Headache frequency and symptoms of depression as predictors of disability in patients with idiopathic intracranial hypertension

Predictors of Headaches and Quality of Life in Women with Ophthalmologically Resolved Idiopathic Intracranial Hypertension

Background/objectives: The aim of this study was to evaluate the long-term outcomes of a cohort of ophthalmologically resolved female idiopathic intracranial hypertension (IIH) patients. Methods: Our cross-sectional study included adult females with at least 6 months of ophthalmologically resolved IIH. Patients with papilledema or who underwent IIH-targeted surgical intervention were excluded. Participants completed a questionnaire consisting of medical information, the Migraine Disability Assessment Scale (MIDAS) and the Headache Impact Test (HIT-6). Electronic medical records and the results of imaging upon diagnosis were retrospectively reviewed. Results: One-hundred-and-four participants (mean age 35.5 ± 11.9 years) were included (7.85 ± 7 years post-IIH diagnosis). Patients with moderate-severe disability according to the MIDAS scale (n = 68, 65.4%) were younger (32.4 ± 8.9 vs. 41.5 ± 14.4 year-old, p < 0.001), had a shorter time interval from IIH diagnosis (5.9 ± 5.3 vs. 11.7 ± 8.5 years, p < 0.001), and had lower FARB scores (indicating a more narrowed transverse-sigmoid junction; 1.28 ± 1.82 vs. 2.47 ± 2.3, p = 0.02) in comparison to patients with low-mild disability scores. In multivariate analysis, a lower FARB score (OR 1.28, 95% CI 0.89-1.75, p = 0.12) and younger age (OR 1.09, 95% CI 0.98-1.19, p = 0.13) showed a trend toward an association with a moderate-severe MIDAS score. Moreover, in the sub-analysis of patients with a moderate-severe MIDAS scale score, the 10 patients with the highest MIDAS scores had a low FARB score (1.6 ± 1.1 vs. 2.7 ± 2.4, p = 0.041). Conclusions: High numbers of patients with ophthalmologically resolved IIH continue to suffer from related symptoms. Symptoms may be associated with the length of time from the diagnosis of IIH and a lower FARB score.

Idiopathic intracranial hypertension: a step change in understanding the disease mechanisms

The understanding of idiopathic intracranial hypertension (IIH) has evolved over the past few years. Previously, IIH was considered a disease exclusively affecting the neuro-ophthalmic axis, characterized by raised intracranial pressure, headache and papilloedema, and resulting in the risk of severe and permanent visual loss and life-changing disabling headaches. Recent advances have begun to redefine IIH as a probable metabolic disease involving a range of systemic manifestations. More than 95% of individuals affected by the disease are women of reproductive age with obesity. The incidence is rapidly rising and parallels the escalating worldwide obesity rates. Contemporary insights identify associations with insulin resistance, type 2 diabetes and a twofold increased risk of cardiovascular disease in excess of that driven by obesity alone. Adipose distribution in people with IIH, like that in other metabolic diseases, is preferentially centripetal and is associated with changes in intracranial pressure. Evidence now demonstrates adipose tissue dysfunction in people with IIH, involving transcriptional and metabolic priming for lipogenesis and weight gain. Hormonal perturbations are also observed, including a unique phenotype of androgen excess that promotes cerebrospinal fluid secretion. Knowledge of these additional disease features is driving research into novel therapeutic targets and altering the approach to multidisciplinary care.

Depression and anxiety in women with idiopathic intracranial hypertension compared to migraine: A matched controlled cohort study

OBJECTIVE

To evaluate mental health burden in women with idiopathic intracranial hypertension (IIH) compared to matched women with migraine and population controls.

BACKGROUND

Depression and anxiety are recognized comorbid conditions in those with IIH and lead to worse predicted medical outcomes. The mental health burden in IIH has not been previously evaluated in a large, matched cohort study.

METHODS

We performed a population-based matched, retrospective cohort study to explore mental health outcomes (depression and anxiety). We used data from IQVIA Medical Research Data, an anonymized, nationally representative primary care electronic medical records database in the United Kingdom, from January 1, 1995, to September 25, 2019. Women aged ≥16 years were eligible for inclusion. Women with IIH (exposure) were matched by age and body mass index with up to 10 control women without IIH but with migraine (migraine controls), and without IIH or migraine (population controls).

RESULTS

A total of 3411 women with IIH, 30,879 migraine controls and 33,495 population controls were included. Of these, 237, 2372 and 1695 women with IIH, migraine controls and population controls, respectively, developed depression during follow-up, and 179, 1826 and 1197, respectively, developed anxiety. There was a greater hazard of depression and anxiety in IIH compared to population controls (adjusted hazard ratio [aHR] 1.38, 95% confidence interval [CI] 1.20-1.58; and aHR 1.40, 95% CI 1.19-1.64, respectively), while hazards were similar to migraine controls (aHR 0.98, 95% CI 0.86-1.13; and aHR 0.98, 95% CI 0.83-1.14, respectively).

CONCLUSION

Depression and anxiety burden in women with IIH is higher than in the general population, and comparable to that in matched women with migraine. This may indicate that presence of headache is a potential driver for comorbid depression and anxiety in IIH.

Headache, Opiate Use, and Prescribing Trends in Women With Idiopathic Intracranial Hypertension: A Population-Based Matched Cohort Study

BACKGROUND AND OBJECTIVES

Physician prescribing habits for opiates and headache therapies have not been previously evaluated in a large, matched cohort study in idiopathic intracranial hypertension (IIH). Our objective was to evaluate opiate and headache medication prescribing habits in women with IIH compared with matched women with migraine and population controls. We also investigated the occurrence of new onset headache in IIH compared with population controls.

METHODS

We performed a population-based matched, retrospective cohort study to explore headache outcomes. Cross-sectional analyses were used to describe medication prescribing patterns. We used data from IQVIA Medical Research Data, an anonymized, nationally representative primary care electronic medical record database in the United Kingdom, from January 1, 1995, to September 25, 2019. Women aged 16 years and older were eligible for inclusion. Women with IIH (exposure) were matched by age and body mass index with up to 10 control women without IIH but with migraine (migraine controls), and without IIH or migraine (population controls).

RESULTS

A total of 3,411 women with IIH, 13,966 migraine controls, and 33,495 population controls were included. The adjusted hazard ratio for new onset headache in IIH compared with population controls was 3.09 (95% CI 2.78-3.43). In the first year after diagnosis, 58% of women with IIH were prescribed acetazolamide and 20% topiramate. In total, 20% of women with IIH were prescribed opiates within the first year of their diagnosis, reducing to 17% after 6 years, compared with 8% and 11% among those with migraine, respectively. Twice as many women with IIH were prescribed opiates compared with migraine controls, and 3 times as many women with IIH were prescribed opiates compared with population controls. Women with IIH were also prescribed more headache preventative medications compared with migraine controls.

DISCUSSION

Women with IIH were more likely to be prescribed opiate and simple analgesics compared with both migraine and population controls. Women with IIH trialed more preventative medications over their disease course suggesting that headaches in IIH may be more refractory to treatment.

[CME: Idiopathic Intracranial Hypertension]

CME: Idiopathic Intracranial Hypertension Abstract. Idiopathic intracranial hypertension is a pressure-induced secondary headache disorder and optic neuropathy. It primarily affects obese women of childbearing age and poses an interdisciplinary challenge both diagnostically and therapeutically. The most common symptom of this disorder are headaches frequently accompanied by photo- and/or phonophobia, whose semiology often resembles that of migraine, followed by transient visual obscurations and pulsatile tinnitus. While protection of visual acuity and visual fields are of first therapeutical priority, adequate headache treatment also plays a key role. In the majority of cases, conservative treatment including weight loss and pharmacological therapy is sufficient. In case of a fulminant disease course or loss of visual function, interventional strategies can be applied additionally. Headache treatment is guided by the predominant semiology.

Depression and generalized anxiety symptoms in idiopathic intracranial hypertension: Prevalence, under-reporting and effect on visual outcome

BACKGROUND

Patients with idiopathic intracranial hypertension (IIH) have been reported to have high prevalence of co-existent mood disorders. We investigated the frequency of symptoms of depression and anxiety in a large cohort of patients with IIH without a known psychiatric diagnosis and compared it with the age- and gender-matched control group. We also studied whether the presence and severity of co-existing mood disorder was related to visual outcome in patients with IIH.

METHODS

The Patient Health Questionnaire-8 (PHQ-8) for depression symptoms and the Generalized Anxiety Disorder-7 (GAD-7) questionnaire for symptoms of generalized anxiety were administered via telephone survey to 100 patients with known diagnosis of IIH and 100 control subjects (matched for age and gender) who did not report a history of anxiety or depression during their prior in-person consultations. All participants were also asked whether they had ever been previously diagnosed with a mood disorder during this telephone assessment. Administered questionnaire results were correlated with final visual outcome in IIH cohort.

RESULTS

34 IIH patients and 36 controls self-reported anxiety and/or depression when specifically asked if they had ever been diagnosed with these conditions although this was not reported on clinic intake questionnaires. Mean PHQ-8 depression scale score was 6.5 ± 0.6 in control group and 7.6 ± 0.6 in IIH group (p = 0.18). Mean GAD-7 score was 6.3 ± 0.5 in control group and 7.7 ± 0.6 in the IIH group (p = 0.06). In multivariable regression, scores on both scales were correlated with higher body mass index (BMI), younger age and presence of headache, but not with IIH diagnosis. In the IIH cohort, visual outcomes were not related to GAD-7 or PHQ-8 scores but were predicted by mean deviation on visual fields at presentation.

CONCLUSIONS

Pre-existing diagnosis of anxiety and depression are highly under-reported. Symptoms of anxiety and depression are very common in young women with elevated BMI and headache, however, there was no statistical difference in frequency of these symptoms between IIH and control groups. Presence and severity of mood disorder symptoms did not correlate with the final visual outcome in patients with IIH.

Incidence of idiopathic intracranial hypertension in Southern Tasmania, Australia

Introduction

Anecdotally, the incidence of idiopathic intracranial hypertension (IIH) is increasing, linked to an increase in the obesity rate in Australian society. However, formal incidence and prevalence studies are rare. We therefore sought to determine the incidence and clinical features of IIH in Southern Tasmania, Australia.

Method

Neurology discharge summaries and lumbar puncture referrals from the single tertiary referral centre in this region were screened for an IIH diagnosis. All regional neurologists were surveyed to capture patients diagnosed through private neurology clinics. A retrospective review of medical records was conducted to confirm the diagnosis and determine whether patients met the Modified Dandy Criteria (MDC). Patients were included if they were above the age of 18 years and received a new diagnosis of IIH between June 2016 and June 2018. Population statistics were obtained from the Australian Bureau of Statistics.

Results

IIH incidence was 5.4/100 000. All patients were females, aged between 18 and 45 years. Headache was the most commonly reported symptom, with high rates of pre-existing or concurrent migraine diagnoses. Weight loss and commencement of oral acetazolamide were the most common treatment approaches. Four patients were medically refractory and required surgical intervention.

Conclusion

The incidence of IIH in Southern Tasmania is comparable with the incidence reported in subgroups of females of childbearing age in recent prior studies. The demographic, diagnostic and therapeutic data presented can inform future local health service provision and serve as a baseline for ongoing assessment of change in incidence and treatment of IIH at a community level.

Headache attributed to idiopathic intracranial hypertension and persistent post-idiopathic intracranial hypertension headache: A narrative review

OBJECTIVE

Headache is a near-universal sequela of idiopathic intracranial hypertension (IIH). The aim of this paper is to report current knowledge of headache in IIH and to identify therapeutic options.

BACKGROUND

Disability in IIH is predominantly driven by headache; thus, headache management is an urgent and unmet clinical need. At present, there is currently no scientific evidence for the directed use of abortive or preventative headache therapy.

METHODS

A detailed search of the scientific literature and narrative review was performed.

RESULTS

Headache in IIH is driven by raised intracranial pressure (ICP) and reduction of ICP has been reported in some studies to reduce headache. Despite resolution of papilledema and normalization of raised ICP, a majority suffer persistent post-IIH headache. The lack of evidence-based management approaches leaves many untreated. Where clinicians attempt to manage IIH headache, they use off-label therapies to target the prevailing headache phenotype. A recent prospective open-label study demonstrated the effective use of a calcitonin gene-related peptide monoclonal antibody therapy in IIH for persistent post-IIH headache.

CONCLUSIONS

There is overwhelming evidence of the headache burden in IIH. Studies are required to investigate the biological foundations of headache related to ICP and to develop treatments specifically directed to manage headache in IIH.

Psychiatric symptoms are frequent in idiopathic intracranial hypertension patients

Idiopathic intracranial hypertension (IIH) is a rare disease with an incidence rate of 0.5-2.0/100,000/year. Characteristic symptoms are headache and several degrees of visual impairment. Psychiatric symptoms in association with IIH are usually poorly described and underestimated. In this study, we evaluated IIH subjects to determine the association with psychiatric symptoms. We evaluated thirty consecutive patients with IIH submitted to neurosurgery from January 2017 to January 2020 in two Brazilian tertiary hospitals. They underwent clinical evaluation, obtaining medical history, comorbidities, body mass index (BMI-kg/m²), and applying Neuropsychiatric Inventory Questionnaire (NPI-Q). There were 28 females and 2 males. Ages ranged from 18 to 66 years old, with mean age of 37.97 ± 12.78. Twenty-five (83%) presented comorbidities, being obese and having arterial hypertension the most frequent. Body mass index ranged from 25 to 35 kg/m² and mean value was 31 ± 3.42. After application of Neuropsychiatric Interview, 26 of 30 presented psychiatric symptoms (86%). Depression-anxiety syndromes were reported in 25 patients (83%). Nighttime disturbances were reported by 14 subjects (46%). Appetite and eating disorders were described by 23 (76%). Psychiatric symptoms in association with IIH are usually poorly described and underestimated. In our sample, twenty-six out of 30 (86%) reported psychiatric symptoms. We highlight the high prevalence of psychiatric symptoms among IIH patients and the need of managing these patients with a multidisciplinary team, including psychiatrists.

Mortality among patients with idiopathic intracranial hypertension enrolled in the IH Registry

OBJECTIVE

To determine (1) if mortality among patients with idiopathic intracranial hypertension (IIH) enrolled in the Intracranial Hypertension Registry (IHR) is different from that of the general population of the United States and (2) what the leading underlying causes of death are among this cohort.

METHODS

Mortality and underlying causes of death were ascertained from the National Death Index. Indirect standardization using age- and sex-specific nationwide all-cause and cause-specific mortality data extracted from the Centers for Disease Control and Prevention Wonder Online Database allowed for calculation of standardized mortality ratios (SMR).

RESULTS

There were 47 deaths (96% female) among 1437 IHR participants that met inclusion criteria. The average age at death was 46 years (range, 20-95 years). Participants of the IHR experienced higher all-cause mortality than the general population (SMR, 1.5; 95% confidence interval [CI], 1.2-2.1). Suicide, accidents, and deaths from medical/surgical complications were the most common underlying causes, accounting for 43% of all deaths. When compared to the general population, the risk of suicide was over 6 times greater (SMR, 6.1; 95% CI, 2.9-12.7) and the risk of death from accidental overdose was over 3 times greater (SMR, 3.5; 95% CI, 1.6-7.7). The risk of suicide by overdose was over 15 times greater among the IHR cohort than in the general population (SMR, 15.3; 95% CI, 6.4-36.7).

CONCLUSIONS

Patients with IIH in the IHR possess significantly increased risks of death from suicide and accidental overdose compared to the general population. Complications of medical/surgical treatments were also major contributors to mortality. Depression and disability were common among decedents. These findings should be interpreted with caution as the IHR database is likely subject to selection bias.

Advances in the understanding of headache in idiopathic intracranial hypertension

PURPOSE OF REVIEW

To review the most relevant developments in the understanding of headache in idiopathic intracranial hypertension (IIH).

RECENT FINDINGS

The phenotype of the typical IIH headache is diverging from the historical thinking of a raised intracranial pressure headache, with the majority being classified as having migraine. A larger proportion of those with IIH have a past medical history of migraine, compared with the general population, highlighting the importance of re-examining those who have a change or escalation in their headache. The mechanisms underlying headache in IIH are not understood. Additionally, factors which confer a poor headache prognosis are not established. It is clear, however, that headache has a detrimental effect on all aspects of the patient's quality of life and is currently ranked highly as a research priority by IIH patients to better understand the pathophysiology of headache in IIH and identification of potential headache specific therapeutic agents.

SUMMARY

Headache remains the predominate morbidity in the majority of those with IIH. Headache management is an unmet need in IIH and future studies are required to investigate the probable complex mechanisms, as well as effective management.