Treatment of Headache After Viral Meningitis?

Randolph Warren Evans, MD

Disclosures

December 19, 2000

Question

What is the recommended treatment for protracted intractable headache following viral meningitis? CT scan and other tests show no complicating factors.

Response from Randolph Warren Evans, MD

First, I would want to confirm the diagnosis of acute viral meningitis, even though it has resolved. Even with a normal CT scan, an MRI scan of the brain can further exclude a parameningeal focus, meningeal enhancement, low-grade neoplasm, or paranasal sinusitis (such as ethmoid or sphenoid). A lumbar puncture will determine whether the CSF has indeed returned to normal. I presume there is no evidence of any other systemic disease such as HIV, Lyme, sarcoidosis, cancer, or collagen vascular disease, or drug-induced meningitis (eg, due to nonsteroidal anti-inflammatory drugs [NSAIDs], antibiotics such as trimethoprim/sulfamethoxazole, carbamazepine, or ranitidine).[1]

Neufeld and associates[2] provide an excellent description of the natural history of "postmeningitis headache." They reported on 70 patients from 5-78 years of age with acute meningitis (viral in 53 and bacterial in 17) who were interviewed about 5 years after the initial illness. After recovery from meningitis, 54% of those with previous headache reported increased frequency of the headache, and 37% experienced new-onset postmeningitis headache. However, only 21% of the new-onset headache group experienced the postmeningitis headaches within the first year. Patients who developed postmeningitis headache were significantly younger than those who did not. Forty-six percent of patients with meningitis reported headaches on follow-up compared with 26% of age- and sex-matched controls. New-onset daily headache has also been associated with Epstein-Barr virus-induced immune changes.[3]

Treatment of postmeningitis headache is the same as treatment of any other chronic daily headache. Could medication rebound be contributing to the headaches? If some of the headaches meet migraine criteria, a triptan could be tried for symptomatic treatment. Other symptomatic medications that might be of benefit include baclofen, NSAIDs, and tizanidine. Preventive medications for chronic daily headache could also be tried such as tricyclics, venlafaxine, valproic acid, and topiramate. Nonmedication approaches that could be tried include biofeedback, massage, and acupuncture. The patient might also benefit from hospitalization for a few days for a trial of intravenous DHE and/or valproate sodium.[4]

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