Management of Idiopathic Intracranial Pressure

Weight Loss

• A low-sodium weight reduction program is recommended for all obese patients with IIH and appears to alleviate symptoms and signs in many but not all patients
• Case series of IIH patients undergoing gastric surgery report improvement of IIH symptoms and signs including papilledema, headache, tinnitus, and cerebrospinal fluid (CSF) pressure
• These findings were observed over one to three years after surgery and were associated with mean weight loss of 45 to 58 kg

Medication

1. Acetazolamide

• Refer query on ‘Acetazolamide for Idiopathic intracranial hypertension’ for detailed answer
• Adult patients: start with 500 mg twice per day and advance the dose as required and tolerated by the patient.
• Although doses of up to 2 to 4 g per day can be administered, many patients develop dose limiting side effects at higher levels.
• Children, the recommended starting dose is 25 mg/kg per day with a maximum dose of 100 mg/kg or 2 g per day

2. Topiramate

• antiepileptic drug that inhibits carbonic anhydrase activity
• Case reports and one small unblinded study suggest that topiramate appears to have a similar efficacy to acetazolamide with regard to visual field improvement and symptom relief .
• However, further study is needed before this can be considered a first-line treatment for IIH

3. Frusemide

• may be a useful adjunctive therapy toacetazolamide in IIH
• Adult: 20 to 40 mg per day for adults
• Children: 1 to 2mg/kg per day
• rapid clinical response with resolution of papilledema, reduction in the mean CSF pressure after the first week of treatment, and normalization of CSF pressure within six weeks of starting therapy

4. Corticosteroid

• Although corticosteroids (eg, prednisone) have been recommended in the past for IIH, we avoid the use of corticosteroids in IIH for the following reasons:

- Corticosteroids can cause weight gain that might worsen IIH.

- Steroid withdrawal can cause severe rebound intracranial hypertension associated with marked visual loss.

- There are significant systemic side effects from chronic corticosteroids

• In the setting of acute visual loss, a short course of intravenous corticosteroids may be useful as a temporizing measure prior to surgical intervention in IIH. One case series describes successful use of methylprednisolone (250 mg four times a day for five days followed by an oral taper) 
• Most recommendation suggest not using corticosteroids for long-term management of IIH

5. Others (Lacks Evidence)

•  indomethacin may have efficacy in the treatment of secondary intracranial hypertension (eg, traumatic brain injury, hepatic encephalopathy) presumably by causing cerebral vasoconstriction and reducing cerebral blood flow
• Iron supplementation in IIH patients with iron deficiency anemia appeared to be efficacious in a case series of six patients

6. Headache Prophylaxis

• Patients with IIH can continue to have headaches despite improvement in papilledema and visual function.
• Medications used in the prophylactic treatment of migraine headaches are often used for headache management in IIH
• choice of agent is influenced by the propensity of some of these medications (eg, valproate, tricyclic antidepressants) to produce weight gain

Reference

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