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Eds e cefalea 141113

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Eds e cefalea 141113

  1. 1. La Cefalea nella Sindrome dell’Ipermobilità Articolare o Ehlers-Danlos Ipermobile F. Puledda, V. Di Piero Dipartimento di Neurologia e Psichiatria “Sapienza” Università di Roma
  2. 2. Le Cefalee Classificazione attuale • Parte I: Cefalee Primarie • Parte II: Cefalee Secondarie • Emicrania con e senz’aura Cefalea Tensiva Cefalea a grappolo Parte III: Nevralgie craniche dolori facciali centrali o primari e altre cefalee
  3. 3. Epidemiologia Emicrania con e senz’aura Nella popolazione generale prevalenza di circa 5% degli uomini e 10-15% delle donne (2,5-3 volte più frequente) Nel 50-70% dei casi esiste una storia familiare Nella maggior parte dei casi Il 1° attacco si verifica durante l’adolescenza o intorno ai 20 anni. Rara l’insorgenza oltre i 40 anni Remissione frequente dopo la menopausa o la 5° e 6° decade
  4. 4. Cosa significa soffrire di emicrania? Emicrania Terapia 34 13 48 52 Medico Diagnosi 100 18 21
  5. 5. Carico della patologia emicranica WHO Global burden of disease (Report 2004) Le prime 20 cause di perdita annuale di produttività, in tutte le età, in entrambi i sessi  1. Depressione unipolare  6. Schizofrenia  7. Disordine affettivo bipolare  9. Alzheimer e altre demenze  12. Emicrania
  6. 6. Costi della patologia emicranica Aspetti da considerare: The Migraine Iceberg  Malattia cronica invalidante che si protrae per lungo periodo della vita del paziente ed interessa l’età giovanile adulta  L’attacco emicranico é caratterizzato da sintomi multipli  Elevata comorbidità
  7. 7. Costi della patologia emicranica Costi diretti Visite mediche Farmaci Costi indiretti Costi intangibili Assenze da lavoro/ scuola Ridotta produttività Ricoveri Riduzione della qualità di vita Diagnostica
  8. 8. Costi diretti Costituiscono la minima parte dell’impatto economico dell’emicrania 8% 92% In USA l’impatto dei costi diretti sulla spesa totale dovuta all’emicrania è pari all’8% Hu XH, 1999
  9. 9. Costi della patologia emicranica Costi diretti Visite mediche Farmaci Costi indiretti Costi intangibili Assenze da lavoro/ scuola Ridotta produttività Ricoveri Riduzione della qualità di vita Diagnostica
  10. 10. Costi indiretti Si tratta dei costi relativi all’assenza da lavoro o alla ridotta produttività La fascia di età 25-55 anni è la più colpita da emicrania...
  11. 11. Costi indiretti Impatto dell’emicrania sul lavoro Minori possibilità di lavoro e di guadagno potenziale Giorni di lavoro persi per assenza dovuta all’emicrania: 1-4 giorni/anno per ogni paziente emicranico Giorni di lavoro persi per ridotta capacità lavorativa: 1-8 giorni/anno per paziente emicranico Costo stimato della perdita di produttività 2.000 miliardi/anno!
  12. 12. Costi della patologia emicranica Costi diretti Visite mediche Farmaci Costi indiretti Costi intangibili Assenze da lavoro/ scuola Ridotta produttività Ricoveri Riduzione della qualità di vita Diagnostica
  13. 13. Costi intangibili Modificazioni della normale attività Rinuncia ad attività sociali 26 30 Rinuncia ad attività familiari 18 Cefalea tensiva 31 Emicrania Perdita giornate lavorative 8 19 0 10 20 30 40%
  14. 14. Comorbidità ed Emicrania Ereditarietà Fattori Predisponenti Asma Epilessia Depressione Emicrania Stroke (raro) Neuroticismo Disturbi d’Ansia Fattori scatentanti scatenanti Rischio cronicizzazione
  15. 15. Emicrania e rischio cronicizzazione Cefalee croniche 3-5% Emicrania cronica 2% Cefalea da abuso di analgesici 1-4% 30-50% dei pazienti che afferiscono ai Centri Cefalee
  16. 16. Comorbidità ed Emicrania Ereditarietà Fattori Predisponenti Asma Epilessia Depressione Emicrania Stroke (raro) Neuroticismo Disturbi d’Ansia Fattori scatentanti scatenanti Altro…
  17. 17. Sindrome dell’ Ipermobilità Articolare o Ehlers-Danlos Ipermobile (JHS/EDS-HT) e Cefalea Comorbidità Neurologiche        Fatica cronica e astenia Disturbi del sonno Patologie neuromuscolari Neuropatie Epilessia Ipotensione intracranica Aspetti malformativi  CEFALEE PRIMARIE (fino al 65% dei pz, da precedenti studi) Castori M, et al. Am J Med Genet 2010
  18. 18. Gestione dell’emicrania in una popolazione con dolore cronico: descrizione di 33 casi di Sindrome dell’Ipermobilità Articolare o Ehlers-Danlos Ipermobile F. Puledda, A. Viganò, B. Petolicchio, M. Toscano, V. Di Piero Dipartimento di Neurologia e Psichiatria C. Celletti, F. Camerota Dipartimento di Medicina Fisica e Riabilitativa “Sapienza” Università di Roma
  19. 19. Obiettivi dello Studio • Descrivere le caratteristiche della cefalea in una popolazione di pazienti con Sindrome dell’Ipermobilità Articolare o S. di EhlersDanlos Ipermobile (JHS/EDS-HT) • Confrontarle con un gruppo di controllo di pazienti emicranici • Valutare se le caratteristiche (prevalenza, frequenza, disabilità) dell’emicrania differiscono da quelle di una popolazione normale • Offrire migliori strategie diagnostiche e terapeutiche in una popolazione con dolore cronico
  20. 20. Materiali e Metodi - Arruolamento Criteri di inclusione Gruppo JHS/EDS-HT - M/F tra 14 e 60 aa - Beighton Score ≥5 - ID Migraine ≥2/3 Gruppo MO - Numero doppio di pz, match per età e sesso - Ordine consecutivo - ID Migraine ≥ 2/3 Criteri di esclusione - Donne in gravidanza - Altre patologie croniche/neurologiche - Cefalee secondarie
  21. 21. Materiali e Metodi Indagini cliniche: • Visita Neurologica (conferma diagnosi di emicrania) • EO, EN, Anamnesi strutturata • Screening per emicrania Età d’esordio Storia familiare Localizzazione e tipo di dolore Durata ed intensità media (NRS) degli attacchi Presenza e tipologia di aura Presenza di sintomi associati(foto fono e osmofobia, nausea e vomito) Frequenza di giorni/mese Compilazione di MIDAS, HIT-6 Terapie d’attaccoe di profilassi
  22. 22. Risultati - Epidemiologia 45 pz JHS/EDS-HT totali 35 pz JHS/EDS-HT con ID-Migraine ≥ 2/3 (77,8%) 2 drop-out • 33 pz EDS arruolati:29 - 4 età media 32,11 aa - Diagnosi confermata dal colloquio clinico nel 100% dei casi - • 66 pz MO arruolati: 58 - 8 età media 32,11 aa
  23. 23. Risultati – Epidemiologia (2) CARATTERISTICHE GENERALI EMICRANIA JHS/EDS-HT n=33 MO n=66 Storia familiare n= 31 (93,4%) n= 63 (95,5%) Qualità del dolore Pulsante Costrittivo n= 25 (75,8%) n= 8 (24,2%) n= 53 (80,3%) n= 13 (19,7%) Localizzazione dolore Unilaterale Bilaterale Entrambe n= 12 (36,4%) n= 12 (36,4%) n= 9 (27,3%) n= 25 (37,9%) n= 26 (39,4%) n= 15 (22,7%) Aura Visiva Sensoriale Linguaggio n= 12 (36,4%) n= 12 n= 1 n= 1 n= 26 (39,4%) n= 22 n= 3 n= 1 Intensità media 8,5 ± 1,3 8,6 ± 1,2 Durata media 33,8 ± 22,0 36,1 ± 24,2
  24. 24. Risultati - Severità Migraine Onset 20 20 p=0,01 15 15 Age Migraine days/month Migraine Frequency 10 p=0,005 10 5 5 0 0 JHS/EDS-HT MO JHS/EDS-HT MO Frequenza di giorni/mese di emicrania  più elevata nel gruppo JHS/EDS-HT (15,1 vs. 9,3) Età di insorgenza emicrania  più bassa nel gruppo JHS/EDS-HT (12,1 aa vs. 17 aa) Migraine Disability (HIT-6 and MIDAS) 80 p=0,04 60 JHS/EDS-HT MIDAS 0 HIT-6 20 HIT-6 40 MIDAS p=0,03 MO HIT-6 (64,3 ± 5,0 vs. 60,9 ± 9,1) e MIDAS (63,2 ± 57,4 vs. 40,3 ± 44,7) più elevati nel gruppo JHS/EDS-HT Sindrome emicranica più severa
  25. 25. Risultati – Terapia dell’attacco L’efficacia dei farmaci per l’attacco non differisce tra i due gruppi, ma: Assunzione mensile farmaci d’attacco p=0,006 p<0,001 8.0 2.0 1.0 0.0 JHS/EDS-HT MO p=0,03 TRIPTANI 3.0 FANS 4.0 TRIP 5.0 AN. COMB 6.0 ANALGESICI COMBINATI 7.0 FANS Numero di pillole/mese 9.0
  26. 26. Comorbidità ed Emicrania Ereditarietà Fattori Predisponenti Asma Epilessia Emicrania Depressione Stroke (raro) Neuroticismo Disturbi d’Ansia EDS-HT Fattori scatenanti Rischio cronicizzazione
  27. 27. Conclusioni •I pazienti con S. dell’Ipermobilità Articolare o EDS-HT hanno una sindrome emicranica più frequente, sottodiagnostica e severa rispetto agli emicranici normali •Nonostante questo, tendono ad assumere meno farmaci d’attacco, sebbene l’efficacia sia simile OBIETTIVI FUTURI: diagnosi precoce di cefalea (rischio cronicizzazione) terapie mirate non solo alla patologia di base
  28. 28. Cronicizzazione: fattori di rischio • Sesso femminile • Basso livello educativo • Alta frequenza di attacchi dall’inizio • Obesità • Eventi stressanti • Disturbi del sonno • Fattori psicologici • Comorbidità psichiatrica • Abuso di farmaci EMICRANIA CRONICA
  29. 29. Fattori di rischio • Sesso femminile • Basso livello educativo • Alta frequenza di attacchi dall’inizio • Obesità • Eventi stressanti • Disturbi del sonno • Fattori psicologici • Comorbidità psichiatrica • Abuso di farmaci FATTORI DI RISCHIO NON-MODIFICABILI
  30. 30. Fattori di rischio • Sesso femminile • Basso livello educativo • Alta frequenza di attacchi dall’inizio • Obesità • Eventi stressanti • Disturbi del sonno • Fattori psicologici • Comorbidità psichiatrica • Abuso di farmaci EDUCAZIONE STILE DI VITA INFORMAZIONI DEL MEDICO
  31. 31. Fattori di rischio •Sesso femminile • Basso livello educativo • Alta frequenza di attacchi dall’inizio • Obesità • Eventi stressanti • Disturbi del sonno •Fattori psicologici •Comorbidità psichiatrica •Abuso di farmaci TERAPIA DI PROFILASSI PSICOTERAPIA BREVE TOSSINA BOTULINICA DISINTOSSICAZIONE
  32. 32. Strategie Terapeutiche Terapie per l’attacco acuto Terapie di profilassi: •Valproato •Topiramato •Amitriptilina… Tossina Botulinica Infiltrazione del GON Psicoterapia breve Disintossicazione
  33. 33. Proposte per ridurre il carico della cefalea nei pz con JHS/EDS-HT  Maggior coinvolgimento dei curanti nella gestione dei pazienti con emicrani ed JHS/EDS-HT  Impiego più mirato dei farmaci  Educazione dei pazienti a monitorare i propri attacchi allo scopo di valutarne correttamente il grado di disabilità •Approccio multidisciplinare nei pazienti con JHS/EDS-HT mirato non solo alla patologia di base
  34. 34. Grazie per l’attenzione Centro Cefalee – Dipartimento di Neurologia e Psichiatria

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