Epidural Steroids and Idiopathic Intracranial Hypertension
Epidural steroid injections do not cause idiopathic intracranial hypertension (IIH); however, systemic corticosteroid withdrawal—not epidural administration—has been associated with secondary intracranial hypertension.
Evidence for Corticosteroid-Related Intracranial Hypertension
The relationship between corticosteroids and intracranial hypertension is paradoxical and relates to withdrawal rather than administration:
Corticosteroid withdrawal has been documented to cause a syndrome indistinguishable from benign intracranial hypertension in children when dosage is reduced, with the total duration and rate of reduction appearing to be important factors 1.
Secondary adrenal insufficiency following withdrawal of corticosteroids (including inhaled formulations) can present as IIH, with gradual improvement after steroid replacement 2.
In a systematic review of drug-induced intracranial hypertension, corticosteroids were classified as only moderately associated (Category III) with drug-induced intracranial hypertension 3.
Epidural Steroid Injections: Distinct Complications
Epidural steroid injections carry different risks unrelated to IIH:
The primary intracranial complication from epidural injections is intracranial hypotension (not hypertension) due to CSF leak, which can be associated with spinal epidural hematoma 4.
This represents the opposite pathophysiology from IIH—decreased rather than increased intracranial pressure 4.
Diagnostic Criteria Context
IIH is defined by specific criteria that exclude secondary causes 5:
- Elevated intracranial pressure without hydrocephalus or mass lesion
- Normal CSF composition
- No underlying etiology identified (hence "idiopathic")
- Strong association with obesity, particularly in women of childbearing age 5
Clinical Pitfalls to Avoid
Do not confuse epidural steroid administration with systemic corticosteroid therapy. The local depot effect of epidural steroids does not produce the systemic exposure or subsequent withdrawal syndrome associated with intracranial hypertension 1, 2.
If a patient develops symptoms of raised intracranial pressure after epidural injection, consider intracranial hypotension from dural puncture first, not IIH 4. The headache characteristics differ: low-pressure headaches worsen when upright and improve when supine, opposite to typical IIH headaches 5.
When evaluating potential drug-induced intracranial hypertension, the strongly associated medications are vitamin A derivatives, tetracycline-class antibiotics, recombinant growth hormone, and lithium—not epidural steroids 3.