A 32-year-old Caucasian female presents to your office with a two month history of headaches. Initially, her headaches occurred only in the evening and while she tried to take a nap, but recently they seem to be persistent during the day. She describes them as diffuse throughout her entire head. She also complains of some nausea, occasional numbness of her fingertips, and blurry vision. Over-the-counter ibuprofen provides minimal relief. She denies any fevers, vomiting, imbalance, falls, or neck pain. She used to have migraines as a teenager, but they stopped years ago. Her family history is significant for migraines in her mother and older sister. Current medications include an oral contraceptive pill and a daily multivitamin. She smokes one pack of cigarettes per day and drinks alcohol occasionally. Her blood pressure is 152/90 mmHg and heart rate is 76/min. Her BMI is 35 kg/m². Neurological examination is unremarkable. Which of the following is the best next step in managing this patient?

Question

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Explanation: The most likely diagnosis in this patient is idiopathic intracranial hypertension, also known as pseudotumor cerebri. This disorder most commonly affects women of childbearing age who are overweight. The underlying cause is not well understood. Headache is the primary symptom in most patients, although the character of the headaches is variable and not distinct from other etiologies of headache such as tension headaches or migraines. Most patients with pseudotumor cerebri also complain of visual disturbances and nausea, although these complaints are often present in patients with migraines as well. Although this patient's personal and family history of migraines should be taken into consideration, it is somewhat atypical for patients to have a recurrence of migraines after they have been symptom free for years. The primary physical examination finding in patients with idiopathic intracranial hypertension is papilledema, so an ophthalmoscopic examination is the most appropriate next step. (Choice A) The presence of headaches and papilledema suggests that there is elevated intracranial pressure that could be secondary to an intracranial mass lesion. Some form of neuroimaging study (MRI) is needed, but this should follow the ophthalmologic examination. (Choice C)A lumbar puncture is frequently performed following a neuroimaging study, but would obviously be contraindicated if a mass lesion was seen intracranially due to the risk of herniation. An opening pressure greater than 20-25 cmH2O can help to confirm the diagnosis of pseudotumor cerebri. (Choice D)While this patient's blood pressure is elevated, hypertension generally does not cause headaches unless the blood pressure is markedly elevated. This patient should have a follow-up blood pressure measurement in the near future to determine the need for initiating antihypertensive therapy. (Choice E)This patient's presentation is more suggestive of intracranial hypertension than either headaches caused by medication overuse or migraines. Educational objective: Idiopathic intracranial hypertension, also known as pseudotumor cerebri, is a potential cause of headaches typically seen in overweight women of childbearing age. Papilledema is classically seen on ophthalmoscopic examination. A negative neuroimaging study (except an empty sella) and an elevated opening pressure on lumbar puncture can help to confirm the diagnosis.

A 32-Year-Old Caucasian Female Presents to Your Office with a Two