Skip to main content


  • Letter to the Editor
  • Open Access

Stabbing headache as the initial manifestation of herpetic meningoencephalitis

  • 1Email author,
  • 1,
  • 1,
  • 2,
  • 2 and
  • 2
The Journal of Headache and Pain201011:220

  • Received: 27 March 2010
  • Accepted: 22 April 2010
  • Published:


  • Herpes Simplex
  • Herpes Zoster
  • Acyclovir
  • Varicella Zoster Virus
  • Cerebral Spinal Fluid

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 [13]. 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.


Conflict of interest


Authors’ Affiliations

Department of Neurology, Hospital e Maternidade São Camilo Pompeia, Maranhão st., 500/30, São Paulo, SP, 01240-000, Brazil
Department of Infectious Diseases, Hospital e Maternidade São Camilo Pompeia, São Paulo, SP, Brazil


  1. 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, 8665588PubMedView ArticleGoogle Scholar
  2. 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/s101940200012PubMed CentralView ArticleGoogle Scholar
  3. Pascual J (2009) Other primary headaches. Neurol Clin 27:557–571, 10.1016/j.ncl.2009.01.005, 19289232PubMedView ArticleGoogle Scholar
  4. Gilden D (2004) Varicella zoster virus and central nervous system syndromes. Herpes 11:89A–94A, 15319095PubMedGoogle Scholar
  5. 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, 19673047PubMedView ArticleGoogle Scholar
  6. 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, 15836587PubMedView ArticleGoogle Scholar


© Springer-Verlag 2010


By submitting a comment you agree to abide by our Terms and Community Guidelines. If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate. Please note that comments may be removed without notice if they are flagged by another user or do not comply with our community guidelines.