Neurological masks of post-COVID syndrome

Post-COVID syndrome (PCS) refers to a constellation of signs and symptoms that develop during or after a coronavirus infection, persist for more than 12 weeks, and cannot be explained by an alternative diagnosis. Neurological manifestations of PCS may include cognitive impairment (CI), dizziness, headaches, and musculoskeletal pain. However, several neurological conditions can mimic PCS, including neurodegenerative diseases with CI, persistent postural-perceptual dizziness (PPPD), chronic migraine (CM), and chronic non-specific back pain.

This article presents case reports of patients with Alzheimer's disease, PPPD, CM, medication-overuse headache (MOH), and chronic musculoskeletal pain (CMSP), who were misdiagnosed with PCS and did not receive effective treatment for their underlying conditions. Targeted therapy for PPPD, CM, MOH, and CMSP led to regression of symptoms and rapid improvement in the patients' condition.

The persistence of cognitive dysfunction, dizziness, and chronic pain syndromes warrants thorough evaluation to identify alternative diagnoses that may be masked by PCS. Early diagnosis and appropriate treatment of these conditions can significantly improve outcomes for many patients who otherwise receive prolonged and ineffective treatment for PCS.

1. Rogers JP, Watson CJ, Badenoch J, et al. Neurology and neuropsychiatry of COVID-19: a systematic review and meta-analysis of the early literature reveals frequent CNS manifestations and key emerging narratives. J Neurol Neurosurg Psychiatry. 2021 Sep;92(9):932-41. doi: 10.1136/jnnp-2021326405. Epub 2021 Jun 3.

2. Parfenov VA, Kulesh AA. Acute and long-term neurological disorders in patients with coronavirus infection. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2022;14(3):4-11. doi: 10.14412/2074-2711-2022-3-4-11 (In Russ.)].

3. Premraj L, Kannapadi NV, Briggs J, et al. Mid and long-term neurological and neuropsychiatric manifestations of post-COVID-19 syndrome: A meta-analysis. J Neurol Sci. 2022 Mar 15;434:120162. doi: 10.1016/j.jns.2022.120162. Epub 2022 Jan 29.

4. COVID-19 rapid guideline: managing the long-term effects of COVID-19. London: National Institute for Health and Care Excellence (NICE); 2020 Dec 18 Last updated: 25 January 2024. Available at: https://www.nice.org.uk/guidance/ng188

5. Stefanou MI, Palaiodimou L, Bakola E, et al. Neurological manifestations of longCOVID syndrome: a narrative review. Ther Adv Chronic Dis. 2022 Feb 17;13:20406223221076890. doi: 10.1177/20406223221076890

6. Takao M, Ohira M. Neurological post-acute sequelae of SARS-CoV-2 infection. Psychiatry Clin Neurosci. 2023 Feb;77(2):72-83. doi: 10.1111/pcn.13481. Epub 2022 Oct 17.

7. Petersen RC. How early can we diagnose Alzheimer disease (and is it sufficient)? The 2017 Wartenberg lecture. Neurology. 2018 Aug 28;91(9):395-402. doi: 10.1212/WNL.0000000000006088

8. Dubois B, Villain N, Frisoni GB, et al. Clinical diagnosis of Alzheimer's disease: recommendations of the International Working Group. Lancet Neurol. 2021 Jun;20(6):484-96. doi: 10.1016/S1474-4422(21)00066-1. Epub 2021 Apr 29..

9. Jack CR Jr, Andrews JS, Beach TG, et al. Revised criteria for diagnosis and staging of Alzheimer's disease: Alzheimer's Association Workgroup. Alzheimers Dement. 2024 Aug;20(8):5143-69. doi: 10.1002/alz.13859. Epub 2024 Jun 27.

10. Parfenov VA, Grishina DA, Tyurina AY. Alzheimer's disease: diagnosis and treatment, errors in patient management. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2024;16(2):95100. doi: 10.14412/2074-2711-2024-2-95-100 (In Russ.)].

11. Rudnicka-Drozak E, Drozak P, Mizerski G,et al. Links between COVID-19 and Alzheimer's Disease-What Do We Already Know? Int J Environ Res Public Health. 2023 Jan 25;20(3):2146. doi: 10.3390/ijerph20032146

12. Ciaccio M, Lo Sasso B, Scazzone C, et al. COVID-19 and Alzheimer's Disease. Brain Sci. 2021 Feb 27;11(3):305. doi: 10.3390/brainsci11030305

13. Itzhaki RF. COVID-19 and Alzheimer's Disease: What Is the Connection? J Alzheimers Dis. 2023;91(4):1273-6. doi: 10.3233/JAD220955

14. Zamergrad MV, Parfenov VA, Ostroumova OD, et al. Functional dizziness: from diagnostic criteria to clinical profiles and therapy. Expert consensus. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2024;16(4):4-13. doi: 10.14412/2074-2711-2024-4-4-13 (In Russ.)].

15. Staab JP. Persistent Postural-Perceptual Dizziness: Review and Update on Key Mechanisms of the Most Common Functional Neuro-otologic Disorder. Neurol Clin. 2023 Nov;41(4):647-64. doi: 10.1016/j.ncl.2023.04.003. Epub 2023 Jun 1.

16. Webster KE, Harrington-Benton NA, Judd O, et al. Pharmacological interventions for persistent postural-perceptual dizziness (PPPD). Cochrane Database Syst Rev. 2023 Mar 9;3(3):CD015188. doi: 10.1002/14651858.CD015188.pub2

17. Li C, Guo D, Ma X, et al. The Impact of Coronavirus Disease 2019 Epidemic on Dizziness/Vertigo Outpatients in a Neurological Clinic in China. Front Neurol. 2021 Apr 29;12:663173. doi: 10.3389/fneur.2021.663173

18. Li C, Guo D, Liu S, et al. COVID-19 pandemic impacts on the elderly: the relationship between PPPD and prefrontal alpha rhythm. Int J Neurosci. 2024 Apr;134(4):341-6. doi: 10.1080/00207454.2022.2102978. Epub 2022 Oct 28.

19. Tana C, Bentivegna E, Cho SJ, et al. Long COVID headache. J Headache Pain. 2022 Aug 1;23(1):93. doi: 10.1186/s10194-02201450-8

20. Brauer T, Paika S, Kotwani R, Khanna D. Neurological Complications of COVID-19 Infection: A Comprehensive Review. Cureus. 2024 Jul 23;16(7):e65192. doi: 10.7759/cureus.65192

21. Al-Hassany L, MaassenVan Den Brink A,Kurth T. Sex-related differences in the association between migraine, COVID-19, and long COVID: a populationbased cohort. Front Neurol. 2025 Mar 21;16:1547893. doi: 10.3389/fneur.2025.1547893

22. Magdy R, Elmazny A, Soliman SH, et al.Post-COVID-19 neuropsychiatric manifestations among COVID-19 survivors suffering from migraine: a case-control study. J Headache Pain. 2022 Aug 12;23(1):101. doi: 10.1186/s10194-022-01468-y

23. Golovacheva VA, Golovacheva AA, Tarshilova AR, Osipova VV. Typical clinical practice of treating patients with chronic migraine. Nevrologiya, neiropsikhiatriya, psikhosomatika= Neurology, Neuropsychiatry, Psychosomatics. 2024;16(1S):31-7. doi: 10.14412/2074-2711-2024-1S-31-37 (In Russ.)].

24. Papalia GF, Petrucci G, Russo F, et al.COVID-19 Pandemic Increases the Impact of Low Back Pain: A Systematic Review and Metanalysis. Int J Environ Res Public Health. 2022 Apr 11;19(8):4599. doi: 10.3390/ijerph19084599

25. Parfenov VA, Golovacheva VA, Isaikin AI, et al. Treatment of chronic non-specific (musculoskeletal) back pain. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2024;16(3S):1-16. doi: 10.14412/2074-27112024-3S-1-16 (In Russ.)].

26. Golovacheva VA, Golovacheva AA, Tarshilova AR. Chronic musculoskeletal low back pain: mistakes in patient management and optimization issues. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2024;16(3):103-9. doi: 10.14412/2074-27112024-3-103-109 (In Russ.)].