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Background and objective Venous manometry (VM) is the reference standard for confirming hemodynamically significant transverse sinus stenosis (TSS) in idiopathic intracranial hypertension (IIH). However, no standardized approach exists for triaging refractory IIH (rIIH) patients for VM, and current IIH diagnostic criteria were not designed for this purpose. We evaluated the performance of established IIH diagnostic frameworks and imaging markers in detecting VM-confirmed TSS (vTSS).Methods We retrospectively reviewed consecutive rIIH patients undergoing VM at a tertiary center (2022–2023). vTSS was defined as a trans-stenotic pressure gradient ≥8 mm Hg. Four IIH frameworks (Friedman 2013, modified Dandy 2014, Korsbæk 2023, and a modified 2023 schema), and predefined vascular and non-vascular MRI/MR venography signs were compared against vTSS.Results Among 48 rIIH patients (mean age 38.9±9.9 years; all female; body mass index 36.8±9.1 kg/m²), vTSS was present in 33/48 (68.8%). Sensitivity/specificity for vTSS were: Friedman 2013 (78.6%/53.8%), modified Dandy 2014 (83.3%/60.0%), Korsbaek 2023 (90.6%/35.7%), and modified 2023 (93.5%/35.7%). Vascular imaging signs were highly sensitive (96.3%) across definitions; the modified 2023 vascular criteria achieved the highest specificity (42.9%). Five (15.2%) vTSS patients lacked papilledema.Conclusion Current IIH frameworks vary in accuracy for detecting vTSS. 2023-based criteria maximize sensitivity for vTSS, while modified Dandy 2014 criteria offer greater specificity. Vascular imaging signs outperform non-vascular signs. These findings support incorporating standardized imaging protocols and refined triage algorithms to optimize VM referral in rIIH.