Prevalence and outcome of headache in tuberculous meningitis

OBJECTIVE: To evaluate headache severity, and its correlation with clinical, cerebrospinal fluid, and neuroimaging parameters of tuberculous meningitis (TBM) patients, and its impact on outcome. METHODS: This prospective observational study was conducted at King George’s Medical University, Lucknow, India between October 2012 and March 2014. Ninety-five newly diagnosed TBM patients underwent detailed clinical, laboratory, and neuroimaging evaluation. A numeric rating scale was used to assess the headache severity, and patients were grouped into mild, moderate, severe, and intolerable groups. Patient outcome was evaluated at 6-months follow up. RESULTS: Holocranial stabbing type headache (p=0.002), modified Barthel index ≤12 (p<0.001), diplopia (p=0.055), seizures (p<0.001), visual impairment (p=0.024), cranial nerve palsy (p=0.002), meningeal signs (p=0.016), definite cases of TBM (p=0.001), British Medical Research Council stage III (p<0.001), and CSF protein >2.5 g/l (p<0.001) were significantly associated with severity of headache. Neuroradiological features significantly associated with severity of headache were meningeal enhancement (p=0.015), basal exudates (p<0.001), and hydrocephalus (p=0.003). Eleven out of 15 patients who died had intolerable headache at admission. Significant predictors of poor outcome in severe and intolerable headache groups were CSF protein>2.5g/L, cranial nerve palsies, paraparesis, and infarcts. Patients of the mild and moderate headache group were headache free at 6 months follow up with good outcome. CONCLUSION: Severity of headache was associated with multiple clinical, CSF protein, and radiological factors. As intolerable and severe headache had an unfavorable impact on outcome, we could prognosticate the TBM patients on the basis of headache severity.