Obstructive Sleep Apnea And Intracranial Pressure (Part 1)

Guest blog by Deborah Wardly, MD

It seems to be a little known fact that obstructive sleep apnea (OSA) can cause an increase in intracranial pressure (ICP).  In 1989 Jennum and Borgeson showed that individual apneas lead to an increase in ICP in addition to an increase in arterial pressure, but also that in patients with OSA, more than half of them have elevated ICP while awake in the morning, and the ICP in the morning is higher than it is in the evening.  Since that time there have been a few papers addressing this phenomenon, but surprisingly less than one might expect, and probably as a result most doctors do not seem to be aware of the connection.  
There is more information in the ophthalmology literature and this specialty seems to be knowledgable about the relationship between OSA and papilledema (swelling of the optic nerve head) as seen in pseudotumor cerebri.  There are reports of patients with OSA and intracranial hypertension with papilledema showing improvement in disc edema and visual fields with the use of CPAP.  
However there is less awareness of the condition of IIHWOP: idiopathic intracranial hypertension without papilledema.  In IIHWOP the headache pattern may be identical to that of migraine, and in the absence of papilledema it may not be possible to diagnose it without a lumbar puncture for opening pressure.  The diagnosis of this subset of IIH must be considered in order to detect it. 
In IIH the symptoms include most prominently headache, which is worse in the morning, and can be increased by anything which increases ICP, like coughing or sneezing (a Valsalva).  The pain can go into the neck and upper back, and may be felt behind the eyes.  There can also be nausea and vomiting, as well as dizziness.  Many patients have a symptom called pulsatile tinnitus, which is a whooshing sound in the ears synchronous with the pulse.  Less frequently there can be numbness of the extremities, generalized weakness, and balance problems.  The ICP can affect the cranial nerves, notably the sixth nerve, and as above can lead to swelling of the optic disc which may cause visual changes.  IIH can even present with psychiatric symptoms: depression, anxiety, and rarely self injurious behavior and psychosis.
The classic presentation of a person with IIH is an obese woman in her 40s, prior to menopause.  The IIH is found to improve if the woman loses weight.
However there is a recent association noted in men with IIH: they are more likely to have OSA and testosterone deficiency.  Therefore in addition to OSA, hormones seem to play a role in whether a person develops IIH.  There is also a suggestion in the literature that IIH may in some cases be related to a hypercoagulable state.  This may explain its prominence in people with higher estrogen levels.  We know that OSA promotes hypercoagulability, is made worse by obesity, and may cause morning headache.  OSA also will improve with weight loss.
I hope the reader can see the correlation and overlap between the symptoms of intracranial hypertension and those of OSA.  It is my impression that there is likely a significant amount of IIH that is unrecognized among patients with OSA, because the relationship between apnea and ICP is not well known.  Could it be that the severe fatigue and other debilitating symptoms in UARS are actually a result of unrecognized intracranial hypertension?  I also suspect that problems in making the diagnosis of OSA may lead to underdiagnosis of OSA as the cause of many recognized cases of IIH. 
What is your experience?  As physicians were you aware that OSA may cause ICP?  Do you have patients with both OSA and IIH?  Do you have OSA patients with many of the IIH symptoms who might need further evaluation?  As a patient with OSA, do you see yourself in the description of IIH?


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23 thoughts on “Obstructive Sleep Apnea And Intracranial Pressure (Part 1)

  1. First of all,thank you so much for your research and the information you have provided. Why are most doctors in the dark about this illness and doing a more through investigation of symptoms? To me,a good doctor,would be one that is a medical detective.I have been suffering with no answers and think this article has given me insight,as to what is going on. Now,the biggest issue is finding a doctor that is willing to actually take me seriously. My health is rapidly declining and I don’t know where else to turn. The doctors dismisss me,as my visual field test was normal,but had tear abnormailities? My mri and ct looked normal,with noted small ventricles and swollen parotid gland. The neurosurgeon that put in my shunt,refuses to do an lp. He sees no cause for it. These are my symptoms: Severe headache apon waking,that has been mostly frontal,but am getting stabbing like pain under my left occipital bone. I have tried loratab and it doesn’t even help. For the past 2 months,my balance is off,my ears are so full and tinnitis,I can’t even hear my phone now. I am disoriented and shaky. I am getting very depressed and even getting suicidal. I keep losing more weight and have no appetite,and feel nauseous all the time. I am desperate for help. I feel as if I’m on drugs,it is very strange.I had a sleep test a few years back,but it wasn’t a good study,as I only slept 3 hours,as they were laughing and being loud,so I got up and went home. They said I didn’t appear to have OSA but never entered deep sleep.

  2. hi Susan;
    I just found your post and I don’t know if you will get this so many months later. but you do sound like you may have IIH. isn’t that what your shunt is for? I know exactly what that feeling of being on drugs is: that is elevated intracranial pressure. but if you have undiagnosed OSA, that may be making things worse, despite your shunt. you can get support for this at Daily Strength pseudotumor cerebri forum.
    Dr. Deb

  3. I have pulsitile tinnitus that started after a virus. This virus, went on for a month and I coughed and sneezed a lot. The coughing went on another month after the virus stopped and during this time I had what I call about 4 or 5 “violent” coughing spells that would last for 10 or 15 minutes, where I would be gasping for air and gagging and had no control. The pulsitile tinnitus followed at the end of this virus. I’ve had sleep apnea for over 15 year and use a cpap machine set on chronic tritation. I saw a neurotolargologist and he did a MRA, it was negative and he suggested intercranial hypertension. Things are getting worse. I feel dizzy, sometimes my finger tingle and my neck aches and sometime I have mild headache. The doctors I’ve seen can’t or won’t help me. Is my cpap machine to blame? Where do I go from here? What kind of doctor will listen to me!? Please, please help!!

  4. the virus you had sounds like Pertussis, with the bad coughing spells. these were causing a valsalva, which can increase intracranial pressure. but if you don’t have an underlying ICP problem, the pressure generated should not be sustained after you recover from the cough. if you have intracranial hypertension triggered by your sleep apnea, it may be that the OSA is just getting worse as you get older, and the virus made it worse suddenly. if your CPAP is automatic, it may not be treating all of your flow limitations which can be a problem in intracranial hypertension. also the expiratory pressure can also act as a valsalva. in this case, BiPAP may be better tolerated and getting a new titration at a good sleep lab and then setting the machine to the new settings rather than using the auto feature might help. but, an MRA cannot rule out intracranial hypertension; the only way to diagnose this is with a spinal tap. a neurologist normally orders this but any doc can order it to be done at a hospital by a neuroradiologist. if you have an issue with your optic nerves, this will get their attention, and the ophthalmologist can order the spinal tap also. I would see an ophthalmologist to get your optic nerves evaluated, and also see a neurologist. see my other blogs on this topic for more info. good luck!

  5. I read your article above and am suffering from may of the symptoms you mention.
    I was hospitalized with a severe migraine that caused breathing problems resulting in my blood gasses being all messed up. The diagnosed me with OSA and put me on bipap 12/5 with a humidifier. The headaches went away but other symptoms started. I woke unrefreshed and as the day wore on I began to get extremely light sensitive and cognitively impaired. I had the feeling like my brain could not take in any more information, migraine meds helped some but not completely. The symptoms would eventually moderate but return the next day. My pressures were raised to 17/10 and the symptoms got worse. I decided to go off the bipap for 2 days and the symptoms went away but the headaches returned so I went back on but this was after my Dr. changed the settings to auto adjust. Now the headaches are back regardless if I use it or not and the side effects of the bipap are there. These symptoms are very much like what you present in your paper. Counld the bipap be causing increased intracranial pressure?

  6. I believe it is possible for BiPAP to increase ICP. I get headaches if I try to use it. I experience the expiratory pressure as a Valsalva, which is known to increase ICP. you were probably better off on the lower pressure of 12/5, but it may be that the 12 was too much. I find PAP to be a catch 22 when a person has OSA and IIH. my son has both and he does well with BiPAP and I don’t completely understand why some people can tolerate it and some cant. if you have IIH you may have sensory problems that cause the stimulation of the PAP machine to lead to sleep deprivation and overstimulation leading to increases in ICP.

    I’ve written more here: http://doctorstevenpark.com/obstructive-sleep-apnea-and-intracranial-pressure-part-2
    and here: http://www.sciencedirect.com/science/article/pii/S0306987714003806
    where I discuss the possibility that CPAP is increasing ICP significantly in those with IIH.

    you can go here: to see a list of symptoms that real IIH patients complain of:

    it sounds to me like a visit to a neurologist and a question about a spinal tap might be your next step. I did much better with a tongue retaining device, when I could get it to stay on, and ultimately opted for jaw surgery which fixed the problem.
    good luck!

  7. I was diagnosed with IIH a few years ago with papilledema. I was just recently diagnosed with severe sleep apnea at Stanford University. I’m surprised my sleep doctor didn’t say anything to me. He did refer me to a good neuro at Stanford that I will see this Monday.

  8. Jennifer,

    Thanks for commenting. It’ll be interesting to see if you still have IIH after you’ve been properly treated for your OSA. Good luck, and please keep up up to date.

  9. Jennifer;
    don’t be surprised. I was also diagnosed at Stanford and titrated to CPAP when they knew I had IIH. I had to call them and ask for the BiPAP and a letter for my insurance to justify it based on my IIH. no one knows much at all about this, even though the physiology is clearcut if you are a doc and personally experiencing it. it ought not to be rocket science, but somehow it is. that’s why I’ve written my papers. good luck!

  10. Hi, I was diagnosed nearly 3 yrs ago with psuedo tumor cerebri after a weekend of explosive symptoms. I had been having mild blurred vision even 6 months before that but that specific weekend when it hit, my head felt like it would explode from pressure. I was also having pulsatile tinnitus and ct showed empty sella. I was referred to an eye dr who diagnosed massive bilateral papilledema and referred me to neuro for LP which was done showing an opening pressure of 160. After the LP and starting diamox, my headache was immediately relieved. My headaches have come and gone over these years but nothing like the first weekend. My dr says my headaches now are simply migraines. I take 50mg topamax and 250mg diamox daily. This has been working fairly well until recently when I started waking all through the night with intense headaches behind my eyes and temples and just a feeling of pressure. I go see my dr next week by im laying here dreading sleeping tonight and waking 4-5 times with the headaches. Even just laying here in bed I’m already hurting. I’m curious if you think this pressure is migraine or related to my PTC. thanks!

  11. hi Candice;
    I think that if you are waking that frequently at night, that it is OSA causing that, and that OSA is triggering your headaches, which are all ICP related. have you had a sleep study? I know that most neurologists think that migraines and PTC can co-exist, but I believe that a great deal of what they call migraine is actually undiagnosed PTC (aka IIH). I have yet to meet a migraine patient who had an LP to rule out PTC, and I know many “migraine” patients who got better on Topamax which is used to reduce ICP. people who have obvious ICP type triggers for their headaches, but were never diagnosed with PTC, only migraine, and again, no LP done. my ICP went from 23 down to 14 after jaw surgery, and funny thing is that I don’t get my “migraines” anymore. that’s because they never were migraines. unless your doctor can prove that your ICP is below 15 at the time of your headache, I would be skeptical of his diagnosis. either way, OSA can trigger migraines too, so make sure you get that assessed, especially since you are having frequent arousals. you can try to sleep with the head of your bed elevated for now, and try not to sleep on your back. good luck! also check out Daily Strength PTC forum.

  12. Thank you for your response! I will bring up the sleep study at my next visit since I’ve never had one. I mistyped above. My opening pressure originally was 60, not 160 lol! I had a repeat test done a year later (2 years ago this april) due to continued milder headaches and it was 18 at that time which my dr said proved it was only migraine. I switched doctors last August and this new dr hasn’t suggested another LP so not sure where I stand now. I do feel like my vision is effected and def my sleep as well so I appreciate your help!

  13. I was wondering about that OP, figured it must be a typo! 60 is massive anyway. I don’t think I’ve heard of one that high. were the two LPs done in the same position? if it is done prone, they must add the length of the needle, which is at least 6 cm. if they forgot to do that, your OP was higher than 18 cm. how did you feel after that LP? did you feel better? or did you have low pressure headaches? if you felt better, then 18 is probably still high for you.
    take a look at this paper:

    anyway, sleep apnea can cause ICP to spike, but that ICP may not remain high during the day. there are people who have papilledema from OSA who have normal ICP during the day. you could have ICP spikes while you are sleeping, causing these nocturnal headaches, while your ICP may drop once you wake up and stand up, such that by the time you go in for the LP you are down to 18. I was told that technically in children, ICP should be no higher than 15. Higgins above talks about how the “normal” ranges were determined from LPs done on people who were not normal neurologically, just presumed to not have ICP issues. not very scientific, I think. I think they don’t know what true normal is.

  14. I just read your article and it has answered so many questions for me. I was diagnosed with sleep apnea, pseudotumor and spinal stenosis. My neurologist told me to lose 20 lbs for the pseudotumor ( I am 5’3″ and weighed 160) and he prescribed a CPAP for me (after a sleep study). After doing my own research, I found out through John-Hopkins and the Mayo Clinic that they are all related when it comes to their effects. I must admit that I stopped using my CPAP for a while. After reading your article and reflecting back, I realized that the pulsating stopped while I was using the CPAP. Needless to say, I am now back on my CPAP. I also noticed that I the pulsating returned after I gained weight (six lbs). I am currently working on losing weight and using my CPAP nightly.

    Thank you so much for this article. It has been so informative and I now feel like I can better manage my health.

  15. I’m so glad it helped you Sandra. there is a part 2 to the blog on IIH, so search this site for it. it has links to papers I have published on the topic.
    if you think that CPAP is a double edged sword for your ICP, try BiPAP. it was much more tolerable for me, although still not the whole package. I ended up going into remission after jaw surgery.

  16. I have pretty much the symptoms you described, back in August of 2015, I was working outside doing a lot of bending over. I noticed that when I stood up I would get a little dizzy. I though nothing of it until I started getting the a type of pressure headache like a 5 lb. weight sitting on top of my head. I noticed that the headaches have become a little worse and are now a daily problem always on the right temple area just above my ear. My wife says I don’t sleep well at night and maybe due to sleep apnea. I recently visited a neurologist who did a full physical exam and scheduled me for a MRI with contrast. The physical exam noted upon checking my right eye noted optic disc edema. I am 47 years old 5′ 11″ 240 lbs. I should be around 190-200 lbs. I also noted when I was in the pool the other day I could not go lower than a foot in the pool without the pressure in my head hurting. I visited a ear nose and throat doctor to check any other possible nasal problems. A previous MRI with no contrast a year ago noted Mucosal thickening of the Posterior Nasal sinus. In reading your article I believe that the intracranial pressure is due to my sleep apnea and obesity. I will try a weight reduction plan and some type sleep apnea product to see if the headaches and intracranial pressure subside. However I do not know if intracranial pressure is involved in my particular case at this time. I will keep you informed as I believe anyone can learn from what I’m going through and how to best help themselves.

  17. I’m someone who has these issues who has lost weight and has no pap issues. can there be any other reason to why I am experiencing these same issues for over 7years?. Is there any more research on this and where can i get it from ?Also have you investigated IIH and seziures as i have them too and wondered if you have any findings on that at all many thanks

  18. Great article.

    I was diagnosed with osa about 4 years ago. Love my cpap. I feel best when I’m using it.
    Diagnosed with iih about 6 months ago. Lp showed a pressure of 39 laying flat. I was already on diamox and topmax. Vp shunt 3 weeks ago.
    Still miserable.
    In bed with my cpap most of the time.

    Nose pillows make it comfortable and unobtrusive.

  19. hi Jessica;
    I know several women who have IIH and seizures. it seems to me that the OSA makes the seizures worse, which has been documented in the scientific literature. OSA and IIH are very difficult to treat together, as many OSA treatments can increase ICP, and even a little bit of apnea makes ICP worse. The only solution for me was jaw surgery. if you are not obese then you should still look into how much sleep apnea you may have. other things that can cause this besides obesity are some medications, like Accutane and Doxycycline. There is a long list of secondary causes of IIH.

    Laurie I’m so sorry you still feel ill after the shunt. my concern would be that the CPAP could be contributing to your ICP not completely normalizing. BiPAP is better in your situation although for me even BiPAP was a problem. you also need to make sure they have not overdrained you. if you are having more headaches upon standing up, then these could now be low pressure headaches.

  20. I agree that it’s proby low pressure.
    My surgeon told me i needed more time to get used to my new normal and will adjust it at my 6 week follow up.
    My head pain is better but im seeing double snd triple and experince waves of nausea, dizzieness and just oversll feeling horrible after being upright for more than a half hour or so.

    Time will tell. I’m not giving up on it.
    I will talk to my sleep apnea Dr about a bipap.
    I havn’t seen them since i was diganosed with iih.

    I live on the Olympic Peninsula where Dr’s are few and far between and most have never heard of IIH.

    I also have Hidradentinitis Superlative Dermatitis.
    I took Accutane for 7 days and became disabled bleeding and im extream pain with IIH symptoms.
    I didn’t have sleep apnea before either.

  21. yes it sounds like the Accutane triggered the IIH. but you likely had the OSA before, it’s just that it wasn’t causing you so many problems until you could no longer maintain a normal ICP. then the apnea aggravated that situation, necessitating tight control over your sleep breathing.
    I hope you feel better soon. however I suspect with what you are describing that your neurosurg is blowing you off and your shunt needs to be adjusted. it is probably set too low for you.

  22. Yes this is definitely true. I had severe headaches, pain in the neck, head and eyes, vomiting, anxiety, heart palpitations, depression, memory problems, problems with having no energy to complete house chores. This is an unknown phenomena I think or it is not spoken about!! But it is a serious issue that can lose one’s family, job, previous respect or status. Once corrected with a high starting pressure on an APAP machine, energy returns, but it is a miserable existence prior to treatment, where people think you are lazy and they can’t understand why you can’t change what is happening. Appropriate treatment is the only way your energy returns. Also I need to have water in the humidifier at all times to prevent the migraines and vomiting from recurring.