Therapeutic lumbar puncture for headache in idiopathic intracranial hypertension: Minimal gain, is it worth the pain?

Abstract

Background Headache is disabling and prevalent in idiopathic intracranial hypertension. Therapeutic lumbar punctures may be considered to manage headache. This study evaluated the acute effect of lumbar punctures on headache severity. Additionally, the effect of lumbar puncture pressure on post-lumbar puncture headache was evaluated. Methods Active idiopathic intracranial hypertension patients were prospectively recruited to a cohort study, lumbar puncture pressure and papilloedema grade were noted. Headache severity was recorded using a numeric rating scale (NRS) 0-10, pre-lumbar puncture and following lumbar puncture at 1, 4 and 6 hours and daily for 7 days. Results Fifty two patients were recruited (mean lumbar puncture opening pressure 32 (28-37 cmCSF). At any point in the week post-lumbar puncture, headache severity improved in 71% (but a small reduction of -1.1 ± 2.6 numeric rating scale) and exacerbated in 64%, with 30% experiencing a severe exacerbation ≥ 4 numeric rating scale. Therapeutic lumbar punctures are typically considered in idiopathic intracranial hypertension patients with severe headaches (numeric rating scale ≥ 7). In this cohort, the likelihood of improvement was 92% (a modest reduction of headache pain by -3.0 ± 2.8 numeric rating scale, p = 0.012, day 7), while 33% deteriorated. Idiopathic intracranial hypertension patients with mild (numeric rating scale 1-3) or no headache (on the day of lumbar puncture, prior to lumbar puncture) had a high risk of post- lumbar puncture headache exacerbation (81% and 67% respectively). Importantly, there was no relationship between lumbar puncture opening pressure and headache response after lumbar puncture. Conclusion Following lumbar puncture, the majority of idiopathic intracranial hypertension patients experience some improvement, but the benefit is small and post-lumbar puncture headache exacerbation is common, and in some prolonged and severe. Lumbar puncture pressure does not influence the post-lumbar puncture headache.

Association Between Idiopathic Intracranial Hypertension and Risk of Cardiovascular Diseases in Women in the United Kingdom

“… 26 Migraine is diagnosed in approximately 80% of patients with IIH. 27 Therefore, we included migraine as a covariate in model 3 to assess whether comorbid migraine was a factor in the observed increase in CVD risk; however, the results were unaffected, suggesting no association.…”

Emerging themes in idiopathic intracranial hypertension

“…Patients who achieve 10-15% weight loss often see an improvement in their headache [46], although sometimes this can only be achieved with bariatric surgery [63]. Although therapeutic LP may reduce headache in the short term, repeated LPs are not recommended as they may result in complications such as intracranial hypotension [64,65]. Headache generation and pain are thought to be due to peripheral sensitisation of the trigeminovascular system, in which innervation of the dura by nociceptive trigeminal fibers, leads to release of vasoactive neuropeptides including calcitonin gene-related peptide (CGRP) and substance P [66][67][68].…”

Stauungspapille, Pseudotumor cerebri und idiopathische intrakranielle Hypertension – Was gibt es Neues?

“…Zu den Säulen der IIH-Therapie gehören (noch) wiederholte Lumbalpunktionen, die kurzfristig die Beschwerden und Symptome lindern können. Jedoch regt sich Kritik an diesem Vorgehen, da der nur vorübergehende Benefit die häufige Exazerbation des postpunktionellen Kopfschmerzes nicht rechtfertigt [20]. Auch entwickeln die meisten Patienten rasch eine regelrechte Aversion gegen die Prozedur.…”