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Fragoso. Neuroimmunol Neuroinflammation 2021;8:50-2 I http://dx.doi.org/10.20517/2347-8659.2020.42 Page 51

for 3 days, as did the increased temperature. No analgesic or anti-inflammatory drug affected the intensity
of the headache. On the fourth day, his temperature returned to normal and a persistent dry cough started.
The intensity of headache during the episodes of cough increased. The patient slept for many hours a
day and remained in a dark, silent bedroom. PCR was positive for COVID-19. His parents tested PCR-
positive for COVID-19 a week later. His father, who is a medical doctor, had moderate symptoms of the
viral infection while the mother remained asymptomatic. Two weeks after the patient’s initial symptoms,
he recovered fully and had no more headaches. At no time did he have abnormalities in his neurological
examination, including meningeal signs. He has been followed for 6 weeks now and has returned to his
usual healthy condition.

To the best of our knowledge, this is the first report of severe headache as the onset and main symptom of
[4]
COVID-19 infection. It can be classified as “9.2.2.1-Acute headache attributed to systemic viral infection” .
Physicians at the front line of COVID-19 management should be aware of severe headache as a possible
main symptom of this infection. This patient had a migraine-like headache, but he had high temperature
and no previous history of migraine. Although neurological examination was normal, we must consider
the possibility of meningeal involvement in the inflammatory process. The intolerance to light and sound,
the worsening with coughing, and the throbbing characteristic of the headache which was irresponsive
to treatment suggest meningeal vascular involvement. Although a case of meningitis and encephalitis by
COVID-19 has been recently published, the clinical presentation of that patient was a lot more serious and
[5]
life-threatening . In our case, we emphasize that patients seen at the Emergency Department complaining
of severe headache might be dismissed without a COVID-19 hypothesis.

DECLARATIONS
Authors’ contributions
The author contributed solely to the article.

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
The author declared that there are no conflicts of interest.

Ethical approval and consent to participate
This report was approved by the Ethics Committee at Universidade Metropolitana de Santos, under the
number CAAE 56332016.4.0000.5509.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2021.

REFERENCES
1. Lake MA. What we know so far: COVID-19 current clinical knowledge and research. Clin Med (Lond) 2020;20:124-7.
2. Han Q, Lin Q, Jin S, You L. Coronavirus 2019-nCoV: a brief perspective from the front line. J Infect 2020;80:373-7.
3. Mao L, Jin H, Wang M, Hu Y, Chen S, et al. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan,