Tratamento Agudo e Profilático da Enxaqueca

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Aula ministrada por Dr. Rafael Higashi, mdico neurologista, sobre o tratamento agudo e profiltico da enxaqueca. Aula ministrada para o grupo de cefalia da Universidade Federal Fluminense (2006). www.estimulacaoneurologica.com.br

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  • 1. TRATAMENTO AGUDO E PROFILTICO DA MIGRNEA Dr Rafael Higashi Mdico neurologista Ambulatrio de cefalias do servio de neurologia do HUAP-UFF www.estimulacaoneurologica.com.br

2. MODALIDADES DE TRATAMENTO

  • Tratamento no farmacolgico
  • Tratamento farmacolgico
  • ( agudo e preventivo )
  • Procedimentos intervencionistas

3. TRATAMENTO NO FARMACOLGICO

  • Fatores deflagradores da crise
  • Abuso de analgsicos
  • Parar o tabagismo
  • Regularizar o sono e alimentao
  • Exerccios regulares
  • Obesidade
  • Controle do stress : Biofeedback e terapia cognitiva comportamental
  • Psicoterapia

4.

  • Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. Pain 1992;49:221230.
  • NIH Technology Assessment Panel. Integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia. JAMA 1996;276:313318.
  • Clinical trials studying pharmacotherapy and psychological treatments alone and together Jennifer A. Haythornthwaite. NEUROLOGY 2005 ; 65(Suppl 4):S20S31

EVIDNCIAS 5. FISIOPATOLOGIADA MIGRNEA J NEJM 2002 6. Importncia da inflamao neurognica na fisiopatologia da migrnea . Neurology 2005 7. TRATAMENTO FARMACOLGICO NA CRISE AGUDA DE MIGRNEA: no especficos

  • ANALGSICOS :paracetamol, aspirina, dipirona
  • AINES :indometacina, cido mefenmico, diclofenaco de sdio , ibuprofeno, naproxeno e rofecoxib
  • ANTIEMTICOS :metoclopramida, domperidona
  • NEUROLPTICOS :clopromazina, haldol
  • CORTICIDES :dexametasona

8. TRATAMENTO FARMACOLGICO NA CRISE AGUDA DE MIGRNEA: especficos

  • TRIPTANOS:sumatriptano, rizatriptano, naratriptano, zolmitriptano, eletriptano, flavotriptano, almotriptano
  • DERIVADOS DO ERGOT : ergotamina ediidroergotamina

9. MECANISMO DE AO DOS TRIPTANOS : NEJM 2002 Triptans have three potential mechanisms of action: cranial vasoconstriction,[88] peripheral neuronal inhibition, [48] and inhibition of transmission through second-order neurons of the trigeminocervical complex. [102] Which mechanism is the most important is as yet unclear. [103] These actions inhibit the effects of activated nociceptive trigeminal afferents and, in this way, control acute attacks of migraine (Figure 2). 10. Crise aguda de migrnea associado avmitos intensos

  • Sumatriptano 10 mg intra nasal
  • Sumatriptano 6 mg SC
  • Indometacina 100 mg supositrio retal

11. Crise aguda de migrnea associado a prodrmos e nuseas intensas (hipersensibilidade dopaminrgica)

  • Domperidona 10 mg 2 comp VO
  • Metoclopramida 10 mg VO
  • Trimebutina 200 mg VO
  • Haldol
  • Clorpromazina

12. COMBINAES POSSVEIS NO TRATAMENTO AGUDO DE ENXAQUECA

  • Sumatriptano 50 mg + naproxeno
  • Rizatriptano 10 mg + refecoxib
  • Sumatriptano 50 mg + acido tolfenmico
  • Rizatriptano 10 mg + trimebutina
  • Rizatriptano 10 mg + acido tolfenmico
  • Sumatriptano 50 mg + metoclopramida

13. ESTUDO DUPLO CEGO, CRUZADO, RANDOMIZADO COMPARANDO O USO DO SUMATRIPTANO, COM A TRIMEBUTINA, COM O MELOXICAN, COM A ASSOCIAO DAS TRS DROGAS NO TRATAMENTO AGUDO DE ENXAQUECA Higashi R, 1235Moreira Filho PF 1 , Krymchantowski AV 134 1 Departamento de neurologia Hospital Universitrio Antnio Pedro da Universidade Federal Fluminese, Niteri, Brasil,2Servio de Neurologia do Hospital Naval Marclio Dias, Rio de Janeiro, Brasil,3Centro detratamento da dor de cabea do Rio de Janeiro, Brasil,4Instituto de Neurologia Deolindo Couto,5HospitalPan Americano, Rio de Janeiro, Brasil. Distribuio dos pacientes que completaram o estudo 14. ESTUDO DUPLO CEGO, CRUZADO, RANDOMIZADO COMPARANDO O USO DO SUMATRIPTANO, COM A TRIMEBUTINA, COM O MELOXICAN, COM A ASSOCIAO DAS TRS DROGAS NO TRATAMENTO AGUDO DE ENXAQUECA Higashi R, 1235Moreira Filho PF 1 , Krymchantowski AV 134 1 Departamento de neurologia Hospital Universitrio Antnio Pedro da Universidade Federal Fluminese, Niteri, Brasil,2Servio de Neurologia do Hospital Naval Marclio Dias, Rio de Janeiro, Brasil,3Centro detratamento da dor de cabea do Rio de Janeiro, Brasil,4Instituto de Neurologia Deolindo Couto,5HospitalPan Americano, Rio de Janeiro, Brasil. 15. STATUS MIGRANOSO

  • Metoclopramida 10 mg EV + Diidroergotamina 1 mg EV (EUA)
  • Metoclopramida 10 mg EV + Dexametasona 4 mg EV + Diazepam 10 mg (opcional)
  • Clorpromazina 0.4 mg/kg EV diludos em 100 ml SF 0.9% aps hidratao

16. TRATAMENTO DA AURA PROLONGADA

  • Hidratao venosa
  • Prometazina 25 mg EV (hipersensibilidade dopaminrgica)
  • Sulfato de Magnsio 1 g EV (deficincia de Mg)
  • Prometazina 25 mg + Sulfato de Magnsio 1 g
  • Furosemida intravenosa 20 mg (diminui o acmulo de potssio extra-celular na depresso cortical alastrante)

17. TRATAMENTO MEDICAMENTOSOPREVENTIVO DA MIGRNEA

  • INDICAO
  • CONTRAINDICAES
  • COMORBIDADES

18. CRITRIOS PARA PREVENO: indicao

  • 2 ou mais crises no ms com incapacidades que duram de 3 a mais dias
  • Contra-indicao ou ineficincia das medicaes sintomticas
  • Uso de medicao abortiva mais de 2 x na semana
  • Circunstncias especiais como a migrnea hemiplgica ( a crise pode levar leses neurolgicas permanentes )
  • Incio da crises previsveis

19. COMORBIDADES

  • NEUROLGICAS : epilepsia e AVC isqumico
  • PSIQUITRICAS : depresso, bipolaridade, transtorno ansioso, sndrome do pnico, transtornos da personalidade
  • OUTROS : fenmeno de Raynauds, sndrome do coln irritvel, asma e outros transtornos dolorosos

20. MEDICAES PREVENTIVAS

  • BETA BLOQUEADORES :propranolol, atenolol e metoprolol.
  • ANTIDEPEPRESSIVOS TRICICLICOS:amitriptilina, nortriptilina
  • ANTISEROTONINRGICOS :pizotifeno e metisergida
  • ANTAGONISTAS DOS CANAIS DE CLCIO :verapamil e flunarizina
  • ANTICONVULSIVANTES :divalproato e topiramato
  • AINES :naproxeno

21. Combinar drogas que atuem em sistemas de neurotransmissores diferentes (em casos de refratariedade a monoterapia)

  • Metisergida 2-3mg/dia + nortriptilina 10-25mg/dia
  • Topiramato 100mg/dia + nortriptilina 10-25mg/dia
  • Divalproato de sdio 750-1000mg/dia + atenolol 60-100mg/dia

Krymchantowski AV. Cefalias Primrias. Como Diagnosticar e Tratar, 2001 22. PROCEDIMENTOS INTERVENCIONISTAS

  • Bloqueios ( facetas, nervos, espao epidural, ligamento interespinhoso e msculos somticos)
  • Procedimentos de radiofrequncia
  • Neuroestimulao
  • Outros

23. PROPHYLACTIC EFFECT OF LOCAL INFILTRATION IN PREVENTIVE-RESI PROPHYLACTIC EFFECT OFLOCAL INFILTRATION IN PREVENTIVE-RESISTANT MIGRAINE WITH LOCAL CRANIAL OR NECK TENDER POINTS. RESULTS OF AN OBSERVATIONAL STUDY OF 21 CASES A. ALFARO-SAEZ , C. SERNA-CANDEL, L. TURPIN-FENOLL, S. MARTI-MARTINEZ, J. MORERA-GUITART 1Servicio De Neurologia. Hospital General Universitari Dalacant, ALACANT, Spain;2Unitat De Neurologia. Hospital San Vicent. San Vicent Del Raspeig, ALACANT, Spain Chronic head and neck tender points could be triggers of migraine crisis. Their treatment might have a beneficial effect on migraine. AIMS : To investigate the therapeutic value of anaesthetic plus steroid infiltration of cranial or neck tender points in migraine prophylaxis. MATERIAL AND METHODS :We performed an observational and longitudinal study. We recruited 21 migraineurs from a Headache Unit, who presented neck or cranial tender points. When preventive treatment was ineffective, local infiltration with 1 ml of mepivacaine (2%) and 1 ml of triamcinolone was performed. We tested the effect of this method in the change of frequency, intensity and duration of crisis, response to symptomatic treatment and analgesic abuse, before and after (1-3 months) infiltration. RESULTS : 20 of 21 of patients were women (mean age 39). Mean time of symptoms onset was 123.5 months. 76,2% took Non-Steroid Anti-inflammatory Drugs with low efficacy, and 71,4% used triptans (useful in four patients). Preventive treatment had been tested in all patients (33,3% more than two types) which was effective in 40%. 69,2% of tender points were a finding in physical exam. 47,6% of patients had one tender point and 52,4% had two or more. Infiltration was effective in 60% and very effective in 22% (82% of global efficacy), but was ineffective in 18% of cases. 71,4% required just one infiltration. After treatment 52,4% reported better response to symptomatic drugs, 52,4% had a decrease in crisis duration, 33,3% reduction in crisis frequency and 47,6% had an improvement of crisis intensity. It strikes that all these parameters improved in 33,3% of patients. Similar efficacy was observed in migraineurs with and without aura. Two cases presented mild local complications (pain and haematoma).CONCLUSION : Local infiltration seems to be useful and safe in migraineurs resistant to preventive treatment who present cranial or neck tender points 24. GREAT OCCIPITAL NERVE BLOCKADE IN CHRONIC MIGRAINE WITH CERVICO-OCCIPITAL LOCALIZATION: