Headaches

Figuring out the cause

Some headaches are due to the activation of pain nerves in the head. Tension headaches and migraines are examples of these kinds of headaches. Other times, headaches are a symptom of another condition. These other conditions include a hangover from alcohol, low blood sugar, allergies or sinus congestion, ear infections, dental problems or over-use of pain medications. Headaches can also be a side effect of a prescription drug.

Some headaches can be a symptom of a serious or even life-threatening condition, such as:

• encephalitis (inflammation of the brain) or meningitis (inflammation of the membranes around the brain and spinal cord), often due to an infection
• depression
• syphilis
• bleeding around the brain
• stroke
• cancer

Headaches that are severe, last for more than a few hours or happen regularly should be taken seriously. This is especially true if these symptoms are new.  For instance, severe headaches that last for hours are certainly problematic, but potentially less concerning if you have a history of migraines and your symptoms are identical to your previous headaches.

That said, certain headache “red flags” should be addressed urgently when they occur. A severe headache that comes on very suddenly or reaches its maximum intensity within minutes could be a sign of a very serious problem. In these cases, get medical attention right away.

If you have recurrent or severe headaches, talk to your healthcare provider. They may refer you to a neurologist or HIV specialist for a comprehensive diagnosis. It is best not to treat such headaches with pain medications until the problem has been diagnosed and treatment has been prescribed. Pain medication can help make the headache hurt less, but it can also make it more difficult to detect if something more serious is happening.

Be sure to describe to your healthcare provider how often your headaches occur, how severe they are, whether there is any pattern to their occurrence (for example, time of day, after eating certain foods or doing certain activities). Also describe whether you experience any other symptoms, such as fever or neurological symptoms (for example, physical weakness).

Don’t forget the possibility that your headache may be related to something other than HIV. Healthcare providers sometimes use diagnostic procedures that focus too much on opportunistic infections and HIV- related conditions, forgetting that people living with HIV are also susceptible to other conditions.

Antiretroviral therapy

Headaches can sometimes be a side effect of antiretroviral therapy. In some cases, headaches will only occur when you start or change treatment, gradually disappearing over a few weeks. In other cases, they may remain long-term. One possibility to discuss with your healthcare provider is switching drugs. Medications should be particularly suspected as a cause of headaches when a new drug treatment has recently been started. Note, however, that headaches can begin even after months of using a particular drug.

Another possible cause of headaches is lactic acidosis if someone is taking one of the nucleoside analogues (such as AZT or d4T). As these drugs are not commonly used in Canada for long-term care, lactic acidosis in people living with HIV has become extremely rare.

Drugs such as abacavir (Ziagen and in Kivexa, Trizivir and generic formulations) and tenofovir (Viread, and in Truvada, Delstrigo, Atripla, Complera Stribild, and generic formulations) are much less likely to cause lactic acidosis than their older counterparts, so this has become less of a concern in recent years. TAF (tenofovir alafenamide; the safer formulation of tenofovir) is also widely used and any association with lactic acidosis is extremely rare.

Lactic acidosis may be suspected if the headache is combined with other symptoms of this condition. These include fatigue, nausea, vomiting, unexplained weight loss, difficulty breathing, cold hands and feet, blue skin colour or pain in the stomach, abdomen, or liver. Sudden symptoms of peripheral neuropathy may also be a sign of lactic acidosis. 

Infections and other conditions

Headaches can also be a symptom of many different infections and conditions that are important to diagnose and treat, including:

• neurosyphilis (an advanced stage of syphilis) 
• herpes outbreaks
• endocarditis (heart infection)
• COVID-19
• cryptococcal meningitis
• toxoplasmosis
• CMV encephalitis
• progressive multifocal leukoencephalopathy (PML)
• primary central nervous system (CNS) lymphoma.

Stroke and aneurysm

The risk of cardiovascular disease increases with age. Cardiovascular disease can occur at a younger age in HIV-positive people than is typical in HIV-negative people.

With any severe headache, the possibility of a stroke (the loss of blood flow to a part of the brain) or the rupturing of an aneurysm (a bulge or ballooning of a blood vessel in the brain) should always be considered. 

Common symptoms of a stroke are sudden paralysis or weakness in the face or limbs, especially on one side of the body. Other symptoms include sudden problems with balance or walking, sudden vision problems slurred speech or sudden confusion or difficulty understanding simple statements.

With a ruptured aneurysm, a headache — sometimes described as the worst headache ever — often comes on quickly and reaches maximum intensity in minutes. It can be accompanied by confusion, numbness, trouble seeing, speaking or walking, a stiff neck, a high fever or nausea or vomiting.

If you experience one or more of these symptoms, seek medical attention immediately. Call 911 if your region has that emergency service.

Stabilizing your blood sugar

Blood sugar problems may also contribute to headaches. As people living with HIV grow older, they may develop insulin resistance, pre-diabetes and eventually diabetes, which can result in serious blood sugar problems. When your blood sugar drops too low, it can cause a headache that may not resolve for a number of hours. If you are having recurrent blood sugar ups and downs, this can cause recurrent headaches. These headaches can be resolved by stabilizing your blood sugar. Eating frequent, small meals that are nutritionally balanced with fibre, complex carbohydrates and protein can help, as can exercising regularly.

Magnesium deficiency

Magnesium deficiency can occur in people with HIV and can cause headaches. Supplementing with magnesium can eliminate this problem, but seek immediate medical attention for severe or recurrent headaches. If no other cause for your headache is found, keep the possibility of this deficiency in mind. Be aware that doses of magnesium above 350 mg per day can cause diarrhea. Magnesium glycinate may be better tolerated than other forms. However, first check with your pharmacist to find out if this form of magnesium will interact with any of the medicines that you are taking. 

Pain medications

If you are treating your headache with pain medication, it is important to consider other factors that may also be affecting you, such as:

• other medications you are taking, because of potential drug interactions
• medical conditions such as liver problems, because medications like acetaminophen (Tylenol) can be hard on the liver
• other medical conditions such as stomach ulcers, gastrointestinal bleeding problems, intestinal Kaposi’s sarcoma, low platelets, kidney dysfunction or low serum albumin.

A pain medication from the class called non-steroidal anti-inflammatory drugs (NSAIDs) is one choice. NSAIDs include ibuprofen (Advil, Motrin), naproxen (Aleve) and acetylsalicylic acid (Aspirin). Long-term use of Aspirin or other NSAIDs can cause damage to the lining of the stomach and intestines and can lead to gastrointestinal bleeding. Also, people taking tenofovir should talk to their healthcare providers about taking NSAIDs as there is a risk of kidney injury. In general, only use pain medication when you need them to relieve headaches, and avoid long-term use if possible.

Acetaminophen (Tylenol) is another common pain medication and is found in many over-the-counter medications. Acetaminophen overdose is a concern. It is the most common cause of acute liver failure in North America, and alcohol consumption or liver disease, such as hepatitis C, can substantially increase the risk. The standard maximum short-term dose is 3,000 mg per day (six extra-strength 500-mg tablets). In people who drink alcohol, liver damage may occur with consumption of only 2,600 mg of acetaminophen a day. It is strongly recommended that people who drink alcohol regularly limit their use of acetaminophen to a maximum of 2,000 mg per day. This means taking no more than two to four standard-strength pills within a 24-hour period.

Acetaminophen is also an active ingredient in many other medications, including common headache and cold remedies such as Dayquil, Nyquil, Anacin 3 and others. It is important to read the labels of all over-the- counter medications and prescription medications very carefully to be certain you never take more than the recommended dose.

Some people who take acetaminophen regularly also take the supplement N-acetyl-cysteine (NAC; 500 to 1,000 mg, twice daily) to help normalize levels of the antioxidant glutathione. During acetaminophen overdose, glutathione is depleted in the liver and can lead to liver toxicity. Taking NAC at the same time as acetaminophen may decrease the risk of liver toxicity. Even then, the recommended daily limit of acetaminophen should not be exceeded.

Complementary therapies

Some kinds of headaches can be treated with other types of therapy, including deep-tissue massage, acupuncture or acupressure and herbs. The herb feverfew, for example, contains parthenolide, an agent that reduces spasms in blood vessels in the head. Feverfew has been shown to work for both migraines and tension headaches.

Be sure to tell your pharmacist or healthcare provider about all the medications, over-the-counter drugs, supplements and herbal therapies you take. These products can interact with your antiretroviral drugs, lowering their efficacy or increasing the risk of experiencing side effects.