Headache Management in Idiopathic Intracranial Hypertension

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

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

Characteristics

If there is 1 characteristic feature of the recurrent or persistent headache in patients with normal or low ICP, it is that these headaches are different from the "IIH headache" that was present during the presentation. Thus, a careful headache history focusing on the characteristics of the headache must be obtained. The characteristics of the patient's posttreatment headache should be carefully compared with those of the pretreatment headache. The ICHD-II criteria should be applied as strictly as possible to determine the headache phenotype, as phenotypic classification will guide management. Tension-type headache, migraine without aura, and chronic daily headache phenotypes are most common.

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Table 1. Common Headache Features and Associated Symptoms
Typical IIH headache features
Most severe headache experienced
Different from previous headaches
Pulsatile
Daily symptoms
Slowly progressive intensity
Awakens from sleep
Associated symptoms
Neck stiffness
Nausea
Retrobulbar pain

Table 2. Summary of Common Preventative and Symptomatic Treatments
Medication	Dose	Headache Type	Category	Comment
Topiramate	Start 25 mg qhs titrate up to 100 mg bid	Migraine	Preventative	Useful for weight loss
β-blockers
Atenolol	25 mg qd	Migraine	Preventative	Causes exercise intolerance
Propranolol	10–20 mg bid	Migraine	Preventative	Causes exercise intolerance
Tricyclics	10 mg qhs	Migraine and tension type	Preventative	Caution with weight gain, helpful in insomniacs
Triptans	Varies	Migraine	Symptomatic	Avoid use more than twice weekly
NSAIDS
Naproxen	200–400 mg qd	Migraine and tension type	Symptomatic	Indomethacin reduces ICP, caution with GI side effects
Indomethacin	50 mg bid-tid	Migraine and tension type	Symptomatic	Indomethacin reduces ICP, caution with GI side effects