Management of Viral Meningitis Headache
Viral meningitis headache is primarily managed with supportive care as there are no specific antiviral treatments proven effective for most causes of viral meningitis. 1
Diagnosis and Initial Assessment
- Viral meningitis presents with meningism (neck stiffness, headache, and photophobia), with headaches occurring in up to one-third of patients 1
- Fever may not always be present; other non-specific symptoms can include diarrhoea, vomiting, muscle pain, and sore throat 1
- CSF analysis is essential for diagnosis, with PCR testing for enteroviruses, herpes simplex viruses (HSV-1 and HSV-2), and varicella zoster virus (VZV) 1
- Distinguishing viral meningitis from bacterial meningitis is crucial due to different treatment approaches and outcomes 1
Treatment Recommendations
Supportive Care (Primary Management)
- For most viral meningitis cases (particularly enterovirus), supportive care focusing on symptom management is the mainstay of treatment 1
- Analgesics for headache relief (acetaminophen, NSAIDs) 1
- Adequate hydration and rest 1
- Monitor for neurological deterioration that might suggest encephalitis rather than meningitis 1
Specific Antiviral Treatment
- For most viral causes of meningitis, no specific antiviral treatment is recommended 1
- Aciclovir/valaciclovir should NOT be given as prophylaxis for recurrent herpes meningitis (HSV or VZV) 1
- For HSV-2 meningitis specifically:
- First episode: Aciclovir 10 mg/kg IV every 8 hours until resolution of fever and headache, followed by valaciclovir 1g three times daily to complete a 14-day course 1
- For recurrent episodes: Oral therapy may be used for the entire course 1
- Note: Valaciclovir 500 mg twice daily is NOT recommended for suppression of HSV-2 meningitis 1
Management of Post-Lumbar Puncture Headache
If headache occurs after diagnostic lumbar puncture:
- Post-LP headache is typically self-limiting but may require intervention in persistent cases 2
- Bed rest is NOT proven to reduce risk of post-LP headache 2
- Increased hydration shows no difference in post-LP headache rates 2
- For persistent post-LP headache, a blood patch may be required 2
Follow-Up Care
- Many patients feel well at discharge but may not be able to return immediately to normal activities 1
- Fatigue, sleep disorders, and emotional difficulties are frequently reported in the weeks and months after discharge 1
- Support from hospital clinicians and GPs can help patients stage their return to work or studies on a part-time basis initially 1
- Consider assessment for potential long-term sequelae, both physical and psychological 1
Important Considerations
- Viral meningitis is often considered benign but can cause significant morbidity and profound psychological impacts 1
- If there is doubt between viral meningitis and encephalitis, patients should be managed as suspected encephalitis 1
- Emotional difficulties are well documented after acquired brain injury; consider early referral to mental health services if needed 1
- Support organizations can provide crucial help with information and advocacy for patients 1
Clinical Pitfalls to Avoid
- Failing to distinguish between viral meningitis and encephalitis, which requires different management 1
- Unnecessary prolonged bed rest after lumbar puncture, which increases hospital stay without clinical benefit 2
- Overuse of antivirals in cases where they have not shown benefit 1
- Missing altered consciousness, which suggests an alternative diagnosis such as bacterial meningitis, encephalitis, or other intracranial pathology 1