A 27 year-old woman attends the neurology clinic complaining of headache

A 27 year-old woman attends the neurology clinic complaining of headache and visual disturbance. She has recently immigrated from Ghana. Her symptoms began approximately one month ago, shortly after the birth of her first child. She experiences dull frontal headache which is worst in the mornings and on coughing or straining, as well as transient episodes of ‘darkening’ of her vision. She saw a doctor in Ghana and was diagnosed with idiopathic intracranial hypertension. She is taking acetazolamide 250mg BD and no other medication.

On examination the visual fields are markedly constricted and the right blind spot is enlarged. Fundoscopy shows bilateral papilloedema worse on the right. The remainder of the neurological examination is unremarkable. BMI is 18 kg/m².

Plain computed tomography of the brain is normal.

Incidentally as she is leaving the clinic she mentions that she has also been experiencing pins and needles in the hands and feet.

What is the best course of action?

Increase dose of acetazolamide

Request nerve conduction studies

Organise for therapeutic lumbar puncture

Refer to neurosurgeons for consideration of ventriculo-peritoneal shunting

Request CT venography

The history of headache suggestive of raised intracranial pressure associated with transient visual obscurations, as well as the examination findings, are all compatible with idiopathic intracranial hypertension (IIH). However, the onset of symptoms in the puerperium, in a slim patient with no other risk factors for IIH, raises the suspicion that this may actually be a cerebral venous sinus thrombosis. All patients with IIH should have imaging of the venous system with CT or MR to exclude a thrombus which can be more appropriately treated with anticoagulation.
Therapeutic lumbar puncture can ease the headache of IIH but is a short-term measure. Ventriculo-peritoneal shunting can be used where medical management has failed.
There is no role for nerve conduction studies in this patient. Paraesthesia are a common side effect of acetazolamide, and this patient is unlikely to tolerate an increase in the dose.