Introduction

Women of reproductive age with recent substantial weight gain often present with intractable headaches and blurred vision,

and 15–57% also have obesity-related PCOS.¹ In the absence of papilloedema, they are frequently undertreated. This study

aims to improve awareness, recognition, and management of idiopathic intracranial hypertension without papilloedema

(IIHWOP) in this clinical subgroup.^4-8

Method

We present a case of a woman with refractory headaches and intermittent visual disturbance evaluated for suspected

IIHWOP. A focused literature review was conducted using PubMed, Cochrane Library, and Embase to identify studies relating

to IIHWOP, obesity, PCOS and exenatide

Results

A 27-year-old woman with PCOS presented with intermittent visual blurring, diplopia, and chronic headaches following a 14 kg

weight gain over eight months. Monocular visual acuity was 6/5 bilaterally, with reduced binocular acuity of 6/12. Fundoscopy

was normal with no papilloedema. MRI revealed an enlarged pituitary fossa, partial empty sella, and optic nerve sheath

dilatation, while lumbar puncture confirmed an elevated opening pressure of 280 mmH₂O with normal CSF constituents,

supporting a diagnosis of IIHWOP.

Initial treatment with acetazolamide was discontinued due to intolerance. The GLP-1 receptor agonist exenatide resulted in

early improvement in headache frequency and diplopia. Continued treatment was associated with weight reduction and further

improvement in visual symptoms, insulin resistance, and menstrual regularity. The literature search found similar results regarding exenatide.

Conclusion

IIHWOP, reported in 5.7% of patients with IIH, is likely more common than originally recognised and should be considered in

obese women with chronic daily headaches refractory to conventional therapy. IIHWOP typically spares visual acuity, but

reduced binocular vision may occur due to diplopia from raised intracranial pressure compressing the abducens nerve and

impairing convergence.^2-3 Pulsatile tinnitus is also a common feature, reflecting altered intracranial venous flow. The mean CSF

opening pressure in IIHWOP is usually lower than in classic IIH.^2-3

 

Weight loss remains the cornerstone of IIH management and a first-line intervention in PCOS.^2-6 However, exenatide, the most

extensively studied GLP-1 receptor agonist, has demonstrated dual benefits^.5-8 In IIH, it acts on GLP-1 receptors within the

choroid plexus, reducing CSF secretion via Na⁺/K⁺-ATPase inhibition, thereby lowering intracranial pressure.⁷In PCOS,

exenatide improves insulin sensitivity, decreases compensatory hyperinsulinaemia, and restores hypothalamic–pituitary–

ovarian axis function. Importantly, GLP-1 receptors are also expressed in ovarian tissue, where exenatide may directly

enhance granulosa cell activity, support follicular maturation, and promote ovulation.^5-8

IIHWOP should be recognised in obese women with PCOS who present with intractable headaches and diplopia. GLP-1

receptor agonists may represent a promising dual therapeutic option in this group, acting directly on the choroid plexus and

ovarian tissue, and indirectly through weight loss.^4-8