Cognitive impairment in idiopathic intracranial hypertension: A conceptual framework and therapeutic implications

Background: Cognitive impairment is an increasingly recognized but poorly understood manifestation of idiopathic intracranial hypertension (IIH). Although deficits in attention, executive functioning, memory, processing speed, and reaction time have been reported, the characteristics, trajectory, and underlying mechanisms of cognitive dysfunction remain incompletely defined. Interpretation of the literature is limited by heterogeneity in study design, variability in neurocognitive assessment methods, and the absence of standardized cognitive outcome measures. Consequently, cognitive morbidity is overlooked in clinical practice and is not incorporated into treatment decision-making, which remains centered around visual outcomes and papilledema. Methods: In this narrative review, we synthesize evidence from IIH studies and related disease models to examine the putative mechanisms underlying cognitive dysfunction and propose a conceptual framework for its pathogenesis. Results: Cognitive dysfunction in IIH may arise through interactions between elevated intracranial pressure, cerebral venous hypertension, symptom-related amplifiers including chronic headache, sleep disturbance, pulsatile tinnitus, and psychiatric comorbidity, and broader biological and socioeconomic modifiers influencing cognitive vulnerability and recovery. This framework integrates current evidence and identifies potential pathways linking IIH to cognitive impairment. Conclusion: Improved understanding of the cognitive effects of IIH may help improve recognition of cognitive dysfunction in clinical care. Recognition of cognition as a clinically meaningful and potentially treatment-responsive outcome may help inform future studies evaluating whether cognition has a role in treatment selection, particularly in patients without papilledema, in whom disease burden may currently be underestimated.