The Journal of Headache and Pain

Official Journal of the "European Headache Federation" and of "Lifting The Burden - The Global Campaign against Headache"

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Volume 16 Supplement 1

1st Joint ANIRCEF-SISC Congress

Open Access

P027. Idiopathic intracranial hypertension without papilledema in refractory chronic daily headache

  • Valentina Favoni1Email author,
  • Francesco Toni2,
  • Sabina Cevoli1,
  • Luigi Cirillo2,
  • Chiara La Morgia1,
  • Giulia Giannini1,
  • Rossana Terlizzi1,
  • Hana Privitera Hrustemovic1,
  • Monica Messia2,
  • Pietro Cortelli1 and
  • Giulia Pierangeli1
The Journal of Headache and Pain201516(Suppl 1):A108

Published: 28 September 2015


MigraineOptical Coherence TomographyChronic MigraineChronic Daily HeadachePapilledema


A diagnosis of idiopathic intracranial hypertension without papilledema (IIHWOP) should be considered in unresponsive chronic daily headache (CDH) patients[1]. A CSF opening pressure (OP) above 200 mm H2O has been detected in chronic migraine patients with conflicting result, ranging from 10% to 86% of patients[1, 2]. Moreover, controversies exist regarding the OP cut-off value greater than 200 or 250 mm H2O and the role of transverse sinus stenosis (TSS)[3, 4].


To investigate the frequency of IIHWOP and TSS in adult patients with refractory CDH.


In a prospective study, patients with refractory CDH underwent ophthalmologic evaluation and Optical Coherence Tomography to rule out the presence of papilledema; cerebral MR venography (MRV) to detect TSS; and a lumbar puncture to measure OP. In patients showing an OP < 200 mmH2O the procedure was stopped after a 6 mL CSF withdrawal for routine analysis. In subjects with an OP > 200 mm H2O, intracranial pressure measurements were repeated every 2 mL of extracted CSF, up to about 100 mm H2O. An MRV was repeated 1 month after LP in patients with OP > 200 mmH2O. TSS was identified using a combined conduit score (CCS).


Thirty-six patients were enrolled. Five patients were excluded due to protocol violations. Analyses were conducted in 31 patients (24 F, 7 M; mean age 50.4±11; mean BMI 26.5±6.5). None of the patients had papilledema. All displayed an OP lower than 250 mm H2O (range 102-245). Six patients (19%) had an OP greater than 200 mm H2O: three of them achieved an improvement of headache frequency or intensity after 8-18 ml CSF withdrawal. Fifteen patients (48%) had MRV evidence of TSS: bilateral in 4 and unilateral in 11. Using a Pearson's correlation coefficient test, no significant correlation between CCS and OP was found. After CSF withdrawal, no changes of CCS were found in the six patients who repeated MRV.


In our series, all patients displayed normal OP values (< 250 mm H2O). Nineteen percent of patients had an OP greater than 200 mm H2O. Our results confirm a low prevalence of IIHWOP in chronic headache sufferers. Moreover, the prevalence of sinus venous stenosis (50%) was lower than previously described in unresponsive chronic headache patients (92.8%), but similar to a series of unselected chronic headache patients (50.6%)[1, 5]. Transverse sinus stenosis seems not to correlate with CSF opening pressure, putting its role into question.

Written informed consent to publication was obtained from the patient(s).

Authors’ Affiliations

Department of Biomedical and NeuroMotor Sciences (DIBINEM) Alma Mater Studiorum-University of Bologna, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
Neuroradiology Department, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy


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© Favoni et al. 2015

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