Rationale: A pandemic COVID-19 infection is a multisystemic serious viral infection had emerged in Wuhan, China in December 2019. Cluster headache is one of the most severe headaches in the patient life. Interestingly, the presentation of cluster headache in a course of COVID-19 infection is not known. Patient concerns: A young female COVID-19 patient presented to the physician outpatient clinic with cluster headache and mild pneumonia. 

Diagnosis: COVID-19-inducing cluster headache with suggested cerebral hypoxia.

Interventions: Chest CT scan, brain CT scan, electrocardiography, and oxygenation. 

Outcomes: Acute dramatic clinical, and radiological improvement had happened. 

Lessons: COVID-19 virus can be inducing cluster headaches. It signifies the role of oxygen in COVID-19 inducing cluster headache with pneumonia. The evanescence of cluster headache post-oxygenation in COVID-19 infection is recommended for further wide-study for cerebral hypoxia. 

CBC: Complete blood count 

COVID-19: Coronavirus disease 2019

ECG: Electrocardiography

NSR: Normal sinus rhythm 

O2: Oxygen

POC: Physician outpatient clinic

SGOT: Serum glutamic-oxaloacetic transaminase

SGPT: Serum glutamic-pyruvic transaminase 

VR: Ventricular rate

         The initial appearance of a pandemic Coronavirus-2 (COVID-19) that is resulting in severe acute respiratory syndrome (SARS) had emerged in Wuhan, China in December 2019 [1]. COVID-19 Disease is a highly infectious, rapidly spread, fatal global disease [2]. There are no available reports of the presence of cluster attacks during the COVID-19 pandemic [3]. This reveals undertreatment of headaches and those fewer patients than usually given suitable acute in-hospital management [3]. In cluster headaches, it may be essential to use steroids to abolish a cluster attack [4]. Cluster headache causes severe ipsilateral the temporal or periorbital pain, lasting 15 to 180 minutes and associated with autonomic manifestations in the nose, eyes, and face. Headaches mostly repeat at the same time every day during the cluster period and maybe lasting for weeks to months [5]. Studies show the one-year prevalence to be as high as 53 per 100,000 adults [6]. The standard onset for age is generally 20 to 40 years [7]. The overall male-to-female ratio is 4.3 but is considerably higher in chronic cluster headache than in the episodic form (15 vs. 3.8, sequentially) [6]. Episodic cluster headache is 6 times more common than the chronic form [6]. The following are the diagnostic criteria for cluster headache [5]; 1. At least one ipsilateral symptom in the eye, nose, or face; restlessness or agitation. 2. About 15 to 180 minutes in duration (if untreated). 3. One episode every other day to eight episodes per day in frequency. 4. Located unilateral in temporal or periorbital area. 5. The pain is severe, and is named as “suicide headache”. The pathophysiology of cluster headache is still unknown. There are currently comprised theories mechanisms such as vascular dilation, trigeminal nerve stimulation, and circadian effects. Histamine induction, elevated mast cells, genetic agents, and stimulation of the autonomic nervous system may be also implicated [5]. Triptans and supplemental O2 are first-line abortive therapies for cluster headaches [8]. Verapamil, steroids, valproic acid, topiramate, ergotamine, melatonin, and capsaicin are commonly used medications in the prophylaxis of episodic cluster headaches [9]. Verapamil and lithium are the mainstays of treatment for chronic cluster headaches [5].

I think that the reported cluster headache with COVID-19 pneumonia is the first recorded case.

         A 32-year-old married housewife Egyptian female patient presented to the physician outpatient clinic (POC) with severe headache, fever, cough, and palpitations. Malaise, anorexia, and generalized body aches were associated symptoms. She gave a history of tachypnea for 2 days. Headache was severe, in the ipsilateral right periorbital area, nose, and face, lasting about 30 minutes in duration, recurrent every other day, and associated with restlessness. She had a history of recent contact with his neighbor who confirmed a COVID-19 patient in the past 12 days. Informed consent was taken. Upon general physical examination; generally, the patient was tachypneic, distressed, with a regular pulse rate (VR of 74), blood pressure (BP) of 110/70 mmHg, respiratory rate of 26 bpm, the temperature of 38 °C, and pulse oximeter of oxygen (O2) saturation of 94%. No more relevant clinical data were noted during the clinical examination. The patient was treated at home with a cluster headache in COVID-19 pneumonia. Initially, the patient was treated with O2 inhalation by O2 cylinder (100%, by nasal cannula, 5L/min for 10 minutes). The patient was maintain treated with cefotaxime; (1000 mg IV every 8hours), azithromycin (500 mg PO single daily dose), oseltamivir (75 mg PO twice daily only for 5 days), and paracetamol (500 mg IV every 8 hours as needed). SC enoxaparin 80 mg twice daily), aspirin tablet (75 mg, once daily), clopidogrel tablet (75 mg, once daily), and hydrocortisone sodium succinate (100 mg IV every 12 hours) were added. A long-acting verapamil oral tablet (240 mg, once daily) was prescribed. The patient was daily monitored for temperature, pulse, blood pressure, O2 saturation, and episodes of cluster headache. The initial ECG on presentation showing normal sinus rhythm (NSR; of VR of 73) with no abnormality detected. (Figure 1A). The initial complete blood count (CBC); Hb was 10.9 g/dl, RBCs; 3.99*103/mm3, WBCs; 2.10*103/mm3 (Neutrophils; 49 %, Lymphocytes: 43%, Monocytes; 5%, Eosinophils; 3% and Basophils 0%), Platelets; 212*103/mm3. S. Ferritin was normal (65 ng/ml). D-dimer was normal (300 ng/ml). CRP was high (12g/dl). LDH was high (670 U/L). SGPT (18 U/L) and SGOT (22 U/L) were normal. Serum creatinine (0.7mg/dl) and blood urea (25 mg/dl) were normal. RBS was normal (83 mg/dl). Ionized calcium was normal (1.2mmol/L). ESR was high; 40mm/first hour and; 77mm/second hour. The troponin test was negative. After 7 days of management; RBS was normal; 113 mg/dl. CBC; Hb was 9.99 g/dl, RBCs; 3.78*103/mm3, WBCs; 5.1*103/mm3 (Neutrophils; 66 %, Lymphocytes:29%, Monocytes; 4%, Eosinophils; 1% and Basophils 0%), Platelets; 116*103/mm3. Serum ferritin was normal; 109 ng/ml. D-dimer was normal (118 ng/ml). CRP was negative (0.5 g/dl). LDH was still high; 561 U/L. SGPT was normal (27 U/L) and SGOT was normal (39 U/L) were normal. Serum creatinine (1.3 mg/dl) and blood urea ( 36 mg/dl) were normal. Ionized calcium was normal (1.08 mmol/L). ESR was normal; 8mm/first hour and; 13mm/second hour. The first chest CT scan was taken within 3 days of the presentation showing bilateral tiny or minute ground-glass opacities in the posterior-basal areas (Figure 1B). A brain CT scan was taken within 3 days of the presentation showing no abnormality detected. (Figure 1C). COVID-19-inducing cluster headache with suggested cerebral hypoxia was the most probable diagnosis. Within 7 days of the above management, the patient finally showed nearly complete clinical, radiological, and laboratory improvement. The patient was continued on aspirin tablet (75 mg, once daily) and Verapamil long-acting oral tablet (240 mg, once daily) with further recommended neurological and chest follow-up.

Figure A

Figure B

Figure 1: A. ECG tracing was done on the initial ECG on presentation showing normal sinus rhythm (of VR of 73) with no abnormality detected. B. Chest CT scan was taken within 3 days of the presentation showing bilateral tiny or minute ground-glass opacities in the posterior-basal areas (lime arrows). C. Brain CT scan was taken within 3 days of the presentation showing no abnormality detected. 

• Overview:

• A young female COVID-19 patient presented to the physician outpatient clinic (POC) with cluster headache and mild pneumonia. 

• The primary objective for my case study was the presence of cluster headache in the COVID-19 pneumonia in the POC.

• The secondary objective for my case study was the question of; How did you manage the case?

• There was a history of direct contact to confirmed the COVID-19 case. 

• The presence of direct contact to confirmed the COVID-19 case, and bilateral ground-glass consolidation on top of acute tachypnea will strengthen the COVID-19 diagnosis.

• The fever, tachypnea, and mild bilateral tiny or minute ground-glass opacities in chest CT scans are highly suggestive of associated pneumonia.

• An association of newly diagnosed cluster headache starting in a course of COVID-19 pneumonia may be indicating cerebral hypoxia due to COVID-19 infection.

• There is a dramatic improvement of cluster headache post-oxygenation had happened.

• Oxygen set was only repeated for another cluster attack. 

• So, aborting of probable future cluster attack may be due to either the used oral verapamil or hydrocortisone as steroids in COVID-19.

• I can’t compare the current case with similar conditions. There are no similar or known cases with the same management for near comparison.

• The only limitation of the current study was the unavailability of the cerebral MRA. 

• Overview:

• A young female COVID-19 patient presented to the physician outpatient clinic (POC) with cluster headache and mild pneumonia. 

• The primary objective for my case study was the presence of cluster headache in the COVID-19 pneumonia in the POC.

• The secondary objective for my case study was the question of; How did you manage the case?

• There was a history of direct contact to confirmed the COVID-19 case. 

• The presence of direct contact to confirmed the COVID-19 case, and bilateral ground-glass consolidation on top of acute tachypnea will strengthen the COVID-19 diagnosis.

• The fever, tachypnea, and mild bilateral tiny or minute ground-glass opacities in chest CT scans are highly suggestive of associated pneumonia.

• An association of newly diagnosed cluster headache starting in a course of COVID-19 pneumonia may be indicating cerebral hypoxia due to COVID-19 infection.

• There is a dramatic improvement of cluster headache post-oxygenation had happened.

• Oxygen set was only repeated for another cluster attack. 

• So, aborting of probable future cluster attack may be due to either the used oral verapamil or hydrocortisone as steroids in COVID-19.

• I can’t compare the current case with similar conditions. There are no similar or known cases with the same management for near comparison.

• The only limitation of the current study was the unavailability of the cerebral MRA. 

There are no conflicts of interest.

• I wish to thanks my wife to save time and improving the conditions for helping me.