Disclosures: Nima Yazdanpanah, DO: No financial relationships or conflicts of interest

Case Diagnosis: Hemicrania Continua

Case Description: 31-year-old male with history of hemicrania continua (HC) previously well controlled on indomethacin, presented with severe-unremitting headache lasting over 60 days, after receiving second-dose of Moderna COVID-19 vaccine. Patient was formerly misdiagnosed with childhood migraine headaches, with increasing severity and duration until 28 years old, when use of indomethacin led to complete symptom resolution. Patient reported sudden-onset headache 5 hours after receiving second-dose of vaccine, described as shocking and throbbing, 10/10 severity, radiating to left temporal, maxillary molars, and auricular areas, worse with sudden movements, with no relieving factors, associated with disrupted daily activities. Magnetic resonance imaging demonstrated no intracranial pathology. Physical exam showed left-sided conjunctival injection, lacrimation, ptosis, facial flushing and swelling.

Setting: Outpatient rehabilitation clinicAssessment/

Results: Patient with history of HC with severe-constant headache unresponsive to indomethacin after receiving COVID-19 vaccine. Trials of rizatriptan, steroids, ketorolac, and fremanezumab were unsuccessful. Minor pain relief obtained with greater occipital nerve block using levobupivacaine and dexamethasone.

Discussion: HC is an indomethacin-responsive primary headache disorder with hypothesized mechanism of posterior hypothalamic and dorsal rostral pons activation with secondary disinhibition of the trigeminal-autonomic reflex. It presents as a unilateral headache with cranial autonomic symptoms and migrainous features with a persistent-featureless background-headache at baseline. Common complications of COVID-19 vaccine include fatigue, headache, myalgia, fever, chills, and injection-site pain. Any-systemic reaction after second-dose vaccine occurs in 81.9% of vaccine recipients versus 38.4% of placebo, whereas any-headache occurs in 62.8% of vaccine recipients versus 25.4% of placebo. Significant systemic reactions disrupting daily activities or requiring medical intervention occur in 17.4% of vaccine recipients vs. 2.1% of placebo, whereas significant headaches occur in 5% of vaccine recipients versus 1.2% of placebo.

Conclusion: This case-report demonstrates HC exacerbation after COVID-19 vaccination, now unresponsive to indomethacin and other conventional treatments. Further studies regarding adverse-events and related mechanisms of COVID-19 vaccine in patients with chronic headache and HC is warranted.

Level of Evidence: Level IV

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/severe-unremitting-headache-unresponsive-to-indomethacin-after-receiving-second-dose-of-covid-19-mrna-vaccine-in-patient-with-hemicrania-continua-a-case-report/