Headache

Stabbing headache?

(also called ice-pick headache) This consists of a single stab or series of stabs in the distribution of the first trigeminal nerve with no other accompanying signs or symptoms. Stabs last for up to a few seconds and recur with irregular frequency ranging from 1 to many per day Usually indomethacin responsive.

Epidemiology of cluster headaches?

- About 1 in 1,000 people suffer from cluster headache. - M>F - 20-40 (but can at any age)

Triggers of migraine?

- CHOCOLATE ? - CHeese - OCP especially combined pill - Caffeine (overuse, can use to treat?) - alcohOL - Anxiety - Travel - Exercise - dehydration no hunger - change of routine - general stress

Acute glaucoma?

- Constant unilat eye pain, radiating to forehead - ↓ acuity, haloes, n/v - Red eye, cloudy cornea. - Dilated, non-responsive pupil

Analgesic overuse?

- Episodic headache becomes daily chronic headache - Use OTC analgesia on 6 days/month max

Risk factors for chronic daily headache?

- Head , neck and spinal injuries , - Sleep disorders and snoring - Previous history of migraine - Overuse of analgesia; aspirin, paracetamol. Ibuprofen, combinations, barbiturates, opioids - High BMI - Stress, depression, anxiety - Being female - Being white European (also associated with a worse prognosis) - Excessive caffeine intake ; particular risk factor for women under 40.

Cardiac cephalgia?

- May be severe - Aggravated by exertion - Accompanied by nausea - Develops concomitantly with acute myocardial ischemia - Resolves after effective medical therapy for myocardial ischemia - Failure to recognize and correctly diagnose cardiac cephalgia can have serious consequences

Trigeminal neuralgia?

- Paroxysms (seconds to <2min) of unilateral intense stabbing pain in trigeminal distribution (usually V2/3) - Electric and shock like - Triggers: washing area, shaving, eating, talking - Male > 50yrs - Secondary in 14%: compression of CNV, MS, Zoster, Chiari malformationO - Ix: exclude 2 cause by MRI. • Medical management → carbamazepine, lamotrigine, gabapentin, baclofen, phenytoin, valproate, lamotrigine • Surgical management (for refractory cases, after 2-3 failed medications → microvascular decompression

TMJ dysfunction?

- Preauricular pain on chewing - Assoc. ̄c crepitus - Earache, headache

Venous sinus thrombosis?

- Sagittal: headache, vomiting, seizures, ↓vision, papilloedema - Transverse: headache ± mastoid pain, focal CNS signs, seizures, papilloedema

Cortical vein thrombosis?

- Thunderclap headache - Stroke-like focal symptoms over days - Focal seizures are common

Idiopathic intracranial hypertension?

- Variable headache (retro-orbital or vertex) - Overweight females - Papilloedema (except "IIHWOP") - Visual obscurations with bending - Visual field loss - Unilateral or bilateral tinnitus - Normal imaging - CSF pressures > 20 cm H2O (14mmHg)

Pathophysiology of migraine?

- Vascular: cerebrovascular constriction → aura, dilatation → headache. - Brain: spreading cortical depression - Inflammation: activation of CN V nerve terminals in meninges and cerebral vessels.

ICP?

- ↑: worse in AM, stooping, visual probs (papilloedema), obese women - ↓: worse sitting or standing

Investigations

1) Bloods 2) Urine 3) Micro - Blood cultures - Serology: enterovirus (common cause of viral meningitis), HSV, HIV, syphilis, crypto - CSF 4) Radiology - Non-contrast CT * SAH: blood in sulci, cisterns (white). 90% sensitivity in first 24h - MRI * MRA: aneurysm * MRV: sinus thrombosis 5) Special: CSF - Opening pressure (norm = 5-20cm H2O): ↑: SAH, meningitis ↓: spontaneous intracranial hypotension - Xanthochromia: yellow appearance of CSF due to bilirubin. Detect by spectrophotometry.

Classification of cluster headaches?

1) Episodic cluster headaches These are CHs occurring in periods lasting from seven days to one year, separated by pain-free periods lasting a month or longer. Cluster periods usually last between two weeks and three months. 2) Chronic CHs These are defined as CHs occurring for one year without remissions or with short-lived remissions of less than a month. Chronic CH may arise de novo or develop from episodic CH.

List the causes of secondary headache

1) Head and neck trauma 2) Cranial or cervical vascular disorder - Stroke/TIA - Vasculitis - Venous thrombosis (intracranial) 3) Substance or its withdrawal - Carbon monoxide - Medication over use headache 4) Infection - Intracranial infection - HIV/AIDS - Chronic post-infection headache 5) Disorders of homeostasis • Hypoxia and/or hypercapnia (obstructive sleep apnoea). • Dialysis headache. • Arterial hypertension. • Hypothyroidism. • Fasting. • Cardiac cephalalgia. • Other disorder of homoeostasis. 6) ENT disorders 7) Psychiatric disorders

Indomethacin responsive headache syndromes?

1) Trigemino-autonomic cephalgias - Hemicrania continua - Chronic paroxysmal hemicrania - Episodic paroxysmal hemicrania 2) Idiopathic stabbing headache - Jabs and jolts syndrome 3) Valsalva-induced headaches - Benign sexual headache - Benign exertional headache - Benign cough headache Note indomthacin is best given with a PPI

Diagnostic criteria of migraine?

1) Typical aura + headache, or 2) ≥ 5 headaches lasting 4-72h with either n/v or photo/phonophobia + ≥2 of: - Unilat - Pulsating - Interferes with normal life [moderate or severe intensity of pain] - Worsened by routine activity

Classification of headaches

1. Primary a. Tension-type headache b. Migraine c. Cluster headache d. Other → stabbing headache, cough headache, exertional headache, sexual headache, thunderclap headache, hypnic headache, hemicrania continua 2. Secondary

1st line proph?

1st Line: Betablockers & Amitripyline • In theory, the ideal beta-blocker for use in migraine should be hydrophilic and cardioselective so as to produce fewer side-effects, and have no sympathomimetic activity, so as to be more effective. • Atenolol and metaprolol are recommended. Propanolol also has good evidence but isn't cardioselective and often requires 2 doses/day. • For amitriptyline a dose of 10-150 mg daily 1-2 hours before bedtime is recommended and is particularly useful when chronic pain, insomnia or depression co-exists.

2nd line proph?

2nd line: topiramate and sodium valproate • These are anticonvulsants (treat migraine as have effect on blood vessels in brain) Can cause tingling in arms, weight loss, increased risk of stones, glaucoma and psych issues

Classification of migraine?

3 maint types 1) Migraine with aura (classical) 2) Migraine w/o aura (common migraine) 3) Migraine aura without headache The third edition of the International Classification of Headache Disorders was published in 2013 and classifies migraine as follows: • Migraine without aura. • Migraine with aura. • Hemiplegic migraine. • Chronic migraine. • Complications of migraine: status migrainosus, persistent aura without infarction, migrainous infarction, migraine aura-triggered seizure. • Probable migraine, with or without aura. • Episodic syndromes that may be associated with migraine: recurrent gastrointestinal disturbance, cyclical vomiting syndrome, abdominal migraine, benign paroxysmal vertigo, benign paroxysmal torticollis.

Intracranial tumor ?

30% have headache Dull or aching, morning, wakes u up Increased with Valsalvaa N&V Neuro exam may be normal

3rd line proph?

3rd line: Pizotifen and gabapentin. • Pizotifen (also a 5-HT antagonist) 1.5 mg daily has been used for a long time but evidence of efficacy is limited and certainly there is no justification for higher doses. It may cause weight gain • May consider botox as 4th line.

Epidemiology of migraine?

8% prevalence F:M = 2:1

Classification of chronic daily headache?

A chronic daily headache (CDH) can be defined as a headaches which occur for 15 days or more per month, for at least 3 months Headaches which occur for less than 15 days per month are classified as episodic headaches. Headaches which last less than 4 hours are more likely to be cluster headaches.

Sexual headache?

A headache precipitated by sexual activity, usually starting during intercourse and peaking at orgasm. It may have an explosive onset at orgasm, in which case SAH will need to be excluded at least on the first occurrence.

Management of cluster headaches?

Acute attack o Sumatriptan 6mg SC (or 50 mg PO) o Sumatripitan nasal spray (can also give intranasal lidocaine) o 100% O2 via non-rebreathe mask for 15 minutes up to 5x/day Prevention o Verapamil is 1st line, stated at doses of 40mg BD building up to as much as 960 mg daily • ECG monitoring is needed when increasing doses or using doses above 120mg o Prednisolone (may be preferred as started at full dose) • 60-100 mg, once-daily for 2-5 days is recommended • To be reduced after 5 days in 10 mg increments every 2-3 days, so that treatment is discontinued in 2-3 weeks. o Lithium should be considered if verapamil is not effective, at doses of 600-900 mg daily. • Others → melatonin, topiramate, sodium valproate, ergotamine, nifedipine, antihistamines, occipital nerve blockage or stimulation, lithium

Examination?

Always examine the following in patients with headache: • Optic fundi. • Blood pressure. • Head and neck (scalp, neck muscles and temporal arteries). • Head circumference in children. Neurological examination between attacks is normal. Abnormalities suggest another cause. Examination during an attack may reveal localised oedema of the scalp, face, or under the eyes; scalp tenderness; prominence of temporal blood vessels; neck stiffness and tenderness.

Presentation of migraine?

Headache - Aura lasting 15-30min then unilat, throbbing headache - Paroxysmal, tends to be unilateral - Phono/photophobia - n/v - Allodynia - Often premenstrual - Tired, depressed, difficulty concentrating - Typically lasts 4-72 hours - General light headedness Prodrome (50%): precede migraine by hrs - days - Yawning - Food cravings - Changes in sleep, appetite or mood Aura (20%): precedes migraine by mins (<60) and may persist - Visual: distortion, lines, dots, zig-zags, scotoma, hemianopia. Stars in one and may spread. May be homonymous. - Sensory: paraesthesia (fingers → face). Unilateral and fully reversible. Leg sometimes affected. Rarely occurs alone, and usually follows visual auras. - Motor: dysarthria, ataxia, ophthalmoplegia, hemiparesis (hemiplegic migraine) - Speech: dysphasia, paraphasia NOTE: the headache begins before the end of the auraor within an hour of the end and has the same feratures as migraine w/o aura.

Diagnostic criteria for secondary headache?

Headache - often without specific diagnostic features, in which: • Another disorder known to be able to cause headache has been demonstrated. • Headache occurs in close temporal relation to the other disorder and/or there is other evidence of a causal relationship. • Headache is greatly reduced or resolves within three months of successful treatment or spontaneous remission of the causative disorder.

Infectious causes of headache?

Meningitis Encephalitis Epidural abscess AIDS

Risk factors for migraine?

Obesity PFO

Hemicrania continua?

Paroxysmal hemicranias: cluster-like headache lasting 5-45min, 5-30x/day. Lasts for more than 3 months. 1) All of the following characteristics: - Unilateral - Daily and continuous - Moderate intensity but with exacerbations 2) At least 1 autonomic feature occuring during exacerbation: - Ipsilateral conjuctival injection or lacrimation - Nasal congestion or rhinorrhoea - Ptosis or miosis Indomethacin-responsive .. SUNCT: short-lasting unilateral neuralgia with conjunctival injection and tearing, attacks last 15-60s, recur 5-30x/hr

Presentation of cluster headaches?

Pattern of occurence • Headaches typically occur in bouts which last 6-12 weeks, once a year or two years, often at the same time each year. • The headache typically occurs at night, 1-2 hours after falling asleep, although this is not always the case. • 10% of those with episodic CH go on to develop chronic CH. • The pain comes on rapidly (without aura) over about 10 minutes. • The pain maintains an intensity, is excruciating, sharp and penetrating (not pulsatile as with migraine). • The pain is centred around or behind the eye, temple or forehead, although the neck and other parts of the head can be involved. • Pain is unilateral and mostly stays on the affected side with each attack. • It typically lasts from 45-90 minutes (range is 15 minutes to 3 hours). • Attacks of pain occur once- or twice-daily (occasionally more often, even up to 8 times daily). • Wakened patients may beat their heads against the wall in distress. • Associated autonomic features of ipsilateral lacrimation, rhinorrhoea, nasal congestion, eyelid swelling, facial sweating or flushing and conjunctival injection and a partial Horner's syndrome with miosis and ptosis may be present: two or more in the presence of the extremely severe periocular headache will secure the diagnosis. • Nausea may accompany the pain, but is much less of a feature than with migraine. • Sufferers, unlike with migraine, cannot keep still and are described typically as restless. • Patients pace around, occasionally banging their heads on walls and furniture.

Thunderclap headache?

Primary thunderclap headache is a high-intensity headache of sudden onset reaching maximum intensity in under a minute and lasting from 1 hour to 10 days. It resembles SAH, from which it cannot be distinguished on clinical grounds alone. When such a headache presents in primary care, without other symptoms, there is a 1 in 10 chance that this represents SAH. Primary thunderclap headache is not recurrent, generally, although it may recur in the first week after onset: i. Evidence that thunderclap headache exists as a primary condition is poor - the search for an underlying cause should be exhaustive, as the differential diagnoses are serious. ii. Thunderclap headache is frequently associated with serious vascular intracranial disorders, particularly SAH - it is mandatory to exclude this and a range of other such conditions including intracerebral haemorrhage, cerebral venous thrombosis, unruptured vascular malformation (mostly aneurysm), arterial dissection (intracranial and extracranial), CNS angiitis, reversible benign CNS angiopathy and pituitary apoplexy. iii. Other organic causes of thunderclap headache are colloid cyst of the third ventricle, CSF hypotension and acute sinusitis (particularly with barotrauma).

Paryoxysmal hemicrania characteristics?

Severe Multiple attacks daily Lateral orbital, supraorbital, or temporal pain Lasts 2 to 30 minutes Associated with at least 1 of the following autonomic signs, ipsilateral: - Conjunctival injection or lacrimation - Nasal congestion or rhinorrhea - Eyelid oedema - Forehead or facial sweating - Miosis or ptosis Indomethacin-responsive

What is step one of acute medical management of migraine?

Step one: simple analgesic with or without anti-emetic - This is appropriate for mild-to-moderate migraine in a stratified approach. Often patients will already have tried and failed with some of these treatments. In these and in patients with moderate-to-severe migraine, move to step three. • Use early in the attack to avoid gastric stasis. • Use soluble aspirin 600-900 mg (not in children) or ibuprofen 400-600 mg. • Avoid opiate-containing medications, including codeine. • Use prochlorperazine 3 mg buccal tablet if there is nausea and vomiting (anti-emetics are not recommended for children or adolescents). • Consider switching to prokinetic anti-emetic in adults (improves absorption - eg, domperidone or metoclopramide 10 mg). • Consider other non-steroidal anti-inflammatory drugs (NSAIDs) ± anti-emetics (naproxen 500 mg, diclofenac 50-100 mg, tolfenamic acid 200 mg). Don't use delayed-release NSAIDs. • Consider combination preparations - eg, Paramax.

What is step three of acute medical management of migraine?

Step three: specific anti-migraine drugs • In a stratified approach to management, patients identified as having moderate-to-severe migraine should move straight to step three. • Triptans (5HT1-receptor agonists) or ergotamine (the use of ergotamine is limited by absorption problems and side-effects such as nausea, vomiting and abdominal pain).

What is step two of acute medical management of migraine?

Step two: rectal analgesia and rectal anti-emetic • Use diclofenac suppositories 100 mg with domperidone suppositories 30 mg if needed for vomiting. • Avoid if contra-indicated or unacceptable to the patient.

Chiari malformation?

Structural defects within the cerebellum causing the cerebellum and brainstem to be pushed downward Symptoms: - dizziness - occipital/nuchal headache - problems with balance and coordination - Headaches are usually not associated with hydrocephalus Treatment: suboccipital decompression surgery

TTH vs. Migraine

TTH is... • More gradual in onset. • More variable in duration (usually shorter). • More constant in quality. • Less severe. • Usually responsive to 'over-the-counter' medication (in the episodic variety).

Exertional headache?

This is a pulsating headache brought on by exercise and lasting 5 minutes to 48 hours. It occurs particularly in hot weather or at high altitude. Due to its sudden onset, SAH may need to be excluded. At altitude it is essential to consider acute mountain sickness and high-altitude cerebral oedema, and in view of their seriousness these should be the first-line diagnoses until disproved.

Official diagnosis for medication overuse headaches?

To be diagnosed with MOH, there must be a 3 month history of medication overuse Individuals who had episodic headaches and have daily use of NSAIDS, caffeine, opioids and barbiturates, are more at risk of developing MOH

Glossopharyngeal neuralgia?

Unilateral pain - Pharynx - Soft palate - Base of tongue - Ear - Mastoid Treatment as for Trigeminal Neuralgia

Cough headache?

a headache precipitated by coughing or straining in the absence of any other headache disorder. Sinusitis is a cause

What is the link between anxiety and headaches?

o Headaches associated with stress and anxiety disorders are tension (featureless, often generalised, mild-severe) and migraine (severe, often unilateral and can be associated with aura) headaches. o Headaches can be a common symptom and sometimes a good indicator of an anxiety disorder, particularly generalised anxiety disorder. o Researchers have suggested that a common predisposition to anxiety disorders and depression may exist as migraines and chronic daily headaches are common in people who suffer anxiety disorders. o Migraine headaches can precede the onset of mental disorders, according to a 2009 study. Researchers found that 11 percent of participants in the study had migraines and a variety of disorders. o Many studies have found that people with GAD and panic disorder in particular experience migraines or other types of headaches

RED FLAGS - associated features

o Patients with risk factors for cerebral venous sinus thrombosis (including pregnancy). o Jaw claudication or visual disturbance. o New-onset headache in a patient with a history of HIV infection. o New-onset headache in a patient with a history of cancer which can metastasise to the brain (or any history of cancer in a patient aged under 20 years). o Symptoms suggestive of giant cell arteritis o Symptoms and signs of acute narrow-angle glaucoma. o Vomiting without any other obvious cause. o Headache after head injury or within 90 days of head injury (subdural in the elderly). o Papilloedema. o Immunosuppression. o Headache associated with neurological deficit. o Headache associated with visual disturbance or jaw claudication (temporal arteritis). o Headache with fever, rash or neck stiffness

Hypnic headache?

this is a dull headache that wakens the patient from sleep, occurs on at least half of all days and lasts at least 15 minutes after waking. It affects those aged over 50 years only. There are no other signs or symptoms but intracranial disorders must be excluded.

New daily persistent headache?

this is a headache that is daily and unremitting virtually from onset. It can resemble TTH but may build to become severe. If nausea is present it is only mild, but photophobia or phonophobia can also occur. It is very difficult to treat. Risks - Non-prescription prophylactic agents and over the counter analgesics, such as Aspirin, Paracetamol etc. taken on more than 3 days per week for > 6 weeks - Combination preparations & Specific migraine medication such as Migraleve, Triptans etc. taken on more than 2 days per week

Triggers of cluster headaches?

• Alcohol • Histamine and nitroglycerine • Heat, exercise and solvents can precipitate attacks. • Disruption to sleep patterns (for example, by shift work, jet lag, etc) can also exacerbate or trigger CHs.

Diagnostic criteria of cluster headaches?

• At least five attacks fulfilling the criteria below. • Severe, or very severe, unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes if untreated. • Headache accompanied by at least one of: 1) Ipsilateral conjunctival injection and/or lacrimation. 2) Ipsilateral nasal congestion and/or rhinorrhoea. 3) Ipsilateral eyelid oedema. 4) Ipsilateral forehead and facial sweating. 5) Ipsilateral miosis and/or ptosis. 6) A sense of restlessness or agitation. - Attacks occur from one every other day to eight times daily. - Not attributable to another disorder.

Diagnostic criteria for TTH?

• Bilateral or generalised, and of mild-to-moderate intensity (interfering with but not preventing activities). • Frontal-occipital. • Non-pulsatile in quality (pressing or tightening). • Not aggravated by routine physical activity.

Classification of TTH?

• Episodic TTH. This occurs on fewer than 15 days each month. It can evolve into the chronic variety. • Chronic TTH. This occurs on more than 15 days each month and has all the features of the episodic TTH. This separation seems slightly arbitrary but it has practical importance because: • The chronic type is more likely to be medication-induced. • The chronic type is more likely to be associated with comorbidity such as depression, which also needs to be treated if the condition is to be managed successfully

Indications of migraine prophylaxis?

• Frequent attacks are two or more attacks per month that produce disability lasting for three days or more. • Medication overuse is a risk when medication is used on more than two days per week on a regular basis. Overuse needs to be addressed before further treatment can begin. • Prophylaxis should be used when standard analgesia and triptans are either contra-indicated or ineffective.

Management of intractable migraine?

• NICE recommends botulinum toxin type A as an option for the prophylaxis of headaches in adults with chronic migraine (headaches on at least 15 days per month of which at least eight days are with migraine) that has not responded to at least three prior pharmacological prophylaxis therapies, and whose condition is appropriately managed for medication overuse. o Treatment with botulinum toxin type A should be stopped in people whose condition is not adequately responding to treatment (defined as less than a 30% reduction in headache days per month after two treatment cycles) or o has changed to episodic migraine (defined as fewer than 15 headache days per month) for three consecutive months. • NICE currently advises against the routine use of occipital nerve stimulation for intractable chronic migraine because, although there appears to be some efficacy in the short term, there is very little evidence about long-term outcomes and there is a risk of complications, requiring further surgery. • NICE currently advises that there is only limited evidence for the benefit of transcranial magnetic stimulation (TMS) for the treatment or prevention of migraine and therefore does not recommend the use of TMS for routine clinical practice. Evidence on its safety in the short and medium term is adequate but there is uncertainty about the safety of long-term or frequent use of TMS

Management of tension headache?

• OTC ibuprofen or aspirin first choice in episodic tension headaches • For chronic TTH, as frequency of headache increases, so does the risk of medication-induced headache, therefore above treatments are not indicated • Amitriptyline is the treatment of choice for frequently recurring episodic TTH or chronic TTH

RED FLAGS

• Onset features o New onset of, or change in, headache in patients who are aged over 50 years. o Headache in patients who are aged under 5 years. o Thunderclap: rapid time to peak headache intensity (seconds to five minutes) - same-day specialist assessment required. o Headache waking the patient up (NB: migraine is the most frequent cause of morning headache). o Headache precipitated by physical exertion or Valsalva manoeuvre (eg, coughing, laughing, straining). o Headache onset with exertion or sex. • Neurological red flag features o Headache onset with seizure or syncope (SAH). o Headache associated with altered conscious level, memory loss, altered cognitive state or change in personality. o Focal neurological symptoms (eg, limb weakness, aura <5 minutes or >1 hour). o Non-focal neurological symptoms (eg, cognitive disturbance). o Abnormal neurological examination. • Headache features o First or worst headache of the patient's life. o Headache that changes with posture.

Presentation of TTH?

• TTH is a featureless, often generalised headache. • It is mild to moderate in severity. • Typically, TTH is described as pressure or tightness, like a vice or tight band around the head. • There is often a relationship to the neck, with pain into or from the neck. • TTH can be disabling for a few hours but lacks the specific features and associated symptoms of migraine. • Although photophobia and exacerbation by movement are common to many headaches, photophobia, phonophobia and visual/sensorimotor disturbance are not present. • Mild nausea may occur, especially if there is medication-induced headache, but profound nausea and vomiting do not occur 30 mins to 7 days

Epidemiology of TTH?

• TTH is the most common type of chronic recurring head pain. • It is one of the most common conditions for which patients seek medical advice. • It is more common in women than in men (ratio 1.4:1). • It is most common in young adults.

Menstrual migraine?

• This is migraine without aura, occurring regularly within a day or two of the onset of menstruation and at no other time. • It is probably due to falling oestrogen levels. • Timing is critical for this diagnosis. Only 14% of women with migraine experience menstrual migraine but up to 60% experience menstrual-associated migraine. • Migraine diaries can accurately differentiate menstrual migraine from menstrual-associated migraine. This is important, as the preventative treatment of menstrual migraine is different from that of menstrual-associated migraine. Prophylaxis with triptann is effective to be taken 2-3 days before day 1

Low ICP headache?

• Usually following LP or epidural anaesthetic - Usually following LP or epidural anaesthetic - may occur spontaneously or as a result of trauma - Worse with sitting or standing Pain: vertex or occipital, Pulling steady, radiating into shoulders - Nausea is common - transient 3rd or 6th nerve palsies possible • post-LP headache usually resolves spontaneously • Bedrest, caffeine, theophylline, steroids • Resistant cases o Epidural blood patch (less effective in spontaneous leaks than in post-LP headache) o Surgical repair of the leak if epidural patch ineffective (if you identify the leak!)

Idiopathic intracranial hypertension treatment?

• Weight loss • Reduce CSF production o Acetazolamide, (Topiramate) o Furosemide • Low salt diet • CSF shunting • Incision of optic nerve sheath