Migraine and Long COVID: When the Headache Does Not Leave

[00:00]

The infection is gone, so why is your migraine still here?

[00:04]

Welcome to Migraine Heroes, a podcast for anyone living with migraine,

[00:09]

and wondering why nothing has fully worked yet.

[00:12]

I'm Diane Ducarme. Over the past 7 years, I've helped hundreds of people living with migraine.

[00:18]

What I've learned? No two migraine stories are exactly the same, and none of them are simple.

[00:23]

That is why, in this podcast, we explore migraine from many different angles.

[00:28]

Food, hormones, stress, sleep, the nervous system, emotions, and much more,

[00:34]

through the lens of both modern science and traditional Chinese medicine.

[00:38]

A quick note before we start, what we talk about here is educational.

[00:42]

For anything related to diagnosis or medication, please keep working with your doctor.

[00:48]

Now take a deep breath, and let's dive in.

[00:51]

In this episode, you will learn why long COVID can sometimes trigger a new headache,

[00:56]

or make an existing migraine pattern worse,

[00:59]

and what scientists currently believe may be happening inside the nervous and immune systems.

[01:04]

Why symptoms such as fatigue, poor sleep, dizziness, brain fog, exercise intolerance,

[01:11]

and migraine may sometimes travel together,

[01:14]

and why looking only at the head may miss part of this picture.

[01:18]

And why your migraine pattern may change after long COVID,

[01:22]

and why recognizing that new pattern can be more useful than assuming

[01:26]

your old triggers still explain everything.

[01:30]

So I want to talk to you about, we're going to call her Beatrix,

[01:34]

because her story changed the way I understood migraine after COVID-19.

[01:39]

So I met Beatrix in 2020, in the very early days of Migraine Heroes.

[01:43]

She was the best friend of one of my closest friends,

[01:47]

a brilliant woman with a demanding international job and three children.

[01:51]

And like so many of you, she was quietly carrying migraine through all of it.

[01:56]

And we identified the migraine patterns she was showing,

[01:59]

and we worked on them together, and she got better.

[02:02]

And then, a few months later, she came back.

[02:05]

She had had COVID, and she told me, everything has changed, my migraines are back.

[02:10]

But what was striking was that they had not simply come back in the same way,

[02:15]

her patterns had completely changed, and her triggers as well.

[02:19]

And at the end of this episode, I'll come back to Beatrix,

[02:22]

and tell you what we found, and what happened.

[02:24]

So if you developed strange symptoms after COVID-19,

[02:28]

perhaps you felt something like, but my infection is gone,

[02:31]

my tests look normal, and why am I not better yet?

[02:34]

And if migraine is part of the picture, this can be especially confusing,

[02:38]

not to say completely disheartening.

[02:40]

So maybe you had migraine before,

[02:42]

and suddenly the attacks became longer, or more frequent, or more stubborn.

[02:48]

Maybe you rarely had headaches before, but after the infection, something changed.

[02:53]

Or perhaps, headache is just one part of a much bigger picture involving exhaustion,

[02:59]

dizziness, poor concentration, disrupted sleep, palpitation,

[03:02]

or a body that, quite frankly, seems to react badly

[03:06]

every time you try to push yourself back to normal.

[03:08]

And if it sounds familiar, there's an important message in the science.

[03:12]

Persistent headache is a recognized part of the post-coronavirus disease picture.

[03:18]

So that does not mean that every headache following an infection is caused by long COVID.

[03:22]

It does not mean there is one single long COVID headache,

[03:26]

but the association itself is well, well documented.

[03:30]

So what exactly is long COVID?

[03:32]

So the World Health Organization, it uses the term long COVID,

[03:36]

or long COVID-19 condition, for symptoms that usually appear

[03:40]

or persist around three months after the initial infection,

[03:44]

last for at least two months, and cannot be better explained by another diagnosis.

[03:49]

So symptoms can persist from the original infection,

[03:53]

disappear and return, or begin after someone initially seems to recover.

[03:57]

Fatigue, breathlessness, and cognitive problems are among the best known symptoms,

[04:02]

but headache is also commonly reported.

[04:04]

And one of the frustrating things about long COVID is that it's not one tiny disease

[04:10]

with one tiny mechanism.

[04:11]

It appears to be a heterogeneous condition,

[04:15]

meaning that different biological processes may dominate in different people.

[04:20]

And that matters tremendously when we talk about migraine

[04:22]

because migraine itself is not simply a problem of pain in the head.

[04:26]

It involves altered sensory processing, and activation of networks connecting to the brain,

[04:31]

and blood vessels, and meninges and pain pathways, and the trigeminal system.

[04:37]

So when a systematic illness disrupts immunity, disrupts sleep, disrupts autonomic regulation,

[04:45]

energy, exercise tolerance, and stress physiology all at the same time,

[04:49]

we can begin to see why a migraine-prone nervous system may struggle.

[04:53]

So what does the headache look like?

[04:56]

So there's no single long COVID headache.

[04:58]

There was a major review published in the Journal of Headache and Pain in 2022,

[05:02]

so post-COVID, and it described several patterns.

[05:06]

For some people, a pre-existing headache disorder becomes worse.

[05:09]

For others, a new headache begins during the acute infection and simply does not disappear.

[05:15]

And still for others, headache begins later.

[05:18]

And for some, headaches resemble migraine,

[05:20]

with features such as throbbing pain and sensitivity to light or sound.

[05:23]

Others resemble tension-type headache closely.

[05:26]

So at this point, researchers actually cannot pinpoint to one biomarker and say,

[05:33]

this is why your long COVID migraine is happening.

[05:36]

That uncertainty is important.

[05:38]

Instead, several biological mechanisms are being investigated,

[05:42]

and they overlap in fascinating ways with what we already know about migraine.

[05:47]

So I'm going to take you through a couple of mechanisms.

[05:49]

Mechanisms of COVID-19 that affect migraine or share commonalities with migraine.

[05:55]

So mechanism number one is that persistent immune activation.

[06:00]

So there's a possibility that the immune system remains altered after the acute infection.

[06:07]

So during the infection, the inflammatory signaling is going to be useful.

[06:11]

Your immune system is supposed to respond.

[06:13]

But scientists have questioned whether in a subset of people with prolonged symptoms,

[06:18]

the immune signaling remains disturbed after the initial infection has passed.

[06:23]

And why could this matter for migraine?

[06:25]

Well, because inflammation and migraine biology are not strangers, right?

[06:28]

So the sensory nerves around the head and face communicate through the trigeminal system,

[06:34]

and inflammatory signaling can influence the excitability of those pathways.

[06:39]

So a 2022 review specifically highlighted the persistent immune activation together

[06:45]

with the trigeminovascular activation as plausible contributors to long COVID headache.

[06:49]

And these remain proposed mechanisms rather than a complete explanation.

[06:53]

So think of it this way.

[06:54]

A migraine brain may already have a lower threshold for certain disturbances,

[06:58]

then add an infection, add inflammatory signals, add therefore worse sleeps,

[07:04]

reduced physical capacity, and changes in eating patterns together with stress,

[07:08]

and a nervous system trying to regulate all of that simultaneously.

[07:12]

So the question may no longer be what single thing caused my migraine.

[07:16]

A better question sometimes may then be,

[07:19]

how many layers of load is my nervous system trying to carry at the same time?

[07:23]

So that's the mechanism number one, sort of a persistent immune activation.

[07:28]

Now, a second mechanism suspected is the trigeminal pain system remains sensitized.

[07:35]

So we've been talking a lot about the trigeminal system in this podcast,

[07:39]

and it's because it's one of the principal highways

[07:42]

through which migraine pain is generated and transmitted.

[07:46]

So when the system becomes activated repeatedly,

[07:48]

the sensory processing can become increasingly sensitive.

[07:52]

Light feels brighter, sounds feel louder, the smells become more intolerable,

[07:57]

the normal physical movement may hurt, the scalp may feel tender,

[08:01]

and events that previously did not trigger a migraine may suddenly cross that threshold.

[08:06]

And both viral headache researchers have proposed that activation of this trigeminovascular

[08:09]

system may contribute to persistent headache following coronavirus infection.

[08:14]

So this may explain something patients often describe as,

[08:18]

my migraine seems easier to trigger now.

[08:21]

It does not necessarily mean that the structure of the brain has been damaged.

[08:25]

Sensitivity and structural damage are not the same thing,

[08:28]

but it may mean that the neurological threshold separating tolerable stimulation

[08:33]

from migraine attack has temporarily or persistently shifted.

[08:36]

Now, the West would say permanently or temporarily,

[08:40]

the East would look at a bit different, and we're going to see that in the story of Beatrix.

[08:44]

So that's number two, with the trigeminal pain system more sensitized.

[08:48]

Now, mechanism number three, the autonomic nervous system comes into play.

[08:52]

So this is where the picture becomes particularly interesting.

[08:56]

So you have your autonomic nervous system,

[08:58]

handles functions that you normally do not have to consciously manage.

[09:03]

Autonomic symptoms have been extensively reported in people with post-coronavirus conditions.

[09:08]

So in 2024, there was a review in Nature Reviews Neurology,

[09:12]

and post-coronavirus dysautonomia was analyzed,

[09:16]

and it was emphasized that the autonomic dysfunction

[09:19]

appears relevant to at least a subset of patients,

[09:22]

while also making an important scientific point.

[09:25]

Much of the research remains observational,

[09:27]

and there are still major gaps in our understanding

[09:30]

of exactly which autonomic mechanisms are involved.

[09:33]

So why would someone with migraine care about that?

[09:36]

Well, because imagine trying to run an already sensitive nervous system

[09:40]

while the mechanisms regulating circulation, heart rate,

[09:44]

temperature, and physical exertion are also struggling.

[09:47]

Some people describe dizziness when standing,

[09:49]

a racing heart, weakness, exercise intolerance, temperature sensitivity, and headache.

[09:55]

And these symptoms do not automatically prove autonomic dysfunction.

[09:59]

Other conditions can produce them too.

[10:01]

But when they occur together,

[10:03]

it gives clinicians a reason to consider the whole regulatory system

[10:07]

rather than treating every symptom as if it exists independently.

[10:11]

Now, mechanism number four, sleep, fatigue, and the shrinking migraine threshold.

[10:16]

So then we have one of the less glamorous,

[10:18]

but extraordinarily important piece of the puzzle,

[10:21]

sleep and energy regulation.

[10:23]

So long COVID is going to frequently involve fatigue

[10:26]

and involve sleep disturbance and cognitive difficulties.

[10:29]

I'm just now having a thought for one of our Hero Women. She's

[10:32]

had COVID six times.

[10:34]

So just, you know, a kind thought in passing

[10:37]

as I'm thinking about him and sharing this podcast with you.

[10:40]

So a large systematic review and meta-analysis

[10:43]

was published in BMC Neurology in 2025.

[10:46]

So here we're a bit longer.

[10:47]

Now we have a bit more time, a bit more data.

[10:49]

It pulled research involving more than 4 million people

[10:53]

who had recovered from COVID-19.

[10:55]

And across the included studies,

[10:57]

long-term neurological symptoms included fatigue,

[11:00]

included memory problems, cognitive impairments,

[11:03]

sleep disturbance, concentration difficulties, headache, and dizziness.

[11:06]

And the researchers estimated headache

[11:08]

in roughly one-fifth of participants, so 20%.

[11:12]

Although there was substantial variation between studies.

[11:14]

Now this is where I want you to think about the idea of a trigger.

[11:18]

Sometimes we imagine migraine triggers like switches,

[11:20]

like chocolate causes migraine, or stress causes migraine,

[11:23]

or weather causes migraine.

[11:25]

But biology is often slightly messier.

[11:28]

You probably have noticed that too.

[11:29]

So imagine instead that you have a threshold.

[11:32]

On a good day, you start well below it.

[11:34]

Then you sleep badly.

[11:35]

The level rises.

[11:36]

You skip breakfast.

[11:38]

It rises again.

[11:39]

And then you're dehydrated up again.

[11:40]

And then you spend hours concentrating despite brain fog.

[11:44]

And it goes higher.

[11:45]

Then you push through a workout

[11:47]

because you think you should be back to normal by now.

[11:49]

And finally, there's enough total load to cross that line.

[11:53]

And the workout looks like the trigger,

[11:55]

but it may have been the last drop in the glass.

[11:58]

And so for someone living with long COVID,

[12:00]

the glass may already start much fuller than it used to.

[12:04]

Now I want to talk a little bit about exertion.

[12:07]

Exertion deserves a bit of a special attention.

[12:10]

So some people who live with long COVID

[12:12]

report symptoms becoming substantially worse

[12:15]

after physical or after mental exertion.

[12:19]

And this phenomenon is often called

[12:21]

a post-exertional symptom exacerbation.

[12:24]

And this is one reason advice like just exercise

[12:27]

can be over-simplistic.

[12:28]

So movement can be very valuable for human health.

[12:32]

Absolutely.

[12:33]

But the right amount of activity

[12:34]

depends on the individual clinical picture.

[12:37]

If you repeatedly notice that physical or cognitive exertion

[12:40]

is followed by a significant,

[12:42]

steady, worsening fatigue, headache,

[12:44]

cognitive problems, or other symptoms,

[12:46]

consider that physical pattern

[12:47]

rather than continually trying to push through it.

[12:49]

There's a big difference between

[12:51]

gradually rebuilding capacity

[12:52]

and repeatedly overwhelming a system

[12:55]

that has not yet recovered.

[12:57]

Let's change lenses.

[12:58]

Traditional Chinese medicine

[13:00]

does not describe COVID-19 immune cytokines

[13:03]

or trigeminal pathways

[13:04]

using the language of modern neurology.

[13:06]

And we should not pretend that ancient Chinese concepts

[13:09]

are scientific descriptions of long COVID.

[13:11]

They're not.

[13:12]

But traditional Chinese medicine

[13:13]

offers something else that can sometimes be super useful.

[13:17]

A different way of organizing

[13:19]

the lived experience of illness.

[13:21]

So instead of asking only where is the pain,

[13:24]

it's going to ask what happened before the pain.

[13:26]

What makes it better?

[13:28]

What makes it worse?

[13:29]

How is your sleep?

[13:31]

How is your digestion?

[13:32]

How is your energy?

[13:33]

Do you feel hot or cold?

[13:35]

Do you recover after exhaustion?

[13:36]

What else changed when the headache has changed?

[13:39]

So in other words,

[13:40]

it's going to try to understand

[13:42]

the terrain in which the headache is occurring.

[13:45]

And that is particularly interesting in long COVID

[13:47]

because long COVID is rarely experienced

[13:49]

as only one symptom.

[13:51]

Now, traditional Chinese medicine

[13:53]

might interpret a long illness

[13:54]

as something that has consumed

[13:56]

or disturbed the body's underlying resources.

[13:59]

So the traditional language

[14:00]

may talk to you about weakness of qi

[14:02]

or about deficiencies and imbalances

[14:04]

affecting different functional systems.

[14:06]

And you do not need to take those concepts literally

[14:09]

to understand the metaphor.

[14:10]

But think about your phone.

[14:12]

When the battery is at 90%,

[14:13]

you can have maps running

[14:15]

and messages arriving,

[14:16]

music playing,

[14:17]

and 10 applications open.

[14:19]

At 11%, suddenly everything,

[14:21]

every unnecessary operation matters.

[14:24]

The same stimulus costs more.

[14:26]

This is a beautiful way to think about

[14:27]

a person after a prolonged illness.

[14:30]

Maybe before the infection,

[14:32]

you could sleep six hours,

[14:34]

skip lunch,

[14:35]

work 10 hours,

[14:36]

go to the gym,

[14:36]

have two glasses of wine,

[14:38]

and somehow function.

[14:39]

And after the illness,

[14:40]

the body may say,

[14:41]

no, that budget has changed.

[14:43]

And from a traditional Chinese medicine perspective,

[14:45]

this is not weakness.

[14:46]

It's the normal sense.

[14:48]

It's an invitation to respect

[14:50]

the available resources.

[14:51]

The old Chinese medical tradition

[14:53]

repeatedly values balance

[14:55]

between expenditure and restoration.

[14:57]

And modern physiology uses

[14:59]

very different concepts and terminology.

[15:01]

But there's something intuitively useful

[15:03]

about asking,

[15:04]

am I repeatedly spending more energy

[15:06]

than my system can currently restore?

[15:08]

So that's the first idea.

[15:10]

It's an idea of depleted reserves, right?

[15:13]

That's something that you need to replenish.

[15:15]

Now, there's a second idea,

[15:16]

which is the idea of stagnation,

[15:18]

of when things do not flow easily.

[15:21]

It's a concept that is really important,

[15:24]

and it should not be confused

[15:25]

with biomedical diagnosis.

[15:27]

But metaphorically,

[15:28]

stagnation describes something

[15:29]

many migraine patients understand immediately.

[15:31]

The body feels stuck.

[15:33]

The head feels pressurized.

[15:35]

The neck tightens.

[15:36]

The breathing becomes shallow.

[15:38]

The digestion slows.

[15:40]

The movement feels heavy,

[15:42]

and the emotion feels trapped.

[15:43]

And sleep is not restorative,

[15:45]

and everything seems to feed everything else.

[15:48]

And so traditional approaches

[15:49]

might work with gentle movement,

[15:52]

gentle breathing,

[15:53]

gentle acupuncture,

[15:54]

gentle food patterns,

[15:56]

gentle food choices,

[15:57]

and sleep written in an attempt

[15:59]

to restore what practitioners describe

[16:00]

as more harmonious flow.

[16:02]

The question hidden inside the philosophy

[16:04]

is where in your life and body

[16:07]

have you stopped oscillating

[16:08]

between effort and recovery?

[16:10]

Because health is not permanent as an activity.

[16:12]

Our heart contracts and releases.

[16:14]

Lungs inhale and exhale.

[16:16]

We wake up and sleep.

[16:17]

Muscles work and recover.

[16:19]

And nature itself moves between seasons.

[16:21]

So the Eastern model reminds us

[16:23]

that the rest is not the opposite of progress.

[16:26]

Rest is one phase of your healthy cycle.

[16:30]

Now, let's acknowledge something else.

[16:32]

The migraine patient often

[16:34]

becomes very good at pushing.

[16:37]

That's something I see again and again

[16:39]

in people who have lived with chronic symptoms.

[16:41]

They become extraordinary at functioning,

[16:44]

while unwell.

[16:46]

They show up.

[16:47]

They work.

[16:48]

They parent.

[16:48]

They care for other people.

[16:50]

They compensate.

[16:51]

They hide their symptoms.

[16:52]

They schedule recovery around obligations.

[16:55]

Eventually, pushing becomes automatic.

[16:57]

Then long COVID arrives,

[16:59]

and suddenly the old strategy,

[17:00]

well, it no longer works.

[17:02]

The harder they push,

[17:03]

the more unstable everything seems to become.

[17:06]

And this is where an Eastern perspective

[17:07]

can offer a different instruction.

[17:09]

Not fight harder,

[17:10]

not control your body,

[17:12]

but listen,

[17:13]

and listen soon, sooner.

[17:15]

In Chinese philosophy,

[17:16]

water is powerful precisely

[17:18]

because it does not always confront

[17:19]

force with greater force.

[17:21]

Water yields.

[17:22]

It goes around obstacles.

[17:23]

It waits.

[17:24]

And yet, over time,

[17:26]

water can reshape stone.

[17:27]

There may be a lesson there for recovery.

[17:29]

The path forward does not always

[17:31]

require more force.

[17:32]

Sometimes it requires better observation

[17:35]

and a willingness to work

[17:37]

with your present capacity,

[17:38]

rather than constantly comparing yourself

[17:40]

with the body you had before.

[17:42]

So let me come back to Beatrix.

[17:45]

The first time we were together,

[17:46]

we identified her migraine patterns,

[17:48]

and we worked on them.

[17:50]

Over time,

[17:51]

they stopped showing up

[17:53]

the way they used to.

[17:54]

She was so happy.

[17:55]

Then, she caught COVID.

[17:57]

And when she came back to me,

[17:59]

her migraine had returned,

[18:01]

but not in the same way.

[18:02]

She now had three new patterns.

[18:05]

And I remember her telling me,

[18:06]

now garlic is causing me migraine.

[18:08]

She was really, really unhappy

[18:10]

about the COVID situation.

[18:12]

And it wasn't simply

[18:13]

that her migraine had come back.

[18:14]

The terrain had changed.

[18:15]

So let me ask you

[18:17]

a few of the questions

[18:18]

we explored with her.

[18:19]

Just answer them in your head.

[18:21]

Since your illness,

[18:22]

or since something big

[18:24]

changed in your life,

[18:25]

do you tire more quickly

[18:26]

and take longer to recover

[18:28]

after effort?

[18:29]

Does your breathing feel shallower?

[18:31]

Or do you seem to catch

[18:33]

every cold going around?

[18:34]

Do you feel heavy,

[18:36]

foggy or slow,

[18:37]

as if your body

[18:37]

is wading through something?

[18:39]

And for Beatrix,

[18:40]

the answer to all three was yes.

[18:43]

COVID was still very new then,

[18:45]

so I called Dr. Zhang,

[18:46]

who was helping us build

[18:47]

the Migraine Heroes method,

[18:49]

to understand how Chinese medicine

[18:50]

would read what we were seeing.

[18:52]

And for Dr. Zhang,

[18:53]

the picture was familiar.

[18:54]

Not because of COVID itself,

[18:56]

but because the Chinese medicine

[18:57]

had described for a very long time

[18:59]

what a serious illness

[19:00]

can leave behind.

[19:01]

An illness that had drained

[19:03]

Beatrix's reserves,

[19:04]

especially what Chinese medicine

[19:05]

called Lung qi,

[19:06]

the energy linked to breathing

[19:08]

and the body's defenses.

[19:10]

Hardly surprising

[19:11]

after a respiratory virus.

[19:13]

And on top of that,

[19:14]

a heaviness and fog

[19:15]

that hadn't cleared.

[19:17]

A form of dampness.

[19:18]

And different words

[19:20]

from the ones we used

[19:21]

in the earlier episode,

[19:23]

but a similar story.

[19:24]

The aftermath of inflammation

[19:27]

and illness.

[19:28]

So we started working

[19:29]

with these new patterns.

[19:31]

And slowly,

[19:31]

she got back on her feet.

[19:33]

And getting better

[19:34]

mattered to her enormously.

[19:36]

With three children

[19:37]

and a demanding job,

[19:38]

migraine was never just a headache.

[19:40]

One day could disrupt

[19:41]

the entire family.

[19:43]

And I'm deeply grateful to her.

[19:45]

Because she taught us something

[19:46]

we still use every day.

[19:48]

Migraine patterns are unfixed.

[19:49]

A major event in the body,

[19:51]

like an illness,

[19:51]

a hormonal change,

[19:52]

or a long period of stress,

[19:53]

can change the way

[19:54]

your migraine show up.

[19:56]

And when it does,

[19:57]

the old explanations

[19:58]

may no longer fit.

[20:00]

Your migraine has its own pattern.

[20:02]

And as Beatrix showed us,

[20:04]

those patterns can change.

[20:06]

And if something big

[20:07]

has happened in your body,

[20:09]

it's maybe worth

[20:10]

looking at your pattern

[20:11]

as it is today.

[20:13]

Not as it was.

[20:14]

That's what the Migraine Heroes

[20:15]

method was built for.

[20:16]

And the app is where it lives.

[20:19]

It starts by helping you discover

[20:21]

your own migraine pattern.

[20:23]

That's all for today.

[20:24]

I hope this episode

[20:25]

helped you notice some new things.

[20:27]

If you'd like to keep

[20:28]

exploring your patterns,

[20:30]

you can find us on

[20:32]

MigraineHeroes.com.

[20:34]

Your body has a story to tell.

[20:35]

Let's keep listening.

[20:37]

I will be back with you soon.

[20:43]

MigraineHeroes.com