.027-0.755); number of prior preventive medications (OR: 0.349; 95% CI: 0.158-0.771) and hemicranial headache (OR: 0.159; 95% CI: 0.32-0.798). Conclusion Amitriptyline was effective in treating patients with persistent post-covid-19 headache six months after the acute phase. Prior history of painful conditions, the number of preventive medications and hemicranial headache were associated with a lower probability of response.

Professor

Effect of Covid 19 Infection on Episodic Migraine Patients in Saudi Populations and Role of Vaccination

Abstract text (incl. figure legends and references) Background: Migraine is one of the most common medical disorders, it affects almost 1 billion patients worldwide and it is a chronic disabling disease affects women more than men. Few neurological disorders have been reported to be a possible complication of COVID 19 infection. AIM OF THE STUDY: to evaluate and assess the effect of covid 19 infection on the episodic migraine patients and if there were any differences either the patients are vaccinated or not. STUDY DESIGN: our study was prospective and retrospective observational study and has been done at Neuroscience department, King Fahad Armed Forces Hospital (KFAFH) in Jeddah, Saudi Arabia. We have two group of episodic migraine patients each was 30 patients; the first group was the non-vaccinated while the second one was the vaccinated group, and we assessed all the patients and reviewed their daily headache at periods of 3 months and 6 months from COVID 19 infection which was confirmed with PCR. Also, we compared it with their last daily headache before the infection. Results: total 11 patients (36.6%) from the non-vaccinated group developed chronic migraine after 3 months (7 females, 4 males), The vaccinated group only 5 patients (16.6 %) developed chronic migraine (3 females, 2 males) (p value 0.0014). while only 5 patients (16.6%) developed chronic migraine after 6 months (3 females, 2 males) in the non-vaccinated group while the vaccinated one only 3 patients (10 %) developed chronic migraine (2 females, 1 males) (p valuen0.0001). Conclusion: COVID 19 infection has negative effects on the episodic migraine patients. However, the covid vaccination has a protective role against its conversion to chronic migraine. Key Words: Episodic migraine, Chronic migraine, COVID 19 infection, COVID 19 Vaccination.

Occipital neuralgia after COVID-19 vaccination: a case report

Pathophysiology others than migraine and cluster

Abstract text (incl. figure legends and references) INTRODUCTION Headache is the most commonly reported neurological adverse effect after COVID-19 vaccination, with mild to moderate headaches being reported in 25-52% of patients after BNT162b2. Herein, we describe the first case reported of an occipital neuralgia after BNT162b2. CLINICAL CASE A 39-year-old caucasian woman with no previous story of headache, was admitted to our hospital with two weeks of a bilateral paroxysmal stabbing shock-like pain beginning in the occipital zone. Six days before, she received the first dose of Pfizer-BioNtech vaccine against SARS-CoV-2, with fever reported in the first day after the administration of this vaccine. She had never experienced any kind of headaches after other vaccinations. The pain was a bilateral stabling shock-like pain, severe (intensity of 8/10), with a short duration (few seconds) and spontaneously initiated or triggered by touching or brushing the hair, appearing many times per day and, over the time, in the period between the shocks, she starts to feel a dull pain in the vertex and nuchal region, with concomitant dysesthesia in these zones. On examination, pressure over the occipital nerves revealed local tenderness and elicited a paroxysm of pain. A probable occipital neuralgia was considered, and bilateral occipital blockage had been performed in the emergency department, with significant relief of the pain. It was started gabapentin (up to 300 mg) and amitriptyline (up to 25 mg). Neuroimagiology (brain CT, brain and cervical MRI) was unremarkable. Since then, the patient has been re-evaluated in consultation, with 3-month intervals, with administration of large occipital nerve blockages, with significant improvement in shocking pain, and with progressive improvement in constant dull pain over the months. CONCLUSION Two cases of trigeminal neuralgia after COVID-19 vaccination had already been reported, however this is the first time that a case of occipital neuralgia after this vaccine is described.

Impact of SARS-CoV2 vaccine on migraine course in patients receiving CGRP monoclonal antibodies

CGRP inhibitors in the clinic

Abstract text (incl. figure legends and references) Questions COVID-19 vaccines reduce the risk of death and major sequelae related to SARS-CoV2. Despite proven safety, they present adverse events among which headache is one of the most frequently reported. We aim to evaluate vaccine impact on headache frequency in migraine patients receiving monoclonal antibodies targeting CGRP pathway (anti-CGRP mAbs) Methods We enrolled 139 migraine patients actively treated with one of the 3 anti-CGRPmAbs currently available in Italy(erenumab, galcanezumab or fremanezumab). We collected: i) clinical and demographic data; ii) self-perceived headache changes after the 1st and 2nd vaccine doses (frequency, intensity and acute drug's efficacy); iii) monthly headache and migraine days (MHD and MMD), days and doses of acute drug intake in the month before(mpre) and after(mpost) vaccine administrations through paper diaries Results The dataset is formed by 100 migraine patients who received COVID-19 vaccine(fig.1) during mAbs treatment (73% females, migraine history 36.7±12.2yrs). At baseline 96% of patients had a diagnosis of chronic migraine (86.5% of them also had medication overuse headache). 13% of the patients reported a subjective worsening of headache frequency and intensity. Still, headache diaries demonstrated an objective reduction in MHD, days and doses of acute drug intake after the 1st and 2nd vaccine doses. All parameters showed a reduction trend without reaching significance, except for MHD after the 1stvaccine dose (MHD1stdose mpre 14.6±9.8;mpost13.2±9.7, p=0.01; 2nddose mpre14.0±10.9; mpost13.0±9.7,p=0.15)(fig.2). No correlation was found between demographic or baseline headache features and subjective headache worsening Conclusions In our cohort of migraine patients treated with anti-CGRPmAbs, COVID-19 vaccination did not induced any worsening in migraine characteristics. Our data suggest that mAbs treatment may prevent headache worsening frequently reported in patients with migraine exposed to COVID-19 vaccination

The Regional Outreach Programme of the International Headache Society in sub-Saharian Africa: partnership with the DREAM program and results from the first survey on headache training

Multidisciplinary clinical assessments

Data science in research and digital medicine

Abstract text (incl. figure legends and references) Background Neurology is one of the least represented medical specialties in the African continent. In Sub-Saharan Africa (SSA) neurologic care is mostly delivered by non-physician healthcare professionals (np-HCPs). Here we report the results of a survey conducted to evaluate training, needs, and knowledge about headache of a representative group of np-HCPs in Malawi. Methods The Regional Outreach Programme of the International Headache Society (ROPE-IHS) promotes headache education worldwide. In SSA ROPE-IHS is developing an education program in collaboration ith the Disease Relief through Excellent and Advanced Means (DREAM) program, a recognized primary care health programme that has activated healthcare facilities in 10 SSA countries. In order to customize the training program on the specific needs of local HCPs, we performed a survey among np-HCPs working in the different DREAM centres in MW. For this purpose, we created a specific questionnaire to test the level of preparation and interest on headache. Results Fifty-one healthcare workers (23 women) participated (median age 37 years; median duration of education 3 years): 26 were clinical officers, 6 nurses, 5 clinicians, and 14 had other roles. All respondents agreed on the importance to receive education and training on headache; 84% never attended a full headache course. Past headache courses were mainly delivered by np-HCPs. Only 2% of headache patients are referred to doctors while the vast majority (84%) are seen by clinical officers or local healers (57 and 27%, respectively). Conclusions Insufficient education among healthcare providers is the main barrier to care for headache patients in SSA. A partnership between international societies and recognized local providers is a valid tool to provide bottom-up tailored education on headache at primary care level in difficult contexts as in SSA. The partnership also accomplishes the WHO Intersectoral Global Action Plan.

Prof

A Case of Migrainous Infarction in a 40-Year-Old Male with a History of Spontaneous Coronary Artery Dissection

Neuroimigang in headache disorders

Abstract text (incl. figure legends and references) Objective Spontaneous coronary artery dissection (SCAD) is associated with a history of migraine, though this association is poorly understood. It classically affects young and middle-aged women and is rare in men.(1) SCAD patients with migraine tend to be younger at the time of SCAD. Migrainous infarction is an infrequent, but specific type of ischemic stroke developing during an attack of migraine with aura.(2) We present a case of a migrainous infarction in a man with a history of SCAD a decade earlier. Background A 40-year-old man developed episodes of visual aura which was associated with slurred speech and left-sided limb weakness, lasting 3-4 minutes before resolving. A second episode occurred and symptoms persisted for over an hour. A unilateral throbbing headache followed. His medical history was significant for migraine with aura and a spontaneous coronary artery dissection age 29-years. There was a family history of migraine and TIA. He Blood pressure, neurological and cardiac examinations were normal. Results Infectious and inflammatory markers were normal, and electrocardiogram showed normal sinus rhythm. CT brain was unremarkable. MRI Brain revealed a small area of diffusion restriction in the right parietal lobe along the postcentral sulcus consistent with an acute infarction. Carotid dopplers, echocardiogram and holter monitor were unrevealing. CT Angiogram found no evidence of vessel abnormality. Conclusions Migrainous infarction has not previously been described in a patient with a history of SCAD. This occurred in a male, which is also unusual as both SCAD and migraine predominately affect women. References 1.Kok SN, Hayes SN, Cutrer FM, Raphael CE, Gulati R, Best PJM, et al. Prevalence and Clinical Factors of Migraine in Patients With Spontaneous Coronary Artery Dissection. J Am Heart Assoc. 2018;7(24):e010140 2.Laurell K, Lundström E. Migrainous infarction: aspects on risk factors and therapy. Curr Pain Headache Rep. 2012;16(3):255-60

Poster session 7

Appointment

Chair

Programme