So let's talk a little bit more
about high-pressure headaches.
What are the types?
How do we evaluate them
and what are the treatment?
headaches occur as a result
of increase in the
total cranial volume.
And there's really 3 things
that sit in the cranial vault,
there's the brain tissue, the
CSF, and the vascular system.
And an increase in any of those
one compartments too quickly
can result in a
Too much brain can result
in a high-pressure headache,
and that's a brain tumor.
Too much cerebral spinal fluid can
result in a high-pressure headache,
and we call that
It looks like a tumor.
But when we do imaging to evaluate
the tumor, we don't see it.
It's not a too much brain
problem or brain tumor,
it's too much CSF, that's contributing
to that patient's symptoms.
Or too much of
the blood vessels,
and in this case,
the veins and the finding,
we would see there would be a venous sinus
thrombus increase in the total venous
volume can contribute to
And these patients can have a
positional component to their headache.
However, the early awakening
is the most concerning feature
that really is the red flag that points
us to needing secondary evaluation.
So what are the full constellation of
symptoms that we see in these patients?
Patients can present
with frontal headache,
but we see many causes
of frontal headache.
And so that's not the most
specific clinical description.
The headache can be
worse with lying flat,
but that's actually not
the most prominent symptom
that we usually see
in most patients.
What is important is
early-morning awakening headaches.
When we go to sleep,
we slowly reduce our respiratory rate.
And as the respiratory rate goes
down, we maintain good oxygenation.
But we reduce the amount
of CO2 that we blow off.
There's extra CO2 circulating
around in the system at night,
and it builds up slowly
over the course of night.
CO2 can cross the blood brain
barrier and it is a venodilator.
So over the course of the
evening and the night,
we get extra CO2 in
the cerebral veins,
there is relative venodilation.
And that venodilation increases the
total volume in the cranial vault.
And so patients with
high pressure headaches,
develop increased pressure in
the brain developing overnight
and present with
They don't wake up and then find they
have a headache at 3 or 4 or 5am.
The headache awakens
them from sleep,
and that's a red flag symptom that prompts
and needs to prompt further evaluation.
These headaches can be initiated
by coughing, sneezing, or Valsalva.
Again, those are maneuvers that reduce
the venous egress from the brain.
When you Valsalva
or sneeze or cough.
There's reduced venous
egress, venous exit,
drainage of the blood through
the venous system from the brain.
There's extra blood within the venous
compartment and that increases rapidly
resulting in increased
total brain volume
and accentuates that
Patients can present with peripheral field
defects, pulsatile tinnitus, or nausea.
And here on the schematic to the
right, we can see how the brain drains.
We have the superior sagittal sinus
and the inferior sagittal sinus
and obstruction to
either of those veins
can cause a high-pressure headache
like we saw in our patient.
Those drain down into the transverse
sinus which runs around the cerebellum
and we saw this transverse
sinus thrombosis in our patient.
This drains into the sigmoid sinus and
then ultimately down into the jugular vein
and blockage of any of those veins
can cause increase total brain
a volume and a high-pressure
headache or a venous sinus thrombus
as was the case for our patient.
So what are some of the causes
of high-pressure headaches?
We talked about increased brain
tissue from a brain tumor,
a brain abscess or inflammatory lesions
like Balo's concentric sclerosis.
Each of those can cause increase
in the total brain volume
and present with a
often with some other focal
neurologic deficit or seizure.
Too much CSF and that's called pseudotumor
cerebri or intracranial hypertension.
For some reason there is
increased CSF production
without the ability to reabsorb
that results in increased
total brain volume and a
Those patients present
like they have a tumor.
They can have papilledema
and high-pressure headaches.
And when we do a scan,
we don't see the tumor
and it's called
And then vascular system problems
like venous sinus thrombus.
So those are the three things
to consider in patients
who present with
How do we evaluate
Fundoscopic exam is critical.
This is a high pressure headache,
there is increased ICP and we look for that
through fundoscopy and
looking for papilledema
which is increased pressure
of the optic nerve head.
Papilledema would point us to needing
additional imaging with either CT or MRI.
And really MRI is the modality of
choice with and without contrast.
And we're looking for signs of a venous
sinus thrombosis or a tumor abscess
or other contributing cause.
And ultimately lumbar
puncture may be needed.
That's how we look at the pressure,
we can check an opening pressure
and look whether the opening
pressure in the CSF is elevated.
An opening pressure greater
than 25 or around 25 cm of water
is considered elevated
and would be diagnostic
of intracranial hypertension
or elevated ICP.
Here's an example of endoscopy and a
patient with intracranial hypertension.
This patient has
We see both the right and the left eye,
we're looking right in on the optic nerve,
and we see the optic
nerve head is bulging out.
We do not see a clear disc, a clear
line of well-demarcated optic disc.
Instead, as it bulges out,
we see a poorly defined
of the optic disc.
Sometimes that bulging
out obscures blood vessels
and we lose the ability
to see the blood vessels
as they course out
of the optic nerve
and optic disc to feed
the rest of the retina.
This is severe
which is indicative
of increased ICP
and would be consistent with a
high-pressure headache presentation.
This patient was treated with both
medical therapy, maximum medical therapy
and over time there was resolution
of the patient's papilledema.
And here in the bottom,
we see very well-demarcated optic nerves.
Look at the difference between the
bottom and top, those optic nerves.
We see the arteries exiting out
of the optic nerve and optic cup.
You can see the entire
course of the arteries
and resolved papilledema in
this patient who was treated.
And this is why funduscopy
is so important.
It's how we see the pressure
in the brain non-invasively.
How do we treat
Well, it really depends
on what the cause is.
Pseudotumor cerebri that idiopathic
too much pressure is treated
with a number of interventions.
Weight loss is important, to increase
weight can cause increased CSF production.
And so weight gain can be
one contributing factor
not always the only cause but an
important contributing factor.
And this is a
where we can reduce patient's likelihood
of developing severe vision loss
in association with
Acetazolamide is a medicine that
has carbonic anhydrase properties
that reduces CSF production.
It's not perfect,
and some patients can
fail this medicine.
But in patients where there's increased
CSF production, acetazolamide,
which reduces CSF production is
an important to intervention.
And for those that fail
with weight loss
will consider CSF diversion of ventricular
shunt diverting CSF out of the brain.
And in some cases,
for patients who have severe vision loss
or impending vision loss,
we would consider optic
and that's making small
cuts into the optic sheath
that surrounds the optic nerve and
allowing that CSF to egress out
to avoid a compression and ischemia
or infarction of the optic nerve.
For patients that have a brain tumor,
we need to find and treat the tumor
or whatever that cause may be
abscess or an inflammatory lesion.
And in patients who have
a venous sinus thrombus,
the treatment choices
and removal of the
Whether it be oral contraceptive pills
or underlying hypercoagulability,
or what the nytus was for of
the venous sinus thrombus.
So let's talk at the very end about
idiopathic intracranial hypertension.
This is a very important
condition to understand.
And I'd like for you know a little
bit about how we treat this.
The other name for this
is pseudotumor cerebri.
And you will see both of
those used interchangeably.
Weight loss is an
It's often not the
but weight gain is a
modifiable risk factor.
And so we counsel patients
in weight management
to help reduce the amount of CSF
production and manage this condition.
In addition, if patients do not
have an immediate threat to vision,
then we would consider medical
therapy with acetazolamide.
Starting at a moderate dose and
escalating that dose as needed
based on the
patient's vision exam
and so ophthalmology consultation
is critical for these patients.
We think about a headache assessment
evaluating the headache phenotype,
eliminating medications that may be
contributing or causing this condition.
Tetra cycling's are known
to cause pseudotumor cerebri
and there are others that
need to be evaluated,
and then we treat again with
acetazolamide and weight loss.
assessments are critical.
Looking at the degree of
papilledema is important
to understanding patient's
response to treatment.
If significant deterioration
in visual function occurs,
we would consider
diagnostic lumbar puncture.
We want to make sure that
the reason for the decline
is increase in
it's worsening of the
If the LP shows pathologically
high opening pressure,
then we would consider temporizing with a
lumbar drain to drain off the spinal fluid,
and if needed, potentially a
shunt or other intervention
to manage a CSF
or optic nerve fenestration.
Though this is really
rarely done these days,
and few ophthalmologists
would consider this
and really favor CSF
diversion these days.
If the opening pressure is
not pathologically high,
then we have time to reevaluate and
treat other potential offending causes.
So the management of
is important to understand
those broad strokes
if not each of the
And if the patient does present with
fulminant threat to their vision,
we would consider going straight
to CSF diversion or lumbar drain
or a procedure that would quickly
resolve this increase in CSF pressure.