Evaluating PPE-Associated Headaches Among Health Care Workers

Researchers in Iran sought to quantify headaches related to personal protective equipment (PPE) among frontline health care workers.

Headaches resulting from personal protective equipment (PPE) are common and can decrease hospital staff efficiency and performance, according to results of a cross-sectional study carried out in Iran. Findings, published in Brain and Behavior, underscore the importance of considering this issue for health care personnel and providing modalities to reduce the risk of headache, researchers wrote.

Throughout the COVID-19 pandemic, frontline health workers experienced drastic changes in their daily lives, including “wearing specialized masks and clothing, extended hours of stressful work in the hospital, separation from family, along with the fear of contracting the disease and transmitting it to relatives, and the risk of death," authors explained.

As the World Health Organization recommended use of masks for medical staff operating in normal wards and masks, gowns, and shields for those in COVID-19 wards, reports of associated headache complaints among workers increased.

PPE-associated headaches could be caused by hypoxia, hypercapnia, local compression on the face or scalp, or other factors; previous studies have found that 30% to 80% of personnel who wear N95 masks report headaches, authors said.

To better evaluate the occurrence of PPE-associated headache among health care staff during the COVID-19 pandemic, investigators conducted a cross-sectional study among personnel at 4 centers in Tehran, Iran.

All centers received patients with COVID-19, and physicians, nurses, and other staff members took part in the study between April and July 2020. “Hospital staff were required to wear surgical masks in general wards and N95 masks with or without gowns, shields, and goggles in the COVID-19 wards,” the authors wrote. All participants had continuously used PPE for at least 4 hours.

In addition to completing questionnaires, participants also had their blood oxygen saturation and heart rate recorded via pulse oximeter before and 4 hours post PPE use, or if they reported shortness of breath or headache.

A total of 243 frontline health workers were included in the study; they had a mean (SD) age of 36 (8) years, and 75% of workers were women.

Analyses revealed:

  • Headache prevalence following mask use was 72.4%, with the N95 mask being the most commonly reported cause of headache (41%).
  • Prevalence of headache after using shields and goggles was 27.2% and 27.3%, respectively.
  • Among those reporting headaches, 25.1% developed external pressure; 22.2%, migraine; and 15.2%, tension-type headaches.
  • Headache was more common among women.
  • The most common headache-associated symptoms were nausea (37%) and vomiting (14.4%).
  • Apart from gender, only increased heart rate was significantly associated with headache due to mask use (P = .03 and .00, respectively).
  • Mean (SD) heart rate was 97.7 (13.68) in participants with headache compared with 65.8 (35.63) in those without headache.
  • No significant relationship was found between headache and venous blood gas parameters, including oxygen and carbon dioxide partial pressure.

Of those who developed a PPE-associated headache, 44.3% had a previous history of headache, including migraine and tension type. However, this factor was not associated with PPE-related headache. In comparison, 56% of participants “did not report a history of headaches and were considered to have developed de novo PPE-associated headaches,” researchers said.

PPE-associated headache could be due to local compression on pain-sensitive structures, worsening of pre-existing headaches, or physiological changes in heart rate or respiratory rate, in addition to anxiety about wearing the device, they hypothesized.

“Designing new breathing devices that eliminate the risk factors of headache can improve mask tolerance, which can improve PPE compliance and performance among healthcare workers,” authors concluded.


Jafari E, Togha M, Kazemizadeh H, et al. Evaluation of headache associated with personal protective equipment during COVID-19. Brain Behav. Published online November 13, 2021. doi:10.1002/brb3.2435