A 22-year-old woman comes to the physician after several months of headaches. She describes them as moderate intensity and occurring frequently, now daily. She occasionally hears a noise similar to wind blowing during the headaches. The patient has taken escalating doses of over-the-counter painkillers with some relief. She smokes marijuana occasionally.
Her blood pressure is 132/80 mm Hg and heart rate is 87/min. On neurologic examination, there is no muscle weakness or sensory loss. Deep-tendon reflexes are normal. The neck is supple. Funduscopic findings (as shown) are the same in both eyes.

Which of the following is the most likely diagnosis?

Question

A 22-year-old woman comes to the physician after several months of headaches.  She describes them as moderate intensity and occurring frequently, now daily.  She occasionally hears a noise similar to wind blowing during the headaches.  The patient has taken escalating doses of over-the-counter painkillers with some relief.  She smokes marijuana occasionally. 
Her blood pressure is 132/80 mm Hg and heart rate is 87/min.  On neurologic examination, there is no muscle weakness or sensory loss.  Deep-tendon reflexes are normal.  The neck is supple.  Funduscopic findings (as shown) are the same in both eyes.

Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_987e_3ccc_853d_0bfc8e114e49_MD0002_00 This patient has the following characteristic features of idiopathic intracranial hypertension (IIH), or pseudotumor cerebri: Chronic pulsatile headache exacerbated by lying flat and improved by sitting up"Whooshing" or wind-like tinnitusPapilledema with blurring of the optic disk margins Chronic pulsatile headache exacerbated by lying flat and improved by sitting up "Whooshing" or wind-like tinnitus Papilledema with blurring of the optic disk margins Other common features of IIH may include blurry vision or vision loss and horizontal binocular diplopia. IIH is typically seen in young obese women and is believed to be caused by either excess cerebrospinal fluid production or inadequate absorption. Neuroimaging (ie, MRI) should be performed to exclude other causes of increased intracranial pressure (eg, metastatic lesions, venous sinus thrombosis, obstructive hydrocephalus) but will usually show only normal findings or minor nonspecific abnormalities. If imaging is normal, the diagnosis can be confirmed with lumbar puncture showing elevated opening pressure (>200-250 mm H₂O). Initial management for most cases of IIH is acetazolamide and weight loss. Some patients will require the addition of loop diuretics, and surgery is occasionally needed to relieve intracranial pressure. The primary risk of untreated IIH is loss of vision due to optic nerve injury. (Choice B) Medication overuse headache typically occurs after daily exposure (>15 days/month) to an analgesic medication (especially opiates). It is not associated with papilledema. (Choice C) Meniere disease, or endolymphatic hydrops, is a disorder of the inner ear that results from overproduction or under-absorption of endolymph. Patients will typically develop tinnitus in one ear associated with ear fullness and progressive sensorineural hearing loss and vertigo. Papilledema, blurry vision, and headache are not associated with Meniere disease. (Choice D) Multiple sclerosis is a relapsing-remitting autoimmune disease caused by demyelinating lesions in the central nervous system that are disseminated in space and time. Attacks can manifest as optic neuritis, characterized by acute headache with unilateral blurry vision and papilledema/papillitis. Chronic headaches and bilateral papilledema are not typical of acute optic neuritis from multiple sclerosis. (Choice E) Open-angle glaucoma accounts for 90% of glaucoma cases in the United States. It presents clinically with gradual painless loss of vision rather than acute attacks. Funduscopy may show characteristic optic nerve changes (such as increased cup-to-disk ratio). Tonometry usually shows elevated intraocular pressures. Papilledema is not usually seen with open-angle glaucoma but can be seen with closed-angle glaucoma due to very high intraocular pressures. increased cup-to-disk ratio Educational objective: Idiopathic intracranial hypertension (pseudotumor cerebri) is characterized by chronic pulsatile headaches, often associated with "whooshing" tinnitus. The headaches are worsened by lying flat. Funduscopy should be performed to evaluate for the presence of papilledema, which suggests elevated intracranial pressure. If neuroimaging is negative, the diagnosis can be confirmed by measuring opening pressure on lumbar puncture. __________ References: Idiopathic intracranial hypertension: pseudotumor cerebri. (http://www.ncbi.nlm.nih.gov/pubmed/24512582)

A 22-Year-Old Woman Comes to the Physician After Several Months