Robin N. Bai, Adam G. Evans, Anjani Patibandla, Yifan Guo
Long COVID headache is one of the most common yet poorly understood symptoms following SARS-CoV-2 infection, persisting for at least 3 months after the initial infection. Prior meta-analyses report the prevalence of persistent post-COVID headache to range from 6% to 18% beyond 6 months. Management remains challenging because of the unclear etiology and heterogeneous clinical presentation. Patients may experience either an exacerbation of pre-existing headache disorders or the development of new intermittent or daily headaches during or after infection. Clinical phenotypes may resemble migraine or tension-type headache. Because no established treatment guidelines currently exist, management generally mirrors that of primary headache disorders, with variable success. Here, we present the case of a 19-year-old female with a history of complex regional pain syndrome type I (CRPS I) of the left leg and postural orthostatic tachycardia syndrome (POTS), but no prior history of headache disorders, who developed debilitating de novo, mixed phenotype long COVID headaches that persisted for 2 years despite medical therapy (PedMIDAS > 50). Following a favorable response to diagnostic nerve blocks, she underwent bilateral supraorbital, supratrochlear, and greater occipital nerve decompression. At her 1-year postoperative follow-up, she reported complete resolution of her daily headaches (PedMIDAS 0, HIT-6 42), with mild episodes lasting at most 1 hour once per week, typically triggered by loud noise. She also reported marked improvement in academic performance, quality of life, and return to activities of daily living. This case supports the hypothesis that chronic neural inflammation and neurovascular compression may contribute to the pathophysiology of long COVID headache. To our knowledge, this is the first reported case of refractory long COVID headache successfully treated with peripheral nerve decompression following a positive diagnostic nerve block response.