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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
Read Full Study
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:

1
Direct Viral Effects
SARS-CoV-2 may directly affect the trigeminal vascular system through cytokine storms
2
Nerve Invasion
Potential direct invasion of trigeminal nerve endings by the virus
3
Inflammatory Response
Elevated inflammatory markers (HMGB1, NLRP3, IL-6) activating pain pathways
4
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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