IIH is one of the most commonly encountered diseases in neuro-ophthalmology and its management often comes with significant challenges, one of which is headache management.

 

A “state of art review” written by Deborah Friedman (click on logo) and published in the March 2019 edition of the JNO offers an excellent approach to headache management in IIH and provides an overview of the currently used medications for different types of headaches associated with IIH.

 

Although the entire article is undoubtfully worth reading, here is a summary of a few key concepts that I found particularly interesting. 

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APPROACH OF HEADACHE MANAGEMENT IN IIH:     

 

 

I found the 6 FACTORS TO CONSIDER in headache management in IIH suggested in the

article very useful. Here is a summary:

 

1. IIH Control

   1. Make sure that the patient is adherent to the ICP lowering therapy.

   2. Assess shunt functioning – In absence of recurrent papilledema, repeating the             LP might be indicated.

2. Determine headache phenotype (Refer to Table 1 of the article for ICHD-3 criteria)

   1. Migrainous type

   2. Tension type

   3. Chronic headache

3. Review treatments tried

   1. Previously tried medications – Effectiveness and Side effects

   2. Ask specifically for over the counter medications and

4. Determine other risk factors

   1. OSA

   2. Caffeine intake (I personally tend to forget to ask about caffeine, but the potential of caffeine in increasing the intracranial pressure, even if transient, should not be overlooked.)

5. Coexisting conditions:

   1. Conditions that can affect the choice of headache medication: Obesity (try to avoid medication associated with weight gain), anxiety, depression (some medication can be useful for both headaches and despression), PCOS

6. Other factors contributing to adherence

   1. Cost, Insurance coverage.

 

OVERVIEW OF THERAPIES BASED ON HEADACHE TYPE:

 

Here is a summary of the medications discussed in the article. *Refer to Table 3 of the article for a complete list of treatment options *

 

1. Migraine or chronic headache phenotypes

   • ACUTE: Nonpharmacologic (ice, massage, biofeedback…), Simple analgesics (Acetaminophen 1000mg), Triptans, dihydroergotamines. NEW options: Neuromodulation (supraorbital nerve stimulation, noninvasive vagus nerve stimulation, transcranial nerve stimulation), CGRP (atogepant and rimegepant) and 5-HT1F receptor agonist (lasmiditan).

*Try to avoid medications that contain opioids or barbiturates, as well as combinations with caffeine (can raise ICP transiently) *

• CHRONIC: Consider If patient needs more that 2-3 times of acute therapy weekly, or if the headaches have a significant impact on the daily activities, there are more than 4 severe attacks per month or the patient has contraindications for acute therapy.

  • Antiepileptics: Topiramate (Level A- 50-200mg dailyà can promote weight loss which is attractive in IIH. Cognitive side effects can limit its use. CI in pregnancy. Zonisamide is another option is Topiramate is not tolerated. Sodium valproate/divalproex and gabapentin can cause weight gain.

  • Antidepressants: Useful especially in patients with coexisting depression. Amitriptyline (Level B - recommended as a preventive migraine medication in IHTT) and Venlafaxine (Level B withdrawal symptoms might limit its use)

  • NSAIDS: Longer-acting are less associated with medication overuse headache (Naproxen – Level B 500-1500mg/Ketoprofen) compared with short-acting NSAIDS like ibuprofen.

  • Antihypertensives: Bblockers (Propanolol - Level A 80-240mg daily) but may worsen depression which is commonly present in IIH.

  • Other: Magnesium citrate (Level B 400-600mg daily), Riboflavin (Vitamin B2 400mg daily – Level B), Onabotulinumtoxin A every 12 weeks (Level A- 31 prefixed injections of 5 UI in the head and neck). More recently, Anti-CGRP (Erenumab, Fremanezumab, Galcanezumab) Level of evidence still pending although studies suggest Level A for migraines. Consider if failure with other oral preventives.

   2. Tension-Type headaches

• ACUTE: NSAIDS

• CHRONIC: Combination of muscle relaxant and antidepressand (e.g. tizanidine or cyclobenzaprine). Mirtazapine commonly causes weight gain and is probably not ideal for patients with IIH.

Behavioral treatments 

• Relaxation training, biofeedback, cognitive behavioral therapies, mindfulness meditation,…

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Link to full article: https://journals.lww.com/jneuro-ophthalmology/Fulltext/2019/03000/Headaches_in_Idiopathic_Intracranial_Hypertension.15.aspx