An 18-year-old woman comes to the clinic due to persistent headaches, which have occurred daily for 3 months. The headaches are holocranial, pulsating, and especially bothersome at night. Ibuprofen has not helped the pain. The patient has double vision when looking sideways and blurry vision in both eyes. She has no history of head trauma prior to the onset of symptoms and no fever, vomiting, photophobia, or weakness. The patient has no chronic medical conditions and does not use tobacco, alcohol, or illicit drugs. Her mother and sister have migraine headaches. Temperature is 37 C (98.6 F), blood pressure is 130/85 mm Hg, and pulse is 90/min. BMI is 34 kg/m². Physical examination shows no nuchal rigidity or sinus tenderness. Eye examination reveals optic disc edema and left lateral rectus palsy. CT scan of the head without contrast is normal. Which of the following is the best next step in management of this patient?

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11ec25c8_d486_2228_bc81_49f000e7f630_MD0003_00 This patient has headaches, visual abnormalities, and optic disc edema suggestive of increased intracranial pressure (ICP). In the context of a normal CT scan, these findings are likely due to idiopathic intracranial hypertension (IIH). This condition is most commonly seen in young, obese (BMI >30 kg/m²) women and is also associated with certain medications (eg, retinoids, tetracyclines, growth hormone). ² Patients with IIH typically have holocranial headache, vision changes (blurry vision, diplopia), and pulsatile tinnitus ("whooshing" sound in the ears). Abducens nerve (CN VI) palsy (lateral rectus palsy) and papilledema are signs of increased ICP that are often present on examination (as in this patient). Initial evaluation of IIH includes complete ocular examination and neuroimaging to exclude secondary causes of intracranial hypertension (eg, mass, hemorrhage). MRI, often with venography to rule out cerebral vein thrombosis, is the preferred imaging modality; however, CT is generally faster and easier to obtain in emergencies. After a space-occupying lesion is excluded, lumbar puncture (LP) can be performed safely and is indicated to document elevated opening pressure (>250 mm H₂O). Cerebrospinal fluid studies (eg, cell counts) are normal in IIH. (Choice A) CT angiogram is helpful for diagnosing aneurysms, which are usually asymptomatic if unruptured. Patients with ruptured aneurysms (eg, subarachnoid hemorrhage) typically have acute onset of severe headache, often with vomiting and loss of consciousness. In contrast, this patient has had symptoms for 3 months. (Choice B) CT scan of the paranasal sinuses may be used in the evaluation of sinusitis; however, sinus infection typically causes nasal congestion, rhinorrhea, and sinus tenderness, which are not present in this patient. (Choice C) The erythrocyte sedimentation rate is elevated in cases of vasculitis, such as giant cell arteritis (GCA). Although GCA can cause headache and vision changes, it is extremely rare at age <50. (Choice E) Sumatriptan is a 5-hydroxytryptamine-1 receptor agonist used in the acute treatment of migraines, which classically cause unilateral, throbbing headaches and photophobia. Although this patient has a family history of migraine, her holocranial headache and optic disc edema are suggestive of IIH rather than migraine disorder. Educational objective: Idiopathic intracranial hypertension typically presents in young, obese women with headache, vision changes, papilledema, and abducens nerve (CN VI) palsy. Diagnosis is confirmed by lumbar puncture showing elevated opening pressure and normal cell counts. References: Update on the diagnosis and treatment of idiopathic intracranial hypertension. (http://www.ncbi.nlm.nih.gov/pubmed/26444398) Idiopathic intracranial hypertension: diagnosis, monitoring and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/22981270)

An 18-Year-Old Woman Comes to the Clinic Due to Persistent