Is my headache meningitis?
by Laurence Degelsmith, MD
February 1, 2008
It’s hard to think of a more ominous, fear-provoking disease than meningitis.
Just the name itself causes people’s heartbeat to rise. Whenever I tell a patient that I have to rule out meningitis, it’s like they’ve heard the word cancer and they start to panic. In fact, meningitis is potentially a very serious illness, but the vast majority of cases (probably over 90%) are caused by viruses and are not life threatening. The goal for physicians is to diagnose the few cases of bacterial meningitis that present every year and begin appropriate antibiotic therapy as soon as possible. The outcome may depend on how quickly the antibiotics are started because some people can deteriorate in a matter of hours.
Meningitis is defined as an inflammatory process affecting the membrane and fluid surrounding the brain and spinal cord. This inflammatory process is usually thought to be infectious, but occasionally a non-infectious cause is the culprit, such as metastatic cancer spreading to the meningeal membrane or medication can induce it.
Infectious causes of meningitis are the focus of this article; the most common types are viral and bacterial. I’ve had patients with meningitis ranging in age from five days to ninety-five years. It can cause illness in anyone, but certain subgroups of the population are more at risk than others. Newborns up to one month, immuno-compromised people and the elderly (over 60) are highly susceptible due to their weaker immune systems. They are also harder to diagnose since the common symptoms of meningitis are not always apparent in these populations. College students living in dormitories and military recruits are also at increased risk due to their crowded living conditions, which seems to be a factor in many cases of meningitis.
Vast majority of headaches presented to the emergency department are not meningitis
I want to stress from the beginning that the vast majority of headaches presenting to the emergency department are not meningitis, and the vast majority of meningitis cases are viral and rarely life threatening. The symptoms of meningitis usually begin with headache, fever and sensitivity to light. Neck stiffness is also very common but often develops later, as does vomiting. The symptoms of viral meningitis usually stop there.
But bacterial meningitis, if untreated, will usually progress, causing decreased responsiveness, seizures, neurological impairment and often death. Meningitis can present slowly over days or quickly over hours. There are exceptions of course, but the general rule is that the quicker the symptoms present and the more severe the symptoms, the more likely it is to be bacterial. Viral meningitis often remains mild for days and resolves without medical intervention. Occasionally symptoms become severe enough to seek medical attention. Bacterial meningitis usually causes more severe symptoms within a period of hours or only one day. I have seen several exceptions to the above, so I make no decisions on treatment until a thorough history and physical are performed followed by various laboratory tests.
Bacterial meningitis
The most common causes of bacterial meningitis vary by the age of the patient. In newborns, the three most prevalent organisms are a form of Streptococci called Group B Strep, E. coli and Listeria. (H Influenzae used to be prevalent before its vaccine was available.) Newborns are hard to diagnose with meningitis because they can’t complain of headaches and they often don’t have fevers. Sometimes the only signs of meningitis might be poor feeding and decreased activity. This is why we will often perform spinal taps on neonates who present with mild symptoms and especially any child under the age of two months with a temperature of 100.4 or higher. In older children and adults, the most common organisms are Streptococcus pneumonia (Group A strep) and Neisseria meningitidis. Generally, children over the age of 2 present with similar symptoms as adults with meningitis.
Pneumococcal meningitis has the highest mortality and morbidity of the bacterial causes of meningitis. The mortality rate approaches 20% with treatment and can reach as high as 90% if there are focal neurological findings, such as an altered level of consciousness, at the time of presentation.
Viral meningitis
There are many common viruses that can cause meningitis, but most don’t cause serious or permanent symptoms. One exception is the herpes virus, which can cause a serious case of meningitis or encephalitis. Lyme disease is also responsible for many cases of meningitis, especially in this area. It usually presents two to three months after the typical Lyme rash appears, but only if the disease goes untreated. Meningitis caused by Lyme or herpes is treatable once diagnosed. Tuberculosis is another potential cause of meningitis, but I have seen perhaps one case in 10 years. It is much more common in third world countries where tuberculosis is endemic. The most common presenting symptoms in older children and adults with either viral or bacterial meningitis are headache, fever, neck stiffness and sensitivity to light.
How do we diagnose meningitis?
Unfortunately, the only way to diagnose meningitis is to do a spinal tap. This procedure consists of inserting a long needle into the lower spinal canal to remove a sample of fluid to send to the lab. The procedure is done with a local anesthetic; it is very safe and often painless or close to it. Usually the only pain is when the anesthetic is injected into the skin and that lasts for only a few seconds. Within an hour, the fluid is analyzed and a diagnosis of meningitis can be made or ruled out. If meningitis is suspected because of the history and physical exam, antibiotics are usually started immediately, before the spinal tap.
The major diagnostic dilemma is deciding whether we should do a spinal tap. There are many illnesses that can cause a headache and fever. Strep throat, ehrlichiosis and mononucleosis often mimic meningitis, but so can the flu and various other viral illnesses. I will often defer doing a spinal tap until I get the results of those tests, strep, ehrlichiosis and mono, which can be done fairly rapidly in the emergency department. If all of those tests are negative and the patient has a headache with fever or neck pain, a spinal tap is highly recommended.
I had a 16-year-old patient last week I was pretty sure had meningitis. He had all of the symptoms including a severe headache for one day, fever to 102 and a stiff neck. I was so confident he had meningitis that I treated him with the antibiotics before doing the spinal tap. He got better with intravenous fluids and pain medication and his spinal fluid was completely normal. Not doing a spinal tap with those symptoms would be potentially catastrophic.
On the other hand, over the previous summer I saw a 15-year-old girl with a headache and low grade fever of 100.6. She had a history of migraines and her current headache was similar to previous migraines. She had no neck stiffness and was comfortable while eating potato chips on the stretcher. I diagnosed and treated her successfully as a migraine headache and mild viral illness. She went home and returned in six hours with a worse headache and a stiff neck. She was eventually diagnosed with viral meningitis and did well. The risk from the spinal tap is so minimal compared to the risk of death or permanent neurological disability from untreated meningitis, so a spinal tap is highly recommended if the symptoms suggest possible meningitis.
It is sometimes easy to differentiate bacterial meningitis from non-bacterial meningitis from the spinal fluid, but often it is not obvious. When the fluid is clearly consistent with bacterial meningitis, antibiotics are given for one to two weeks. We will sometime still treat presumptive viral meningitis with antibiotics and antivirals (to treat a possible herpes virus infection) until the spinal fluid cultures come back negative, which usually takes about two days. Most patients with any form of meningitis get admitted anyway because they require aggressive pain management for severe headaches.
Treating close contacts
Although meningitis is potentially contagious, we usually only hear about isolated cases of a single college student. It usually doesn’t affect others around them. I can’t ever remember hearing about several cases at the same time in the same area.
Nevertheless, we currently treat all people who might have been in contact with the infected person for an hour or more. Anyone that might have been exposed to the person’s secretions, such as EMS or hospital personnel, also gets treated. The preventative treatment usually consists of one dose of Ciprofloxacin or four doses of Rifampin.
Preventative treatment is only recommended when the offending organism is Neisseria meningitidis or H. influenzae. H. influenzae is much less common these days due to the routine immunizations against it. In fact, vaccines against Pneumococcus, Neisseria and H. influenza now exist. All children are being routinely immunized against Pneumococcus and Haemophilus from early childhood. The Neisseria vaccine is recommended by the CDC for certain high risk children ages two through ten and all children ages 11 – 12. It is also highly recommended that college students living in dorms and military recruits get the vaccine. The Neisseria vaccine is not 100 percent protective since it only covers against two of the three strains of Neisseria in the U.S., but it does greatly decrease one’s chances of developing meningococcal disease. For more information about the meningitis vaccine, please go to http://www.cdc.gov/vaccines/vpd-vac/mening/default.htm.
Hopefully this information hasn’t scared too many people. Meningitis is certainly a dangerous illness when the cause is bacterial, Lyme or Herpetic. However, it is usually viral and not very common. It is easily diagnosed with a spinal tap and usually treatable when caught early. Neonates and the elderly present a specific problem since they don’t have the usual symptoms that older children and adults have with meningitis, so we as physicians need to have a low threshold for performing spinal taps when vague symptoms exist in these age groups. The chances of contracting and then dying from meningitis are fairly remote.
Author’s note: This article encompasses general guidelines taken from several published sources as well as my ten years of personal experience as an emergency physician. There will often be exceptions to the above guidelines because the risk vs. benefit ratio of using any medication will be different for each patient.
Laurence Degelsmith graduated from Horace Greeley High School in 1985, has an undergraduate degree from Washington University in Saint Louis, attended New York Medical College and did his residency in emergency medicine at the University of Michigan. He is an emergency department physician at Northern Westchester Hospital in Mt. Kisco and a member of the Chappaqua Volunteer Ambulance Corps.
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