Exposition on the International headache society subclassification of secondary headaches providing a broad overview of headache secondary to infection

1. HEADACHE SECONDARY TO
INFECTION
DR MALLUM
NEUROLOGY UNIT
LUTH

2. HEADACHE SECONDARY TO INFECTION
• Headache attributed to intracranial infection
• Headache attributed to systemic infection

3. Headache attributed to intracranial infection
• Headache attributed to bacterial meningitis
or meningoencephalitis
• Headache attributed to viral meningitis or
encephalitis
• Headache attributed to intracranial fungal or
other parasitic infection
• Headache attributed to brain abscess
• Headache attributed to subdural empyema

4. Headache attributed to systemic infection
• 9.2.1 Headache attributed to systemic
bacterial infection
• 9.2.2 Headache attributed to systemic viral
infection
• 9.2.3 Headache attributed to other systemic
infection

5. Headache disorders attributed to extracranial
infections of the head
• Headache disorders attributed to extracranial
infections of the head (such as ear, eye and
sinus infections)
• Headache or facial pain attributed to disorder
of the cranium, neck, eyes, ears, nose, sinuses,
teeth, mouth or other facial or cervical
structure.

6. The general criteria
• A. Headache fulfilling criterion C
• B. An infection, or sequela of an infection, known to
• be able to cause headache has been diagnosed
• C. Evidence of causation demonstrated by at least two
• of the following:
• 1. headache has developed in temporal relation to
• the onset of the infection
• 2. either or both of the following:
• a) headache has significantly worsened in parallel
• with worsening of the infection
• b) headache has significantly improved or
• resolved in parallel with improvement in or
• resolution of the infection
• 3. headache has characteristics typical for the
• infection
• D. Not better accounted for by another ICHD-3
• diagnosis.

7. Primary or Secondary Headache
• Headache occurring for the first time in close
temporal relation to an infection=Secondary
headache attributed to that infection.
• True whether headache has attributes of any of
the primary headaches.
• Pre existing primary headache is made worse or
becomes chronic in close temporal relation to an
infection= the initial headache diagnosis and a
diagnosis of Headache attributed to infection.

8. Acute, chronic or persistent?
• Acute: Active infection resolving within 3
months of eradication of the infection.
• Chronic: after 3 months
• Persistent: infection resolves or is eradicated
but the headache does not remit

9. INTRODUCTION
• Systemic viral infections such as influenza
• Also, sepsis; more rarely it may accompany
other systemic infections.
• In intracranial infections, headache is usually
the first and the most frequently encountered
symptom.

10. Headache attributed to intracranial
infection
• intracranial bacterial, viral, fungal or other
parasitic infection or by a sequela of any of
these.

11. Headache attributed to bacterial
meningitis or
meningoencephalitis
• headache is either or both of the following:
• a) holocranial
• b) located in the nuchal area and associated
with
• neck stiffness
• Not better accounted

12. • A variety of microorganisms may cause
meningitis and/or encephalitis, including
Streptococcus pneumoniae,
• Neisseria meningitides and Listeria
monocytogenes.

13. PATHOPHYSIOLOGY
• Direct stimulation of the sensory terminals
located in the meninges by the bacterial infection
causes the onset of headache.
• Bacterial products (toxins), mediators of
inflammation such as bradykinin, prostaglandins
and cytokines
• pain sensitization and neuropeptide release.
• In the case of encephalitis, increased intracranial
pressure may also play a role in causing
headache.

14. Headache attributed to viral meningitis or
encephalitis
• should be suspected whenever headache is
associated with fever, stiff neck, light
sensitivity, nausea and/or vomiting.
• Enteroviruses- most cases
• Herpes simplex, adenovirus, mumps

15. DIAGNOSIS
• CSF polymerase chain reaction (PCR)
-Positive CSF PCR for Herpes simplex virus
(HSV)1 & 2
-serology for HSV-1&2 DNA = HSV encephalitis
• PCR sensitivity is reduced by more
than half when the test is performed 1 week
• diagnosis can be made on the basis of an
altered CSF/blood antibody ratio.

16. • Headache attributed to viral meningitis
-Neuroimaging shows enhancement of the
Leptomeninges
• Headache attributed to viral encephalitis
• -Either or both of the following:
• 1. neuroimaging shows diffuse brain oedema
• 2. at least one of the following:
• a) altered mental state
• b) focal neurological deficits
• c) seizures.

17. • Headache attributed to viral encephalitis should be
suspected:
-altered mental state
-Pain is usually diffuse, with the focus in frontal and/or retro-
orbital areas, severe or extremely severe, throbbing or
pressing type.
• disturbances of speech or
• hearing, double vision, loss of sensation in some
• parts of the body, muscle weakness, partial paralysis
• in the arms and legs, ataxia, hallucinations,
• personality changes, loss of consciousness and/or
• memory loss.

18. Headache attributed to intracranial fungal
or other
parasitic infection
• usually observed in a context of congenital or
acquired immunosuppression.
• headache develops progressively,1 and is either
• or both of the following:
• a) holocranial
• b) located in the nuchal area and associated with
• neck stiffness

19. Headache attributed to intracranial fungal
or other
parasitic infection
• suspected whenever headache
• is associated with fever, progressively altered
• mental state (including impaired vigilance) and/or
multiple
• focal neurological deficits of increasing severity,
• and neuroimaging shows enhancement of the
leptomeninges
• and/or diffuse brain oedema.

20. DIAGNOSIS
• CSF culture and CSF PCR investigations
• Direct detection of the pathogen (cytological detection,
microscopic visualization, culture and identification of
fungal elements in the biological materials under
observation)
• aspergillosis, the galattomannan antigen can be
detected in biological fluids (serum, bronchoalveolar
washing liquid or CSF).
• other systemic fungal infections, serum 1,3--D-glucan
• The India ink test enables staining of the capsule of
cryptococcus.

21. groups are to be considered
at risk:
• people with significant neutropaenia (<500
neutrophils/mm3)
• people who have undergone allogenic graft of stem
cells
• chronic steroid therapy (prednisone 0.3mg/kg/day or
equivalent for more than 3 weeks)
• ongoing or recent (within the previous 90 days)
treatment with immunosuppressor drugs
(cyclosporine, TNF blockers, monoclonal antibodies,
analogues of nucleosides)
• people with severe hereditary immunodeficiency.

22. Headache attributed to brain abscess
• caused by brain abscess, usually associated
with fever, focal neurological deficit(s) and/or
altered mental state (including impaired
vigilance)
• worsening of other symptoms and/or clinical
• signs arising from the abscess
• b) evidence of enlargement of the abscess
• c) evidence of rupture of the abscess

23. • headache has at least one of the following
three
• characteristics:
• a) intensity increasing gradually, over several
• hours or days, to moderate or severe
• b) aggravated by straining or other Valsalva
• manoeuvre
• c) accompanied by nausea

24. • The most common organisms causing brain
abscess include streptococcus, staphylococcus
aureus, bacteroides species and enterobacter.
• Predisposing factors include infections of the
paranasal sinuses, ears, jaws, teeth or lungs.
• Direct compression and irritation of the
meningeal and/or arterial structures and
increased intracranial pressure

25. Headache attributed to subdural
empyema
• Subdural empyema is often secondary to
sinusitis or
• otitis media. It may also be a complication of
• meningitis.
• Headache attributed to subdural empyema is
• caused by meningeal irritation, increased
intracranial
• pressure and/or fever.

26. Headache attributed to systemic
infection
• Headache of variable duration caused by systemic
infection, usually accompanied by other
symptoms and/or clinical signs of the infection.
• Headache in systemic infections is usually a
relatively inconspicuous symptom, and
diagnostically unhelpful.
• Nevertheless, some systemic infections,
particularly influenza, have headache as a
prominent symptom along with fever and others

27. mechanisms causing
headache
• direct effects of the microorganisms
themselves.
• Activated microglia and monocytic
macrophages, activated astrocytes and blood-
brain barrier and endothelial cells,
• immunoinflammatory mediators(cytokines,
glutamate, COX-2/PGE2 system, NO–iNOS
system and reactive oxygen species system).

28. Headache attributed to systemic
bacterial infection
• headache has either or both of the following
• characteristics:
• a) diffuse pain
• b) moderate or severe intensity

29. • Headache attributed to systemic viral
infection
• Headache attributed to other systemic
infection