Headache in HIV

See Also

Precautions

Headache location does not differentiate cause in HIV patients
HIV patients typically present without meningeal signs despite underlying Meningitis
HAART has decreased Incidence of opportunistic infection causes of Headache
1. However HIV patients require a high level of vigilence in evaluation due to confounding factors

Differential Diagnosis

Primary HIV related Headaches
1. Aseptic HIV Meningitis
  1. Often self-limited, presenting at any HIV Stage
2. Chronic HIV Meningitis
  1. Presents as persistent moderate Tension Headache-like symptoms
Secondary HIV related Headaches
1. Opportunistic Meningitis
  1. Cryptococcal Meningitis
    1. Common cause of Headache in AIDS patients and uniformly lethal if untreated
    2. Bilateral occipital and bifrontal Headaches
  2. Tuberculous Meningitis
  3. Meningovascular Syphilis
2. Malignant Meningitis
  1. Lymphomatous Meningitis
3. Focal Brain Lesions
  1. Brain Abscess
  2. Primary CNS Lymphoma
  3. Progressive Multifocal Leukoencephalopathy (PML)
    1. Common cause of Headache in AIDS patients
    2. Bifrontal and diffuse Headaches
4. Diffuse Brain Lesions
  1. HSV Encephalitis
    1. Common cause of Headache in AIDS patients
  2. CMV Encephalitis
  3. Toxoplasmosis
Non-HIV related Headaches
1. See Medication Causes of Headache (includes Zidovudine)
2. Meningitis
  1. Bacterial Meningitis (especially Pneumococcal Meningitis)
    1. Relative Risk of Bacterial Meningitis in HIV is 19 fold higher than the general population
    2. Higher risk with CD4 Count <200 cells/mm3, without Pneumococcal Vaccine, and comorbid Cirrhosis or cancer
    3. Often presents with focal neurologic deficit and without meningeal signs
  2. Viral Meningitis
3. Non-CNS InfectionHeadaches
  1. Acute Sinusitis
  2. Migraine Headache or Tension Headache
    1. Most common Headache Causes in outpatient HIV patients on HAART
    2. Headaches routinely occur in 50% of HIV patients and most of these are Migraine Headaches
    3. Migraine Headaches increase in Incidence with decreasing CD4 Counts
    4. Kirkland (2012) Headache 52(3): 455-66 [PubMed]

Imaging

Indications
1. Serious HIV Headache Red Flags (CD4<200/mm3 or concerning Headache findings)
Modalities
1. MRI Brain or
2. CT Head with contrast
  1. Obtain without contrast first if risk of CNS Hemorrhage
Findings
1. See Brain Lesion in HIV
2. Enhancing Brain Lesions
  1. Toxoplasmosis
  2. Primary CNS Lymphoma
3. Non-enhancing Brain Lesions
4. Brain Lesion absent
  1. Cryptococcal Meningitis

Labs
Lumbar Puncture

Indications
1. Serious HIV Headache Red Flags (CD4<200/mm3 or concerning Headache findings)
2. Non-diagnostic imaging
Contraindications
1. See Lumbar Puncture
2. Consider serum markers if Lumbar Puncture contraindicated
  1. Cryptococcal Antigen has very high Test Sensitivity
CSF Labs
1. Opening pressure
  1. Important in diagnosis of Cryptococcal Meningitis
  2. Cryptococcal Meningitis is associated with opening pressure >350 mm H2O
2. Standard CSF Tests
  1. CSF Cell Count and differential
  2. CSF Protein
    1. Low yield (frequently normal despite CNS Infection in HIV)
  3. CSF Glucose
    1. Low yield (frequently normal despite CNS Infection in HIV)
3. Cultures and stains
  1. Bacterial Culture
  2. Fungal Culture
  3. India Ink Stain
4. Specific organism testing
  1. Cryptococcal Antigen
  2. Toxoplasma PCR
  3. Epstein-Barr Virus PCR (EBV PCR)
  4. John Cunningham Virus PCR (JCV PCR)
  5. Cytomegalovirus PCR (CMV PCR)
  6. Herpes Simplex Virus PCR (HSV PCR)
  7. VDRL

Evaluation
Serious HIV Headache Red Flags

Findings suggestive of AIDS with CD4<200 cells/mm3
1. AIDS-Defining Illness
2. Absolute Lymphocyte Count <1000 cells/mm3
  1. See Absolute Lymphocyte Count Estimation of CD4 Count
Concerning Headache findings
1. Fever
2. New or changing Headache
3. Altered Mental Status
4. Seizure
5. Focal neurologic changes
  1. Hearing Loss
  2. Vision Loss
  3. Cranial Nerve deficit
Approach
1. Consult infectious disease
2. Neuroimaging and
3. Lumbar Puncture (if not contraindicated)

Evaluation
Low risk findings

Stage 1 HIV
1. See HIV Staging
2. No history of AIDS-Defining Illness
3. CD4 Count >500 Cells/mm3
  1. As alternative (if CD4 Count not known): Absolute Lymphocyte Count >2000 cells/mm3
  2. See Absolute Lymphocyte Count Estimation of CD4 Count
Stage 2 HIV (with caution)
1. Known recent CD4 Count >200 Cells/mm3 and CD4 percentage >15%
  1. As alternative (if CD4 Count not known): Absolute Lymphocyte Count >2000 cells/mm3
  2. See Absolute Lymphocyte Count Estimation of CD4 Count
2. No history of AIDS-Defining Illness
3. No comorbidities (e.g. Hepatitis C)
4. HAART Therapy (Compliant and not recently initiated)
  1. Not required but significantly decreases risk of opportunistic CNS Infection
Low-risk Headache (uncomplicated)
1. Headache is not new or changing
2. No fever or meningismus
3. Normal sensorium
4. No Seizure
5. No focal neurologic deficits
  1. No Hearing Loss or Vision Loss
  2. No Cranial Nerve deficit
Other findings suggestive of uncomplicated Headache (e.g. Sinusitis, Migraine Headache, Tension Headache)
1. Unilateral, abrupt onset Headache with photophobia
2. No associated focal weakness or Paresthesias
3. Other findings do not distinguish Headache cause (Nausea or Vomiting, Blurred Vision or confusion)
Approach
1. Consider Consultation with infectious disease
2. Close interval follow-up with precautions
3. Treat suspected Headache cause

References

Perkins (2013) Crit Dec Emerg Med 27(3): 2-9
Kirkland (2012) Headache 52(3): 455-66 [PubMed]