Headache Medicine, v.1, n.1, p. 5-8, jan./fev./mar. 2010 5

Headaches and hyperhidrosis: clinical features

and outcomes after surgery

Dores de cabeça e hiperidrose: características clínicas e os resultados

após a cirurgia

RESUMORESUMO

RESUMO

Cefaleias e hiperidrose são doenças comuns e incapacitantes.

Várias cefaleias primárias têm proeminente envolvimento do

sistema nervoso autônomo. A principal opção terapêutica

para a hiperidrose focal grave aborda o sistema nervoso autô-

nomo (simpatectomia toracoscópica). Avaliamos os resultados

das características das cefaleias em pacientes com hiperidrose

antes e após a simpatectomia. A amostra foi composta de 53

pacientes (43 mulheres e 10 homens) com hiperidrose e dores

de cabeça. As características clínicas e os resultados foram

avaliados no início e após a cirurgia. A média de idade da

amostra foi de 27,1 anos, 29 pacientes apresentaram hiperi-

drose palmar-plantar, 17 tinham palmar-axilar, 9 tiveram

craniofacial e 4 apresentavam hiperhidrose axilar pura. Vinte

e quatro (54,8%) pacientes preencheram critérios para diag-

nóstico de enxaqueca, 20 (37,7%) tinham provável enxaqueca

e 4 (7,5%) apresentaram cefaleia do tipo tensional. Cefaleia

ocorreu após o início da hiperidrose em 37 (69,8%) pacientes.

A ansiedade foi relatada por 94% dos pacientes. Vinte e quatro

(45,3%) pacientes relataram melhora dos sintomas de dor

após a cirurgia, 23 (43,4%) não relataram nenhuma mudança

e 6 (11,3%) tiveram piora dos sintomas após a cirurgia. A

freqüência de crises de cefaleia foi significativamente reduzida

após a cirurgia. A hiperidrose pode ser uma comorbidade da

enxaqueca, que compartilham uma disfunção autonômica.

alavrasalavras

alavras

chave:chave:

chave: Hiperidrose; cefaleia; simpatectomia.

ORIGINAL ARTICLE

ABSTRACTABSTRACT

ABSTRACT

Both headache disorders and hyperhidrosis are debilitating

conditions. Several primary headache syndromes have

prominent autonomic features; the main therapeutic option

for severe, focal hyperhidrosis addresses the autonomic system

(thoracoscopic sympathectomy). Accordingly, herein we

assessed headache outcomes in patients with hyperidrosis after

sympathectomy. Sample consisted of 53 patients (43 women

and 10 men) with hyperhidrosis and headaches. Headache

clinical features and outcomes were assessed at baseline and

after surgery. Mean age of sample was 27.1 years; 29 patients

had palmar-plantar hyperidrosis, 17 had palmar-axillary, 9

had craniofacial and 4 had purely axillary hyperhidrosis. Twenty

four (54.8%) patients had migraine; 20 (37.7%) had probable

migraine and 4 (7.5%) had tension-type headache. Headache

onset occurred after hyperhidrosis onset in 37 (69.8%) patients.

Anxiety was reported by 94% of patients. Twenty four (45.3%)

patients reported improvement of headache symptoms after

surgery, 23 (43.4%) reported no change and 6 (11.3%) had

worsening of symptoms after surgery. Overall headache

frequency was significantly reduced after surgery, as contrasted

to baseline. Hyperhidrosis may be comorbid to migraine,

trough shared autonomic dysfunctions.

ey words: ey words:

ey words: Hyperhidrosis; headache; sympathectomy

Mario Fernando Prieto Peres,

Bianca Ferreira S. Brandão,

Paulo Kauffman,

1,2

José Ribas Milanez de Campos

1,2

Fábio Biscegli Jatene,

1,2

Nelson Wolosker

1,2

Hospital Israelita Albert Einstein, Instituto Israelita e Ensino e Pesquisa Albert Einstein

São Paulo-SP, Brazil

Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (USP)

São Paulo-SP, Brazil

Peres MFP, Brandão BFS, Kauffman P, Campos JRM, Jatene FB, Wolosker N

Headaches and hyperhidrosis: clinical features and outcomes after surgery. Headache Medicine. 2010;1(1):5-8

6 Headache Medicine, v.1, n.1, p. 5-8, jan./fev./mar. 2010

MARIO FERNANDO PRIETO PERES E COLABORADORES

INTRODUCTION

Both primary headache syndromes and hyperhidrosis

are common and debilitating disorders. Taking migraine

as an example, it affects around 10% of men and 20% of

women from the general population.

1-3

Primary focal

hyperhidrosis is a disorder of idiopathic excessive sweating

that typically affects the axillae, palms, soles, and face.

4,5

Although epidemiologic data on hyperhidrosis are scarce

and insufficient to provide precise prevalence or impact

estimates, the condition seems to affect up to 9% of the

population, in the U.S., a prevalence of 2.8% was found, of

which 0.5% were intolerable.

6,7

Hyperhidrosis is associated

with significant psychosocial impact.

Comorbidity is one of the most challenging areas in

the headache field,

relevant to epidemiology,

10-12

mechanisms,

and management.

Hyperhidrosis and

migraine have features in common. First, autonomic

features are prominent in both conditions,

15,16

although

with different magnitude of effect. Second, therapeutic

interventions targeting the autonomic system are first line

for the treatment of both conditions. Beta-blockers are

approved for the preventive treatment of migraine,

while

thoracoscopic sympathectomy is the first-line treatment for

hyperhidrosis.

Finally, both conditions have common

comorbidities, including anxiety and obesity.

10,19-21

Although the many similarities, headache disorders

and hyperhidrosis have not been studied in detail.

Accordingly, herein we aimed to study, in patients with

migraine and hyperhidrosis, headache outcomes after

thoracoscopic sympathectomy.

PATIENTS AND METHODS

Our sample was identified from a pool of 1,119

patients with hyperhidrosis, referred to surgical intervention

from 1995 to 2004. Since this study is retrospective, we

identified 53 patients that had spontaneously reported

migraine headaches in the pre-surgical assessments.

All patients were evaluated in detail before the

surgery, and information was documented. Data on age,

gender, time of onset of hyperhidrosis, hyperhidrosis

location and subtype, headache diagnosis, headache

frequency 3 months before and after surgery, level of

surgery (G2, 3, 4), and improvement or worsening of

headaches after surgery were collected.

Headache diagnosis was made according to the

International Headache Society diagnostic criteria

(2004)

and reviewed by one of the authors (MFP).

Anxiety levels were also ascertained before surgery. Anxiety

was categorized in absent, mild, moderate, or severe.

Data were summarized using descriptive statistics. Pre-

post analyses were conducted using the paired t-test. A

significance level of 0.05 was defined a priori.

RESULTS

Our sample consists of 43 women and 10 men, with

mean age of 27.1 years.

16-52

Of them, 29 had palmar-

plantar hyperhidrosis, 17 had palmar-axillary, 9

craniofacial and 4 pure axillary hyperhidrosis symptoms.

All patients were submitted to surgery, 10 at the G2

level, 5 at G2 and G3, 20 at G3, and 18 at G3 and G4.

All procedures involved thermal ablation. A total of 24

(54.8%) patients had migraine, 20 (37.7%) had probable

migraine and 4 (7.5%) had tension-type headache.

Headache onset preceded onset of hyperhidrosis in

16 (30.2%) patients; it appeared after hyperhidrosis onset

in 37 (69.8%). Anxiety was reported by 50 patients (94%),

being mild in 2, moderate in 17, severe in 24 and very

severe in 7.

Twenty four (45.3%) patients reported improvement

of headache symptoms after surgery, 23 (43.4%) reported

no change and 6 (11.3%) reported worsening after

surgery. Comparing headache frequency reported 3

months before and after surgery, 28 (53%) patients

reported no change in frequency; 13 (24.5%) were

headache free; 7 (13.2%) reported reduction of 50% or

more, and only 5 (9.3%) reported increased headache

frequency.

Mean headache frequency was 7.9 ± 1.6 headache

days before surgery, and was significantly reduced after

surgery (4.8 ± 2.1, p<0.01). Both migraine and tension-

type headache equally improved after surgery.

DISCUSSION

Herein we assessed headache outcomes in patients

with headache and hyperhidrosis submitted to thoracoscopic

sympathectomy. Since autonomic dysfunctions are of

importance in both conditions,

15,16,23

the topic is of

relevance, although poorly studied.

The sample size of our study was neither large nor

selected to be representative of the population. It is indeed

a convenience sample of patients with hyperhidrosis who

spontaneously complained about headaches to the

Headache Medicine, v.1, n.1, p. 5-8, jan./fev./mar. 2010 7

thoracic surgeon. Since the prevalence of primary

headache disorders is much higher than the 5% rate found

in our sample,

2,24,25

we acknowledge the existence of an

enrollment bias and issues of non-representability. The

proportion of individuals with anxiety (94%) supports this

assumption. Accordingly, we emphasize that this is not a

study designed to evaluate headache prevalence in

individuals with hyperhidrosis, but to investigate headache

outcomes in individuals submitted to autonomic surgical

intervention, who were unaware of the potential benefit

of the intervention to the headaches.

Our data collection is retrospective, not obtained from

headache diaries. Although the obtained information may

not be precise, the subjective perception of improvement

after surgery should be real. Since improvement of

hyperhidrosis after surgery is high,

8,26

and patients

satisfaction with surgery is higher than 90%, the observed

headache response after surgery could be secondary to

improvement in self-image and reduction of overall

burden due to hyperhidrosis. Few patients reported

worsening of headaches after surgery. Accordingly,

although our data suggest headache improvement after

thoracoscopic sympathectomy, putative mechanisms

(autonomic ablation versus decrease in anxiety or stress)

need to be further studied.

Headache is commonly reported by individuals with

hyperhidrosis. In a study of 388 patients, most frequent

associated features were facial blushing (60.3%),

palpitations (52.3%), muscle contraction (48%), hand

tremors (31.8%) and headaches (30.8%), although

headache diagnosis was not performed.

Anxiety disorders are also highly associated with

hyperhidrosis

and with headache disorders.

After

surgery, patients with hyperhidrosis are less likely to report

anxiety and other symptoms including headaches (29%

before versus 9% after surgery).

Causality is still to be

determined, and it may be that headache response is

explained by autonomic regulation after sympathectomy.

Indeed, hyperhidrosis and headache disorders may share

common pathophysiologic mechanisms included altered

sympathetic nervous system and hypothalamic dysfunction.

CONCLUSION

In patients with hyperhidrosis, migraine was the most

common primary headache type. Headaches usually

started after the onset of hyperhidrosis symptoms. Most

but not all patients reported headache improvement after

thoracic sympathectomy.

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HEADACHES AND HYPERHIDROSIS: CLINICAL FEATURES AND OUTCOMES AFTER SURGERY

8 Headache Medicine, v.1, n.1, p. 5-8, jan./fev./mar. 2010

Correspondence

Mario FMario F

Mario F

ernando Pernando P

ernando P

rieto Prieto P

rieto P

eres, MDeres, MD

eres, MD

01424-001 – São Paulo-SP – Brazil

http://cefaleias.com.br

marioperes@yahoo.com

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MARIO FERNANDO PRIETO PERES E COLABORADORES