Headache Relief in Viral Encephalitis
For headache relief in viral encephalitis, use standard analgesics (acetaminophen or NSAIDs) as supportive care while treating the underlying encephalitis with appropriate antiviral therapy; avoid delaying aciclovir initiation, as treating the primary disease process is the most effective approach to symptom resolution. 1, 2
Primary Treatment Framework
The management of headache in viral encephalitis is fundamentally tied to treating the underlying encephalitis itself, not isolated symptom management:
- Immediate empiric aciclovir 10 mg/kg IV every 8 hours must be started for all adults with suspected encephalitis while awaiting diagnostic confirmation, as this addresses the root cause and will ultimately resolve headache 3
- For HSV encephalitis specifically, aciclovir 10 mg/kg IV every 8 hours for 14-21 days is the definitive treatment that reduces mortality by 50% and improves all symptoms including headache 3, 4
- Do not delay antiviral therapy to await serological confirmation, as early treatment dramatically influences survival and reduces permanent brain injury 5, 6
Supportive Headache Management
While treating the underlying encephalitis, symptomatic headache relief follows standard approaches:
- Standard analgesics (acetaminophen, NSAIDs) are appropriate for headache symptom control as part of supportive therapy 1, 7
- Supportive therapy forms an important basis of management alongside specific antiviral treatment 5
- Monitor for signs of increased intracranial pressure, which requires different management than simple headache 1, 3
Critical Distinctions by Etiology
The approach varies slightly based on the specific viral pathogen:
- VZV encephalitis requires aciclovir 10-15 mg/kg three times daily, with consideration of corticosteroids (60-80 mg prednisolone daily for 3-5 days) if there is a vasculitic component 1
- For enterovirus encephalitis, pleconaril reduced headache symptoms by approximately two days compared to placebo in phase III trials, though it is not widely available 1
- VZV cerebellitis is self-limiting and does not require antiviral treatment, only supportive care including analgesics for headache 8
When Headache Signals Deterioration
Headache accompanied by declining consciousness requires escalation:
- Falling level of consciousness with worsening headache requires urgent ICU assessment for airway protection, management of raised intracranial pressure, and optimization of cerebral perfusion pressure 1, 2, 3
- Access to neuroimaging (MRI preferred) within 48 hours is essential to evaluate for complications like cerebral edema or hemorrhagic conversion 3, 5
- Surgical decompression is indicated for impending uncal herniation or increased intracranial pressure refractory to medical management 5, 7
Common Pitfalls to Avoid
- Do not withhold aciclovir while pursuing diagnostic workup - the safety profile is excellent and delaying treatment of HSE is life-threatening 6, 7
- Do not use corticosteroids routinely for viral encephalitis headache, as their role remains controversial except in specific situations (VZV with vasculitis, ADEM) 1, 5, 7
- Do not mistake isolated viral cerebellitis for encephalitis - cerebellitis does not warrant aciclovir and exposes patients to unnecessary renal toxicity risk 8
- Ensure renal function is monitored frequently when using aciclovir, particularly at higher doses (15 mg/kg) for VZV 1