What is the recommended treatment for a patient with viral meningitis and chronic migraines?

Management of Chronic Migraines in a Patient with Viral Meningitis

For a patient with viral meningitis who has complained of migraines for several months, the chronic migraines should be managed as a separate condition requiring migraine-specific preventive therapy, while the viral meningitis receives supportive care with analgesics for acute headache relief. 1, 2

Acute Management of Viral Meningitis-Related Headache

Supportive care is the mainstay for viral meningitis, as no specific antiviral treatment is recommended for most cases. 3, 1

First-Line Analgesics

• Acetaminophen and NSAIDs (ibuprofen, naproxen) are recommended for headache relief in viral meningitis, though caution is warranted as NSAIDs can rarely cause aseptic meningitis. 1, 4
• Ensure adequate hydration and rest during the acute illness. 1, 4
• Monitor for neurological deterioration that might suggest encephalitis rather than meningitis, which would require different management. 1, 4

Important Caveat

If the patient has HSV-2 meningitis specifically, aciclovir 10 mg/kg IV every 8 hours should be given until resolution of fever and headache, followed by valaciclovir 1g three times daily to complete a 14-day course. 1, 5 This is the only viral meningitis etiology with effective antiviral treatment for reducing headache duration. 5

Management of Chronic Migraines (Several Months Duration)

This patient meets criteria for migraine preventive therapy based on having migraines for several months, which likely represents ≥2 migraine days per month with disability. 2

First-Line Preventive Medications

Start with one of these evidence-based first-line agents:

• Propranolol 80-240 mg/day (strong evidence, FDA-approved). 2
• Timolol 20-30 mg/day (strong evidence). 2
• Topiramate 100 mg/day (typically 50 mg twice daily, titrate slowly). 2
• Candesartan (particularly useful if the patient has comorbid hypertension). 2

Implementation strategy: Start at a low dose and titrate slowly over 2-3 weeks until clinical benefits are achieved or side effects limit further increases. 2 An adequate trial period of 2-3 months is required before determining efficacy. 2

Second-Line Preventive Medications

If first-line agents fail or are not tolerated:

• Amitriptyline 30-150 mg/day (particularly effective if the patient has mixed migraine and tension-type headache). 2
• Sodium valproate 800-1500 mg/day or divalproex sodium 500-1500 mg/day (strictly contraindicated in women of childbearing potential due to teratogenic effects). 2

Acute Migraine Treatment During Attacks

For mild to moderate migraine attacks:

• NSAIDs (ibuprofen, naproxen sodium, diclofenac potassium, or aspirin) are first-line. 6, 7, 8
• Acetaminophen is an alternative, particularly during the acute viral meningitis phase. 6, 7

For moderate to severe migraine attacks:

• Triptans (sumatriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, frovatriptan, or naratriptan) should be administered early in the attack. 6, 7, 8
• Combination therapy with a triptan plus NSAID yields better efficacy than either alone. 7, 8
• Antiemetics (metoclopramide, prochlorperazine) can be added for nausea. 7

Critical Medication Overuse Warning

Limit acute migraine medication use to a maximum of 10 days per month to prevent medication-overuse headache, which can interfere with preventive treatment efficacy. 2, 8

Post-Viral Meningitis Follow-Up

Many patients experience ongoing symptoms after viral meningitis discharge, including fatigue, sleep disorders, emotional difficulties, and persistent headaches (occurring in up to one-third of patients). 3, 1

• Support a staged return to work or studies, starting part-time initially. 3, 1
• Consider early referral to mental health services if emotional difficulties develop, as these are well-documented after acquired brain injury. 3, 1
• Post-discharge follow-up should be offered to all patients with confirmed viral meningitis, as many issues only become apparent after discharge. 3

Common Pitfalls to Avoid

• Failing to distinguish between viral meningitis headache and chronic migraine, which require different management approaches. 1, 4
• Starting preventive medications at too high a dose, leading to poor tolerability and discontinuation. 2
• Inadequate duration of preventive trial (less than 2-3 months before declaring treatment failure). 2
• Missing medication overuse headache from frequent use of acute medications, which undermines preventive therapy. 2, 8
• Assuming the chronic migraines will resolve once the viral meningitis clears—these are likely separate conditions requiring distinct treatment strategies. 1, 2