Cefaléia em salvas durante a gravidez: um desafio a mais no tratamento / Cluster headache during pregnancy: an extra challenge for treatment

Cefaléia em salvas é uma cefaléia trigêmino-autonômica relativamente rara. Sua ocorrência na gravidez e as possíveis abordagens terapêuticas são apresentadas.

Dexamethasone decreases migraine recurrence observed after treatment with a triptan combined with a nonsteroidal anti-inflammatory drug

BACKGROUND AND OBJECTIVES: Triptans are effective drugs for the acute treatment of migraine. However, 30-40 percent of the patients commonly present recurrence before 24 hours therefore requiring another dose. Nonsteroidal anti-inflammatory drugs (NSAID) such as tolfenamic acid and naproxen sodium combined with sumatriptan have demonstrated efficacy in reducing recurrence observed with the single use of this drug. Steroids also have been suggested to treat refractory migraine and status migranosus. The aim of this study was to evaluate whether patients presenting frequent recurrence with the combination triptan plus NSAID, would decrease it with the association of dexamethasone. METHOD: Twenty three patients, 17 women and 6 men with migraine according to IHS criteria were prospectively studied. All patients presented frequent recurrence ( > or = 60 percent, mean recurrence rate 74,8 percent) with the single use of sumatritpan 100mg or zolmitriptan 2,5mg or rizatriptan 10mg in at least 5 consecutive attacks, and didn't present a reduction of the recurrence rate superior than 20 percent with the combination of tolfenamic acid 200mg or rofecoxib 25mg in at least 5 other consecutive attacks (mean recurrence rate 60 percent). The patients had to treat 6 consecutive moderate or severe migraine attacks with their usual combination plus 4mg of dexamathasone with a maximum of twice a week, and fill out a diary reporting headache parameters. RESULTS: Twenty patients, 16 women and 4 men completed the study. Of those who completed the study, 11 took rizatriptan plus rofecoxib, 4 rizatriptan plus tolfenamic acid, 3 zolmitriptan plus rofecoxib, 1 zolmitriptan plus tolfenamic acid and 1 patient took sumatriptan plus tolfenamic acid, having the 20 patients taken as a third medication, a single tablet of 4mg of dexamethasone. All patients took oral formulations and none presented vomiting after that. Among all 20 patients, one female and one male patient presented recurrence in 3 out of the 6 attacks (50 percent) while the remaining 18 patients revealed recurrence in 1 or 2 treated attacks (mean 23,4 percent) (p<0,001). CONCLUSION: We concluded that the judicious use of oral dexamethasone might be useful for a limited population of migraine patients still presenting recurrence with the combination of a triptan and a NSAID. Case-control studies and studies with a randomized double-blind design are necessary to confirm these observations

Naproxen sodium decreases migraine recurrence when administered with sumatriptan

Forty to 78 per cent of the patients using sumatriptan for the acute treatment of migraine may present recurrence at least occasionally. The concomitant use of a NSAID (nonsteroidal anti-inflammatory drug) has been recommended to decrease the recurrence rate. Sixty seven patients that treated successfully 8 migraine attacks with 100 mg of sumatritpan PO and presented recurrence in at least 5 attacks were studied prospectively. The patients received 100 mg of sumatriptan and 550 mg of naproxen sodium PO to treat 4 consecutive moderate or severe migraine attacks. The recurrence rate, once at least 62.5 per cent (5 out of 8 attacks), decreased to 14.2 per cent (38 out of 268 attacks) with the combination of compounds (p<0.0001). We then studied two groups of 13 patients made randomicaly from the 67 initially evaluated, that were given sumatriptan 100 mg plus naproxen sodium 550 mg or placebo, in a double-blind design, to treat 3 other consecutive migraine attacks. Each group of patients treated 39 attacks. The recurrence among the patients taking sumatriptan plus placebo was 59 per cent (23 out of 39 attacks) and the recurrence presented by the group taking sumatriptan plus naproxen was 25.5 per cent (10 out of 39 attacks) (p<0.0003). We concluded that the combination of sumatriptan plus naproxen sodium decreases significantly migraine recurrence presented by patients taking sumatriptan alone.

Antinociceptive effect of sumatriptan in mice.

Antinociceptive effect of the antimigraine drug sumatriptan (5-HT1A agonist) was studied against acetic acid-induced writhing in mice. Sumatriptan produced the effect in a dose-dependent manner (1, 5, 10 and 20 mg/kg, s.c.). Naloxone (1 mg/kg i.p.) an opiate antagonist failed to reverse sumatriptan-induced antinociception. Cholinomimetic physostigmine (0.05 mg/kg, i.p.) potentiated and the muscarinic antagonist atropine (5 mg/kg, i.p.) blocked the antinociceptive effect of sumatriptan, respectively. The antinociceptive effect of sumatriptan was compared with an another 5-HT agonist (5-HT1A) buspirone which also produced antinociception. Like sumatriptan-analgesia, the buspirone response was also potentiated by physostigmine in atropine sensitive way. Further, buspirone potentiated the analgesic effect of sumatriptan. These observations suggest that 5-HT1A agonists produce antinociception possibly by modulating central cholinergic activity.

Fisiopatologia da enxaqueca (ou migrânea) / The pathophysiology of migraine

A fisiopatologia da enxaqueca tem sofrido uma evoluçäo considerável, principalmente nos últimos quinze anos. O conhecimento dos mecanismos genéticos, incluindo a participaçäo do gene CACNL1A4 no cromossoma 19p13.1, que codifica a subunidade alfa-1 de um canal de cálcio, tipo P/Q, específico do cérebro, dos mediadores e neurotransmissores envolvidos com a inflamaçäo neurogênica, tais como o Peptídeo Relacionado ao Gene da Calcitonina (CGRP), a NK-1 e a SP; a influência do NO como molécula algógena fundamental na enxaqueca; o desenvolvimento de modelos experimentais, incluindo o modelo do extravasamento de plasma, conforme desenvolvido pelo grupo do Moskowitz; e novas técnicas de neuroimagem (PET, MR e MEG) säo alguns exemplos dos avanços alcançados. Isto tem propiciado o desenvolvimento de novos medicamentos antienxaquecosos. A depressäo alastrante de Leäo tem sido confirmada como o fenômeno neurofisiológico mais importante na enxaqueca: ativa o sistema trigeminovascular, induz vasodilataçäo mediada por CGRP e a expressäo de c-fos no núcleo do trigêmio, no tronco cerebral. A dor na migrânea näo é secundária à vasodilataçäo, o que näo mais justifica a divisäo das cefaléias em "vasculares" e "näo vasculares".

Cefaléias primárias: aspectos clínicos e terapêuticos / Primary headaches: clinical and therapeutic aspects

Nesta revisäo, as cefaléias primárias säo conceituadas como doenças crônicas, de apresentaçäo episódica ou contínua, com etiologia desconhecida, mas de natureza disfuncional, näo estrutural. As quatro principais formas de cefaléia primária (enxaqueca, cefaléia em salvas, tensional e crônica diária) säo discutidas em seus aspectos etiopatogênicos, clínicos e terapêuticos.

O sumatriptano no tratamento da crise de enxaqueca / Using Sumatriptan to treat headache

A cefaléia é um dos sintomas mais comuns da clínica médica tanto em adultos como em crianças. Dos pacientes que procuram atendimento médico pela queixa de cefaléia, em aproximadamente um quarto é feito o diagnóstico de enxaqueca segundo os critérios da International Headache Society (IHS) de 1988. Feito o diagnóstico de exaqueca, a terapêutica tem como base a intensidade da crise. Nas crises de leve à moderada intensidade se orienta ao paciente repouso e uso de analgésicos comuns (tipo AAS), e nos casos mais resistentes o uso de antiinflamatórios näo-esteróide (AINES). Nas crises de moderada à severa intensidade está indicado o uso de derivados do ergot e, mais recentemente, o sumatriptano, um agonista dos receptores 5-HT1D, como alternativa eficaz e relativamente segura. No presente artigo é apresentada uma revisäo acerca do uso do sumatriptano no tratamento das crises de enxaqueca e, em especial, dos seus aspectos farmacológicos