Review Question - QID 103379

This overweight woman is presenting with a headache, blurry vision, and papilledema which is concerning for idiopathic intracranial hypertension (IIH). Oral contraceptive pills are not necessary for this woman who is not sexually active and may worsen this condition.

Combined oral contraceptive pills (OCPs) are a widely used method of contraception. The combination of estrogen and progesterone functions to prevent ovulation and thicken the cervical mucous to prevent sperm penetration into the uterus. Oral contraceptive pills are a potential exacerbating medication for IIH. IIH presents with increased intracranial pressure usually in a young and overweight woman. History may demonstrate a headache and blurry vision. Papilledema can be seen on exam and a head CT should be performed to rule out an intracranial mass. Other findings in this condition include cranial nerve palsies (in particular cranial nerve VI). The most appropriate initial step in management after a head CT is to perform a lumbar puncture which is both diagnostic and therapeutic. Subsequently, weight loss, acetazolamide, and discontinuing any exacerbating factors (such as OCPs or vitamin A) should take place. Serial lumbar punctures can be performed for symptom control.

Figure/Illustration A is the physical exam finding of papilledema (blue circle) which can be seen when there is increased intracranial pressure.

Incorrect Answers:
Answer 2: Discontinue vitamin K would not treat this patient's IIH. Vitamin A usage is associated with IIH and could worsen this condition. While vitamin K is unnecessary in this patient, it is likely not the etiology of her symptoms.

Answer 3: Initiate diltiazem is a prophylactic medication against cluster headaches and migraine headaches; however, this patient's gradually worsening headaches associated with blurry vision in the setting of her obesity and papilledema makes IIH more likely.

Answer 4: Initiate glatiramer is a medication that can prevent future episodes of multiple sclerosis which presents with sudden-onset, painful unilateral vision loss (optic neuritis), numbness, paresthesias, and urinary retention. This patient's numbness that is symmetric and only occurs when laying down is more suggestive of cubital tunnel syndrome.

Answer 5: Initiate sumatriptan is an appropriate medication that can be used to treat acute flares of migraine and cluster headaches. A migraine headache presents with a unilateral and pulsatile headache while a cluster headache presents in a young man with a unilateral ice-pick headache with unilateral rhinorrhea/lacrimation.

Bullet Summary:
Oral contraceptive pills can worsen idiopathic intracranial hypertension.