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TRATAMENTO DA MIGRANEA REFRATÁRIA NA EMERGÊNCIA
No full textBackground: Headaches are among the most common neurological complaints in emergency care, predominantly affecting young women of childbearing age. Migraines, as a subtype, are particularly disabling, significantly reducing quality of life and posing a burden on healthcare systems. When standard preventive and acute treatments fail, migraines are classified as refractory, requiring alternative therapeutic strategies.
Objective: This study aimed to evaluate the therapeutic response to a treatment protocol for refractory migraine in the Emergency Unit of the Barbacena Hospital Complex.
Methods: A prospective observational study was conducted from August 1, 2023, to July 31, 2024, involving 16 patients (15 females, 1 male, mean age: 32 years) classified as refractory due to non-response to at least three adequately dosed migraine medications. After obtaining informed consent, demographic and medical history data were collected, and pain intensity was measured using the Visual Analog Scale (VAS). Patients received 5 mg of haloperidol and 4 mg of dexamethasone, either orally or intravenously. The pain was reassessed two hours post-treatment.
Results: All patients demonstrated a reduction of at least 2 points on the VAS two hours after treatment. The combination of haloperidol and dexamethasone proved effective, providing significant pain relief in this refractory population.
Conclusion: The study highlights the potential of haloperidol and dexamethasone as a promising treatment strategy for refractory migraine, offering meaningful pain reduction in patients unresponsive to conventional therapies. Further studies are warranted to validate these findings in larger populations.Abstract
One of the primary neurological complaints in emergency care units is headaches, predominantly affecting young women of childbearing age. Among headache subtypes, migraines are highly disabling, significantly impacting quality of life and imposing a substantial burden on healthcare systems. When preventive and acute migraine treatments fail, the condition is classified as refractory, requiring more aggressive approaches.
This study aimed to evaluate the therapeutic response to treatment of refractory migraine in the Emergency Unit of the Barbacena Hospital Complex. It was a prospective observational study involving patients classified as refractory, here defined by failure to respond to at least three adequately dosed medications. After obtaining consent, demographic and medical history data were collected, and patients completed the Visual Analog Scale (VAS) to quantify pain.
The treatment protocol included 5 mg of haloperidol (oral or intravenous) and 4 mg of dexamethasone (oral or intravenous). Pain intensity was reassessed and quantified two hours post-administration. The study was conducted from August 1, 2023, to July 31, 2024, with 16 participants: 15 females and 1 male, with a mean age of 32 years.
The results were favorable, with a reduction of at least 2 points on the pain scale in all patients. This suggests that the combination of haloperidol and dexamethasone is a promising option for treating patients unresponsive to conventional therapies, providing significant pain relief
Profile of hospital admissions for migraine and other headache syndromes in children and adolescents in Brazil between 2013 and 2023
No full textIntroduction: Migraine is a chronic neurological disease, with a prevalence of 15.2% in Brazil. It is defined as an abnormal neurovascular reaction that occurs in a genetically vulnerable individual. Clinically manifests itself in recurrent episodes of headache associated with other symptoms, dependent on triggering factors. Objective: To describe the epidemiological profile of hospital admissions of children and adolescents for migraine and other headache disorders. Methods: This was a retrospective and descriptive epidemiological study carried out with data extracted from the Brazilian Unified Health System\u27s Hospital Information System (SIH/SUS), indexed to the Department of Informatics of the Unified Health System (DATASUS). Hospital admissions were selected based on age groups, with an emphasis on children under nine years old and adolescents between 10 and 19 years old, residing in Brazil, between July 2013 and June 2023. Results: Of 93,821 hospital admissions, there were 16,149 hospitalizations (17.2%) of children and adolescents (62.5% women and 37.5% men) due to migraine and other headache disorders. There was a predominance of the age group between 15 and 19 years old (50.2%), with a higher number of cases in the Southeast region (35.9%) and of brown ethnicity (42.6%). Over 10 years, there was a progressive increase in the number of hospital admissions, reaching a peak in 2019 (1,925/16,149; 11.9%), followed by a decline in 2020 and increasing again in subsequent years. Twenty-four deaths were found (24/16,149; 0.1%), 13 men and 11 women, with a predominance in the age group of 15 to 19 years (45.8%), coming from the Northeast region (58.3 %) and of brown ethnicity (58.4%). Deaths occurred predominantly in the years 2022 and 2023 (46.6%). Conclusions: There is an increase in the number of hospital admissions of children and adolescents due to migraine and other headache disorders with a consequent increase in the number of deaths
Enxaqueca com componente neuropático periocular: relato de caso
No full textRELATO DE CASO
Migraine with periocular neuropathic component: A Case Report
KUHN, Leonardo José1; DE LAZARI, Alan Henrique1; GONÇALVES, Christian1; DE LAZARI, Kassia Beatriz Valério Saibert1; IORA, Giovana1; OLIVEIRA, Sara Pessoa de2; BARBOZA, Barbara Evelin Gonçalves3
1 Acadêmicos do Curso de Medicina do Centro Universitário Integrado de Campo Mourão – PR
2 Médica, Neurologista, Mestre, Docente do Centro Universitário Integrado de Campo Mourão - PR
3 Médica, Oftalmologista, Docente do Centro Universitário Integrado de Campo Mourão - PR
Contato com autor: KUHN, Leonardo José
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Endereço:
Introduction: Chronic migraine affects around 2% of the world\u27s population, being more common in women and significantly impacting quality of life and being more disabling than episodic attacks, generating annual expenses exceeding 20 billion dollars.
Objective: To present a case report of migraine with periocular neuropathic component.
Case Report: Woman, 43 years old, has suffered from migraines since the age of 11, presenting with a hemicranial, pulsatile headache of moderate intensity, associated with photophobia and phonophobia. Attacks fonofobia, lasting 3 days, worsen with movement and occur twice a month. During attacks, use dipyrone or sumatriptan 50 mg. However, what bothers her most is nonspecific and continuous right eye pain, about three times a week. The identified triggers are lack of sleep, stress and sun exposure. Not related to the menstrual period. Personal history includes endometriosis, myopia, astigmatism, keratoconus spots and Wolff-Parkinson-White syndrome, underwent surgery in childhood to ablate an anomalous beam. Currently, he has been using gabapentin 300 mg/night for 4 months. She has already used riboflavin and topiramate without significant improvement or adverse effects. In the initial assessment, he reported non-refreshing sleep, anxiety, irritability and constipation, and normal BMI. Duloxetine 30 mg was prescribed in the morning and magnesium chelate 300 mg at night, and she was referred to an ophthalmologist who began fitting her with corrective lenses. After 30 days of treatment, he observed a good response with adaptation to the medication and improvement in sleep, with only 4 days of pain in the last month. Currently, he continues to use Velija 30 mg in the morning, gabapentin 300 mg in the evening and biomagnesium 300 mg in the evening. It was decided to maintain medications and joint monitoring with the ophthalmologist.
Conclusion: The reduction in the frequency and intensity of migraine attacks, as well as the positive response to treatment, highlight the importance of a multidisciplinary and individualized approach in the management of this complex condition, where the correction of astigmatism was fundamental as a factor in improving the attacks, resulting in a significant improvement in the patient\u27s quality of life.
Keywords: Migraine with Aura; Migraine Disorders; Therapeutics
Correlations between retinal and choroidal microvascular changes and disease duration, severity and cognitive impairment in episodic migraine patients
Get PDFIntroduction: Migraine is recognized as a neurovascular disorder resulting from dysfunction of hypothalamic and brain stem nuclei, with consequent changes in cortical excitability. The retina can be considered an extension of the central nervous system. Retinal and choroidal thickness, measured by optical coherence tomography (OCT), may reflect neurovascular changes in migraine. Objective: To evaluate the relationship between the changes identified in OCT and optical coherence tomography angiography (OCTA) in patients with migraine with aura (MA) and migraine without aura (MWA) and the duration and severity of the disease using the Headache Impact Test-6 (HIT-6) questionnaire and cognitive assessment through the Montreal Cognitive Assessment (MoCA). Methods: In this cross-sectional study, 32 eyes of 16 patients with MA and 30 eyes of 15 patients with MWA were compared with 32 eyes of 16 healthy age-matched controls. Measurements of the thickness of the peripapillary retinal nerve fiber layer (pRNFL), total macula, ganglion cell complex (GCC), and choroidal thickness were evaluated by OCT as well as the superficial vascular density of the macula by OCTA. Results: Statistically significant differences between the groups in relation to the layers analyzed by OCT and OCTA of the macula were not found. Lower choroidal thickness values in the fovea and in the superior internal, superior external, external temporal and average thickness regions were found in individuals with migraine when compared to the control group (p < 0.05). The cognitive assessment of patients in relation to controls did not determine statistically significant differences. Statistically significant negative correlations were found between disease duration and total macular thickness (p = 0.037; in the average thickness of the MWA group), ganglion cell complex (GCC) thickness (p = 0.017; in the average thickness of the MWA group) and choroidal thickness (p = 0.039; in the average thickness of the MWA group), as well as the HIT-6 score and the peripapillary retinal nerve fiber layer (pRNFL) thickness (p = 0.027; in the average thickness of the MWA group). Conclusion: Compared with controls, individuals with migraine showed a significant reduction in choroidal thickness. Our results showed that the longer the disease duration was, the thinner the total macula, GCC and choroidal thickness were. Additionally, the thickness of the pRNFL layer showed an inverse correlation with the disability caused by migraine. The results of this study contribute to the understanding of the vascular changes in migraine
Epidemiological profile and costs of hospitalizations for migraines in Paraná between 2014 and 2023
Get PDFIntroduction: Headaches represent common complaints in medical care and an important cause of morbidity worldwide, often resulting in hospital admissions. Headaches have significant repercussions for public health, according to the literature, affecting between 43% and 93% of the Brazilian population, potentially impairing quality of life. The most affected group comprises women, young adults, black, and brown people. The number of hospitalizations for this condition is higher in the Southeast, Northeast, and South regions.
Objective: To identify the epidemiological profile and the cost of hospitalizations for headaches in Paraná from 2014 to 2023.
Methods: Observational, descriptive, quantitative, and cross-sectional study. Based on secondary data from the Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH/SUS) of the Departamento de Informação e Informática do Sistema Único de Saúde (DATASUS). The analyzed variables were age, sex, color or race, total value, average value, and average length of stay.
Results: In Paraná, between 2014 and 2023, there were 14.578 hospitalizations for migraine and other headache syndromes. The year 2019 stands out with 2.833 hospitalizations. There was a prevalence of hospitalizations in women (9.068), in white individuals (11.488), and aged between 40 to 49 years (2.640 cases). The majority of hospitalizations were urgent (13.582). The total cost of hospitalizations was R490.21 per hospitalization and an average duration of 2.7 days.
Conclusion: There was correspondence between the epidemiological profile found in the state of Paraná and what is observed in the current literature, showing a high number of hospitalizations for migraine and other headache syndromes, with significant expenditure on the public health system, requiring further investigation into the causality of these events, so that, the prevention of crises can be intensified within the most affected group
Persistent post-traumatic headache in a pediatric patient with cerebral venous thrombosis: a case report
Get PDFIntroduction: The most common symptom of post-traumatic headache (PTH) is a significant overlap with the symptoms of migraine or tension-type headache. The clinical of cerebral venous thrombosis (CVT) includes isolated headache or increased intracranial pressure, focal neurological presentations, subacute encephalopathy and cavernous sinus syndrome with multiple cranial neuropathies. CVT resulting from TBI processes in pediatrics is considered rare. Only 4% of the cases with TVC are associated with TBI.
Objective: This presentation aims to demonstrate an atypical case of CVT following TBI in a pediatric patient, associated with persistent headaches. Therefore, discusses the importance of an early differential diagnosis between PTH and headache related to CVT in order to reduce the risk of unfavorable outcomes.
Case presentation: Male, 5 years, manifesting persistent headache 48 hours after the TBI to the occipital region. In addition, on neurological admission he presented with inconsolable crying and 2 episodes of emesis, not preceded by nausea. Physical examination showed no focal deficits. A non-contrasted computed tomography (CT) scan of the skull was performed to better investigate the condition, which revealed a diastasis of the occipitomastoid suture on the left, with no other alterations. Was discharged with symptomatic treatment and monitored. After 48 hours, he was readmitted to the service due to a new sudden episode of headache, associated with episodes of emesis. A new skull CT scan showed hyperdensity in the region of the left transverse sinus. Was followed up with venous angiography of the skull, which showed a failure of the flow signal in the left transverse and sigmoid sinus, extending to the distal internal jugular vein, compatible with cerebral venous thrombosis. After diagnosis, full anticoagulation and strict neurological observation were initiated. Discharged without any neurological deficits and complete resolution.
Conclusion: This is an atypical case in pediatric patient of persistent PTH related to CVT. Treatment of the condition must be individualized according to each case. Currently, there are no specific guidelines on therapeutic resources for resolving cases of persistent headache related to trauma
HIPOTENSÃO LIQUÓRICA ESPONTÂNEA POR FÍSTULA VENO LIQUÓRICA- : UM RELATO DE CASO
No full textINTRODUCTION
Spontaneous cerebrospinal fluid hypotension (CSFH) is characterized by an abnormal reduction in cerebrospinal fluid (CSF) pressure, which commonly leads to secondary orthostatic headache and incapacitating symptoms such as nausea, vomiting, pulsatile tinnitus, neck pain, and dizziness. The etiologies are challenging for neurologists, neurosurgeons, and radiologists, especially when dealing with CSFH due to a CSF-venous fistula (CVF); a recent discovery that requires a meticulous approach and detailed imaging studies, such as ultrafast dynamic CT myelography.
OBJECTIVE
To highlight the importance of early diagnosis of CSFH due to CVF using ultrafast dynamic CT myelography, in comparison to conventional CT myelography, for an accurate and effective approach.
CASE REPORT
A 59-year-old male patient sought specialized care at a hospital in southern Paraná in May 2022, with complaints of orthostatic headache, sudden bilateral tinnitus, continuous and worse in silence. Cranial CT and MRI revealed bilateral subdural collections and pachymeningeal enhancement, raising suspicion of spontaneous cerebrospinal fluid hypotension. A non-guided blood patch was performed as a treatment. After the procedure, there was no clinical improvement, and the patient returned to the hospital after seventeen days. These sequential events led to the performance of neuroaxis MRI and conventional CT myelography, which reinforced the diagnosis of CSFH, with a new blood patch being requested. One month later, the patient was admitted with signs of mental confusion and slight motor coordination loss due to the worsening of the subdural collection. An ultrafast dynamic CT myelography was then performed, revealing a right posterolateral T8-T9 level CSF-venous fistula. With the definitive CSF-venous fistula localization, the patient underwent subdural fluid drainage and CVF surgical correction.
CONCLUSION
Ultrafast dynamic CT myelography for CVF cases has a high positive predictive value, capable of identifying the exact location of the leak. Therefore, it should be considered in CSFH cases with orthostatic headache patterns and therapeutic failures.INTRODUÇÃO
A hipotensão liquórica espontânea (HLE) se caracteriza por uma redução anormal da pressão do líquido cefalorraquidiano (LCR) que comumente leva à cefaleia secundária de padrão ortostático e sintomas incapacitantes como náusea, vômito, tinnitus pulsátil, dor cervical e tontura. Quanto às etiologias, são um desafio para neurologistas, neurocirurgiões e radiologistas, principalmente quando se trata de HLE por fístula veno-liquórica (FVL); uma descoberta recente que necessita de abordagem e exames de imagens minuciosos, como a mieloTC dinâmica.
OBJETIVO
Retratar a importância do diagnóstico precoce de HLE por FVL, a partir de uma mieloTC dinâmica, em comparação a mieloTC convencional, para uma abordagem hábil e com acurácia.
RELATO DO CASO
Paciente do gênero masculino, 59 anos, em maio de 2022 busca atendimento especializado em hospital da região sul paranaense, com queixas de cefaleia ortostática, zumbido bilateral súbito, contínuo, com piora no silêncio. Ao ser submetido a tomografia e ressonância magnética de crânio, identificou-se coleção subdural bilateral e realce paquimeníngeo, levantando suspeita de hipotensão liquórica espontânea e, como conduta, blood patch não guiado. Após o procedimento não houve melhora do quadro clínico e o paciente retorna ao hospital em dezessete dias. Esses acontecimentos sequenciais levaram à realização de uma RNM de neuroeixo e MieloTc convencional, a quais reforçaram o quadro de hipotensão liquórica, com indicação de segundo blood patch. Ao passar um mês dos últimos procedimentos, o paciente volta ao atendimento com confusão mental e leve perda da coordenação motora; é então solicitado uma mieloTc dinâmica com achado fiel de fístula veno-liquórica em T8-T9, região posterior e à direita. Tendo o diagnóstico definitivo, o paciente foi sabidamente submetido a drenagem do fluido, além da correção de FVL e resolução do caso clínico.
CONCLUSÃO
A mieloTc dinâmica para casos de FVL, possui alto valor preditivo positivo, capaz de identificar o local exato do extravasamento. Portanto, deve ser cogitada mediante HLE com padrões de cefaleia ortostática e falhas terapêuticas.
 
Should anti-CGRP monoclonal antibodies always be the drug of first choice for migraine prophylaxis in Brazil? – a pharmacoeconomic study
Get PDFIntroduction: Efficacy (success of therapy under ideal conditions), efficiency (relationship between costs and results of a given intervention), and effectiveness (balance between efficacy and efficiency in clinical practice) are measures of evaluating health interventions. Thus, both in private practice and the public health system, knowledge of these pharmacoeconomic data should weigh in the choice of appropriate treatment. Migraine prophylaxis is included in this context, traditional medications (sodium valproate, topiramate, amitriptyline) can be obtained in the public health system, while galcanezumab (anti-GRP monoclonal antibody) is not routinely available.
Objective: To compare the efficacy, efficiency, and effectiveness of Galcanezumab and traditional therapeutic alternatives (Sodium Valproate, Topiramate, and Amitriptyline).
Methods: Efficacy data were obtained from the pertinent literature (PubMED) and cost values from the ABCFARMA magazine. For the analysis of economic impacts, the cost of living of an economically active adult individual in Brazil (IBGE) was considered.
Results: Efficacy: Galcanezumab has 50%; Topiramate: 31%; Amitriptyline: 40%; and Sodium Valproate: 35%. Efficiency: Galcanezumab 4%, Topiramate 103%, Sodium Valproate 77%, and Amitriptyline 200%. Finally, effectiveness was: Galcanezumab 27%, Topiramate 67%, Sodium Valproate 56%, and Amitriptyline 120%.
Conclusion: Galcanezumab is the most efficacious; however, it is neither the most efficient nor the most effective. In a broader analysis, considering payers and patients\u27 financial availability, it indicates that in real life, therapy based solely on efficacy may not be feasible. Therefore, anti-CGRP antibodies will not be the first-choice drugs in migraine prophylaxis under all circumstances
Neuroimaging in headaches: a literature review on diagnostic advances
Get PDFIntroduction: Headaches have become one of themost common conditions worldwide and are a primary reason for seeking medical attention. It isestimated that seven out of ten people in Brazil sufferfrom some form of headache. Accurate analysis ofthe disease is crucial for developing effectivetreatment strategies, as there are various types ofheadaches. Neuroimaging techniques such as magnetic resonance imaging (MRI), computedtomography (CT), functional magnetic resonanceimaging (fMRI), and positron emission tomography(PET) have revolutionized medicine. Their analysisprovides a comprehensive view of current and future diagnostic trends, allowing for differentiation ofheadache types and aiding in their treatment.
Objective: to understand the diagnostic advances in neuroimaging for headaches.
Methods: This study was a literature review utilizingPubMed, Scielo, and Scopus databases. Articlescontaining information on neuroimaging andheadaches published in the last 20 years wereselected.
Results: Advances in neuroimaging provide a betterunderstanding of headaches and improve differentialdiagnosis. Functional magnetic resonance imaging(fMRI) can identify functional changes in specificbrain regions during migraine attacks (Dodick, 2018), revealing patterns of different types of headachesand enabling the understanding of chronicheadaches. The use of techniques such as magneticresonance spectroscopy (MRS) has also shownpromise. This technique can assess metabolicchanges in the brain during headache episodes, providing insight into the associated biochemicalchanges (Zhang et al., 2020). The use of artificial intelligence stands out for its potential to enhancediagnostic accuracy and personalize treatments. These algorithms can help predict treatmentresponse in patients with chronic headaches, allowing for personalized therapeutic approaches (Chen et al., 2021).
Conclusion: These findings emphasize thatadvances in neuroimaging have made it possible togain a deeper understanding of headache types andthe biochemical changes that cause them. Furthermore, it is possible to expedite the diagnosticprocess and provide personalized treatment, therebyimproving the patient\u27s quality of life
Blood pressure monitoring and outcomes-related hypertension in patients with migraine treated with erenumab: a systematic review and meya-analysis
No full textINTRODUCTION: Erenumab is an anti-CGRP receptor antagonist approved for the preventive treatment of migraine. The US Prescribing Information for this medication was recently updated to include the risk of hypertension based on postmarketing data, although prior clinical evidence did not link erenumab use to adverse vascular events. Therefore, this association remains uncertain.
OBJECTIVE: We performed a systematic review and single-arm meta-analysis to explore the relationship between erenumab and blood pressure variations in patients with migraine.
METHODS: Embase, PubMed, and Cochrane databases were searched up to June 18 for studies evaluating the impact of initiation of erenumab on blood pressure (BP) in migraineurs. Records were screened by two independent reviewers using pre-determined eligibility criteria. Mean difference (MD) and incidence were computed using random-effects model. I2 statistics and prediction intervals (PI) were analyzed to assess heterogeneity. Sensitivity and subgroup analysis were used to explore the heterogeneity.
RESULTS: Ten studies comprising 3.218 patients undergoing treatment with erenumab were included. Systolic (MD 0.86; P>0.05; I2 = 63%) and diastolic (MD 1.33; P>0.05; I2 = 69%) BP measures did not significantly differ between post- and pre-erenumab treatment. This lack persisted at 3 and 12 months. The leave-one-out technique did not change heterogeneity substantially. The proportion of participants presenting a worsening on BP appears to be 21.9% (PI 0.93, 89.37), with 56.1% corresponding to non-hypertensive individuals at baseline. The incidence of patients starting antihypertensive medications during the study was 3.7% (PI 0.04, 79.52), with 63% being non-hypertensive patients.
CONCLUSION: We did not find an association of erenumab with an increased BP. Regarding clinical significance, the incidence of patients initiating antihypertensive treatment seems to be low. There is a significant degree of fragility in the current evidence available. The decision to prescribe erenumab or not, especially for patients with multiple comorbidities and risk factors for hypertension, must be made with the multidisciplinary team and weighing up the risks and benefits. Further studies are needed to confirm this association