Headache following vaccination against COVID-19 among healthcare workers with a history of COVID-19 infection: a cross-sectional study in Iran with a meta-analytic review of the literature

Abstract

Background
There is evidence of the occurrence of headache after vaccination against COVID-19. However, only a few studies have examined the headache characteristics and related determinants, especially among healthcare workers with a history of COVID-19 infection.

Methods
We evaluated the incidence of headaches after injection of different types of COVID-19 vaccine to determine factors relating to the incidence of headache after vaccination among the Iranian healthcare workers who had previously contracted COVID-19. A group of 334 healthcare workers with a history of COVID-19 infection were included and vaccinated (at least one month after recovery without any COVID-19 related symptoms) with different COVID-19 vaccines. The baseline information, headache characteristics and vaccine specifications were recorded.

Results
Overall, 39.2% reported experiencing a post-vaccination headache. Of those with a previous history of headache, 51.1% reported migraine-type, 27.4% tension-type and 21.5% other types. The mean time between vaccination and headache appearance was 26.78 ± 6.93 h, with the headache appearing less than 24 h after vaccination in most patients (83.2%). The headaches reached its peak within 8.62 ± 2.41 h. Most patients reported a compression-type headache. The prevalence of post-vaccination headaches was significantly different according to the type of vaccine used. The highest rates were reported for AstraZeneca, followed by Sputnik V. In regression analysis, the vaccine brand, female gender and initial COVID-19 severity were the main determinants for predicting post-vaccination headache.

Conclusion
Participants commonly experienced a headache following vaccination against COVID-19. Our study results indicated that this was slightly more common in females and in those with a history of severe COVID-19 infection.

Full text

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Nasergivehchi et al. Head & Face Medicine (2023) 19:19
https://doi.org/10.1186/s13005-023-00363-4 Head & Face Medicine
*Correspondence:
Mansoureh Togha
togha1961@gmail.com
Full list of author information is available at the end of the article
Abstract
Background There is evidence of the occurrence of headache after vaccination against COVID-19. However, only
a few studies have examined the headache characteristics and related determinants, especially among healthcare
workers with a history of COVID-19 infection.
Methods We evaluated the incidence of headaches after injection of different types of COVID-19 vaccine to
determine factors relating to the incidence of headache after vaccination among the Iranian healthcare workers who
had previously contracted COVID-19. A group of 334 healthcare workers with a history of COVID-19 infection were
included and vaccinated (at least one month after recovery without any COVID-19 related symptoms) with different
COVID-19 vaccines. The baseline information, headache characteristics and vaccine specifications were recorded.
Results Overall, 39.2% reported experiencing a post-vaccination headache. Of those with a previous history of
headache, 51.1% reported migraine-type, 27.4% tension-type and 21.5% other types. The mean time between
vaccination and headache appearance was 26.78 ± 6.93 h, with the headache appearing less than 24 h after
vaccination in most patients (83.2%). The headaches reached its peak within 8.62 ± 2.41 h. Most patients reported
a compression-type headache. The prevalence of post-vaccination headaches was significantly different according
to the type of vaccine used. The highest rates were reported for AstraZeneca, followed by Sputnik V. In regression
analysis, the vaccine brand, female gender and initial COVID-19 severity were the main determinants for predicting
post-vaccination headache.
Conclusion Participants commonly experienced a headache following vaccination against COVID-19. Our study
results indicated that this was slightly more common in females and in those with a history of severe COVID-19
infection.
Keywords COVID-19, Vaccination, Post-vaccination headache
Headache following vaccination against
COVID-19 among healthcare workers
with a history of COVID-19 infection: a cross-
sectional study in Iran with a meta-analytic
review of the literature
Somayeh Nasergivehchi1,2, Mansoureh Togha1,3* , Elham Jafari1, Mehrdad Sheikhvatan4,5 and Donya Shahamati6

Page 2 of 8Nasergivehchi et al. Head & Face Medicine (2023) 19:19
Introduction
With the onset of the COVID-19 pandemic in December
2019, efforts began to provide effective and safe drugs
to treat the disease and prevent its development. In line
with what has been observed in previous pandemics, the
efforts to produce effective vaccines increased rapidly. A
few months after the start of such efforts and with the
rapid spread of COVID-19 and its variants, the first gen-
erations of effective immunogenic vaccines were intro-
duced and gradually approved by international scientific
reference committees, including the Centers for Disease
Control and Prevention (CDC) and World Health Orga-
nization (WHO) [1, 2].
It did not take long to generate various brands of vac-
cines in countries such as the United States, China,
Germany, Japan, India, Russia, and even in developing
countries such as Iran and Cuba, and introduce them to
the world [3–5]. However, as the production and com-
mercialization of these vaccines accelerated, concerns
arose. First, with the emergence of COVID-19 variants,
especially the Delta strain, concern increased about
reduced immunogenicity against the virus variants. e
protective effects of some vaccines initially having an
immunogenicity level of over 90% were seen to decrease
to less than 70% [6, 7]. More importantly, following inoc-
ulation with various vaccine brands against COVID-19,
potential and, rarely, life-threatening side effects were
reported. Common side effects for the COVID-19-vac-
cines included local inflammation, headache, muscle
pain, nausea, fatigue, fever and chills [8]. Anaphylaxis,
thromboembolic events, myocarditis, pericarditis and
even death were rarely reported, but seriously called into
question the safety of some brands [9].
One of the most common side effects following injec-
tion of the different brands of COVID-19 vaccine has
been headache. According to the Zoe Health Study,
the overall prevalence of headache after vaccination by
Pfizer-BioNTech vaccine ranged from 25 to 42% [10]. e
CDC Trusted Source page reported that approximately
one-third of people experienced severe post-vaccination
headache, regardless of the type or brand of vaccine, at
a rate of 1% after the first dose and 3% after the second
dose [11].
One study in Italy reported on the increased likeli-
hood of headache after vaccination by AstraZeneca vac-
cine, followed by the Pfizer vaccine [12]. Ekizoglu et al.
assessed the history of headache following influenza vac-
cination and during Covid-19. ey found that 30.6%
healthcare personnel had experienced headache follow-
ing Covid vaccination that was more common in females
with pre-existing primary headaches, thyroid disorders,
headache during COVID-19, or headache related to the
influenza vaccine [15]. Sekiguchi et al. in their study in
Japan performed a survey on nursing staff. eir result
demonstrated that participants with the history of head-
ache (migraineurs and non-migraineurs) will develop
more headache compare to the healthy controls [13].
However, overall information about headache follow-
ing those brands, as well as others, has been limited and
requires further evaluation. is is especially important
for individuals who have experienced COVID-19 infec-
tion prior to vaccination. is study evaluated and com-
pared the incidence of headache following inoculation
with different types of commonly used COVID-19 vac-
cines and determined the factors related to the incidence
of headache following vaccination among selected Ira-
nian healthcare workers who had previously recovered
from COVID-19.
Materials and methods
e participants in this cross-sectional study com-
prised 334 healthcare personnel who had initially recov-
ered from COVID-19 infections of different intensities.
According to our institutional protocol, these individu-
als were vaccinated at least one month after recovery
with one of the brands of COVID-19 vaccine mentioned
above between April and September 2021. e brands of
corona vaccine that were commonly used among health-
care workers in this study included AstraZeneca, Sino-
pharm (China), Sputnik V (Russia), Bharat (India) and
COVIran Barekat (Iran).
An online questionnaire designed to cover all the
necessary data. is questionnaire included the demo-
graphics characteristics, the brand of vaccine adminis-
tered, severity of initial COVID-19 infection (defined as
quarantine at home, hospitalization in an isolated ward
or ICU), concomitant clinical symptoms, PCR positivity
after vaccination, rate of analgesic use after vaccination
and COVID-19 positivity between two vaccine doses.
In addition, information related to the post-vaccination
headache, including time duration between vaccination
and headache occurrence, time to reaching peak inten-
sity after onset, pattern and location of the headache and
medication used for headache relief also were assessed.
All patients were reassured about the privacy of their
information and, after explaining the objectives of the
project, verbal consent was obtained from all. e study
endpoint was to determine the prevalence of headache
and its characteristics following the use of each vaccine
brand and then to determine the effect of vaccination
of the different brands while adjusting for gender, initial
COVID-19 severity and previous history of headache.
In this regard, the severity of the COVID-19 was deter-
mined based on the Criteria for Clinical Severity of Con-
firmed COVID-19 as released by WHO [1, 2].
For statistical analysis, results were presented as
mean ± standard deviation (SD) for the quantitative vari-
ables and were summarized by frequency (percentage)

Page 3 of 8Nasergivehchi et al. Head & Face Medicine (2023) 19:19
for categorical variables. Continuous variables were com-
pared using the t-test or Mann-Whitney test whenever
the data did not appear to have a normal distribution
or when the assumption of equal variance was vio-
lated across the study groups. e multivariable logistic
regression model was employed to examine the effect of
type of vaccine on post-vaccination headache as adjusted
for gender, history of headache and COVID-19 severity.
P-values of ≤ 0.05 were considered statistically significant.
e statistical software SPSS (version 23.0) for Windows
(IBM; USA) was used for statistical analysis.
Results
A total of 334 hospital staff members who had a history
of COVID-19 infection and had subsequently been vac-
cinated with different brands of vaccines in Iran were
assessed (Table1). e average age of participants was
36.62 ± 4.36year. of which 72.8% were female and 27.2%
were male. Of the vaccines used, 12.9% were vaccinated
with AstraZeneca, 16.2% with Sinopharm, 62.3% with
Sputnik V, 6.9% with Bharat and 1.8% with other brands.
e initial COVID-19 severity of the participants was
assessed and it was determined that 62.6% had quaran-
tined at home, 32.3% had been hospitalized in a general
ward and 5.1% had been admitted to an ICU.
Overall, 39.2% of participants reported experiencing
post-vaccination headache and 30.8% of participants
reported a history of headache. Of those, 51.1% charac-
terized their previous headaches as of the migraine type,
27.4% as tension type and 21.5% as other types. e mean
time between injection of the vaccine and the onset of
headache was 26.78 ± 6.93 h. Most participants (83.2%)
reported the onset of headache to be less than 24h after
vaccination. ey reported the headache reaching a peak
within about 8.62 ± 2.41 h after the onset and the over-
all duration of the headache to be 4.22 ± 1.26h. In 50% of
participants, the headache duration was less than 6h.
With respect to the symptoms accompanying the post-
vaccination headache, the most frequent was nausea
(9.2%), followed by sensitivity to noise (6.9%) and photo-
phobia (4.6%). In most patients, the headache was of the
compression type and most reported that the headache
was felt diffusely in various parts of the head. e sever-
ity of headache in most participants (93.0%) was such
that they resorted to the use of some type of analgesic
(Table2).
Figure 1 shows that the prevalence of post-vaccina-
tion headache was significantly different according to
the brand of vaccine administered. e prevalence of
post-vaccination headache was highest for AstraZen-
eca (62.8%), followed by Sputnik V (40.4%) and Bharat
(30.4%) (p < 0.001). Post-vaccine headache was found to
be significantly higher in females than in males (43.6%
versus 27.5%; p = 0.001). Table 3 reveals that, although
the onset of headache (early or delayed) did not differ
across vaccine brands, the pattern of headache did differ.
Compression headache was reported more often by those
vaccinated with AstraZeneca or Sputnik V. Pulsatile
Table 1 Baseline characteristics of study population (n = 334)
Gender (%) Male 91 (27.2)
Female 243 (72.8)
Type of vaccine (%) Astrazeneca 43 (12.9)
Sinopharm 54 (16.2)
Sputnik 208 (62.3)
Baharat 23 (6.9)
Others 6 (1.8)
COVID-19 severity (%) Hospitalization 108 (32.3)
ICU admission 17 (5.1)
Quarantine at home 209 (62.6)
Concomitant symptoms (%) Joint pain 59 (17.7)
Chilling 13 (3.9)
Muscular pain 72 (21.6)
Runny nose 23 (6.9)
Sleep problem 6 (1.8)
Dizziness 8 (2.4)
Neural symptoms 20 (6.0)
PCR positivity after vaccination (%) 2 (0.6)
Analgesic use after vaccination (%) 28 (8.4)
Table 2 Characteristics of headache after vaccination in study
population (n = 334)
Prevalence of post-vaccination headache (%) 131 (39.2)
Previous history of head-
ache (%)
Migraine 67 (51.1)
Tension 36 (27.4)
Other types 28 (21.5)
Mean time of occurring headache after vaccination, hour 26.78 ± 6.93
Form of headache after vac-
cination (%)
Early (≤ 24 h) 109 (83.2)
24 to 72 h) 10 (7.6)
72 h to 7 days 8 (6.1)
> 72 h 4 (3.1)
The mean duration of headache (hour) 4.22 ± 1.26
Pattern of post-vaccination
headache (%)
Pressing 97 (74.0)
Pulsatile 22 (16.8)
Neurologic type 12 (9.2)
Location of post-vaccina-
tion headache (%)
Frontal 14 (10.7)
Temporal 13 (9.9)
Occipital 4 (3.1)
Parietal 7 (5.3)
Diffuse 43 (32.8)
Neck 1 (0.7)
Mixed 49 (37.5)
Other symptoms along with
headache (%)
Nausea 21 (9.2)
Photophobia 6 (4.6)
Sensitivity to sound 9 (6.9)
Medication used for head-
ache relief (%)
Acetaminophen 65 (49.6)
Ibuprofen 17 (12.9)
Naproxen 16 (12.2)
Other analgesics 24 (18.3)

Page 4 of 8Nasergivehchi et al. Head & Face Medicine (2023) 19:19
headaches were reported to occur most often following
vaccination with Sinopharm.
Table4 indicates that, in multivariate logistic regres-
sion analysis, the brand of vaccine (OR = 1.328; p = 0.040),
female gender (OR = 1.934; p = 0.017) and COVID-19
severity (OR = 3.541; p = 0.001) were the main determi-
nants for prediction of post-vaccination headache. It was
noted that a history of headache before vaccination was
not significantly associated with the occurrence of post-
vaccination headache.
Discussion
Recent studies have reported on the occurrence of head-
ache after inoculation with COVID-19 vaccines; how-
ever, the present study is the first to evaluate this event in
individuals who have been vaccinated after initial infec-
tion by and recovery from COVID-19 and who experi-
enced post-vaccination headaches. It should be noted
that, post-vaccination, there were no signs of re-infection
among participants.
e predominant finding of the present study has been
that about one-third of the vaccinated individuals in the
study group reported various types of post-vaccination
headache. A review of the literature (Table5) showed that
the incidence of post-vaccination headache ranged from
19.5 to 49.4% regardless of the type of vaccine used or
the target population (general population or healthcare
workers). In a meta-analysis of these studies, we found
an overall prevalence of 31.2% (95% CI: 25.3–37.9%) for
headache, with a prevalence of 34.6% (95% CI: 27.4–
42.5%) among healthcare workers, but with considerable
heterogeneity across the studies (I2 = 99.037 (Figs. 2) and
98.343 (Fig. 3), respectively; p < 0.001) [12–33]. ese
divergent results could relate to the different brands of
Table 3 The quality of headache according to type of vaccines
used (n = 131)
Characteristics Astrazeneca Sinopharm Sput-
nik
Ba-
ha-
rat
P
value
Form of headache 0.984
Early 23 (85.2) 10 (83.3) 69
(82.1)
6
(85.7)
Delayed 4 (14.8) 2 916.7) 15
(17.9)
1
(14.3)
Pattern of
headache
0.046
Pressing 20 (74.1) 8 (66.7) 63
(75.0)
4
(57.1)
Pulsatile 1 (3.7) 4 (33.3) 13
(15.5)
2
(28.6)
Neuralgic type 6 (22.2) 0 (0.0) 8
(9.5)
1
(14.3)
Location of
headache
0.814
Frontal 0 (0.0) 2 (16.7) 10
(12.0)
1
(14.3)
Temporal 2 (7.4) 1 (8.3) 10
(12.0)
0
(0.0)
Occipital 0 (0.0) 0 (0.0) 4
(4.8)
0
(0.0)
Parietal 3 (11.1) 0 (0.0) 4
(4.8)
0
(0.0)
Diffuse 10 (37.0) 5 (41.7) 23
(27.7)
5
(71.4)
Neck 0 (0.0) 0 (0.0) 1
(1.2)
0
(0.0)
Mixed 12 (44.4) 4 (33.3) 31
(37.3)
1
(14.3)
Fig. 1 Prevalence of post-vaccine headache according to type of vaccine used (p = 0.001)

Page 5 of 8Nasergivehchi et al. Head & Face Medicine (2023) 19:19
vaccine used as well as differences in the study popula-
tions. It could be concluded that about one-third of indi-
viduals who have been vaccinated against COVID-19
experienced various degrees of headache, with a slightly
higher incidence rate among healthcare personnel.
More interestingly, most headaches occurred within
the first 24 h after vaccination (83.2%) with the mean
time between vaccination and headache onset to be
26.78 ± 6.93 h. As indicated by Göbel et al. [34], the
latency between vaccination against COVID-19 and the
occurrence of headache was on average 18.0 ± 27.0 h.
More than half of their participants perceived the
headache in less than 10 h and 80% within 24 h after
vaccination, which is similar to our findings. Koji Seki-
guchi et al. [35] also reported that the median onset of
headache after the first and second vaccine doses were
10 and 12h, respectively, and mean duration of head-
ache was 4.5 and 8.0 h, respectively. In that study, the
mean time to onset of headache after vaccination was
4.22 ± 1.26h. In 50% of their participants, the headache
duration was less than 6h and in 80% was less than 22h.
Göbel et al. [34] reported a mean headache duration of
14.2 + 21.4h.
About one-third of participants reported general-
ized headache. Göbel et al. [34] reported bilateral head-
ache in 73.1% of their subjects, with the most prominent
Table 4 The effect of type of vaccine on post-vaccination headache adjusted for gender, history of headache, and COVID-19 severity
Factor B S.E. Sig. Exp(B) 95.0% C.I.for EXP(B)
Lower Upper
Type of vaccine 0.283 0.138 0.040 1.328 1.013 1.740
Male gender -0.660 0.277 0.017 0.517 0.301 0.889
History of headache -0.240 0.127 0.059 0.787 0.613 1.009
COVID-19 severity 1.264 0.671 0.001 3.541 1.668 5.642
Hosmer-Le meshow Goodness of Fit : Chi-Square = 9.428, p = 0.307
Table 5 Reviewing the studies on post-vaccination headache
Author, Country Type of study Number of
population
Targeted
population
Type of vaccine Preva-
lence of
headache
Serwaa, Ghana [13] Cross-sectional 654 Personnel AstraZeneca 27.3% 178
García-Azorín, Norway [14] Cross-sectional 77 General Non-replicant adenovirus vector-
based vaccines
49.4% 38
Ekizoglu, Turkey [15] Cross-sectional 1819 Personnel CoronaVac (Pfizer) 30.6% 556
Göbel, Germany [16] Cohort 12,000 General ChAdOx1 nCoV-19 19.5% 2340
Sekiguchi, Japan [17] Cross-sectional 171 Personnel Pfizer 39.7% 68
Hatmal, Jordan [18] Cross-sectional 2213 General Sinopharm, AstraZeneca,
Pfizer-BioNTech
46.9% 1038
Solomon, Ethiopia [18] Cross-sectional 672 Personnel AstraZeneca 50.2% 337
Adam, Saudi Arabia [19] Cross-sectional 330 General Pfizer, AstraZeneca 24.2% 86
Pokharel, Nepal, [20] Cross-sectional 220 Personnel Covishield 19.5% 43
Klugar, Czech Republic
[21]
Cross-sectional 599 Personnel Pfizer, AstraZeneca 53.6% 321
Saeed, UAE [22] Cross-sectional 1102 General Sinopharm 10.0% 110
Almufty, Iraq [23] Cross-sectional 1012 General Pfizer, AstraZeneca, Sinopharm 34.0% 344
Quiroga, Spain [24] Cross-sectional 708 General Pfizer 34.0% 240
Cuschieri, Malta [25] Cross-sectional 1480 Personnel Pfizer 44.2% 655
Kaya, Turkey [26] Cohort 329 Personnel Pfizer 16.8%, 56
Raid, Czech Republic [27] Cross-sectional 92 Personnel AstraZeneca 29.3%, 27
Abu-Hammad, Jordan
[28]
Cross-sectional 409 Personnel Pfizer, AstraZeneca, Sinopharm 42.0% 172
Lee, Seoul Korea [29] Cross-sectional 265 Personnel Pfizer 48.7% 129
Zhang, China [30] Cross-sectional 1526 Personnel Pfizer 6.0% 92
El-Shitany, Saudi Arabia
[31]
Cross-sectional 124 General Pfizer 22.5% 28
Kadali, USA [32] Cross-sectional 1245 Personnel Pfizer 45.4% 565
Kim, Seoul Korea [33] Cross-sectional 1403 Personnel Pfizer, AstraZeneca 47.4% 665
Our study, Iran Cross-sectional 334 Personnel AstraZeneca, Sinopharm Sputnik v
Bharat, Co Iran barekat
39.2% 131

Page 6 of 8Nasergivehchi et al. Head & Face Medicine (2023) 19:19
zones being the forehead (38.0%) followed by the temple
(32.2%). Sekiguchi et al. [35] reported the rate of bilat-
eral headache in healthy controls having no history of
headache, and history of migraine and non-migraine
headaches as being 78.8%, 62.5% and 75.9%, respectively.
e participants in the present study primarily reported
compression-type headaches. Göbel et al. [34] reported
compression headache and dull pain in 49.2% and 40.7%
of participants, respectively. Ekizoglu et al. [15] reported
throbbing headaches in 40.1% of participants and com-
pression headache in 30.4%.
Another important finding was the occurrence of post-
vaccination headache as being potentially influenced by
the factors of the female gender and severity of the ini-
tial COVID-19 infection. Research released by the CDC
on the safety of COVID-19 vaccinations indicated post-
vaccination side-effects occurred among 79.1% of women
but only in 61.2% of men [36]. As migraine and tension
headaches are more prevalent in women than in men [37,
38], such a difference may affect the likelihood of post-
vaccination headache among women compared to men.
e current study found a significant difference in the
prevalence of headache according to vaccine brand used
among different countries. As shown, the highest rate of
headache was after AstraZeneca vaccination, followed by
Sputnik V; however, the literature reviewed (Table5) did
not differentiate between vaccines in relation to post-vac-
cination headache. For example, the rate of post-vaccina-
tion headache following vaccination by Pfizer-BioNTech
ranged from 6.0 to 48.7%. Additionally, information
about the incidence of side-effects of brands such as Sin-
opharm and Sputnik V vaccines has been limited.
ere is no documented and comprehensive expla-
nation of the pathomechanisms of headache following
vaccination against COVID-19. Some believe that such
a headache may originate from the spike protein of the
virus used to produce the vaccine [39]. Others have spec-
ulated that the immune response triggered by such pro-
teins plays a significant role [40]. is means that flaring
pro-inflammatory cascades and secretion of cytokines
and prostaglandins may be responsible for vaccination-
related headache and other concurrent symptoms [41,
41]. It should be noted that the technologies and mate-
rials used for creating the vaccines could play a role in
post-vaccination headache. is should be evaluated in
further studies.
One limitation of the study was that some of the most
commonly used brands globally, such as Pfizer, were not
Fig. 3 Prevalence of post-vaccine headache among healthcare workers
in different studies
Fig. 2 Prevalence of post-vaccine headache among total population in
different studies

Page 7 of 8Nasergivehchi et al. Head & Face Medicine (2023) 19:19
widely available in Iran; thus was not possible to evaluate
the post-vaccination headache for these brands. Addi-
tionally, the pattern of headache among the healthcare
workers as participants was not evaluated during the first
exposure to COVID-19.
Conclusion
e current study examined the incidence of post-vac-
cination headache among healthcare workers who were
vaccinated against COVID-19 after recovering from a
previous bout of the virus. Different brands of vaccine
were examined and it was found that 39.2% of partici-
pants experienced post-vaccination headache. is inci-
dence was greater among females than males as well as
those who had experienced more severe cases of COVID-
19 before vaccination. Among the brands used in our
population, the highest rate of post-vaccination headache
was for the AstraZeneca, followed by Sputnik V. Consid-
ering that COVID-19 will continue to infect the global
population in the future, vaccination, as well as identifi-
cation and classification of post-vaccination headache,
can improve appropriate management of the virus. e
differentiation of such headaches from other post-vacci-
nation side-effects, such as cerebrovascular thrombotic
events, can be vital to the targeted management of these
events.
Acknowledgements
We are grateful to all the healthcare workers who completed the
questionnaire carefully.
Author contributions
Somayeh Nasergivehchi contributed to the study conception and design,
acquisition of data and drafting of the manuscript. Mansoureh Togha
contributed to the study conception and design and the critical revision of
the manuscript. Elham Jafari contributed to the study conception and design,
acquisition of data and revision of the manuscript. Mehrdad Sheikhvatan
contributed to analysis and statistics of the data. Donya Shahamati
contributed to data entry and processing.
Funding
This paper was not funded.
Availability of data and materials
Data available on request due to privacy/ethical restrictions.
Declarations
Competing interests
The authors declare no potential conflict of interest with respect to the
research, authorship, and/or publication of this article.
Ethic approval and patient consent
All participants provided informed written consent to participate in this study.
The study protocol complied with the guidelines of the 2013 version of the
Helsinki Declaration. The study was approved by the Ethics Committee of
Tehran University of Medical Sciences: IR.TUMS.NI.REC.1400.054.
Consent for publication
All authors have consented to publish the article.
Author details
1Department of Headache, Iranian Center of Neurological Research,
Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
2Department of Neurology, Baharloo University Hospital, Tehran
University of Medical Sciences, Tehran, Iran
3Department of Headache, Neurology Ward, School of Medicine, Sina
University Hospital, Tehran University of Medical Sciences, Tehran, Iran
4Tehran University of Medical Sciences, Tehran, Iran
5Heidelberg University Hospital, Heidelberg, Germany
6Faculty of Nutrition Sciences and Food Technology, National Nutrition
and Food Technology Research Institute, Shahid Behehshti University of
Medical Sciences Tehran, Tehran, Iran
Received: 29 January 2023 / Accepted: 8 May 2023
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