Herpes zoster (HZ) also known as shingles is a painful, blistering skin eruption in a dermatomal distribution. When the patients are suffering from a headache or facial pain (pre-eruptive pain) associated with acute herpes zoster of the head, specifically before the appearance of characteristic skin eruptions (pre-eruptive phase), it is often arduous to make a final diagnosis and thus the treatment.

Lee H L, et al. performed a study to put forward the clinical characteristics of a headache or facial pain due to acute herpes zoster of the head and to explain the association between the manifestation of these symptoms in the pre-eruptive phase and upcoming herpes zoster.

Between January 2011 and December 2015, the clinical features of 152 patients with acute herpes zoster involving only the head were presented within 10 days of rash onset at Chungbuk National University Hospital, a tertiary hospital in Chungcheongbuk-do (South Korea).

Mean age of the patients was 54.3 ± 19.8 years. A total of 18 patients had herpes zoster in the upper cervical nerves,  34 in nervus intermedius and 100 in the trigeminal nerve. A total of 112 patients  (73.7%) had pre-eruptive pain with a mean duration of 3.0 ± 1.3 days (range, 1–6 days). As for the severity of pain, the presence of pre-eruptive pain (p = 0.040) was concerned. Other than two patients who had severe meningitis symptoms, and was of moderate to severe intensity (90.1%), the headache or facial pain was restricted to the ipsilateral side of the face and head in all patients. Total 120  patients (84.2%) patients experienced stabbing pain and 146 (96.1%) revealed this type of pain for the first time. Of all, 94 (61.8%) patients reported a sleep disturbance due to pain and 61 patients (54.5%) out of 112 patients with pre-eruptive pain visited a hospital during the pre-eruptive phase. Their pre-eruptive phase was notably longer (p<0.001) and more frequently awakened them from sleep (p=0.008). The presumptive diagnostic pattern was: tension-type headache (n = 20, 32.8%); no decision (n = 18, 29.5%); herpes zoster (n = 5, 8.2%); migraine (n = 3, 4.9%); pain associated with upper respiratory tract infection (n = 3, 4.9%); parotitis (n = 2, 3.3%); dry eye (n = 2, 3.3%); and other (n = 1 each: trigeminal neuralgia, glaucoma, pharyngitis, vestibular neuronitis, tonsillitis, teeth problems, otitis media, and occipital neuralgia).

It was thus concluded that the typical pain of acute herpes zoster of the head has a stabbing quality, is felt unilaterally, varies from moderate to severe, often disturbs sleep, and has not been formerly experienced by most patients. When experiencing patients with these features accompanied by pain onset of less than one week, acute herpes zoster of the head should be taken into consideration, even without characteristic vesicles, after prohibiting other secondary causes by appropriate diagnostic workup.