Botulinum toxin type A versus amitriptyline for the treatment of chronic daily migraine.

OBJECTIVE: To compare the effects of botulinum toxin type A with those of amitriptyline on the treatment of chronic daily migraines. METHODS: Chronic migraine sufferers were randomized into two groups and treated with 25 or 50mg/day of amitriptyline or 250U of botulinum toxin type A. A reduction of at least 50% in the number of pain episodes, in the intensity of pain, and in the number of drug doses for pain and reports of improvement by the patient or by the examiner were the main endpoints. RESULTS: Seventy-two subjects were enrolled in the study. A reduction of at least 50% in the number of days of pain was recorded in 67.8% of the patients in the BTX-A group and 72% (n=23) of the patients in the AM group (p=0.78; RR=0.94; CI=0.11-8). The reduction in the intensity of pain, as assessed using the visual analogical scale, was 50% in the BXT-A group and 55.6% in the AM group (p=0.79; RR=1.11; CI=0.32-3.8). The reduction in the number of pain drug doses was 77% for the toxin group and 71% for the amitriptyline group (p=0.76; RR=0.92; CI=0.45-1.88). CONCLUSIONS: Botulinum toxin type A was as effective as amitriptyline for the prophylactic treatment of chronic daily migraines.

Botulinum toxin type A in refractory chronic migraine: an open-label trial.

Botulinum toxin type A (BT-A) has been described as an important strategy to various types of pain such as cervical dystonia, myofascial pain syndrome and headache. Although BT-A efficacy has not been proven in tension type headache, its use in migraine continues controversial. In this open trial, we evaluated the efficacy of BT-A in refractory migraine. BT-A was injected in patients diagnosed with migraine who had previously used three classes of prophylactic drugs by at least one year with no response. The most important improvement was observed within 30 days, but pain intensity and frequency of headache had been decreased until the end of three months of follow up. Side effects of BT-A were mild and self limited. We conclude that BT-A seems to be a safe and effective treatment to refractory migraine patients.

Botulinum toxin type A in refractory chronic migraine: an open-label trial

Botulinum toxin type A (BT-A) has been described as an important strategy to various types of pain such as cervical dystonia, myofascial pain syndrome and headache. Although BT-A efficacy has not been proven in tension type headache, its use in migraine continues controversial. In this open trial, we evaluated the efficacy of BT-A in refractory migraine. BT-A was injected in patients diagnosed with migraine who had previously used three classes of prophylactic drugs by at least one year with no response. The most important improvement was observed within 30 days, but pain intensity and frequency of headache had been decreased until the end of three months of follow up. Side effects of BT-A were mild and self limited. We conclude that BT-A seems to be a safe and effective treatment to refractory migraine patients.

Toxina botulínica tipo A (TB-A) tem sido descrita como importante estratégia para diversos tipos de dor como cefaléia e dores relacionadas a distonia cervical ou síndrome miofascial. Embora a eficácia da TB-A não tenha sido demonstrada na cefaléia do tipo tensional, seu uso na enxaqueca continua controverso. Nesse estudo avaliamos a eficácia da TB-A na enxaqueca refratária. TB-A foi injetada em pacientes com enxaqueca que fizeram tratamento prévio com no mínimo três classes de medicamentos profiláticos, sem resultados satisfatórios. A melhora mais significativa dos pacientes foi observada após 30 dias de aplicação de TB-A, enquanto intensidade da dor e freqüência de cefaléia continuaram reduzidas até o final de três meses de seguimento. Os efeitos colaterais observados após a aplicação de TB-A foram moderados e auto-limitados. Os nossos dados mostram que TB-A parece ser um tratamento seguro e eficaz para pacientes com enxaqueca refratária.

[Role of patent foramen ovale and of the Eustaquian valve in the trhomboembolic events]. / Papel do forame oval patente e da válvula de Eustáquio nos eventos tromboenbólicos.

The association between patent foramen ovale (PFO) and paradoxical emboli is described in medical literature. When have not association with atrial septal aneurysm, arguments arise about the clots origin, because it have been difficult to gave evidence of the clots passing from venous circulation across shunt right to left. We describe four cases of vascular events whose transesophageal echocardiography showed clots nailed within the PFO associated the prominent Eustachian valve, without septal aneurysm. This paper aim to illustrate and to warm about the potentially role of the PFO and Eustachian valve in the paradoxical embolism.

Papel do forame oval patente e da válvula de Eustáquio nos eventos tromboenbólicos / Role of patent foramen ovale and of the Eustaquian valve in the trhomboembolic events

A associação entre forame oval patente (FOP) e embolia paradoxal é assunto já descrito na literatura médica. Quando não existe associação com aneurisma de septo atrial, surgem dúvidas quanto à origem do trombo devido à dificuldade que se tem de documentar a passagem de êmbolos vindos da circulação venosa pelo shunt direita-esquerda. Descrevemos quatro casos de eventos vasculares, cujos ecocardiogramas transesofágicos demonstraram a presença de trombo aderido ao FOP associado à válvula de Eustáquio proeminente na ausência de aneurisma de septo. Esse artigo visa ilustrar e chamar atenção para o potencial papel do FOP e da válvula de Eustáquio na ocorrência da embolia paradoxal.

Defeitos de septo atrial como fator de risco para migrânea: um estudo de caso controle / Atrial septal defects as a risk factor for migraine: a case-control study

Para determinar a magnitude da associação entre defeitos de septo atrial (DSA) e migrânea avaliamos 101 indivíduos submetidos ao ecocardiograma transesofágico (ETE). Eles foram questionados sobre a presença de cefaléia. Migrânea foi diagnosticada segundo os critérios da Sociedade Internacional para Estudo das Cefaléias segunda edição. Pareamos 1:1 em portadores de DSA (casos) e indivíduos com septo atrial normal (controles). Calculamos frequência de migrânea e de aura e a ocorrência de mais de três crises no último mês. Analisamos as diferenças pelo teste do qui-quadrado. Pareamos 34 casos e controles. Média etária 38,7(±11,2) e 38,9(±11,17) sendo 82,4 por cento mulheres. Migrânea ocorreu em 79,4 por cento dos casos e 55,9 por cento dos controles (or= 4,3 ic 95 por cento = 1,048 - 8,89) (p= 0,038). Aura ocorreu em 65,1 por cento(casos) e 40 por cento(controles). Em 76,7 por cento casos e 60 por cento dos controles ocorreram mais de três crises no último mês. DSA se constituiu fator de risco para migrânea com aura na amostra estudada. DSA parece aumentar a freqüência de crises de migrânea.

[Atrial septal defects as a risk factor for migraine: a case-control study]. / Defeitos de septo atrial como fator de risco para migrânea: um estudo de caso controle.

To determine the magnitude of the association between atrial septal defect (ASD) and migraine. We evaluated 101 subjects submitted to transesophageal echocardiography (TEE). They have been asked about headache. Migraine diagnosis was established according the criteria of the International Headache Society (IHS). The subjects were match in cases (ASD carrier) and controls (without ASD). We analyzed the occurrence of migraine, of aura and the frequency of crises in the last month by chi-square test. We matched 34 cases and controls: 82.4% female, the mean age, in years was 38.7 (+/-11.24) and 38.9 (+/-11.17)). Migraine occurred in 79.4% of the cases and in 55.9% of the controls (OR = 4.3) CI = 95% (1.04-8.8), (p = 0.038). Aura occurred in 65.1% (cases) and 40% (controls). It was observed more than three migraine crises in the last month in 76.7% of the cases and 60% of the controls (OR = 1.56) (p = 0.2) (95% CI, 0.6 to 7.6). ASD is a risk factor to migraine with aura in the sample studied. ASD apparently increase the frequency of migraine crises.

Exacerbated inflammatory cellular immune response characteristics of HAM/TSP is observed in a large proportion of HTLV-I asymptomatic carriers.

BACKGROUND: A small fraction of Human T cell Leukemia Virus type-1 (HTLV-I) infected subjects develop a severe form of myelopathy. It has been established that patients with HTLV-I associated myelopathy/tropical spastic paraparesis (HAM/TSP) show an exaggerated immune response when compared with the immunological response observed in HTLV-I asymptomatic carriers. In this study the immunological responses in HAM/TSP patients and in HTLV-I asymptomatic carriers were compared using several immunological assays to identify immunological markers associated with progression from infection to disease. METHODS: Immunoproliferation assays, cytokine levels of unstimulated cultures, and flow cytometry analysis were used to evaluate the studied groups. Nonparametric tests (Mann-Whitney U test and Wilcoxon matched-pairs signed ranks) were used to compare the difference between the groups. RESULTS: Although both groups showed great variability, HAM/TSP patients had higher spontaneous lymphoproliferation as well as higher IFN-gamma levels in unstimulated supernatants when compared with asymptomatic carriers. Flow cytometry studies demonstrated a high frequency of inflammatory cytokine (IFN-gamma and TNF-alpha) producing lymphocytes in HAM/TSP as compared to the asymptomatic group. This difference was accounted for mainly by an increase in CD8 cell production of these cytokines. Moreover, the HAM/TSP patients also expressed an increased frequency of CD28-/CD8+ T cells. Since forty percent of the asymptomatic carriers had spontaneous lymphoproliferation and IFN-gamma production similar to HAM/TSP patients, IFN-gamma levels were measured eight months after the first evaluation in some of these patients to observe if this was a transient or a persistent situation. No significant difference was observed between the means of IFN-gamma levels in the first and second evaluation. CONCLUSIONS: The finding that a large proportion of HTLV-I carriers present similar immunological responses to those observed in HAM/TSP, strongly argues for further studies to evaluate these parameters as markers of HAM/TSP progression.

Gabapentina no tratamento da dor decorrente de cistos perineurais sacrais: relato de caso / Gabapentin to treat sacral perineural cyst-induced pain: case report

JUSTIFICATIVA E OBJETIVOS: Os cistos perineurais podem gerar dor com características neuropáticas de difícil controle. Os anticonvulsivantes são medicações utilizados para tratamento de dores com essas características. O objetivo deste relato é mostrar um caso com total remissão da dor com uso de gabapentina após o insucesso no tratamento com todas as outras alternativas terapêuticas utilizadas. RELATO DE CASO: Paciente de 67 anos, diabética, com queixa de dor lombossacra há dois meses, com as seguintes características: diária, em pontada e queimação, de intensidade leve a moderada e com irradiação para região posterior da coxa. Piorava com o movimento e com a posição ortostática. Há seis meses havia tido um episódio semelhante de dor, que melhorou com o uso de corticoesteróides. A ressonância nuclear magnética da coluna lombossacra mostrava lesões císticas perineurais sacrais em S1, S2 e S3 com diâmetro de 2,5 a 4 cm, comprimindo o saco dural associado à erosão óssea. Foi introduzida a gabapentina em doses progressivas até 900 mg/dia, com alívio completo do quadro álgico. CONCLUSÕES: A dor neuropática provocada pelo cisto de Tarlov pode ser controlada de maneira adequada com gabapentina.

BACKGROUND AND OBJECTIVES: Perineural cysts may induce difficult to control neuropathic pain. Anticonvulsivants are used to treat such pain. This report aimed at presenting a case of total pain remission with gabapentin after failure of all other therapeutic alternatives used. CASE REPORT: Female, diabetic patient, 67 years old, complaining of lumbosacral pain for two months, with the following characteristics: daily, sharp and burning pain of mild to moderate intensity irradiating to posterior thigh. Pain would worsen with movement and in the standing position. Six months before she had had a similar pain episode which improved with steroids. Lumbosacral spine MRI showed 2.5 cm sacral perineural cyst injuries at S1, S2 and S3, compressing the dural sac and associated to bone erosion. Gabapentin was introduced in progressive doses until 900 mg/day, with complete pain relief. CONCLUSIONS: Tarlov's cyst neuropathic pain may be adequately controlled with gabapentin.

JUSTIFICATIVA Y OBJETIVOS: Los quistes perineurales pueden generar dolor con características neuropáticas de difícil control. Los anticonvulsivantes son medicaciones utilizadas para tratamiento de dolores con esas características. El objetivo de este relato es mostrar un caso con total remisión del dolor con el uso de gabapentina después del mal suceso en el tratamiento con todas las otras alternativas terapéuticas utilizadas. RELATO DE CASO: Paciente de 67 anos, diabética, con queja de dolor lombosacra hace dos meses, con las siguientes características: diaria, en puntada y quemazón, de intensidad leve a moderada y con irradiación para región posterior del muslo. Peoraba con el movimiento y con la posición ortostática. Hace seis meses tuvo un episodio semejante de dolor, que mejoró con el uso de corticoesteróides. La resonancia nuclear magnética de la columna lombosacra mostraba lesiones císticas perineurales sacrales en S1, S2 y S3 con diámetro de 2,5 a 4 cm, comprimiendo el saco dural asociado a la erosión ósea. Fue introducida la gabapentina en dosis progresivas hasta 900 mg/día, con alivio completo del cuadro álgico. CONCLUSIONES: El dolor neuropático provocado por el quiste de Tarlov puede ser controlada de manera adecuada con gabapentina.

Gabapentin to treat sacral perineural cyst-induced pain. Case report.

BACKGROUND AND OBJECTIVES: Perineural cysts may induce difficult to control neuropathic pain. Anticonvulsivants are used to treat such pain. This report aimed at presenting a case of total pain remission with gabapentin after failure of all other therapeutic alternatives used. CASE REPORT: Female, diabetic patient, 67 years old, complaining of lumbosacral pain for two months, with the following characteristics: daily, sharp and burning pain of mild to moderate intensity irradiating to posterior thigh. Pain would worsen with movement and in the standing position. Six months before she had had a similar pain episode which improved with steroids. Lumbosacral spine MRI showed 2.5 cm sacral perineural cyst injuries at S1, S2 and S3, compressing the dural sac and associated to bone erosion. Gabapentin was introduced in progressive doses until 900 mg/day, with complete pain relief. CONCLUSIONS: Tarlov's cyst neuropathic pain may be adequately controlled with gabapentin.