Headache associated with intracranial infection

Jong-Ling Fuh MD (Dr. Fuh of Taipei Veterans General Hospital and National Yang-Ming University School of Medicine has no relevant financial relationships to disclose.)
Shuu-Jiun Wang MD, editor. (

Dr. Wang of the Brain Research Center, National Yang-Ming University, and the Neurological Institute, Taipei Veterans General Hospital, received consulting fees from Eli Lilly and Novartis for advisory board membership and honorariums from AbbVie as a speaker.

Originally released September 20, 1995; last updated October 27, 2020; expires October 27, 2023


Headache is usually the first and most frequently encountered symptom in intracranial infection, but it only accounts for less than 1% of acute headache presentation to the emergency department. Encephalitis is characterized by headache, fever, alteration of consciousness, focal neurologic deficit, and seizures (usually focal). Because the brain parenchyma has no sensory receptors, the headache of encephalitis and brain abscess may result from the meningeal inflammation that often accompanies these processes, including a nonspecific response to fever, increased intracranial pressure, or a mass-effect producing traction on pain-sensitive intracranial structures. The most common predisposing conditions of brain abscesses are otitis or mastoiditis. Headache was reported in around 6% to 10% of symptomatic COVID-19 patients. Physical signs of meningeal inflammation do not help clinicians rule in or rule out meningitis accurately. The headaches attributed to intracranial infection are further divided into 4 subtypes in International Classification of Headache Disorders, 3rd edition. Headache remits with resolution of the infection in most cases, and headache might persist for more than 3 months after resolution of the causative infection in only a few patients. However, a longitudinal study showed that the 1-year prevalence of headache suffering was not higher amongst patients with prior intracranial infection than in the general population.

Key points


• No physical sign of meningeal irritation could accurately distinguish those with and without meningitis.


• Headache is the most common symptom of bacterial meningitis (87%), but bacterial meningitis is not a common etiology of acute headache presentation to the emergency room (<1%).


• The diagnosis of headache attributed to localized brain infection (code 9.1.4) included headache caused by brain abscess, subdural empyema, infectious granuloma, or other or other localized infective lesion, usually associated with fever, focal neurologic deficit(s), and/or altered mental state (including impaired vigilance).


• The existence of chronic post-bacterial meningitis headache is debatable.

Historical note and terminology

Bacterial meningitis was first described by Vieusseaux after an outbreak in Switzerland in 1805 and was named "epidemic cerebrospinal fever." The meningococcus was first isolated from cerebrospinal fluid (CSF) by Weichselbaum in 1887. In 1932 the antimicrobial properties of sulfonamides were appreciated (Scheld and Mandell 1984) as an effective treatment for meningococcal, pneumococcal, and haemophilus-related diseases. Survival from all three types of meningitis dramatically improved after penicillin was introduced in the 1940s (Rosenberg and Arling 1984).

In 1893 Sir William Macewen described surgical drainage as a successful treatment of brain abscess.

Quinke introduced the lumbar puncture in 1881 and originally described viral meningitis and encephalitis in 1896. In 1917, von Economo proposed the first pathologic correlates of presumed viral encephalitis during the epidemics of encephalitis lethargica. Aseptic meningitis, a term introduced by Wallgren in 1925, describes a benign and self-limited variant of meningitis usually caused by a viral infection, with headache a prominent feature of the illness.

Nathan Strong, a medical student, recognized meningismus as a diagnostic sign of meningitis in 1810. Vladimir Mihailovich Kernig described his maneuver for detecting meningeal irritation in 1882. In 1909 Jozef Brudzinski described at least five different meningeal signs in patients with meningitis.

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