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BackgroundThe type of medical care received (self-medication and/or medical care provided by a general practitioner or a neurologist) may be associated with differences in the frequency of medication overuse headaches.MethodThis cross-sectional analytical study included 222 records of patients with chronic daily headaches seen at the National Institute of Neurological Sciences Outpatient Unit in Lima, Peru. A pre-designed questionnaire was used to assess and categorize patients with frequent and chronic headaches.ResultsNinety-four patients (42.34% of those with chronic daily headaches) met the criteria for medication overuse headache. Of these, 19 (28%) self-medicated, 22 (36%) consulted with the general practitioner, and the highest proportion of subjects, 53 (58%), consulted with a neurologist. On bivariate analysis, subjects who had received care from a general practitioner and self-medicated were 38% and 51% less likely to have MOH than the subjects whoreceived medical care from the neurologist (p=0.012; 95% CI 0.42-0.90 and p=0.001; 95% CI 0.32-0.74). On multivariate analysis adjusting by sociodemographic and clinical factors, the association remained significant in regards to self-medication, but became marginal (p=0.055) in regard to being seen by a general practitioner.ConclusionIn this study, the frequency of the headache due to overuse of medication was higher in patients attending a neurologist than those attending a general practitioner or self-medicated. This cross-sectional design cannot assess whether this reflects more severe cases looking for specialized care or more medication overuse headaches as a result of inappropriate management.

ObjectiveTo identify the prevalence of migraine associated to menstruation in a population of students at a college in Brazil’s inland.MethodsThe students were recruited and submitted to the Test for the Identification of Women with Menstrual Period-Related Headache based on the ID-MigraineTM and Menstrual Migraine Assessment Tool questionnaires. Migraine diagnosis was made according to ICHD-3 criteria.ResultsOf the 424 students, 312 (73.5%) answered affirmatively in at least two of the four questions in the first part of the questionnaire and in the following 216 (69.2%) of these reported having migraine related to their menstrual period in the majority of the months.ConclusionsMenstrual migraine is a prevalent public health problem that deserves attention in order to ensure a better quality of life for women affected by such a condition.

Introduction Cluster headache is a very disabling neurological disorder that usually presents with unilateral severe headache associated with ipsilateral cranial autonomic symptoms. Even among the typical cases, there is a considerable diagnostic delay and most patients will have seen three general practitioners before being referred to neurology services, some having been to colleagues in dentistry or otorhinolaryngology. The extratrigeminal presentation of this condition poses a great obstacle to a proper diagnostic workup. Objective This consecutive case series study aimed to report clinical features, treatment, and outcome of 3 patients with extratrigeminal Cluster Headache. Materials and Methods Case series of our Headache Clinic. Data disclosure was authorized by the patients through an informed consent form. Results Two males and one female were evaluated. The ages were 53, 64, and 71 years. The mean age of symptoms onset was 50, 60, and 66 years, respectively. Two patients described excruciating shoulder pain and one presents severe pain in the malar area. All patients reported prominent autonomic ipsilateral symptoms such as lacrimation, conjunctival injection, nasal symptoms, and restlessness accompanying pain attacks. Preventive treatment with verapamil and occipital nerve block was useful. Conclusion Extratrigeminal cluster presentation is a diagnostic challenge. Proper recognition of these cases prevents unnecessary examination and treatment trials and directly benefits the patients since effective treatment is already available. A proper case definition of this rare clinical presentation may provide new insight into our understanding of the cluster headache mechanisms. Keywords: Cluster headache, Extratrigeminal headache, Shoulder pain.

Introduction Migraine is a common and very disabling neurological disease. It typically causes severe throbbing pain or a pulsing sensation, usually on one side of the head. It's often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. According to the definition of headache, the pain should be located in the head or in the face above the orbitomeatal line. Beyond this classical view, recent evidence has shown that it could be an arbitrary boundary, and other clinical features can prevail during the diagnosis process. Objective This consecutive case series study aimed to report clinical features, treatment, and outcome of 5 patients with a lower-half facial presentation of migraine. Materials and Methods Case series of our Headache Clinic. Data disclosure was authorized by the patients through an informed consent form. Results Of the 5 patients, 3 were women and 2 were men. Mean age was 34, 6 (13-56 years). The mean age of symptoms onset was 15,2 (11-29 years). All patients described a throbbing, moderate to severe pain in the malar area. Four patients reported frequent phonophobia and photophobia accompanying pain attacks. One patient reported great relief of pain with rizatriptan and another with sumatriptan. Preventive treatment with pizotifen, propranolol, flunarizine, amitriptyline, divalproex sodium, and pregabalin was useful. All patients underwent extensive dental and otolaryngological evaluation and treatment, which were worthless. Conclusion Migraine orofacial presentation is a diagnostic challenge. Proper recognition of these cases not only prevents unnecessary examination and treatment trials but directly benefits the patients since effective treatment is already available. A proper case definition of this rare clinical presentation may provide new insight into our understanding of the migraine mechanisms. Keywords: Facial pain, Migraine, Lower half-face migraine.

Introduction The headache field, mainly migraine, is passing through a transformative era of new treatments. These breakthroughs would not be possible without the evolving knowledge on mechanisms of headaches. However, there are still unmet needs for headaches' understanding and treatments. Objectives Assess whether there is a trend in the number of publications regarding physiopathology of each primary headache disorders (PHD) in the past 50 years. Secondarily, we aimed to evaluate how the SARS-CoV-2 pandemics impacted on physiopathology research of PHD. Methods PHD were divided hierarchically in first- and second-digit, according to ICHD-3 criteria. PubMed database was searched using both the name of the PHD and MeSH terms related to physiopathology. Each search yielded the number of publications for a determined PHD along the period selected (1971-2021). Data were retrieved and separated in two groups: a) per decades (1971-2020); and b) per year (2011-2021). Ratios between every two timepoints in each group were calculated, as well as a total ratio for the whole interval. Results Either divided per decades, or divided annually for the last 10 years, migraine had the highest absolute number of pathophysiology publications, significantly above the other PHD. Divided per decades, with exception of tension-type headache (TTH), all the other PHD groups have increased their number of publications over time. Meanwhile, TTH in the last decade decreased the total number of mechanisms research. The number of papers published in 2020 was lower than in 2019 for TTH, trigeminal autonomic cephalalgias (TACs) and group 4 "other PHD" (4.OPHD), migraine kept practically the same number. Conclusion There is a clear disparity in the number of publications on mechanisms of each PHD, being migraine well above TTH, TACs and 4.OPHD. As expected, the recent COVID pandemics has clearly impaired pathophysiologic research in the headache field. Keywords: Headache, Migraine, Mechanisms, Physiopathology, Research.

Introdução A Red Ear Syndrome (RES) é um distúrbio enigmático com aproximadamente 100 casos publicados na literatura. Apesar da variabilidade da apresentação clínica da, os sintomas mais comuns incluem ataques de dor e eritema da orelha. O distúrbio é classificado nas formas idiopática e secundária, frequentemente associada a cefaleias primárias e distúrbios da parte superior da coluna cervical, respectivamente. Tais apresentações possuem diferenças importantes. Objetivos Investigar os aspectos fisiopatológicos e clínicos das diferentes formas da RES. Material e Métodos Foi realizada uma revisão sistemática da literatura. Revisamos todos os casos publicados e 53 artigos foram selecionados seguindo as diretrizes do Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Todos os 94 pacientes dos relatos de casos coletados foram categorizados em dois grupos: idiopático ou secundário. Os grupos foram analisados separadamente e depois comparados. Resultados Em ambos os grupos, há uma prevalência em mulheres, ataques unilaterais são mais comuns, a duração dos ataques pode variar de segundos a horas e podem ocorrer diariamente. No grupo idiopático, 73,7% dos pacientes tinham ataques associados a cefaleias primárias e 20% tinham ambas as condições isoladas, o gatilho mais comum foi o estímulo tátil. Por outro lado, no grupo secundário, o gatilho mais comum foi movimentos da cabeça e pescoço. Além disso, em 61,2% dos casos a dor se estende a outras regiões além da orelha, principalmente nos casos secundários. Conclusões O trabalho mostra diferenças clínicas importantes entre RES primária e secundária. Esses resultados impactam no reconhecimento desta condição peculiar e suas variadas manifestações.

Introdução A Red Ear Syndrome (RES) é uma afecção rara (cerca de 50 casos idiopáticos foram publicados em 24 anos), de etiologia e tratamentos ainda mal definidos. Caracteriza-se por hiperemia da orelha descrita como uma sensação de queimação, e na maioria dos casos idiopáticos está associada a cefaleia primária, mas pode ocorrer isoladamente. Objetivo Reportar um relato de caso sobre a RES em conjunto com enxaqueca. Material e Métodos Relato de uma mulher, 31 anos, apresentou-se há 10 anos com dor aguda, edema e eritema acentuado no pavilhão da orelha, ocasionalmente acompanhada por hiperidrose e queimação local. Estes, ocorreram de forma espontânea ou foram induzidos por gatilhos. Durante os ataques, o resfriamento era o único meio de alívio. A paciente relatava associação clara entre a orelha vermelha e algumas crises de enxaqueca. Exames complementares não mostraram anormalidades. Resultados O diagnóstico dessa paciente é de RES. Existem duas formas da afecção: idiopática que ocorre mais frequentemente em pessoas jovens, sendo espontânea ou associada a cefaleia; e a forma secundária associada a disfunção da porção superior da coluna cervical ou a disfunção temporomandibular. Acredita-se que a ativação do sistema trigêmino-vascular seja a via comum para ambas as formas. Conclusões A incerteza sobre a etiologia desta síndrome é um obstáculo para o tratamento. Novos relatos sobre o distúrbio são importantes para aumentar o conhecimento dos médicos e profissionais da saúde e diminuir o retardo diagnóstico e sofrimento dos pacientes

Introduction Dengue fever is currently a significant public health problem as an emerging pandemic-prone viral disease in many parts of the world. Up to 100 million individuals, distributed in over 100 countries, are estimated to be infected annually, putting nearly half of the world's population at risk. The headache associated with dengue fever is considered to be very intense, bilateral, throbbing, frontal, and retro-orbital. New daily persistent headache (NDPH) is a relatively rare headache entity. It has already been reported that systemic infectious disease may precede the onset of NDPH. We report the data of an epidemiologic study analyzing the cases of NDPH among 450 subjects who had dengue fever. Method The study was performed in a medium-size town in southeastern Brazil (Franca, population 370,000). During the year 2015, 600 cases of dengue fever were reported to the Franca Health Authority. All these patients were contacted by telephone, and 450 of the patients were located and interviewed. Results Of these 450 interviews, three possible cases of NDPH were identified. Conclusion The observed prevalence of NDPH attributed to dengue fever was 1:150 cases of dengue fever (0.67%).

Made available in DSpace on 2021-07-14T10:18:35Z (GMT). No. of bitstreams: 0 Previous issue date: 2016-03. Added 1 bitstream(s) on 2021-07-14T11:26:49Z : No. of bitstreams: 1 S0004-282X2016000300017.pdf: 296980 bytes, checksum: 61532e35d8a3544c1e4f26fc993603b3 (MD5) Neste artigo um grupo de especialistas no tratamento de cefaleia da Sociedade Brasileira de Cefaleia através de um consenso elaborou medidas estratérgicas para tratar uma crise de migrânea tanto na criança como no adulto. Uma enfase particular foi dada no tratamento da migranea na mulher, incluindo gravidez, lactação e período perimenstrual. In this article, a group of experts in headache management of the Brazilian Headache Society developed through a consensus strategic measurements to treat a migraine attack in both the child and the adult. Particular emphasis was laid on the treatment of migraine in women, including at pregnancy, lactation and perimenstrual period. Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto Universidade Federal de São Paulo, Escola Paulista de Medicina Universidade Federal do Rio Grande do Norte Universidade do Federal do Paraná Faculdade de Medicina de Catanduva Universidade Federal Ciências da Saúde de Porto Alegre Hospital Mário Gartti Universidade Federal Fluminense Universidade Estadual de Campinas Unichristus Hospital Geral de Fortaleza Universidade Federal de Santa Catarina Sociedade Brasileira de Cefaleia Universidade Federal de Pernambuco Hospital Esperança Universidade Estadual Júlio de Mesquita Filho Universidade Federal do Rio de Janeiro Faculdade de Medicina de Barbacena Santa Casa de São Paulo Universidade Federal de Minas Gerais Universidade Estadual Júlio de Mesquita Filho

To determine the prevalence of cluster headache (CH) in Barbacena, a medium-size city in the State of Minas Gerais, Brazil. Methods The total population of Barbacena is 126,284 inhabitants and the Family Health Strategy Program covers 84,610 of them. In order to identify patients with cluster headache, 36,145 of these inhabitants were screened, following which, a questionnaire was completed by 181 health agents distributed throughout the 28 health posts belonging to the Family Health Strategy network. The completed questionnaires were selected based on the clinical criteria established by the International Headache Society, and those patients (18 years of age or older) with a possible CH diagnosis were later assessed by a headache specialist. This was an observational, cross-sectional study. Results In all, 15 patients were diagnosed as having CH, comprising a prevalence of 0.0414%; or 41.4/100,000 inhabitants. Conclusion The prevalence of cluster headache in Barbacena was lower than that observed in many locations worldwide. RESUMO Determinar a prevalência de cefaléia em Salvas (CS) em Barbacena, uma cidade de tamanho médio do Estado de Minas Gerais, Brasil. Métodos A população total de Barbacena, totaliza 126.284 habitantes e o Programa de Estratégia de Saúde da Família cobre 84.610 deles. A fim de identificar pacientes com Cefaléia em Salvas, 36.145 deles foram rastreados através de um questionário que foi completado por 181 agentes de saúde, distribuídos entre os 28 postos de saúde pertencentes à rede de Estratégia de Saúde da Família. Os questionários preenchidos foram selecionados com base nos critérios clínicos estabelecidos pela International Headache Society, e aqueles pacientes (com idade igual ou maior de 18 anos) com um possível diagnóstico de CH foram posteriormente avaliados por um especialista em dor de cabeça. Este é um estudo observacional, transversal. Resultados No total, 15 pacientes foram diagnosticados com CH, compreendendo uma prevalência de 0,0414%; ou 41,4 / 100,000 habitantes. Conclusão A prevalência de Cefaleia em Salvas em Barbacena foi menor do que a observada em muitos locais do mundo.

Objectives The relationship between indomethacin (IMC) and headache treatment has long intrigued clinicians and clinical researchers in Headache Medicine. Why is it efficacious in many types of headache disorders when other medications are not, and what is the mechanism behind its efficacy? IMC and headache related topics that have been explored in detail in the literature include IMC-responsive headache disorders (“traditional”), pharmacology of IMC, symptomatic headaches responsive to IMC, “novel” headache conditions that respond, cluster headache and IMC, IMC provoking headache, the issue about” absolute” and “non-absolute” effect of IMC on headache disorders, and the morphing trigeminal autonomic cephalalgias (TACs). Data source A PubMed/MEDLINE search was used for Clinical Studies Categories and Systematic Reviews on the PubMed Clinical Queries. The search details were “indomethacin” AND “headache” spanning all previous years until February 1, 2015. Methods were in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Review methods Articles were excluded if IMC had not been used to treat headache disorders in adults, if the article concerned IMC-responsive headaches but made no reference to the use of IMC, and articles not addressing the above mentioned topics. Results and conclusions The “velocity” of publications on IMC and headache seems to be decreasing, particularly on the use of IMC for the treatment of TACs. The science behind the understanding of the putative mechanisms of IMC's action on headache has moved forward, but the answer to why it works better than other nonsteroidal anti-inflammatory drugs has been elusive. There are case reports of other rare headache disorders that may be responsive to IMC. The dosages of IMC used as a tool for detecting IMC responsive disorders vary according to different centers of investigation. In many circumstances, headache disorders similar to “primary” IMC-responsive disorders are actually symptomatic disorders. Cluster headache as an IMC-resistant headache disorder may not be as absolute as once thought. Sometimes, IMC has been found to provoke headache; differentiating IMC-provoked headache from IMC-resistant headache can make headache diagnosis and management difficult. As for the “absolute” responsiveness of IMC, it is possible that using higher dosages leads to higher sensitivity, probably at the expense of decreased specificity. There are many reports about the occurrence of two or more IMC-responsive disorders (latu sensu) in the same patient, which may be coincidental.

Consenso Latinoamericano para las Directrices de Tratamiento de la Migraña Crónica. Headache Medicine. 2012;3(4)

Chronic migraine is a condition with significant prevalence all around the world and high socioeconomic impact, and its handling has been challenging neurologists. Developments for understanding its mechanisms and associated conditions, as well as that of new therapies, have been quick and important, a fact which has motivated the Latin American and Brazilian Headache Societies to prepare the present consensus. The treatment of chronic migraine should always be preceded by a careful diagnosis review; the detection of possible worsening factors and associated conditions; the stratification of seriousness/impossibility to treat; and monitoring establishment, with a pain diary. The present consensus deals with pharmacological and nonpharmacological forms of treatment to be used in chronic migraine. A migrânea crônica é uma condição com prevalência significativa ao redor do mundo e alto impacto socioeconômico, sendo que seu manuseio tem desafiado os neurologistas. Os avanços na compreensão de seus mecanismos e das condições a ela associadas, bem como nas novas terapêuticas, têm sido rápidos e importantes, fato que motivou as Sociedades Latino-americana e Brasileira de Cefaleia a elaborarem o presente consenso. O tratamento da migrânea crônica deve ser sempre precedido por uma revisão cuidadosa do diagnóstico, pela detecção de possíveis fatores de piora e das condições associadas, pela estratificação de gravidade/impossibilidade de se tratar e pelo monitoramento com um diário da dor. Este consenso apresenta abordagens farmacológicas e não-farmacológicas para tratar a migrânea crônica.

Objective.— To contrast the cervical range of motion (CROM) in women with episodic migraine (EM), transformed migraine (TM), and controls without migraine headaches. Background.— Migraineurs often complain about neck pain. Furthermore, neck problems can worsen the headaches in individuals with migraine. Individuals with neck pain usually have reduced CROM. Nonetheless, studies assessing the CROM in migraineurs are scarce. Methods.— Our sample was selected in an outpatient headache clinic, and consisted of 45 women aged 20-54 years old, 15 per group. Cervical mobility was evaluated in movements of flexion, extension, right lateral flexion, left lateral flexion, right rotation, and left rotation using the CROM technique, and was contrasted among the groups. Migraine clinical patterns were also evaluated (frequency, duration of migraine, pain in the moment of evaluation, pain in movement, and pain localization) as a function of CROM. Results.— Compared with controls, individuals with TM had numerically inferior CROM in all parameters, and significant reduction in 3 of them: extension (59.3 vs 68.1, P = .02), left lateral flexion (44.5 vs 49.1, P = .03), and right rotation (62.2 vs 69.6, P = .02). Compared with individuals with migraine, the TM group presented significantly reduced mobility only for extension (59.3 vs 68.4, P = .02). Migraineurs also had numerically inferior ROM, contrasted to controls, in 5 of the 6 parameters, although significance was seen just for right rotation (60.8 vs 68.6 P

Thunderclap headache attributed to reversible cerebral vasoconstriction (THARCV) is a syndrome observed in a number of reported cases. In this article we reviewed this new headache entity (idiopathic form) using the clinical-radiological findings of 25 reported patients. In this series of patients 72% were women, the mean age at the onset of first headache episode was 39.4 +/- 2.3 years. In addition to the sine qua non condition of being abrupt and severe (thunderclap) at the onset, the headache was usually described as being explosive, excruciating, or crushing. The feature of pulsatility, accompanied or not by nausea was described by 80% of the patients. Forty percent of the cases manifested vomiting and 24% photophobia. Usually the headache was generalized, and in three cases it was unilateral at least at the onset. In 21 of 25 patients (84%) there was at least one recurrence or a sudden increase in the intensity of the headache. A past history of migraine was present in 52% of the patients. Precipitating factors were identified in 56% of the patients. Sexual intercourse was described by six patients. Of the 25 patients with THARCV syndrome studied, 12 (48%) developed focal neurological signs, transitory ischemic attack (n = 1), or ischemic stroke (n = 11, 44%), and two (8%) of them manifested seizures. The THARCV syndrome is a neurological disturbance perhaps more frequent than expected, preferentially affecting middle aged female migraineurs, and having an unpredictable prognosis, either showing a benign course or leading to stroke.

The purpose of our study was to prospectively evaluate the impact of preventive drug treatment on the quality of life of patients with episodic migraine (EM). Quality of life evaluations can enhance traditional measures of therapeutic efficacy. Thirty–five consecutive EM without aura patients attending a tertiary care unit (Batatais Headache Clinic) entered the study. They were given a prescription for preventive medication and completed the validated Portuguese version of the generic instrument Short Form–36 (SF–36) questionnaire. Six months later, patients were given another SF–36. We compared the pre–treatment and post–treatment scores for the SF–36 and analysed the headache diaries. The mean age of the 35 patients (32 women and 3 men) was 40.2 years (range 18–60 years). All 35 patients completed the pretreatment and follow–up SF–36. The pre–treatment and post–treatment mean frequency of migraine attacks was 9.16 and 2.4 crises per month, respectively (p

Background.—The pathophysiology of the explosive type of headache associated with sexual activity is not completely understood. Five reported cases of patients with thunderclap headache, precipitated by sexual activity, in association with concomitant cerebral arterial narrowing, were found in the literature. Methods.—A 44-year-old woman with both coital and masturbatory headaches during orgasm associated with segmental reversible cerebral artery vasospasm was investigated. Cerebral anatomy and eventual spasm was documented by magnetic resonance imaging or digital angiography before, during, and after resolution of the orgasmic headache-vasospasm clinical manifestation. Conclusion.—Findings of cerebral arterial narrowing, presented by some patients shortly after orgasmic headache attacks, support the hypothesis that segmental vasospasm may exert a role in the pathogenesis of this uncommon type of headache. The literature is reviewed, and possible mechanisms underlying the development of orgasmic headache are discussed.

We applied the second edition of the International Classification of Headache Disorders (ICHD-II) in 417 children (age range, 2–12 years) with chronic headaches attending a pediatric headache clinic. The initial diagnosis was made according to the ICHD-II while the final diagnosis was, based on the longitudinal intuitive clinical diagnosis (LICD), deemed to be the gold standard. The diagnosis of migraine without aura had a sensitivity of 52%, a specificity of 100% and a positive predictive value of 100%; for the diagnosis of migraine (at the one-digit level) these values were 87%, 100% and 100%, respectively. The ICHD-II criteria for migraine without aura have high specificity but low sensitivity in childhood, even considering the minimal duration of the attacks to be 1 hour. Other factors, such as the existence of subgroup 2.4 (probable tension-type headache), are responsible for the low sensitivity of ICHD-II criteria for the diagnosis of migraine without aura in patients of this age group.

Background.—The search for rationality in health expenses in developing countries collides with the lack of effectively conducted epidemiologic studies. Purpose.—To present an estimate of the impact and costs of migraine in the Brazilian public health system and to estimate the impact on these costs and the effectiveness of a model of stratified care in the management of migraine. Methods.—An analytical model of utilization of the Brazilian public health system was constructed. Data refer to 1999 and were obtained in accordance with the following steps: (1) Brazilian demographic characteristics; (2) characteristics of the public health system related to its 3 hierarchical levels—primary, secondary, and tertiary care, the last being subdivided into emergency department and hospital care; and (3) estimation of the number of migraine consultations at each complexity level. In Brazil, migraineurs seen in the public health system are most often discharged with an acute treatment, usually a nonspecific medication. We compared this treatment with a proposed stratified care model that uses a triptan as an acute care medication. We have made the following assumptions: (1) 15% of the patients would fall into the Migraine Disability Assessment (MIDAS) grade I category, 25% would fall into the MIDAS grade II category, 30% into the grade III category, and 30% into the MIDAS grade IV category; (2) the mean number of migraine attacks per year are: MIDAS I, 7.49; MIDAS II, 8.02; MIDAS III, 12.22; and MIDAS IV, 27.01. The annual costs of the treatment were calculated according to the following equation: AC = P × N × C + P × Cp + P × Cat × AMA, where P is the number of patients; N, the number of consultations per patient; C, the cost of consultation per level; Cp, the cost of preventive drugs; Cat, the cost of acute therapy drugs; and AMA is the number of migraine attacks per year. Results.—The public health system resources included 55 735 ambulatory units (primary and secondary) and 6453 emergency department and public hospital units, with a corresponding budget of US $2 820 899 621.26. The estimated cost of a consultation on the primary care level was US $11.53; on the secondary care level, US $22.18; in the emergency department, $34.82; and for hospitalization, US $217.93. The total estimated public health system expenses for migraine were US $140 388 469.60. The proposed model would imply a cost reduction of 6.2% (US $7 514 604.40) with an improvement in the quality of the public health system from the actual 18.2% to an estimated 84.5%. Conclusion.—Migraine seems to pose a huge burden on the Brazilian public health system. The implementation of a stratified care model of treatment that would include specific acute migraine therapies could result in a dramatic increase in the quality of migraine care and a significant reduction in cost.

Acute headaches are responsible for a significant percentage of the case load at primary care units and emergency rooms in Brazil. Dipyrone (metamizol) is easily available in these settings, being the most frequently used drug. We conducted a randomized, placebo-controlled, double-blind study to assess the effect of dipyrone in the acute treatment of episodic tension-type headache. Sixty patients were randomized to receive placebo (intravenous injection of 10 ml saline) or 1 g dipyrone in 10 ml saline. We used seven parameters of analgesic evaluation. The patients receiving dipyrone showed a statistically significant improvement (P

Objective.—To compare the intensity of pain and associated symptoms after placebo administration in patients with migraine with aura and migraine without aura. Background.—Studies that evaluate drugs used in the acute treatment of migraine ideally should include a placebo arm. The International Headache Society also recommends stratification according to age and sex but not by the presence versus absence of aura. Methods.—The study was conducted as part of a placebo controlled randomized survey comparing four active drugs against placebo in the acute treatment of migraine. Patients were blinded as to treatment received. Placebo consisted of 10 mL of normal saline (0.9%) intravenously. Pain intensity was evaluated by a 10-point analogical-verbal scale. Nausea, photophobia, and phonophobia were evaluated by a four-point analogical-verbal scale. For statistical analysis, unpaired t-test with Welch correction was used. Results.—After placebo administration, reduction of symptom intensity (pain, nausea, photophobia, and phonophobia) in patients with migraine without aura was significantly greater than that observed in patients with migraine with aura. Conclusions.—Our findings suggest that studies comparing placebo against an active drug should use stratification according to the presence versus absence of aura.

Background.— Dipyrone (Metamizol) has been used in the acute treatment of migraines in Brazil. Some investigators have found it to be a highly effective medication for migraine pain and associated symptoms. Objective.—To conduct a randomized, placebo controlled, double blind study to assess the effect of dipyrone on the pain and symptoms associated with migraine without aura or with aura and the adverse effect profile of this medication. Methods.—For the migraine without aura group, 44 patients were assigned at random to receive 1 g intravenous dipyrone, and 30 patients received 10 mL 0.9% physiological saline. For the migraine with aura group, 30 patients received both dipyrone or placebo. We used seven parameters of analgesic evaluation and an analog scale to assess nausea, photophobia, and phonophobia. Results.—Patients receiving dipyrone demonstrated a statistically superior improvement (P

Acute headache is a very frequent symptom, responsible for a significant percentage of caseload at primary care units and emergency rooms. Chlorpromazine is easily available in such settings. The aim of this study is to conduct a randomized, placebo-controlled, double-blind study to assess the efficacy of chlorpromazine on the acute treatment of episodic tension-type headache. We randomized 30 patients to receive placebo (10 ml of saline intravenous injections) and 30 patients to receive 0.1 mg/Kg chlorpromazine intravenously. We used 7 parameters of analgesic evaluation. Patients receiving chlorpromazine showed a statistically significant improvement (p < 0.05 and p < 0.01) of pain compared to placebo, far up to 30 minutes after the drug administration. The therapeutic gain was 36.7% in 30 minutes and 56.6 % in 60 minutes. The number needed to treat (NNT, the reciprocal or the therapeutic gain) was 2.7 in 30 minutes and 1.8 in 60 minutes. There were reductions in the recurrence and in the use of rescue medication in the chlorpromazine group. We can conclude that intravenous chlorpromazine is an effective drug to relief the pain in tension-type headache. Cefaléia aguda é queixa frequente, responsável por percentual significativo dos casos atendidos em unidades básicas de saúde e unidades de emergência. A clorpromazina é droga usualmente disponível nessas unidades. Apresentamos dados de estudo randomizado, controlado por placebo e com mascaramento duplo, que avaliou a eficácia da clorpromazina no tratamento agudo da cefaléia do tipo tensional episódica. Trinta pacientes foram randomizados para receber placebo (10 ml de solução salina endovenosa) e 30 pacientes para receber clorpromazina endovenosa, na dose de 0,1 mg/Kg. Foram usados 7 parâmetros de avaliação analgésica. Pacientes que receberam clorpromazina mostraram significativa redução da dor quando comparados com o grupo placebo (p < 0,05 and p < 0,01), 30 minutos após a administração da droga. O ganho terapêutico foi de 36,7% em 30 minutos e 56,6 % em 60 minutos. O número que se necessita tratar (NNT, a recíproca do ganho terapêutico) foi 2,7 em 30 minutos e 1,8 em 60 minutos. Houve redução nos índices de recorrência e de utilização de medicação de resgate no grupo que recebeu clorpromazina. Podemos concluir que clorpromazina em administração parenteral é droga efetiva para o alívio da dor de pacientes com cefaléia do tipo tensional, seu uso sendo justificado nesses casos.

The aim of this study is to assess, in a double blind randomized clinical trial, the effect of Chlorpromazine (CPZ) on the pain and associated symptoms in patients with migraine. Sixty patients with migraine with aura and 68 patients with migraine without aura were assigned at random to receive IV 0.1 mg/Kg CPZ or placebo. We assessed pain intensity, nausea, photophobia, and phonophobia at baseline, 30 min, and 60 min post-IV administration. End-point efficacy at 60 min was used to calculate the number needed to treat (NNT). We also recorded adverse effects, need for rescue medication at 24 h, and recurrence of headache at 24 h. We found clinically and statistically significant (p < 0.01) improvement associated with CPZ in pain scores, nausea, photophobia, phonophobia, and need for rescue medication, all at 60 min, and in rate of recurrence at 24 h, both in patients with and without aura. NNT = 2. Those allocated to CPZ had less nausea and dyspepsia, but more drowsiness and postural hypotension than those receiving placebo. CPZ is an excellent option for the treatment of migraines, with and without aura, in the Emergency Department.

Magnesium sulphate has been used in the acute treatment of migraines; some studies found it to be a highly effective medication in the acute control of migraine pain and associated symptoms. This randomized, double-blind, placebo-controlled study assesses the effect of magnesium sulphate on the pain and associated symptoms in patients with migraine without aura and migraine with aura. Sixty patients in each group were assigned at random to receive magnesium sulphate, 1000 mg intravenously, or 0.9% physiological saline, 10 ml. We used seven parameters of analgesic evaluation and an analogue scale to assess nausea, photophobia and phonophobia. In the migraine without aura group there was no statistically significant difference in the patients who received magnesium sulphate vs. placebo in pain relief. The analgesic therapeutic gain was 17% and number needed to treat was 5.98 at 1 h. There was also no statistical difference in relief of nausea. We did observe a significant lower intensity of photophobia and phonophobia in patients who received magnesium sulphate. In the migraine with aura group patients receiving magnesium sulphate presented a statistically significant improvement of pain and of all associated symptoms compared with controls. The analgesic therapeutic gain was 36.7% at 1 h. A smaller number of patients continued to have aura in the magnesium sulphate group compared with placebo 1 h after the administration of medication. Our data support the idea that magnesium sulphate can be used for the treatment of all symptoms in migraine with aura, or as an adjuvant therapy for associated symptoms in patients with migraine without aura.

A despeito da enorme quantidade de pesquisas referentes à classificação, epidemiologia, diagnóstico, fisiopatologia e tratamento da migrânea, a aura migranosa permanece bem menos estudada. O objetivo do presente estudo é, portanto, verificar a evolução da aura em pacientes submetidos a placebo e a três diferentes drogas disponíveis em unidades públicas de saúde brasileiras. Foram estudados 86 pacientes em vigência de crise de migrânea com aura, apresentando aura no momento da randomização. Após a randomização os pacientes recebiam uma das seguintes substâncias, por via endovenosa: placebo, dipirona, clorpromazina, sulfato de magnésio. O sulfato de magnésio foi superior ao placebo (p < 0,05) 30 e 60 minutos após a administração. Dipirona e clorpromazina reduziram o número de pacientes com aura, em relação ao placebo, 60 minutos após a administração. Os achados acima possibilitam especulações sobre a fisiopatologia da migrânea e apresentam opções terapêuticas para o tratamento da aura. In spite of the enormous amount of research regarding classification, epidemiology, diagnosis, pathophisiology and treatment of migraines, aura, one of its hallmarks, stays much less studied. The objective of this study is, therefore, to evaluate the evolution of aura in patients submitted to placebo and three different drugs available in Brazilian public health units. We studied 86 patients during an acute migrainous attack, with aura at the moment of the evaluation. Patients were randomized to receive one of the following substances, in a parenteral route: placebo, dipyrone, chlorpromazine and magnesium sulphate. Magnesium sulphate was superior to placebo (p

Um número crescente de pacientes vêm sendo submetidos a procedimentos dialíticos em todo o mundo. Cerca de 70% deles apresentam cefaléia. A despeito disso, a cefaléia não é sintoma bem estudado nesse grupo de pacientes. Os objetivos desse estudo são: avaliar possíveis fatores desencadeantes da cefaléia relacionada à hemodiálise e avaliar o tratamento analgésico utilizado nessa situação. Foram estudados prospectivamente 50 pacientes com insuficiência renal crônica seguidos em três serviços de hemodiálise da cidade de Ribeirão Preto, Estado de São Paulo, Brasil, entre janeiro de 1998 e dezembro de 1999. Todos apresentavam cefaléia estritamente relacionada às sessões de hemodiálise. Cefaléia ocorreu principalmente na segunda metade das sessões de hemodiálise (86%). Hipertensão arterial (38%), hipotensão arterial (12%) e alterações no peso corporal durante as sessões de hemodiálise (6%) foram os fatores desencadeantes mais frequentemente identificados. Em 28% dos casos não se identificou qualquer fator. Dipirona foi o analgésico mais utilisado (56%). A despeito de ser tão comum é surpreendentemente escassa a literatura disponível a respeito da associação entre cefaléias e insuficiência renal crônica. Esses pacientes, além de suportarem o fardo de conviver com um procedimento doloroso e monótono, porém necessário para mantê-los vivos, têm ainda que conviver com o impacto adicional das cefaléias na maioria das sessões. A identificação dos possíveis fatores desencadeantes e do tratamento disponível pode contribuir para o nosso conhecimento sobre essa associação, com consequente redução do impacto das cefaléias em portadores de insuficiência renal crônica. A growing number of patients have been undergoing dialysis procedures all around the world. Around 70% of the patients receiving dialysis treatment complain about headaches. In spite of this, headache is not well studied in this group of patients. The aims of this study are: to evaluate possible triggering factors related to hemodialysis headache and to evaluate the analgesic treatments used under this situation. We prospectively studied 50 patients with chronic renal failure attending to three dialysis services from the town of Ribeirão Preto, State of São Paulo, Brazil, from January 1998 to December 1999. All of them presented headaches strictly related to the hemodialysis sessions. Headache occurred mainly in the second half of the hemodialysis (86%). Arterial hypertension (38%), arterial hypotension (12%) and changes in the weight during the hemodialysis sessions (6%) were the most consistently triggering situations. In 28% of the cases no factors were identified. Dipyrone was, by far (56%), the most frequently analgesic used. Despite being so common it noteworthy how scarce are studies in literature concerning headaches in patients with chronic renal failure. These patients, besides having to bear the burden of living with a painful and boring procedure to keep them alive, many of them have the additional burden, to live with a headache in most of the sessions. The identification of possible triggering factors and further evaluations of the treatment might increase our knowledge and contribute to reduce the burden of the headaches in patients with chronic renal failure.

Since the creation of the Brazilian Headache Society in 1978, substantial developments have taken place in both research and clinical practice in the field of headache medicine in Brazil. The Society now has almost 300 members throughout the country, actively working to improve the health of the general population and, in particular, diagnose and treat headache disorders. In addition, in a few large cities, such as Sao Paulo, Rio de Janeiro, Recife, Ribeirao Preto, Curitiba, and Porto Alegre, headache specialists have come together to promote research projects and increase knowledge in the field through MSc, PhD, and postdoctoral programs. Furthermore, scientific journals have emerged and books have been published to record and disseminate Brazilian scientific production in headache medicine. In this narrative review, we will briefly describe some important aspects of headache medicine in Brazil from prehistoric times to the present day, discuss the origin of headache medicine as a specialty in Brazil, the principal publications dealing with headache disorders, the use of plants and other unconventional forms of treatment used by faith healers, the main training centers, and the research produced to date by Brazilians. In conclusion, in recent years enormous progress has been made in headache medicine in Brazil stimulating us to review and expand our role in an increasingly international scenario.

Importância do problema: cefaléia é dos sintomas mais comuns na prática clínica, responsável por cerca de 9% dos atendimentos em unidades primárias de saúde e por 1% a 3% dos atendimentos em unidades de emergência, acarretando, portanto, considerável impacto econômico sobre o serviço público de saúde.Comentários: a maioria das unidades de emergência, em nosso meio, não dispõem de drogas utilizadas em outros países para tratamento agudo da cefaléia, como os compostos ergotamínicosou triptanos. Os autores revisam aspectos diagnósticos e terapêuticos das cefaléias primárias agudas, propondo protocolos para seu tratamento em uma unidade de emergência.

Cefaléia é dos sintomas mais comuns na prática clínica. Acarreta considerável impacto econômico e sobrecarrega as unidades de emergência. A maioria destas, em nosso país, não dispõe de triptans. O presente estudo analisa o tratamento instituído na Unidade de Emergência do Hospital das Clínicas de Ribeirão Preto. Em 1996, 1254 pacientes foram atendidos com esta queixa e 64 necessitaram de internação. Dos pacientes não internados (NI), 77% apresentavam cefaléias primárias, contra 29,7% dos pacientes internados (I). A percentagem de melhora nos pacientes com migrânea com a dipirona endovenosa foi 83,8%, com o diclofenaco intramuscular 66,7% e com a clorpromazina (endovenosa) 81,8%. As percentagens de pacientes com cefaléia do tipo tensional que melhoraram, frente às mesmas drogas foram, respectivamente 77,8%, 80% e 100%. Dos NI 16,3% tiveram melhora sem qualquer tratamento medicamentoso. Concluímos que as drogas utilizadas apresentam perfis semelhantes de eficácia e custo, podendo ser utilizadas em unidades básicas de saúde. O maior inconveniente é a administração parenteral. Headache is one of the most common symptoms observed in clinical practice. It has a considerable economic impact and overburdens emergency rooms. In Brazil, most emergency rooms have no tryptans. The present study analyses the treatment provided by the Emergency Room of the University Hospital of Ribeirão Preto. In 1996, 1254 patients were treated for headache and 64 of them required hospitalization. Of the non-hospitalized (NH) patients, 77% had primary headache, as opposed to 29.7% of hospitalized patients. Of the patients with migraine, 83.6% improved with intravenous dipyrone, 66.7% improved with intramuscular diclofenac and 81.8% improved with intravenous chlorpromazine. The percentages of patients with tension-type headache who improved with the same drugs were 77.8%, 80% and 100%, respectively. Among NH patients, 16.3% improved without any medication. We conclude that the drugs used have similar efficacy profiles and costs and can be used at basic health unities. The major drawback is parenteral administration.

The middle turbinate and nasal septum are innervated by the anterior ethmoidal nerve, a branch of the ophthalmic division of the trigeminal nerve. As reported in the classical work of Wolff (1948), stimulation of these regions causes pain in the medial canthus of the supraorbital region. Periorbital pain due to middle turbinate compression against the septum or the lateral wall of the nose may be due to congestion of the nasal mucosa or to pneumatization of the middle turbinate (concha bullosa). The diagnosis is made by exclusion and requires a high index of suspicion, anterior rhinoscopy, computerized tomography (CT), and confirmation by the lidocaine test. We present five cases of middle turbinate headache syndrome, all with concha bullosa. Four were treated surgically by partial middle turbinectomy and septoplasty more than 1 year ago, with excellent results. One patient refused surgical treatment which was suggested after failure of medical treatment with antihistamines, decongestants, and a topical corticosteroid, and continues to be symptomatic. Despite the small number of cases studied, the authors concluded that the procedure used was effective for the resolution of headache.

A migrânea crônica é uma condição com prevalência significativa ao redor do mundo e alto impacto socioeconômico, sendo que seu manuseio tem desafiado os neurologistas. Os avanços na compreensão de seus mecanismos e das condições a ela associadas, bem como nas novas terapêuticas, têm sido rápidos e importantes, fato que motivou as Sociedades Latino-americana e Brasileira de Cefaleia a elaborarem o presente consenso. O tratamento da migrânea crônica deve ser sempre precedido por uma revisão cuidadosa do diagnóstico, pela detecção de possíveis fatores de piora e das condições associadas, pela estratificação de gravidade/impossibilidade de se tratar e pelo monitoramento com um diário da dor. Este consenso apresenta abordagens farmacológicas e não-farmacológicas para tratar a migrânea crônica. Chronic migraine is a condition with significant prevalence all around the world and high socioeconomic impact, and its handling has been challenging neurologists. Developments for understanding its mechanisms and associated conditions, as well as that of new therapies, have been quick and important, a fact which has motivated the Latin American and Brazilian Headache Societies to prepare the present consensus. The treatment of chronic migraine should always be preceded by a careful diagnosis review; the detection of possible worsening factors and associated conditions; the stratification of seriousness/impossibility to treat; and monitoring establishment, with a pain diary. The present consensus deals with pharmacological and nonpharmacological forms of treatment to be used in chronic migraine. Universidad de Santiago de Chile and Sociedad de Neurologia Psiquiatria y Neurocirugia Universidad de Costa Rica Hospital San Juan de Dios Universidade Federal de Minas Gerais Hospital das Clinicas Universidade Jose do Rosario Vellano Universidade de São Paulo Faculdade de Medicina Barao de Maua Faculdade de Medicina de Ribeirao Preto Universidad Nacional de Cordoba Brazilian and International Headache Societies Academia Brasileira de Neurologia Centro Universitario de Volta Redonda Universidade Federal Fluminense (UFF) Universidad de la Republica Hospital Maciel Facultad de Medicina Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Sector of Investigation and Treatment of Headaches at Clinical Neurology in the Neurology Discipline Universidade Federal do Rio Grande do Norte Universidade Federal do Parana UFF Associacao Latino-Americana de Cefaleia Universidade Estadual de Campinas Faculdade de Medicina de Catanduva USP Faculdade de Medicina de Ribeirao Preto Universidade Federal de Ciencias da Saude de Porto Alegre Academia Brasileira de Neurologia Universidade de La Sabana USP Faculdade de Medicina Hospital Perez Carreno UFF Universidad Mayor de San Andres Universidad Central de Venezuela Hospital Vargas de Caracas Universidade de Santo Amaro Escola Paulista de Medicina da UNIFESP Universidad de Guadalajara UNIFESP Universidade Federal de Santa Catarina USP Faculdade de Medicina de Ribeirao Preto Centro Educacional Barao de Maua Universidade Federal de Pernambuco Universidad Mayor de San Andres Hospital das Clinicas Academia Mexicana de Neurologia Hospital Especialidades Centro Medico La Raza Sociedad Neurologica Hospital Israelita Albert Einstein UNIFESP Universidad de Concepcion Universidade Federal do Rio de Janeiro Hospital Universitario Clementino Fraga Filho Faculdade de Medicina University of Trondheim ASS Colombiana de Neurologia AHS Universidad de Buenos Aires Universidad Central de Venezuela Hospital Vargas Universidad Diego Portales Universidad de Santiago Instituto de Neurologia UFF Medicine School UNIFESP, EPM, Sector of Investigation and Treatment of Headaches at Clinical Neurology in the Neurology Discipline Universidade de Santo Amaro Escola Paulista de Medicina da UNIFESP, Universidade Federal de Santa Catarina Hospital Israelita Albert Einstein UNIFESP SciELO

Head-up tilt tests were performed in six cluster headache patients in a bout of attacks, but in a pain-free interval at the time of investigation; and in eleven controls matched for age, basal blood pressure, and heart rate. A Doppler servomethod was used for a noninvasive, beat-to-beat blood pressure determination. There were no significant differences between the cluster headache and control groups for heart rate and systolic blood pressure response to the head-up tilt. However, the average diastolic blood pressure seemed to drop more after the tilt in the cluster headache group than in the control group; in particular, in the later part of the test. This might suggest a dysfunction of the baroreflex in cluster headache patients in a bout, also outside of attacks, and most probably of the sympathetically-mediated vasomotor response.