Dr Sudhir Kumar MD DM
Consultant Neurologist, Apollo Hospitals, Hyderabad
Coronavirus disease 2019 (COVID-19) caused by SARS-CoV2 is a global pandemic, which has already affected about 2.6 million people belonging to about 200 countries. Healthcare workers (HCW) working in high-risk areas (such as emergency room, isolation wards, ICU, etc) are mandated to wear personal protective equipment (PPE), including close-fitting N95 face mask and protective eyewear (mainly goggles) while attending to the patients.
Aims of the Study
A recent study was conducted at Singapore (Reference: Headache, 30 March, 2020) to study the effects of PPE in development of de novo (new onset) headaches as well as their impact on personal health and work performance. The impact of COVID 19 on pre-existing headache disorders was also investigated.
Participants in the Study
158 healthcare workers participated in the study. 78% of them were in 21-35 year age group. 70% were females. Majority were either nurses (65%) or doctors (32%). 29% had pre-existing headache disorders (19% had migraine and 10% had tension-type headache).
Main Findings of the Study
Out of 158 healthcare workers, 128 (81%) developed de novo PPE-associated headaches. Persons with pre-existing primary headaches were 4.2 times more likely to develop de novo PPE-associated headaches. People using PPE for more than 4 hours per day had a 3.9 fold higher risk of developing PPE-associated headaches.  HCW working in emergency department had a 2.4 times higher risk of developing PPE-associated headaches.
Clinical Characteristics of PPE-associated Headaches
Headaches were bilateral in location. The location of discomfort corresponded to the areas of contact from the face mask or goggles and their corresponding head straps. Discomfort was described as a sensation of pressure or heaviness of affected sites in 87% and throbbing or pulling pain in 12%.
The time interval between donning of face mask or protective eyewear and onset of headache was less than 60 minutes in most people. After removal of PPE, the headache resolved within 30 minutes.
Most people reported an attack frequency of 1-4 days in a 30-day period. The intensity of headache was mild in most. 23% reported accompanying symptoms of nausea, vomiting, phonophobia or photophobia.

Various types of Face mask and Protective eye gear

 Location of headache in association with N95 facemask and protective eyewear

About 70% did not take any painkillers. 30% took either paracetamol or NSAIDs.
83% opined that PPE-associated headaches resulted in a slight decrease in work performance.
Pathogenesis of de novo PPE-associated headaches
The proposed mechanisms care mechanical compression, hypoxemia, hypercarbia and stress.
What could mitigate the risks of PPE-associated headaches?
1.     Shorter duty shifts and resultant shorter duration PPE usage could be a better strategy, 2. Better cushioning of head straps to minimize mechanical compression over scalp, 3. Reducing stress levels among HCWs.
Key points
1.     New-onset headaches are common after using PPE (N95 mask and protective eye gears),
2.     Healthcare workers in ED and those using PPE for more than 4 hours daily have a higher chance of developing headaches.
3.     People with pre-existing headaches have a higher chance of getting headaches.
4.     Headaches begin within 60 minutes of donning PPE and subside within 30 minutes of removing PPE,
5.     Headaches affect both sides of head and are usually mild in nature,
6.     Headaches respond to paracetamol and NSAIDs,
7.     Headaches decrease the work performance,
8.     Shorter shift duration (resulting in shorter duration use of PPE) could be the way forward,
9.     Though the primary aim of PPE is to reduce the risk of virus spread and transmission, we also need to make them user friendly in future.

Dr Sudhir Kumar MD DM

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