Treatment of status migrainosus by general anesthesia: a case report / Tratamento do estado de mal-enxaquecoso pela anestesia geral: relato de caso

ABSTRACTBACKGROUND AND OBJECTIVES: The status migrainosus is a complication of migraine characterized by severe headache for more than 72 h that did not respond to treatment, with risk of stroke and suicide. Researches on treatment are directed to drugs that stimulate GABA receptors; propofol and isoflurane act on sub-GABAa receptors and theoretically could be interesting. The first has been the subject of research in severe migraine. Opioids are employed in pain, and its use in chronic headache is debatable, but these agents are employed in acute cases. The goal is to present a case of refractory status migrainosus in that we decided to break the pain cycle by general anesthesia.CASE REPORT: Female patient, aged 50 years, with status migrainosus, in the last five days with visits to the emergency department, medicated parenterally with various agents without result. Without comorbidities, dehydrated, described her pain as "well over 10" in Visual Numeric Scale (VNS). After consulting the literature, and given the apparent severity of the condition, we opted for a general anesthesia: induction with fentanyl, propofol, and vecuronium and maintenance with isoflurane and propofol for two hours. Following the treatment, in the postanesthetic recuperation (PAR), the patient related her pain as VNS 3, and was released after five hours with VNS 2. Subsequently, her preventive treatment was resumed.CONCLUSION: Status migrainosus is a rare disabling complication and anesthetics have been the subject of research in its treatment; the option for general anesthesia with agents that stimulate GABA receptors, propofol and isoflurane, in association with fentanyl, proved effective and should encourage new research.

RESUMOJUSTIFICATIVA E OBJETIVOS: O estado de mal-enxaquecoso é complicação da migrânea caracterizada por cefaleia severa por mais de 72 horas não responsiva à terapêutica com risco de AVC e suicídio. Pesquisas no tratamento se direcionam às drogas que estimulam receptores GABA; propofol e isoflurano atuam nos sub-receptores GABAa e teoricamente poderiam ser interessantes. O primeiro já foi objeto de pesquisas na migrânea severa. Opioides são empregados em dor, seu uso crônico nas cefaleias é discutível, mas são empregados nos casos agudos. O objetivo é apresentar caso de estado de mal-enxaquecoso refratário em que se optou para quebrar o ciclo álgico por uma anestesia geral.RELATO DE CASO: Paciente do sexo feminino com 50 anos em estado de mal-enxaquecoso havia cinco dias com passagens anteriores por serviço de urgências, medicada por via parenteral com vários agentes sem resultado. Sem comorbidades, desidratada, descrevia sua dor como "muito superior a 10" na ENV. Após consulta à literatura, face à gravidade aparente do quadro, optou-se pela feitura de uma anestesia geral; a indução foi com fentanil, propofol, vecurônio e manutenção com isoflurano e propofol por duas horas. No fim, na RPA, no primeiro contato classificou sua dor com ENV 3, teve alta após cinco horas com ENV 2. Ulteriormente retomou seu tratamento preventivo.CONCLUSÃO: O mal-enxaquecoso é uma complicação rara incapacitante e anestésicos têm sido objeto de pesquisas no tratamento; a opção por uma anestesia geral com agentes que estimulam os receptores GABA, propofol e isoflurano, aliados ao fentanil, mostrou-se eficaz e deve incentivar pesquisas.

[Treatment of status migrainosus by general anesthesia: a case report]. / Tratamento do estado de mal-enxaquecoso pela anestesia geral: relato de caso.

BACKGROUND AND OBJECTIVES: The status migrainosus is a complication of migraine characterizedby severe headache for more than 72 h that did not respond to treatment, with risk of strokeand suicide. Researches on treatment are directed to drugs that stimulate GABA receptors; propofol and isoflurane act on sub-GABAa receptors and theoretically could be interesting. The first has been the subject of research in severe migraine. Opioids are employed in pain, and its use in chronic headache is debatable, but these agents are employed in acute cases. The goalis to present a case of refractory status migrainosus in that we decided to break the pain cycle by general anesthesia. CASE REPORT: Female patient, aged 50 years, with status migrainosus, in the last five days withvisits to the emergency department, medicated parenterally with various agents without result. Without comorbidities, dehydrated, described her pain as "well over 10" in Visual NumericScale (VNS). After consulting the literature, and given the apparent severity of the condition, we opted for a general anesthesia: induction with fentanyl, propofol, and vecuroniumand maintenance with isoflurane and propofol for two hours. Following the treatment, in the postanesthetic recuperation (PAR), the patient related her pain as VNS 3, and was released after five hours with VNS 2. Subsequently, her preventive treatment was resumed. CONCLUSION: Status migrainosus is a rare disabling complication and anesthetics have been the subject of research in its treatment; the option for general anesthesia with agents that stimulate GABA receptors, propofol and isoflurane, in association with fentanyl, proved effective and should encourage new research.

Treatment of status migrainosus by general anesthesia: a case report.

BACKGROUND AND OBJECTIVES: The status migrainosus is a complication of migraine characterized by severe headache for more than 72h that did not respond to treatment, with risk of stroke and suicide. Researches on treatment are directed to drugs that stimulate GABA receptors; propofol and isoflurane act on sub-GABAa receptors and theoretically could be interesting. The first has been the subject of research in severe migraine. Opioids are employed in pain, and its use in chronic headache is debatable, but these agents are employed in acute cases. The goal is to present a case of refractory status migrainosus in that we decided to break the pain cycle by general anesthesia. CASE REPORT: Female patient, aged 50 years, with status migrainosus, in the last five days with visits to the emergency department, medicated parenterally with various agents without result. Without comorbidities, dehydrated, described her pain as "well over 10" in Visual Numeric Scale (VNS). After consulting the literature, and given the apparent severity of the condition, we opted for a general anesthesia: induction with fentanyl, propofol, and vecuronium and maintenance with isoflurane and propofol for two hours. Following the treatment, in the postanesthetic recuperation (PAR), the patient related her pain as VNS 3, and was released after five hours with VNS 2. Subsequently, her preventive treatment was resumed. CONCLUSION: Status migrainosus is a rare disabling complication and anesthetics have been the subject of research in its treatment; the option for general anesthesia with agents that stimulate GABA receptors, propofol and isoflurane, in association with fentanyl, proved effective and should encourage new research.

Migrânea: etiologia, fatores de risco, desencadeantes, agravantes e manifestações clínicas / Migraine: etiology, risk, triggering, aggravating factors and clinical manifestations / Migraña: etiología, factores de riesgo, desencadenantes, agravantes y manifestaciones clínicas

Este estudo objetivou identificar a etiologia e as manifestações clínicas da migrânea. Foi realizada revisão integrativa de literatura norteada pela questão: quais as evidências disponíveis na literatura sobre a etiologia e os sinais e sintomas da migrânea? A busca de artigos foi conduzida nas bases eletrônicas PubMed e LILACS, contemplando publicações do período de 2006 a 2010. Os artigos selecionados foram categorizados e avaliados segundo o nível de evidência. Foram encontrados 1.677 artigos, sendo selecionados 26 para leitura na íntegra. A maioria dos estudos (84,6%) consistiu em delineamento não experimental, sendo classificados com nível de evidência IV. Apesar das manifestações clínicas encontradas neste estudo confirmarem os dados disponíveis na literatura, nota-se que a migrânea ainda não possui suas causas devidamente estabelecidas.

This study aimed to identify the etiology and clinical manifestations of migraine. An integrative literature review was performed guided by the question: What is the evidence available in the literature about the etiology, signs and symptoms of migraine? The article search was conducted in the electronic databases PubMed and LILACS, considering publications in the period from 2006 to 2010. The selected articles were categorized and evaluated according to the level of evidence. One found 1,677 articles and 26 were selected for full reading. Most studies (84.6%) consisted of a non-experimental design and were classified as evidence level IV. Although the clinical manifestations found in this study confirm the data available in the literature, it is noticed that migraine does not have well-established causes.

El objetivo fue identificar la etiología y las manifestaciones clínicas de la migraña. Fue realizada revisión integradora de laliteratura por medio de la pregunta: cuáles evidencias están disponibles en la literatura acerca de la etiología y los signos y síntomas de la migraña? La búsqueda de los artículos se realizó en las bases electrónicas PubMed y LILACS, y abarcó publicaciones del período 2006-2010. Los artículos seleccionados fueron clasificados y evaluados de acuerdo con el nivel deevidencia. Se encontraron 1.677 artículos y 26 fueron escogidos para lectura completa. La mayoría de los estudios (84,6%) consistió en el diseño no experimental, clasificados con nivel de evidencia IV. Las manifestaciones clínicas encontradas en este estudio confirman los datos disponibles en la literatura, pero se percibe que la migraña aún no posee causas debidamente establecidas.

Cefaléia termossensível: relato de caso relacionado ao trabalho / Climate-related migraine: occupational case report

A cefaléia é um problema de saúde muito prevalente em todo o mundo, com conseqüências importantes não só para os indivíduos afetados, mas para a sociedade em geral. A importância econômica da enxaqueca pode ser evidenciada pelo seu pico de prevalência, 25 a 55 anos, faixa em que se encontra a maior parte da população economicamente ativa. O caso apresentado é de importância por alertar para a possibilidade de nexo com o trabalho para uma doença não reconhecida clássica e oficialmente reconhecida como tal, o que influencia sobremaneira os desdobramentos do caso, especialmente para o paciente, a empresa e a Previdência Social. São discutidas questões como a importância da anamnese ocupacional e do diário de atividades; a dificuldade do estabelecimento do nexo causal e a importância e dificuldades da reabilitação profissional.

Headache is a prevalent problem throughout the world, and its consequences are important to both individual and society levels. Migraine occurs more commonly among economically active patients (25-55 years old) having thus an additional importance. Among the various causes of migraine lies the influence of climate. In this case report not also this factor was identified as the precipitating one, but was considered as related to work. The case is of great importance to underline the possibility of considering the occupational nexus for some diseases which are not officially recognized as related to work. We discuss the importance of occupational anamnesis and the diary of activities; the problems one has to face to establish the relation with work and the importance and difficulties of Brazil’s Social Security System in providing professional rehabilitation.