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| 50th Annual Meeting of the American Headache Society |
Boston, Massachusetts June 26-29, 2008 |
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No evidence-based research
supports idiopathic ntracranical Hypertension
Treatments |
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BY MAURY M. BREECHER
Contributing Writer |
BOSTON — Although no evidence-based
therapy exists for the successful treatment of
Idiopathic Intracranical Hypertension (IICH), several
therapies are in use today that have varied results,
according to a presentation by Dr. Deborah Friedman at
the 50th Annual Scientific Meeting of the American
Headache Society on June 28.
“The major goal of treatment is to preserve vision, but
there is absolutely no evidence-based guidelines for
treating this disorder and all medication use is off
label,” emphasized Dr. Friedman of the University of
Rochester, New York.
What about headache in the IICH patient population?
Headaches in this population correlate poorly with
opening lumbar pressure and the degree of papilledema,
but medication overuse headache is common, said Dr.
Friedman.
According to Dr. Friedman, however, there is no
characteristic pattern of headache in IICH patients. The
headache is frequently described as being bifrontal,
pressure-like, constant, chronic, and “the worst in my
life,” but they also have been described as more like
migraines—pounding and occasionally unilateral. Often
these patients evolve into chronic headache patients.
Treatment for these headaches generally starts with
diuretics.
The rationale for using diuretics is that they work at
the level of the choroid plexis and they decrease the
secretion of cerebrospinal fluid and sodium ion
transport, said Dr. Friedman.
“It is not certain why they work. It is not certain if
they work,” she observed.
Dr. Friedman said corticosteroids are also used to treat
IICH and work initially to decrease intracranial
pressure, but they are not recommended because they
cause weight gain and fluid retention and have other
serious long-term side effects. Their withdrawal is also
associated with increased intracranial pressure.
“I wish no one used corticosteroids,” she said.
“Unfortunately, they are still in most textbooks as
acceptable treatments for IICH. They have so many
problems associated with them that my advice is to stay
away from their use.”
Dr. Friedman continued that the standard advice to IICH
patients is to lose weight.
She speculated that “perhaps there is some type of
effect on spinal fluid homeostasis that is a consequence
of losing adipose tissue.”
She told of a study of nine obese patients with
papilledema who were treated with strict diet and a
limitation of fluids and sodium. Their papilledema, or
swollen optic nerves, resolved over the next two to 36
months. (Arch. Intern. Med. 1974;133:802-807).
Three other retrospective studies showed mixed to good
results. Kupersmith et al. reported on 48 patients who
lost 2.5 kg in three months. Compared to controls who
lost less weight, the patients who lost 2.5 kg showed
more improvement in papilledema grade in their worse eye
at six months (P=0.03), but no difference in visual
field grade or time to improvement
(Neurology.1998;50:1094-1098).
Stenting has also been suggested as an ICH treatment,
but Dr. Friedman said that surgical treatment “is not
ready for prime time.”
“There is no convincing data to recommend stenting at
this time and there are safety concerns,” she said.
Those concerns involved transient hearing loss and
intraluminal thrombi.
Lumboperitoneal shunt works initially, Dr. Friedman
reported, but had a high failure rate as they were 2.5
times more likely to require revision, primarily from
obstruction. Shunt failure requires revision surgery.
She added that Optic Nerve Sheath Fenestration is a
procedure that appears to work, but has some risk. It
appears to be beneficial because papilledema and the
visual field improve in most IICH patients. However, the
procedure initially causes a leak of spinal fluid when
the optic nerve is cut.
There is a small risk that people can permanently lose
vision from this procedure, said Dr. Friedman.
“The procedure is only done in patients with papilledema
and preferably in patients who have visual loss from
papilledema,” said Dr. Friedman. |
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