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)

HEADACHE IN 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 CEREBRI SYMPTOMS Constant headache, worse in morning Double vision (6 th 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 CEREBRI DIAGNOSIS CT Scan or MRI –No Intracranial Mass –Empty Sella Turcica –Narrow Ventricles Elevated CSF on Lumbar Puncture –> 250 mm H 2 O

PSEUDOTUMOR CEREBRI INCIDENCE 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 CEREBRI TREATMENT Acetozolamide Repeated lumbar drainage Lumboperitoneal shunt Optic nerve fenestration BARIATRIC SURGERY

PSEUDOTUMOR PATHOPHYSIOLOGY 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 H 2 O Could headaches result from an increased CSF pressure < 250 mm H 2 O? 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