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Factors Associated with the Presence of Headache in Hospitalized COVID

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Factors Associated with the Presence of Headache in Hospitalized COVID Trigo et al. The Journal of Headache and Pain (2020) 21:94 The Journal of Headache https://doi.org/10.1186/s10194-020-01165-8 and Pain RESEARCH ARTICLE Open Access Factors associated with the presence of headache in hospitalized COVID-19 patients and impact on prognosis: a retrospective cohort study Javier Trigo1, David García-Azorín1* , Álvaro Planchuelo-Gómez2, Enrique Martínez-Pías1, Blanca Talavera1, Isabel Hernández-Pérez1, Gonzalo Valle-Peñacoba1, Paula Simón-Campo1, Mercedes de Lera1, Alba Chavarría-Miranda1, Cristina López-Sanz1, María Gutiérrez-Sánchez1, Elena Martínez-Velasco1, María Pedraza1, Álvaro Sierra1, Beatriz Gómez-Vicente1, Juan Francisco Arenillas1,3,4 and Ángel L. Guerrero1,3 Abstract Introduction: Headache is one of the most frequent neurologic manifestations in COVID-19. We aimed to analyze which symptoms and laboratory abnormalities were associated with the presence of headache and to evaluate if patients with headache had a higher adjusted in-hospital risk of mortality. Methods: Retrospective cohort study. We included all consecutive patients admitted to the Hospital with confirmed SARS-CoV-2 infection between March 8th and April 11th, 2020. We collected demographic data, clinical variables and laboratory abnormalities. We used multivariate regression analysis. Results: During the study period, 576 patients were included, aged 67.2 (SD: 14.7), and 250/576 (43.3%) being female. Presence of headache was described by 137 (23.7%) patients. The all-cause in-hospital mortality rate was 127/576 (20.0%). In the multivariate analysis, patients with headache had a lower risk of mortality (OR: 0.39, 95% CI: 0.17–0.88, p = 0.007). After adjusting for multiple comparisons in a multivariate analysis, variables that were independently associated with a higher odds of having headache in COVID-19 patients were anosmia, myalgia, female sex and fever; variables that were associated with a lower odds of having headache were younger age, lower score on modified Rankin scale, and, regarding laboratory variables on admission, increased C-reactive protein, abnormal platelet values, lymphopenia and increased D-dimer. Conclusion: Headache is a frequent symptom in COVID-19 patients and its presence is an independent predictor of lower risk of mortality in COVID-19 hospitalized patients. Keywords: COVID-19, Nervous system diseases, Headache disorders, secondary, Mortality, laboratory parameters * Correspondence: [email protected]; [email protected] 1Department of Neurology, Hospital Clínico Universitario de Valladolid, Avenida Ramón y Cajal 3, 47003 Valladolid, Spain Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Trigo et al. The Journal of Headache and Pain (2020) 21:94 Page 2 of 10 Background We included all consecutive patients that were admit- Coronavirus disease 2019 (COVID-19) is caused by se- ted to the Hospital with a confirmed SARS-CoV-2 infec- vere acute respiratory syndrome coronavirus 2 (SARS- tion diagnosis between March 8th and April 11th, 2020. CoV-2) [1]. The severity of symptomatic cases varies The diagnosis was set, according to the World Health from mild to critical. In the case of Spain, analyzing data Organization (WHO) protocols [13], by real-time reverse from more than 250,000 infected patients, 38.4% of pa- transcriptase polymerase -chain reaction (RT-PCR) assay tients needed hospitalization, 3.9% were admitted to the (LightMix Modular SARS-CoV (COVID19) E-gene and Intensive Care Unit (ICU) and 8.2% expired [2]. Several LightMix Modular SARS-CoV-2 RdRP, Roche Diagnos- factors may affect the prognosis, including male sex, tics) from oropharyngeal swab, sputum sample, or lower older age, hypertension, diabetes, smoking, cardiovascu- respiratory tract sample; or by the presence of anti- lar disorders, chronic neurological disorders, and pul- SARS-CoV-2 IgM + IgA antibodies (COVID-19 ELISA monary diseases, among others [3, 4]. Regarding clinical IgM + IgA, Vircell, S.L. Granada, Spain) in patients with manifestations, fever and dyspnea have been associated clinical symptoms. Patients were excluded if the with severity and mortality of COVID-19 as well [3]. hospitalization was not done from the emergency de- Headache is one of the most frequent neurologic man- partment (ED) or if the patients’ records were not ifestations in COVID-19. The reported frequency of accessible. headache in a recent meta-analysis was 12% of patients [5], ranging from 6.5% [6] to 70.3% [7] depending on the Data sources studies, with most of the studies reporting a frequency Data were collected from electronic medical records. The within 10–30% of patients [8, 9]. Headache might be information was gathered from primary care records, caused by the release of cytokines, endothelial damage emergency room records, and discharge reports. Data and macrophage activation; or it could be related to the were extracted between April 21st and May 1st, and the inflammation of lymphatic structures, as the lymphatic minimum follow-up time after admission was 20 days organs located in the naso- and oropharynx around the (ranging from 20 to 61 days) and the last patients were Waldeyer’s ring [10, 11]. The real causes of headache in contacted on May 25th. Details of the study have been de- COVID-19 are still uncertain. Whether the presence of scribed elsewhere [4]. In those patients in which the pres- headache reflects a more severe course of COVID-19, or ence of headache was not described, a trained neurologist if it is associated with a better prognosis because of a contacted the patient or their relatives by phone and spe- more efficient host response against the virus is also cifically inquired about it. All patients were evaluated after unclear. the resolution of all symptoms COVID-19 or after 20 days In the present study, we aimed to evaluate whether of COVID-19 symptoms. The detailed description of the prognosis of hospitalized patients with COVID-19, eval- headache screening process is available in supplementary uated by in-hospital all-cause mortality rate, differed in materials. We analyzed the presence of any new onset patients with headache compared to those without head- headache developed in temporal relation to the onset of ache. As a secondary objective, we assessed which vari- the viral infection, or any headache described as different ables were associated with the presence of headache in to the pre-existing headache. During the hospitalization, COVID-19 patients. We hypothesized that the presence patients were treated according to the national standard of headache might be related to a different COVID-19 of care [14, 15]. presentation in terms of severity and inflammatory response. Study objectives The primary objective was to evaluate if hospitalized Methods COVID-19 patients with headache had a higher risk of We performed an observational analytic study with a all-cause in-hospital mortality compared to those with- retrospective cohort design. The study was done in a ter- out headache. The secondary objective was to analyze tiary academic public hospital (Clinic University Hospital which variables were independently associated with the of Valladolid, Valladolid, Spain) with a reference popula- presence of headache in COVID-19 patients. tion of 280,000 patients. The study was performed ac- cording to the strengthening the reporting of Variables observational studies in epidemiology (STROBE) state- Baseline variables included demographic data, presence ment [12]. The study was designed and data were ana- of comorbidities, and details about treatment for any lyzed by the authors. All co-authors contributed to the chronic diseases. Demographic data included age, sex collection, analysis and interpretation of data, as well as and baseline performance status according to the modi- to the reviewing and approving of the final version of fied Rankin scale (mRS) [16]. The evaluated comorbidi- the manuscript. ties included hypertension, diabetes, smoking habits, Trigo et al. The Journal of Headache and Pain (2020) 21:94 Page 3 of 10 cardiovascular diseases, pulmonary diseases, cancer, an using the Kolmogorov-Smirnov test. We used two-tailed immunocompromised state, and chronic neurological chi-square tests or Fisher’s exact tests for hypothesis diseases [4], and we also assessed whether patients had a testing of qualitative variables, and an independent sam- prior history of headache. We analyzed whether patients ples Student’s t-test or a median test
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