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Tratamento da migranea refratária na unidade de emergência do complexo hospitalar de barbacena – rede FHEMIG
No full textHeadache is one of the primary neurological complaints in emergency departments. It is not uncommon for headaches to persist even with appropriate treatment. The initial evaluation should differentiate between primary and secondary headaches, determine the need for further investigation, and treat the acute pain. Migraines, in particular, are among the most disabling primary headches, affecting quality of life and burdening the healthcare system. Refractory migraine is characterized by the lack of response to standard preventive and acute treatment, requiring a more aggressive therapeutic approach.
The objective of the study is to evaluate the therapeutic response in the treatment of refractory migraine at the Emergency Department of the Barbacena Hospital Complex, two hours after the administration of a combination of 5 mg of intravenous or oral haloperidol and intravenous or oral dexamethasone in patients classified as refractory to initial treatment.
The study was conducted as a prospective observational study with patients considered refractory to initial migraine treatment. Patients who did not respond to at least three adequate dose medications were included. After obtaining consent, demographic data and medical histories were collected, and patients completed the Visual Analog Scale (VAS) to quantify pain. They received 5 mg of haloperidol (oral or intravenous) and 4 mg of dexamethasone (oral or intravenous). After two hours, pain intensity was reassessed and quantified.
The study is ongoing, with data collection from August 1, 2023, to July 31, 2024. However, with the end approaching, it is now possible to evaluate the results and clarify the proposed objective. Currently, there are 16 patients, 15 females and 1 male, with an average age of 28 years. The results are favorable, showing improvement after therapy by at least 2 points on the VAS and a maximum of 10 points, with only one result indifferent to the treatment.
The combination of haloperidol and dexamethasone appears promising in treating patients who do not respond to conventional therapy, providing significant pain relief. This approach can reduce patient morbidity and healthcare costs. Additional studies are needed to optimize the doses and combinations of these medications to maximize efficacy and minimize risks
CONCOMITÂNCIA DE ENXAQUECA E NEURALGIA OCCIPITAL: IMPORTÂNCIA DO RECONHECIMENTO E TRATAMENTO PARA O CONTROLE DE AMBAS
No full textINTRODUCTION: The concomitance of migraine and occipital neuralgia is a rare but significant clinical challenge. Occipital neuralgia often presents with intense, continuous pain that can be mistaken for other headache disorders, complicating diagnosis and treatment. Identifying and managing refractory migraine, especially when complicated by occipital neuralgia, requires a comprehensive understanding of preventive treatments and their limitations. The difficulty in treating such conditions underscores the importance of using evidence-based interventions, such as occipital nerve stimulation and peripheral nerve blocks, which have shown efficacy in reducing headache severity and improving patients quality of life. The rarity and complexity of these conditions demand careful diagnostic and therapeutic strategies to achieve optimal outcomes. Effective pain management strategies, including nerve blocks and nerve stimulation, have proven beneficial for many patients, highlighting the critical need for accurate diagnosis and tailored treatment plans. OBJECTIVE: Describing and recognizing a rare pathology. CASE REPORT: Patient: Female, 32-year-old, diagnosed 5 years ago with partially controlled Chronic Migraine, developed a refractory condition after the sudden onset of a lancinating pain in the right occipital region, of short duration, radiating to the vertex. The migraine, characterized by right hemicrania of moderate intensity, nausea, vomiting, phonophobia, and photophobia, worsened significantly. Imaging studies (CT and MRI of the brain) and neurological examination were normal, except for pain on palpation at the base of the right occipital region (Tinel sign), leading to a diagnosis of Right Occipital Neuralgia. In addition to treatment with Topiramate, a block of the greater and lesser occipital nerves was performed and Gabapentin was introduced, resulting in substantial improvement of both pains. The occipital nerve block was repeated at any sign of worsening occipital pain. Occipital neuralgia, rare and concomitant with other headaches, tends to exacerbate pain and complicate the control of primary headache. CONCLUSION: Occipital neuralgia, rare and concomitant with other headaches, tends to exacerbate pain and complicate the control of primary headache. In this case, the coexistence of chronic migraine and occipital neuralgia required a multifaceted treatment approach. Evidence-based interventions such as occipital nerve stimulation and peripheral nerve blocks played a crucial role in managing the patient\u27s symptoms and improving her quality of life. This case underscores the importance of accurate diagnosis and individualized treatment plans in managing complex headache disorders, emphasizing the need for continued research and clinical awareness of such rare conditions to enhance patient outcomes.
INTRODUÇÃO: A concomitância de enxaqueca e neuralgia occipital é um desafio clínico raro, mas significativo. A neuralgia occipital frequentemente se apresenta com dor intensa e contínua que pode ser confundida com outros distúrbios de cefaleia, complicando o diagnóstico e o tratamento. Identificar e manejar a enxaqueca refratária, especialmente quando complicada pela neuralgia occipital, requer uma compreensão abrangente dos tratamentos preventivos e suas limitações. A dificuldade em tratar essas condições ressalta a importância do uso de intervenções baseadas em evidências, como a estimulação do nervo occipital e bloqueios de nervos periféricos, que demonstraram eficácia na redução da gravidade da cefaleia e na melhoria da qualidade de vida dos pacientes. A raridade e complexidade dessas condições exigem estratégias diagnósticas e terapêuticas cuidadosas para alcançar resultados ótimos. Estratégias eficazes de manejo da dor, incluindo bloqueios de nervos e estimulação de nervos, têm se mostrado benéficas para muitos pacientes, destacando a necessidade crítica de um diagnóstico preciso e planos de tratamento personalizados. OBJETIVO: Descrever e reconhecer uma patologia rara. RELATO DE CASO: Paciente: Feminina, 32 anos, diagnosticada há 5 anos com enxaqueca crônica parcialmente controlada, desenvolveu uma condição refratária após o início súbito de uma dor lancinante na região occipital direita, de curta duração, irradiando para o vértice. A enxaqueca, caracterizada por hemicrania direita de intensidade moderada, náuseas, vômitos, fonofobia e fotofobia, piorou significativamente. Estudos de imagem (TC e RM do cérebro) e exame neurológico foram normais, exceto pela dor à palpação na base da região occipital direita (sinal de Tinel), levando ao diagnóstico de Neuralgia Occipital Direita. Além do tratamento com Topiramato, foi realizado um bloqueio dos nervos occipitais maior e menor e introduzido Gabapentina, resultando em melhora substancial de ambas as dores. O bloqueio do nervo occipital foi repetido a qualquer sinal de piora da dor occipital. A neuralgia occipital, rara e concomitante com outras cefaleias, tende a exacerbar a dor e complicar o controle da cefaleia primária. CONCLUSÃO: A neuralgia occipital, rara e concomitante com outras cefaleias, tende a exacerbar a dor e complicar o controle da cefaleia primária. Neste caso, a coexistência de enxaqueca crônica e neuralgia occipital exigiu uma abordagem de tratamento multifacetada. Intervenções baseadas em evidências, como estimulação do nervo occipital e bloqueios de nervos periféricos, desempenharam um papel crucial no manejo dos sintomas da paciente e na melhoria de sua qualidade de vida. Este caso ressalta a importância de um diagnóstico preciso e planos de tratamento individualizados no manejo de distúrbios complexos de cefaleia, enfatizando a necessidade de pesquisas contínuas e conscientização clínica sobre tais condições raras para melhorar os resultados dos pacientes
Neuralgia do trigêmeo secundária: relato de caso de espessamento da dura-máter no cavum do trigêmeo por doença relacionada à IgG4.
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Objetivo: caso clínico de neuralgia secundaria a engrosamiento de la duramadre en la cavidad del trigémino por enfermedad relacionada con IgG4.
Caso: Paciente de 87 años, que consulta por dolor facial en los últimos años en las ramas V1, V2 y V3. Los episodios fueron inicialmente aislados, en los últimos meses se han vuelto mucho más frecuentes y dolorosos ante estímulos sensoriales de masticación, habla y faciales. Características del dolor: episodios eléctricos paroxísticos de segundos de duración (entre 20/30 episodios por día). Ante la sospecha de neuralgia del trigémino, se inició carbamazepina como primera línea de tratamiento, con respuesta parcial inicial, y se solicitó resonancia magnética cerebral con angiografía por resonancia magnética mediante protocolo CISS/FIESTA. El informe de resonancia magnética: engrosamiento de la duramadre en el sector anterior del cavum del trigémino izquierdo, con realce poscontraste. Entre los diagnósticos diferenciales se consideró una enfermedad inflamatoria idiopática (posiblemente relacionada con IgG4). Ante este desafío, la paciente fue evaluada por el equipo HIBA IgG4, quienes solicitaron todas las pruebas de laboratorio correspondientes para confirmar el diagnóstico. El paciente logró el control total de la crisis con carbamazepina 100 mg cada 8 horas y dosis bajas de dexametasona.
Conclusión: La baja frecuencia de estas patologías inmunomediadas que pueden resultar del deterioro del nervio trigémino obliga a considerar trabajar con un equipo multidisciplinario y evaluar otras alternativas terapéuticas no convencionales
Pituitary tumor simulating cluster headache
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INTRODUCTION: Pituitary tumors are neoplasms that arise in the pituitary gland, a critical structure for the regulation of the body’s hormonal functions. Headache is a frequently reported symptom in patients with pituitary tumors. OBJECTIVE: Highlighting the importance of considering alternative diagnoses in patients presenting atypical with cluster headaches. CASE REPORT: Patient, male, 42 years old, with periocular pain radiating to the right temporal region, associated with malaise and vomiting. He had intermittent headaches lasting a few minutes several times a day. These headaches always occur at similar times and partial drooping of the right eyelid and tearing, which have occurred in several previous episodes. After the emergency room (ER), he had partial relief with intravenous dipyrone and nasal oxygen (O2), and a probable diagnosis of cluster headache was made. Due to the high frequency of headaches (7 days per month), a decision was made to initiate prophylactic treatment with verapamil in addition to abortive treatment. Additionally, he presented with a visual field defect (bitemporal hemianopsia). The MRI with and without contrast showed an expansive sellar and suprasellar process with slight extension into the cavernous sinus. The diagnosis was revised to a pituitary macroadenoma, and the patient was referred for surgical treatment. DISCUSSION: Pituitary tumors account for approximately 17% of all intracranial neoplasms with the majority being pituitary adenomas. Often, these are found incidentally during a workup for headache, in special the trigeminal autonomic cephalalgias (TACs). The TACs include cluster headache, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing, and hemicrania continua, and can be mimicked by symptomatic causes in a small minority of patients, for example tumors, dissections and infections, but a causal relationship between the underlying lesion and the headache is difficult to determine in many cases. CONCLUSION: A pituitary tumor presenting with cluster headache is challenging to diagnose due to the variability of symptoms and the need to accurately identify the headache type. The main challenge is to create a treatment plan that effectively addresses both conditions, minimizes side effects, and improves the patient\u27s quality of life through multidisciplinary care.
 
Prevalence of episodic headache in workers on different shifts in Brazilian industry
Get PDFIntroduction. Headache is one of the most prevalent and impactful clinical conditions globally. With varied estimates, there is currently a prevalence of up to 52% for episodic forms of headache in general, and 4.6% for chronic ones. Specifically, some studies indicate a global prevalence of 14% for migraine, of which only around 7% of these correspond to the chronic form, and 26% for tension-type headache (TTH). Smaller studies estimate a prevalence of 21.6% for frequent episodic TTH. As with chronic forms of TTH and migraine, sleep disorders are associated with their episodic forms, increasing the impact and frequency of attacks.
Objective. To calculate the prevalence of frequent episodic headaches in workers from different shifts in an industry in Brazil, and evaluate the possible association with sleep disorders.
Methods. This is an analytical cross-sectional observational study. The survey was carried out using an electronic form via the Google Forms® platform. Data regarding headache frequency, shift and work sector (production or others) and sleep were evaluated. Workers aged ≥ 18 years were included, who completely responded to the form and agreed to the free and informed consent form; Those reporting an age ≥ 51 years were excluded. Binary logistic regression was used to estimate the odds ratio (OR) and a 95% confidence interval was considered to express the degree of association between the independent variables. The research project was approved by the Research Ethics Committee of the Health Sciences Sector of the Federal University of Paraná.
Results. 354 volunteers met analysis criteria. A prevalence of episodic headache of 52.82% was found, with no statistically significant difference between work shifts (p=0.949) or sector (p=0.569). Although a significant number reported increased sleep latency (42%), non-restorative sleep (59.4%) and daytime sleepiness (28.8%), these variables did not show a statistically significant association with episodic headache.
Conclusion. The prevalence found of frequent episodic headache was higher than that described in the literature and was not associated with sleep disorders or work shifts
Migraine under treatment: findings from the Americas’ Migraine Observatory Study (AMIGOS)
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Migraine patients face significant challenges that limit their access to treatment. Epidemiologic studies conducted in individual countries often lack consistent methodologies, hindering broader interpretation. The Americas\u27 Migraine Observatory Study (AMIGOS) is a Pan-American epidemiological study designed to evaluate the burden and treatment of migraine and other headache disorders across the Americas. Here, we present preliminary data on migraine treatment rates.
Objectives
To describe the percentage of individuals suffering from migraine in the Americas using acute and prophylactic treatment through a unified sampling methodology at a specific time point.
Materials and Methods
Data were collected online from a sample representative of the demographic and social characteristics of each country, with a confidence level of 98% and a margin of error of 5%. We conducted both qualitative and quantitative research on key aspects of headaches among 17,037 individuals in 20 countries from Canada to Chile. Migraine diagnosis was made based on the ICHD-3 criteria.
Results
Overall, 73.3% of migraine patients reported using acute medication for their attacks. Higher percentages of acute medication use were observed in Bolivia (88.2%), while lower rates were found in Brazil (59.8%). Current and past use of preventives were reported by 19.5% and 8.1% of migraine patients, respectively. Preventive use was highest in Peru (42.6%) and lowest in Uruguay (7.2%). Among those who were not taking and had not taken prophylactic medications in the past, 54.7% experienced headaches on four or more days per month. This percentage rose above 60% in Venezuela (64.3%), Guatemala (63.9%), Costa Rica (63.3%), Nicaragua (61.7%), and the USA (60.7%), and was lowest in Uruguay (40.5%).
Conclusion
This is the first comprehensive Pan-American migraine epidemiological study. Results indicate that migraine is largely undertreated in the Americas, with the most alarming figures related to prophylactic treatment. Improving access to headache care in the region is essential
Rare case of secondary headache due to intracranial dural arteriovenous fistula
Get PDFIntroduction: spontaneous subarachnoid hemorrhage (SAH) accounts for 5% of all strokes, 85% caused by the rupture of intracranial aneurysms. There are many potential causes of non-aneurysmal SAH (15%), sometimes the source of bleeding is not identified. Up to 10% of SAH cases are caused by vascular malformations, such as cerebral arteriovenous malformations (AVMs) or dural arteriovenous fistulas (DAVF), which account for 15% of these malformations. DAVF is defined by an abnormal connection between branches of arteries and veins in the dura mater. Objectives: we present a rare case of secondary headache due to DAVF. Case report: a 55-year-old female presented to the emergency department reporting "the worst headache of her life". In the previous week, she experienced a mild occipital headache. Her medical history included systemic hypertension, treated breast cancer, currently taking the oral aromatase inhibitor Letrozole, and right mastoidectomy due to recurrent otitis. Blood pressure, neurological and general clinical examination were unremarkable. Due to alarm signs in her history, a cranial CT scan of the head with and without contrast was performed, showing minimal cortical hyperdensity in the left frontal region suggestive of subarachnoid hemorrhage. Subsequently, an MRI was performed, confirming minimal hyperintensity on FLAIR. Magnetic Resonance Angiography (MRA) was unremarkable. She underwent cerebral digital subtraction angiography, which demonstrated a right parietal dural arteriovenous fistula – with irrigation by the posterior meningeal artery (branch of the ascending pharyngeal artery) and drainage to a single cortical vein, classified as Cognard type 3. Embolization of the fistula was performed using liquid embolic material, resulting in complete resolution, and the patient was discharged asymptomatic 2 days later. After 2 years of follow-up, she remained free of new headaches, and control angiography showed total exclusion of the fistula. Conclusion: Dural arteriovenous fistulas with cortical venous drainage are associated with a high risk of bleeding and early rebleeding. The history of right mastoidectomy, as the oral taking of aromatase inhibitor were considered as possible risk factors in our case. This case report illustrates the importance of paying attention to alarm signs related to headaches, as well as conducting proper and early investigation and treatment
Case Report: Occipital Headache with Ipsilateral Autonomic Symptoms
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Trigeminal autonomic cephalalgias (TACs) are primary unilateral headaches that typically affect the trigeminal territory, most commonly the V1 division. They are accompanied by prominent autonomic symptoms such as eyelid edema, ptosis, miosis, lacrimation, and eye redness. Atypical presentations, such as bilateral cluster headaches, have been described in the literature.
Objective:
To report a case of a short-lasting, recurrent occipital headache associated with ipsilateral autonomic features and the response to indomethacin during follow-up at the Central Institute of the University of Medicine at the University of São Paulo.
Case Report:
A 64-year-old female patient with a personal history of restless legs syndrome, obstructive sleep apnea, arterial hypertension, depressive disorder, and critical cervical spinal canal stenosis with arthrodesis in 2010 presents with headaches that began 20 years ago. The headaches were unilateral and occipital, lasting four minutes, with an average frequency of four episodes daily, associated with tearing and eyelid ptosis ipsilateral to the pain. Additionally, the patient reports a second daily neck pain related to movement. On examination, there was mild pain on palpation of the greater and lesser occipital nerves on the left and pain in the area of the bilateral trapezius muscle. Over the years, various treatment attempts, including gabapentin, lamotrigine, amitriptyline, topiramate, botulinum toxin, and verapamil, were unsuccessful. Melatonin was introduced, resulting in a slight improvement in frequency, and subsequently, indomethacin was initiated. Currently, with the use of indomethacin 50 mg daily, combined with melatonin 5 mg, there has been a significant reduction in the frequency of pain, decreasing to weekly episodes. Complementary tests included skull resonance with intracranial arterial and venous angiography from 2017, which showed no abnormalities.
Conclusion:
We report a patient with occipital headache associated with atypical trigeminal activation that does not meet the criteria for paroxysmal hemicrania, cluster headache, SUNCT/SUNA, or migraine. However, there is a notable response to indomethacin
Brazilian medical Students\u27 knowledge and interest in headache and other common pain conditions: a comprehensive survey
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Pain is a pervasive issue in healthcare, necessitating that future doctors are well-versed in various pain syndromes, their origins, diagnoses, and treatments. Assessing their preparedness to manage diverse pain types in emergency and outpatient settings is crucial. However, there are few studies estimating medical students\u27 knowledge and interest in primary pain syndromes(PS), particularly headaches.
Objectives
The study aims to assess medical students\u27 knowledge of the main PS, quantify the frequency of pain-related classes in medical school, and identify potential gaps in the medical curriculum.
Methodology
This cross-sectional, descriptive study involved medical students from various Brazilian universities. Data was collected using an online questionnaire that included demographic information (age, gender, university, year of graduation, faculty, city, and state), objective questions to assess knowledge of main PS, and questions about the frequency of pain-related classes during medical school. The questionnaire was distributed through university communication channels, social media, and student organizations, with responses collected over seven months. Results were subsequently analyzed.
Results
Responses were obtained from 520 undergraduate medical students across 54 medical universities nationwide. Although most students (90%) recognize the frequency of headache complaints in the emergency room, a large portion (56.9%) have not had classes on evaluating these patients initially, and about 70.6% have never participated in conferences on this complaint. In contrast, only 33.7% have not had classes in the emergency department to evaluate patients with chest pain, and only 26.7% have not learned how to approach abdominal pain in the emergency room. These data highlight the negligence of educational institutions regarding headaches compared to other types of pain frequently encountered in hospital settings.
Conclusion
Our results reveal a substantial knowledge gap concerning headaches and other pain syndromes in the medical education curriculum, despite their high prevalence in clinical practice. This deficiency in training leads to patient dissatisfaction, frequent cases of malpractice, and undertreatment. It is crucial for future doctors to address this issue. Therefore, medical students must receive comprehensive education on headache management, particularly in emergencies. Integrating dedicated classes and events into the academic curriculum can enhance proficiency in pain management in clinical practice and healthcare services.
 
Petasites hybridus in migraine prophylaxis: literature review
Get PDFIntroductionOver the past 25 years, Petasites hybridus has been used effectively in migraine prophylaxis. It acts on its pathophysiological mechanisms, modulating nociception, reducing the release of CGRP, decreasing inflammatory mediators and blocking calcium channels.ObjectiveTo review clinical studies already published on Petasites hybridus in migraine prophylaxis, with emphasis on the initial study by Grossmann and Schmidramsl in 2000.MethodsThis study was an integrative and retrospective review of articles on the use of Petasites hybridus in the prophylactic treatment of migraine that were published in English in the last 25 years.ResultsFive clinical studies were found, all placebo-controlled, three of which were double-blind, involving 488 patients with migraine aged between 6 and 60 years. These studies showed that Petasites hybridus was superior to placebo, proving its effectiveness in the prophylactic treatment of migraine and with good tolerability, including by children and adolescents.ConclusionsClinical studies proved that Petasites hybridus was well tolerated by children and adults and effective in migraine prophylaxis, reducing the number of days with headache by ≥ 50% in the first three months