Headaches in the Context of HIV

Headaches are a universal experience, but in regions like South Africa, the landscape of headache causes can be significantly shaped by the prevalence of infectious diseases, particularly Human Immunodeficiency Virus (HIV). While common headaches like migraines and tension headaches are prevalent here as elsewhere, both individuals and healthcare providers must be aware of how infections, especially HIV and its associated opportunistic infections, can manifest as headaches.

At Nervous Doc, our goal is to provide accessible, educational content that empowers you to better understand your health. Today, we're shedding light on a critical topic: HIV and other infectious causes of headaches in South Africa. Understanding these connections is crucial for early diagnosis, effective treatment, and enhanced outcomes and productivity.

The Landscape of HIV in South Africa

South Africa carries the most significant burden of HIV globally. According to recent estimates from Thembisa, the leading mathematical model of HIV and TB in South Africa, the number of people living with HIV reached the eight million mark in 2024, representing approximately 12.8% of the total population (Spotlight, 2025). While significant strides have been made in antiretroviral therapy (ART) coverage, with around 6.2 million people on treatment in 2024, a notable proportion of individuals are not on treatment or only start treatment once their immune systems are severely compromised (Spotlight, 2025). This reality makes awareness of opportunistic infections and their neurological manifestations, like headaches, particularly critical.

Headaches in the Context of HIV: More Than Just a Symptom

For people living with HIV (PLWH), headaches are a common complaint. They can range from benign primary headaches (like migraines or tension-type headaches) that happen to co-exist with HIV to more sinister "secondary headaches" that signal an underlying infection or other HIV-related neurological complication. The severity of immunosuppression (often measured by CD4 count) plays a significant role in determining the risk of these opportunistic infections.

The direct impact of HIV on the brain can also cause headaches, leading to inflammation that damages brain function (NINDS, 2025). Furthermore, HIV-associated neurocognitive disorders (HAND), which encompass a range of cognitive impairments, can also present with headaches, particularly in advanced stages of HIV (Johns Hopkins Medicine, 2024).

Key Infectious Causes of Headache in PLWH in South Africa

When a person living with HIV presents with a new or persistent headache, especially if accompanied by other neurological symptoms or fever, a thorough investigation for opportunistic infections is paramount. Here are some of the most common and critical infectious causes seen in the South African context:

1. Tuberculous Meningitis (TBM):

• The Threat: Tuberculosis (TB) is the leading cause of death among people living with HIV in Africa, and TB Meningitis (TBM) is its most lethal form, affecting the central nervous system. South Africa is a high-TB-burden country (MDPI, 2023).
• Symptoms: TBM often presents with a sub-acute-onset headache (worsening over days to weeks) accompanied by fever, neck stiffness, confusion, nausea, vomiting, and sometimes neurological deficits. The symptoms can be nonspecific in the early stages, leading to a delayed diagnosis.
• Why it's a Red Flag: TBM requires urgent diagnosis and prolonged multi-drug antitubercular treatment. Untreated, it has a high mortality rate and can lead to severe neurological complications.

2. Cryptococcal Meningitis (CM):

• The Fungal Culprit: Cryptococcal meningitis, caused by the fungus Cryptococcus neoformans, is the most common cause of HIV-related adult meningoencephalitis in central and southern Africa, including South Africa (NICD, 2023). It primarily affects individuals with significantly weakened immune systems (CD4 count below 200 cells/µL).
• Symptoms: Similar to TBM, CM often presents with a sub-acute headache that worsens over days, accompanied by fever, neck stiffness, altered mental status, and sometimes visual disturbances.
• Why it's a Red Flag: CM is a major cause of death among PLWH in the region. South Africa has implemented a national cryptococcal antigen (CrAg) screening program for high-risk individuals, enabling early diagnosis and preemptive therapy (BMJ Open, 2022). Prompt diagnosis and antifungal treatment are critical.

3. Neurosyphilis:

• The Bacterial Connection: Syphilis, a bacterial infection, can affect the nervous system at any stage of the disease, leading to neurosyphilis. This can manifest as meningitis (syphilitic meningitis), causing headaches, neck stiffness, and other neurological symptoms.
• Prevalence in SA: While specific prevalence data for neurosyphilis in PLWH in South Africa is more complex to isolate, studies indicate a significant co-morbidity between syphilis and HIV (SAJP, 2012), highlighting the importance of screening for both conditions due to shared risk factors.
• Why it's a Red Flag: Neurosyphilis can lead to permanent neurological damage if not diagnosed and treated promptly with appropriate antibiotics.

4. Toxoplasmosis Encephalitis:

• The Parasitic Threat: Caused by the parasite Toxoplasma gondii, toxoplasmosis encephalitis is a common opportunistic infection in PLWH, particularly in high-income countries, but it's also a significant concern in advanced HIV in South Africa.
• Symptoms: Often presents with focal neurological deficits (e.g., weakness on one side of the body, speech difficulties, seizures) along with headache and fever due to brain lesions.
• Why it's a Red Flag: Requires specific antiparasitic treatment and can be life-threatening.

5. Viral Meningitis/Encephalitis (e.g., Cytomegalovirus, Herpes Simplex Virus):

• The Viral Assailants: Various viruses can cause inflammation of the brain (encephalitis) or its surrounding membranes (meningitis) in individuals with compromised immune systems.
• Symptoms: Depending on the specific virus and affected areas of the brain, symptoms can range from sudden, severe headaches with fever and confusion to more insidious neurological changes.
• Why it's a Red Flag: These conditions require specific antiviral treatments and can lead to significant morbidity and mortality.

6. Neurocysticercosis:

• A Less Common but Important Parasite: Caused by the larval stage of the pork tapeworm (Taenia solium), neurocysticercosis is a parasitic brain infection. While not exclusively tied to HIV, it is endemic in parts of South Africa, particularly rural areas with free-range pig farming (University of Pretoria, 2009; UCT Health Sciences, 2004).
• Symptoms: Can cause headaches, seizures (it's a significant cause of epilepsy in endemic areas), and other neurological symptoms depending on the location and number of cysts.
• Why it's a Red Flag: Requires antiparasitic treatment and management of symptoms like seizures.

When to Seek Urgent Medical Help (Revisiting Red Flags in an HIV Context)

We've previously discussed general Red Flags in Headaches that warrant immediate medical attention. These are even more critical for individuals living with HIV, given their increased susceptibility to severe opportunistic infections. Pay particular attention to:

• New, severe, or sudden onset of headache.
• Headache accompanied by fever and neck stiffness.
• Headache with new neurological symptoms (weakness, vision changes, difficulty speaking, confusion, seizures).
• The headache worsens with changes in position, coughing, or straining.
• Any new headache in an individual with a very low CD4 count.

The Diagnostic Approach: A Medical Detective Story

Diagnosing the cause of a headache in a person living with HIV requires a comprehensive approach. This often involves:

• Detailed Medical History, including HIV status, CD4 count, viral load, ART adherence, recent travel, and exposure history.
• Thorough Neurological Examination: To identify any focal neurological deficits.
• Imaging of the Brain: A CT scan or MRI of the brain is often crucial for detecting lesions, inflammation, or hydrocephalus.
• Lumbar Puncture (LP) / CSF Analysis: This involves collecting cerebrospinal fluid (CSF) for analysis. CSF tests for various infections (e.g., TB, Cryptococcus, syphilis, viral DNA/RNA) are often the definitive diagnostic step (SAHIVSOC, 2025). The Southern African HIV Clinicians Society ART guidelines explicitly recommend investigating meningitis before starting ART if a patient presents with a headache (SAHIVSOC, 2025).

Managing Headaches in PLWH: An Integrated Approach

Effective headache management in PLWH requires an integrated approach that addresses both the underlying infectious cause and the headache symptoms.

• Treating the Infection: This is the primary step. Once an infectious cause is identified, specific antimicrobial, antifungal, antiparasitic, or antiviral treatments are initiated immediately.
• Antiretroviral Therapy (ART): For PLWH, optimising ART and achieving viral suppression is fundamental. ART helps to restore the immune system, reducing the risk of future opportunistic infections. However, in some instances (like TBM or CM), ART initiation may be temporarily delayed to prevent immune reconstitution inflammatory syndrome (IRIS) (SAHIVSOC, 2025).
• Symptomatic Headache Management: Once the underlying cause is being treated, headaches can be managed with appropriate pain relievers, similar to primary headaches, but with careful consideration of drug interactions with ART.
• Managing Complications: Addressing complications like raised intracranial pressure (e.g., with repeated lumbar punctures) or seizures (with anti-epileptic drugs) is also critical.

Your Role: Awareness and Proactive Health Seeking

Living with HIV in South Africa means being particularly vigilant about your health. If you are experiencing new, persistent, or severe headaches, especially if accompanied by any of the red flags mentioned, do not delay seeking medical attention. Be open with your healthcare provider about your HIV status and any symptoms you are experiencing.

At Nervous Doc, we are committed to being your reliable source for neurological health information. We believe that empowering you with knowledge about conditions like HIV and its neurological manifestations can lead to earlier diagnosis, better treatment outcomes, and, ultimately, a more productive and fulfilling life.

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