Pain and COVID-19
Keywords:
back pain, COVID-19, fibromyalgia, headache, myalgia, painAbstract
Pain is one of the most common COVID-19 symptoms, independently of the gravity of the infection. The most common pain syndromes are headache and myalgia. They may occur during the acute phase of the infection and to get over, or to become chronic. Post-COVID syndrome appears in 10% of the patients, and is presented with chronic fatigue, dyspnea, brain fog syndrome with cognitive disturbances, chronic pain syndrome and sleep disturbances. The most common complains are back pain, headache and myalgia. The criteria for fibromyalgia are fulfilled in 30% of patients with myalgia. Fibromyalgia is caused by central sensitization and neuropathic pain. Back pain in post-COVID syndrome is most common in patients with BMI over 30 and is connected with stress, anxiety, depression, lack of mobility and prolonged sitting work online.
Headache in post-COVID syndrome has the symptoms of chronic migraine, tension type headache and new daily persistent headache. Chronic tension type headache and migraine are characterized by neuropathic pain due to central sensitization. The new daily persistent headache may be caused by the infection, triggering autoimmune neurogenic inflammation and sensitization of the nociceptive pathways.
Headache may be also caused by increased levels of calcitonine gene-related peptide (CGRP) during the acute phase of the infection. It is also possible that circulating inflammatory mediators activating the trigeminovascular system in meninges play role in headache. The third possible mechanism is connected with the ACE2 receptors in the brain blood vessels and subsequent damage of meningeal endotel during the acute infection.
Treatment of acute back pain and muscle pain is with nonsteroid anti-inflammatory drugs (NSAID), paracetamol, gabapentin, pregabalin, weak opioids (tramadol) and physiotherapy. The combination of paracetamol and tramadol is very effective against both nociceptive and neuropathic pain.
NSAID should be used with caution in patients treated with anticoagulants and antiaggregants. Treatment with corticosteroids is not recommended. The musculoskeletal pain in patients with fibromyalgia is treated also with tricyclic and SNRI antidepressants. Headache, depending on its type is treated with drugs for prophylactics of tension type headache (amitriptyline, venlafaxine, mirtazapine) or migraine – topiramate, beta-blockers, calcium channel blockers, amitriptyline and botulinum toxin. Drugs for treatment of migraine attacks (triptans) and acute tension type headache (NSAID or paracetamol) are also used.
References
Abdullahi, A., Candan, S.A., Abba, M.A., Bello, A.H., Alshehri, M.A., Afamefuna, V.E., Umar, N.A., Kundakci, B. Neurological and musculoskeletal features of COVID-19: A systematic review and meta-analysis. Front. Neurol., 2020, 11, 687.
Ahearn-Ford, S., Lunjani, N., McSharry, B., MacSharry, J., Fanning, L., Murphy, G., Everard, C., Barry, A., McGreal, A., Al Lawati, S.M., Lapthorne, S., Sherlock, C., McKeogh, A., Jackson, A., Faller, E., Horgan, M., Sadlier, C., O'Mahony, L. Long-term disruption of cytokine signalling networks is evident in patients who required hospitalization for SARS-CoV-2 infection. Allergy, 2021, 76, 9, 2910-2913.
Angotti, M., Mallow, G.M., Wong, A., Haldeman, S., An, H.S. Samartzis, D. COVID-19 and its impact on back pain. Global Spine J., 2022, 12, 1, 5-7.
Bakılan, F., Gökmen, I.G., Ortanca, B., Ucan, A., Güvenc, Ş.E., Mutlu, F.Ş., Gökmen, H.M., Ekim, A. Musculoskeletal symptoms and related factors in postacute COVID-19 patients. Int. J. Clin. Pract., 2021, 75, 11, e14734.
Bierle, D.M., Aakre, A.C., Grach, S.L., Salonen, B.R., Croghan, I.T., Hurt, R.T., Ganesh, R. Central sensitization phenotypes in post acute sequelae of SARS-CoV-2 infection (PASC): defining the post COVID syndrome. J. Prim. Care Community Health, 2021, 12, 21501327211030826.
Bileviciute-Ljungar, I., Norrefalk, J.R., Borg, K. Pain burden in post-COVID-19 syndrome following mild COVID-19 infection. J. Clin. Med., 2022, 11, 771.
Boldrini, M., Canoll, P.D., Klein, R.S. How COVID-19 affects the brain. JAMA Psychiatry, 2021, 78, 6, 682-683.
Butler, R.K., Finn, D.P. Stress-induced analgesia. Prog. Neurobiol., 2009, 88, 3, 184-202.
Carfì, A., Bernabei, R., Landi, F. Persistent symptoms in patients after acute covid-19. JAMA, 2020, 324, 6, 603-605.
Caronna, E., Alpuente, A., Torres-Ferrus, M., Pozo-Rosich, P. Toward a better understanding of persistent headache after mild COVID-19: three migraine-like yet distinct scenarios. Headache J. Head Face Pain, 2021, 6 1277-1280.
Cernuda-Morollon, E., Larrosa, D., Ramón, C., Vega, J., Martínez-Camblor, P., Pascual, J. Interictal increase of CGRP levels in peripheral blood as a biomarker for chronic migraine, Neurology, 2013, 81, 14, 1191-1196.
Chen, R., Wang, K., Yu, J., Howard, D., French, L., Chen, Z.,Wen, C., Xu, Z. The spatial and cell-type distribution of SARSCoV-2 receptor ACE2 in the human and mouse brains. Front. Neurol., 2021, 11, 573095.
Clauw, D.J., Häuser, W., Cohen, S.P., Fitzcharles, M.A. Considering the potential for an increase in chronic pain after the COVID-19 pandemic. Pain, 2020, 161, 8, 1694-1697.
Cohen, S.P. Rowlingson, J., Abdi, S. Low back pain. In: Principles and practice of pain medicine. Warfield, C.A., Bajwa, Z.H., eds., McGraw-Hill, New York, 2004, 273-282.
Conde Cardona, G., Quintana Pájaro, L.D., Quintero Marzola, I.D., Ramos Villegas, Y., Moscote Salazar, L.R. Neurotropism of SARS-CoV 2: mechanisms and manifestations. J Neurol Sci. 2020;412:116824.
Davido, B., Seang, S., Tubiana, R., de Truchis, P. Post-COVID-19 chronic symptoms: a postinfectious entity? Clin. Microbiol. Infect., 2020, 26, 11, 1448-1449.
De Virgiliis, F., Di Giovanni, S. Lung innervation in the eye of a cytokine storm: neuroimmune interactions and COVID-19. Nat. Rev. Neurol., 2020, 16, 645-652.
Eren, F., Özkan, B., Demir, A. Myalgia-arthralgia and associated factors in patients with COVID-19. Turk. J. Neurol., 2021, 27, Suppl. 1, 15-20.
Fernández-de-Las-Peñas, C., Rodríguez-Jiménez, J., Fuensalida-Novo, S., Palacios-Ceña, M., Gómez-Mayordomo, V., Florencio, L.L., Hernández-Barrera, V., Arendt-Nielsen, L. Myalgia as a symptom at hospital admission by severe acute respiratory syndrome coronavirus 2 infection is associated with persistent musculoskeletal pain as long-term post-COVID sequelae: a case-control study. Pain, 2021, 162, 12, 2832-2840.
Filatov, A., Sharma, P., Hindi, F., Espinosa, P.S. Neurological complications of Coronavirus disease (COVID-19). Encephalopathy, 2020, 12, 3.
Gupta, A., Madhavan, M.V., Sehgal, K., Nair, N., Mahajan, S., Sehrawat, T.S., Bikdeli, B., Ahluwalia, N., Ausiello, J.C., Wan, E.Y., Freedberg, D.E., Kirtane, A.J., Parikh, S.A., Maurer, M.S., Nordvig, A.S., Accili, D., Bathon, J.M., Mohan, S., Bauer, K.A., Leon, M.B., Krumholz, H.M., Uriel, N., Mehra, M.R., Elkind, M.S.V., Stone, G.W., Schwartz, A., Ho, D.D., Bilezikian, J.P., Landry, D.W. Extrapulmonary manifestations of COVID-19. Nature Medicine volume, 2020, 26, 1017-1032.
Guymer, E., Littlejohn, G.O. Fibromyalgia syndrome: Clinical aspects and management. In: Muscle pain: Diagnosis and treatment. Mense, S., Gerwin, R.D., eds., Berlin, Springer-Verlag, 2010, 105-141.
Hasan, L.K., Deadwiler, B., Haratian, A., Bolia, I.K., Weber, A.E., Petrigliano, F.A. Effects of COVID-19 on the musculoskeletal system: clinician’s guide. Orthopedic Research and Reviews, 2021, 13, 141-150.
Häuser, W., Sarzi-Puttini, P., Fitzcharles, M.A. Fibromyalgia syndrome: Under-, over- and misdiagnosis. Clin. Exp. Rheumatol., 2019, 37, 90-97.
Javed, A. Neurological associations of SARS-CoV-2 infection: A systematic review. CNS Neurol. Disord. Drug Targets, 2021, 21, 3.
Kemp, H.I., Corner, E., Colvin, L.A. Chronic pain after COVID- 19: implications for rehabilitation. Br. J. Anaesth., 2020, 125, 4, 436-440.
Kosek, E. Fibromyalgia. In: Handbook of clinical neurology. Pain. Cervero, F., Jensen, T.S. eds., Elsevier B.V., Amsterdam, 2006, 81, 763-777.
Lehmann, L.E., Bajwa, Z.H. Fibromialgia and myofascial pain. In: Principles and practice of pain medicine. Warfield, C.A., Bajwa, Z.H., eds., McGraw-Hill, New York, 2004, 513-517.
Littlejohn, G.O. Gender, genetics, and other risk factors increasing vulnerability to fibromyalgia. In: Muscle pain: Diagnosis and treatment. Mense, S., Gerwin, R.D., eds., Berlin, Springer-Verlag, 2010, 143-157.
Loeser, J.D. Pain as a disease. In: Handbook of clinical neurology. Pain. Cervero, F., Jensen, T.S. eds., Elsevier B.V., Amsterdam, 2006, 81, 11-20.
Logue, J.K., Franko, N.M., McCulloch, D.J., McDonald, D., Magedson, A., Wolf, C.R., Chu, H.Y. Sequelae in adults at 6 months after COVID-19 infection. JAMA Netw. Open, 2021, 4, 2,e210830.
Mao, L., Jin, H., Wang, M., Hu, Y., Chen, S., He, Q., Chang, J., Hong, C., Zhou, Y., Wang, D., Miao, X., Li, Y., Hu, B. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol., 2020, 77, 6, 683-690.
Martelletti, P., Bentivegna, E., Luciani, M., Spuntarelli, V. Headache as a prognostic factor for COVID-19. Time to re-evaluate. SN Compr. Clin. Med., 2020, 2, 12, 2509-2510.
Martelletti, P., Bentivegna, E., Spuntarelli, V., Luciani, M. Long- COVID headache. SN Compr. Clin. Med., 2021, 3, 8, 1704-1706.
Membrilla, J.A., Caronna E., Trigo-López, J., González-Martínez, A., Layos-Romero, A., Pozo-Rosich, P., Guerrero-Peral, A., Gago-Veiga, A.B., Andrés-López, A., Díaz de Terán, J. Persistent headache after COVID-19: Pathophysiology, clinic and treatment. Neurology Perspectives, 2021, 1, Suppl. 1, S31-S36.
Murat, S., Karatekin, B.D., Icagasioglu, A., Ulasoglu, C., Icten, S., Incealtin, O. Clinical presentations of pain in patients with COVID-19 infection. Irish Journal of Medical Science, 2021, 190, 913-917.
Nalbandian, A., Sehgal, K., Gupta, A., Madhavan, M.V., Mc- Groder, C., Stevens, J.S., Cook, J.R., Nordvig, A.S., Shalev, D., Sehrawat, T.S., Ahluwalia, N., Bikdeli, B., Dietz, D., Der-Nigoghossian, C., Liyanage-Don, N., Rosner, G.F., Bernstein, E.J., Mohan, S., Beckley, A.A., Seres, D.S., Choueiri, T.K., Uriel, N., Ausiello, J.C., Accili, D., Freedberg, D.E., Baldwin, M., Schwartz, A., Brodie, D., Garcia, C.K., Elkind, M.S.V., Connors, J.M., Bilezikian, J.P., Landry, D.W. Wan, E.Y. Postacute COVID-19 syndrome. Nat. Med., 2021, 27, 601-615.
O’Sullivan, P. It’s time for change with the management of nonspecific chronic low back pain. Br. J. Sports. Med., 2011, 46, 224-227.
Pincus, T., Burton, A.K., Vogel, S., Field, A.P. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine, 2002, 27, 5, E109–E120.
Ranade, M., Deshmukh, P., Purushottham, S., Kasliwal, P. Systematic review of post covid myalgia literature. Acta Scientific Orthopaedics, 2021, 4, 73-77.
Rossi, P., Tassorelli, C., Allena, M., Ferrante, E., Lisotto, C., Nappi, G. Focus on therapy: hemicrania continua and new daily persistent headache. J. Headache and Pain, 2010, 11, 259-265.
Sagát, P., Bartík, P., González, P.P., Tohănean, D.I., Knjaz, D. Impact of COVID-19 quarantine on low back pain intensity, prevalence, and associated risk factors among adult citizens residing in Riyadh (Saudi Arabia): A cross-sectional study. Int. J. Environ. Res. Public Health, 2020, 17, 19, 7302.
Salvi, L. Lifestyle therapy in migraine. Management and therapeutic strategies. One Way Publishing, Milano, 2008, pp. 56.
Sarzi-Puttini, P., Giorgi, V., Marotto, D., Atzeni, F. Fibromyalgia: An update on clinical characteristics, aetiopathogenesis and treatment. Nat. Rev. Rheumatol., 2020, 16, 645-660.
Sindrup, S. H., Finnerup, N. B., Otto, M., Jensen, T. S. Principles of pharmacological treatment. In: Handbook of clinical neurology. Pain. Cervero, F., Jensen, T.S. eds., Elsevier B.V., Amsterdam, 2006, 81, 843-853.
Ursini, F., Ciaffi, J., Mancarella, L., Lisi, L., Brusi, V., Cavallari, C., D'Onghia, M., Mari, A., Borlandelli, E., Cordella, J.F., La Regina, M., Viola, P., Ruscitti, P., Miceli, M., De Giorgio, R., Baldini, N., Borghi, C., Gasbarrini, A., Iagnocco, A., Giacomelli, R., Faldini, C., Landini, M.P., Meliconi, R. Fibromyalgia: a new facet of the post-COVID-19 syndrome spectrum? Results from a webbased survey. RMD Open, 2021, 7, 3, e001735.
Verdu, B., Decosterd, I., Buclin, T., Stiefel, F., Berney, A. Antidepressants for the treatment of chronic pain. Drugs, 2008, 68, 18, 2611-2632.
Wang, C., Pan, R., Wan, X., Tan, Y., Xu, L., Ho, C.S., Ho, R.C. Immediate psychological responses and associated factors during the initial stage of the 2019 Coronavirus Disease (COVID-19) epidemic among the general population in China. Int. J. Environ. Res. Public Health, 2020, 17, 5, 1729.
Wolfe, F., Clauw, D.J., Fitzcharles, M.A., Goldenberg, D.L., Häuser, W., Katz, R.L., Mease, P.J., Russell, A.S., Russell, I.J., Walitt, B. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin. Arthritis Rheum., 2016, 46, 319-329.
Zhou, L., Zhang, M., Wang, J., Gao, J. Sars-Cov-2: underestimated damage to nervous system. Trav. Med. Infect. Dis., 2020, 36, 101642.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2021 Ivan Milanov
This work is licensed under a Creative Commons Attribution 4.0 International License.
