Cefaléias

Question 1

Como fazer o seguimento objetivo da enxaqueca?

Answer 1

Once a diagnosis of migraine has been established, it is important to assess the extent of a patient’s disease and disability. The Migraine Disability Assessment Score (MIDAS) is a well-validated, easy-to-use tool

Question 2

Como faço a educação dos pacientes com enxaqueca?

Answer 2

Patient education is an important aspect of migraine management. Information for patients is available at www.achenet.org, the website of the American Council for Headache Education (ACHE). It is helpful for patients to understand that migraine is an inherited tendency to headache; that migraine can be modified and controlled by lifestyle adjustments and medications, but it cannot be eradicated; and that, except in some occasions in women on oral estrogens or contraceptives, migraine is not associated with serious or life-threatening illnesses

Question 3

Quais os principais controles de gatilho da enxaqueca?

Answer 3

A regulated lifestyle is helpful, including a healthful diet, regular exercise, regular sleep patterns, avoidance of excess caffeine and alcohol, and avoidance of acute changes in stress levels. Since the stresses of everyday living cannot be eliminated, lessening one’s response to stress by various techniques is helpful for many patients. These may include yoga, transcendental meditation, hypnosis, and conditioning techniques such as biofeedback.

Question 4

Quais as opções de tratamento abortivo da enxaqueca?

Answer 4

Most drugs effective in the treatment of migraine are members of one of three major pharmacologic classes: anti-inflammatory agents, 5-HT1B/1D receptor agonists, and dopamine receptor antagonists.
Evidence from randomized controlled trials show that coadministration of a longer-acting NSAID, naproxen (220–550 mg PO bid), with sumatriptan (50–100 mg tablet at onset; may repeat after 2 h (max 200 mg/d) will augment the initial effect of sumatriptan and, importantly, reduce rates of headache recurrence. Delayed absorption occurs even in the absence of nausea and is related to the severity of the attack and not its duration. Therefore, when oral NSAIDs and/or triptan agents fail, the addition of a dopamine antagonist such as metoclopramide 10 mg should be considered to enhance gastric absorption.

Question 5

Por que não devemos utilizar opióides na enxaqueca?

Answer 5

Narcotics do not treat the underlying headache mechanism; rather, they act to alter the pain sensation. Moreover, in patients taking oral narcotics such as oxycodone or hydrocodone, narcotic addiction can greatly confuse the treatment of migraine. Narcotic craving and/or withdrawal can aggravate and accentuate migraine.

Question 6

Como orientar pacientes com enxaqueca a evitar o abuso de analgésicos?

Answer 6

Migraine patients who have two or more headache days a week should be cautioned about frequent analgesic use

Question 7

Como usar as drogas profiláticas para enxaqueca?

Answer 7

The probability of success with any one of the antimigraine drugs is 50–75%. Many patients are managed adequately with low-dose amitriptyline, propranolol, topiramate, gabapentin, or valproate. If these agents fail or lead to unacceptable side effects, second-line agents such as methysergide or phenelzine can be used. Once effective stabilization is achieved, the drug is continued for ∼6 months and then slowly tapered to assess the continued need. Many patients are able to discontinue medication and experience fewer and milder attacks for long periods, suggesting that these drugs may alter the natural history of migraine.

Question 8

Como fazer o tratamento abortivo da cefaleia tensional?

Answer 8

The pain of TTH can generally be managed with simple analgesics such as acetaminophen, aspirin, or NSAIDs. Behavioral approaches including relaxation can also be effective.

Question 9

Quais os tratamentos profiláticos para cefaleia tensional?

Answer 9

For chronic TTH, amitriptyline is the only proven treatment (Table 8-7); other tricyclics, selective serotonin reuptake inhibitors, and the benzodiazepines have not been shown to be effective. There is no evidence for the efficacy of acupuncture. Placebo-controlled trials of onabotulinum toxin type A in chronic TTH have not shown benefit.

Question 10

Qual o tratamento abortivo da cefaleia em salvas?

Answer 10

Many patients with acute cluster headache respond very well to oxygen inhalation. This should be given as 100% oxygen at 10–12 L/min for 15–20 min. It appears that high flow and high oxygen content are important. Sumatriptan 6 mg SC is rapid in onset and will usually shorten an attack to 10–15 min; there is no evidence of tachyphylaxis. Oral sumatriptan is not effective for prevention or for acute treatment of cluster headache.

Question 11

Quais os tratamentos profiláticos da cefaleia em salvas?

Answer 11

Many experts favor verapamil as the first-line preventive treatment for patients with chronic cluster headache or prolonged bouts. While verapamil compares favorably with lithium in practice, some patients require verapamil doses far in excess of those administered for cardiac disorders. The initial dose range is 40–80 mg twice daily; effective doses may be as high as 960 mg/d. Side effects such as constipation and leg swelling can be problematic. Of paramount concern, however, is the cardiovascular safety of verapamil, particularly at high doses. Verapamil can cause heart block by slowing conduction in the atrioventricular node, a condition that can be monitored by following the PR interval on a standard ECG. Approximately 20% of patients treated with verapamil develop ECG abnormalities, which can be observed with doses as low as 240 mg/d; these abnormalities can worsen over time in patients on stable doses. A baseline ECG is recommended for all patients. The ECG is repeated 10 days after a dose change in those patients whose dose is being increased above 240 mg daily. Dose increases are usually made in 80-mg increments. For patients on long-term verapamil, ECG monitoring every 6 months is advised.
A 10-day course of prednisone, beginning at 60 mg daily for 7 days and followed by a rapid taper, may interrupt the pain bout for many patients. Lithium (600–900 mg qd) appears to be particularly useful for the chronic form of the disorder.

Question 12

Qual o tratamento abortivo para SUNA/SUNCT?

Answer 12

Therapy of acute attacks is not a useful concept in SUNCT/SUNA since the attacks are of such short duration. However, IV lidocaine, which arrests the symptoms, can be used in hospitalized patients.

Question 13

Qual o tratamento preventivo para SUNCT/SUNA?

Answer 13

Long-term prevention to minimize disability and hospitalization is the goal of treatment. The most effective treatment for prevention is lamotrigine, 200–400 mg/d. Topiramate and gabapentin may also be effective. Carbamazepine, 400–500 mg/d, has been reported by patients to offer modest benefit.

Question 14

Como fazer a profilaxia da cefaleia crônica diária?

Answer 14

The first step in the management of patients with CDH is to diagnose any underlying condition (Table 8–10). For patients with primary headaches, diagnosis of the headache type will guide therapy. Preventive treatments such as tricyclics, either amitriptyline or nortriptyline at doses up to 1 mg/kg, are very useful in patients
with CDH arising from migraine or tension-type headache. Tricyclics are started in low doses (10–25 mg) daily and may be given 12 h before the expected time of awakening in order to avoid excess morning sleepiness. Anticonvulsants, such as topiramate, valproate, and gabapentin, are also useful in migraineurs. Flunarizine can also be very effective for some patients, as can methysergide or phenelzine

Question 15

Como abordar o abuso de analgésicos?

Answer 15

A small dose of an NSAID such as naproxen, 500 mg bid, if tolerated, will help relieve residual pain as analgesic use is reduced. NSAID overuse is not usually a problem for patients with daily headache when the dose is taken once or twice daily; however, overuse problems may develop with more frequent dosing schedules. Once the patient has substantially reduced analgesic use, a preventive medication should be introduced. It must be emphasized that preventives generally do not work in the presence of analgesic overuse. The most common cause of unresponsiveness to treatment is the use of a preventive when analgesics continue to be used regularly. For some patients, discontinuing analgesics is very difficult; often the best approach is to directly inform the patient that some degree of pain is inevitable during this initial period.

Question 16

Qual o tratamento inicial da cefaleia por hipotensão liquorica?

Answer 16

Initial treatment for low CSF volume headache is bed rest. For patients with persistent pain, IV caffeine (500 mg in 500 mL saline administered over 2 h) can be very effective. An ECG to screen for arrhythmia should be performed before administration. It is reasonable to administer at least two infusions of caffeine before embarking on additional tests to identify the source of the CSF leak. Since IV caffeine is safe and can be curative,
it spares many patients the need for further investigations. If unsuccessful, an abdominal binder may be helpful. If a leak can be identified, an autologous blood patch is usually curative. A blood patch is also effective for post-LP headache; in this setting, the location is empirically determined to be the site of the LP. In patients with intractable pain, oral theophylline is a useful alternative; however, its effect is less rapid than caffeine

Question 17

Qual deve ser a investigação de uma paciente com cefaleia e papiledema?

Answer 17

Brain imaging can often reveal the cause, such as a space-occupying lesion. NDPH due to raised CSF pressure can be the presenting symptom for patients with idiopathic intracranial hypertension (pseudotumor cerebri) without visual problems, particularly when the fundi are normal. Persistently raised intracranial pressure can trigger chronic migraine. These patients typically present with a history of generalized headache that is present on waking and improves as the day goes on. It is generally worse with recumbency. Visual obscurations are frequent. The diagnosis is relatively straightforward when papilledema is present, but the possibility must be considered even in patients without funduscopic changes. Formal visual field testing should be performed even in the absence of overt ophthalmic involvement. Headache on rising in the morning or nocturnal headache is also characteristic of obstructive sleep apnea or poorly controlled hypertension.
Evaluation of patients suspected to have raised CSF pressure requires brain imaging. It is most efficient to obtain an MRI, including an MR venogram, as the initial study. If there are no contraindications, the CSF pressure should be measured by LP; this should be done when the patient is symptomatic so that both the pressure and the response to removal of 20–30 mL of CSF can be determined. An elevated opening pressure and improvement in headache following removal of CSF is diagnostic.

Question 18

Qual o manejo inicial do pseudotumor cerebri?

Answer 18

Initial treatment is with acetazolamide (250–500 mg bid); the headache may improve within weeks. If ineffective, topiramate is the next treatment of choice; it has many actions that may be useful in this setting, including carbonic anhydrase inhibition, weight loss, and neuronal membrane stabilization, likely mediated via effects on phosphorylation pathways. Severely disabled patients who do not respond to medical treatment require intracranial pressure monitoring and may require shunting.

Question 19

Qual o manejo da cefaleia cronica após TCE?

Answer 19

Treatment is largely empirical. Tricyclic antidepressants, notably amitriptyline, and anticonvulsants such as topiramate, valproate, and gabapentin, have been used with reported benefit. The MAOI phenelzine may also be useful in carefully selected patients. The headache usually resolves within 3–5 years, but it can be quite disabling.

Question 20

Qual o tratamento da hemicrania contínua?

Answer 20

Treatment consists of indomethacin; other NSAIDs appear to be of little or no benefit. The IM injection of 100 mg indomethacin has been proposed as a diagnostic tool and administration with a placebo injection in a blinded fashion can be very useful diagnostically. Alternatively, a trial of oral indomethacin, starting with 25 mg tid, then 50 mg tid, and then 75 mg tid, can be given. Up to two weeks at the maximal dose may be necessary to assess whether a dose has a useful effect. Topiramate can be helpful in some patients. Occipital nerve stimulation may have a role in patients with hemicrania continua who are unable to tolerate indomethacin

Question 21

Qual o tratamento para cefaleia primaria em pontadas?

Answer 21

The response of primary stabbing headache to indomethacin (25–50 mg two to three times daily) is usually excellent. As a general rule, the symptoms wax and wane, and after a period of control on indomethacin, it is appropriate to withdraw treatment and observe the outcome.

Question 22

Qual o tratamento da cefaleia primaria associada a tosse?

Answer 22

Indomethacin 25–50 mg two to three times daily is the treatment of choice. Some patients with cough headache obtain pain relief with LP; this is a simple option when compared to prolonged use of indomethacin, and it is effective in about one-third of patients. The mechanism of this response is unclear.

Question 23

Qual o tratamento para cefaleia primaria relacionada aos esforços?

Answer 23

Exercise regimens should begin modestly and progress gradually to higher levels of intensity. Indomethacin at daily doses from 25 to 150 mg is generally effective in benign exertional headache. Indomethacin (50 mg), ergotamine (1 mg orally), dihydroergotamine (2 mg by nasal spray), or methysergide (1–2 mg orally given 30–45 min before exercise) are useful prophylactic measures.

Question 24

Qual o tratamento para cefaleia primaria associada ao sexo?

Answer 24

Benign sex headaches recur irregularly and infrequently. Management can often be limited to reassurance and advice about ceasing sexual activity if a mild, warning headache develops. Propranolol can be used to prevent headache that recurs regularly or frequently, but the dosage required varies from 40 to 200 mg/d. An alternative is the calcium channel–blocking agent diltiazem, 60 mg tid. Ergotamine (1 mg) or indomethacin (25–50 mg) taken about 30–45 min prior to sexual activity can also be helpful.

Question 25

Qual o tratamento da cefaleia hipnica?

Answer 25

Patients with hypnic headache generally respond to a bedtime dose of lithium carbonate (200–600 mg). For those intolerant of lithium, verapamil (160 mg) or methysergide (1–4 mg at bedtime) may be alternative strategies. One to two cups of coffee or caffeine, 60 mg orally, at bedtime may be effective in approximately one-third of patients. Case reports suggest that flunarizine, 5 mg nightly, can be effective.

Question 26

Qual o manejo da cefaleia primaria em thunderclap?

Answer 26

The first presentation of any sudden-onset severe headache should be vigorously investigated with neuroimaging (CT or, when possible, MRI with MR angiography) and CSF examination. Formal cerebral angiography should be reserved for those cases in which no primary diagnosis is forthcoming and for clinical situations that are particularly suggestive of intracranial aneurysm. Reversible segmental cerebral vasoconstriction may be seen in primary thunderclap headache without an intracranial aneurysm. In the presence of posterior leukoencephalopathy, the differential diagnosis includes cerebral angiitis, drug toxicity (cyclosporine, intrathecal methotrexate/cytarabine, pseudoephedrine, or cocaine), posttransfusion effects, and postpartum angiopathy. Treatment with nimodipine may be helpful, although by definition the vasoconstriction of primary thunderclap headache resolves spontaneously.