HEADACHE IN THE SEVERELY OBESE

Harvey Sugerman, MD, FACS, FASMBS

Editor: Surgery for Obesity and Related Diseases

Co-owner, Chief Medical Officer:

Spark Medical, LLC (manufacturer of negative abdominal pressure device: the Abshell)

HEADACHEIN THE SEVERELY OBESE

• Pseudotumor Cerebri– AKA: Idiopathic Intracranial Hypertension (IIH)

and Benign Intracranial Hypertension– Signs/Symptoms– Pathophysiology

• Migraine ??? Headaches

• Preeclampsia

• Negative Abdominal Pressure Device

PSEUDOTUMOR CEREBRISYMPTOMS

• Constant headache, worse in morning

• Double vision (6th Cranial Nerve)

• Pulsatile tinnitus

• Nausea, vomiting

• 25% Asymptomatic until vision loss

• Elevated CSF pressure (> 250 mm Hg)

• Papilledema

• Other cranial nerve abnormalities (V, VII)

PSEUDOTUMOR CEREBRIDIAGNOSIS

• CT Scan or MRI– No Intracranial Mass– Empty Sella Turcica– Narrow Ventricles

• Elevated CSF on Lumbar Puncture– > 250 mm H2O

PSEUDOTUMOR CEREBRIINCIDENCE

• 1/100,000 Overall; 19/100,000 in obese

• Fundus imaging in bariatric patients + Ophthalmological examination + spinal fluid pressure measurement: 0.9% (9/1,000)*

• Obesity present in 94% of pseudotumor patients

* Handallah IN … Ali M. Higher than expected prevalence of pseudotumor cerebri: a prospective study. Surg Obes Rel Dis (in press)

PSEUDOTUMOR CEREBRITREATMENT

• Acetozolamide

• Repeated lumbar drainage

• Lumboperitoneal shunt

• Optic nerve fenestration

• BARIATRIC SURGERY

PSEUDOTUMORPATHOPHYSIOLOGY

• Increased Intra-abdominal Pressure

• Why is it rarely seen in men?– 92% Women– Combined effects with female hormones?

GBP CORRECTS PSEUDOTUMOR CEREBRI

• Significant Decrease in Headaches

• Significant Decrease in Pulsatile Tinnitus

• Significant Decrease in CSF Pressure

• Relieves Cranial Nerve Palsies: I (Visual Field Cuts), III (Ocumolotor), V (Bell’s Palsy), VII (Tic Doloreux), VIII (Tinnitus)

MIGRAINE HEADACHES*• 102/702 patients had physician diagnosed migraine headaches• 81 followed for > 12 mos after RYGB• Clinical improvement within 8 mos in 89% of patients: 57 total

and 15 partial resolution• Those who had migraine headaches prior to compared to after

the development of obesity had a lower frequency of improvement with weight loss

* Gunay Y, et al. Surg Obes Relat Dis (in press)

MIGRAIINES?

• All didn’t undergo examinations for papilledema

• All 81 patients responded to an anti-migraine medication with an acute attack

• CSF pressure was not measured

• Only 25/81 had an aura with their headache

* Gunay Y, et al. Roux-en-Y gastric bypass achieves substantial resolution of migraine headache in the severely obese: a 9-year experience in 81 patients. Surg Obes Rel Dis (in press).

MIGRAINE VS. PSEUDOTUMOR

• Does pseudotumor require papilledema?

• Pseudotumor, according to Modified Dandy criteria, requires a CSF opening pressure > 250 mm H2O

• Could headaches result from an increased CSF pressure < 250 mm H2O?

• No way to measure CSF pressure without spinal tap

• Hypothesis: “pseudotumor” under-diagnosed

ECLAMPSIA/PREECLAMPSIA

• Could increased intra-abdominal pressure be the cause of eclampsia/preeclampsia secondary to impaired jugular venous flow?

• Would application of the externally applied negative abdominal pressure device be an effective treatment for preeclampsia?

PREECLAMPSIA

• Venous flow bassically passive; doesn’t take much IAP to decrease it

• Decreased venous flow leads to decreased capillary and arterial flow– Extremities: edema– Uterus: placental/fetal ischemia– Kidney: hypertension, proteinuria– Liver/Spleen: HELLP syndrome– Lung : Hypoxemia, ARDS– Cerebral flow: headache/seizure

WHY NOT ALL PREGNANCIES?INCREASED FREQUENCY IN:

• Morbidly Obese Women

• Twin + pregnancies

• Later vs. earlier gestation

• Primiparas

• Previous Preeclampsia

THE ANSWER THIS SUMMER IN PADUA!

Or maybe my son-in-law’s right: I’m just a modern day

Don Quixote