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Pandemic Care: How Healthcare Providers Can Prevent PPE Headaches

December 15, 2020
Clinicians require well-fitting equipment, hydration, and adequate breaks to help prevent mask-related headaches.

Personal protective equipment (PPE) has become an aspect of everyday life for clinicians. While specific PPE differs based on procedure and availability of equipment, respirators are often worn for extended periods of time – sometimes combined with protective eyewear and water-resistant gowns. This extended use of PPE during the COVID-19 pandemic has been associated with the development of de novo headaches and the exacerbation of pre-existing headache disorders.

“With COVID, a high-stress situation is combined with extended hours, and PPE puts pressure on soft tissue, potentially decreases oxygenation, and adds a mechanical burden – causing people to adjust their posture in adverse ways,” says Lillie Rosenthal, DO, an integrative pain management specialist in New York, New York.

Recently, a cross-sectional study examined the occurrence of headaches in 158 healthcare providers (HCPs). While professionals based in emergency departments averaged longer combined durations of PPE (7.0 hours) than those based in isolated wards (5.2 hours), 81% of all respondents reported de novo headaches. These headaches were independently associated with combined duration of PPE for more than 4 hours per day and pre-existing headache disorders.1

The wellbeing of medical professionals is a crucial part of personal health as well as patient care. Steps should be taken to minimize the harm of PPE and to maximize optimal health outcomes, says Dr. Rosenthal, beginning with properly fitting masks.         

The mechanical burden and neck strain of PPE should not be overlooked, and is something that can often be addressed in the moment. (iStock)


Types of PPE Filters and Respirators

A common part of PPE is the filtering face piece respirator (FFP), with different options having slightly different effects. The N95 mask, for instance, can cause a degree of breathing resistance. Hypoventilation is the primary cause of discomfort when wearing N95 masks. When worn for 1 hour, hypoventilation does not seem to present a risk.2 However, due to the pandemic, practitioners are wearing masks for an average of 5 hours to 7 hours.In addition to masks, the wearing of protective eyewear, gloves, and gowns can add to their feelings of overheating and discomfort.

Elastomeric half mask respirators (EHMRs) are reusable FFPs, equipped with a silicone mouthpiece and replaceable filter cartridges. While they may be monetarily preferable to the disposable N95 masks, they present increased breathing resistance and may cause the wearer to experience reduced oxygen and increased carbon dioxide buildup.2 Both the N95 and the EHMR require a fit test to properly protect the wearer. Given time restraints (and equipment shortages), however, this is not always possible.

Powered air-purifying respirators (PAPRs) are another reusable alternative to the N95 mask. PAPRs do not require a fit test, but (like EHMRs) they must be properly sanitized between uses. The PAPR fan blows fresh air through the filter, making it easier for the wearer to breathe and preventing a buildup of carbon monoxide. However, while the user should not experience difficulty breathing, the fan’s noise can be disruptive and may cause headaches, distraction, and difficulty communicating.3

Overall, an ill-fitted respirator can fail to properly protect the healthcare worker and increase the risk for facial pain.4

According to the CDC, more HCPs prefer the N95 mask for comfort but believe that EHMRs and PAPRs are more protective during high-risk periods (ie, the viral pandemic).2

While the demands of caring for high numbers of ill patients, combined with staff shortages, often prohibits physicians, nurses, and caregivers from taking adequate breaks to remove PPE – there are additional steps providers can take to minimize headaches and improve their health during this difficult period. 

Hydrate When Wearing PPE

While “one of the most important measures to prevent headaches is taking breaks,” says Dr. Rosenthal – advice supported by the CDC – dehydration is another major factor. “The mask is a physical barrier to drinking,” Dr. Rosenthal adds. “I recommend keeping water on your desk, or in the break area. This gives you a visual cue and reminds you to drink more often.”

The heat caused by PPE may cause people to sweat more, increasing their need for hydration. A healthful plant-based diet may also be beneficial for preventing dehydration. In addition to nutrients and calories, these foods often have higher water content.

Position Masks to Reduce Mechanical Burden, Neck Strain

Dr. Rosenthal adds that the mechanical burden of PPE should not be overlooked, and is something that can often be addressed in the moment. “The added weight of PPE can change the way we position our heads. Additionally, because voices may be muffled by masks and because some respirators make it difficult to hear, we may lean our heads forward, stressing the cervical spine," she explains. "Practicing body awareness can be a useful tool.”

Practically speaking, Dr. Rosenthal recommends using headsets to prevent crunching the neck and setting an hourly “alignment alarm” that reminds you to check-in with yourself.

Quick Ways to Reduce PPE Related Headaches

In addition to the above tips, Dr. Rosenthal recommends:

  • opening a window
  • self-massage, directly under the scalp
  • peppermint oil on the temples
  • breathing exercises – 4 counts of inhalation and 8 counts of exhalation
  • magnesium, from foods such as beans, leafy vegetables, almonds, cashews, milk, and yogurt (check with your own PCP if you prefer a magnesium supplement)  
  • lemon water 
  • head and neck stretches

“A lot of this is also to reduce stress,” shares Dr. Rosenthal. Healthy eating, quality sleep, and exercise count as well.


While extended use of PPE in clinical care settings seems to be an accepted part of the new normal, the increase in headaches among HCPs should not be. Choosing PPE that is most protective and least disruptive is one part of the equation. It is also crucial to make sure that equipment fits properly and is not worn for longer than is absolutely necessary – having sufficient amounts of proper equipment on hand is part of this equation.

Breaks should be taken outside and should include hydration and stress reduction. Without the health of the frontline practitioner, it will be impossible to provide proper care for the patient. 

The January/February 2021 issue of PPM focuses on how to conduct telemedicine exams (and prescribe) for pain, rheumatic disease, and chronic headache. Plus, what to watch for in those recovering from COVID-19 infection, including cardiac risks.

Last updated on: January 5, 2021
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