Stabbing headache as the initial manifestation of herpetic meningoencephalitis

Dear Editor,

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 [3].

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 [1] 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 [6].

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.