19th June 2023

Management

There are 3 principles when it comes to the management of IIH:

1. Treat the underlying disease
2. Protect the vision
3. Manage headache itself

To treat the underlying disease – Weight loss is the only disease modifying therapy for typical IIH known to induce disease remission. Patients with IIH with a BMI >30 kg/m2 should be counselled about weight management, whilst also considering the biopsychosocial complexities around weight and weight loss.

To protect the vision – in the presence of declining visual function, surgical options are the most appropriate management options:

• CSF diversion procedures, e.g. ventriculoperitoneal shunt
• Optic nerve fenestration.

Lumbar drain can be a useful temporary option to protect vision whilst preparing for urgent surgical intervention.

To manage headache 

• Acetazolamide – carbonic anhydrase inhibitor. Reduces CSF production and can improve quality of life.

• Topiramate – if intolerant to acetazolamide. It has some carbonic anhydrase activity and can cause appetite suppression. Patients should be counselled about possible side effects, including teratogenicity, before prescribing topiramate.
• Acute headaches can be managed with NSAIDs and paracetamol, however, opioids are not recommended.
• Serial LP procedures (also known as therapeutic taps) can provide temporary relief of headaches; however, the CSF is rapidly replaced. It is not recommended due to potential associated risks, anxiety, and potential for acute and chronic back pain as a complication.

Follow up is advised with a multidisciplinary team, including ophthalmologist and neurologist. Frequently co-existing conditions like obstructive sleep apnoea, low mood, and polycystic ovary syndrome should be managed under the relevant specialist team.