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Prevalence of chronic headache in workers in a Brazilian industry
Get PDFIntroduction. Primary headaches and sleep disorders are closely related conditions. The global prevalence of chronic headache reaches values of 4.6%, while in Brazil it corresponds to 6.9%. Up to 50% of patients with migraine report insomnia. The recurrence of headaches generates important economic losses and affects the patient\u27s quality of life, with tension type headache and migraine accounting for 6.5% of years lived with disability worldwide.
Objective. To calculate the prevalence of chronic headaches in workers in an industry and evaluate the association with work shifts and sleep disorders.
Methodology. This is an analytical cross-sectional observational study. The research was carried out remotely, using an electronic form via the Google Forms® platform. The prevalence of chronic headache per work shift was calculated, the independence of the variables was verified using the Chi-Square test, binary logistic regression was used by estimating the odds ratio and 95% confidence intervals were considered, to express the degree of association between the independent variables and the presence of chronic headache. The research project was approved by the Research Ethics Committee of the Health Sciences Sector of the Federal University of Paraná.
Results. The global prevalence of chronic headache was higher than the general population (12.43%). No statistically significant association was found between the presence of chronic headache and work shift (p=0.999), increased sleep latency (p=0.087), short sleep duration (p=0.754), restorative sleep (p=0.348) and daytime sleepiness (p=0.910).
Conclusion. There was an increased prevalence of chronic headache in relation to that described in the global and national literature for the general population. In the sample, it was independent of clinically significant changes in sleep and work shift, which may suggest the possibility of individual adaptation of the worker to the work shift
Cluster-tic syndrome – 10 anos até o diagnóstico – Um relato de caso
No full textIntroduction: Cluster-Tic syndrome is characterized by the coexistence of elements from trigeminal neuralgia and cluster headache, which is a questioned entity because of its heterogeneous presentation in the cases described.
Objective: Describe a case that took about 10 years to be assertively diagnosed.
Case report: 30-year-old patient, doctor, history of a headache which met the criteria for low frequency episodic migraine without aura since childhood. 10 years ago, during medical school, presented an intense stabbing headache in the V2 territory on the left side of the head which lasted about 30 minutes and did not get better during the attacks, associated with agitation and ipsilateral dysautonomia symptoms such as conjunctival hyperemia, semi-ptosis and tearing. These episodes used to happen daily during about 6 weeks, presenting an inter-crisis period of about 2 years, and could be triggered by the consumption of alcoholic beverages, not depending on the quantity. Due to the prominent algic syndrome, during this 10 year period, the patient went to many neurologists for help, but did not get an assertive diagnosis and many prophylactic (amitriptyline, venlafaxine, botulinum toxin) and abortive (NSAIDs, triptans, corticosteroid) medications were prescribed , without an adequate answer in the prevention or improvement of the pain during the attacks. The patient also went through an investigation in 2018 using a brain MRI to discover a possible secondary headache, evidencing a neurovascular conflict on the opposite side of the patient’s symptom. In this context, the cluster-tic diagnosis was confirmed and the doctors tried a treatment directed to cluster headache with subcutaneous sumatriptan during the crisis, as well as verapamil during 6 weeks as a prophylactic for the attacks associated with blocking the left lesser and major occipital nerves, resulting in a positive response during both treatments.
Conclusion: Due to the variety of presentations, cluster-tic syndrome can go unnoticed, leading to a diagnostic and therapeutic delay, consequently resulting in a reduced quality of life for the patient.
Introdução: A Cluster-Tic syndrome é caracterizada pela coexistência de elementos da cefaleia em salvas e da neuralgia do trigêmeo, sendo uma entidade questionada, tendo em vista sua apresentação heterogênea pelos casos descritos na literatura e se deveria ser tratada como uma síndrome isolada.
Objetivo: Descrever um caso que demorou cerca de 10 anos para o diagnóstico assertivo.
Relato de caso: Paciente de 30 anos, médica, com histórico de cefaleia que preenchia critérios para enxaqueca episódica de baixa frequência sem aura desde a infância, apresentou, durante a graduação em medicina, há 10 anos, cefaleia intensa, em facadas, em território de V2 a esquerda, com duração de cerca de 30 minutos, sem melhora durante os ataques, associada a sintomas disautonômicos ipsilaterais como hiperemia conjuntival, semi-ptose palpebral e lacrimejamento. A paciente ainda referiu que durante os episódios ficava bastante agitada, com sensação de “querer arrancar os dentes”. Esses episódios álgicos costumavam ser diários durante cerca de 6 semanas, podendo ser precipitados por consumo de bebida alcoólica, em qualquer quantidade. Após 6 semanas, essa cefaleia cessou, apresentando um período intercrise de cerca de 2 anos. Devido quadro álgico proeminente, durante esse período de 10 anos, a paciente procurou ajuda em diversos neurologistas, porém sem um diagnóstico assertivo, tendo sido prescritas diversas medicações profiláticas (amitriptilina, venlafaxina, toxina botulínica) e abortivas (AINEs, triptanos, corticoide), todas sem resposta adequada na prevenção ou melhora da dor no período dos ataques. Também realizou uma investigação em 2018 com RM de crânio, para pesquisa de cefaléia secundária, evidenciando um conflito neurovascular contralateral à queixa da paciente. Nesse contexto, foi realizado o diagnóstico de cluster-tic e tentado um tratamento direcionado para cefaleia em salvas com sumatriptano subcutâneo durante a crise, além de verapamil durante 6 semanas para profilaxia dos ataques, além de bloqueio de nervos occipitais maior e menor a esquerda, tendo resposta positiva em ambos os tratamentos.
Conclusão: Devido a variedade de apresentações, a cluster-tic syndrome pode passar despercebida, levando a um atraso diagnóstico e terapêutico, com consequente perda de qualidade de vida e enorme sofrimento para o paciente.
 
ATUAÇÃO DA ODONTOLOGIA HOSPITALAR E NEUROLOGIA NO TRATAMENTO E DIAGNÓSTICO CONJUNTO DE NEUROPATIAS: RELATO DE CASO
No full textIntroduction: Neuropathic pain is an algic syndrome resulting from lesion, disease or dysfunction in the central and/or peripheral nervous system and can be associated with invasive dental procedures. Objective: Report the conjoined role of Hospital Dentistry (HD) and Neurology in the diagnosis and treatment of a patient with peripheral neuropathy (PN).
Case report: 67-year-old female diagnosed with trigeminal neuralgia (TN) was referred from a service external to the Neurology ambulatory of Fortaleza’s General Hospital- SESA to be evaluated by the HD team, with recommendation of extirpating the inferior alveolar nerve due to the failure of many drug therapies. During the clinical examination, the patient referred to acute and persistent pain in the middle and inferior thirds on the right side of the face which started after an endodontic procedure. In the oral cavity the patient presented bimaxillary partial edentulism, inferior alveolar ridge with signs of resorption and knife edge pattern. Therefore, the PN hypothesis was considered and a new therapeutic protocol was suggested. The management was based on the switch of medication by the doctor team associated with photobiomodulation performed by the HD team. To measure the pain level the Visual Analogue Scale (VSA) was used each session, which made it possible to observe the expressive reduction in symptomatology, reducing the score from 9 to 3 at the end of the second protocol.
Conclusion: The interdisciplinary cooperation between the HD and neurology teams made the correct diagnosis and treatment possible, managing pain and improving life quality through conservative therapy.Introdução: A dor neuropática é uma sensação dolorosa originada de lesão, doença ou disfunção do sistema nervoso periférico e/ou central, podendo estar associada a procedimentos odontológicos invasivos.
Objetivo: Relatar a atuação conjunta da Odontologia Hospitalar (OH) e Neurologia no diagnóstico e tratamento de uma paciente com neuropatia periférica (NP).
Relato de caso: Paciente feminina, 67 anos, diagnosticada com neuralgia do trigêmeo (NT), foi encaminhada de um serviço externo ao ambulatório de Neurologia do Hospital Geral de Fortaleza-SESA, para avaliação conjunta da equipe de OH, com indicação de extirpação do nervo alveolar inferior, devido insucesso de múltiplas terapias medicamentosas. Ao exame clínico, relatou dor aguda e persistente em região de terço médio e inferior da face à direita, com início após realização de tratamento endodôntico. Intraoral apresentava edentulismo parcial bimaxilar, rebordo alveolar inferior com sinais de reabsorção e em lâmina de faca. A partir disso, foi levantada a hipótese de NP, assim, foi proposto um novo protocolo terapêutico. A conduta baseou-se na troca de medicação, pela equipe médica, associada à fotobiomodulação, realizada pela OH. Para aferir o nível de dor, utilizou-se a Escala Visual Analógica a cada sessão, onde houve uma expressiva diminuição da sintomatologia, com redução de nota 9 para 3, ao fim do segundo protocolo.
Conclusão: A atuação interdisciplinar entre OH e neurologia possibilitou o correto diagnóstico e tratamento, com manejo da dor e melhora da qualidade de vida por meio de terapia conservadora
Differences in cortical activity in interictal, ictal, and chronic migraine
Get PDFIntroduction
Migraine is a fluctuating disorder. Analyzing changes in cerebral activity at different stages of migraine has significantly advanced our understanding of its pathophysiology. However, most neuroimaging methods evaluate indirect markers of brain activation, such as regional metabolism or blood flow. In contrast, electrophysiological assessments provide direct information about underlying neuronal processes. This study aimed to compare cortical activity among interictal, ictal, and chronic migraine patients and healthy controls using an electrophysiological-based neuroimaging approach.
Materials and Methods
One hundred participants (25 healthy controls and 75 migraine patients: 25 ictal, 25 interictal, and 25 chronic) were included. A sixty-second low-artifact resting-state 22-channel electroencephalogram (EEG) segment from each individual was analyzed using Exact Low Resolution Brain Electromagnetic Tomography (eLORETA). Mean subject-normalized Delta, Theta, Alpha, Beta, and Gamma band activity was compared (whole brain, voxel-wise) between groups using Statistical Parametric Mapping (SPM) nested in MATLAB. Brain areas showing differences in neural activation were selected for data-driven post-hoc region of interest (ROI) analyses.
Results
Significantly decreased activity in the left subcallosal area was observed in ictal migraine patients compared to other groups. Additionally, increased activity in the right temporoparietal junction was noted in ictal migraine patients compared to interictal migraine patients, and increased activity in the left temporoparietal junction in interictal patients compared to healthy controls.
Conclusions
Our results are anatomically consistent, but mostly physiologically discordant with previous neuroimaging studies.(1) Notably, we observed increased neuronal activity in the right temporoparietal junction and decreased activity in the left subcallosal area in ictal patients, both areas previously reported to be activated in this stage using conventional neuroimaging techniques. We hypothesize that these discrepancies arise because inhibitory and excitatory neuronal activity produces similar metabolic changes, making them indistinguishable to conventional neuroimaging techniques, but easily discriminated using electrophysiological methods. The decreased activity in the left subcallosal area appears to be a homeostasis-restoring mechanism, absent in healthy controls and interictal patients, maximal in ictal patients, and dysfunctional in chronic migraine
Boundaries of visual phenomena in migraine: the charles bonnet’s syndrome - report of two cases
Get PDFIntroductionTwo patients were referred to a tertiary headache center due to complex visual phenomena that might be related to migraine aura. Eventually, it turned out that they were Charles Bonnet syndrome (CBS) patients. The syndrome is characterized by vivid visual hallucinations in the absence of other psychiatric symptoms, often in patients with optical morphophysiological disorders. The pathophysiology of CBS remains uncertain, and the syndrome lacks robust diagnostic criteria. So far, reports on CBS are scarce in Brazilian neurological literature, leading to challenges in identification and diagnosis. The condition is primarily recognized through anamnesis and clinical examination.ObjectiveTo report two cases of CBS to draw the attention of headache specialists about this syndrome.Case reportsThe first case involves a 93-year-old male patient, retired, who reported experiencing vivid hallucinations sometimes of an old white car and sometimes a group of children. Despite the clarity of these visions, the patient remained aware that they were not real. In the second case, a 70-year-old male farmer began experiencing hallucinations involving scratches, scribbles, letters, stones, and women in his visions. ConclusionHere two cases of CBS were reported concerning a not so rare condition, but for sure very uncommon to headache specialists
Desarranjo interno em articulação temporo mandibular em paciente jovem: Tratamento Conservador x Tratamento cirúrgico Parte 1.
No full textAbstract: The patient presents with algia in the left mandible and in the ocular region, specifically at the base of the orbit. Initially, after clinical examination, the suspicion was migraine associated with bruxism with internal joint disorder. After imaging exams by tomography and magnetic resonance imaging with T1, T2, and DP contrast, it was observed that in the left temporomandibular joint, there is disc displacement without reduction, and in the right temporomandibular joint, the disc shows partial recovery. After one year of using an interocclusal device, the patient shows improvement in pain symptoms; however, the disc has only slightly improved in recovery, suggesting the possibility of future open surgery for disc repositioning through discopexy.Resumo: Paciente com algia em mandibula esquerda e em região ocular especificamente na base da órbita. A princípio após o exame clinico a suspeita era de migranea associada a bruxismo com presença de desarranjo interno articular. após exames de imagem por tomografia e ressonancia magnética com contraste T1, T2 e DP, observou-se na articulação temporo mandibular esquerda deslocamento de disco sem redução e na articulação temporo mandibular direita o disco apresenta recuperação parcial. Paciente após um ano de uso de dispositivo interoclusal apresenta melhora do quadro álgico, contudo o disco apresentou ligeira melhora na recuperação, o que se sugere a possibilidade futura de realização de recuperação o posicionamento discal por cirurgia aberta através de discopexia
Terapia com anticorpos monoclonais para dor de cabeça crônica refratária semelhante à enxaqueca relacionada à doença de Lyme: relato de caso
No full textIntroductionLyme disease, caused by Borrelia burgdorferi, can lead to diverse neurological manifestations, including headache. While most Lyme-associated headaches resolve with antibiotics, some may evolve into a refractory chronic migraine-like syndrome. We present a case of post-Lyme chronic migraine-like headache responsive to galcanezumab, a calcitonin gene-related peptide (CGRP) monoclonal antibody.Case ReportA 42-year-old woman developed chronic migraine-like headaches following treatment for Lyme neuroborreliosis. The headaches were refractory to standard preventive therapies and only partially responsive to onabotulinumtoxinA. Administration of galcanezumab resulted in significant reduction of headache frequency, intensity, and impact on daily activities.CommentThis case highlights the potential of CGRP-targeted therapies for persistent migraine-like headaches following Lyme neuroborreliosis. The favorable response to galcanezumab suggests a role for CGRP in the pathophysiology of post-Lyme headache. While further research is needed to establish efficacy and safety, clinicians should consider CGRP monoclonal antibodies for chronic migraine-like headaches refractory to standard treatments in the post-infectious phase of Lyme disease. The emergence of chronic migraine-like headaches following Lyme neuroborreliosis and the response to a CGRP monoclonal antibody in this case underscore the importance of considering targeted migraine therapies in the management of persistent headaches after antibiotic treatment. This report contributes to the understanding of Lyme disease sequelae and potential treatment options, warranting further investigation into the utility of CGRP-targeted therapies in this context.IntroduçãoA doença de Lyme, causada pela espiroqueta Borrelia burgdorferi, pode apresentar diversas manifestações neurológicas, incluindo cefaleia. Embora a maioria das cefaleias associadas à doença de Lyme se resolva com antibioticoterapia, algumas podem evoluir para uma síndrome semelhante à migrânea crônica refratária. Apresentamos um caso de cefaleia crônica do tipo migrânea pós-Lyme que respondeu ao galcanezumabe, um anticorpo monoclonal que atua no peptídeo relacionado ao gene da calcitonina (CGRP).Relato de casoUma mulher de 42 anos desenvolveu cefaleia crônica do tipo migrânea após o tratamento para neuroborreliose de Lyme. As crises de cefaleia eram refratárias às terapias preventivas convencionais e apenas parcialmente responsivas à onabotulinumtoxinA. A administração de galcanezumabe resultou em uma redução significativa da frequência, intensidade e impacto da cefaleia nas atividades diárias da paciente.DiscussãoEste caso destaca o potencial das terapias direcionadas ao CGRP para o tratamento de cefaleias persistentes do tipo migrânea após a neuroborreliose de Lyme. A resposta favorável ao galcanezumabe sugere um papel do CGRP na fisiopatologia da cefaleia pós-Lyme. Embora sejam necessários mais estudos para estabelecer a eficácia e a segurança, os médicos devem considerar os anticorpos monoclonais anti-CGRP para o tratamento de cefaleias crônicas do tipo migrânea refratárias às terapias convencionais na fase pós-infecciosa da doença de Lyme. O surgimento de cefaleia crônica do tipo migrânea após a neuroborreliose de Lyme e a resposta a um anticorpo monoclonal anti-CGRP neste caso ressaltam a importância de considerar terapias específicas para migrânea no tratamento de cefaleias persistentes após a antibioticoterapia. Este relato contribui para a compreensão das sequelas da doença de Lyme e das possíveis opções terapêuticas, justificando uma investigação mais aprofundada sobre a utilidade das terapias direcionadas ao CGRP nesse contexto clínico
Real-World effectiveness after initiating fremanezumab treatment in Brazilian patients with episodic and chronic migraine
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Background: Migraine is a debilitating condition, estimated to affect 30 million people in Brazil. Prevention may be considered for both episodic (EM) and chronic (CM) migraine and represents a real challenge in patient management. Fremanezumab, a fully humanized monoclonal antibody, is a specific migraine treatment directed against CGRP ligand. Regulatory approval for this molecule in Brazil occurred in December 2019, becoming an option of treatment in our country. Given the relatively recent approval, studies and publications that address real-world data on the use of Fremanezumab are needed, which we will refer to in this study.
Methods: This is real-world, retrospective chart review study that assessed demographic and clinical aspects of 170 Fremanezumab treated patients. The safety of the drug was evaluated to all patients who received at least 1 Fremanezumab treatment, and the effectiveness for EM and CM patients that completed 12 weeks of treatment based in monthly headache days (MHD) pre- and post-Fremanezumab. Data was obtained from two tertiary neurology services, in São Paulo, southeast region, and Fortaleza, northeast region of Brazil, between 2021 and 2022. Inclusion criteria were a physician diagnosis of EM or CM, age ≥ 18 years at the time of first Fremanezumab initiation, ≥ 1 dose of Fremanezumab treatment; ≥ 1 follow-up visit since first initiation; and measurement of monthly headache days (MHD at initiation and after 12 weeks of medication use). Efficacy measures were considered to patients that presented ≥ 50% improvement, ≥ 75% improvement or ≥ 100% after 12 weeks in MHD after Fremanezumab treatment initiation.
Results: There were no differences between of the two centers population. Of the total sample, women represent 76.5%, and the mean age was 46.04 (±13.94) years. The average age of migraine onset was 15.7 (± 9.28) years, and the mean age when receiving the first Fremanezumab treatment was 45.08 (±14.11) years. The time of CM in years before initiating Fremanezumab was 8.87 (± 7.65) years. All this sample had the medication monthly. The improvement analyses considered 102/170 patients, 60% of the sample, who have completed the 12 weeks follow-up visit. Overall, 65% of the patients showed an improvement after this period of treatment. The mean number of MHD at the initiation of the treatment was 19.31, falling to 8.89 at the first month and 6.94 at the third month. When considering the 12 weeks follow-up visit 81.4% of the sample improved ≥ 50%, 35.3% improved ≥ 75%, and 2.9% presented a 100% resolution of MHD. Side effects observed with Fremanezumab use were none to 65% of patients, limited local pain in 30.3%, site injection erythema in 9.9%, flu-like symptoms, and intestinal constipation 0.7% each. From the total patients of this sample only 3 patients interrupted the treatment because of side effects: 1 with local erythema, 1 with flu-like symptoms, and 1 with intestinal constipation.
Conclusion: For this Brazilian sample of EM or CM patients Fremanezumab proved to be a very efficient, safety, and well tolerated option for migraine treatment. Real-world evidence studies are valid and useful tools to understand the behavior of patients in many life scenarios. Our findings reassure the pattern of response to Fremanezumab in everyday migraine treatment worldwide
Analysis of performance of physical activities in patients with headache - data from a Brazilian cohort
Get PDFIntroduction: Physical exercise is recommended to improve the pain pattern. However, some headaches worsen or are triggered during physical exercise. Studies show that patients with headaches perform less physical exercise than those without headaches, but the direction of this relationship has yet to be discovered. Objective: to verify whether there is a relationship between the presence of headache and the performance of light, moderate, and vigorous physical activities; whether there is a correlation between headache frequency and intensity and the frequency of light, moderate, and vigorous physical activities, and whether there is a difference in the frequencies of physical activities between those with episodic/chronic headaches. Methods: An analytical and descriptive study from a cohort of live births (1978/79) in Ribeirao Preto/SP. The variables of interest were: Presence, frequency, and headache intensity in the last 3 months. Days of continuous walking, moderate activities (cycling lightly, swimming, dancing, doing light aerobics, volleyball) and vigorous activities (running, playing football, cycling quickly, playing basketball, carrying heavy weights), for ≥10 continuous minutes, in the last week. Results: 1775 individuals (average age of 38.13±0.579, 52.3% female) participated. 63% reported headache in the last 3 months (16.3% with chronic headache). The proportions of individuals with and without headaches among those who performed walking (50.90% versus 51.07%; p=0.945) or moderate physical activities (50.72% versus 46.71%; p=0.104) were no different. Among those who performed vigorous physical activities, there was a lower proportion of individuals with headache (23% versus 31.9%, p<0.001). There was no correlation between headache frequency and frequency of light (rs=0.026; p=0.387), moderate (rs=0.045; p=0.137), or vigorous physical activity (rs=0.138; p<0.001). There was no correlation between headache intensity and frequency of light (rs=0.025; p=0.411), moderate (rs=0.030; p=0.319), or vigorous physical activity (rs=-0.079; p=0.008). There was no difference in the frequency of light (p=0.226), moderate (p=0.342), or vigorous physical activity (p=0.112) between patients with episodic/chronic headache. Conclusion: Fewer individuals with headaches were observed performing vigorous physical activities. No correlation was observed between headache frequency and intensity and frequency of physical activities. There was no difference in the frequency of physical activities between those with chronic or episodic headaches