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Challenges in dual etiology diagnosis: probably idiopathic intracranial hypertension and systemic arterial hypertension in a case of headache with facial palsy
Get PDFChallenges in Dual Etiology Diagnosis: probably Idiopathic Intracranial Hypertension and Systemic Arterial Hypertension in a Case of Headache with Facial Palsy.
INTRODUCTION:
The facial palsy secondary to Idiopathic Intracranial Hypertension (IIH) is an uncommon clinical condition, with relatively few studies, mostly case reports - some pointing to a probable traction of the facial nerve or simply its edema due to intracranial hypertension. The Systemic Arterial Hypertension (SAH) is a known cause of cranial neuropathies, but it most often affects cranial nerves 3, 4, and 6 – furthermore, the facial palsy due to SAH is more common in children.
OBJECTIVES
The objective is to describe the challenges of the etiological diagnosis of facial paralysis with two possible pathophysiologies, whose treatments overlapped in time.
CASE REPORT
JOS, female, 37 years old, hypertensive, taking valsartan 160 mg/day, reported waking up due to a new pattern of headache (she had previous migraine symptoms, with no red flags until then). She was admitted with BP 280x180 mmHg, non-specific visual clouding and peripheral facial palsy on the left, with no other alterations on neurological examination. Intravenous sodium nitroprusside was started under multiparameter monitoring. Brain CT was normal (hypoplasia of the left transverse sinus on angiotomography), and brain MRI showed a partially empty sella. Lumbar puncture had an opening pressure of 22 cmH2O, but with total and immediate improvement of the headache and partial improvement of PFP after the puncture. Cerebrospinal fluid, serologies, inflammatory and rheumatological tests were normal. After six days, her blood pressure and palsy improved, with prescription for acetazolamide and adjustments to her antihypertensive medication.
CONCLUSIONThis case illustrates the challenge in encountering a headache with neurological deficit with two possible etiologies of fluctuating nature and with less common clinical manifestations. Diagnosis hinges on understanding the pathophysiology, the relationship with clinical signs, and the temporal connection, which can suggest two hypotheses that are not mutually exclusive and require simultaneous management due to their associated risks. Moreover, in this instance, intracranial hypertension may be "incipient", exacerbated by SAH, as blood pressure impacts intracranial pressure under both normal and pathological conditions
Are the AHA life´s essential 8 factors useful for migraine prevention? Insights from a 4-year follow-up with 4,293 participants in the ELSA-Brasil study
Get PDFBackground: Migraine disorders are polygenic, neurovascular disorders thought to be influenced by lifestyle and environmental factors. It is unknown whether well-established lifestyle and health factors related to cardiovascular health would be associated with lower migraine occurrence. Objective: We aimed to evaluate the risk of migraine and its chronification associated with the Life´s Essential 8 (LE8) behavior (diet, physical activity, sleep, and nicotine exposure) and health (body mass index, blood lipids, blood glucose, and blood pressure) factors scores proposed by the American Heart Association (AHA) in a middle-aged population. Methods: This is a prospective analysis based on the exposure to LE8 factors at the baseline (wave 1: 2008-2010) and diagnosis of migraine without aura (MWO), migraine with aura (MWA) at inter-wave 2013-2014 among subset of participants from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). The LE8 factors scores were computed following the AHA´s scoring system. Migraine diagnoses were based on ICHD-3. Modified Poisson regression models estimated the risk ratios (RR) with 95% confidence interval for migraine diagnoses, according to the adherence levels to the LE8 factors categorized as low (reference), moderate, and high (recommended by AHA). Results: Among 4,293 adults (mean age: 51.3, ±8.9 years, 54.6 % female), 19.4 % and 10.5 % were diagnosed as MWO and MWA, respectively, after a mean (SD) follow-up of 4.0 (0.38) years. In the models adjusted for sex, age, race, household income, education, marital status, and migraine preventive medication, high adherence to LE8 factors was associated with lower risk of both migraine types. The associations with MWO presented an inverted J-shaped curve, with an increase in the RR for moderate adherence (RR: 1.06 [0.84, 1.35]), followed by a decrease with high adherence to LE8 factors (RR: 0.80 [0.58, 1.10], quadratic p-trend = 0.015). For MWA, there was a linear decrease in the risk as adherence increased to the recommended level (RR: 0.55 [0.377, 0.82], linear p-trend = 0.003). Conclusion: In the ELSA-Brasil study, high adherence to AHA LE8 factors was associated with lower risk of both migraine types.
Migraine prevalence: findings from the Americas’ Migraine Observatory Study (AMIGOS)
Get PDFIntroduction
Ascertaining the prevalence of headache disorders is fundamental for designing effective public health strategies. Epidemiologic studies conducted in individual countries often lack consistent methodologies, limiting broader interpretation. The Americas’ Migraine Observatory Study (AMIGOS) is a Pan-American epidemiological study designed to evaluate the burden and access to treatment of migraine and other headache disorders across the Americas. Here, we present preliminary data on migraine prevalence.
Objectives
To describe the prevalence of migraine in the Americas using 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
The overall prevalence of migraine was 9.74% (12.6% among females, 6.8% among males). The highest prevalence was observed in Brazil (14.1%), Canada (13.3%), and the United States (13.1%), while the lowest prevalence was found in Bolivia (5.6%), Paraguay (6.7%), and Guatemala (7.5%). On average, migraine sufferers reported experiencing headaches 6.5 days per month, with 14% experiencing headaches on fifteen or more days per month.
Conclusion
This is the first comprehensive Pan-American migraine epidemiological study. Results indicate that migraine is highly prevalent in the Americas, with significant variations among different countries. Genetic and environmental factors may explain these observed differences
Assessment of nurses approach to headache during triage in the emergency department
Get PDFIntroduction: Nurses need a broad set of information and skills to properly assess patients during triage in the emergency department. Most healthcare services use the Manchester Triage System, developed in 1997, which improves care by ensuring that patients needing immediate attention receive priority according to the severity of their condition. Headache has its own pathway in this classification system, with the time to treatment varying based on pain intensity.
Objective: To evaluate nurses\u27 approach to headache during triage in the emergency department of a private hospital.
Method: Data were retrospectively obtained from the Electronic Patient Record using a Business Intelligence tool. All visits from June 2024 were analyzed, including patients diagnosed with headache in the emergency department of a private hospital in Recife, which uses the Manchester Triage System. Variables assessed included the flowchart chosen by the nurse during triage, the color of the wristband assigned during risk classification, medical diagnoses, and characteristics of the patients\u27 primary complaint.
Results: Of the 7,464 visits, 361 (4.8%) were for patients with a medical diagnosis of headache and its variations. Of these, 258/361 (71.5%) reported headache as the primary complaint and were placed by the nurse in the "headache" flowchart. The remaining 103/361 (28.5%) were classified by the nurse in other flowcharts. Among patients classified in other flowcharts, 54 showed characteristics of migraine but were not correctly placed in the "headache" flowchart by the nurse. In this group, 14 patients were diagnosed with migraine without aura (G-43.0) and 40 with headache (R-51). A prevalence of the "adult malaise" flowchart (17/54; 31.5%) was observed among incorrectly classified patients. Most patients (333/361; 92.2%) received a green wristband, indicating a treatment time of up to 120 minutes.
Conclusion: Although most patients were included by the nurse in the "headache" flowchart, a portion was still placed in different flowcharts despite presenting characteristics of migraine. This highlights the need to improve the classification of patients with headache
O Protocolo de estudo para um registro observacional multicêntrico em cefaleia : Registro Brasileiro de Cefaleia - REBRACEF II
No full textObjectiveThis article presents the protocol for the Brazilian Headache Registry (REBRACEF), the first national registry designed to systematically collect real-world data on patients with primary and secondary headaches at specialized centers in Brazil. The main objective is to describe the methods for patient selection, the registry infrastructure, data collection, and the standardized instruments used.MethodologyREBRACEF is a prospective, observational, multicenter cohort study conducted in real-world settings.Expected resultsThis protocol aims to standardize and enable the structuring of the registry, allowing its implementation in other centers across Brazil. It also ensures external feasibility by establishing a robust framework that can be replicated in other national and international healthcare institutions.ConclusionThe registry protocol provides a standardized framework for the collection of real-world data on patients with primary and secondary headaches, facilitating the improvement of headache management and research in Brazil.O diagnóstico e o tratamento das cefaleias primárias e secundárias apresentam desafios significativos devido ao acesso limitado a cuidados especializados, imprecisão diagnóstica e uso subótimo de tratamentos baseados em evidências. Apresentamos o protocolo do estudo REBRACEF, um registro longitudinal, multicêntrico e do tipo "real world". Trata-se do primeiro registro brasileiro de cefaleia, abrangendo pacientes com cefaleias primárias e secundárias. Descrevemos detalhadamente os processos de elaboração do registro, incluindo os critérios de elegibilidade, tamanho amostral, desenho do estudo, métodos de diagnóstico conforme a Classificação Internacional de Cefaleia (ICHD-3), métodos de coleta, tratamento e segurança dos dados, treinamento das equipes, além dos questionários e escalas padronizadas utilizados
Quality of life in women with migraine: a systematic review
Get PDFIntroduction: Several chronic diseases interfere with quality of life (QoL), including migraine, especially in women who are the most affected. However, effective therapeutic interventions are capable of modifying the disease.
Objective: Our objective was to review the literature on QoL in women with migraine, before and after treatment.
Methods: This study was a systematic review of clinical trials on migraine in women and QoL published between November 2019 and October 2024. The research was carried out in the online database PubMed, using the descriptors “migraine in women” and “quality of life”.
Results: Eight articles were analyzed. They described 1,337 women with migraine aged 18 to 50 years. There was an improvement in QoL after therapeutic intervention, both drug and non-drug.
Conclusions: Women with migraine have their QoL impaired, but therapeutic interventions can modify the disease.Introdução: Diversas doenças crônicas interferem na qualidade de vida (QV), entre elas a migrânea, principalmente em mulheres que são as mais acometidas. Entretanto, intervenções terapêuticas eficazes são capazes de modificar a doença. Objetivo: Nosso objetivo foi revisar a literatura sobre QV em mulheres com migrânea, antes e após o tratamento. Métodos: Este estudo foi uma revisão sistemática de ensaios clínicos sobre migrânea em mulheres e QV publicados entre novembro de 2019 e outubro de 2024. A pesquisa foi realizada na base de dados online PubMed, utilizando os descritores “migraine in women” e “quality of life”. Resultados: Foram analisados oito artigos. Eles descreveram 1.337 mulheres com migrânea com idade entre 18 e 50 anos. Houve melhora na QV após intervenção terapêutica, tanto medicamentosa quanto não medicamentosa. Conclusões: Mulheres com migrânea têm sua QV prejudicada, mas intervenções terapêuticas podem modificar a doença
Da morfologia cirúrgica à anatomia microscópica: visualizando o plexo coroide e seu papel na pesquisa da cefaleia
No full textThe choroid plexus (ChP) is pivotal in cerebrospinal fluid (CSF) production, intracranial pressure regulation, and brain homeostasis, intricately linked to headache pathophysiology. This study integrates macroscopic, microsurgical, and microstructural analyses to explore the anatomy and function of the ChP, highlighting its structural and functional significance.MethodsMacroscopic and microsurgical dissections were performed on cadaveric specimens, with arteries and veins injected with colored silicone to enhance visualization. Microstructural analysis was conducted using scanning electron microscopy to reveal detailed surface morphology.ResultsThe ChP in the lateral ventricles exhibits a characteristic C-shaped configuration, attached to the taenia along the choroidal fissure, a critical surgical landmark. Microsurgical views emphasize the ChP at the interventricular foramen, a key region frequently encountered during neurosurgical procedures. The ChP’s luminal surface displays intricate architecture, including villi, microvilli, cilia, and interdigitations, reflecting its active role in CSF dynamics.ConclusionsThese findings underscore the ChP’s specialized surface features and cellular organization, which are fundamental for maintaining CSF homeostasis and regulating intracranial pressure. Disruptions in ChP morphology or function could contribute to headache development, particularly in conditions associated with CSF flow and pressure dysregulation. By bridging macroscopic neuroanatomy, microsurgical techniques, and ultrastructural insights, this study lays the groundwork for future research into the ChP’s involvement in headache pathophysiology and its potential as a therapeutic target. Exploring this vital yet underexplored structure in neuroscience offers promising avenues for advancing our understanding of neurological disorders.O plexo coroide (ChP) é essencial na produção do líquido cefalorraquidiano (LCR), na regulação da pressão intracraniana e na homeostase cerebral, intrinsecamente ligado à fisiopatologia da cefaleia. Este estudo integra análises macroscópicas, microcirúrgicas e microestruturais para explorar a anatomia e a função do ChP, destacando sua significância estrutural e funcional.MétodosDissecções macroscópicas e microcirúrgicas foram realizadas em espécimes cadavéricos, com artérias e veias injetadas com silicone colorido para melhorar a visualização. A análise microestrutural foi conduzida usando microscopia eletrônica de varredura para revelar a morfologia detalhada da superfície.ResultadosO ChP nos ventrículos laterais exibe uma configuração característica em forma de C, anexada à tênia ao longo da fissura coroide, um marco cirúrgico crítico. As vistas microcirúrgicas enfatizam o ChP no forame interventricular, uma região-chave frequentemente encontrada durante procedimentos neurocirúrgicos. A superfície luminal do ChP exibe uma arquitetura complexa, incluindo vilosidades, microvilosidades, cílios e interdigitações, refletindo seu papel ativo na dinâmica do LCR. ConclusõesEssas descobertas ressaltam as características de superfície especializadas e a organização celular do ChP, que são fundamentais para manter a homeostase do LCR e regular a pressão intracraniana. Interrupções na morfologia ou função do ChP podem contribuir para o desenvolvimento de cefaleia, particularmente em condições associadas à desregulação do fluxo e da pressão do LCR. Ao unir neuroanatomia macroscópica, técnicas microcirúrgicas e insights ultraestruturais, este estudo estabelece as bases para pesquisas futuras sobre o envolvimento do ChP na fisiopatologia da cefaleia e seu potencial como alvo terapêutico. Explorar essa estrutura vital, porém pouco explorada na neurociência, oferece caminhos promissores para avançar nossa compreensão de distúrbios neurológicos
O Papel do Sistema Imune na Fisiopatologia da Migrânea
No full textMigraine is a disease characterized by recurrent episodes of headache mediated by trigeminal activation and release of CGRP peptide. Additionally, there is a complex interaction with the immune system through neurogenic inflammation and neuroinflammation, with an imbalance between the pro-inflammatory response and the regulatory response. The innate immune system acts in migraine mainly through the increase of pro-inflammatory cytokines, notably IL-1β, whose production may occur in the cortex-meningeal complex due to spreading cortical depression or in the trigeminal ganglion sensitized by CGRP. Some evidence also suggests an effect of the adaptive immune system Th1 and mainly Th2, culminating in the activation of meningeal mast cells. On the other hand, regulatory T cells are quantitatively decreased in migraine, and there are fluctuations in the levels of IL-10, the main anti-inflammatory cytokine. There is evidence of the immune system\u27s involvement in migraine; however, its effect is still poorly understood, requiring further investigation.A migrânea é uma doença caracterizada por episódios repetidos de cefaleia que são mediados pela ativação trigeminal e liberação do peptídeo CGRP. Adicionalmente existe uma complexa interação com o sistema imune através da inflamação neurogênica e neuroinflamação, com um desequilíbrio entre a resposta pró-inflamatória e a resposta regulatória. O sistema imune inato atua na migrânea principalmente por meio do aumento das citocinas pró-inflamatórias, com destaque para IL-1β cuja produção pode ocorrer no complexo córtex-meninge em decorrência da depressão cortical alastrante ou no gânglio trigeminal sensibilizado pelo CGRP. Algumas evidências sugerem também efeito do sistema imune adaptativo Th1 e principalmente Th2 que culmina com a ativação de mastócitos meníngeos. Por outro lado, células T regulatórias estão quantitativamente diminuídas na migrânea e acontecem oscilações dos níveis de IL-10, principal citocina anti-inflamatória. Existem evidências da atuação do sistema imune na migrânea, no entanto seu efeito ainda é pouco conhecido, com necessidade de investigação adicional
Efeito do óleo essencial de hortelã-pimenta (Mentha piperita L.) nas respostas semelhantes às da enxaqueca em ratas
No full textMigraine is a severe and disabling neurological disorder characterized by headache, photophobia, phonophobia, nausea and vomiting. It is considered the top cause of years lived with disability between the ages of 15–49, being two to three times more common in women than in men. Pharmacological treatment of migraine has advanced in the past years but is still considered unsatisfactory for a significant number of patients. There is growing evidence that essential oils may provide benefit for migraineurs. Herein it was tested the hypothesis that peppermint essential oil (Mentha piperita L.) could reduce migraine-related responses in rats. The model consisted in the injection of calcitonin-gene-related peptide (CGRP) in the trigeminal ganglion (TG) of female rats to induce the development of immediate periorbital cutaneous allodynia and late photosensitivity (24 h after CGRP). Inhalation of the peppermint essential oil during 15 minutes before CGRP injection in the TG did not reduce periorbital allodynia and photosensitivity of female rats. However, when the exposure occurred after CGRP injection, peppermint essential oil caused a significant reduction in both parameters. Likewise, intranasal application of menthol, a major component of peppermint essential oil caused a significant reduction of periorbital allodynia induced by CGRP. In conclusion, peppermint essential oil and menthol may represent a safe, low cost and noninvasive adjuvant abortive therapy for headache pain in migraine patients. However, further high-quality clinical studies are clearly warranted to determine efficacy, safety and to establish their best treatment regimen.A enxaqueca é um distúrbio neurológico grave e incapacitante caracterizado por cefaleia, fotofobia, fonofobia, náuseas e vômitos. É considerada a principal causa de incapacidade entre 15 e 49 anos, sendo duas a três vezes mais frequente no sexo feminino. O tratamento farmacológico da enxaqueca avançou nos últimos anos, mas ainda é considerado insatisfatório para um número significativo de pacientes. Existem evidências de que os óleos essenciais podem trazer benefícios no tratamento da enxaqueca. Neste estudo, foi testada a hipótese de que o óleo essencial de hortelã-pimenta (Mentha piperita L.) poderia reduzir as respostas relacionadas à enxaqueca em ratas. O modelo consistiu na injeção de peptídeo relacionado ao gene da calcitonina (CGRP) no gânglio do trigêmeo (TG) de ratas para induzir o desenvolvimento de alodinia cutânea periorbital imediata e fotossensibilidade tardia (24 horas após o CGRP). A inalação do óleo essencial de hortelã-pimenta durante 15 minutos antes da injeção de CGRP não reduziu a alodinia periorbital e a fotossensibilidade das ratas. No entanto, quando a exposição ocorreu após a injeção de CGRP, o óleo essencial de hortelã-pimenta causou uma redução significativa em ambos os parâmetros. Da mesma forma, a aplicação intranasal de mentol causou uma redução significativa da alodinia periorbital induzida pelo CGRP. Em conclusão, o óleo essencial de hortelã-pimenta e o mentol podem representar uma terapia abortiva adjuvante, segura, de baixo custo e não invasiva para o controle das crises. No entanto, estudos clínicos de boa qualidade são necessários para determinar eficácia, segurança e estabelecer o melhor regime de tratamento
Potential antinociceptive effects of cannabinoid compounds on migraine-associated responses in an experimental model in female rats
Get PDFIntroduction: Migraine is a painful and debilitating neurological disorder characterized by attacks of throbbing headache, frequently associated with photo and phonofobia, as well as nausea and vomiting. Despite advances in the pharmacological treatment of migraine, it is estimated that half of the patients do not achieve satisfactory pain control, highlighting the need for novel therapeutic options. In this context, cannabinoid compounds, including cannabidiol (CBD), cannabigerol (CBG), and tetrahydrocannabinol (THC), have demonstrated a potential for migraine treatment. Objective: To assess the efficacy of different combinations of cannabinoid compounds in an animal migraine model. Methods: Adult female Wistar rats were used, and protocols were approved by CEUA-BIO/UFPR #1589. The CBD “plus minor cannabinoid traces” (CBC, CBN, and CBG), CBD/CBG 2:1 ratio, CBD/THC, and CBD/CBG 2:1 Ratio/THC (CBD 30 mg/kg; THC 0.3%) or vehicle were administered systemically via intraperitoneal injection. Thirty minutes later, the animals received an intraganglionar injection (i.g.) of saline or calcitonin gene-related peptide (CGRP, 0.1 nmol/10 μL) into the trigeminal ganglion to induce cutaneous allodynia, which was evaluated by application of von Frey filaments (0.04 – 8g) to the periorbital area, from 0.5 to 6 hours after CGRP injection. The same animals were tested in the open field 1 hour after saline or CGRP injection to assess locomotion and anxiety-like behavior. In addition, 24 hours after i.g injections, the same animals were exposed to bright light for 1 hour to reactivate cutaneous allodynia, which was assessed from 0.5 to 4 hours. Results: In female rats, treatment with CBD “plus minors traces,” CBD/THC and CBD/CBG 2:1 prevented the development of cutaneous allodynia induced by CGRP, but CBD/THC showed long-lasting effects (up to 3 hours). CBD/CBG 2:1/THC did not change significantly the mechanical threshold compared to the control group. CBD plus minors and CBD/THC, but not CBD/CBG 2:1 and CBD/CBG 2:1/THC, prevented the development of photosensitivity. Data from the open field test are being analyzed, and ongoing experiments in male rats will be included in the final presentation. Conclusion: CBD plus minor cannabinoids and CBD/THC exhibited promising antinociceptive and anti-hyperalgesia effects in a pre-clinical model of migraine, which remains to be validated in the clinical setting