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How COVID-19 Changes Migraine Patterns

Posted on May 22 2025, By: Cerebral Torque

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How COVID-19 Changes Migraine Patterns

A case series reveals changes in migraine frequency, severity, and treatment response following SARS-CoV-2 infection

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April 2025 | Published in Cureus | Shah et al.

Study Overview

This case series examined seven patients with pre-existing migraine disorders who contracted COVID-19 between 2021-2024. The research reveals concerning patterns of migraine worsening following SARS-CoV-2 infection, with implications for both acute and long-term neurological care.

Key Research Finding

Patients experienced significant worsening of their migraine patterns after COVID-19 infection, including increased frequency, severity, duration, and reduced medication effectiveness. Many also developed additional neurological symptoms consistent with long COVID.

Major Changes Observed

7/7

Patients with Worsened Migraine

Experienced increased frequency, severity, or duration of migraine attacks post-COVID

6/7

Reduced Medication Efficacy

Previously effective treatments became less helpful, requiring regimen changes

3/7

Pain Pattern Changes

Shift from localized to diffuse, "headband-type" pain throughout the head

2/7

New Neurological Symptoms

Developed brain fog, aphasia, or ADHD-like symptoms not present before infection

Treatment Response Patterns

Post-COVID Treatment Effectiveness

Botox Injections Most Effective

Traditional Triptans Reduced Efficacy

NSAIDs (Excedrin, etc.) Limited Relief

Anti-CGRP Medications Mixed Results

Botox: The Most Promising Treatment

Three patients in the study found significant relief with Botox (onabotulinumtoxinA) injections. Cases 1 and 7 achieved well-controlled migraines only after adding Botox to their regimen, while Case 3's previously effective Botox became less helpful but still provided some benefit.

Neurological and Psychological Impact

Beyond the physical changes in migraine patterns, patients experienced significant neurological and psychological symptoms that impacted their quality of life:

Additional Symptoms Reported

Brain Fog: Difficulty with concentration and mental clarity during and between migraine attacks

Aphasia: Rare but notable language difficulties during severe migraine attacks

ADHD-like Symptoms: Attention and focus problems resembling attention deficit disorder

Depression and Discouragement: Emotional impact from worsened, less controllable migraine

Reduced Functional Capacity: Difficulty performing daily activities, exercise, and work tasks

Patient Case Summary

Detailed breakdown of migraine changes observed in each of the seven study participants following COVID-19 infection.

Patient Profile	Pre-COVID Migraine Pattern	Post-COVID Changes	Treatment Response
Case 1: 34-year-old woman Migraine since age 10	10 migraine attacks/month, severity 4/10 Gustatory and olfactory auras 1-3 day duration	Increased to 14/month, severity 5/10+ Headband-type pulsing pain Brain fog and aphasia Increased screen sensitivity	Botox effective Added to amitriptyline and Aimovig regimen
Case 2: 74-year-old man Migraine since teens	14 migraine attacks/month, severity 5-6/10 Left eye pain radiating through head 2-6 hour duration	Increased to 26/month, severity 6-7/10 Diffuse rather than localized pain Duration over 6 hours Depression and discouragement	Poor control Switched Aimovig to Quilipta, increased rescue medication dependence
Case 3: 61-year-old Hispanic woman Chronic migraine since age 20	0-1 migraine attacks/month with Botox Localized pain, severity 3/10 7-24 hour duration	Increased to 2/month, severity 7-8/10 Diffuse rather than localized pain 24-48 hour duration Body aches, falls, ADHD-like symptoms	Reduced Botox efficacy Minimal relief from triptans and NSAIDs
Case 4: 32-year-old man Migraine since age 14	1 migraine attack/month, severity 6/10 Severe pulsating pain 6-8 hour duration	Same frequency but longer duration (6-12 hours) Increased severity to 8/10 Worsened photophobia and nausea Significant lifestyle impact	No relief Triptans and Excedrin ineffective
Case 5: 74-year-old woman Migraine since age 28	4-6 migraine attacks/month, severity 5/10 Throbbing in temples and skull Several hour duration Extreme light sensitivity	Increased to 6+/month, severity 8-9/10 Almost constant head pain Tightening sensation in forehead/frontal sinuses Feeling "much older," reduced function	No relief OTC medications (Excedrin, Tylenol) ineffective
Case 6: 35-year-old woman Migraine since age 28	1 migraine attack/month, severity 6/10 Throbbing, localized to forehead Few hour duration Menstrual cycle related	Increased to 2-3/month, severity 8/10 Several more hours duration Sleep disturbances Reduced exercise ability	Limited relief EC-naproxen and Ubrelvy prescribed, uses Ubrelvy sparingly
Case 7: 61-year-old woman Migraine since early 20s	1 migraine attack every few months Severity 10/10, frontal and ocular Up to full day duration Visual aura with spots	1+ migraine attack/month 2-3 day duration, severity 10/10 COVID appears to directly trigger migraine attacks Same aura and pain location	Botox effective Only treatment providing relief; Imitrex and Ubrelvy ineffective

Proposed Biological Mechanisms

The researchers propose several potential mechanisms by which COVID-19 may worsen migraines:

Direct Viral Effects

SARS-CoV-2 may directly affect the trigeminal vascular system through cytokine storms

Nerve Invasion

Potential direct invasion of trigeminal nerve endings by the virus

Inflammatory Response

Elevated inflammatory markers (HMGB1, NLRP3, IL-6) activating pain pathways

Endothelial Dysfunction

ACE2 receptor involvement affecting blood vessel function in the brain

Clinical Implications and Recommendations

For Healthcare Providers
Screen patients with past COVID-19 infection with pre-existing migraine for worsening symptoms
Consider Botox as a treatment option for post-COVID migraine management
Be prepared to modify treatment regimens as traditional medications may be less effective
Include psychological support in migraine management plans
Monitor for additional neurological symptoms like brain fog and aphasia

For Patients

If you have a history of migraine and have had COVID-19, discuss any changes in your migraine patterns with your healthcare provider. Keep a detailed migraine diary noting frequency, severity, duration, and any new symptoms. Don't hesitate to seek help if your current treatments are no longer effective.

Study Limitations and Future Directions

While this research provides valuable insights, the authors acknowledge several limitations:

Study Considerations

Sample Size Small (7 patients)

Data Collection Self-report and medical records

Imaging Data Not available

Recall Bias Potential factor

Future research should include larger longitudinal studies to investigate the long-term effects of COVID-19 on migraine patterns, identify specific mechanisms of action, and develop targeted treatment protocols for post-COVID migraine management.

Our Understand of Long COVID Continues to Evolve

This case series demonstrates that COVID-19 can significantly impact migraine patterns in people with pre-existing migraine disorders. The changes are not trivial, and often often require substantial modifications to treatment plans and can significantly impact quality of life.

Takeaways
COVID-19 can worsen pre-existing migraines in frequency, severity, and duration
Pain patterns may shift from localized to diffuse
Traditional migraine medications may become less effective
Botox appears to be a promising treatment option for post-COVID migraines
Additional neurological symptoms may develop as part of long COVID
Psychological support should be considered part of comprehensive care

Study Citation: Shah N, Patel D, Sousa A, Leder AN. Changes in Migraine Headaches Following SARS-CoV-2 Infection: A Case Series. Cureus. 2025;17(4):e82708. DOI: 10.7759/cureus.82708

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