The document discusses the acute and prophylactic treatment of migraines, focusing on pharmacological and non-pharmacological approaches. It details various medications, including triptans and non-steroidal anti-inflammatory drugs, as well as intervention techniques like nerve blocks for managing chronic migraine. It also emphasizes the importance of addressing triggering factors and the role of multidisciplinary treatment strategies in effectively reducing migraine severity and frequency.

1. TRATAMENTO AGUDO E PROFILÁTICO DA MIGRÂNEA Dr Rafael Higashi Médico neurologista Ambulatório de cefaléias do serviço de neurologia do HUAP-UFF www.estimulacaoneurologica.com.br

2. MODALIDADES DE TRATAMENTO Tratamento não farmacológico Tratamento farmacológico ( agudo e preventivo ) Procedimentos intervencionistas

3. TRATAMENTO NÃO FARMACOLÓGICO Fatores deflagradores da crise Abuso de analgésicos Parar o tabagismo Regularizar o sono e alimentação Exercícios 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;49:221–230. NIH Technology Assessment Panel. Integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia. JAMA 1996;276:313–318. Clinical trials studying pharmacotherapy and psychological treatments alone and together Jennifer A. Haythornthwaite. NEUROLOGY 2005 ; 65(Suppl 4):S20–S31 EVIDÊNCIAS

5. FISIOPATOLOGIA DA MIGRÂNEA J NEJM 2002

6. Importância da inflamação neurogênica na fisiopatologia da migrânea . Neurology 2005

7. TRATAMENTO FARMACOLÓGICO NA CRISE AGUDA DE MIGRÂNEA: não específicos ANALGÉSICOS : paracetamol, aspirina, dipirona AINES : indometacina, ácido mefenâmico, diclofenaco de sódio , ibuprofeno, naproxeno e rofecoxib ANTIEMÉTICOS : metoclopramida, domperidona NEUROLÉPTICOS : clopromazina, haldol CORTICÓIDES : dexametasona

8. TRATAMENTO FARMACOLÓGICO NA CRISE AGUDA DE MIGRÂNEA: específicos TRIPTANOS: sumatriptano, rizatriptano, naratriptano, zolmitriptano, eletriptano, flavotriptano, almotriptano DERIVADOS DO ERGOT : ergotamina e diidroergotamina

9. MECANISMO DE AÇÃO 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 migrânea associado a vômitos intensos Sumatriptano 10 mg intra nasal Sumatriptano 6 mg SC Indometacina 100 mg supositório retal

11. Crise aguda de migrânea associado a prodrômos e náuseas intensas (hipersensibilidade dopaminérgica) Domperidona 10 mg 2 comp VO Metoclopramida 10 mg VO Trimebutina 200 mg VO Haldol Clorpromazina

12. COMBINAÇÕES POSSÍVEIS NO TRATAMENTO AGUDO DE ENXAQUECA Sumatriptano 50 mg + naproxeno Rizatriptano 10 mg + refecoxib Sumatriptano 50 mg + acido tolfenâmico Rizatriptano 10 mg + trimebutina Rizatriptano 10 mg + acido tolfenâmico Sumatriptano 50 mg + metoclopramida

13. ESTUDO DUPLO CEGO, CRUZADO, RANDOMIZADO COMPARANDO O USO DO SUMATRIPTANO, COM A TRIMEBUTINA, COM O MELOXICAN, COM A ASSOCIAÇÃO DAS TRÊS DROGAS NO TRATAMENTO AGUDO DE ENXAQUECA Higashi R, 1235 Moreira Filho PF 1 , Krymchantowski AV 134 1 Departamento de neurologia Hospital Universitário Antônio Pedro da Universidade Federal Fluminese, Niterói, Brasil, 2 Serviço de Neurologia do Hospital Naval Marcílio Dias, Rio de Janeiro, Brasil, 3 Centro de tratamento da dor de cabeça do Rio de Janeiro, Brasil, 4 Instituto de Neurologia Deolindo Couto, 5 Hospital Pan Americano, Rio de Janeiro, Brasil. Distribuição 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 ASSOCIAÇÃO DAS TRÊS DROGAS NO TRATAMENTO AGUDO DE ENXAQUECA Higashi R, 1235 Moreira Filho PF 1 , Krymchantowski AV 134 1 Departamento de neurologia Hospital Universitário Antônio Pedro da Universidade Federal Fluminese, Niterói, Brasil, 2 Serviço de Neurologia do Hospital Naval Marcílio Dias, Rio de Janeiro, Brasil, 3 Centro de tratamento da dor de cabeça do Rio de Janeiro, Brasil, 4 Instituto de Neurologia Deolindo Couto, 5 Hospital Pan 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 diluídos em 100 ml SF 0.9% após hidratação

16. TRATAMENTO DA AURA PROLONGADA Hidratação venosa Prometazina 25 mg EV (hipersensibilidade dopaminérgica) Sulfato de Magnésio 1 g EV (deficiência de Mg) Prometazina 25 mg + Sulfato de Magnésio 1 g Furosemida intravenosa 20 mg (diminui o acúmulo de potássio extra-celular na depressão cortical alastrante)

17. TRATAMENTO MEDICAMENTOSO PREVENTIVO DA MIGRÂNEA INDICAÇÃO CONTRAINDICAÇÕES COMORBIDADES

18. CRITÉRIOS PARA PREVENÇÃO: indicação 2 ou mais crises no mês com incapacidades que duram de 3 a mais dias Contra-indicação ou ineficiência das medicações sintomáticas Uso de medicação abortiva mais de 2 x na semana Circunstâncias especiais como a migrânea hemiplégica ( a crise pode levar lesões neurológicas permanentes ) Início da crises previsíveis

19. COMORBIDADES NEUROLÓGICAS : epilepsia e AVC isquêmico PSIQUIÁTRICAS : depressão, bipolaridade, transtorno ansioso, síndrome do pânico, transtornos da personalidade OUTROS : fenômeno de Raynaud’s, síndrome do colón irritável, asma e outros transtornos dolorosos

20. MEDICAÇÕES PREVENTIVAS BETA BLOQUEADORES : propranolol, atenolol e metoprolol. ANTIDEPEPRESSIVOS TRICICLICOS: amitriptilina, nortriptilina ANTISEROTONINÉRGICOS : pizotifeno e metisergida ANTAGONISTAS DOS CANAIS DE CÁLCIO : 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 sódio 750-1000mg/dia + atenolol 60-100mg/dia Krymchantowski AV. Cefaléias Primárias. Como Diagnosticar e Tratar, 2001

22. PROCEDIMENTOS INTERVENCIONISTAS Bloqueios ( facetas, nervos, espaço epidural, ligamento interespinhoso e músculos somáticos) Procedimentos de radiofrequência Neuroestimulação Outros

23. PROPHYLACTIC EFFECT OF LOCAL INFILTRATION IN PREVENTIVE-RESI PROPHYLACTIC EFFECT OF LOCAL 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 1 Servicio De Neurologia. Hospital General Universitari Dalacant, ALACANT, Spain; 2 Unitat 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: A CLINICAL AND GREAT OCCIPITAL NERVE BLOCKADE IN CHRONIC MIGRAINE WITH CERVICO-OCCIPITAL LOCALIZATION: A CLINICAL AND NEUROPHYSIOLOGICAL STUDY F. Di Stani , G. Bruti, C. Mostardini, L. Scattoni, D. Dugoni, V. Villani, N. Vanacore, R Cerbo 1 Pain Center &quot;Enzo Borzomati&quot;/Policlinico Umberto I, Rome, Italy Background and aims : Physiological and physiopathological data showed the convergence of trigeminal and cervical afferents on to neurons in the trigeminocervical-complex (TCC) of the brain stem. Great occipital nerve (GON) infiltration with local anesthetics and steroids was successfully used for diagnostic and therapeutic purpose in cervicogenic headache. Aim of the study was to evaluate in chronic migraine with cervico-occipital localization the efficacy of (GON) blockade in stopping pain and in incrementating efficacy of preventive therapy. Secondary endpoint was to evaluate the trigeminocervical reflex in chronic migraine patients before and after the GON blockade and comparing them with healthy subjects. Methods : we enrolled consecutively 14 healthy subjects and 10 patients affected from chronic migraine according to IHS criteria 2004. All patients suffered from cervico-occipital distribution of pain and were submitted, at T=0, to GON blockade using lidocaine 2% (5 ml) and betametasone (2 mg) and to neurophysiological studies before the injection. Follow-up visits were done at 1 (T=1), 3 (T=2) and 6 (T=3) months. Neurophysiological and clinical data, numeric pain intensity scale (NPIS) and Migraine Disability Assessment Scale (MIDAS) were collected and administered at every step. Results: at the baseline our patients showed the following characteristics: 1) headache frequency (days per month): 18 ± 3; 2) pain-killer assumption: 14 ± 3; 3) NPIS score: 8 ± 1; 4) MIDAS score: 55 ± 9. At T=1 and T=3 follow-up visits we observed a significant reduction in all clinical parameters considered (p<.05). Conclusions : our results showed that GON blockade in chronic migraine with cervico-occipital localization is effective in reducing pain intensity, pain-killer assumption, disability and headache frequency up to first month after injection. Otherwise this positive effect disappear at 6 months follow-up visit. The Authors suppose that the efficacy of the GON blockade could be due to its action on TCC.

26. Obrigado a todos pela atenção ! Dr Rafael Higashi www.estimulacaoneurologica.com.br