Consensus of the Brazilian Headache Society on the treatment of chronic migraine.

Chronic migraine poses a significant personal, social and economic burden and is characterized by headache present on 15 or more days per month for at least three months, with at least eight days of migrainous headache per month. It is frequently associated with analgesic or acute migraine medication overuse and this should not be overlooked. The present consensus was elaborated upon by a group of members of the Brazilian Headache Society in order to describe current evidence and to provide recommendations related to chronic migraine pharmacological and nonpharmacological treatment. Withdrawal strategies in medication overuse headache are also described, as well as treatment risks during pregnancy and breastfeeding. Oral topiramate and onabotulinum toxin A injections are the only treatments granted Class A recommendation, while valproate, gabapentin, and tizanidine received Class B recommendation, along with acupuncture, biofeedback, and mindfulness. The anti-CGRP or anti-CGRPr monoclonal antibodies, still unavailable in Brazil, are promising new drugs already approved elsewhere for migraine prophylactic treatment, the efficacy of which in chronic migraine is still to be definitively proven.

Consensus of the Brazilian Headache Society on the treatment of chronic migraine / Consenso da Sociedade Brasileira de Cefaleia sobre o tratamento da migrânea crônica

ABSTRACT Chronic migraine poses a significant personal, social and economic burden and is characterized by headache present on 15 or more days per month for at least three months, with at least eight days of migrainous headache per month. It is frequently associated with analgesic or acute migraine medication overuse and this should not be overlooked. The present consensus was elaborated upon by a group of members of the Brazilian Headache Society in order to describe current evidence and to provide recommendations related to chronic migraine pharmacological and nonpharmacological treatment. Withdrawal strategies in medication overuse headache are also described, as well as treatment risks during pregnancy and breastfeeding. Oral topiramate and onabotulinum toxin A injections are the only treatments granted Class A recommendation, while valproate, gabapentin, and tizanidine received Class B recommendation, along with acupuncture, biofeedback, and mindfulness. The anti-CGRP or anti-CGRPr monoclonal antibodies, still unavailable in Brazil, are promising new drugs already approved elsewhere for migraine prophylactic treatment, the efficacy of which in chronic migraine is still to be definitively proven.

RESUMO A migrânea (enxaqueca) crônica determina uma carga pessoal, social e econômica significativa e é caracterizada por dor de cabeça presente em quinze ou mais dias por mês por ao menos três meses, com no mínimo oito dias de cefaleia migranosa a cada mês. É frequentemente associada ao uso excessivo de medicação analgésica ou antimigranosa aguda e isso não deve ser negligenciado. Este consenso foi elaborado por um grupo de membros da Sociedade Brasileira de Cefaleia, para descrever as evidências atualmente disponíveis e fornecer recomendações relacionadas ao tratamento farmacológico e não farmacológico da migrânea crônica. Estratégias de retirada na cefaleia por uso excessivo de medicamentos também são descritas, assim como os riscos dos tratamentos durante a gravidez e a amamentação. O topiramato oral e as injeções de toxina onabotulínica A são os únicos tratamentos que receberam a recomendação classe A, enquanto que o valproato, a gabapentina e a tizanidina receberam recomendação classe B, juntamente com acupuntura, biofeedback e mindfulness. Os anticorpos monoclonais anti-CGRP ou anti-CGRPr, ainda não disponíveis no Brasil, são novos fármacos promissores, já aprovados em outros países para o tratamento profilático da migrânea, cuja eficácia na migrânea crônica ainda está por ser definitivamente comprovada.

Injecction of trigger points in the temporal muscles of patients with miofascial syndrome.

OBJECTIVE: The aim was to examine the effect of blocking trigger points in the temporal muscles of patients with masticatory myofascial pain syndrome, fibromyalgia and headache. METHOD: Seventy patients with one trigger point were randomly divided into 3 groups: injection with saline or anesthetic and non-injected (control). RESULTS: Pain was reduced in 87.71% patients injected with saline and 100% injected with anesthetic. Similar results were obtained for headache frequency. With regard to headache intensity, the injection groups differed from the control group, but not between themselves. CONCLUSION: Treatment with injection at trigger points decreased facial pain and frequency and intensity of headache. Considering the injected substance there was no difference.

Injecction of trigger points in the temporal muscles of patients with miofascial syndrome / Infiltrações de pontos-gatilho na musculatura temporal em pacientes com fibromialgia e cefaleia

Objective : The aim was to examine the effect of blocking trigger points in the temporal muscles of patients with masticatory myofascial pain syndrome, fibromyalgia and headache.Method : Seventy patients with one trigger point were randomly divided into 3 groups: injection with saline or anesthetic and non-injected (control).Results : Pain was reduced in 87.71% patients injected with saline and 100% injected with anesthetic. Similar results were obtained for headache frequency. With regard to headache intensity, the injection groups differed from the control group, but not between themselves.Conclusion : Treatment with injection at trigger points decreased facial pain and frequency and intensity of headache. Considering the injected substance there was no difference.

Objetivo : Comparar o efeito terapêutico do bloqueio de pontos-gatilho na musculatura temporal com soro fisiológico e anestésico em pacientes com síndrome da dor miofascial mastigatória, fibromialgia e cefaleia, entre sí e com controles não-infiltrados.Método : Setenta pacientes que apresentaram pelo menos um ponto-gatilho na musculatura temporal foram aleatoriamente divididas em 3 grupos: infiltração com soro fisiológico, infiltração com anestésico e controle (não-infiltradas).Resultados : Houve redução na intensidade de dor na face em 87,71% dos pacientes infiltrados com soro fisiológico e em 100% dos pacientes infiltrados com anestésico, mas não no grupo controle. Houve similaridade dos resultados considerando a frequência da cefaléia. Quanto à intensidade da cefaléia, tanto a infiltração com soro fisiológico, quanto com anestésico foram efetivos e sem diferença significativa entre sí, ao contrário do grupo controle.Conclusões : O tratamento com infiltração diminui a dor na face, bem com a frequência e a intensidade da cefaléia. Quando considerado a substância infiltrada não há diferenças no tratamento.

Receptores opioides até o contexto atual / Opioid receptors to date

JUSTIFICATIVA E OBJETIVOS: Devido à finalidade do ambulatório e os fármacos utilizados rotineiramente, o objetivo deste estudo foi rever e atualizar os conhecimentos sobre os receptores opioides e como complemento de estudo após palestra apresentada aos integrantes da equipe. CONTEÚDO: Foram revisados desde os aspectos históricos até os conhecimentos mais recentes sobre receptores opioides, descritos seus subtipos e mecanismos de ação. Para tal, foram consultadas referências indexadas pelo Pubmed. CONCLUSÃO: Com os dados presentes na literatura atual, concluiu-se que ainda existe muito a ser pesquisado sobre o tópico, visando medicações mais seguras e novas técnicas biomoleculares ainda são necessárias.

BACKGROUND AND OBJECTIVES: Due to the objective of the outpatient setting and to routinely used drugs, this study aimed at reviewing and updating the knowledge about opioid receptors and worked as a study complement after a lecture presented to team members. CONTENTS: We have reviewed from historical aspects to most recent developments about opioid receptors, in addition to describing subtypes and action mechanisms. For such, Pubmed-indexed references were queried. CONCLUSION: After reviewing current literature data, we have concluded that there is still a lot to be researched about the topic, aiming at safer drugs, and new biomolecular techniques are still needed.

Massaging over the greater occipital nerve reduces the intensity of migraine attacks: evidence for inhibitory trigemino-cervical convergence mechanisms.

Activation of the trigemino-cervical system constitutes one of the first steps in the genesis of migraine. The objective of this study was to confirm the presence of trigemino-cervical convergence mechanisms and to establish whether such mechanisms may also be of inhibitory origin. We describe a case of a 39-years-old woman suffering from episodic migraine who showed a significant improvement in her frontal headache during migraine attacks if the greater occipital nerve territory was massaged after the appearance of static mechanical allodynia (cortical sensitization). We review trigemino-cervical convergence and diffuse nociceptive inhibitory control (DNIC) mechanisms and suggest that the convergence mechanisms are not only excitatory but also inhibitory.

Massaging over the greater occipital nerve reduces the intensity of migraine attacks: evidence for inhibitory trigemino-cervical convergence mechanisms

Activation of the trigemino-cervical system constitutes one of the first steps in the genesis of migraine. The objective of this study was to confirm the presence of trigemino-cervical convergence mechanisms and to establish whether such mechanisms may also be of inhibitory origin. We describe a case of a 39-years-old woman suffering from episodic migraine who showed a significant improvement in her frontal headache during migraine attacks if the greater occipital nerve territory was massaged after the appearance of static mechanical allodynia (cortical sensitization). We review trigemino-cervical convergence and diffuse nociceptive inhibitory control (DNIC) mechanisms and suggest that the convergence mechanisms are not only excitatory but also inhibitory.

Ativação do sistema trigemino-cervical constitui um dos primeiros passos na gênese da crise de migrânea. O objetivo do estudo foi descrever um caso clínico que sugere a existência de mecanismos de convergência trigemino-cervical (CTC) e que esses possam ser do tipo inibitórios. Nós descrevemos o caso de mulher de 39 anos com migrânea episódica que mostrou significante melhora em sua cefaléia frontal durante suas crises quando realizava massagem sobre o território do nervo occipital maior ipsilateral a dor. A melhora clínica só ocorria quando a paciente apresentava alodinia mecânica estática (sensibilização cortical). Neste estudo nós revisamos os conceitos de CTC e de mecanismos de controle inibitório nociceptivo difuso (MCIN), sugerindo que este último é um elemento comprobatório da presença de CTC do tipo inibitório durante as crises de migrânea.