HEADACHE SECONDARY TO INFECTION

DR MALLUM

NEUROLOGY UNIT

LUTH

HEADACHE SECONDARY TO INFECTION

• Headache attributed to intracranial infection

• Headache attributed to systemic infection

Headache attributed to intracranial infection

• Headache attributed to bacterial meningitis or meningoencephalitis

• Headache attributed to viral meningitis or encephalitis

• Headache attributed to intracranial fungal or other parasitic infection

• Headache attributed to brain abscess

• Headache attributed to subdural empyema

Headache attributed to systemic infection

• 9.2.1 Headache attributed to systemic bacterial infection

• 9.2.2 Headache attributed to systemic viral infection

• 9.2.3 Headache attributed to other systemic infection

Headache disorders attributed to extracranialinfections of the head

• Headache disorders attributed to extracranialinfections of the head (such as ear, eye and sinus infections)

• Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses,

teeth, mouth or other facial or cervical structure.

The general criteria

• A. Headache fulfilling criterion C• B. An infection, or sequela of an infection, known to• be able to cause headache has been diagnosed• C. Evidence of causation demonstrated by at least two• of the following:• 1. headache has developed in temporal relation to• the onset of the infection• 2. either or both of the following:• a) headache has significantly worsened in parallel• with worsening of the infection• b) headache has significantly improved or• resolved in parallel with improvement in or• resolution of the infection• 3. headache has characteristics typical for the• infection• D. Not better accounted for by another ICHD-3• diagnosis.

Primary or Secondary Headache

• Headache occurring for the first time in close temporal relation to an infection=Secondary headache attributed to that infection.

• True whether headache has attributes of any of the primary headaches.

• Pre existing primary headache is made worse or becomes chronic in close temporal relation to an infection= the initial headache diagnosis and a diagnosis of Headache attributed to infection.

Acute, chronic or persistent?

• Acute: Active infection resolving within 3 months of eradication of the infection.

• Chronic: after 3 months

• Persistent: infection resolves or is eradicated but the headache does not remit

INTRODUCTION

• Systemic viral infections such as influenza

• Also, sepsis; more rarely it may accompany other systemic infections.

• In intracranial infections, headache is usually the first and the most frequently encountered symptom.

Headache attributed to intracranial infection

• intracranial bacterial, viral, fungal or other parasitic infection or by a sequela of any of these.

Headache attributed to bacterial meningitis or

meningoencephalitis

• headache is either or both of the following:

• a) holocranial

• b) located in the nuchal area and associated with

• neck stiffness

• Not better accounted

• A variety of microorganisms may cause meningitis and/or encephalitis, including Streptococcus pneumoniae,

• Neisseria meningitides and Listeria monocytogenes.

PATHOPHYSIOLOGY

• Direct stimulation of the sensory terminals located in the meninges by the bacterial infection causes the onset of headache.

• Bacterial products (toxins), mediators of inflammation such as bradykinin, prostaglandins and cytokines

• pain sensitization and neuropeptide release.

• In the case of encephalitis, increased intracranial pressure may also play a role in causing headache.

Headache attributed to viral meningitis orencephalitis

• should be suspected whenever headache is associated with fever, stiff neck, light sensitivity, nausea and/or vomiting.

• Enteroviruses- most cases

• Herpes simplex, adenovirus, mumps

DIAGNOSIS

• CSF polymerase chain reaction (PCR)

-Positive CSF PCR for Herpes simplex virus (HSV)1 & 2

-serology for HSV-1&2 DNA = HSV encephalitis

• PCR sensitivity is reduced by more

than half when the test is performed 1 week

• diagnosis can be made on the basis of an altered CSF/blood antibody ratio.

• Headache attributed to viral meningitis-Neuroimaging shows enhancement of theLeptomeninges• Headache attributed to viral encephalitis• -Either or both of the following:• 1. neuroimaging shows diffuse brain oedema• 2. at least one of the following:• a) altered mental state• b) focal neurological deficits• c) seizures.

• Headache attributed to viral encephalitis should be suspected:

-altered mental state-Pain is usually diffuse, with the focus in frontal and/or retro-orbital areas, severe or extremely severe, throbbing or pressing type.• disturbances of speech or• hearing, double vision, loss of sensation in some• parts of the body, muscle weakness, partial paralysis• in the arms and legs, ataxia, hallucinations,• personality changes, loss of consciousness and/or• memory loss.

Headache attributed to intracranial fungal or other

parasitic infection• usually observed in a context of congenital or

acquired immunosuppression.

• headache develops progressively,1 and is either

• or both of the following:

• a) holocranial

• b) located in the nuchal area and associated with

• neck stiffness

Headache attributed to intracranial fungal or other

parasitic infection• suspected whenever headache

• is associated with fever, progressively altered

• mental state (including impaired vigilance) and/or multiple

• focal neurological deficits of increasing severity,

• and neuroimaging shows enhancement of the leptomeninges

• and/or diffuse brain oedema.

DIAGNOSIS

• CSF culture and CSF PCR investigations

• Direct detection of the pathogen (cytological detection, microscopic visualization, culture and identification of fungal elements in the biological materials under observation)

• aspergillosis, the galattomannan antigen can be detected in biological fluids (serum, bronchoalveolarwashing liquid or CSF).

• other systemic fungal infections, serum 1,3--D-glucan

• The India ink test enables staining of the capsule of cryptococcus.

groups are to be consideredat risk:

• people with significant neutropaenia (<500 neutrophils/mm3)

• people who have undergone allogenic graft of stem cells

• chronic steroid therapy (prednisone 0.3mg/kg/day or equivalent for more than 3 weeks)

• ongoing or recent (within the previous 90 days) treatment with immunosuppressor drugs (cyclosporine, TNF blockers, monoclonal antibodies, analogues of nucleosides)

• people with severe hereditary immunodeficiency.

Headache attributed to brain abscess

• caused by brain abscess, usually associated with fever, focal neurological deficit(s) and/or altered mental state (including impaired vigilance)

• worsening of other symptoms and/or clinical

• signs arising from the abscess

• b) evidence of enlargement of the abscess

• c) evidence of rupture of the abscess

• headache has at least one of the following three

• characteristics:

• a) intensity increasing gradually, over several

• hours or days, to moderate or severe

• b) aggravated by straining or other Valsalva

• manoeuvre

• c) accompanied by nausea

• The most common organisms causing brain abscess include streptococcus, staphylococcus aureus, bacteroides species and enterobacter.

• Predisposing factors include infections of the paranasal sinuses, ears, jaws, teeth or lungs.

• Direct compression and irritation of the meningeal and/or arterial structures and increased intracranial pressure

Headache attributed to subdural empyema

• Subdural empyema is often secondary to sinusitis or

• otitis media. It may also be a complication of

• meningitis.

• Headache attributed to subdural empyema is

• caused by meningeal irritation, increased intracranial

• pressure and/or fever.

Headache attributed to systemic infection

• Headache of variable duration caused by systemic infection, usually accompanied by other symptoms and/or clinical signs of the infection.

• Headache in systemic infections is usually a relatively inconspicuous symptom, and diagnostically unhelpful.

• Nevertheless, some systemic infections, particularly influenza, have headache as a prominent symptom along with fever and others

mechanisms causingheadache

• direct effects of the microorganisms themselves.

• Activated microglia and monocyticmacrophages, activated astrocytes and blood-brain barrier and endothelial cells,

• immunoinflammatory mediators(cytokines, glutamate, COX-2/PGE2 system, NO–iNOSsystem and reactive oxygen species system).

Headache attributed to systemic bacterial infection

• headache has either or both of the following

• characteristics:

• a) diffuse pain

• b) moderate or severe intensity

• Headache attributed to systemic viral infection

• Headache attributed to other systemic infection