A 55-year old white Hispanic male, blood type O-positive with normal BMI (22 kg/m2) presented with mild-to-moderate flu-like symptoms (cough, malaise and bone aches, more pronounced on lower back and legs) and without respiratory distress, headache, fever, ageusia or anosmia/parosmia. The viral illness presented in March, 2019 and lasted less than a week. No medical attention was sought since COVID-19 was not suspected, and the patient self-medicated 500 mg of acetaminophen once during the acute episode. One week later, the patient’s wife developed similar symptoms and was diagnosed with COVID-19 by RT-PCR (BioGX, BD MAX). Failure to confirm COVID-19 by RT-PCR on a nasal swab obtained from our patient was obtained approximately one month after acuity. However, positivity for anti-N SARS-CoV-2 antibodies (48.49 units; Eclisys, Roche) was obtained approximately two months later, allowing a retrospective diagnosis of COVID-19.
Starting approximately four months after COVID-19 onset, the patient has experienced four episodes of sudden, stabbing, severe headaches (Visual Analog Scale intensity 9, scale 0-10), in the central-retro-orbital area, irradiated to the occiput in an approximate V1 distribution. The pain lasts < 40 seconds and progressively wanes. On two occasions, headache was accompanied by tearing and so severe that the patient stopped all activity and massaged his head. Classical migraine features (throbbing/pounding/pulsating character, aggravation with physical activity/movement, prolonged duration or aura) were absent. Mental status alteration or motor deficits were absent. Prior medical history and physical examination were unremarkable. The patient takes vitamin D (25 micrograms per day). No allergies, sinus disease, drug use, smoking or excessive alcohol intake were reported. Regular yearly influenza vaccination without side effects was noted. Repeat antibody testing was performed 19-days after completion of vaccination and was positive for N (15.19 units, Eclisys, Roche) and S (250 units, Eclisys, Roche) proteins. Routine CBC, comprehensive metabolic panel (CHEM20), endocrine panel, lipid panel, sexually transmitted disease panel, iron studies, vitamin B12, vitamin D, immunoglobulins (IgG, IgA and IgM), hemoglobin A1c, C-reactive protein and erythrocyte sedimentation rate were normal.
After the second headache episode, the patient received the BioNTech COVID-19 vaccine (Pfizer). On 1/23/21, twelve days after the second vaccine dose, the last episode of stabbing headache occurred twice during a lapse of three hours. Brain magnetic resonance imaging done after this last episode revealed no acute findings throughout the brain parenchyma. The previous two episodes were separated by approximately three months. Since this cephalalgia is episodic no treatment has been administered and the patient remains asymptomatic.