Headache Management in Idiopathic Intracranial Hypertension

Courtney E. Francis, MD; Peter A. Quiros, MD


Int Ophthalmol Clin. 2014;54(1):103-114. 

In This Article

Recurrent/Persistent Headache

Few studies have focused on the effect of IIH therapy on headache. The rates of recurrent or persistent headaches vary widely with some studies demonstrating relatively low numbers, whereas others show these to be as high as 83%.[30,31] Residual or recurrent headache does seem to be high with most studies demonstrating about two thirds of patients with some form of either recurrent or persistent headache despite stabilization of vision.[32–34] In most cases headache recurrence is accompanied by the recurrence of other signs and symptoms.[33–35] In a recent prospective study of 18 newly diagnosed IIH patients, Yri et al[33] found that 67% had headache present on follow-up. They found the presence of headache to be unrelated to visual stabilization and independent of recurrence. They therefore concluded that the headache was persistent, difficult to classify, and equally present in patients regardless of remission or relapse.

These headaches can also be complex and have overlapping features with other primary headaches.[36] Establishing the characteristics of the headache at baseline can be very helpful later in the disease course by allowing the clinician to distinguish between the elevated ICP headache and a new primary headache. For treatment purposes it is often best to separate these patients with persistent headache complaints into 2 groups: those with elevated ICP and those with normal ICP.

Headache With Elevated ICP

It would seem logical that persistent elevation of the ICP would lead to continued headache. The majority of these patients will not only complain of persistent headache but also they will have worsening vision. As a result, many of these patients with persistently elevated ICP undergo CSF diversion. Although CSF diversion can stabilize vision by lowering ICP it does not always improve the headache. In a series of 53 patients who underwent shunting and were followed for 10 years, 96% complained of headache preoperatively. After shunting 68% of patients complained of persistent headache despite normal CSF pressures and improvement in visual acuity and function. Over time, an additional 28% of patients developed low-pressure headaches.[37] The largest series of shunting for headache included 115 patients; 95% reported initial headache improvement, but 48% had recurrent headaches within 36 months.[28] Both of these studies imply that pressure alone is not responsible for headache in many patients. Wang et al[36] compared 2 groups of chronic daily headache patients, one with IIH without papilledema and the other with normal CSF pressure. Initial headache characteristics did not differ between the 2 groups, most having transformed migraine (now termed chronic migraine) with analgesic overuse [(now termed medication overuse headache (MOH)]. Lowering ICP did not improve the headaches in the elevated ICP group.

It seems therefore that not all headaches, even those experienced with elevated ICP, can be attributed to the ICP itself. Although ICP must be lowered in order to preserve vision, the headache may be a separate entity requiring additional medical therapy.

Headache With Normal or Low ICP

It would seem that control of ICP should result in headache control. As noted above per ICHD-II guidelines, ICP-related headache should resolve within 72 hours of pressure normalization. However, it is not unusual for patients who have achieved improvement in their visual fields, resolution of papilledema, and even headache resolution to complain of recurrent and often persistent headaches. In a large retrospective study of 82 patients by Friedman and Rausch,[32] the characteristics of the patients' headaches were assessed pre-IIH and post-IIH treatment. In all cases patients had undergone either a successful medical or surgical treatment as defined by improvement in visual fields and/or resolution of papilledema. The authors applied the ICHD-II criteria and found that 68% of patients continued to experience headaches. However, these headaches were different in characteristics from the elevated ICP headache described at diagnosis. The authors reported episodic tension-type headache in 37% of patients, migraine without aura in 27%, chronic tension-type headache in 24%, MOH in 12%, and migraine with aura in 10%. Thirteen percent of patients had headaches that could not be classified, and 23% met criteria for >1 type of headache. Nearly all patients improved with conventional symptomatic and/or prophylactic headache medication.