Management of High Pressure Headache Symptoms with Normal Opening Pressure
When a patient presents with symptoms suggestive of elevated intracranial pressure but has normal opening pressure on lumbar puncture, treat the headache phenotype directly with migraine-specific therapies rather than pursuing ICP-lowering interventions. 1
Initial Assessment and Recognition
The key clinical challenge here is distinguishing between true intracranial hypertension and other headache disorders that mimic elevated ICP symptoms. Normal opening pressure (typically <20-25 cm H₂O) effectively rules out idiopathic intracranial hypertension as the primary driver of symptoms. 2, 3
Important caveat: A single normal LP does not completely exclude intermittent or positional ICP elevations, but pursuing invasive ICP monitoring should only occur in highly selected cases within a multidisciplinary setting. 1
Primary Management Strategy
Headache Phenotype Assessment and Treatment
Characterize the specific headache features: Assess for migrainous characteristics including moderate-to-severe throbbing pain, photophobia, phonophobia, nausea, and movement intolerance, which occur in 68% of patients initially suspected of having IIH. 1
Implement lifestyle modifications immediately: Limit caffeine intake, ensure regular meals with adequate hydration, establish sleep hygiene, and introduce behavioral techniques such as cognitive-behavioral therapy or mindfulness. 1
Initiate acute migraine therapy: Use triptans combined with NSAIDs (such as indomethacin, which may have additional ICP-lowering effects) or paracetamol plus an antiemetic with prokinetic properties, limiting use to maximum 2 days per week or 10 days per month to prevent medication overuse. 1
Start preventative medications early: Introduce migraine preventatives promptly as they require 3-4 months to reach maximal efficacy. 1
Critical Pitfall: Medication Overuse Headache
Screen aggressively for medication overuse headache (MOH), which is extremely common in this population and will prevent any preventative treatment from working. 1
- Non-opioid and triptan medications can be stopped abruptly or weaned within one month. 1
- If opioids are involved (which should never be prescribed for these headaches), gradual removal over at least one month is required. 1
- Successfully addressing MOH significantly improves headache outcomes and is essential before other interventions will be effective. 1
What NOT to Do
Do not use acetazolamide for headache treatment alone—it has not been shown to be effective for headache management in the absence of elevated ICP. 1
Do not perform repeated lumbar punctures for headache treatment when opening pressure is normal—this is not recommended and lacks evidence. 1
Do not consider CSF diversion procedures (shunting) for headache management without documented elevated ICP on continuous monitoring in a multidisciplinary setting. 1
Avoid neurovascular stenting, which is not a treatment for headache alone. 1
When to Escalate Care
If headaches remain refractory to conservative migraine management and medication overuse has been addressed:
- Refer to a specialist headache service for advanced management. 1
- Consider multidisciplinary discussion regarding continuous ICP monitoring only if there is strong clinical suspicion for intermittent ICP elevations despite normal LP. 1
- Continuous ICP monitoring (not single LP measurements) would be required before any surgical intervention could be justified. 1
Special Monitoring Considerations
While these patients do not have confirmed intracranial hypertension, if papilledema was present at any point or visual symptoms exist, ophthalmologic follow-up is warranted to ensure no progression occurs. 1 However, the absence of elevated opening pressure makes aggressive ICP-directed therapy inappropriate.