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Treatment ineffective: case report A 58-year-old female exhibited lack of efficacy during treatment with paracetamol and diphenhydramine for headache [not all routes and doses stated]. The woman had a history of multiple sclerosis treated with fingolimod, chronic migraine well-controlled on fremanezumab and cerebrovascular ischaemic disease. She was diagnosed with COVID-19 pneumonia and was hospitalised. She had been taking fremanezumab for the past 1 year with excellent efficacy. Prior preventive therapies included topiramate and onobotulinum-toxin-A. She was receiving treatment with gabapentin and tizanidine for restless leg syndrome. She presented with cough, followed by fever, generalised weakness and headache. Then she developed shortness of breath. She had progressive worsening of her headache, described as throbbing and tight. She had nausea without emesis, photophobia, poor appetite and phonophobia. By the time of her hospitalisation, her headache became unbearable. During hospitalisation, she experienced auditory hallucinations and showed odd behaviors. At that time, she had been receiving diphenhydramine, promethazine, prochlorperazine, gabapentin and a single dose of lacosamide. She also exhibited mild transaminitis. Based on neck stiffness, auditory hallucinations and odd behaviors, as well as refractoriness to treatment, there was a possiblility of secondary headache disorder such as meningoencephalitis (unconfirmed differential diagnosis) from SARS-CoV-2. Subsequently, she received rescue treatment with IV paracetamol [acetaminophen] 1g and either prochlorperazine* , promethazine* , or ondansetron* co-administered with diphenhydramine every 8 hours; however, this rescue treatment was ineffective. Then, she received lacosamide, for which she showed robust response after initial administration. Her headache numeric rating decreased from 10/10 to 2/10. However, this effect was not sustained and was not replicated with further dosing of lacosamide. Therefore, gabapentin dose was increased, while topiramate was restarted. Fremanezumab was administered 2 weeks early. She also received lidocaine patch to the back of the neck, with which she showed some improvement. She received off-label treatment with hydroxychloroquine and azithromycin for COVID-19 pneumonia. Subsequently, she developed recurrent fever and had increasing oxygen requirements. Therefore, she was transferred to an ICU and was intubated. A lumbar puncture was not obtained to confirm or refute meningoencephalitis (still unconfirmed diagnosis) since it would not change management, and she had a brain MRI without new areas of enhancement including the leptomeninges. She continued to receive lacosamide and gabapentin in ICU and upon discharge from the hospital. After 1 week of hospitalisation, her headache resolved. * Exactly administered drugs not clear. Arca KN, et al. Treatment-Refractory Headache in the Setting of COVID-19 Pneumonia: Migraine or Meningoencephalitis? Case Report. SN Comprehensive Clinical 803506892 Medicine 2: 1200-1203, N