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Migrânea com aura após retirada do clopidogrel: evidência de inflamação como um gatilho de enxaqueca? - Relato de caso
No full textThis article presents the case of a PFO (patent foramen ovale) closure patient with double antiplatelet therapy in whom aspirin was discontinued before clopidogrel and that, at clopidogrel withdrawal, presented “de novo” migraine with visual aura attacks. Migraines with aura associated with atrial right-to-left shunts (PFO and other atrial septal defects) are attributed to the arrival of vasoactive substances in the brain, since not cleared by the lungs. In this case, discontinuation of clopidogrel one year after PFO closure induced “de novo” migraine with aura.
Conclusion
Rather than confirming the prophylactic effects of clopidogrel for migraine with aura, its triggering at clopidogrel withdrawal is more likely related to a proinflammatory effect of discontinuing clopidogrel. This proinflammatory effect has been described in cardiological research, and reinforces that patients receiving dual antiplatelet therapy (clopidogrel and aspirin) should always have clopidogrel discontinued before aspirin in order to avoid proinflammatory or pro-thrombotic events.Este artigo apresenta o caso de um paciente com fechamento de FOP (forame oval patente) com terapia antiplaquetária dupla em que a aspirina foi suspensa antes do clopidogrel e que, na retirada do clopidogrel, apresentou enxaqueca “de novo” com crises de aura visual. Migrâneas com aura associadas a shunts atriais direita-esquerda (FOP e outros defeitos do septo atrial) são atribuídas à chegada de substâncias vasoativas ao cérebro, desde que não depuradas pelos pulmões. Neste caso, a interrupção do clopidogrel um ano após o fechamento do FOP induziu enxaqueca “de novo” com aura.
Conclusão
Em vez de confirmar os efeitos profiláticos do clopidogrel para enxaqueca com aura, é mais provável que seu desencadeamento na retirada do clopidogrel esteja relacionado a um efeito pró-inflamatório da suspensão do clopidogrel. Esse efeito pró-inflamatório foi descrito em pesquisas cardiológicas e reforça que pacientes em uso de terapia antiplaquetária dupla (clopidogrel e aspirina) devem sempre ter o clopidogrel suspenso antes da aspirina, a fim de evitar eventos pró-inflamatórios ou pró-trombóticos
Red flags para cefaleias secundárias: desafiosna prática clínica
No full textIntroduction
The World Health Organization (WHO) ranks migraine as one of the top 20 causes of impaired healthy life years per year worldwide. Migraine alone is responsible for about 400,000 lost workdays per year per one million inhabitants in developed countries. Headache is probably among the five most important causes of disability worldwide.
Method
This literature review was carried out by searching the Pubmed, Lilacs and Scopus databases, using the following Health Science Descriptors (DeCS) of the Virtual Health Library and in particular the current data collected by the WHO or health entities in the various countries: "secondary headaches" AND "red flags" AND "review". Articles published in Portuguese and English were selected. The eligibility criteria defined for the inclusion of articles were studies that addressed the chosen theme.
Results
The use of "Red Flags" in clinical practice is of considerable relevance. The combination of "Red Flags", anamnesis, physical examination, laboratory, and imaging examination accentuate the probability of predicting the etiology that may underlie the onset of a secondary headache. However, despite this widely useful screening tool, there are still gaps in the prognosis.
Conclusion
Much remains unclear as there is a lack of prospective epidemiological studies. In addition, some "Red Flags" such as pattern change are poorly elucidated. Large-scale studies are needed due to the low incidence of many secondary causes. New patients with headache should be screened using the SNNOOP10 list to increase the likelihood of detecting a secondary cause.Introdução
A Organização Mundial de Saúde (OMS) classifica a enxaqueca como uma das 20 principais causas de perda de anos de vida saudável por ano no mundo. A enxaqueca, isoladamente, é responsável por cerca de 400 mil dias de trabalho perdidos por ano, por um milhão de habitantes, nos países desenvolvidos. A cefaleia como um todo provavelmente está entre as cinco mais importantes causas de incapacidade em nível mundial.
Método
Esta revisão de literatura foi realizada através da busca nas bases de dados Pubmed, Lilacs e Scopus, utilizando os seguintes Descritores em Ciências da Saúde (DeCS) da Biblioteca Virtual em Saúde e em especial nos dados atuais levantados pela OMS ou entidades de saúde nos diversos países: “cefaleias secundárias”; “red flags”; “revisão”. Foram selecionados artigos publicados nos idiomas português e inglês. Os critérios de elegibilidade definidos para a inclusão dos artigos foram estudos que abordaram a temática escolhida.
Discussão
É de notável relevância a utilização das “Bandeiras Vermelhas” na prática clínica. A combinação de “Bandeiras Vermelhas”, anamnese, exame físico, laboratorial e de imagem acentuam a probabilidade de prever a etiologia que pode estar subjacente ao aparecimento de uma cefaleia secundária. Todavia, apesar dessa ferramenta de triagem ser de ampla utilidade ainda existem lacunas no que compreende os prognósticos.
Conclusão
Muito permanece obscuro, uma vez que há uma falta de estudos epidemiológicos prospectivos. Além disso, algumas “Bandeiras Vermelhas” como mudança de padrão são pouco elucidadas. Estudos em larga escala são necessários devido à baixa incidência de muitas causas secundárias. Novos pacientes com cefaleia devem ser rastreados usando a lista SNNOOP10 para aumentar a probabilidade de detectar uma causa secundária.
Evaluation of the genetic variant - 889 C > T Of Il-1α in migraine - partial analysis
Get PDFIntroductionThe pathophysiology of migraine integrates inflammatory and genetic aspects, with interleukin-1α being a component of this picture. This pro-inflammatory cytokine, responsible for inducing pyrogenic, hematological, and metabolic phenomena, is produced by macrophages and monocytes. Genetic variants, which can be found in the regulatory region of the gene for this substance, have clinical implications in different systems.ObjectiveTo evaluate the frequency of the -889C>T genetic variant of IL-1α and its association with clinical variables related to migraine. MethodsProspective case-control study composed of migraine patients and healthy controls aged between 18 and 60 years of age. Project approved by the Research Ethics Committee of PUCPR (No. 3,029,972). Demographic, clinical data on migraine classification and characteristics were collected using a structured form and validated questionnaires on anxiety (STAIY2), depression (BDI) and migraine-related disability (MIDAS). Genetic evaluation was performed with blood or saliva samples that were subjected to polymerase chain reaction (PCR), followed by electrophoresis in 1.5% agarose gel. Categorical data were analyzed by chi-square test or Fisher\u27s exact test and continuous data by t-test or Mann-Whitney test. ResultsA total of 156 participants, 73 migraineurs and 83 controls, were evaluated. The -889C>T variant of IL-1α was not associated with increased susceptibility to migraine when evaluated in allelic, codominant, dominant, or recessive models. The C allele, the lowest producer of the cytokine, was associated with a higher frequency of osmophobia in patients with migraine (65.5% vs. 48.2%; p=0.038). ConclusionNo association was identified between the -889C>T variant of IL-1α and susceptibility to migraine. Its effect on osmophobia should be further investigated. However, the present work is a partial analysis whose main limitation is the small sample size.IntroductionThe pathophysiology of migraine integrates inflammatory and genetic aspects, with interleukin-1α being a component of this picture. This pro-inflammatory cytokine, responsible for inducing pyrogenic, hematological, and metabolic phenomena, is produced by macrophages and monocytes. Genetic variants, which can be found in the regulatory region of the gene for this substance, have clinical implications in different systems.ObjectiveTo evaluate the frequency of the -889C>T genetic variant of IL-1α and its association with clinical variables related to migraine. MethodsProspective case-control study composed of migraine patients and healthy controls aged between 18 and 60 years of age. Project approved by the Research Ethics Committee of PUCPR (No. 3,029,972). Demographic, clinical data on migraine classification and characteristics were collected using a structured form and validated questionnaires on anxiety (STAIY2), depression (BDI) and migraine-related disability (MIDAS). Genetic evaluation was performed with blood or saliva samples that were subjected to polymerase chain reaction (PCR), followed by electrophoresis in 1.5% agarose gel. Categorical data were analyzed by chi-square test or Fisher\u27s exact test and continuous data by t-test or Mann-Whitney test. ResultsA total of 156 participants, 73 migraineurs and 83 controls, were evaluated. The -889C>T variant of IL-1α was not associated with increased susceptibility to migraine when evaluated in allelic, codominant, dominant, or recessive models. The C allele, the lowest producer of the cytokine, was associated with a higher frequency of osmophobia in patients with migraine (65.5% vs. 48.2%; p=0.038). ConclusionNo association was identified between the -889C>T variant of IL-1α and susceptibility to migraine. Its effect on osmophobia should be further investigated. However, the present work is a partial analysis whose main limitation is the small sample size
New precipitating factors for migraine during Covid-19 pandemic lockdown
Get PDFBackground: Lock down caused sudden lifestyle changes and represented a massive impact on human health. We aimed to report new migraine headache precipitating factors due to lifestyle changes during coronavirus disease 2019 (COVID-19) Pandemic lockdown.
Methods: This cross-sectional survey included patients diagnosed with migraine based on The International Classification of Headache Disorders, 3rd edition (ICDH-3). During the lockdown, we submitted an online self-reported web-based questionnaire to patients already diagnosed with migraine and attending headache clinic at Ibn Sian Hospital in Kuwait. Questions explored different new precipitating factors of migraine headache attacks during COVID-19 pandemic lockdown compared to precipitating factors before lockdown.
Results: A total of 340 migraine patients responded to online questionnaire. The mean age of them is 34.65 years. Females were predominant 79.1%. Majority of the cohort 85 % has more than one trigger of migraine headache attack. During pandemic, the common precipitating factors were smell of strong odors in 214 (62.9%), followed by certain food in 175 (51.8%), sleep disturbance in 120 (35.3%), emotional or mental stress in 80 (23.6%), caffeine in 80 (23.6%), flickers of light in 78 (22.9%), weather changes in 68(20%), smoking in 65 (19.12%), noise in 56 (16.5%), sun light exposure in 41 (12.1%), fasting/ hypoglycemia in 40 (11.7%), hormonal changes in 37 (10.6%), physical excretion/fatigue in 24 (7.1%), screen exposure in 20 (5.9%), and dehydration in 14 (4.1%) patients. Before pandemic, noises 200 (58.8%), flicker of light 180 (52.9%), weather changes 175 (51.5%), sun light 170 (50%), food 160 (48.5%) and 130 (38.2%) sleep deprivation were the most common precipitating factors of migraine. 40% did not report precipitating factors for migraine before lockdown.
Conclusions: Change of habits during lock down exposed migraine patients to different precipitating factors. Strong odors, food, sleep disturbance and stress were the most common migraine headache precipitating factors during COVID-19 lockdown
Avaliação da reserva ovariana em pacientes com enxaqueca
No full textObjective
The aim of our study is to investigate the relationship between migraine and ovarian reserve. Methods
The study group consists of women between the ages of 25-51, including 44 patients diagnosed with migraine and 43 controls. Ovarian reserves were performed by antral follicle count and measured anti-Müllerian hormone level.
The cohort was divided into four subgroups according to age as follows: 30 years and below, 31-35 years, 36-40 years, and 41 years of age and above.
Results
Of the 87 individuals included in this study, 44 were migraine patients, and 43 were healthy controls. The mean ages of the study and control groups were 34.3 (minimum: 25, maximum: 51) and 36.5 (minimum: 27, maximum: 51) years, respectively. There was no statistically significant difference between the two groups regarding age (p=0.48). In the study and control groups, respectively; mean AMH levels were 2.67 ± 2.46 ng/mL and 2.55 ± 2.38 ng/mL (p=0.819), mean basal FSH levels were 7.92 ± 2.52 U/L and 9.11 ± 3.19 U/L (p=0.066), mean basal LH levels were 6.35 ± 3.59 U/L and 6.06 ± 2.86U/L (p=0.681), mean basal estradiol levels were 65.02 ± 69.54 ng/L and 49.47 ± 27.08 ng/L (p=0.244), and mean AFC were 10.9 ± 3.9 and 10.2 ± 3.7 (p=0.435). Between subgroups aged ≤30 years, serum anti-Müllerian hormone levels were found to be significantly different (p=0.036). There was no statistically significant difference between any age subgroups in terms of antral follicle count.
Conclusion
In conclusion, detecting possible reduction of ovarian reserves in reproductive-age (especially younger than 30 years) migraine patients by utilizing anti-Müllerian hormone and ultrasonographic markers would allow these women to make cognizant decisions regarding marriage and family planning, as well as inform them whether they are in early menopause riskObjetivoO objetivo do nosso estudo é investigar a relação entre enxaqueca e reserva ovariana.MétodosO grupo de estudo é composto por mulheres entre 25 e 51 anos, incluindo 44 pacientes com diagnóstico de enxaqueca e 43 controles. As reservas ovarianas foram realizadas por contagem de folículos antrais e dosagem de hormônio anti-Mülleriano. A coorte foi dividida em quatro subgrupos de acordo com a idade: 30 anos eabaixo, 31-35 anos, 36-40 anos e 41 anos de idade e acima.ResultadosDos 87 indivíduos incluídos neste estudo, 44 eram pacientes com enxaqueca e 43 eram controles saudáveis. As idades médias dos grupos de estudo e controle foram de 34,3 (mínimo: 25, máximo: 51) e 36,5 (mínimo: 27, máximo: 51) anos, respectivamente. Houvenão houve diferença estatisticamente significativa entre os dois grupos quanto à idade (p=0,48). Nos grupos estudo e controle, respectivamente; os níveis médios de AMH foram 2,67 ± 2,46 ng/mL e 2,55 ± 2,38 ng/mL (p=0,819), os níveis médios de FSH basal foram 7,92 ± 2,52 U/L e 9,11 ± 3,19 U/L (p=0,066), LH basal médio os níveis foram 6,35 ± 3,59 U/L e 6,06 ± 2,86U/L (p=0,681), os níveis médios de estradiol basais foram 65,02 ± 69,54 ng/L e 49,47 ± 27,08 ng/L (p=0,244), e os níveis médios de estradiol foram 10,9 ± 3,9 e 10,2 ± 3,7 (p=0,435). Entre os subgrupos com idade ≤30 anos, os níveis séricos de hormônio anti-Mülleriano foram significativamente diferentes (p=0,036). Não houve diferença estatisticamente significativa entre quaisquer subgrupos de idade em termos de contagem de folículos antrais.ConclusõesEm conclusão, detectar uma possível redução das reservas ovarianas em pacientes com enxaqueca em idade reprodutiva (especialmente com menos de 30 anos) utilizando hormônio anti-Mülleriano e marcadores ultrassonográficos permitiria a essas mulheres tomar decisões conscientes sobre casamento e planejamento familiar, bem como informá-las se eles estão em risco de menopausa precoc
Efeitos da fisioterapia na cefaleia do tipo tensional
No full textIntroduction
Tension-type headache (TTH) has been considered the most common primary headache in adults, characterized by the presence of bilateral pain, presenting in the form of pressure or tightness (non-pulsating), with intensity ranging from mild to moderate.
Objectives
To analyze the medium-term effects of manual therapy techniques, stretching and muscle strengthening exercises on functionality, pain and disability in patients with TTH.
Methods
The following variables were evaluated: pain through the Visual Analog Scale (VAS); the strength of the cervical musculature through dynamometry; the disability by the Neck Disability Index (NDI); and the impact of headache on activities of daily living (ADL) through the application of the Headache Impact Test (HIT-6) before and after the intervention. Six physiotherapy sessions were performed, once a week, for six weeks. Results
There was a reduction in the post-intervention pain pattern (4.2 ± 2.3 vs. 0.2 ± 0.5; p=0.019). In terms of disability, there was a difference between the pre- and post-intervention periods (11.4 ± 1.5 vs. 6.6 ± 2.3; p=0.022). In addition, after the intervention, there was a reduction in HIT-6 levels when compared to the pre-intervention period (51.0 ± 7.5 vs. 59.6 ± 3.9; p=0.038).
Conclusion
The physical therapy intervention protocol proved to be effective in reducing the pattern of pain, disability, and headache impact on ADL of patients with TTH.Introdução: A Cefaleia do Tipo Tensional (CTT) é a mais frequente dentro do grupo das cefaleias primárias, sendo responsável por gerar um alto impacto socioeconômico para a sociedade, além de prejudicar as relações sociais, profissionais e familiares. Objetivos: Analisar os efeitos de um protocolo de intervenção fisioterapêutica, incluindo técnicas de terapia manual, alongamentos e fortalecimento muscular sobre a funcionalidade, dor e incapacidade em pacientes com CTT. Métodos: Trata-se de um estudo de caráter intervencionista, exploratório-descritivo com abordagem quantitativa, realizado com cinco indivíduos com quadro sintomático de CTT. A dor foi avaliada através da Escala Analógica Visual (EVA); a incapacidade pelo Neck Disability Index (NDI) e o impacto da cefaléia em atividades de vida diária (AVD) mediante aplicação do Headache Impact Test (HIT-6) antes e após intervenção. Foram realizadas seis sessões de fisioterapia, uma vez por semana, durante seis semanas. Resultados: Houve redução no padrão de dor pós-intervenção (4,2 ± 2,28 x 0,2 ± 0,45; p=0,0189). No quesito incapacidade, houve diferença entre os períodos pré e pós-intervenção (11,4 ± 1,54 x 6,6 ± 2,30; p=0,0220). Além disso, após a intervenção, houve redução nos níveis do HIT-6 quando comparado ao período pré-intervenção (51 ± 7,45 x 59,6 ± 3,91; p=0,0381). Conclusão: O protocolo de intervenção fisioterapêutica mostrou-se eficaz na redução do padrão de dor, incapacidade e impacto da cefaleia nas AVD de pacientes com CTT
Secondary hypnic headache: A literature review in the last 34 years
Get PDFIntroduction: Hypnic headache is a rare primary headache disorder that occurs during sleep. Its pathophysiology is uncertain, but hypothalamic dysfunction is hypothesized. It is usually a primary headache, but it can have secondary causes.
Objectives: We aimed was to review articles published in the last 34 years on hypnic headache and analyze secondary cases.
Methods: Based on a literature search in the major medical databases and using the descriptor “hypnic headache” we included articles published between 1988 and 2020. Of the 359 patients found, only 18 met the inclusion criteria and were analyzed.
Results: We found 18 patients (6 men and 12 women) with secondary hypnic headache. The mean age of patients was 58.7±15.0 years, ranging from 20 to 84 years. The causes of hypnic headache were attributed to cranial vascular disorder (five), to non-vascular intracranial disorder (six), to a substance or its withdrawal (three) and to disorder of homoeostasis (four).
Conclusions: Although most cases of hypnic headache are primary, some symptomatic cases are described in the literature.Introdução: A cefaleia hípnica é uma cefaleia primária rara que ocorre durante o sono. Sua fisiopatologia é incerta, mas há hipótese de disfunção hipotalâmica. Geralmente é uma cefaleia primária, mas pode ter causas secundárias.
Objetivos: Nosso objetivo foi revisar artigos publicados nos últimos 34 anos sobre cefaleia hípnica e analisar casos secundários.
Métodos: Com base em pesquisa bibliográfica nas principais bases de dados médicos e utilizando o descritor “hypnic headache” foram incluídos artigos publicados entre 1988 e 2020. Dos 359 pacientes encontrados, apenas 18 preencheram os critérios de inclusão e foram analisados.
Resultados: Encontramos 18 pacientes (6 homens e 12 mulheres) com cefaleia hípnica secundária. A média de idade dos pacientes foi de 58,7±15,0 anos, variando de 20 a 84 anos. As causas de cefaleia hípnica foram atribuídas a distúrbio vascular craniano (cinco), a distúrbio intracraniano não vascular (seis), a uma substância ou sua abstinência (três) e a distúrbio de homeostase (quatro).
Conclusões: Embora a maioria dos casos de cefaleia hípnica seja primária, alguns casos sintomáticos são descritos na literatura
Higher cerebrospinal fluid (CSF) opening pressure in patients with idiopatic intracranial hypertension (IIH) with permanent visual impairment
Get PDFObjective
The aim of this study was to identify potential visual prognostic markers in patients with idiopathic intracranial hypertension (IIH).
Methods
Patients with IIH of an outpatient headache clinic in São Paulo, Brazil, were retrospectively evaluated and divided in two groups with and without the presence of permanent visual deficit attributed to IIH. Body mass index (BMI), opening CSF pressure, and the frequency of IIH related MRI abnormalities were compared between these two groups.
Results
Twenty-nine patients, with 35,39±9,93 years, being twenty-eight female (96.55%) were included in the study. Reduced visual acuity attributed to IIH was registered in 16 (55.17%). According to BMI 17.4% had overweight and 82.6% were obese. Brain MRI was normal in 6 (20.69%). BMI, obesity, and the presence of MRI abnormalities were not associated with visual impairment. Initial CSF opening pressure was significantly higher in the group of patients with reduced visual acuity (40.4±13.14 x 30.5±3.41, P=0,015).
Conclusion
Higher CSF opening pressure at onset was significantly associated with a higher percentage of visual impairment in patients with IIH suggesting this measure as a potential prognostic marker for patients with IIH.
OBJETIVO: O objetivo deste estudo foi identificar potenciais marcadores prognósticos visuais em pacientes com hipertensão intracraniana idiopática (HII).
MÉTODOS: Pacientes com HII de um ambulatório de cefaleia em São Paulo, Brasil, foram avaliados retrospectivamente e divididos em dois grupos de acordo com a presença ou não de redução visual permanente atribuída a HII. O índice de massa corporal (IMC), a pressão de abertura do LCR e a frequência de anormalidades de RM relacionadas à HII foram comparados entre esses dois grupos.
RESULTADOS: Vinte e nove pacientes, com 35,39±9,93 anos, sendo vinte e oito do sexo feminino (96,55%), foram incluídos no estudo. A redução da acuidade visual atribuída à HII foi registrada em 16 (55,17%). De acordo com o IMC, 17,4% tinham sobrepeso e 82,6% eram obesos. A ressonância magnética cerebral foi normal em 6 (20,69%). O IMC, a frequência de obesidade e a frequência de anormalidades na RM relacionadas à HII não foram associados à deficiência visual. A pressão inicial de abertura do LCR inicial foi significativamente maior no grupo de pacientes com acuidade visual reduzida (40,4±13,14 x 30,5±3,41, P=0,015).
CONCLUSÃO: Os pacientes com deficiência visual permanente associada à HII tiveram maior pressão de abertura do LCR, sugerindo que esse parâmetro tenha potencial valor para a avaliação prognóstica destes pacientes
Correlation between kinesiophobia, muscle strength and neck endurance in patients with migraine
Get PDFIntroductionMigraine is a highly disabling primary headache that can be accompanied by pain and musculoskeletal dysfunction in the cervical region. These individuals with cervical musculoskeletal dysfunction present a greater tendency toward fear and catastrophic thoughts and a greater risk of migraine chronification, developing behaviors such as hypervigilance in order to avoid further injury presenting the fear of movement which can be characterized as kinesiophobia. Kinesiophobia is defined as an "irrational and devastating fear of movement, arising from a belief in the fragility of injury or a fear of re-injury." In addition, kinesiophobia can also be characterized as a fear of symptoms of fatigue or exhaustion, physical or mental discomfort. Individuals with cervical musculoskeletal dysfunctions are more prone to fear and catastrophic thoughts, and have a higher risk of migraine chronification, as well as an overreaction to actual or potential threats, developing behaviors such as hypervigilance in order to avoid further injury. The Kinesiophobia is a prevalent condition in individuals with migraine and the association between the presence of migraine and kinesiophobia has recently been investigated. However, it is not yet known whether there is a correlation between muscle strength and cervical endurance with kinesiophobia.
ObjectiveTo evaluate the correlation between muscle strength and neck muscle endurance with kinesiophobia in patients with migraine.
Methods
Were included 70 women aged between 18 and 55 years, with a mean age of 31 years (SD=9.35; CI=2.19), and a mean body mass index of 23.5 (SD=3.63; CI= 0.85), diagnosed according to the 3rd edition of the ICHD-3. Regarding the clinical characteristics of these patients, they presented headache onset at 14.5 years (SD=9.57; CI=2.24), a frequency of 12 days in the month (SD=9.74; CI=2.28), the intensity of 8/10 on the Numerical Pain Rating Scale (NPRS) (SD=1.60; CI=0.37). (To see the complete abstract, please, check out the PDF)