Yoga Nidra as an Adjunctive Therapy in Idiopathic Intracranial Hypertension: A Case Study

Background

Idiopathic intracranial hypertension (IIH) is a complex neuro-ophthalmic disorder characterized by increased intracranial pressure. ¹ It typically presents with a wide constellation of symptoms including headache, tinnitus, transient visual obstruction, and papilledema. ² Most of the available research evidence states that IIH is more frequent in obese individuals and women of reproductive age. ³ The etiology of IIH is poorly understood. It is believed that IIH is due to hormonal and metabolic factors, raised cerebral venous sinus pressure, and dysregulation of cerebrospinal fluid dynamics. ⁴ Among all the symptoms of IIH, headache remains one of the most important and disturbing symptoms associated with significant morbidity. ⁵ Treatment strategies for the effective management of IIH involve treating the underlying cause, protecting against loss of vision, and minimizing headache-related morbidity. ⁵ The evolving pharmacological management is effective in individuals with IIH, but also has potential adverse effects such as nausea and hypokalemia. ⁶ Additionally, venous sinus stenting is a treatment option for refractory IIH with associated venous sinus stenosis. ⁷ Adverse effects include transient post-procedure headaches, intracranial hemorrhage, and venous thrombosis with secondary ischemia. ⁸

Yoga is a mind-body medicine widely used therapeutically in complementary and integrative medicine. In yoga, yoga nidra or yogic sleep is an ancient relaxation technique that comes under pratyahara (the fifth limb of Ashtanga yoga). ⁹ Yoga nidra combines guided mental imagery with a specific yoga posture called Shavasana (or “corpse pose”). ¹⁰ Throughout the practice, the person will be lying down. Yoga nidra includes breathing awareness. Previous studies with yoga nidra have found it to be beneficial in reducing hypertension, insomnia, anxiety, and depression. ^9,11 However, no previous studies report the effect of yoga nidra in individuals with IIH. Hence, this case report aims to explore the effect of yoga nidra on a patient with IIH.

Case Presentation

A 16-year-old female with a known case of seizures from IIH visited the outpatient department of the Government Yoga and Naturopathy Medical College and hospital with a complaint of headache and disturbed sleep for the past three months associated with on and off fever episodes. The intensity and the severity of the headache worsened day by day and was associated with photophobia and phonophobia. The pain increased with coughing and vomiting. Her history revealed she had one episode of seizure with an ictal cry associated with stiffening of the limbs and uprolling of the eyes and postictal confusion present. She had a known case of absent seizure at the age of 10 years and took anti-epileptic drugs for two years. After two years the drug was withdrawn in consultation with a neurologist. At the time of presentation, she was taking the medications levetiracetam 500 mg twice daily and ceftriaxone injection 1 g BD. Birth and developmental history were normal. On general physical examination, her vitals were stable. There was no pallor, icterus, cyanosis, clubbing, lymphadenopathy, or edema. Gaze evoked nystagmus was present. The finger-nose test and finger-finger test were normal, and Romberg’s test was negative. The power of the muscle was 5/5 in all four limbs.

After the consultation and careful examination, we advised her to practice yoga nidra. We explained the study and a written informed consent was obtained from the patient before starting the intervention. Initially, a single session of yoga nidra intervention was given in person for 45 minutes for the first 10 consecutive days by the yoga and naturopathy physician. Afterwards, it was delivered online through Google Meet three times a week for the next three months. Then the patient was followed up for the next three months without intervention to check the efficacy of the intervention, at which time she reported no relapse.

Yoga nidra is a form of Raja Yoga. It is a sleep with trace awareness, a state of mind between wakefulness and dream. It consists of nine steps as follows: preparation, relaxation, mental affirmation to him/her self of a personal resolution (Sankalpa), rotation of consciousness, awareness of breath, awareness of sensation, inner space, Sankalpa, and ending the practice (Table 1). Yoga nidra was given for 45 minutes, with each step consisting of five minutes duration. ¹² Stress, impact of headache, pain, and sleep quality were assessed by using perceived stress scale (PSS), headache impact test (HIT-6), visual analogue scale (VAS), and Pittsburgh sleep quality index (PSQI) at baseline and three months of the yoga nidra intervention. Additionally, any adverse events during the intervention were monitored. Following three months of yoga nidra intervention for this patient with seizures and IIH, notable improvements were observed across multiple measures: HIT-6 scores decreased from 78 to 50, PSS scores decreased from 30 to 10, PSQI scores decreased from 13 to 9, and VAS scores for pain decreased from 8 to 3 (Table 2).

Discussion

The current case study aimed to explore the effect of yoga nidra on a patient with IIH. The findings from this case report indicate that yoga nidra positively affected an individual with IIH. In previous studies, the practice of yoga nidra was shown to reduce inflammation, ¹³ increase total leukocyte count, ¹⁴ improve sleep quality, ¹⁵ and reduce arterial pressure. ^9,10 The interaction between decreased atrial pressure and increased intracranial pressure (ICP) is complex and involves various mechanisms. ¹⁶ When ICP increases, it reduces cerebral perfusion pressure and increases arterial blood pressure (ABP). ¹⁷ The available research evidence states that yoga nidra reduces ABP by atrial vasodilation and decreases cerebrovascular resistance to maintain cerebral blood flow. Based on these findings, the practice of yoga nidra might reduce IIH.

To our knowledge, this is the first report indicating the impact of yoga nidra in a patient with IIH, observing remarkable changes in HIT-6, PSS, PSQI, and VAS. The authors conclude that yoga nidra had a remarkable effect in reducing pain and stress and improving sleep quality in this patient with IIH. However, this is a single case study, and thus the findings may not be generalizable to a larger population, and the results may differ with a larger sample size. Therefore, further research is needed to confirm the findings and establish a more robust understanding of the phenomenon being studied.