An 18-year-old woman comes to the physician complaining of headaches for the past 3 months. She says that the headaches occur almost daily, are holo-cranial, and have a pulsatile quality. They are especially bothersome at night. She has no photophobia, phonophobia, nausea, vomiting, fever, or neck stiffness. The patient has no other medical problems and takes no medications.
Her blood pressure is 144/90 mm Hg and pulse is 77/min. Her BMI is 34 kg/m². Visual field examination is unremarkable. Cranial nerves are intact. Muscle strength is normal and the deep-tendon reflexes are symmetric. Romberg's test and urine pregnancy test are negative.
Magnetic resonance imaging and magnetic resonance venography of the head reveal an empty sella but no other significant abnormalities.
Which of the following is the best next step in managing this patient?

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11ec193a_9883_1dd4_853d_31c0b6bb0c79_MD0002_00 This patient presents with idiopathic intracranial hypertension (IIH) (ie, pseudotumor cerebri). Symptoms of IIH include headaches, visual symptoms, tinnitus, and diplopia. Headaches are chronic, holo-cranial, and pulsatile in nature; they are exacerbated by lying flat and improved by sitting up. IIH is likely caused by either excess cerebrospinal fluid (CSF) production or inadequate CSF absorption. Although IIH is frequently seen in young obese women, it has also been associated with certain medications (eg, isotretinoin, tetracyclines, growth hormone, and vitamin A). The most important sign of IIH is papilledema, which is frequently bilateral and can lead rapidly to vision loss. Diagnosis of IIH includes complete ocular examination, neuroimaging to exclude secondary causes of intracranial hypertension (eg, mass, hemorrhage, cerebral vein thrombosis), and lumbar puncture to document elevated opening pressure (> 250 mm H₂O). Magnetic resonance imaging (possibly with magnetic resonance venography) is the preferred imaging modality for IIH. Empty sella is present in about 70% of patients with IIH but is not diagnostic. Lumbar puncture is performed with the patient in the lateral decubitus position. An opening pressure of > 250 mm H₂O is considered abnormal. CSF studies are normal in IIH patients. Treatment of IIH includes weight loss, headache prophylaxis, and acetazolamide (+/- furosemide). Short-term treatment may involve corticosteroids and serial lumbar punctures for patients awaiting surgery for progressive visual loss. Surgical choices include optic nerve sheath fenestration and/or CSF shunting procedures. (Choice B) Although Cushing's syndrome may be in the differential diagnosis for this patient, morning serum cortisol is not sensitive or specific and is not recommended as a screening test. Instead, overnight dexamethasone suppression test, 24-hour urinary free cortisol, and late-evening salivary cortisol are the recommended first-line screening tests for Cushing's syndrome. (Choice C) Oral sumatriptan is used to treat migraine headaches. This patient's symptoms do not suggest migraine disorder. (Choice D) Late-onset congenital adrenal hyperplasia presents with premature pubarche, acne, accelerated bone age, hirsutism, and menstrual irregularities. Diagnosis is suggested by elevated serum levels of 17-hydroxyprogesterone and confirmed by marked elevation of the enzyme with ACTH administration. (Choice E) Although thyroid function tests may be included in the workup of this patient, her symptoms are not suggestive of primary thyroid disorder. Educational objective: Idiopathic intracranial hypertension presents with headaches, visual symptoms, tinnitus, and diplopia. Diagnosis involves ocular examination, neuroimaging (magnetic resonance imaging and magnetic resonance venography), and lumbar puncture demonstrating elevated opening pressure (> 250 mm H₂O). If unrecognized, patients are at risk of vision loss. Initial treatment involves discontinuation of the offending medications and weight loss plus acetazolamide in idiopathic cases. __________ References: Idiopathic intracranial hypertension: Diagnosis, monitoring and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/22981270)

An 18-Year-Old Woman Comes to the Physician Complaining of Headaches