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Among women with idiopathic intracranial hypertension (IIH) and a body mass index (BMI) of 35 or higher, bariatric surgery was a more effective means of reducing intracranial pressure and sustaining disease remission compared with a community weight loss program, a 5-year randomized trial showed.

Women assigned to bariatric surgery had significantly lower intracranial pressure, measured by lumbar puncture opening pressure, with adjusted mean cerebrospinal fluid (CSF) differences of -6.0 cm (95% CI -9.5 to -2.4, P=0.001) at 12 months, and -8.2 cm (95% CI -12.2 to -4.2 cm, P<0.001) at 24 months, compared with the weight loss arm, reported Alexandra Sinclair, PhD, of the University of Birmingham in England, and co-authors.

Weight was also significantly lower in the bariatric surgery arm, with adjusted mean differences of -21.4 kg (95% CI -32.1 to -10.7, P<0.001) at 12 months and -26.6 kg (95% CI -37.5 to -15.7, P<0.001) at 24 months, they wrote in .

IIH-related intracranial pressure causes swelling of the optic disc, or papilledema, generally resulting in chronic headaches (often migraine), potentially permanent visual loss, and -- not surprisingly -- an adverse effect on patients' quality of life, the authors said.

Those who underwent bariatric surgery had a significant change in the physical component score of the 36-item Short Form Health Survey at 12 months (adjusted mean difference 7.3, 95% CI 0.2-14.4, P=0.04) and at 24 months (adjusted mean difference 10.4, 95% CI 3.0-17.9, P=0.006).

The study "documented significant improvements in physical component score, energy and fatigue physical functioning, and general health after bariatric surgery ... [which] has been associated with benefits for quality of life as well as with IIH remission," Sinclair and colleagues wrote.

For the U.K. hospital-based study, a total of 66 women (mean age 32) diagnosed with active IIH who had unsuccessfully attempted to achieve adequate weight loss for at least 6 months were randomly assigned to receive either surgery (n=33) or Weight Watchers face-to-face sessions (n=33) from March 1, 2014, to May 25, 2017. The study population had a mean lumbar puncture opening pressure of 35.5 cm CSF and similar baseline characteristics. Approximately 15% were Black, African, or Caribbean, or of mixed race, and about 29% overall were receiving treatment with acetazolamide.

The primary outcome was change in intracranial pressure measured by lumbar puncture opening pressure at 12 months, as assessed in an intention-to-treat analysis. Secondary outcomes included lumbar puncture opening pressure at 24 months, as well as visual acuity, contrast sensitivity, perimetric mean deviation, and quality of life at 12 and 24 months.

Changes in papilledema grade, headache disability, visual function, and other IIH symptoms were similar for both groups, as were anxiety and depression scores.

Weight loss is often difficult for patients with IIH, some of whom may have underlying polycystic ovary syndrome, noted Deborah Friedman, MD, MPH, of the University of Texas Southwestern Medical Center in Dallas, in an .

Furthermore, organized weight loss programs are often not feasible for patients with IIH, which with low income in the U.S., creating socioeconomic disparities that, in addition to symptoms, limit access to individualized dietary programs.

"Notably, 14 [of the 33] participants randomized to the weight management arm never attended a Weight Watchers session, 2 participants withdrew from the study, and 2 participants underwent bariatric surgery on their own ... [which may suggest] an overall frustration with dietary management among patients with IIH," Friedman wrote.

With bariatric surgery, lumbar puncture opening pressure "was reduced to a level that, on average, barely reached the threshold (25 cm CSF) to qualify for a diagnosis of IIH," she noted. "[O]ther outcomes, such as visual function, different symptoms of IIH, and headache disability, improved similarly in both treatment groups."

This demonstrates that controlling CSF pressure is frequently not sufficient to minimize the headache burden, she said. "Nonetheless, there are substantial advantages conferred by bariatric surgery with regard to metabolic syndrome, hypertension, cardiovascular risk, and general medical health."

Friedman also noted that a post-hoc analysis revealed greater reductions in surgical patients' use of acetazolamide, topiramate, and headache preventive medications during the trial compared with little difference among those in the weight management arm.

Sinclair and team acknowledged that the low number of participants prevented them from evaluating patient-centered outcomes and recommending which type of bariatric surgical procedure is best for patients with IIH, which should be investigated in future trials. In addition, the findings do not directly inform treatment among men or women with a BMI lower than 35.

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