11/10/2017. Headache and Increased Pressure: A tale of 2 cases. Kathleen Digre MD University of Utah TWO CASES. 23 yo medical practice manager

Transcription

1 Headache and Increased Pressure: A tale of 2 cases Kathleen Digre MD University of Utah TWO CASES 23 yo medical practice manager September 2016 began developing intense frontal headaches first intermittent then continuous MR microadenoma Ophthalmology for blurred vision diagnosed by retina specialist as papilledema; OCT elevated nerve February 2017: neurologist: LP 230 mm CSF; Diamox started 1500 mg total slight decreased headache but frequency still there Headaches persist Visual blurring more prominent Left eye July

2 Past Medical history Weight lowest 5 years ago 200; has had steady weight gain Polycystic ovarian syndrome Sleep apnea on CPAP Pituitary microadenoma on cabergoline 0.25 mg each week since September 2016 FH: headaches, arthritis, depression SH: single; no smoking no alcohol Medications Acetazolamide 500 mg Three times daily Cabergoline 0.5 mg each week Vitamin D Citalopram 20 mg Etongestrel (implant) 68 mg subdermal Metformin 500 mg each day 2

3 Examination BP; 141/60; HR 85; Weight 294# BMI Normal Neurological examination 20/60; 20/250; no RAPD Visual fields full to finger quadrant; superior nasal red desaturation OS Color 5/6; 1/6; Stereo 5/9 circles Right eye Left eye 3

4 Case 2: 25 yowoman Past history of migraine has 2-3 headaches each week without aura; can last 24 hours. She has light and sound sensitivity and nausea Went to optometrist for routine eye exam and diagnosed with possible papilledema Vision otherwise normal No pulsatile tinnitus, diplopia, dim outs Weight gain 30# after her pregnancy Opening pressure 250 mm CSF VA 20/15 20/50 No RAPD Examination Otherwise normal neurological examination MR normal LP Opening pressure 250 mm CSF 4

5 5

6 Which one has IIH headache? Case 1? Case 2? Both? Neither? What we learned about HA in IIHTT? IIHTT-prospective; all had papilledema Headache present : 84% (165 baseline enrolled) Previous migraine history 41% (vs 18% general population) Headache phenotype by ICHD3 (not one feature diagnosed this headache) 52% migraine with 16% probable migraine 22% tension type with 4% probable tension type Medication overuse: 51% HIT 6 and quality of life correlated Headache disability didn t correlate with opening pressure (baseline or 6 months), BMI, weight loss, papilledema grade, visual field No difference between OP and those with or without headache! Friedman et al Headache 2017; 57:

7 MECHANISMS FOR HEADACHE WITH HIGH PRESSURE Traction on vessels (venous sinuses, arteries base of the brain), on cranial nerves, on cervical nerves Artificial elevation of CSF pressure: mild headache, no headache; therefore, not sure if pressure is the cause of the headache (Fay; Kunkle) Measuring ICP and headache: No correlation with the CSF pressure and headache (Johnston, Patterson) Migraine Connection: the elements are there Headache mechanisms Loss of CSF volume more important than the absolute pressure. Kunkle showed that 10% loss needed to set up headache (Trans Am Acad Ophthalmol Otolaryngol Nov-Dec;67:758-65) Alteration of Elasticity the hydrostatic effect can alter distensibility of the CSF space (Levine, Rapalino J Neuro Scien : 1-8) Over diagnosis of IIH Thinking errors: obese women with headache Examination error: optic nerve appearance (crowded disc, drusen, pseudo edema) Evaluation error: Didn t think about other causes Over diagnosis by pressure alone (too many things affect it: positioning, sedation, needle position, normal variation etc) Fisayo, Bruce, Newman, Biousse Neurology 2016: 86:

8 Do either need a shunt? Migraines do not resolve with shunts Shunts even in IIH fail (over 50%) Headaches do not resolve after shuntsin the long run (Sinclair et al) Eggenbergeret al NEUROLOGY 1996;46: % 77% 79% present absent Sinclair et al Cephalalgia 31(16) Lessons learned Listen to the overall history Don t worship the opening pressure alone Avoid making errors in over diagnosing IIH (be sure it is really papilledema) leads to unnecessary tests and procedures Treat the underlying headache phenotype (migraine) 8