- Letter to the Editor
- Open Access
Stabbing headache as the initial manifestation of herpetic meningoencephalitis
The Journal of Headache and Painvolume 11, pages445–446 (2010)
Stabbing headache (SH) is a short-lasting and painful headache that may happen as a primary headache, develop concurrent with other headache types, or may be associated with several conditions [1–3]. We describe a case of a woman who developed a SH as the first manifestation of herpes zoster (HZ) meningoencephalitis.
A 79-year-old woman was admitted to the emergency department with a 1 day history of stabbing pain paroxysms in the right temporal and frontal regions lasting a few seconds (the duration of each stab was between 1 and 3 s). The stabs of pain started suddenly and were repetitive and very intense. Physical examination revealed itchy red macules, papules and vesicles on her right chest. Neurological examination showed spatial and temporal disorientation and neck stiffness, without altered consciousness or focal neurological signs. The cerebral spinal fluid (CSF) analysis revealed 106 leukocytes/mm3 (62% lymphocytes), protein: 63 mg/dL and glucose 52 mg/dL. Endovenous acyclovir treatment was promptly initiated (10 mg/kg/8 hourly). Brain magnetic resonance imaging and electroencephalogram were normal. Varicella zoster virus IgG by enzyme-linked immunosorbent assay test in the CSF was positive. After 2 days of acyclovir treatment, the stabs of pain completely disappeared and 60 days after symptoms onset, the patient remained asymptomatic.
To our knowledge, this is the first case reporting SH as the initial symptom of HZ meningoencephalitis, alongside with headache improvement after intravenous acyclovir. In previous studies, the authors were able only to report the association with HZ, but no direct relationship between SH and HZ meningoencephalitis .
Headache is one of the most frequent symptoms of HZ meningoencephalitis, usually characterized by severe pain [4, 5]. In our case, the headache characteristics were compatible with SH  that ameliorated with acyclovir, reinforcing its relationship with an infectious agent. Interestingly, another report showed a patient with herpes simplex encephalitis presenting with a migraine-like headache, which also improved after acyclovir therapy .
This case shows the importance of careful evaluation for underlying causes of SH, demonstrating that this uncommon type of headache may be the initial symptom of HZ meningoencephalitis, a potentially life-threatening disease without early recognition and prompt treatment.
Pareja JA, Ruiz J, de Isla C, al-Sabbab H, Espejo J (1996) Idiopathic stabbing headache (jabs and jolts syndrome). Cephalalgia 16:93–96, 1:STN:280:DyaK283ltlCisQ%3D%3D, 10.1046/j.1468-2982.1996.1602093.x, 8665588
Raieli V, Eliseo GL, Vecchia ML, Franca GL, Pandolfi E, Puma D, Ragusa D, Eliseo M (2002) Idiopathic stabbing headache in the juvenile population: a clinical study and review of the literature. J Headache Pain 3:21–25, 10.1007/s101940200012
Pascual J (2009) Other primary headaches. Neurol Clin 27:557–571, 10.1016/j.ncl.2009.01.005, 19289232
Gilden D (2004) Varicella zoster virus and central nervous system syndromes. Herpes 11:89A–94A, 15319095
Braun-Falco M, Hoffmann M (2009) Herpes zoster with progression to acute varicella zoster virus-meningoencephalitis. Int J Dermatol 48:834–839, 10.1111/j.1365-4632.2008.04023.x, 19673047
Peters EW, de Bruijn SF (2005) Migraine treated with acyclovir. Headache 45:396–397, 1:STN:280:DC%2BD2M3gt1yhsQ%3D%3D, 10.1111/j.1526-4610.2005.05082_6.x, 15836587
Conflict of interest