Hyperbaric Oxygen Therapy in Idiopathic Intracranial Hypertension
Hyperbaric oxygen therapy (HBOT) is not currently recommended for the treatment of idiopathic intracranial hypertension (IIH) due to insufficient evidence supporting its efficacy and potential risks. 1, 2
Current Evidence on HBOT in IIH
The 2018 IIH consensus guidelines from the Journal of Neurology, Neurosurgery and Psychiatry make no mention of HBOT as a recommended treatment option for IIH 1. Instead, the guidelines focus on established treatments including:
- Weight loss for patients with BMI >30 kg/m²
- Acetazolamide as first-line pharmacological therapy
- Topiramate as an alternative when acetazolamide is not tolerated
- CSF diversion procedures only in a multidisciplinary setting after intracranial pressure monitoring
- Neurovascular stenting not currently recommended for headache management
Limited Research on HBOT in IIH
The available research on HBOT for IIH is extremely limited:
- A small preliminary study from 1992 reported on only 8 patients with IIH treated with HBO (100% oxygen at 2 atmospheres absolute daily for 15 days) 3
- While this study reported gradual disappearance of signs and symptoms of elevated intracranial pressure, no lasting effects were observed after concluding therapy
- The study was small, uncontrolled, and lacked rigorous methodology
Potential Concerns with HBOT in IIH
Several studies examining HBOT's effects on intracranial pressure raise concerns:
- HBOT may initially reduce ICP due to cerebral vasoconstriction from hyperoxia, but ICP tends to increase gradually during continued HBO inhalation 4
- Rebound elevations in ICP may occur during or after treatment 5
- The effects appear transient with no lasting benefit after therapy conclusion 3, 5
Established Management Approaches for IIH
Current guidelines recommend the following evidence-based approaches 1, 2:
First-line treatments:
- Weight loss program for patients with BMI >30 kg/m²
- Acetazolamide (starting at 250-500mg twice daily, maximum 4g daily as tolerated)
Second-line treatments:
- Topiramate (starting at 25mg daily with weekly escalation to 50mg twice daily)
- CSF diversion procedures (only after intracranial pressure monitoring)
For acute visual deterioration:
- Corticosteroids (short-term use)
- Surgical interventions:
- Ventriculoperitoneal shunt (preferred due to lower revision rates)
- Lumboperitoneal shunt
- Optic nerve sheath fenestration (for asymmetric papilledema)
Monitoring and Follow-up
Regular ophthalmological evaluations are essential to monitor:
- Papilledema
- Visual acuity
- Visual fields
- Optical coherence tomography (OCT)
Follow-up frequency should be based on severity of papilledema and visual field status 1, 2.
Conclusion
While some limited preliminary research suggests HBOT might temporarily affect ICP, there is insufficient evidence to support its use in IIH management. The potential risks of HBOT (including barotrauma, oxygen toxicity, and possible ICP rebound) combined with its cost and time-intensive nature make it an unsuitable option for IIH treatment based on current evidence and guidelines.
Patients with IIH should be managed according to established guidelines with proven interventions including weight loss, acetazolamide, topiramate, and when necessary, surgical interventions for cases refractory to medical management or with threatened vision.