Report the case of a patient suffering from headache refractory to analgesics, months after COVID 19 infection, presented as intracranial hypertension.

The diagnosis and management of headache is a challenge in clinical practice, even more so when an ambulatory case present intracranial hypertension. Headache as an acute manifestation of COVID 19 can occur in almost half of the cases, but it is a rare manifestation several months after acute involvement.

A 75-year-old white female patient presented holocranial headache lasted 6 months and was not relieved by common analgesics. She also stated slight visual change, with poor acuity, but normal in the ophthalmological evaluation. She had a normal brain scan, history of controlled mild systemic arterial hypertension and previous mild COVID infection approximately 6 months ago.  In the evaluation of brain compliance by a non-invasive outpatient exam (Brain4Care @ device) she presented the P2 curve of brain compliance almost double that of P1 (P2 / P1 1.9) manifestating pain during the exam. The patient underwent a lumbar puncture, with liquor drainage of 40ml and completely relief of headache. In the immediate post-puncture assessment with B4C, she showed a comparative improvement in brain compliance with a P2/P1 ratio of 1.4. She returned to a mild headache within 24 hours of the puncture and it was started acetazolamide, relieving the pain again. Around 48 hours after the lumbar puncture, she showed a significant improvement in brain compliance, reaching a normal P2/P1 ratio of 1.13 and remaining headache-free. She was discharged using acetazolamide 500mg BID that was gradually reduced, stoped and she no longer had headache.

Intracranial hypertension should be suspected in rare cases of headache of non-relief with usual analgesics.  Also previous COVID 19 involvement should be remembered  especially in cases not typical to current headache causes.