Challenges in the management of idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IIH) is a complex and increasingly prevalent disorder that results in significant morbidity despite a broad array of available treatments. While lifestyle modifications, pharmacologic agents, and surgical interventions can produce meaningful short-term symptomatic improvements, long-term outcomes are poor, characterized by high rates of symptom recurrence. Weight loss remains the only disease-modifying therapy, though sustained reductions in weight are rarely achieved outside of bariatric surgery. In addition, a subset of patients is not overweight, limiting applicability. Pharmacologic therapies such as acetazolamide, topiramate, and glucagon-like peptide-1 (GLP-1) receptor agonists offer benefits but are limited by the side effect profile and poor efficacy. Surgical approaches often address only a portion of IIH's multifactorial pathophysiology, and recurrent symptoms may arise from persistent venous hypertension or new venous stenoses. This review evaluates the current evidence on medical and surgical treatment failures in IIH, emphasizing unresolved questions in disease pathogenesis and the need for personalized therapeutic approaches that advance the development of more durable treatment options.