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Obesity and headache disorders are two very common conditions in the general population that have been increasing in incidence over the last decades. Recent studies have shown a significant relationship between obesity and headaches, particularly migraine, with an important role in whether the disease is chronic. On the other hand, no such association was found with tension-type headaches. Studies showing an overlapping of hunger-control pathways and those involved in the pathophysiology of migraine may justify the close association between obesity and migraine. Moreover, a secondary headache for which obesity is a strong risk factor is idiopathic Intracranial Hypertension (pseudotumor cerebri), with several studies showing the impact of weight reduction/bariatric surgery in the treatment of the disease. In conclusion, since obesity is a modifiable risk factor, it is important for physicians treating patients with headaches, and particularly migraine, to be aware of the association between these two disorders.

Introduction: Headaches, visual problems and tinnitus are symptoms of Idiopathic Intracranial Hypertension (IIH) which resolve with reduction of CSF pressure. Impaired cranial venous outflow has been implicated in the pathogenesis and there is evidence of good treatment results in IIH using venous sinus stenting. We are currently initiating a multi-centre randomised controlled trial, the VISION study (Venous Intervention versus Shunting in IIH for Optic Disc Swelling) comparing radiological (venous sinus stenting) to surgical intervention (CSF shunting). As part of the preparations for VISION we made a basic questionnaire available to members of the website IIH UK ( www.iih.org.uk )., Methods: 10-point questionnaire pertaining to IIH diagnosis, symptoms and management using www.surveymonkey.com ., Results: 250 questionnaires were returned. 95.6% of respondents were female, mostly ≤40 years of age. 70% were diagnosed in the last 5 years, but only 35% were diagnosed less than a year after onset of symptoms. 59.4% of patients had not undergone any radiological/surgical intervention, 34.9% had had CSF diversion, 3.6% venous stenting and 2.0% had stent plus shunt. 16.8% indicated their lives were most affected by tinnitus and 18.1% by visual problems, but 49.6% said they were most affected by their headaches. 81% of patients indicated they would be happy to participate in a randomised trial comparing the two treatment options of venous stenting and CSF shunting., Conclusion: IIH patients want to be actively involved in their treatment and are favourably disposed towards clinical research. Variation exists in treatment modalities offered. There are individual differences regarding impact of symptoms.

Persistent headache and loss of visual acuity combined with papilledema are the predominant symptoms of idiopathic intracranial hypertension (IIH). The clinical signs are not different from those seen in other diseases with elevated intracranial pressure. To differentiate primary and secondary forms of increased intracranial pressure neuroimaging procedures and analysis of cerebrospinal fluid (CSF) are absolutely essential according to national and international guidelines. Lumbar puncture reveals an elevated opening pressure in cases of IIH as the only pathological finding. Treatment options are serial lumbar punctures combined with body weight reduction as well as medication with carbonic anhydrase inhibitors, such as acetazolamide and topiramate or diuretic therapy with furosemide. In some patients surgical options, e.g. optic nerve sheath fenestration, CSF shunting procedures including ventriculoperitoneal and lumboperitoneal shunt systems and bariatric surgery also have to be considered. In recent years modern neuroradiological procedures have also been applied (e.g. venous stenting in cases of sinus obstruction) in some centers.

Background and Purpose: Our aim was to prospectively describe the course of headache during the first year of idiopathic intracranial hypertension (IIH)., Methods: Patients with newly diagnosed IIH were consecutively included from December 2010 to June 2013. Treatment according to standard guidelines was initiated. Headache history was obtained by headache diaries and standardized interviews performed at baseline and after 1, 2, 3 and 12 months. Parallel changes in papilledema were assessed by optical coherence tomography (OCT). All patients had comprehensive neuro-ophthalmological examinations including automated perimetry., Results: Forty-four patients were included. Thirty-five patients completed the 12-month follow-up. Dramatic improvement in headache occurred within the first weeks after diagnosis. After 1 year, 15 patients reported no or only infrequent headache. However, 15 of the remaining 20 patients reported sustained chronic headache. Early age of onset and high diagnostic intracranial pressure (ICP) were associated with better headache outcome (≤1 headache days/month) after a year. Papilledema decreased rapidly within the first 2 months of diagnosis. After 1 year, OCT measures had normalized. Visual outcome was excellent in most patients., Conclusions: Although headache in 43% of patients responded well to ICP management, sustained long-term headache was seen in the remaining patients, despite resolution of papilledema. Headache in IIH may thus be attributed to more complex mechanisms than ICP elevation alone. High ICP and young age were associated with better headache outcome. Early treatment according to standard guidelines seems sufficient to ensure excellent visual outcome in the vast majority of patients., (© 2014 EAN.)

Pseudotumor cerebri syndrome (PTCS) refers to the primary and secondary disorders that cause elevated intracranial pressure without an intracranial mass lesion, ventriculomegaly, or central nervous system infection or malignancy. Headache is the most frequent symptom of PTCS, but there is considerable overlap between the headache features of raised intracranial pressure and the headache features of primary headache disorders. We review headache subtypes that occur in PTCS, non-headache features that help distinguish PTCS from other headache types, changes to the diagnostic criteria for PTCS with and without papilledema, and headache treatment strategies as they apply to PTCS.

Unlabelled: OBJECT/ BACKGROUND: Large demyelinating lesions (LDLs) may present with unusual features like seizures and significant mass effect and often masquerade a tumour. Even radiological features are confusing. With clinical signs of increased intra-cranial pressure (ICP), decompressive surgery becomes life-saving. However, resection of the involved nervous tissue is unnecessary and may lead to permanent residual deficits that otherwise can be avoided., Material and Methodology: We present a series of eight patients with focal deficits and/or raised pressure symptoms wherein a diagnosis of tumour was made preoperatively. The clinico-radiological picture and outcome has been described., Results: Clinically, all these patients had focal deficits and five had raised ICP. Three patients had seizures. Two patients had long standing visual deterioration in one eye. Radiology showed irregular enhancement in two and concentric rings in one. The deep grey matter was involved in one and cortex in four. Biopsy/decompressive surgery and resection of lesion improved the sensorium in all, but focal deficits persisted. Two patients died after being discharged in a conscious state, and one died in hospital., Conclusion: High index of suspicion is required to diagnose demyelination prior to surgery. Unexplained long standing clinical features, radiology that has contrast enhancement patterns and mass effect (dissociation between contrast enhancement and mass effect) that is unusual for glioma should raise the suspicion of such non-neoplastic lesions. For patients with minimal mass effect with focal deficits, open/stereotactic biopsy from multiple areas of the lesion is preferable for diagnosis. Those presenting with mass effect, decompressive craniectomy and biopsy from the lesion is preferable than attempting complete resection especially in and around the eloquent areas. A second look surgery to resect the lesion can always be undertaken once histopathology suggests a neoplastic etiology and rules out a demyelinating lesion.

Acquired cerebellar tonsillar herniation is a known complication of lumboperitoneal shunt (LPS) for any indication, including idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri.(1) While the underlying pathophysiology of IIH remains unknown, increasing body mass index is a clear risk factor for the development of IIH. We describe an obese patient with IIH unresponsive to LPS who developed symptoms of intracranial hypotension and cerebellar tonsillar herniation after bariatric surgery and a 50-kg weight loss.

Previous MR studies have established that bilateral transverse sinus stenosis (BTSS) predicts idiopathic intracranial hypertension without papilledema (IIHWOP) in migraine. However, it is uncertain whether BTSS identifies IIHWOP in patients with chronic tension-type headache (CTTH): using cerebral MR venography this study aimed to address this question.In a prospective study from February 2002 to December 2006, 198 consecutive patients with CTTH underwent MR venography. Of these patients, 58 underwent lumbar puncture to measure cerebrospinal fluid (CSF) pressure. MR venography and lumbar puncture were also performed in 45 age-matched control subjects. BTSS was considered present when the signal flow was poor or lacking (flow gap) in the mid-lateral portion of both transverse sinuses. IIHWOP was diagnosed if the patient met the diagnostic criteria for idiopathic intracranial hypertension and did not have papilledema. Among the 198 patients with CTTH who underwent MR venography, 18 (9%) had BTSS. Thirteen of these 18 patients with BTSS underwent lumbar puncture, and nine (69.2%) had IIHWOP. CSF opening pressure was normal in all 45 patients as well as in all 45 controls with normal MR venography.These data suggest that BTSS on MR venography is associated with increased intracranial pressure in the absence of papilledema in patients with headache mimicking CTTH.

Benign intracranial hypertension is a clinical diagnosis linked to a number of medical and surgical disorders. A common aetiology has not yet been established. It would seem, however, that many, if not all, of these cases can be related to some degree of cerebral venous outflow obstruction. We present here a series of patients with extraluminal compression of the cerebral venous sinuses that has been amenable to surgical resection. These 'surgical' causes of BIH illustrate an important subset of the disease and inform us about the possible pathophysiological principles underlying the disorder.

We report a case of benign intracranial hypertension (BIH) resulting from corticosteroid withdrawal. A 36-year-old woman was admitted to hospital because of an intractable headache. A neurological examination on admission showed no abnormalities other than a headache and nausea. CT, MRI, and angiogram examinations showed no abnormalities. Hematological and laboratory data were also normal. Continuous monitoring of her cerebrospinal fluid (CSF) pressure showed a value of over 25 mmHg during sleep, but papilledema was not observed. A diagnosis of BIH was made, with corticosteroid withdrawal considered to be the most probable cause. The patient was given isosorbide solution for 3 months. However, her clinical condition continued to deteriorate; she eventually began to develop visual loss, photopsia, and memory disturbances. She underwent lumboperitoneal shunt surgery, which immediately eliminated the headache, photopsia, and memory disturbances. She regained her vision over a five-month period. BIH should be considered as a differential diagnosis when an intractable headache develops after corticosteroid withdrawal, especially in young women.