What are the recommendations for using Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in patients with intracranial hypertension?

NSAIDs in Intracranial Hypertension

Short-term use of NSAIDs, particularly indomethacin, may be beneficial for headache management in idiopathic intracranial hypertension (IIH), but should be limited to avoid medication overuse headache.

Role of NSAIDs in IIH Management

The 2018 consensus guidelines on IIH management specifically address the use of NSAIDs for headache relief in IIH patients 1:

• NSAIDs are recommended for short-term pain relief in newly diagnosed IIH
• Indomethacin may have additional benefit due to its ICP-reducing effect
• Gastric protection may be needed when using NSAIDs due to potential side effects

Mechanism and Benefits

Indomethacin appears to have a dual benefit in IIH patients:

1. Pain relief for headache symptoms
2. Potential reduction of intracranial pressure (ICP) 2, 3

Important Cautions and Limitations

Medication Overuse Risk

Patients must be warned about medication overuse headache (MOH), which can occur with:

• Simple analgesics used on more than 15 days per month
• Combination preparations or triptans used on more than 10 days per month
• For more than 3 months 1

This is particularly important as MOH has been identified as an under-diagnosed problem in shunted IIH patients 4. A retrospective review found that MOH in shunted IIH patients can lead to hospital admissions, additional investigations, and procedures.

Association with IIH

Interestingly, research has shown that NSAID use may be independently associated with IIH. A large study using the Clinical Practice Research Datalink found that NSAID use (p=0.011) was independently associated with IIH after adjusting for confounders 5.

Comprehensive Management Approach for IIH

NSAIDs should be considered as part of a broader management strategy:

1. First-line medical therapy:

   • Acetazolamide (250-500mg twice daily, maximum 4g daily as tolerated) 2
   • Weight loss for patients with BMI >30 kg/m² 2

2. Alternative medications if acetazolamide is not tolerated:

   • Topiramate (starting at 25mg daily with weekly escalation to 50mg twice daily) 2
   • Zonisamide as a second-line option 2

3. Headache management:

   • Short-term NSAIDs or paracetamol for symptomatic relief 2
   • Indomethacin may have additional ICP-reducing benefits 2
   • Avoid opioids for headache management 2

4. Surgical interventions for refractory cases:

   • CSF diversion procedures (VP shunt preferred due to lower revision rates) 2
   • Venous sinus stenting for patients with venous sinus stenosis 2

Monitoring and Follow-up

Regular ophthalmologic evaluations are essential to monitor:

• Papilledema
• Visual acuity
• Visual fields
• Optical coherence tomography (OCT)

The frequency of monitoring should be based on the severity of papilledema and visual field status 2.

Key Pitfalls to Avoid

1. Medication overuse: Limit NSAID use to avoid MOH, which can complicate management and lead to unnecessary interventions 4

2. Neglecting gastric protection: Consider gastroprotective agents when prescribing NSAIDs, especially for longer courses 1

3. Opioid use: Avoid opioids for headache management in IIH patients 1, 2

4. Discontinuing acetazolamide prematurely: The main morbidity of IIH is visual loss, which requires consistent treatment 2

5. Inadequate follow-up: Extended follow-up (>5 years) is essential as late recurrences can occur 2

In summary, while NSAIDs (especially indomethacin) can play a role in managing headaches in IIH patients, they should be used judiciously with appropriate cautions regarding medication overuse and potential side effects. The primary focus of treatment should remain on reducing intracranial pressure through acetazolamide, weight loss, and when necessary, surgical interventions.