Obstructive Sleep Apnea and Intracranial Pressure (Part 2)

Guest blog by Deborah Wardly, MD

Previously I blogged about the relationship between intracranial hypertension and obstructive sleep apnea, and pointed out the similarity between the signs and symptoms of upper airway resistance syndrome (UARS), obstructive sleep apnea (OSA) and those of intracranial hypertension. Intracranial hypertension is characterized by headaches, fatigue, dizziness/vertigo, ringing in the ears (which can be pulsatile), and visual disturbances to include papilledema (swelling of the optic disc). It can be present without papilledema (idiopathic intracranial hypertension without papilledema, or IIHWOP), which many doctors don’t seem to realize, and in these scenarios a lumbar puncture (spinal tap) is the only way to diagnose it. It is associated with obesity in many cases, as is OSA. 

Recently a study was published showing that in a group of patients with chronic fatigue syndrome (CFS), 20% of them met criteria for idiopathic intracranial hypertension (IIH), and 85% of them had improvement in their chronic fatigue syndrome symptoms after reduction of their intracranial pressure after lumbar puncture. The only thing missing from this study was the sleep study results on these patients! But we know how closely UARS can appear to resemble CFS, and this study begs further evaluation of UARS patients’ intracranial pressures, especially given the knowledge that apneas increase intracranial pressure.

My recent published paper discusses what is currently known about how OSA can increase intracranial pressure (ICP), and then further discusses other possibilities for this phenomenon that could be investigated. We know that individual apneas can increase ICP, and that an increase in carbon dioxide effecting an increase in cerebral blood flow may be causal, as well as perhaps an increase in intrathoracic pressure at the termination of the apnea. In my paper I discuss how OSA can increase glutamate excito-toxicity in the brain, and the evidence for glutamate being able to cause brain edema. I discuss how OSA may open the blood-brain barrier, which would also cause brain swelling. 

Alperin, et al. has demonstrated that in obese women with idiopathic intracranial hypertension, they have evidence of both brain swelling and poor jugular venous drainage. I suggest in my paper how the anatomical relationship of the recessed jaw to the narrowed airway, something we recognize is present in many cases of OSA, may also be involved in a compression of the internal jugular veins. This would contribute to the poor jugular venous flow observed in IIH by Alperin, and would increase resistance to CSF outflow. We know that obesity increases the risk of OSA in part by fat compression of the airway in the neck. Perhaps obesity increases the risk of IIH by fat compression of the jugular veins in the neck? Such that it is not entirely a direct causal relationship between OSA and IIH, but that they are conditions which go hand in hand when there is a recession of the mandible or increased fat content of the neck.

An important point that I discuss in my paper is the fact that a Valsalva maneuver will increase ICP. A Valsalva maneuver is created upon “bearing down”, something we do when coughing, sneezing, grunting, crying or shouting, yet even upon laughing, singing or talking. Many people with intracranial hypertension do not tolerate any Valsalva activity, as it will increase their headaches. Think about what it feels like to exhale with your CPAP on—it is a Valsalva as well.  Could this be the reason that some people with OSA/UARS do not tolerate CPAP, but must use BiPAP, or cannot use PAP at all? Do these individuals have undiagnosed IIH?  

If you do not tolerate CPAP, or even BiPAP, do you have headaches or any of the other symptoms of IIH?

Do you find you must have perfect control of your airway problem in sleep, in order to prevent or reduce the headaches, dizziness, and fatigue?

If you have CFS symptoms or IIH symptoms in conjunction with your OSA/UARS, would you consider a spinal tap to further elucidate your symptoms?

Please note: I reserve the right to delete comments that are offensive or off-topic.

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10 thoughts on “Obstructive Sleep Apnea and Intracranial Pressure (Part 2)

  1. Excellent posts on ICP, Dr. Park. Currently I am undergoing orthodontics to reverse the effects of childhood braces and extractions. Since my jaws, especially my top jaw, were pushed back by the braces, thereby locking my cranium up, it would make sense that I have high ICP, as evidenced by my having to “keep a perfect airway” open during the night with cpap in order to feel OK the next day. I find that having even a low AHI, as opposed to an AHI of zero, will leave me feeling not so good the next day. The orthodontics, the Crozat lightwire appliance, has expanded both my top and bottom jaws laterally fairly significantly. It even expanded my jaws forward somewhat, allowing my tongue much more room. Now I am undergoing upper-jaw forward expansion, what is know as “face-pulling,” using the Crane–a reverse-pull headgear that does not use the cranium to push against. From what I’ve read, doing face-pulling not only advances the upper jaw, but it opens up the nasal cavity, even can improve eyesight, and can also allow more room for the brain, hence reduce ICP. This makes sense the upper jaw is connected to all the skullbones (please check this fact Dr. Park). Within 40 days, not only do I hope to see a difference in the forwardness of my face (which will also mean an increase opening of my small airway, since the lower jaw expands along with the top jaw) but I will also have a lowering of ICP. Google face-pulling for me info and before and after pics. [Dr. Park, please feel free to edit, as I might not have worded things right.]

  2. Very interesting post. It all makes sense. Dr. Wardly .
    Will this apply to somebody that has been dx with a pseudotumor of LCR in the brain. And that they are trying to reduce the edema with strong diuretics and that the nerve optic is in danger, si ce this liquid can cause damage of the nerve?
    Thanks Dr. Wardly for that inquisitive mind if really findinf the underlying cause of disease. Dr. Chiappe

  3. Interestingly, coming on the heels of my last submission on this topic, I saw my orthodontist today for a tightening of my orthotic. I told him about your info on ICP, specifically your mention of people who have to have their cpap therapy optimized in order to feel well and who probably have ICP because of their inability to feel well unless their therapy was optimized. My orthodontist said the brain was essentially divided into four “quadrants,” with each being encased by cerebral spinal fluid and pressurized evenly. However, since I had only one tooth extracted and braces as a child–this created a torsion in my cranium, as evidenced by facial distortions. This would then create unequal pressure of the cerebral spinal fluid in the 4 brain quadrants, leading me to not feel well unless my therapy is completely optimized, which is definitely my case. I wonder if this is why others do not feel well unless their therapy is optimized–that their brain quadrants are under unequal pressure by the cerebral spinal fluid, for whatever reason? Just a thought.

  4. Dear Dr. Chiappe;
    IIH is just another term for pseudotumor cerebri, so, yes, this applies to PTC. OSA can increase ICP, and so having PTC, any OSA makes it worse. also, OSA can be a cause of PTC.
    Interestingly, it has been demonstrated that OSA can cause swelling of the optic nerve in the absence of elevated ICP while awake. it was shown that there were ICP spikes that occurred only during apneas while sleeping, and this was sufficient to cause the papilledema.

  5. Dear Jane;
    based on my hypothesis, in order to see significant improvement in ICP with alterations in jaw anatomy, the movement would have to be more so in the antero-posterior direction, rather than a lateral expansion.
    I am not sure what your orthodontist meant by the four quadrants, but there are four ventricles; 2 laterals and the 3rd and 4th ventricles. however, in IIH the pressure is increased not in the ventricles but in the fluid filled spaces outside the brain. a cranial osteopath might be able to shed more light on the issue of how the cranial distortion would affect ICP. my hypothesis has only to do with the internal jugular venous flow.

  6. Dr Park: As always, this is a fascinating post and I find your deductions truly insightful. Please see my questions; I’d appreciate a response if appropriate and possible, esp to ? # 1 (as I’m getting a lumbar puncture soon to check for IH)

    . To answer your questions and describe my situation:
    A. yes, As one with all the symptoms of UARS, diagnoses of:fibromyalgia; and CFIDS, I do have most of the symptoms of IH and daily-weekly headaches and migraines. Note I also have: dizzy-orthostat hypotension; hypothoidism; chronic stiff neck-cervical neck pain; severe cold hands feet; sleep disorders (mild OSA, UARS, and unsure of what else, though it seems to be position ally related, tho my docs cannot explain why…[i feel more rested sleeping upright- with and without cpap]); plus many other diagnoses and symptoms (some weird).

    B. And, yes, I jam willing to behave a lumbar puncture and just requested to be tested for IH at my neurologist (based on this post and artcilesh and he thought it “couldn’t hurt.”

    My FIRST question to you related to IH- (1) what do I need to do or not do (ex – don’t “bear down” ) to ensure an accurate reading when the lumbar puncture is performed or the best possible testing to give an accurate result for IH? Is there a certain position, or preferred specialist etc. Please be detailed if pertinent.
    I understand that IH can be transient, as demonstrated that the valsalva activities. Note I have been repeatedly misdiagnosed with many conditions over the years (which have either wasted a lot of time or caused serious complications – ex, medication side effects), so hope to optimize the lumbar puncture procedure.

    Yes, I do have most IH symptoms, and it would explain many things, including why I have the classic CFIDS / fibromyalgia problem of lack of endurance with activities (eg, not enough endurance or energy to finish emptying a dish washer or take a shower). Although it seems like a diagnosis of IH is not ideal (not treatable at this time), it would be good to know of it and the resulting limitations (vs trying to “push through” as I often do); if you look at me, I look healthy, fit, and like I’m not sick (esp if I wear makeup to cover up my dark circles under my eyes!). But I’m in chronic pain – worse when I sleep less than 9-12 hrs nightly) and am severely sleep deprived (sleep studies show extremely fragmented sleep and poor sleep efficiency); leaving my job, sleeping a lot, and taking meds (including stimulants which I dislike), further the impression to others that I am “not sick.” I basically feel like I have the flu daily. Luckily, I have a supportive husband who believes how sick I am (ex- getting out of bed can take 20-60+ minutes) and supports me.

    Interestingly, I find that a lot of my health problems and related physical complaints seem to be positional related and worsen or improve based on my body position (being upright, movement, etc). Thus, I think your-Dr Park’s-correlation of IH and the OSA/UARS discussion is BRILLIANT- very accurate and insightful. (As always, Dr. Park).

    2nd QUESTION: (2) Are there other conditions that have the same symptoms as UARS and IH? For example, patients with CFIDS, fibromyalgia, IH, and UARS all have similar symptoms and or characteristics. Notably adrenal insufficiency has many of these symptoms (I am hypothyroid, but don’t seem to have adrenal insufficiency per tests and my endocrinologist). I also have had many docs suggest I have a good work up for Lyme disease (missed and chronic).

    What makes me hopeful @ UARS is that it not only describes people with fibromyalgia and CFIDS (or at least me to a “T”), UARS is TREATABLE- tho it has not been an easy road for me and I’m still trying to find a combination of UARS treatments/therapies that may work for me (with considering surgery as last result, if I’m a candidate. Tho I live out of state, I think I’d only trust Dr Park to do it! Only at few of my specialists or consults have even heard of UARS…)

    3rd Question – Would IH or another reason explain why I feel more refreshed in the morning when my AHI on CPAP is higher (vs I feel completely UNrested if my AHI is 5 or below)? My sleep doc, who believes in UARS, finds this unusual. Would IH explain this? yes, I do find I have to have “everything” just right to have even somewhat restful sleep. If my nose is stuffed, it doesn’t work! I prefer to sleep (bec of neck pain-unknown cause other than myofascial pain disorder, trigger points etc), on my back, tho it try to sleep on my side… Note I think that the neck problems could be CAUSED by the throat collapse, resulting effort to try to breath, etc. I can go to sleep with my neck feeling perfect, and wake up in cervical neck pain-agony in the AM. The most helpful treatment to date for me for this is ongoing PT dry needle trigger point therapy (to relieve the tight muscles and release the trigger points).

    Note I am currently on a CPAP (now with nasal plugs-better, but still exhausted), and have an appt to have a bi pap titration (I had to fail CPAP for 6 months before getting bi-pap, tho I asked for bi-pap from the beginning (based on the informative webinars and information you-Dr Park, provide). When I use CPAP at 7 or higher, I have induced central sleep apnea. If my pressure is 4, my readings are good (AHIs resolvd), but I feel terrible. I always feel so terrible with low AHIs and feel better on CPAP with higher AHIs. WHY? I am very much hoping that bi-pap will work, tho I’ve realized that there is not one magic bullet, and need to try many things (I’m reading Butokya breathing, and later will systematically try Joy Muellers Ora facial myology exercises; I want to only change one thing at a time tho. And am too exhausted to do too much….

    Note I also use an advanced mandibular device, both with and without CPAP (tried each one month, and now use together; neither solves my unrefreshed sleep problem and I still cannot function daily due to EDS, brain fog, pain, migraines, etc. But, without the CPAP, I can’t wake up at all and feel even worse than normal. Notably before using CPAP, I had gotten to the point past vivid dreams and not dreaming. Now I dream again, tho very vivid.

    I realize I expounded beyond your questions, but hope the info will be useful in some way to you or your readers. Reading the symptoms of other people on this site made me realize I should not just “accept” my diagnoses of fibromyalgia and CFIDS as my doc implies. Also, I’ve found this site and related feedback invaluable, esp Dr park’s UARS discussion and the info provided /shared; it also gives me hope to never stop trying to get my “health back,” or at least, improve my limited and sometimes non-functional state … :)

    I send my My Best to Dr. Park, the professionals seeking to help patients, those suffering from these related debilitating health problems, and the supportive people who help care for them. I agree with Dr Parks, that we -the patients no their providers- have to be persistent, try multiple treatments, and perhaps use many of them ongoing, to improve.

    Lastly, thank you Dr Parks for sharing your findings and insights, and for increasing awareness of UARS and the related sleep disorders.

    Ms. D. Bensen

  7. Dr Park–
    Dr Wardley’s posts are wonderful– I enjoyed both posts, and even though I am a patient I go quiet a bit out of them and they sounded very familiar.
    I think I am getting the big picture– I am set up for Intra Cranial Pressure (ICP) to happen: I am already halfway there having an overcrowded too small of a cranium. My nose was deviated by the age of 12, I did not have room for my wisdom teeth and they had to be extracted– yet I never got in my 12 year molars. This means my cranium is a “Size 26” rather than a “Size32” (which means the dental palate includes enough width for all of the potential wisdom teeth)– and yet all of my soft tissues have grown to genetic potential size as they are wont to do.

    Yes, I have OSA, (I believe I had UARS as a child), I have migraines (which often will be present when I wake), an extremely stiff neck and upper back, joint pain, adrenal exhaustion, I was colicky as an infant, I have Tinnitus and vertigo since two MVAs, and now pulsing tinnitus and much more hyperacusis with being rear ended 18 months ago. Also– new intermittent double vision, extropia, and binocular insufficiency, and burning eyes with much eye fatigue. I noticed flashes of lights with the first MVA– less so now.

    Here’s the problem:
    There is just not enough room in my already overpacked cranium for any sort of swelling to occur. I am tiny at 5’0– and at this point 95#– not at all obese– and very fit for 60. My jaw was damaged in the older MVA– left retruded and overclosed– leaving me with a 1 mm airspace at the back of the throat. The condyles are remodeled– I am sure pinching some nerves and reducing cranial fluid flow. I wear a dental orthotic at night which prevents the tip of my tongue from being able to fully contact the roof of my mouth at the anteriors– so aha! … less cranial pumping, even though my tongue is not sliding down my throat causing a major number of AHI’s.

    And what about factors– such as: getting stuck behind that asphalt truck on the freeway, or eating that ( fill in the blank) which causes an allergic reaction? More swelling there? — (at least temporarily as the nasal passages revolt and cause a chain reaction and sometimes and instant migraine? It works for me.

    So– I have the picture: the ICP comes from the fluid inside the cranium which is supposed to have a bit more room to expand in a Size 32 cramium– but is in my case causing extra pressure that is throwing the vestibular, vision, respiratory systems (and I am sure other systems) out of balance.

    And then there’s the gut– I heard from all of the Gut and Digestive online Summits that if you have a leaky gut– you have a leaky brain. Dr Datis Kharrazian, author of “Why isn’t my Brain Working” has much to say about this in his wonderful book.
    So– a leaky brain from gut issues is another method by which intracranial pressure can increase. (Not to mention Apneas– which Dr Wardly already did. (And UARS must have its effect as well.)

    Dr Wardley does not mention that whiplash might be a factor in creating this– or any blow to the head. I suspect it must be. More swelling there– especially behind my left eye which constantly feels like it is pulling my head to the left. Here is a site I found connecting the two: http://www.braininjury.com/injured.shtml
    And more: https://www.google.com/?gws_rd=ssl#q=whiplash+intracranial+pressure
    I wonder if my brain is getting enough oxygen with all of that compression? Certainly not during a migraine.

    Here is something I found on “Second Impact Syndrome” — One concussion on top of another from the American Association of Neurological Surgeons:: http://www.aans.org/patient%20information/conditions%20and%20treatments/concussion.aspx

    But– here’s the good part– I have a fix that I have come upon that I want to share: Osteopathy.
    I can certainly recommend my Board Certified Neurologist at UCSD– Dr Joshua Alexander, who is a very gifted Osteopath. He has worked with me over the past year– nearly weekly since the 10-2013 MVA, and after about 35 sessions I went without a migraine for 4.5 months– something that has not happened since the 2001 MVA. Dr Alexander got me out of a migraine right on his treatment table at least 4-5 times. He very early on got rid of the TOS I had considered surgery for a few weeks before I met him. My vertigo greatly reduced, and the pressure in my left eye lessened enormously.
    However– he went on break for a month and the symptoms crept back– he says with my injuries that I am a long term project. We are back on track again and I am improving.
    When I was feeling much better at the point where I had no migraines for 4.5 months, I asked Dr Alexander what he was doing when he worked on my head with his gentle pulsing motions of his hands. He said he was moving lymph. I had no idea!
    Here is a site I pulled up when I searched “Cranial Osteopathy moves lymph”:
    http://www.cranialacademy.com In it Dr Weil has a video explaining the history of Osteopathy and the Primary Respiratory Mechanism– with Dr Robert Fulford: http://www.cranialacademy.com/fulfordvideo.html

    Dr Weil has a page on his site on Osteopathy: http://www.drweil.com/drw/u/ART03223/Cranial-Osteopathy-Craniosacral-Therapy.html
    Here is a quote from it speaking of himself in the third person:
    He also recommends cranial osteopathy for treatment of migraine headaches, disturbed sleep cycles, asthma, neck pain, sinus infections, TMJ syndrome, Ménière’s disease and ear problems in adults. For more information about cranial osteopathy, Dr. Weil recommends reading Dr. Robert Fulford’s book, Dr. Fulford’s Touch of Life (Pocket Books, 1997).

    So– this makes perfect sense to me– there is a way to relieve the ICP– Intra Cranial Pressure caused by the various traumas: put your head into the hands of a gifted Osteopath. Osteopathy is gentle and non forceful movements– you could fall asleep during the 20-30 minute sessions.

    So– in answer to the questions posed by Dr Wardley: 1. Yes– I do find I must have perfect control of my airway problem in sleep– and would surely get some kind of award for most amount of props and lifestyle changes used to make it through the night. But– I do most often sleep *well* after much effort. Yet somehow rarely wake refreshed even though I have my AHI down to an average of a 1.5.
    This condition requires a lot of self disciple to manage– and there is no time off: Everything is PT– and it is worth it because the discomfort is so great when I am not right on top of it.

    2. No– I would not consider a spinal tap to relieve the symptoms– I want to understand what is going on– and figure out a way for me to manage my symptoms. Osteopathy is one, and now that I am on to the idea that lymph needs to move in the cranium– and particularly my too small of a cranium, I am going to increase my skin brushing, self massage to include the neck, and pay more attention to my yoga practice, and pull out that 20 year old Chi Machine. Ayur Veda has head self massage techniques I think I will check back into– now that I know how important they are.

    Thanks Dr Park for another great inspirational Guest Blog. I am thrilled to learn something new that I can use to further my progress.
    Today Dr Alexander and I had a great conversation as he was working on me. I shared with him the printout of Dr Wardley’s two articles on Sleep Apnea and Intracranial Pressure– which he enjoyed reading. We had a wonderful conversation on the history of Osteopathy, Weston Price, malformed jaws and poor airways, Masai that had space behind their third molars, his newborn son’s lovely broad nose, and tongues that are meant to be up against the upper anteriors where they can pump cranial fluids.
    He said that you may want to interview a DO in Santa Monica by the name of Eric Dolgin, who has brought tongue position and the movement of cranial fluids into another level. Here is his page on his site: http://www.osteohome.com/page23/index.html
    This is a great page on The Five Phenomena of the Primary Respiratory Mechanism:

    In Osteopathy– the Primary Respiratory Mechanism is the movement of the cranial components, and the Secondary is the movement of the ribcage we think of as the only respiratory mechanism. Isn’t that fascinating!
    There must be a key here somewhere into one of the secrets of Sleep Apnea.
    Dr Dolgin is the President Emeritus of the Cranial Academy– one of only 33 physicians honored before him. He is currently focusing on the treatment of autism through Osteopathic Manipulation Therapy, and has founded the Kids Brain Trust to assist kids with Autism and Neurodevelopmental Disorders from low income families.

  8. Dear Ms. D Benson;
    I apologize as I just found your post. please update me if you have learned anything new since you posted. I do not trust the CPAP machine to provide the right pressure if used on an auto setting. a BiPAP titration would probably be best given all of your issues, then using a regular BiPAP, not on the auto setting. people with intracranial hypertension feel better sleeping upright, FYI. but if your CPAP is not treating your OSA properly, it will work better if you sleep upright as you will have less collapse in that position. if your airway is still collapsing in sleep despite the CPAP, you will be trying to adapt your neck position in sleep to keep your airway open and this may account for the neck symptoms upon awakening. I am not sure I understand what you are saying about the AHI on CPAP, but what I will say is that I have not found these numbers from the smart card to be either accurate or helpful. your case is not straightforward and I’m not sure that looking at this is going to be anything but just confusing. if you have not found any answers since your post, you may find the following paper quite helpful:
    Higgins: Lumbar puncture, chronic fatigue syndrome and idiopathic intracranial hypertension: a cross-sectional study

    -Dr. Deb

  9. Dear Nancy;
    thank you for your post which I just found. I am glad you have enjoyed my blogs. I just wanted to make a few comments.
    if your cranium is small, your body should still be able to maintain the right ICP, via the CSF drainage mechanisms as long as those are working. the problem may be if your airway is compressed and by the same abnormal anatomy your jugular veins are also compressed. if the pressure differential is not favorable, CSF may not drain properly, regardless of the size of the cranium. in cases where subtemporal decompressions are done, ultimately the ICP goes up again because it is not the size of the skull, but the CSF dynamics: input/output which influence how much volume is retained.

    yes, head injuries can be associated both with the development of OSA and with IIH.

    I have known several people with IIH who get significant improvement with cranial osteopathy, and my only conclusion is that it is assisting CSF drainage to effect the changes observed, and reducing ICP. perhaps it is improved lymph flow, or an improvement in neck position to allow better venous drainage from the skull. the others I know also need regular treatments to maintain the effect. this makes sense. if you have an airway problem, this anatomy is what it is. your body must adapt neck posture to compensate and keep the airway patent. this forward head posture can be involved in TOS, and may even narrow the jugular foramen and contribute to poor CSF drainage. the osteopathy may help with the forward head posture temporarily, but as I say, Airway is King, and you will always go back to the compensated posture.

    the lymph flow idea is very plausible. up to 50% of CSF drainage occurs by way of lymphatics out of the skull, which travel along the cranial nerves. I have found that exercise, which improves lymphatic flow, can help me clear brain fog. this has only been since I improved after jaw surgery. prior to jaw surgery I was intolerant of exercise and it made me worse.

    I would not expect you to use a spinal tap for relieving symptoms. I would recommend it to obtain a definitive diagnosis. if you receive a diagnosis of IIH, then you can stop calling these things migraines, and call them what they are.
    I would also recommend you have a full ophthalmologic exam, with the visual symptoms you describe. you do not want to overlook optic nerve involvement.

    I agree with you about the leaky brain idea and that it is related to leaky gut. if you have not seen Dr. Fasano’s research on zonulin and gluten, you should take a look at that. I think that in these conditions the blood brain barrier is leaky and multiple different exposures can affect this and can cause symptoms when the BBB is leaky, by way of brain swelling which may or may not significantly increase ICP but which will cause symptoms. gluten has been shown to increase zonulin therefore to maintain the integrity of the barriers, I think gluten should be avoided when people have these conditions.

    -Deb Wardly