What is the initial treatment for benign intracranial hypertension (BIH)?

From the Guidelines

The initial treatment for benign intracranial hypertension (BIH), also known as idiopathic intracranial hypertension (IIH), typically involves weight loss and acetazolamide, as recommended by the most recent and highest quality study 1.

Key Components of Initial Management

• Weight loss of 5-10% of total body weight is recommended for overweight patients as it can significantly reduce intracranial pressure.
• Acetazolamide, a carbonic anhydrase inhibitor, is the first-line medication, usually started at 500 mg twice daily and gradually increased to 1000-2000 mg daily in divided doses as tolerated.
• This medication works by reducing cerebrospinal fluid production, thereby lowering intracranial pressure.
• Common side effects include tingling in the extremities, altered taste sensation, fatigue, and nausea.

Alternative and Additional Treatments

• If acetazolamide is not tolerated, topiramate (25-50 mg twice daily, gradually increased) can be used as an alternative.
• For patients with severe symptoms or visual loss, therapeutic lumbar punctures may be performed to provide immediate but temporary relief by directly removing cerebrospinal fluid.
• Adequate hydration and avoiding medications that might exacerbate the condition (such as tetracyclines, vitamin A derivatives, and certain steroids) are also important components of initial management.

Importance of Recent Guidelines

The guidelines from the study 1 emphasize the importance of a multidisciplinary approach to managing IIH, including neurology, neurosurgery, neuroradiology, ophthalmology, nursing, primary care doctors, and patient representatives.

Prioritizing Morbidity, Mortality, and Quality of Life

In managing BIH/IIH, it is crucial to prioritize treatments that reduce morbidity, mortality, and improve quality of life, as outlined in the recent consensus guidelines 1.

From the Research

Initial Treatment for Benign Intracranial Hypertension (BIH)

The initial treatment for BIH typically involves medical management to reduce intracranial pressure and alleviate symptoms.

• The goal of medical treatment is to treat intracranial hypertension symptoms as well as to preserve vision 2.
• Reducing the production rate of cerebrospinal fluid can be achieved using acetazolamide and/or furosemide (carbonic anhydrase inhibitors), although acetazolamide is the most effective drug 2.
• Acetazolamide is often used as a first-line treatment, with doses of 10-20mg/kg per day given every 8h to respect its kinetics 2.
• Repeated lumbar punctures associated with acetazolamide and weight loss are usually efficient enough to manage BIH 3.
• In some cases, alternative treatments such as topiramate may be considered, especially in cases refractory to acetazolamide 4.

Key Considerations

• The management of patients with BIH depends mainly on the presence and severity of ocular symptoms and signs on which the prognostic of the disease is based 3.
• Careful follow-up with repeated formal visual field testing may help preventing a devastating visual loss in these patients 3.
• Surgical treatment (optic nerve sheath fenestration or lumboperitoneal shunt) is required when appropriate medical management does not prevent progressive alteration of vision (visual loss or visual field defect), or when the patients complain of severe, refractory headaches 3, 5.