Acute headache treatment in idiopathic intracranial hypertension: treating to the phenotype?

Background: Effective acute headache treatment is essential for improving the quality of life in people with idiopathic intracranial hypertension (pwIIH). While current guidance recommends “treat to the phenotype”, robust data on effectiveness of available options is lacking. Methods: This retrospective analysis used standardized symptom diaries of pwIIH from the Vienna Idiopathic Intracranial Hypertension (VIIH) database (1-JUL-2021 to 30-JUN-2023). Three classes of acute medications ( nonsteroidal anti-inflammatory drugs [ NSAID], acetaminophen [APAP], and triptans) were analyzed, with NSAIDs as the reference. Headache attacks were classified per ICHD-3 as migraine (MIG), tension-type (TTH), or other (OTH). We used 2-level nested logistic regression models to analyze odds ratio (OR) of treatment response for each headache type, adjusting for covariance within individual pwIIH and concurrent medication with propensity-weighting for age, sex, and headache severity. Results: We analyzed 35,640 medication-outcome pairs from 23,507 headache attacks (45.3% MIG, 21.1% TTH, 33.6% OTH) in 156 patients (89.7% female, mean age 32.9 years). NSAID were most commonly used across all headache types (MIG: 60.5%, TTH: 69.8%, OTH: 70.7%), followed by APAP (MIG: 21.5%, TTH: 21.1%, OTH: 27.7%) and triptans (MIG: 18%, TTH: 10.1%, OTH: 12.8%). Triptans were the most effective across all headache types (OR for MIG: 4.8 [CI 3.9–6.1], TTH: 2.9 [CI 1.8–4.3], OTH: 3.1 [CI 2.2–4.3]). APAP was less effective for MIG (OR 0.81 [CI 0.74–0.90]) but similar to NSAIDs in TTH and OTH. Conclusions: Triptans are more effective than NSAID/APAP in acute management of headaches in pwIIH, particularly – but not exclusively – for migraine-type attacks. These findings support preferential use of triptans, questioning the “treating to the phenotype” approach.