Intended for healthcare professionals

Practice Easily Missed?

Raised intracranial pressure in those presenting with headache

BMJ 2018; 363 doi: (Published 04 October 2018) Cite this as: BMJ 2018;363:k3252
  1. Susan P Mollan, consultant neuro-ophthalmologist1 2 3,
  2. David Spitzer, general practitioner4,
  3. David J Nicholl, consultant neurologist5 6
  1. 1Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
  2. 2Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
  3. 3Institute of Translational Medicine, Birmingham Health Partners, University of Birmingham, UK
  4. 4PHGH Doctors, Temple Fortune Medical Centre, London, UK
  5. 5Department of Neurology, City Hospital, Birmingham, UK
  6. 6Department of Neurology, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
  1. Correspondence to SP Mollan susan.mollan{at}

What you need to know

Untreated raised intracranial pressure (ICP) can lead to permanent sight loss, permanent neurological deficits, and ultimately death.

Typical characteristics of new onset constant or near constant severe headache are non-specific, and only one third of patients with raised pressure report that the headache is worse on waking.

  • Request an ophthalmology opinion if there is difficulty examining for papilloedema, and to determine any visual deficit.

A 24 year old woman attended the emergency department after experiencing a blackout. She was diagnosed with a panic attack and discharged. She returned two days later with increasing headaches and visual disturbances, and was admitted to hospital for investigation. Computed tomography scans of the head and a computed tomography venogram taken on day 3 were normal. On day 7, she underwent lumbar puncture and her cerebrospinal fluid opening pressure was 70 cm CSF. On day 8, she was examined with an ophthalmoscope and found to have papilloedema. Her best corrected visual acuity was reduced at 6/24 bilaterally and she had bilateral peripheral visual field loss to confrontation. She received a diagnosis of fulminant idiopathic intracranial hypertension and was transferred to the neuroscience centre, where on day 9 she underwent an emergency lumbar peritoneal shunt. Within two weeks, her vision improved to 6/9 bilaterally.

Speaking to the BBC about her experience, she says, “I can’t imagine what it would have been like to have been blind”(video 1).

Video 1

Patient experience

What is raised intracranial pressure?

Raised intracranial pressure (ICP) is an abnormal elevation of brain pressure and is a medical emergency. Data on the frequency of raised ICP are lacking (box 1). It has many causes, including some serious ones (box 2), and can be sight and life threatening. The headache history is important, as is examination for signs of papilloedema and documentation of visual function.

Box 2

Causes of raised intracranial pressure

  • Congenital (hydrocephalus)

  • Iatrogenic (certain …

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