What is the treatment for headaches due to Idiopathic Intracranial Hypertension (IIH) or pseudo tumor?

Headache Treatment in Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)

For headaches in IIH, start with short-term NSAIDs or paracetamol (indomethacin preferred for its ICP-lowering effect), immediately counsel patients about medication overuse headache risks, and initiate migraine preventative therapy early since 68% of IIH patients have migrainous headaches—topiramate is particularly advantageous as it addresses both ICP reduction and migraine prevention while promoting weight loss. 1, 2

Acute Headache Management (First Few Weeks)

Initial Analgesics

• Use NSAIDs or paracetamol for short-term relief in newly diagnosed patients 1
• Indomethacin is the preferred NSAID because it specifically reduces intracranial pressure in addition to providing analgesia 1, 3
• Provide gastric protection when using NSAIDs due to GI side effect risks 1
• Never prescribe opioids for IIH headaches—they are contraindicated and increase risk of medication overuse headache 1, 4

Critical Early Counseling

• Warn patients immediately about medication overuse headache: using simple analgesics more than 15 days per month or triptans/opioids more than 10 days per month for over 3 months will worsen their headache burden 1, 3
• Explain that headaches evolve over time and may persist even after ICP normalizes 1, 2

Preventative Therapy (Start Early)

First-Line Preventative Options

• Begin migraine preventatives early since they require 3-4 months to reach maximal efficacy 1, 2
• Topiramate is the preferred preventative agent with multiple mechanisms: carbonic anhydrase inhibition (reduces ICP), weight loss promotion, and migraine prophylaxis 2, 3, 5
• Start topiramate at 25 mg and escalate weekly to 50 mg twice daily 1, 3
• Counsel women that topiramate reduces contraceptive pill efficacy and carries teratogenic risks 1, 3
• Warn about side effects including depression and cognitive slowing 1, 3

Alternative Preventative Agents

• Candesartan: useful alternative with no weight gain or depressive side effects 2, 3
• Venlafaxine: weight-neutral and helpful for comorbid depression, which is common in IIH 2, 3
• Avoid medications that cause weight gain (beta-blockers, tricyclic antidepressants, sodium valproate) as they can worsen IIH 1, 2

Treatment for Migrainous Attacks

Acute Migraine Therapy

• For moderate-to-severe throbbing pain with photophobia, phonophobia, nausea, or movement intolerance, use triptans combined with NSAIDs or paracetamol plus an antiemetic with prokinetic properties 1, 3
• Strictly limit triptan use to 2 days per week or maximum 10 days per month to prevent medication overuse headache 1, 2
• These therapies work best once papilledema has resolved (IIH in ocular remission) 1

Botulinum Toxin

• Consider botulinum toxin A for patients with coexisting chronic migraine 2, 3

Lifestyle Modifications

• Implement strategies to limit caffeine intake 1, 3
• Ensure regular meals and adequate hydration 1, 3
• Establish exercise program and sleep hygiene 1, 3
• Consider behavioral techniques: yoga, cognitive-behavioral therapy, mindfulness 1, 3

What NOT to Do

Ineffective or Harmful Approaches

• Acetazolamide alone does not effectively treat headache in IIH—it addresses ICP and papilledema but not headache disability 1
• Serial lumbar punctures are not recommended for headache management despite providing temporary relief, as CSF is replaced at 25 mL/hour 1, 3
• Greater occipital nerve blocks lack evidence and consensus for IIH headache treatment 1
• CSF diversion surgery is not recommended for headache alone: 68% continue having headaches at 6 months and 79% at 2 years post-procedure 2, 3
• Neurovascular stenting is not recommended for headache treatment due to limited evidence 2

Managing Medication Overuse Headache

Withdrawal Protocols

• Successfully removing excessive analgesic use significantly improves headaches 1
• Non-opioids and triptans: stop abruptly or wean within one month 1, 3
• Opioids: gradually remove over at least one month, then maintain painkiller-free period to assess effectiveness 1, 3
• Addressing medication overuse is essential because it prevents optimization of preventative treatments 1, 3

Common Pitfalls to Avoid

• Failing to start preventative medications early enough—they take 3-4 months to work, so delays prolong suffering 1, 2
• Not recognizing medication overuse headache patterns early—this perpetuates the headache cycle 2, 3
• Prescribing weight-gaining medications for migraine prevention, which worsens the underlying IIH 1, 2
• Relying on CSF procedures for headache relief—these address vision loss, not headache disability 2, 3
• Using acetazolamide as sole headache therapy—it treats elevated ICP but not the migrainous component present in most patients 1