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Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282XOn-line version ISSN 1678-4227

Arq. Neuro-Psiquiatr. vol.78 no.11 São Paulo Nov. 2020  Epub Dec 14, 2020

https://doi.org/10.1590/0004-282x20200187 

Letter

Post-COVID-19 Syndrome? New daily persistent headache in the aftermath of COVID-19

Síndrome Pós-COVID-19? Nova cefaleia diária persistente após COVID-19

Jonathan Wei Ting Wen Liu1 
http://orcid.org/0000-0003-0388-4254

Renata D'altoé de Luca1 
http://orcid.org/0000-0001-7455-8208

Heraldo Oliveira Mello Neto2 
http://orcid.org/0000-0003-1307-5071

Igor Barcellos1 
http://orcid.org/0000-0003-1502-7604

1Hospital Universitário Cajuru, Department of Neurology, Curitiba PR, Brazil.

2Clínica X-LEME Diagnóstico por Imagem, Curitiba PR, Brazil.


Dear Editor,

We read with great interest the systematic review article entitled “Neurological complications in patients with SARS-CoV-2 infection: a systematic review” by Munhoz et al1, published in this journal in May 2020. We want to congratulate the authors for this successful article and add our own contributions.

Recently, we noticed frequent clinical visits (General Neurology Outpatient Clinic and a Radiology Clinic) with complaints suggestive of New Daily Persistent Headache (NDPH) following recovery from SARS-CoV2 infection, which is characterized by a clear and distinct onset, persistent headache. It is known that extracranial viral infections are the main triggering factor of NDPH, in addition to stressful life events and invasive procedures such as intubation2.

Headache is a frequent symptom associated with ongoing SARS-CoV2 infection, as reported by Munhoz et al. (up to 34%); however, headache persistence has been observed even weeks after recovery3, and as described in case reports and in the authors’ experience, enough to fulfill International Classification of Headache Disorders, 3rd edition (ICHD-3), diagnostic criteria for NDPH. To our knowledge, there is still no comprehensive review of remote morbidities following recovery.

In our experience, the following patterns were agreed upon: they had mild or moderate respiratory symptoms, treated on an outpatient basis, mainly without a diagnosis of pre-existing primary headache, had characteristics of holocranial, pressure-like pain starting within 2 weeks after recovery of respiratory symptoms, no pathological causal findings have been observed in contrasted imaging studies (excluding cerebral venous thrombosis, a known neurological complication of SARS-COV2 infection).

The pathophysiology of NDPH is largely unknown, some studies believe that the pain may be due to the production of cytokines and persistent glial activation that arise in response to precipitating events4, which is also one of the hypotheses for CNS involvement by COVID-19, thus occurring synergy between pathophysiological mechanisms.

In clinical practice, most headache specialists treat NDPH based on the main headache phenotype, whether it is migraine or tension-type. No medication has shown to be advantageous in the studies conducted to date. As such, prophylactic treatment was used mostly with a tricyclic antidepressant or anticonvulsant (namely, amitriptyline and topiramate), with varying success4,5.

In our opinion, as we follow an increasing number of patients recovered after SARS-CoV-2 infection, a better understanding of the pathophysiology and course of the disease (and therefore the best treatment approach) is certainly warranted.

References

1. Munhoz RP, Pedroso JL, Nascimento FA, Almeida SM de, Barsottini OGP, Cardoso FEC, et al. Neurological complications in patients with SARS-CoV-2 infection: a systematic review. Arq Neuropsiquiatr. 2020 May;78(5):290-300. https://doi.org/10.1590/0004-282x20200051Links ]

2. Li D, Rozen TD. The clinical characteristics of new daily persistent headache. Cephalalgia. 2002 Feb 1;22(1):66–9. https://doi.org/10.1046/j.1468-2982.2002.00326.xLinks ]

3. Sampaio Rocha‐Filho PA, Voss L. Persistent headache and persistent anosmia associated with COVID-19. Headache. 2020 Aug;60(8):1797-9. https://doi.org/10.1111/head.13941Links ]

4. Yamani N, Olesen J. New daily persistent headache: a systematic review on an enigmatic disorder. J Headache Pain. 2019 Jul 15;20(1):80. https://doi.org/10.1186/s10194-019-1022-zLinks ]

5. Rozen TD. New daily persistent headache. Curr Pain Headache Rep. 2003 May;7(3):218-23. https://doi.org/10.1007/s11916-003-0076-3Links ]

Received: September 30, 2020; Revised: November 12, 2020; Accepted: October 01, 2020

Correspondence: Jonathan Wei Ting Wen Liu; E-mail: jonathan.weiting@gmail.com.

Conflict of interests: There is no conflict of interests to declare.

Authors’ contribution: JWTL and RDL wrote the original draft, HOMN and IB reviewed, edited and supervised the paper. All authors reviewed the final manuscript.


Letter-Reply

Reply

Resposta

Renato Puppi Munhoz1 
http://orcid.org/0000-0002-4783-4067

José Luiz Pedroso2 
http://orcid.org/0000-0002-1672-8894

Fábio Augusto Nascimento3 
http://orcid.org/0000-0002-7161-6385

Sergio Monteiro de Almeida4 
http://orcid.org/0000-0001-5690-105X

Orlando Graziani Povoas Barsottini2 
http://orcid.org/0000-0002-0107-0831

Francisco Eduardo Costa Cardoso5 
http://orcid.org/0000-0003-0808-0116

Hélio Afonso Ghizoni Teive6 
http://orcid.org/0000-0003-2305-1073

1University of Toronto, Toronto Western Hospital, Movement Disorders Centre, Toronto ON, Canada.

2Universidade Federal de São Paulo, Escola Paulista de Medicina, Department of Neurology and Neurosurgery, São Paulo SP, Brazil.

3Baylor College of Medicine, Department of Neurology, Houston TX, USA.

4Universidade Federal do Paraná, Hospital de Clínicas, Neuroinfection Outclinic, Virology Laboratory, Medical Pathology Department, Curitiba PR, Brazil.

5Universidade Federal de Minas Gerais, Hospital das Clínicas, Movement Disorders Unit, Neurology Service, Internal Medicine Department, Belo Horizonte MG, Brazil.

6Universidade Federal do Paraná, Hospital de Clínicas, Internal Medicine Department, Neurology Service, Curitiba PR, Brazil.

We thank Dr. Liu and colleagues for their comments and citation of our systematic review1 apropos of their insightful clinical observation presented in the letter entitled Post-COVID-19 Syndrome? New daily persistent headache in the aftermath of COVID-192.

This description of a potentially new late complication of SARS-CoV-2 infection confirms a previous similar observation3 and provides a reasonable pathophysiological rationale as well as a treatment approach. We congratulate the authors for their astute clinical observation, which may serve as guidance and advice for the clinician involved in the care of these patients.

References

1. Munhoz RP, Pedroso JL, Nascimento FA, Almeida SM de, Barsottini OGP, Cardoso FEC, et al. Neurological complications in patients with SARS-CoV-2 infection: a systematic review. Arq Neuropsiquiatr. 2020 May;78(5):290-300. https://doi.org/10.1590/0004-282x20200051Links ]

2. Liu JWTW, De Luca RD, Mello Neto HO, Barcellos I. Post-COVID-19 Syndrome? New daily persistent headache in the aftermath of COVID-19. Arq. Neuropsiquiatr. 2020. In Press. [ Links ]

3. Sampaio Rocha‐Filho PA, Voss L. Persistent headache and persistent anosmia associated with COVID-19. Headache. 2020 Aug;60(8):1797-9. https://doi.org/10.1111/head.13941Links ]

Correspondence: Renato Puppi Munhoz; E-mail: renato.munhoz@uhn.ca.

Conflict of interests: There is no conflict of interests to declare.

Authors’ contribution: RPM: drafting of the manuscript. JLP, FAN, SMA, OGPB, FECC, and HAGT: manuscript review.

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.