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

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

5. FISIOPATOLOGIA DA MIGRÂNEA J NEJM 2002

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

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).

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.

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