Headache Medicine, v.10, n.4, 2019

EDITORIAL

Do we know all the triggers of migraine?

Conhecemos todos os gatilhos da enxaqueca?

Raimundo Pereira Silva-Néto ............................................................................................................................................................ 173

ORIGINAL ARTICLE

The impact of anxiety and depression on migraine patients’ journey to a tertiary headache center

Impacto da ansiedade e depressão na jornada dos pacientes com enxaqueca a um centro de cefaleia terciário

Érica C Santos; Juliane P P Mercante; André M S Silva; Rosana T Miyazaki; Pamella F Daud; Arao B Oliveira;

Mario F P Peres...................................................................................................................................................................................174-181

Application of thermal microcautery in migraine management

Aplicação da microcauterização térmica no manejo da migrânea

Eleni Papageorgiou; Konstantine Kovas; Camillus Power; Nikolaos Kostopoulos.......................................... 182-185

Cefaleia Dialítica Associada à Cefaleia por Privação de Cafeína em Pacientes Submetidos à Hemodiálise

Dialysis Headache Associated with Caffeine-Withdrawal Headache in Patients Undergoing Hemodialysis

Edarlan Barbosa dos-Santos; Kattiucy Gabrielle da Silva Brito; Bernardo Afonso Ribeiro Pinto; Tatiane

Fernandes da Fonseca Gaban; Antonio Marcos da Silva Catharino.......................................................................186-188

Prevalence of thunderclap headache in patients with ruptured intracranial aneurysms: series of 60 cases

Prevalência de cefaleia thunderclap em pacientes com aneurimas intracraniano roto: série de 60

Bruno Bertoli Esmanhotto;

Elcio Juliato Piovesan;

Marcos Christiano Lange.....................................................189-192

VIEWS AND REVIEWS

Clinical characteristics of headaches attributed to diagnostic and therapeutic procedures

Características clínicas das cefaleias atribuídas a procedimentos diagnósticos e terapëuticos

Raimundo Pereira Silva-Néto.....................................................................................................................................................193-197

Telemedicine in the Management of Primary Headaches: A Critical Review

Telemedicina no manejo das cefaleias primárias: uma revisão crítica

Renan Barros Domingues; Cassio Batista Lacerda; Paulo Diego Santos Silva.................................................198-202

CASE REPORT

Intracranial lipoma manifesting with change in preexisting headache characteristics

Lipoma intracraniano que se manifesta com mudança das características de cefaleia preexistente

Patrick Emanuell Mesquita Sousa Santos; Ivan Rodrigues Silva; Mário Fernando Prieto Peres; Raimundo

Pereira Silva-Néto.........................................................................................................................................................................203-204

IMAGES

The neurologist’s hammer

O martelo do neurologista

Eduardo Nogueira; Yara Dadalti Fragoso.........................................................................................................................205-207

Headache Medicine

Scientic Publication of the Brazilian Headache Society

VOLUME 10 ∙ NUMBER 4 ∙ 2019

ISSN 2178-7468

CONTENTS

Headache Medicine, v.10, n.4, 2019

Headache Medicine

Scientic Publication of the Brazilian Headache Society

Editores-chefes

Marcelo de Moraes Valença

Universidade Federal de Pernambuco, Recife, PE, Brasil.

Mario Fernando Prieto Peres

Hospital Israelita Albert Einstein, IPq – HCFMUSP, São Paulo, SP, Brasil.

Editor Cientíco

Raimundo Pereira Silva-Néto

Universidade Federal do Delta do Parnaíba, Parnaíba, PI, Brasil.

Editor Emeritus

Wilson Luiz Sanvito

FCM Santa Casa de São Paulo, São Paulo, SP, Brasil.

Pesquisa Básica e Procedimentos

Élcio Juliato Piovesan

Universidade Federal do Paraná, Curitiba, PR, Brasil.

Ensino, alunos e residentes

Yara Dadalti Fragoso – Santos, SP, Brasil.

Cefaleia na Mulher

Eliane Meire Melhado

Universidade de Catanduva, Catanduva, SP, Brasil.

Multiprossional

Juliane Prieto Peres Mercante

IPq – HCFMUSP, São Paulo, SP, Brasil.

Arão Belitardo de Oliveira

ABRACES – Associação Brasileira cefaleia em Salvas e

Enxaqueca, São Paulo, SP, Brasil.

Debora Bevilacqua Grossi

FMUSP – Rebeirão Preto, SP, Brasil.

Cefaleias Secundárias

Pedro Augusto Sampaio Rocha

Universidade Federal de Pernambuco, Recife, PE, Brasil.

Hipertensão e Hipotensão Liquórica

Ida Fortini HC FMUSP, São Paulo, SP, Brasil.

Sandro Matas

UNIFESP, São Paulo, SP, Brasil

Cefaleias Trigêmino-Autonômicas

Maria Eduarda Nobre

Rio de Janeiro, RJ, Brasil

Cefaleia na Infância

Marco Antônio Arruda

Universidade Federal de São Paulo, SP, Brasil.

Dor orofacial

Eduardo Grossmann – Porto Alegre, RS, Brasil.

Controvérsias e Expert Opinion

Joao José Freitas de Carvalho – Fortaleza, CE, Brasil.

Clinical Trials

Fabiola Dach

FMUSP, Ribeirão Preto, SP, Brasil.

Teses

Fernando Kowacs, Porto Alegre, RS, Brasil.

Imagens e Vídeos

Paulo Sergio Faro Santos

INC, Curitiba, PR, Brasil.

Advocacy

Elena Ruiz de La Torre

WHAM (World Headache Association for Migraine)

Madri, Espanha.

A revista Headache Medicine é uma publicação de propriedade da Sociedade Brasileira de Cefaleia, indexada no Latindex e no Index Scholar, publicada

pela Sociedade Brasileira de Cefaleia, www.sbcefaleia.com.br. Os manuscritos aceitos para publicação passam a pertencer à Sociedade Brasileira de

Cefaleia e não podem ser reproduzidos ou publicados, mesmo em parte, sem autorização da HM & SBCe. Os artigos e correspondências deverão ser

encaminhados para a HM através de submissão on-line, acesso pela página www.headachemedicine.com.br - Distribuição gratuita para os membros

associados, bibliotecas regionais de Medicina e faculdades de Medicina do Brasil, e sociedades congêneres

Editores Associados

CONSELHO EDITORIAL

ISSN 2178-7468

iii

Headache Medicine, v.10, n.4, 2019

Headache Medicine

Scientic Publication of the Brazilian Headache Society

CONSELHO EDITORIAL

Rodrigo Noseda

Harvard Medical School, Boston, MA, EUA

Marlind Alan Stiles

Jefferson Universtty, Philadelphia, PA, EUA

Charles Siow, Singapore

Maurice Borges Vincent, Indianapolis, IN, EUA

Michele Viana, Novara, Itália

Margarita Sanchez Del Rio, Madri, Espanha

Sait Ashina,

Harvard Medical School, Boston, MA, EUA

Todd D Rozen,

Mayo Clinic, Jacksonville, FL, EUA

Elena Ruiz de la Torre, Espanha

Marco Lisicky, Cordoba, Argentina

Maria Teresa Goycochea, Buenos Aires, Argentina

Alex Espinoza Giacomozzi, Santiago, Chile

Joe Munoz Ceron, Bogotá, Colômbia

Faisal Amin, Copenhague, Dinamarca

Uwe Reuter, Berlim, Alemanha

Abouch Valenty Krymchantowski, Rio de Janeiro, RJ

Alan Chester Feitosa Jesus, Aracaju, SE

Ana Luisa Antonniazzi, Ribeirão Preto, SP

Carla da Cunha Jevoux, Rio de Janeiro, RJ

Carlos Alberto Bordini, Batatais, SP

Daniella de Araújo Oliveira, Recife, PE

Djacir D. P. Macedo, Natal, RN

Elder Machado Sarmento, Barra Mansa, RJ

Eliana Meire Melhado, Catanduva, SP

Fabíola Dach, Ribeirão Preto, SP

Fernando Kowacs, Porto Alegre, RS

Henrique Carneiro de Campos, Belo Horizonte, MG

Jano Alves de Sousa, Rio de Janeiro, RJ

João José de Freitas Carvalho, Fortaleza, CE

Luis Paulo Queiróz, Florianópolis, SC

Marcelo C. Ciciarelli, Ribeirão Preto, SP

José Geraldo Speziali, Ribeirão Preto, SP

Marcelo Rodrigues Masruha, Vitória, ES

Pedro Ferreira Moreira Filho, Rio de Janeiro, RJ

Pedro André Kowacs, Curitiba, PR

Mauro Eduardo Jurno, Barbacena, MG

Paulo Sergio Faro Santos, Curitiba, PR

Pedro Augusto Sampaio Rocha Filho, Recife, PE

Renata Silva Melo Fernandes, Recife, PE

Thais Rodrigues Villa, São Paulo, SP

Renan Domingues, Vitória, ES

Conselho Editorial Internacional

Conselho Editorial Nacional

A revista Headache Medicine é uma publicação de propriedade da Sociedade Brasileira de Cefaleia, indexada no Latindex e no Index Scholar, publicada

pela Sociedade Brasileira de Cefaleia, www.sbcefaleia.com.br. Os manuscritos aceitos para publicação passam a pertencer à Sociedade Brasileira de

Cefaleia e não podem ser reproduzidos ou publicados, mesmo em parte, sem autorização da HM & SBCe. Os artigos e correspondências deverão ser

encaminhados para a HM através de submissão on-line, acesso pela página www.headachemedicine.com.br - Distribuição gratuita para os membros

associados, bibliotecas regionais de Medicina e faculdades de Medicina do Brasil, e sociedades congêneres

ISSN 2178-7468

Headache Medicine, v.10, n.4, 2019

Sociedade Brasileira de Cefaleia – SBCe

liada à International Headache Society – IHS

Av. Tenente José Eduardo n° 453, sala 203

27323-240 Barra Mansa - RJ - Brasil

Fone:+55 (24) 9 8847-9980 www.sbcefaleia.com.br

secretaria@sbcefaleia.com.br

Josiane Moreira da Silva - Secretária Executiva SBCe

DIRETORIA 2018/2021

DELEGADOS

Academia Brasileira de Neurologia (ABN)

Fernando Kowacs

José Geraldo Speziali

American Headache Society (AHS)

Marcelo Cedrinho Ciciarelli

Associación Latinoamericana de Cefaleias (ASOLAC)

Carlos Alberto Bordini

European Headache Federation (EHF)

Marco Antônio Arruda

International Headache Society (IHS)

Pedro André Kowacs

Sociedade Brasileira para o Estudo da Dor (SBED)

Eduardo Grossman - José G Speziali

Responsável pelo Site

Paulo Sérgio Faro Santos

Responsável pelas Mídias Sociais

Arão Belitardo Oliveira

Comissão de Ética

Elcio Juliato Piovesan - Jano Alves de Souza

José Geraldo Speziali - Mauro Eduardo Jurno

Registro de Cefaleia no Brasil

Fernando Kowacs - Mauro Eduardo Jurno

Vanise Grassi - Élder Machado Sarmento

Liselotte Menke Barea - Luis Paulo Queiroz

Marcelo Cedrinho Ciciarelli - Mario FP Peres

Pedro Augusto Sampaio Rocha-Filho

Políticas Públicas, Institucionais e Advocacy

Patricia Machado Peixoto

COMISSÕES

Prêmios

Carlos A Bordini - Djacir Dantas de Macedo

Jano Alves de Souza - Mauro Eduardo Jurno

Pedro F Moreira Filho - Raimundo P Silva-Néto

Atividades Físicas e Fisioterapia

Cláudia Baptista Tavares - Daniela A Oliveira

Debora Bevilaqua-Grossi

Cefaleia na Infância

Marco Antonio Arruda - Thais Rodrigues Villa

Cefaleia na mulher

Eliana Meire Melhado

Dor Orofacial

Ricardo Tanus Valle

Leigos

Celia A P Roesler - Henrique Carneiro de

Campos - João José Freitas de Carvalho

Paulo Sérgio Faro Santos

Alunos Residentes

Yara Dadalti Fragoso - Diego Belandrino Swerts

Izadora Karina da Silva - Marcos Ravi Cerqueira

Ferreira Figueiredo - Caroline Folchini

Saulo Emanuel Gomes Silva - Walkyria Will-

Patrick Emanuell - Eduardo Nogueira

Psicologia

Juliane Prieto Peres Mercante - Rebeca V. A.

Vieira - Rosemeire Rocha Fukue

Procedimentos Invasivos

Cláudio Manoel Brito

Élcio Juliato Piovesan

Presidente Elder Machado Sarmento

Secretário Mario Fernando Prieto Peres

Tesoureiro Pedro Augusto Sampaio Rocha Filho

173

Headache Medicine, v.10, n.4, p.173, Out/Nov/Dez. 2019

EDITORIAL

Do we know all the triggers of migraine?

Conhecemos todos os gatilhos da enxaqueca?

Raimundo Pereira Silva-Néto

Scientic Editor, Headache Medicine

*Correspondence

Raimundo Pereira Silva-Néto

Universidade Federal do Delta do

Parnaíba, Avenida São Sebastião, 2819,

Fátima, Parnaíba, PI, 64001-020, Brasil.

Tel. + 55 3237-2104.

E-mail: neurocefaleia@terra.com.br

Migraine trigger is understood as any factor that is temporally

associated with the development of migraine attacks. These triggers can

be single or multiple for the same patient. In order to study these triggers,

a recent meta-analysis analyzed 85 published articles and found 420

unique triggers that triggered headache attacks in only 86% of migraine

patients

Some of these triggers are noteworthy, such as odors. In an

experimental study, Silva-Néto et al

exposed two groups of patients,

one with migraine; and another with other primary headaches.

Headache attacks were triggered by odor only in patients with migraine,

corresponding to 34.7% of the sample, but in none with other primary

headaches.

When studying the triggers, we must look at some of their

particularities. First, the frequency with which they are found, for

example, stress, odor, prolonged fasting or sleep deprivation are cited

by most migraine patients. Second, the potency of causing pain, that is,

the likelihood of the patient having a headache attack after exposure.

Investigating triggers and clarifying the patient is critical. When he/she

identies any trigger of his pain, there will be a change in behavior in

response to that factor

What is the percentage of migraine attacks that occur without any

triggers? This is a frequent question from neurologists and patients.

According to the meta-analysis shown, 14% of patients did not identify

any triggers

. We do not yet know if there are migraine attacks in the

absence of any triggering factors or if these factors are unknown.

Is the patient able to identify all triggering factors of their migraine

attacks? Would neuronal hyperexcitability make the patient more

vulnerable to external and internal factors? There are many unanswered

questions. Therefore, future studies need to be conducted to clarify these

doubts.

REFERENCES

1. Pellegrino ABW, Davis-Martin RE, Houle TT, Turner DP, Smitherman TA (2018).

Perceived triggers of primary headache disorders: A meta-analysis. Cephalalgia,

38(6):1188-1198.

2. Silva-Néto RP, Rodrigues ÂB, Cavalcante DC, Ferreira PH, Nasi EP, Sousa KM, et al

(2017). May headache triggered by odors be regarded as a differentiating factor

between migraine and other primary headaches? Cephalalgia, 37(1):20-28.

3. Turner DP, Jchtay I, Lebowitz AD, Leffert LR, Houle TT (2018). Perceived migraine

triggers: Understanding trigger perception can improve management. Practical

Neurology, 37-41.

174

Headache Medicine, v.10, n.4, p.174-181, Out/Nov/Dez. 2019

ABSTRACT

ORIGINAL ARTICLE

The impact of anxiety and depression on migraine patients’

journey to a tertiary headache center

Impacto da ansiedade e depressão na jornada dos pacientes

com enxaqueca a um centro de cefaleia terciário

Érica C Santos

1,2

Juliane P P Mercante, PhD

André M S Silva, MD

Rosana T Miyazaki

Pamella F Daud

Arao B Oliveira, PhD

Mario F P Peres, PhD

1,3

Universidade de São Paulo, Faculdade de

Medicina, Instituto de Psiquiatria, São Paulo,

Brazil.

Universidade de São Paulo, Faculdade de

Neurociência e Comportamento, Instituto de

Psicologia, São Paulo, Brazil.

Hospital Israelita Albert Einstein, São Paulo,

Brazil.

Universidade de São Paulo, Faculdade de

Medicina, Departamento de Neurologia São

Paulo, Brazil.

Universidade de São Paulo, Faculdade de

Medicina, Instituto de Psiquiatria, São Paulo,

Brazil.

*Correspondence

Mario Fernando Prieto Peres

E-mail: marioperes@usp.br

Received: November 5, 2019.

Accepted: November 12, 2019.

Objective: To evaluate the role of psychiatric comorbidity in the number of

diagnostic procedures, acute and preventive pharmacological treatments,

and non-pharmacological interventions in migraine patients experienced

before visiting a tertiary headache center in São Paulo, Brazil. Methods: We

conducted a retrospective, observational study of 465 consecutive patients

diagnosed with migraines and evaluated in a specialized tertiary headache

center in São Paulo, Brazil. We collected the data based on medical chart

reviews and a self-administered questionnaire routinely performed during the

rst medical visit. Two standardized instruments were used for the diagnosis

of depression and anxiety, respectively: the Patient Health Questionnaire-9

(PHQ-9) and the Generalized Anxiety Disorder (GAD-7). Results: We studied

465 patients diagnosed with migraines. The patients’ mean age was 37.3 years

(±13.1), and 72.7% of patients were women. The average age of headache onset

was 17.1 years (±11.4) before the rst appointment at our tertiary headache

center, and 51.7% of patients had chronic migraines. Most patients (65.8%)

had a PHQ-9 ≥ 5, indicating at least some depressive symptoms, whereas 152

patients (34.2%) were considered depressed (PHQ-9 ≥ 9). Anxiety symptoms

were observed in 68.2% of patients based on the GAD-7 instrument, and 209

patients (47.0%) were diagnosed with anxiety (GAD-7 ≥ 8). Chronic migraines

were more common than episodic migraines among patients with psychiatric

comorbidity: 63.2% of depressive patients, 61.2% of anxious patients, and

43.5% of patients without any psychiatric disorder. Most patients underwent

laboratory tests and brain imaging (62.4% and 70.5%, respectively) in a similar

proportion among subgroups with and without anxiety or depression. Non-

pharmacological treatment was frequent in all subgroups, and 342 patients

(73.5%) performed at least one modality. Overall, acupuncture was the most

common non-pharmacological treatment (55.2% of patients), and we found

no difference between the subgroups. Depressive and anxious patients more

frequently underwent psychotherapy (54.2% and 50.8%, respectively) when

compared to patients with neither depression nor anxiety (34.7%). Depression

was associated with a reduced likelihood of previous physiotherapy (OR 0.39,

CI 0.16 – 0.99). Patients with severe anxiety used 10.7 times more medicines

than non-severe patients. Conclusion: Depressed patients underwent more

psychotherapy than non-depressed patients, although they had a reduced

chance of previous physiotherapy. Anxiety was also associated with previous

psychotherapy and a risk of 10.7 times of using acute pharmacological

treatment, which may lead to issues related to analgesic abuse. Anxiety and

depression affect the journey of patients with migraines before arriving at a

tertiary headache center.

Keywords: Migraine; Headache; Anxiety; Depression; Psychiatric Comorbidity.

The impact of anxiety and depression on migraine patients

Santos ÉC, et al.

175

Headache Medicine, v.10, n.4, p.174-181, Out/Nov/Dez. 2019

RESUMO

Objetivo: Avaliar o papel da comorbidade psiquiátrica no número de procedimentos

diagnósticos, tratamentos farmacológicos agudos e preventivos e intervenções não

farmacológicas em pacientes com enxaqueca experimentados antes de visitar um

Centro Terciário de Cefaleia em São Paulo, Brasil. Métodos: Realizamos um estudo

retrospectivo observacional de 465 pacientes consecutivos diagnosticados com

enxaqueca e avaliados em um centro especializado em cefaleia terciária em São Paulo,

Brasil. Coletamos os dados com base em revisões de prontuários médicos e em um

questionário autoaplicado rotineiramente realizado durante a primeira consulta médica.

Dois instrumentos padronizados foram utilizados para o diagnóstico de depressão

e ansiedade, respectivamente: o Questionário de Saúde do Paciente-9 (PHQ-9) e o

Transtorno de Ansiedade Generalizada (GAD-7). Resultados: Foram estudados 465

pacientes com diagnóstico de enxaqueca. A idade média dos pacientes foi de 37,3

anos (± 13,1) e 72,7% dos pacientes eram mulheres. A idade média do início da dor de

cabeça foi de 17,1 anos (± 11,4) antes da primeira consulta em nosso Centro Terciário

de Cefaleia, e 51,7% dos pacientes apresentavam enxaqueca crônica. A maioria dos

pacientes (65,8%) apresentou um PHQ-9 ≥ 5, indicando pelo menos alguns sintomas

depressivos, enquanto 152 pacientes (34,2%) foram considerados deprimidos (PHQ-9

≥ 9). Os sintomas de ansiedade foram observados em 68,2% dos pacientes com base

no instrumento GAD-7, e 209 pacientes (47,0%) foram diagnosticados com ansiedade

(GAD-7 ≥ 8). As enxaquecas crônicas foram mais comuns que as enxaquecas episódicas

em pacientes com comorbidade psiquiátrica: 63,2% dos pacientes depressivos, 61,2%

dos ansiosos e 43,5% dos pacientes sem nenhum transtorno psiquiátrico. A maioria

dos pacientes foi submetida a exames laboratoriais e imagens cerebrais (62,4% e

70,5%, respectivamente) em proporção semelhante entre os subgrupos com e sem

ansiedade ou depressão. O tratamento não farmacológico foi frequente em todos

os subgrupos e 342 pacientes (73,5%) realizaram pelo menos uma modalidade. No

geral, a acupuntura foi o tratamento não farmacológico mais comum (55,2% dos

pacientes), e não encontramos diferença entre os subgrupos. Pacientes depressivos

e ansiosos foram submetidos a psicoterapia com mais frequência (54,2% e 50,8%,

respectivamente) quando comparados aos pacientes sem depressão nem ansiedade

(34,7%). A depressão foi associada a uma probabilidade reduzida de sioterapia prévia

(OR 0,39, IC 0,16 - 0,99). Pacientes com ansiedade grave usavam 10,7 vezes mais

medicamentos do que pacientes não graves. Conclusão: Pacientes deprimidos foram

submetidos a mais psicoterapia do que pacientes não deprimidos, embora tivessem

uma chance reduzida de sioterapia anterior. A ansiedade também foi associada à

psicoterapia anterior e a um risco de 10,7 vezes do uso de tratamento farmacológico

agudo, o que pode levar a questões relacionadas ao abuso de analgésicos. Ansiedade

e depressão afetam a jornada de pacientes com enxaqueca antes de chegarem a um

Centro Terciário de Cefaleia.

Descritores: Enxaqueca, Dor de Cabeça, Ansiedade, Depressão, Comorbidade

Psiquiátrica.

INTRODUCTION

Migraine is a common chronic neurological disease

and a leading cause of disability worldwide, affecting

daily and social activities (1). In a study on the global

burden of disease, migraine had an average prevalence

of 14% and was the second highest contributor of

DALYs (disability-adjusted life-years) (2). In Brazil, the

population-based prevalence of migraine varies from

10.7% to 22.1% (3), and in tertiary care centers, migraines

represent 38% of all headaches (4).

Anxiety and mood disorders are the psychiatric

comorbidities most often associated with migraines. These

conditions are 2 to 10 times more common in patients

with migraines than in the general population, which

increases the complexity of their medical management

(5, 6). Patients with migraines and comorbid anxiety

and/or depression experience higher medical costs when

compared to patients with no comorbidities (7) due to

resource utilization, including medical visits, diagnostic

tests, and therapeutic interventions (8, 9). Additionally,

migraineurs are less optimistic and more pessimistic than

non-migraneurs, which may also inuence their medical

care seeking (10).

Patients with anxiety use health care services

for medical consultations, emergencies, and

examinations more often than individuals without

mental disorders (12.5 ± 8.1 vs. 2.4 ± 2.6 visits/year)

(11). In earlier surveys, anxiety and mood disorders

were consistently associated with substantial

impairments in both productive roles (e.g., work

absenteeism, work performance, unemployment, and

underemployment), social roles (e.g., social isolation,

interpersonal tensions, and marital disruption) (12, 13),

and greater stigma (14). Stigma is a signicant aspect

of mental and neurological conditions (15). It is a

process involving labeling, separation, knowledge and

emphasis of stereotypes, prejudice, and discrimination

in the context in which power is exercised over

disadvantaged members of a social group (16).

Tertiary headache centers usually manage more

difcult patients, including those with medical and

psychiatric comorbidities (5). Information regarding the

patient journey to a specialty headache care center is

The impact of anxiety and depression on migraine patients

Santos ÉC, et al.

176

Headache Medicine, v.10, n.4, p.174-181, Out/Nov/Dez. 2019

limited, and the inuence of psychiatric comorbidity on

the migraine patient journey is unknown.

In this study, we aimed to assess the role of psychiatric

comorbidity on the number of diagnostic procedures,

preventive and acute pharmacological treatments, and

non-pharmacological interventions migraine patients

experienced before visiting a tertiary headache center,

in São Paulo, Brazil. We hypothesized that anxiety and

depression increase the number of previous diagnostic

tests and treatment experiences.

METHODS

Study design

We conducted a retrospective, observational study of

465 consecutive patients with migraine diagnoses based

on the International Classication of Headache Disorders

– 3

edition (ICHD-3). The patients were evaluated in

a specialized tertiary headache center from March to

July 2017, in São Paulo, Brazil. We collected the data

through medical chart reviews and a self-administered

questionnaire routinely used during initial medical visits.

The study was conducted in accordance with local laws

and was approved by the local ethics committee.

Eligibility criteria

Inclusion criteria were adult patients of both sexes over

18 years of age who were undergoing initial consultations

at a tertiary headache center in São Paulo. Exclusion

criteria included patients under 18 years, patients unable to

provide reliable information, and patients with signicant

cognitive decits or associated dementia.

Patient characteristics

We collected the following patient characteristics:

sociodemographic variables, headache characteristics,

previous diagnostic methods, clinical history, and

treatments previously used. Additionally, we used two

standardized instruments to diagnose depression and

anxiety, respectively: the Patient Health Questionnaire-9

(PHQ-9) and Generalized Anxiety Disorder (GAD-7).

Instruments and variable denitions

We dened patients with chronic migraines as

having headaches more than 15 days per month for at

least 3 months; patients with episodic migraines had

headaches fewer than 15 days per month.

To evaluate previous diagnostic methods

qualitatively, we asked patients if they had undergone

at least one of the following: laboratory test, cranial

computed tomography, cranial magnetic resonance,

electroencephalogram, and polysomnography.

Regarding previous treatments, we asked patients

if they had undergone at least one of the following:

acupuncture, psychotherapy, physiotherapy, botulinum

toxin, meditation, preventive medicines, and acute

medicines.

We dened depression based on the Patient Health

Questionnaire–9 (PHQ-9), which is designed for use with

adults to assess and monitor the severity of depression

according to the Diagnostic and Statistical Manual of

Mental Disorders (17) and International Classication of

Diseases, 10th Edition, diagnostic criteria (ICD-10) (18, 19).

The PHQ-9 includes nine items that evaluate symptoms

related to depressed mood, anhedonia (loss of interest or

pleasure in doing things), problems with sleep, tiredness

or lack of energy, change in appetite or weight, feelings

of guilt or uselessness, concentration problems, feeling

slow or restless, and suicidal thoughts. Final scores are

calculated by adding each response (“not all,” “several

days,” “more than half the days,” and “almost every day”)

and are classied into ve depression severity groups:

0-4: none; 5-9: mild; 10-14: moderate; 15-19: moderately

severe; 20-27: severe. However, based on a previous

Brazilian study that dened a score of 9 as the best point

of accuracy, and to assess depression as a dichotomized

variable, we divided the patients into two groups: with

depression if their PHQ-9 scores were greater than or

equal to 9, and without depression if their scores were

less than 9 (20).

Anxiety was dened based on the Generalized

Anxiety Disorder (GAD-7) scale, which consists of seven

items arranged on a 4-point Likert scale (0: not at all; 1:

several days; 2: more than half the days; 3: nearly every

day). Final scores are divided into four groups: 0-4:

minimal or no anxiety; 5-9: mild; 10-14: moderate; 15-21:

severe. (21). In our study, we consider a GAD-7 score

greater than or equal to 8 an anxiety diagnosis.

Statistical analysis

For subgroup comparison in a univariate analysis, we

used the qui-square test or Fisher’s exact test. To identify

variables independently related to depression and

anxiety symptoms, we categorized patients in four steps.

Initially, we dened two groups: patients with depression

and patients without depression. Next, we performed a

logistic regression to identify association of previously

performed exams and previously used treatments with

both groups. We then categorized patients as having

anxiety or not, and performed a new logistic regression

to study the same variable’s association with anxiety.

Finally, we performed a third logistic analysis to consider

the severe anxiety and severe depression subgroups.

We used IBM SPSS Statistics version 25 software (IBM,

Armonk, New York, USA) and considered a two-sided P

< 0.05 statistically signicant.

RESULTS

Sample characteristics

We studied 465 patients with migraine diagnosis;

their characteristics are summarized in Table 1. Their

mean age was 37.3 years (±13.1), and 72.7% of patients

were women. The patients’ average age at headache

onset was 17.1 years (±11.4) before the rst appointment

The impact of anxiety and depression on migraine patients

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at our tertiary headache center, and 51.7% of patients had

chronic migraines.

Most patients (65.8%) had a PHQ-9 ≥ 5, indicating at

least some depressive symptoms, whereas 152 patients

(34.2%) were considered depressed (PHQ-9 ≥ 9) (Table 1).

Symptoms of anxiety were observed in 68.2% of patients,

based on their GAD-7 scores, and 209 patients (47.0%)

were diagnosed with anxiety (GAD-7 ≥ 8). Depression and

anxiety were simultaneously diagnosed in 131 patients

(28.2%), and 237 patients (50.9%) had neither anxiety

nor depression. Other self-reported medical conditions

were common: 76.3% of patients had comorbidities,

such as gastritis, sinusitis, hypertension, kidney stones,

bromyalgia, and polycystic ovarian syndrome (Table 1).

We divided the patients into 4 subgroups:

depression, anxiety, depression and anxiety, and neither

depression nor anxiety. The characteristics evaluated

in comparison were migraine type, previous diagnoses

methods, and previous non-pharmacological and

pharmacological treatments.

Chronic migraines were more common than

episodic migraines among patients with psychiatric

comorbidities: 63.2% of depressive patients, 61.2% of

anxious patients, and 43.5% of patients without any

mood disorder experienced chronic migraines (Table 2).

Most patients underwent laboratory tests and

brain imaging (62.4 and 70.5%, respectively) in a similar

proportion among subgroups with or without anxiety or

depression (Table 2). One-third of patients underwent an

electroencephalogram before rst evaluation (Table 2).

Non-pharmacological treatment was frequent in all

subgroups, and 342 patients (73.5%) performed at least one

modality. Overall, acupuncture was the non-pharmacological

treatment most commonly done (55.2% of patients) without

difference between all subgroups. Depressive and anxious

patients (54.2% and 50.8%, respectively) more frequently

underwent psychotherapy compared to patients with

neither depression nor anxiety (34.7%) (Table 2). We found

no differences among the subgroups for other treatment

modalities, such as physiotherapy, botulinum toxin, nerve

blocks, and meditation.

Regarding pharmacological treatments, most patients

in all subgroups used preventive and acute treatments

(Table 2), although the proportion of acute medicine usage

was slightly higher than that of preventive medicine, even

in subgroups with mood disorders. Depressed patients

took preventive medications more often compared to non-

depressed patients (67.1% vs. 59.8%).

Multivariate analysis

Logistic regression was performed to identify factors

associated with depression and anxiety. Depressed

patients were more likely to be female (OR 8.18, CI 2.82 –

23.75), had more chronic migraines (OR 4.25, 1.90-9.50),

and had undergone more psychotherapy (OR 2.56, CI 1.15

– 5.66) than non-depressed patients (Table 3). In addition,

depression was associated with a reduced likelihood of

having previously undergone physiotherapy (OR 0.39,

CI 0.16 – 0.99). Anxiety was also associated with female

gender (OR 3.07, CI 1.36 – 6.95), chronic migraines (OR

3.91, CI 1.90 – 8.04), and previous psychotherapy (OR 2.18,

Sociodemographic and clinical

characteristics

N or

years

% or

Age (Mean ± SD, n=462) 37.3 13.1

Duration of migraine in years (Mean ± SD,

n=462)

17.2 11.4

Gender (n=462)

Men 126 27.3

Women 336 72.7

Religion (n=239)

Yes 204 85.4

Without religion 35 14.6

Migraine type

Chronic 240 51.7

Episodic 224 48.3

Patient Health Questionnaire - 9 (PHQ-9)

(n=445)

Minimal or none (score 0-4) 152 34.2

Mild (score 5-9) 152 34.2

Moderate (score 10-15) 75 16.9

Moderately severe (score 15-19) 35 7.9

Severe (score 20-27) 31 7.0

General Anxiety Disorder - 7 (GAD-7)

(n=445)

None (score 0-4) 139 31.2

Mild (score 5-9) 144 32.4

Moderate (score 10) 93 20.9

Severe (score 15-21) 69 15.5

Final mood diagnosis (n=445)

Depression (PHQ-9≥9) 152 34,2

Anxiety (GAD-7≥8) 209 47.0

Depression and anxiety (PHQ-9≥9 and

GAD-7≥8)

131 28.2

No depression or anxiety (PHQ-9<9 and

GAD-7<8)

237 50.9

Medical comorbidities (n=465)

Rhinitis 180 50.7

Sinusitis 175 49.3

Gastritis 173 48.7

Kidney stone 66 18.6

Polycystic ovary 58 16.3

Hypertension 39 11.0

Endometriosis 22 6.2

Fibromyalgia 21 5.9

Any medical comorbities (n=465) 355 76.3

Tabacco use (n=435) 30 6.5

Alcohol use (n=465) 214 46.0

Table 1. Patients characteristics with migraine.

SD: Standard deviation.

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Table 2. Comparison based in the presence of anxiety and depression

Patients (n=465)

Depression (D) Anxiety (A) D + A Without D or A All patients

N= 152 N=209 N=131 N=237 N=465

N % N % N % N % N %

Migraine Type*

Chronic 96/152 63.2 128/209 61.2 84/131 64.1 103/237 43.5 240 51.7

Episodic 56/152 36.8 81/209 38.8 47/131 35.9 134/237 56.5 224 48.3

Previous test

Laboratory tests 100/152 65.7 134/209 64.1 86/131 65.6 156/237 65.8 290 62.4

Cranial CT 92/152 60.5 130/209 62.2 85/131 64.9 130/237 54.9 260 55.9

Cranial MRI 94/152 61.8 126/209 60.3 84/131 64.1 133/237 56.1 259 55.7

Cranial CT or MRI 112/152 73.7 154/209 73.7 98/131 74.8 168/237 70.9 328 70.5

EEG 57/ 1 5 2 37.5 80/209 38.3 49/131 37.4 83/237 35.0 163 35.1

Non-pharmacological treatments

Any non-

pharmacological

119/152 78.3 164/209 78.5 105/131 80.2 178/237 75.1 342 73.5

Acupuncture 81/141 57.4 117/196 59.7 73/122 59.8 116/226 51.3 233 55.2

Psychotherapy* 77/142 54.2 100/197 50.8 70/123 56.9 78/225 34.7 178 42.2

Physiotherapy 39/141 27.7 60/196 30.6 32/122 26.2 69/223 30.9 129 30.8

Botulinum Toxin 22/141 15.6 31/196 15.8 21/122 17.2 36/225 16.0 67 15.9

Nerve Blockade 35/141 24.8 44/196 22.4 28/122 23.0 47/2 24 21.0 91 21.7

Meditation 19/141 13.5 34/196 17.3 16/122 13.1 41/225 18.2 75 17.8

Pharmacological treatments

Preventive

medicines

102/152 67.1 132/209 63.2 84/122 64.1 144/235 61.3 276 59.6

Acute medicines 103/152 67.8 139/209 66.5 88/131 67.2 150/235 63.8 289 62.4

* numbers in bold present results with difference statistically signicant (p<0.05). D: Depression; A: Anxiety.

Table 3. Multivariate analysis for presence of depression

Variables B Wald OR 95% Condence interval p-value

Age (years) -0.05 5.34 0.95 0.92 – 0.99 0.021

Female 2.10 14.95 8.18 2.82 – 23.75 0.000

Having religion 0.60 1.41 1.82 0.68 – 4.88 0.235

Disease duration (years) 0.03 2.05 1.03 0.99 – 1.08 0.152

Chronic migraine 1.45 12.48 4.25 1.90 – 9.50 0.000

Alcohol use 0.49 1.62 1.63 0.77 – 3.46 0.202

Tobacco use 0.40 0.35 1.48 0.40 – 5.47 0.552

Presence of any comorbidity 0.35 0.46 1.42 0.51 – 3.92 0.499

Cranial MRI 0.44 1.04 1.55 0.67 – 3.60 0.308

Cranial CT -0.13 0.09 0.88 0.39 – 1.99 0.759

Laboratory tests -0.06 0.02 0.94 0.42 – 2.10 0.877

EEG ,0.14 0.11 1.16 0.50 – 2.69 0.737

Acupuncture 0.06 0.03 1.07 0.49 – 2.31 0.869

Psychotherapy 0.94 5.34 2.56 1.15 – 5.66 0.021

Physiotherapy -0.92 3.97 0.40 0.16 – 0.99 0.046

Botulinum toxin 0.29 0.30 1.34 0.47 – 3.78 0.582

Nerve Blockade -0.39 0.66 0.67 0.26 – 1.74 0.417

Meditation -0.82 2.77 0.44 0.17 – 1.16 0.096

Preventive medicines -0.71 2.16 0.49 0.19 – 1.27 0.141

Acute medicines 0.41 0.83 1.51 0.62 – 3.67 0.362

* numbers in bold present results with difference statistically signicant (p<0.05)

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CI 1.07 – 4.47). In addition, anxious patients were less likely

to undergo laboratory tests (OR 0.40, CI 0.19 – 0.85).

Furthermore, we performed a logistic regression

to determine whether severe depression (65 patients)

and severe anxiety (69 patients) were associated with

the same variables. We found that severe depression

was also associated with chronic migraines (OR 4.72, CI

1.53 – 14.56) and female gender (OR 4.62, CI 13-18) and

tended to be associated with previous psychotherapy

(OR 2.72, CI 0.96-7.69). The inverse relationship between

depression and previous physiotherapy was not found

in the severe group. Severe anxiety was also associated

with fewer laboratory tests (OR 0.23, CI 0.09 – 0.60) and

chronic migraines (OR 3.15, CI 1.20 – 8.23). In addition, we

found that severe anxiety patients used 10.7 times more

acute medication than non-severe anxiety patients (OR

10.71, CI 2.60 – 44.08).

DISCUSSION

In our study of migraine patients at a tertiary

headache center, we found depressive symptoms in

65.8% of patients and a depression prevalence of 34.2%.

The prevalence of anxiety was 47.0%, whereas 68.2%

of patients had some anxiety symptoms. Anxiety and

depression were present simultaneously in 28.2% of

patients, (Table 1) and these conditions were strongly

associated with chronic migraines and female gender.

These results align with recent studies that reported

high prevalence of the same psychiatric comorbidities

in patients with chronic migraines (1, 5, 6, 22, 23). The

analysis of previous patient journeys showed that

depressive patients underwent more psychotherapy

and less physiotherapy than non-depressed patients,

whereas anxiety was associated with a higher probability

of undergoing psychotherapy, but a lower probability of

undergoing laboratory tests. Additionally, severe anxiety

increased the risk of using acute medication by 10.7 times.

Patients with migraines frequently have multiple medical

visits before arriving at a tertiary center. Reported on

primary care provided by non-specialists and found

that headache patients had an average of 3 health care

providers prior to consultation with a specialist, with an

average of 11 years of pain duration (24). In our tertiary

headache center, the mean headache duration was 17.1

years (±11.4) before the rst appointment, and most

patients had already performed non-pharmacological

treatments and used preventive medicine. Therefore,

considering the high prevalence of mood symptoms

in migraineurs, non-specialists should be trained in the

management of psychiatric comorbidities in headache

disorders to improve the patient journey.

Regarding ancillary tests performed during

headache diagnosis, cranial computed tomography and

magnetic resonance imaging permit the exclusion of

certain secondary causes of headaches, such as brain

masses and vascular diseases, but their usefulness is

signicantly reduced in patients with chronic headaches.

We consider the previous cranial imaging undergone

by 70% of our patients to be quite unwarranted, as is

the high frequency of previous Electroencephalogram

(EEG) (one-third of our patients had undergone at least

one), which is usually unnecessary for migraine patients.

A detailed evaluation of other symptoms indicative of

secondary headaches should always be considered, so

excessive and costly tests may be precluded in patients

with evident migraine criteria unless other warning signs

are present (25).

We expected more migraine patients with

psychiatric comorbidities to have undergone diagnostic

tests than those without comorbidities, as observed in

previous reports (5, 26), but our study did not conrm

these ndings. This could be due to a trend among

primary physicians of asking tests for most headache

patients, regardless of psychiatric comorbidities.

Another explanation is the fact that we did not quantify

the number of tests performed, but asked the patients if

they underwent a specic test at least once in the past.

In addition, stigma may be an issue, as patients with

anxiety or depression may not be evaluated adequately

and may give up seeking a correct diagnosis. A nding

that supports this hypothesis is that anxious patients

in our study were less likely to undergo laboratory

tests, although one would predict the opposite due to

increased somatization and physical symptoms.

Non-pharmacological treatment was frequent;

patients in all subgroups performed at least one

modality. Interestingly, previous experience with

psychotherapy was frequently a predictor of anxiety and

depression in migraine patients. This could be explained

by previous referrals from physicians or self-referrals

to psychotherapy. More severe patients should have

greater need for medication and non-pharmacological

approaches, but in this case, we found only psychotherapy

and, interestingly, reduced odds of undergoing physical

therapy. The low probability of undergoing physical

therapy could be due to kinesiophobia, a phenomenon

related to the avoidance of physical therapy in the

treatment of chronic pain, in patients with depression

and anxiety (26, 27). Besides the overuse of health care

services, anxiety and depression are both associated

with signicant psychological distress and poor health

perception, whereas physical disability is only associated

with depression and may corroborate the kinesiophobia

(28).

We found no independent association

between depression and a higher likelihood of using

pharmacological treatment. One explanation for this

lack of correlation may be the way we veried the use of

medication. In our study, we did not quantify the number

or duration of drugs previously tried, but evaluated

these factors qualitatively (used or not used). However,

we found a strong association between severe anxiety

and acute medicine consumption. Higher anxiety levels

could cause patients to seek more care and receive

more preventive treatments, but patients may also

use analgesics excessively due to cephalalgiaphobia,

anticipatory anxiety, or compulsion (29). Severe anxiety

patients used 10.7 times more acute medicines than

non-severe anxiety patients. This is also in accordance

with other studies’ ndings. Showed that analgesic

consumption was greater in GAD patients with primary

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headaches than in controls with primary headaches

without GAD (11). Analgesics ingestion can occur prior

to the onset of a headache due to anxiety, and evaluated

the reasons for this behavior: 67% of patients reported

difculty coping with pain, 62% feared its emergence,

and 45% consumed analgesics to reduce anxiety (30).

Our study has some limitations. First, it was an

observational cross-sectional study based on medical

charts and a retrospective self-reported questionnaire,

so associations found may be not due to a cause–effect

relationship. Second, patients were asked to remember all

previously performed procedures, which can be inuenced

by reminder bias. Finally, we performed a single-center

study. Thus, our study reected a specic population, and

selection bias may be have inuenced our results.

CONCLUSION

Anxiety and depression were common in migraine

patients seen at a tertiary headache center, mostly in

patients with chronic migraines. Depressed patients

were often female, had more chronic migraines,

and had undergone more psychotherapy than non-

depressed patients, although they had a reduced

chance of having previously undergone physiotherapy.

Anxiety was also associated with female gender,

chronic migraines, previous psychotherapy, and a risk

of using acute pharmacological treatment that was 10.7

times higher than in other patient groups, which may

lead to issues related to analgesic abuse. Anxiety and

depression affect the journey of patients with migraines,

probably beginning with primary care, and physicians,

who routinely offer rst-aid interventions, should be

concerned with recognizing these mental disorders.

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ABSTRACT

RESUMO

Descritores: Microcauterização térmica, enxaqueca, neuromodulação.

ORIGINAL ARTICLE

Application of thermal microcautery in migraine

management

Aplicação da microcauterização térmica no manejo da

migrânea

Eleni Papageorgiou

Konstantine Kovas

Camillus Power

Nikolaos Kostopoulos

Dept. of Neurology, General Hospital of

Athens, G. Gennimatas, Greece.

Dept. of Pain Medicine, Tallaght University

Hospital, Dublin, Ireland.

Holistic Health Centre, Athens, Greece

*Correspondence

Eleni Papageorgiou

E-mail: helenmorou@yahoo.gr

Received: December 5, 2019.

Accepted: December 26, 2019.

Thermal microcautery is a novel minimally invasive intervention for migraine.

We present a case series of twenty-one patients who underwent this technique.

Nineteen patients reported improvement in migraine management. Of these

four patients went on to complete remission and a further eleven patients

reported over 50% improvement. In addition, the majority of patients noted

reductions in intensity and duration of headache with a better response to

medication. The efcacy of thermal microcautery generates a new hypothesis

that attempts to explain how a neuromodulation technique may be helpful in

the management of migraine.

Keywords: Thermal microcautery; Migraine; Neuromodulation.

A microcauterização térmica é uma nova intervenção minimamente invasiva

para enxaqueca. Apresentamos uma série de casos de vinte e um pacientes

submetidos a essa técnica. Dezenove pacientes relataram melhora no

tratamento da enxaqueca. Desses quatro pacientes, a remissão foi concluída

e outros onze relataram mais de 50% de melhora. Além disso, a maioria dos

pacientes observou reduções na intensidade e duração da dor de cabeça com

uma melhor resposta à medicação aguda. A ecácia da microcauterização

térmica gera uma nova hipótese que tenta explicar como uma técnica de

neuromodulação pode ser útil no tratamento da enxaqueca.

Application of thermal microcautery in migraine management

Papageorgiou E, et al.

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INTRODUCTION

Migraine is a highly disabling disease, with high

nancial and social impact (1). Migraine treatment can

be both acute and preventive, several pharmacological

classes can be effective, as also may non-pharmacological

therapies (2,3). Nerve blocks, botulinum toxin type A,

and neuromodulation may play an important role in the

management of migraine (4)

A number of studies have come to light, showing

that external stimulation of certain parts of the head,

may contribute to the management of pain (5,6,7,8)

Thermal microcautery have been used for the treatment

of pain disorders, but limited information is available

about its role in migraine treatment (9). We aimed in

this study to present our experience in a case series of

patients treated with thermal microcautery.

METHODS

Sample

Patients were selected from the Neurological

Headache outpatient clinic of G.N.A. ‘’G. Gennimatas’’,

from November 2017 up to March 2019.

Inclusion / exclusion criteria

The inclusion criteria were as follows –

1. Diagnosis of chronic migraine with or without

aura and/or Medication Overuse Headache

(MOH).

2. The failure of at least one preventive treatment.

3. Patients were not allowed to undergo

Botox injections (10,11) Acupuncture and

Transcutaneous Electrical Nerve Stimulation for

at least 3 months.

Technique description

In this technique we applied instantly intense heat

(600° C) to an area of localized pain (2) identied by

clinical examination before the procedure. The heat

was applied by a low temperature cautery disposable

ne tip pen, Fiab Disposable electrocautery pensF7255

(28 mm) which is routinely used in dermatology for

microsurgery.

Thermal microcautery was performed on bilateral

cervical, occipital, supraorbital and temporal areas, (12)

depending on what patients referred to as the most

painful points during the attack of migraine and also

between acute attacks.

Post procedure a cooling cream was applied (1gr.,

Pistacia Lentiscus, Shorea robusta)

It was planned that each patient would undergo 4

sessions, every 7-10 days. Each patient had a recording

of the frequency, duration, intensity of episodes of

headache, medication use and response. We recorded

the VAS pain score in each session.

The protocol of the study had been submitted

to the Hospital’s Ethical Committee and had been

approved. All patients were fully informed about the

aim of the study, the procedure and the complications

and had lled out a consent form.

RESULTS

Twenty-one patients have completed the study over

a two-month period with follow-up on all patients for six

months (twenty female patients – one male). The age

ranged from 37 to 68 years old (average 51.1 years old).

All of them had received at least one preventive therapy:

six patients used propranolol, twelve topiramate, three

valproic acid, ve unarizine, four amitriptyline, thirteen

SSRIs-SNRIs, ve botulinum-A. Additional, ve patients

had undergone Acupuncture and two used cannabis

oil on a daily basis. None of them had undergone any

invasive therapy or used anti-CGRP antibodies.

Fourteen patients used triptans at the acute phase

of the episode, all of them paracetamol and/or NSAIDs

and two Cephaly.

Fifteen of twenty-one patients had a combined

diagnosis of migraine and MOH.

Nineteen of twenty-one patients reported overall

improvement of their symptoms.

Four patients reported complete remission of their

migraine which has persisted for six months.

Eleven patients reported over 50% improvement

(reduction in the frequency, intensity and/or duration

of headaches) and four patients reported a 30%

improvement.

15 patients out 19 who reported improvement,

recorded a reduction in the frequency of episodes, 16 a

reduction in the intensity of the pain, 9 a reduction in the

duration of each episode.

15 patients noted a better response to the drugs

administered at the acute phase of pain,

Five patients were able to stop their preventive

treatment in six months.

Patients tolerated the procedure well including

application of the cooling cream. Five patients

Figure 1. Pie graph of evaluation of Migraine symptoms at the

end of the study (21 patients)

Application of thermal microcautery in migraine management

Papageorgiou E, et al.

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Headache Medicine, v.10, n.4, p.182-185, Out/Nov/Dez. 2019

experienced relief of migraine immediately following the

procedure.

The mild burn after the application of cauterization

was healed in 2-3 days, leaving no aesthetic marks. No

skin reactions appeared.

DISCUSSION

The present study shows promising results with

thermal microcautery in migraine preventive treatment,

due to its efcacy and tolerability (13).

Explanations for our ndings may include the

theory of the distorted communication within the

trigeminocervical complex. A possible pathophysiological

mechanism of action is the modication of the perception

of pain through peripheral stimulation (1,14) in the regions

of distribution of trigeminal and occipital nerves (12,15)

Through the anatomical and functional convergence of

these nerve endings, a wider distribution of the stimulus

is supposed to trigger centrifugal pathways that regulate

pain (16). It is known that stimulation of the occipital

nerves regulates the activity of sensory neurons in

the trigeminocervical complex; so, stimulation of the

trigeminal nerve as well, is supposed to have the same

effect. Its branches in the trigeminal divisions and C1 and

C2 dermatomes (9) converge with sensory bers of the

dura mater and share the same receptive eld. Thus, it is

possible that an extracranial stimulation such as thermal

microcautery can also modify the activity of the sensory

bers of the dura.

Migraine originates in a distorted communication

within a complex neural network which leads to the well

described neuro-vascular cascade of events (17). We

hypothesize that a thermal microcautery stimulus resets

this network restoring its natural homeostasis.

The study has several limitations, rst it is not

controlled by a sham procedure or other treatment as

a comparator. A baseline phase before the treatment

performed has not been performed, so a possible recall

bias may affect our results.

Conclusion

Thermal microcautery is a promising therapy

for migraine, further randomized clinical studies are

necessary to conrm its efcacy

REFERENCES

1. 1. Ellens, D. J., & Levy, R. M. (2011). Peripheral neuromodulation

for migraine headache. In Peripheral Nerve Stimulation (Vol.

24, pp. 109-117). Karger Publishers. DOI: 10.1159/isbn.978-3-

8055-9489-9

2. Melzack, R., & Wall, P. D. (1965). Pain mechanisms: a

new theory. Science, 150(3699), 971-979. DOI: 10.1126/

science.150.3699.971

3. Lovati, C., D’Amico, D., & Bertora, P. (2009). Allodynia in

migraine: frequent random association or unavoidable

consequence?. Expert review of neurotherapeutics, 9(3),

395-408. https://doi.org/10.1586/14737175.9.3.395

4. Goadsby, P. J., Holland, P. R., Martins-Oliveira, M., Hoffmann,

J., Schankin, C., & Akerman, S. (2017). Pathophysiology of

migraine: a disorder of sensory processing. Physiological

reviews, 97(2), 553-622. DOI: 10.1152/physrev.00034.2015

5. Lipton R, Goadsby PJ, Cady R, Aurora SK, Grosberg BM,

F., & F G, et al. (2009). PO47 PRISM study: occipital nerve

stimulation for treatment-refractory migraine. Cephalalgia,

29(Suppl 1), 30. Retrieved from http://journals.sagepub.

com/doi/pdf/10.1111/J.1468-2982.2009.01960.X

6. Nayak, R., & Banik, R. K. (2018). Current Innovations in

Peripheral Nerve Stimulation. Pain Research and Treatment.

Hindawi Limited. https://doi.org/10.1155/2018/9091216

7. Lauritsen, C. G., & Silberstein, S. D. (2019, May 1). Rationale

for electrical parameter determination in external trigeminal

nerve stimulation (eTNS) for migraine: A narrative

review. Cephalalgia. SAGE Publications Ltd. https://doi.

org/10.1177/0333102418796781

8. Rapoport, A. M., Lin, T., & Tepper, S. J. (2020). Remote

Electrical Neuromodulation (REN) for the Acute

Treatment of Migraine. Headache: The Journal of Head

and Face Pain.

9. Ishiyama, S., Shibata, Y., Ayuzawa, S., Matsushita, A., &

Matsumura, A. (2018). Clinical Effect of C2 Peripheral Nerve

Field Stimulation Using Electroacupuncture for Primary

Headache. Neuromodulation, 21(8), 793–796. https://doi.

org/10.1111/ner.12772

10. Loeb, L. M., Amorim, R. P., Mazzacoratti, M. da G. N.,

Scorza, F. A., & Peres, M. F. P. (2018). Botulinum toxin a

(BT-A) versus low-level laser therapy (LLLT) in chronic

migraine treatment: A comparison. Arquivos de Neuro-

Psiquiatria, 76(10), 663–667. https://doi.org/10.1590/0004-

282x20180109

11. Zidan, A., Roe, C., Burke, D., & Mejico, L. (2019).

OnabotulinumtoxinA wear-off in chronic migraine,

observational cohort study. Journal of Clinical Neuroscience,

69, 237-240. DOI: 10.1016/j.jocn.2019.07.043

12. Popeney, C. A., & Aló, K. M. (2003). Peripheral

neurostimulation for the treatment of chronic, disabling

transformed migraine. Headache, 43(4), 369–375. https://

doi.org/10.1046/j.1526-4610.2003.03072.x

13. Fishman, M. A., Antony, A., Esposito, M., Deer, T., & Levy,

R. (2019). The Evolution of Neuromodulation in the

Treatment of Chronic Pain: Forward-Looking Perspectives.

Pain Medicine (Malden, Mass.), 20(1), S58–S68. https://doi.

org/10.1093/pm/pnz074

14. Popeney, C. A., & Aló, K. M. (2003). Peripheral

neurostimulation for the treatment of chronic, disabling

transformed migraine. Headache: The Journal of Head and

Face Pain, 43(4), 369-375. https://doi.org/10.1046/j.1526-

4610.2003.03072.x

15. Slavin, K. V., Nersesyan, H., & Wess, C. (2006). Peripheral

neurostimulation for treatment of intractable occipital

neuralgia. Neurosurgery, 58(1), 112–118. https://doi.

org/10.1227/01.NEU.0000192163.55428.62

Figure 2. Bar graph of the clinical benets of treatment.

Application of thermal microcautery in migraine management

Papageorgiou E, et al.

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16. Landy, S., Rice, K., & Lobo, B. (2004). Central sensitisation

and cutaneous allodynia in migraine. CNS drugs, 18(6),

337-342. https://doi.org/10.2165/00023210-200418060-

00001

17. D’Andrea, G., D’Arrigo, A., Dalle Carbonare, M., & Leon, A.

(2012). Pathogenesis of migraine: role of neuromodulators.

Headache: The Journal of Head and Face Pain, 52(7), 1155-

1163. https://doi.org/10.1111/j.1526-4610.2012.02168.x

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ORIGINAL ARTICLE

Cefaleia Dialítica Associada à Cefaleia por Privação de

Cafeína em Pacientes Submetidos à Hemodiálise

Dialysis Headache Associated with Caffeine-Withdrawal

Headache in Patients Undergoing Hemodialysis

Edarlan Barbosa dos-Santos

Kattiucy Gabrielle da Silva Brito

Bernardo Afonso Ribeiro Pinto

Tatiane Fernandes da Fonseca Gaban

Antonio Marcos da Silva Catharino

1,3,4

Universidade Iguaçu, Programa de iniciação

cientíca - Nova Iguaçu - Rio de Janeiro -

Brasil

Hospital Geral de Nova Iguaçu, Nefrologia -

Nova Iguaçu - Rio de Janeiro - Brasil

Hospital Geral de Nova Iguaçu, Neurologia -

Nova Iguaçu - Rio de Janeiro - Brasil

Universidade Iguaçu, Semiologia Médica \

Neurologia - Nova Iguaçu - Rio de Janeiro -

Brasil

*Correspondence

Antonio Marcos da Silva Catharino

E-mail: neurocurso@globo.com

Received: November 20, 2019.

Accepted: December 19, 2019.

ABSTRACT

RESUMO

Descritores: Cefaleia; Diálise Renal; Transtornos da Cefaleia.

Headaches are particularly relevant as a complication of hemodialysis, given

that this condition increases the discomfort felt by patients undergoing this

therapy. The objective of the present study was to evaluate the prevalence

of headache in patients undergoing hemodialysis sessions, particularly

considering dialysis headaches due to caffeine-withdrawal. This was a cross-

sectional, observational, quantitative and qualitative study with questionnaires

and interviews. The questionnaire addressed biopsychosocial aspects, clinical

aspects and criteria for the classication of headaches according to the

International Headache Society. A hundred and sixty patients with stage-V

chronic kidney disease responded to the questionnaire during hemodialysis

sessions. Headache prevalence was 90% and over the period studied 53.1% of

patients presented the symptom. Among these patients with headaches, over

half (55.3%) presented criteria for concomitant caffeine-withdrawal headaches

and dialysis headaches. The beginning of headaches varied between one

month and more than ve years, with most occurring for more than ve years.

Frequency varied from sporadic crises to more than one crisis a day, though

more than one crisis a day predominated. The interval between crises was of

a few days, with mean duration of less than one hour, which ceased with the

use of self-medicated analgesics, with no worsening factor. This condition is

a challenge for neurologists and headache experts. More studies are needed

to decrease this prevalence, to decrease the abusive use of analgesics and

improve the quality of life of these patients.

Keywords: Headache; Renal Dialysis; Headache Disorders.

A cefaleia como complicação da hemodiálise merece um lugar de destaque,

uma vez que aumenta ainda mais o incômodo sofrido pelo paciente submetido

a essa terapia. O objetivo deste trabalho é estudar a prevalência de cefaleia

em pacientes submetidos a sessões de hemodiálise, com ênfase na cefaleia

dialítica e na cefaleia por privação de cafeína. Este foi um estudo transversal,

observacional, quantitativo e qualitativo utilizando questionários e entrevistas.

O questionário abordou aspectos biopsicossociais, aspectos clínicos e critérios

para classicação da cefaleia de acordo com a Sociedade Internacional de

Cefaleia. Cento e sessenta pacientes com IRC em estágio V responderam ao

questionário durante as sessões de hemodiálise. A prevalência da cefaleia foi

de 90% e no período da pesquisa 53,1% dos pacientes apresentavam o sintoma.

Dentre os pacientes com cefaleia, mais da metade (55,3%) apresentavam critérios

para cefaleia por privação de cafeína e cefaleia dialítica concomitantemente. O

início da cefaleia variou de um mês a mais de cinco anos, sendo a maioria há

mais de cinco anos. A frequência variou de crises esporádicas a mais de uma

crise por dia, predominando mais de uma crise por semana. O intervalo entre

as crises foi de dias, com duração média de menos de uma hora, sendo cessada

com uso de analgésicos, automedicados, sem fator agravante. Essa condição é

considerada um desao entre os neurologistas e especialistas em cefaleia. São

necessários mais estudos para diminuir essa prevalência, diminuir o uso abusivo

de analgésicos e melhorar a qualidade de vida desses pacientes.

Dialysis Headache Associated with Caffeine-Withdrawal

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INTRODUCTION

Headaches are classied as either primary or

secondary, based on the absence or not of underlying

structural or metabolic disruptions causing the condition.

This is a very frequent symptom in patients with renal

failure undergoing hemodialysis.

Headaches are triggered by several factors, which

are either intrinsic or extrinsic, since individuals with

migraines have lower thresholds to certain exposures,

leading to a series of events and culminating in pain.

Headaches are particularly relevant as a

complication of hemodialysis, given that this condition

increases the discomfort felt by patients undergoing

this therapy. Moreover, there is an increasing number

of patients that rely on this procedure. The relationship

between hemodialysis and headaches can be observed

at the beginning of the dialysis treatment, which can

be followed by nausea, vomiting, muscle spasms,

disorientation, systemic hypertension and convulsions.

3,4

The most frequent triggering factors for dialysis

headache, either mentioned by patients or by the medical

team, were arterial hypertension (38%), followed by no

identied factor (26%), arterial hypotension (12%) and

changes to body weight (6%). Another factor mentioned

as a trigger for headaches during hemodialysis were

electrolyte disorders.

Dialysis headache frequency was rst described in

1972, with 70% of hemodialysis patients suffering from

headaches. Over the years, this frequency decreased, as

shown in a recent study where this proportion was of 48%.

During hemodialysis, several substances are

depurated. The International Headache Society (IHS)

emphasizes the decrease of serum caffeine as being

responsible for headache crises during dialysis sessions.

The main symptom of cessation of caffeine is headache.

The study of Maia and cols. reports the benets of using

caffeine before hemodialysis sessions as a prophylactic

measure for headaches.

The objective of the present study was to evaluate

the prevalence of headache in patients undergoing

hemodialysis sessions, particularly considering dialysis

headaches due to caffeine-withdrawal.

MATERIAL AND METHODS

This was a cross-sectional, observational, quantitative

and qualitative study conducted at a treatment center

for patients with renal failure who were undergoing

hemodialysis. The study comprised questionnaires and

interviews with these patients.

The questionnaire was developed by the authors

and addressed biopsychosocial aspects (age, gender,

housing, life habits, previous pathological history,

professional activities, among others), in addition to

clinical aspects regarding the presence of headaches

(family history, time of disease, frequency, duration,

location, intensity, quality of pain, associated symptoms,

triggering factors, worsening factors and relief factors

during a crisis) and criteria for the classication of

headaches according to the IHS.

The Google Docs software was used to manage the

database of this research. All patients were consulted in

advance and manifested their interest in taking part of

this investigation by signing a free and informed consent

statement. Thus, patients answered the questionnaire

voluntarily after agreeing to participate in the research.

This project was approved by the ethics in research

committee of the educational institution - UNIG, CAAE:

68978517.4.0000.8044, registry number: 2.416.322.

RESULTS

Questionnaires were applied to 160 patients, with

stage-V chronic kidney disease, during hemodialysis

sessions. Most patients were in their 70s (25%), followed

by patients in their 50s (21.2%). Moreover, most patients

were male (61.9%). Regarding marital status, most

patients were married, and more than half lived with

their spouse and/or children. Over 60% considered

themselves stressed and mentioned hemodialysis and

one of the causes. Only 9% were smokers and 10%

reported drinking alcoholic beverages for more than 10

years. Only 18% carried out physical or cultural activities

regularly. All patients reported not having a professional

occupation because of the disease and 70% reported

feeling difculty in their everyday life. Nearly 87% of

patients presented associated arterial hypertension.

Headache prevalence was 90% and over the period

studied 53.1% of patients presented the symptom. Among

these patients with headaches, over half (55.3%) presented

criteria for concomitant caffeine-withdrawal headaches

and dialysis headaches. In turn, 14.1% only presented criteria

for dialysis headaches, according to the IHS.

The beginning of headaches varied between one

month and more than ve years, with most occurring for

more than ve years. Frequency varied from sporadic

crises to more than one crisis a day, though more than

one crisis a day predominated, which was compatible

with hemodialysis sessions three times a week. The

interval between crises was of a few days, with mean

duration of less than one hour, which ceased with the use

of self-medicated analgesics, with no worsening factor.

The prevailing location of the pain was the front bilateral

region, followed by the occipital and temporal regions,

characterized as pulsating, with no aura, frequently

associated with other symptoms such as scintillating

scotomas, nausea, vomiting and photophobia. When

asked about colors, most patients associated intensity of

pain with the color red, followed by black.

CONCLUSION AND DISCUSSION

A high prevalence of dialysis headache was

observed, a frequent complication of hemodialysis

that worsens the quality of life of patients that already

present a debilitating disease. This condition is a

challenge for neurologists and headache experts. The

association between dialysis headache and headache

by caffeine-withdrawal was observed in more than half

of the patients with any kind of headache. More studies

are needed to decrease this prevalence, to decrease the

Dialysis Headache Associated with Caffeine-Withdrawal

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abusive use of analgesics and improve the quality of life

of these patients.

All patients reported that their headaches only

improved with the use of analgesics. However, there

are no controlled studies on prophylactic treatment or

abortive treatment of dialysis headache.

Frontal bilateral pain, characterized as pulsatile, with

no aura, frequently associated with other symptoms

such as scintillating scotomas, nausea, vomiting and

photophobia is compatible with the literature found.

Despite their high prevalence, dialysis headaches

remain scarcely studied.

REFERENCES

1. Headache Classication Committee of the International

Headache Society (IHS). The International Classication

of Headache Disorders, 3rd edition (beta version)”.

Cephalalgia. 2013; 33: 629-808.

2. PahimLS,Menezes AMB, Rosângela Lima R.Prevalência e

fatores associados à enxaqueca na população adulta de

Pelotas, RS. Rev Saúde Pública. 2006; 40 (4): 692-698.

3. Santos KALM, Martins HAL, Ribas VR, Costa-Neto

J, Silva WF, Valença MM. Cefaleiarelacionada à

hemodiálise: históriaprévia de cefaleia é um fator de risco.

Migrâneascefaleias. 2009; 12(3): 112-14.

4. Moraes AP, Salomão CEM, Soares FHC, Sousa KS, Moraes

TC, Silva MHS, Pimentel AL, Jurno ME. Prevalência de

cefaleiaemumaunidade de diálise. Rev Interdisciplinar de

EstudosExperimentais. 2016; 8: 23-30.

5. Antoniazzi AL, Bigal ME, Bordini CA, Tepper SJ, Speciali

JG. Headacheandhemodialysis: a Prospectivestudy.

Headache2003;43:99-102.

6. Bana DS, Yap AU, Graham JR. Headache duringhemo dialysis

Headache 1972;12:1-14.

7. Shapiro RE. Caffeineandheadaches. NeurolSci. 2007; 28:

179-183.

8. Maia AV, Catharino AMS, et al. Cefaleia por privação de

cafeína em paciente submetida à hemodiálise: relato de

caso. Rev. Neurociências. 2010; 18(3): 324-327.

9. Sousa Melo E, Carrilho Aguiar F, Sampaio Rocha-Filho

PA.Dialysis Headache: A Narrative Review.Headache. 2017;

57(1): 161-164. doi: 10.1111/head.12875.

10. Sav MY, Sav T, Senocak E, Sav NM. “Hemodialysis-related

headache”. Hemodial Int. 2014; 18: 725-729.doi: 10.1111/

hdi.12171.

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ABSTRACT

RESUMO

Descritores: Aneurisma Roto. Cefaleias Vasculares. Hemorragia Subaracnóidea.

ORIGINAL ARTICLE

Prevalence of thunderclap headache in patients with

ruptured intracranial aneurysms: series of 60 cases

Prevalência de cefaleia thunderclap em pacientes

com aneurisma intracraniano roto: série de 60

Bruno Bertoli Esmanhotto

Elcio Juliato Piovesan

Marcos Christiano Lange

Faculdades Pequeno Príncipe, Curso de

Medicina - Curitiba - PARANA - Brasil.

Hospital de Clínicas - Universidade Federal

do Paraná, Departamento de Neurologia -

Curitiba.

*Correspondence

Bruno Bertoli Esmanhotto

E-mail: bbesmanhotto@hotmail.com

Received: December 19, 2019.

Accepted: December 30, 2019.

Thunderclap headache (TCH) is a head pain that begins suddenly and is severe

at onset. TCH might be the rst sign of subarachnoid hemorrhage. This study

was conducted to evaluate the presence of thunderclap headache (TCH) in

patients with ruptured intracranial aneurysm (RIA) and endovascular treatment

(EVT). We evaluated the pattern of headache in 60 patients who suffered a RIA

and EVT at time of admission and prospectively evaluated the characteristics

of previous headache within one year before the rupture. Thirty-one patients

(51,7 %) had TCH related to the rupture. Aneurysm size does not affect the

occurrence of thunderclap headache (p=0,08). The vascular aneurysm territory

is not related to presence of TCH (p=0,527). The prevalence of TCH in this cohort

was similar to previous studies. All patients with acute thunderclap headache

should be evaluated for subarachnoid hemorrhage.

Keywords: Ruptured Aneurysm; Subarachnoid Hemorrhage; Vascular Headache.

Cefaleia thunderclap (CT) é uma dor de cabeça de início súbito e muito intensa.

Pode ser o primeiro sinal de uma hemorragia subaracnoídea (HAS). Este estudo

foi realizado para avaliar a prevalência de cefaleia thunderclap em pacientes que

sofreram ruptura de aneurisma intracraniano (RIA) e submetidos a tratamento

endovascular.(TEV) Foram avaliados 60 participantes com quadro de RIA e TEV

no momento da admissão hospitalar, e foi questionado sobre as características

da dor de cabeça prévia por um ano antes da ruptura. Trinta e um (51,7%) dos

participantes relataram CT no momento da ruptura. O tamanho do aneurisma

não teve relação com a ocorrência da CT (p=0.08). O território vascular também

não teve relação com a presença de CT (p=0,527). A prevalência de CT neste

estudo foi semelhante ao relatado em estudos prévios. Todos os pacientes com

CT devem ser investigados para hemorragia subaracnoídea.

Thunderclap Headache In Ruptured Aneurysm

Esmanhotto BB, et al.

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INTRODUCTION

One of the main symptoms in patients with an

intracranial aneurysm is headache, which is observed

in all stages of the disease, i.e., prior to, during and

after rupture of the aneurysm. Headache may be the

only presenting symptom in up to 40% of patients

Multicenter studies have shown that in the period before

rupture headache is present in up to 36% of cases

The character of the headache is not very specic,

and there is no single pain characteristic that allows a

diagnosis of aneurysm

to be suspected other than the

presence of thunderclap headache (TCH), which requires

investigation for subarachnoid hemorrhage

Subarachnoid hemorrhage is most commonly

due to rupture of an intracranial aneurysm. Ruptured

aneurysms account for 85% of cases, non-aneurysmal peri

mesencephalic hemorrhage (with excellent prognosis)

account for 10%, and various rare disorders (transmural

arterial dissection, cerebral arteriovenous malformation,

dural arteriovenous stula, mycotic aneurysm, and

cocaine abuse) account for the rest

‘‘Thunderclap headache’’ refers to a headache that

is very severe and has abrupt onset, reaching maximum

intensity in less than 1 minute. A thunderclap headache

is typically described by patients as an apoplectic event,

one that clearly stands out from other types of headaches

they may have previously experienced. Patients with

thunderclap headache often liken the sensation to an

explosion in their head or being struck in the head

Primary TCH is diagnosed when all other potential

underlying causes have been eliminated by diagnostic.

Secondary TCH have multiple causes (Table 1)

, and

Subarachnoid Hemorrhage is the most common cause.

It is important to recall that the headache, although

almost always present, is sometimes overshadowed by

other symptoms and this results in misdiagnosis. Prior

migraine, may lead to migraine as an incorrect diagnosis

and not working up patients because their headache has

responded to various analgesics, including triptans, is

another reason for misdiagnosis.

METHODS

We performed a prospective cohort study of

consecutive patients with subarachnoid hemorrhage

secondary to rupture of an aneurysm who had received

EVT. The study was approved by the Hospital de

Clínicas Committee for Ethics in Human Research, and

all participants signed a voluntary informed-consent

form. The exclusion criteria were patients over 18 years

of age with the signs and symptoms of subarachnoid

hemorrhage secondary to rupture of an aneurysm who

had received EVT between June 1st, 2013, and June

1st 2014. The exclusion criteria were patients in coma,

confused or unable to complete the questionnaire

properly because of neurological disabilities, submitted

to neurosurgery, presence of non-saccular aneurysms

and loss of follow-up.

After embolization, these patients were interviewed

about a history of headache using a purpose-built

Table 1. Causes of Thunderclap Headache *

Most Common Causes of Thunderclap Headache

Reversible cerebral vasoconstriction syndrome

Subarachnoid hemorrhage

Less Common Causes of Thunderclap Headache

Cerebral infection

Cerebral venous sinus thrombosis

Cervical artery dissection

Complicated sinusitis

Hypertensive crisis

Intracerebral hemorrhage

Ischemic stroke

Spontaneous intracranial hypotension

Subdural hematoma

Uncommon Causes of Thunderclap Headache

Aqueductal stenosis

Brain tumor

Cardiac cephalgia

Giant cell arteritis

Pituitary apoplexy

Pheochromocytoma

Retroclival hematoma

Spontaneous spinal epidural hematoma

Third ventricle colloid cyst

*Although the exact incidence of each cause of thunderclap

headache is not well-dened, certain causes of thunderclap

headache are more common than others based upon how often

they present with thunderclap headache and the incidence of

the condition itself. For example, although pituitary apoplexy

might commonly present with thunderclap headache, as

pituitary apoplexy is an uncommon condition, it is an unlikely

cause of a patient’s thunderclap headache.

questionnaire by a neurologist. A questionnaire about the

presence of headache based on the ICHD (International

Classication of Headache Disorder) 3

edition

criteria

in the 12 months prior to rupture was applied after EVT.

Depending on the characteristics of their headache at

the rst assessment, patients were classied as having

migraine with aura, migraine without aura or tension-type

headache.

The diagnosis of subarachnoid hemorrhage was

based on computed axial tomography (CAT), when this

failed to conrm the diagnosis, an analysis of cerebrospinal

uid following lumbar puncture was done to conrm the

hemorrhage. After the diagnosis, patients underwent

digital subtraction angiography (DSA) to conrm the

presence of and the site of the aneurysm, allowing the

EVT. Two experienced Interventional Neuroradiologists,

using remodeling technique, performed the coiling.

Patients were treated with Gugliemli Detachable Coils

(GDC, Stryker Neurovascular, Freemont, California, USA)

and Hyperform Occlusion Balloon System (Covidien,

Irvine, California, USA).

Thunderclap Headache In Ruptured Aneurysm

Esmanhotto BB, et al.

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Statistical Analysis

The non-parametric Mann-Whitney test was used

to correlate the aneurysm size with its localization. The

Fisher exact test was used to investigate the association

between qualitative variables, and the Jarque-Bera test

was used to test the variables for normality. P values of

less than 0.05 were considered signicant.

RESULTS

In total, we recruited 60 patients with RIA, 48 (80%)

were women and 12 men (20%), with a mean age of 49.5

± 12.9 years. Thirty-seven (61.7%) had a history of headache

in the 12 months prior to rupture of the aneurysm and

were distributed as follows: 16 (43.2%) with tension-type

headache; 11 (29.7%) with migraine without aura; nine (24.3%)

with migraine with aura; and one (2.7%) with non-specic

characteristics. (Table 2). From 60 cases, 31 (51.7%) had TCH

as clinical presentation of SAH. Arterial Hypertension and

tabagism were present in 18 (58%) patients and 10 (32%)

participants with TCH, respectively. In 23 (74%) participants

with TCH the aneurysm size were less than 10 mm, and in

8 (26%) were larger than 10 mm. The aneurysm size was

not statistically signicant in occurrence of TCH (p=0.08) In

48 patients (80%) the aneurysms were localized in anterior

circulation and 12 (20%) in posterior circulation, but no

difference in prevalence of TCH in this 2 subsets was shown.

(p=0.527)(Table 3).

DISCUSSION

Epidemiological studies in the Brazilian population

have shown the prevalence of migraine and tension-type

headache to be 15.2% and 13%, respectively

9,10

. In the

present study, the prevalence of both types of headache

in patients with an intracranial aneurysm was twice

as high: 33.4% for migraine (15% with aura and 18.4%

without aura) and 26.7% for tension-type headache.

Subarachnoid haemorrhage is the most common

cause of secondary TCH and should be the focus of

the initial assessment given the signicant associated

morbidity and mortality. Initial misdiagnosis and

subsequent rebleeding corresponds with a worsening

prognosis. Historically, the diagnosis of SAH was missed

on initial presentation in 11% to 25%25% of patients

presenting with TCH.

8,11,12

A study performed in 364 patients, with intracranial

aneurysms conrmed by angiography, evaluated

presence of warning signs (moderate or severe headache,

dizziness, nausea/vomiting, transitory sensitivity and/or

motor decit, loss of consciousness, visual or oculomotor

disturbances) preceding major hemorrhage.

Two specic groups are considered: 1) 78 patients

with SAH at admission (Group A). This group of

patients with referral and correct diagnosis at the

rst episode of non-catastrophic SAH is considered

a “recognized” minor leak; 2) 74 patients with SAH

and history of premonitory warning signs (Group B).

These patients had not identied minor leak and were

referred and diagnosed only at a second episode of

SAH. Headache described by the patients as sudden,

severe and unusual was the main symptom in Groups A

and B; in 82.5% of cases it was localized. Thunderclap

headache was an isolated symptom in 14.1 % of patients

in Group A and in 32.4% in Group B and in respectively

37.2% and 28.4% of cases it was associated with

nausea or vomiting.

The present study has shown the

prevalence of TCH was 51,7 %. And TCH associated with

nausea and vomiting was 75 %.

Table 2. Clinical characteristics of patients with primary headache and intracranial aneurysms before their rupture

(n=37).

Characteristics

Migraine with aura Migraine without aura TTH All types*

(n = 9) (n = 11) (n = 16) (n = 37)

Mean Age (years) 47 42,4 48,3 46,3

Thunderclap headache 6 (16,2%) 4 (10,8%) 10 (27%) 21 (56,8%)

Female 9 (24,3%) 8 (21,6%) 12 (32,4%) 30 (81%)

Male 0 3 (8,1%) 4 (10,9%) 7 (19%)

Arterial Hypertension 5 (13,5%) 5 (13,5%) 7 (19%) 18 (48,7%)

Smoker 5 (13,5%) 3 (8,1%) 4 (10,9%) 13 (35,1%)

Aneurysm size

<10 mm 5 (13,5%) 7 (19%) 14 (37,8%) 27 (73%)

10 - 24 mm 3 (8,1%) 1 (2,7%) 2 (5,4%) 8 (21,6%)

>24 mm 0 2 (5,4%) 0 2 (5,4%)

*Including nonspecic headache

Table 3. Presence of TCH according vascular territory

Thunderclap

Headache

Aneurysm Localization

Anterior Circulation Posterior Circulation

n % n %

No 22 45,8% 7 58,3%

Yes 26 54,2% 5 41,7%

Total 48 100,0% 12 100,0%

p= 0,527

Thunderclap Headache In Ruptured Aneurysm

Esmanhotto BB, et al.

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In addition, a recent study identied the presence

of migraine as independent risk factor for rupture of an

intracranial aneurysm

The present study has limitations. Firstly, the patients

may have overlooked episodes of mild headache or

forgotten details of the pain in the 12 months prior to

treatment. Secondly, the number of participants was

small.

CONCLUSION

In summary, we conclude that nearly half of

patients with ruptured intracranial aneurysms presented

thunderclap headache and there is no relation with size

aneurysm and vascular territory.

REFERENCES

1. Suarez JI, Tarr RW, Selman WR. Cerebral aneurysms. N Engl

J Med 2006; 354: 387–96.

2. Wiebers DO, Whisnant JP, Forbes. Unruptured Intracranial

Aneurysms - Risk of Rupture and Risks of Surgical

Intervention. N Engl J Med 1998; 339: 1725–33.

3. Baron EP. Headache, Cerebral Aneurysms, and the Use of

Triptans and Ergot Derivatives. Headache 2015; 55: 739–47.

4. Headache Classication Committee of the International

Headache Society (IHS) The International Classication of

Headache Disorders, 3rd edition. (2018). Cephalalgia 2018;

38: 1–211.

5. Vlak MHM, Rinkel GJE, Greebe P, et al. Risk of rupture of an

intracranial aneurysm based on patient characteristics: A

case-control study. Stroke 2013; 44: 1256–1259.

6. Schwedt TJ. Thunderclap Headache. Headache 2015; 21:

1058–1071.

7. Schwedt TJ, Matharu MS, Dodick DW. Thunderclap

headache. Lancet Neurol 2006; 5: 621–31.

8. Abraham MK, Chang W-TW. Subarachnoid Hemorrhage.

Emerg Med Clin N Am 2016; 34: 901–916.

9. Queiroz LP, Peres MFP, Piovesan EJ, et al. A nationwide

population-based study of migraine in Brazil. Cephalalgia

2009; 29: 642–649.

10. Queiroz LP, Peres MFP, Piovesan EJ, et al. A nationwide

population-based study of tension-type headache in Brazil.

Headache 2009; 49: 71–78.

11. Landtblom AM, Fridriksson S, Boivie J, et al. Sudden onset

headache: A prospective study of features, incidence and

causes. Cephalalgia 2002; 22: 354–60.

12. Linn FHH, Wijdicks EFM, Van Der Graaf Y, et al. Prospective

study of sentinel headache in aneurysmal subarachnoid

haemorrhage. Lancet 1994; 344: 590–593.

13. Bassi P, Bandera R, Loiero M, et al. Warning signs in

subarachnoid hemorrhage: a cooperative study. Acta

Neurol Scand 1991; 84: 277–281.

193

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ABSTRACT

RESUMO

Descritores: Cefaleias secundárias; Procedimentos diagnósticos; Procedimentos

terapêuticos

VIEWS AND REVIEWS

Clinical characteristics of headaches attributed to

diagnostic and therapeutic procedures

Características clínicas das cefaleias atribuídas a

procedimentos diagnósticos e terapëuticos

Raimundo Pereira Silva-Néto

Federal University of the Parnaíba Delta,

Brazil.

*Correspondence

Raimundo Pereira Silva-Néto

Universidade Federal do Delta do

Parnaíba, Avenida São Sebastião, 2819,

Fátima, Parnaíba, PI

64001-020, Brasil. Tel. + 55 3237-2104.

E-mail: neurocefaleia@terra.com.br

Received: December 5, 2019.

Accepted: December 12, 2019.

Headaches may appear after performing diagnostic and / or therapeutic

procedures with close temporal relationship to these events. The objective of

this research was to know the clinical characteristics of headache secondary to

diagnostic and / or therapeutic procedures. We reviewed secondary headaches

according to ICHD-3, and searched for those that arose after performing a

diagnostic and / or therapeutic procedure. A total of 11 different diagnoses

of headache attributed to diagnostic and / or therapeutic procedures were

found. Some secondary headaches are due to diagnostic and / or therapeutic

procedures.

Keywords: Secondary headaches; Diagnostic procedures; Therapeutic

procedures.

Cefaleias podem surgir após realização de procedimentos diagnósticos e/ou

terapêuticos com estreita relação temporal com esses eventos. O objetivo

desta pesquisa foi conhecer as características clínicas das cefaleias secundárias

a procedimentos diagnósticos e/ou terapêuticos. Nós revisamos as cefaleias

secundárias, de acordo com a ICHD-3, e buscamos aquelas que surgiram

após a realização de um procedimento diagnóstico e / ou terapêutico. Foram

encontrados 11 diagnósticos diferentes de cefaleias atribuídas a procedimentos

diagnósticos e / ou terapêuticos. Algumas cefaleias secundárias são decorrentes

de procedimentos diagnósticos e/ou terapêuticos.

INTRODUCTION

Secondary headache is dened

when a new headache occurs for

the rst time in close temporal

relationship to an intracranial

disorder

. The clinical presentation

of all these disorders can be diverse

and often mimics the characteristics

of primary headaches, which may

delay the diagnosis

Headache may appear as a side

effect due to the performance of

some diagnostic and / or therapeutic

procedures, such as neurosurgery,

endovascular treatments, puncture

of the dura mater for cerebrospinal

uid (CSF) removal or injection of

some substance, among others

Knowledge of the clinical char-

acteristics of these headaches is

important to improve diagnostic

accuracy and therapeutic manage-

ment, as well as the development of

prophylactic measures.

METHODS

In this review, we examined the

diagnosis of all secondary head-

aches, according to International

Classication of Headache Disor-

ders, Third Edition (ICHD-3)

. The

headaches that appeared after per-

forming a diagnostic and / or thera-

peutic procedure were selected. In

addition, we seek articles related to

these headaches in the main data-

bases to better characterize them.

RESULTS

A total of 11 different diagnoses

of headache attributed to diagnostic

and / or therapeutic procedures

were found (Table 1).

Clinical characteristics of headaches

Silva-Néto RP.

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DISCUSSION

According to ICHD-3

, some diagnostic and /

or therapeutic procedures may cause headache. In

the following, these headaches that are considered

secondary will be described.

Acute or persistent headache attributed to

craniotomy

A craniotomy is a neurosurgical technique, whereby

part of the skull is opened or removed for access to

treat conditions such as brain tumors, aneurysms, and

arteriovenous malformations

Retrospective studies have shown that more than

30% of the patients submitted to this surgical procedure

had headache attributed to craniotomy as an adverse

event

4-6

However, when headache occurs after head injury

surgery, it will be coded as acute headache attributed to

moderate or severe traumatic head injury.

According to ICHD-3, this headache must have

occurred within seven days after craniotomy, after

the patient has regained consciousness or after

discontinuation of medications that impair the ability to

feel or report headache. In addition, headache should be

resolved within three months of its initiation

Headache attributed to craniotomy is more common

after surgery of the skull base compared to other

locations. Usually, it is felt at the site of the craniotomy,

but may be more diffuse and resemble tension-type

headache or migraine

If headache resolved within three months after its

onset, it will be classied as acute, but if it persists for

more than three months, it will be called chronic. When

headache following craniotomy becomes persistent, the

possibility of medication-overuse headache needs to be

considered

In the abortive treatment of this headache, several

drugs have been tried, such as inltration of the scar

with local anesthesia

, opioids, especially codeine

and morphine, acetaminophen, non-hormonal anti-

inammatories

, and sumatriptan

. There are few studies

on prophylactic treatment of headache attributed to

craniotomy

. The best therapeutic responses were with

verapamil

and divalproex sodium

Post-endarterectomy headache

This headache is caused by the surgical procedure

of carotid endarterectomy. It develops within one week

after of the carotid endarterectomy, but it is resolved

within the rst 30 days. Headache can occur without any

other associated symptom or be a warning symptom

preceding the focal decits of (mostly hemorrhagic)

stroke

Headache is unilateral, on the side of carotid

endarterectomy, and may involve the neck and face. The

headache has a pulsating character and a mild intensity.

It manifests as cluster headache-like pain occurring once

or twice a day in attacks lasting two to three hours

There are three subforms of post-endarterectomy

headache, but they are not coded separately. The rst is

the most frequent (up to 60% of cases), a diffuse, mild

and isolated headache, which occurs in the rst days

after surgery and is a benign, self-limiting condition;

the second (up to 38% of cases), a unilateral cluster

headache-like pain with attacks, lasting two to three

hours, occurring once or twice a day and resolves in

about two weeks; and the third, unilateral pulsating and

severe pain occurring three days after surgery. This latter

subform is part of the rare hyperperfusion syndrome,

often preceding a rise in blood pressure and the onset of

seizures or neurological decits on or about the seventh

day. Urgent treatment is required, since these symptoms

can herald cerebral haemorrhage

Some studies have shown that headache occurs

in 38% to 62% of patients undergoing endarterectomy.

Usually, the location of the pain is on the same side of

the surgical procedure. It has a dull or pressure character

and a moderate to severe intensity. In more than 50%

of patients there is no need for treatment

13,14

, but when

it is part of the hyperfusion syndrome, treatment is an

emergency as these symptoms may indicate a brain

hemorrhage.

Headache attributed to carotid or vertebral

angioplasty or stenting

Carotid and vertebral angioplasty and/or stenting are

performed to treat patients with cervical artery stenosis,

but one-third of these patients develops headache. This

headache is caused by the endovascular procedures of

carotid or cervical angioplasty and / or stenting without

arterial dissection. It develops within a week but resolves

within a one month after angioplasty and / or stenting

Headache attacks usually occur within 10 minutes

in which these procedures are performed. They are

localized to the frontotemporal region, ipsilateral to

the procedure, in pressure, mild intensity, and lasting a

maximum of 10 minutes.

Studies show that carotid percutaneous transluminal

angioplasty may cause arterial dissection, often resulting

Acute or persistent headache attributed to craniotomy

Post-endarterectomy headache

Headache attributed to carotid or vertebral angioplasty or

stenting

Headache attributed to cranial venous sinus stenting

Headache attributed to an intracranial endarterial procedure

Angiography headache

Post-dural puncture headache

Headache attributed to intrathecal injection

Dialysis headache

Headache attributed to radiosurgery of the brain

Post-electroconvulsive therapy headache

Table 1. Headaches attributed to diagnostic and / or

therapeutic procedures, according to ICHD-3

Clinical characteristics of headaches

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in cervical, facial or cranial pain. However, the relative

risk of painful dilation depends on individual risk factors,

such as a history of myocardial infarction. In addition,

the radiation pattern of pain depends on which carotid

segment is dilated

Data on carotid angioplasty headache and

diagnostic criteria are based on few studies. Despite the

scarcity of data, this headache seems to be relatively

frequent. In two studies, its occurrence ranged from 39%

to 51%

15,16

Headache attributed to cranial venous sinus

stenting

In recent years, lateral sinus stenosis stenting has

been used in the treatment of idiopathic intracranial

hypertension. Suppression of stenosis may reduce

intracranial pressure by decreasing the pressure in the

upper longitudinal sinus. However, unilateral headache

may be caused by the stent and on the same side of the

cranial venous sinus stent

This headache devolops within one week after the

jugular or cranial venous stent has been performed.

Headache is ipsilateral to the stenting and it resolves

within three months

In one series of 21patients stented for idiopathic

intracranial hypertension, 10 patients exhibited ‘stent-

headaches’ differing from those experienced before

treatment, located at the site of the stent, in the mastoid

region, and lasting about three weeks. These “stent-

headaches” disappeared after 3 months of stenting

Headache attributed to an intracranial

endarterial procedure

Some studies have shown that balloon ination in the

intracranial arteries during therapeutic embolization of

intracerebral arteriovenous malformations (AVMs) cause

pain by distension of these vessels

. Probably, mechanical

vessel distension activates the trigeminovascular

nociceptive system in susceptible individuals

It is a unilateral headache directly caused by

intracranial endarterial procedure, ipsilateral to the

procedure and lasting less than 24 hours. Pain was

described as brief, sharp or localized pressure of mild to

moderate intensity, felt ipsilaterally to the manipulated

vessel. This headache develops within one week and

resolves within one month after the procedure

1,19

The occurrence of this headache during

endovascular procedures is not yet well-dened.

There is limited information to dene its frequency,

risk factors, pathogenesis and implications for future

pain management

. In some evaluated procedures,

the headache occurrence attributed to an intracranial

endoarterial procedure ranged from 10.6% to 68.0%

18-21

Angiography headache

This headache is caused by intra-arterial carotid

or vertebral angiography. It develops during contrast

injection or within 24 hours after angiography, lasting

less than one hour. It disappears within 72 hours after

angiography

The frequency of post angiography headache

ranges from 30.2% to 39.1%

16,22,23

. Possibly a headache

is due to irritation of the trigeminovascular system by

contrast agents or mechanical stimuli, resulting in the

release of vasoactive peptides

Post-dural puncture headache

Headache occurring within ve days of a lumbar

puncture, caused by CSF leakage through the dural

puncture. It is usually accompanied by neck stiffness

and / or subjective hearing symptoms and it gets worse

when the individual takes the upright position. It remits

spontaneously within two weeks, or after healing from

the leak with autologous epidural lumbar patch

Puncture of the dura-mater occurs during diagnostic

or therapeutic procedures, spinal anesthesia or

inadvertently during epidural anesthesia. After puncture,

post-dural puncture headache may appear as a common

complication in approximately 7.5% of the patients

25,26

Headache attributed to intrathecal injection

Some drugs that act on the central nervous system

such as analgesics, anesthetics, and antineoplastics

are injected directly into the subarachnoid space,

thus avoiding the blood-brain barrier. This route

of administration is known as the subarachnoid or

intrathecal route.

After intrathecal injection, the most common adverse

effects are headache and low back pain

. Headache

develops within four days of intrathecal injection and

signicantly improves within 14 days after intrathecal

injection. Signs of meningeal irritation are present. In

addition, headache experienced in both upright and

recumbent postures

Dialysis headache

Dialysis is a therapeutic procedure used by

patients with kidney failure, where a machine replaces

the diseased kidney and lters the blood, eliminating

toxic substances such as sodium, potassium, urea and

creatinine. Frequently, patients with chronic kidney

disease experience headache during dialysis

, whose

pathophysiology is still unknown.

The prevalence of dialysis headache varies between

27% and 73%

. This headache is characterized by

developing during a hemodialysis session and resolving

within 72 hours after the end of the dialysis session.

Headache episodes cease altogether after successful

kidney transplantation and termination of haemodialysis

Dialysis headache was described for the rst time

by Bana and Yap in 1972

, but its clinical characterization

has been detailed improvement in recent years. In

most patients, headache is pulsatile, located in the

frontal region, moderate to severe intensity, and may

be accompanied by nausea and vomiting

30-33

. There are

Clinical characteristics of headaches

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no controlled studies on the prophylactic or abortive

treatment of dialysis headache.

Headache attributed to radiosurgery of the

brain

Brain radiosurgery is used in the treatment of brain

injuries, such as arteriovenous malformations

and

intracranial tumors

. In some primary headaches, such

as refractory cluster headache, brain radiosurgery may

also be useful

. Cerebral edema is the most frequent

complication of this procedure

37,38

More rarely, headache may appear in a patient in

whom radiosurgery of the brain has been performed. It

develops within seven days, but it is resolved within three

months after radiosurgery. There have been no validation

studies of its diagnostic criteria. Currently, it is in the

appendix of ICHD-3 (A5.7), but it is not better accounted

for by another ICHD-3 diagnosis

Studies on this new headache do not provided

detailed descriptions of its clinical features. In some

cases, the headache syndrome was short-lived, occurred

more than a year after the procedure and resembled

migraine or thunderclap headache

Post-electroconvulsive therapy headache

Electroconvulsive therapy (ECT) is commonly used

in the treatment of various psychiatric disorders, such as

severe depression, schizophrenia, and bipolar disorders.

Headache is the main adverse effect resulting from this

therapeutic procedure. Its incidence varies from 26% to

85% and makes it difcult for the patient to continue with

this treatment

This headache occurs when a course of

electroconvulsive therapy (ECT) has been given in a

headache-free patient to treat an epileptic seizure. It is

necessary that headache has developed after ≥50% of

ECT sessions; each headache has developed within four

hours after ECT; and each headache has resolved within

72 hours after ECT. There have been no validation studies

of its diagnostic criteria. Currently, it is in the appendix

of ICHD-3 (A7.6.3), but it is not better accounted for by

another ICHD-3 diagnosis

Usually, post-ECT headache is treated with

analgesics and / or non-steroidal anti-inammatory

drugs, but other optional treatments are being described.

In some case reports, mirtazapine

and topiramate

were effective.

CONCLUSION

Some secondary headaches are due to

diagnostic and / or therapeutic procedures.

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(1992) Headache following carotid endarterectomy: a

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14. De Marinis M, Zaccaria A, Faraglia V, Fiorani P, Maira G,

Agnoli A (1991) Post endarterectomy headache and the

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ABSTRACT

RESUMO

Descritores: Telemedicina; Cefaleias Primárias; Enxaqueca; Vídeoconsultas;

Aplicativos de Saúde.

VIEWS AND REVIEWS

Telemedicine in the Management of Primary Headaches:

A Critical Review

Telemedicina no manejo das cefaleias primárias:

uma revisão crítica

Renan Barros Domingues

Cassio Batista Lacerda

Paulo Diego Santos Silva, MD

Serviço de Cefaleia, Departamento de

Neurologia, Irmandade da Santa Casa de

Misericórdia de São Paulo.

*Correspondence

Renan Barros Domingues

Rua Vergueiro, 1421 cj 603 Torre Sul, Vila

Mariana, São Paulo, SP, CEP 01504-000

E-mail: contato@renandomingues.med.br

Received: 19 November, 2019.

Accepted: December 5, 2019.

Telemedicine is a modality of health care services delivery with the use of

communication technologies. Its use has grown in several medicine areas. Several

studies evaluated the feasibility, acceptance, efcacy, cost-effectiveness, and

safety of telemedicine in the diagnosis and management of primary headache

disorders. Videoconsultations were shown to be effective, convenient, and safe

for primary headache disorders and migraine follow up. Some mobile health

devices were show to improve adherence favoring better outcomes. Handling

health data is a major concern so that international compliance standards must

be adopted in all telemedicine procedures. The impact in the health system and

increased access to appropriate primary headache treatments with the use of

these technologies has yet to be elucidated.

Keywords: Telemedicine, Primary Headache; Migraine; Videoconsultation;

Mobile Health

A telemedicina é uma modalidade de disponibilização de serviços médicos

com o uso da tecnologia da informação. Seu uso tem crescido enormemente

em várias áreas da medicina. Vários estudos avaliaram a viabilidade, aceitação,

ecácia, custo-efetividade e segurança da telemedicina no diagnóstico e

tratamento das cefaleias primárias. A vídeoconsulta mostrou-se uma forma

ecaz, conveniente e segura no seguimento terapêutico das cefaleias primárias

e da enxaqueca. Alguns aplicativos para dispositivos móveis mostraram

aumento da aderência, favorecendo melhores resultados. A segurança de dados

de saúde é uma preocupação, sendo imprescindível seguir rigorosamente os

protocolos internacionais de conformidade. O impacto no sistema de saúde

e o aumento do acesso a tratamentos adequados proporcionados por estas

tecnologias ainda precisa ser melhor elucidado.

INTRODUCTION

The denition of telemedicine

according to the World Health

Organization is “The delivery of

health care services, where distance

is a critical factor, by all health care

professionals using information and

communication technologies for the

exchange of valid information for

diagnosis, treatment and prevention

of disease and injuries, research and

evaluation, and for the continuing

education of health care providers,

all in the interests of advancing

the health of individuals and their

communities”.

(1,2)

The history of

telemedicine begins in the early 20th

century with the transmission of

eletrocardiographic using telephone

wires.

(3)

Other technologies, such

as closed circuit television, began

to be used in the 1950s and 1960s.

(4,5)

In 1967, the Massachusetts

General Hospital starts to provide

remote health healthcare services

to Boston Logan Airport, being

the rst structured telemedicine

service.

(6)

With the introduction of

World Wide Web (www) in 1990,

the possibility of health information

exchange is greatly expanded, by

replacing analogue processes with

digital ones, increasing enormously

the capacity to store and transmit

data.

(7)

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Domingues RB, et al.

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The delivery of telemedicine services can be made

by four different ways: 1) synchronous – with live video

between patient and provider or non-specialist with

specialist, 2) store and forward - by acquiring medical data

and further transmitting it to a provider or a specialist,

3) remote monitoring - with the use of wearables and

biosensors, and 4) mobile health (mHealth) - which is

the health practice supported by mobile devices.

(8-10)

The use of telemedicine in Neurology is growing due to

the fact that neurological care is still poor around the

world. Telestroke accounts for 65% stroke treatments “in

the USA” - A determiner is probably missing here and

Canada. Several studies have showed potential benets of

telemedicine in the management of Parkinson’s Disease,

Epilepsy, Multiple Sclerosis, Brain and Spinal injury, and

Amytrophic Lateral Sclerosis.

(11,12)

Primary headaches are associated with a signicant

impact.

(13-15)

However, the availability of headache medical

services is poor worldwide and even higher in developing

countries such as Brazil.

(16-21)

Considering the need to

expand access to headache treatment and the high

prevalence of these disorders, telemedicine seems to be

an attractive alternative to provide care for these patients.

In the present review we will critically discuss the current

evidence about this topic.

TELEMEDICINE AND HEADACHE IN

THE LITERATURE

By searching with the words “Telemedicine” and

“Headache” in the PubMed database 53 articles are

found, including several article types, such as clinical

trials, case reports, reviews, and opinion articles. Among

them, twenty are clinical studies or case presentations

evaluating specic telemedicine procedures in the

treatment of headache or specic headache disorders.

The rst scientic paper about the use of communication

technologies in headache care was published in 2004.

Several studies about behavioral interventions on

adherence and outcomes in headache treatment with the

use of mHealth were published between 2004 and 2016,

when the rst well designed, prospective telemedicine

and headache clinical trial article was published.

(22-24)

this critical review we took into consideration the most

important articles evaluating synchronous telemedicine

and mobile health (mHealth).

Synchronous telemedine (videoconsultations)

Müller et al. evaluated synchronous telemedicine

and showed high levels of acceptability, feasibility,

as well as cost effectiveness with videoconsutations

when compared to conventional consultations. The

study was carried out in Northern Norway and included

adult patients referred to a neurologist for non-acute

headache treatment by primary care physician. The

patients were randomized for telemedicine consultations

or conventional face-to-face appointments.

Videoconsultations were performed using appropriate

equipment in a telemedicine hospital room, with audio

and video communication between the neurologist

and the patient in the videoconference room. The

same physician carried out the consultations of the

telemedicine group and the conventional consultation

group. Nearly 400 hundred subjects were randomized

for telemedicine or conventional consultations and

were followed for one year and telemedicine was shown

to be feasible.

(25)

In another publication originated from

the same clinical trial the authors compared efcacy of

telemedicine and conventional treatment with visual

analogue scale (VAS) and headache impact test (HIT-

6), showing non-inferiority of telemedicine approach.

(26)

The satisfaction of patients with telemedicine was

also evaluated by the same study group. Telemedicine

patients did not express less satisfaction than those

with traditional consultation.

(27)

The safety of using

telemedicine was also assessed. The ability to identify

secondary headaches over one year of follow up

was not signicantly different between telemedicine

and conventional consultations. The percentage

of neuroimaging exams indication, neuroimaging

abnormalities, as well as the proportions of hospitalized

patients during the follow up period was not signicantly

different between the two groups. It was estimated that

over 20,000 telemedicine consultations are necessary

to miss one secondary headache.

(28)

The feasibility of telemedicine consultations was

also evaluated in children with headache. Vierhile and

cols. conducted a small open study in which children

were evaluated in a spoke site with the presence of a

nurse practitioner. The connection was established

with a hub center with a specialist. Overall, the

headache outcomes were comparable to outcomes

with conventional in ofce consultations. Most of the

parents liked not having to drive to the medical center

and not having to cancel the activities of the children

due to medical consultation.

(29)

Qubty et al. carried out

a prospective pediatric headache telemedicine study

and showed that telemedicine was convenient, cost-

effective, and patient-centered for routine pediatric

headache follow-up visits. Overall patients and family

were satised with telemedicine.

(30)

The efcacy of telemedicine has also been tested

for the management of specic headache types.

Bekkelung and Müller compared video consultations

and traditional consultations in patients with Medication

Overuse Headache (MOH). The group treated with

telemedicine had non-inferior outcomes, including

reduction in the number of headache days and reduction

of analgesic consumption.

(31)

Friedman et al. conducted

a prospective, randomized trial of telemedicine for

migraine management. Patients were evaluated in an

initial in-ofce visit and then randomized for follow-

up with telemedicine consultations or in-ofce visits.

Telemedicine consultations were conducted with specic

software installed on a patient choice computer and

were carried out by the same physician of the traditional

consultations group. The follow-up time was one year. All

the measured outcomes, including efcacy of treatment,

headache impact, and safety, were similar between the

two groups. Physician productivity was higher with

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Domingues RB, et al.

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telemedicine group. The perception of convenience by the

patients was higher in the telemedicine group.

(32)

Mobile health (mHealth)

The use of mHealth has potential advantages as

an auxiliary tool in the management of headaches,

particularly in patient education and life style modication

that are important in the effective treatment of people

with headache disorders. The mHealth devices may be

a good way to record headache-related symptoms and

information such as possible triggers.

Despite the availability of a growing number of

smartphone apps, in particular electronic headache diaries,

there is still little evidence about its efcacy and safety in

handling patient data. Mosadeghi-Nik and cols. carried out

a systematic review with smartphone headache diaries,

which are presumably easier and more practical to use

than paper-based diaries. One reported advantage is

that electronic diaries can be lled in real time. Another

advantage is that assistant physician can have access

patient data through a web portal, also facilitating the

database generation. However, the authors point that the

evidence of effectiveness and safety of these mobile apps

for headache disorders treatment is still limited.

(33)

In a recent

narrative review, Stubberud and Linde sought for clinical

evidence on mHealth based classical behavioral therapies,

such as cognitive behavioral therapy, biofeedback, and

relaxation in patients with migraine; however, evidence is

still missing in this eld.

(34)

In a systematic review, Hundert

et all. also evaluated clinical evidence with the use of

some available headache diary apps. The authors found

38 headache diary apps but only 18% were developed

with headache expertise. Little evidence regarding its

effectiveness was found.

(35)

Concern about privacy with

headache diary smartphone apps was also reported by

Minem et al. that examined 29 apps (14 diary apps and

15 relaxation apps). Only 11/14 headache diaries disclosed

targeted advertisements. Only 11/15 relaxation apps had

disclosed privacy policies.

(36)

One large and controlled study evaluated the efcacy

of a mHealth device in headache management. The value

of electronic monitoring and alerting system was assessed

in the management of MOH in a controlled multicenter

study. In this study, Tassorelli et cols. evaluated the

Comoestas tool which is a diary with an alerting system

that allows remote monitoring of key clinical data. The

system has a headache diary allowing data collection to

a web platform, generating high and low priority alerts.

The system also facilitates electronic communication with

smartphone, e-diary, and E-mail text messages as well

as smartphone calls. A signicantly higher percentage

of patients were overuse-free, there was a lower rate of

subjects lost to follow-up, and higher level of patients

satisfaction were registered in the group treated with the

aid of Comoestas.

(37)

One study compared the use of paper-based diaries

and electronic diaries. Bandarian-Babooch et al. compared

two paper diaries (short and long) and four types of

electronic diaries. The authors found more missing date

and more errors in data lling in the long paper use than

with short paper diary and electronic diaries. Long paper

diaries were found more burdensome and signicantly

less easy to use than electronic diaries and short paper

diaries. The authors concluded that electronic diary is

a potentially useful tool in clinical trials as well as in the

behavioral treatment of headaches.

(38)

DISCUSSION

The available evidence shows that telemedicine is

effective, convenient, and cost-effective in the treatment

of primary headaches. Concern about safety still exists

but available published data shows that using appropriate

screening tools or a rst face-to-face consultation, the

safety level is in identifying secondary headaches is similar

between telemedicine and conventional consultations.

Therefore, there is scientic evidence that telemedicine is

viable for primary headache disorders follow-up, allowing

higher physician productivity, and it is associated with high

level of satisfaction by the patients or caregivers. There

is also some evidence that the use of mHealth devices

may contribute in monitoring headache, potentially

contributing to better outcomes and easier interaction

between patient and assistant physician.

The health system impact of using telemedicine in

headache care still needs to be measured. Considering

that telemedicine is a potentially useful tool in primary

care, it can be used in this setting in the management

of patients with primary headache disorders.

(39)

Potential advantages would be an earlier introduction of

preventive treatments, better orientation for patients in

the management of headache attacks, lifestyle change

orientation, and analgesics overuse prevention. This

would also facilitate the identication of patients requiring

treatment at a specialized tertiary center. Despite these

potential advantages, there is still need for studies

evaluating the clinical and economic impact in health

system and how it can facilitate the access of patients to

adequate treatments.

The use of telemedicine brings concerns about data

security and compliance with local legislations. Most of

the available synchronous telemedicine studies cited in

this review employed validated and safe telemedicine

platforms that allow the storage and inviolability of data,

as well as making it available to the patient or guardian

upon request. There is still concern about some mHealth

devices, particularly electronic diaries, since many of

them do not disclose data security policy. Creating and

maintaining large headache databases has potential

enormous benets, for example, in generating local

and national headache registries that can help to guide

public health policies.

(40)

Handling these databanks

should be done according to all compliance rules to avoid

targeted advertisements. Health Insurance Portability and

Accountability Act (HIPAA) established security standards

for protecting health information in its electronic form.

(41,42)

The procedures established by HIPAA must be adopted

by every app or system dedicated to telemedicine.

Regulatory and legal issues regarding telemedicine have

specicities around world.

(43)

In Brazil, some general

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rules were published in 2002; however, they do not

address technological developments and telemedicine

advances over the last 17 years. There is a new and more

detailed regulation under discussion and it is expected

that this regulation with more specic rules, detailing

of technological requirements, and better specication

procedures will be available until 2020.

In conclusion, the existing evidence favors

telemedicine as an alternative in the treatment of primary

headache disorders. This modality of delivering medical

care may be an option for patients with difculty in

accessing in-ofce consultations. It is possible that, as in

other areas of medicine, telemedicine may increase the

access to available headache treatments. The current

available treatments are not yet widely available because,

among other factors, there are no headache experts in

many regions. The use of telemedicine within ethical and

compliance parameters by qualied professionals may

be incorporated into the treatment of primary headache

disorders. Not as a new treatment, but as an agile and

scalable way to deliver currently available headache

treatments.

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ABSTRACT

RESUMO

Descritores: Migrânea; Epilepsia; Lipoma intracraniano.

CASE REPORT

Intracranial lipoma manifesting with change in preexisting

headache characteristics

Lipoma intracraniano que se manifesta com mudança das

características de cefaleia preexistente

Patrick Emanuell Mesquita Sousa Santos

Ivan Rodrigues Silva

1,2

Mário Fernando Prieto Peres

Raimundo Pereira Silva-Néto

Federal University of Delta of Parnaíba, Brazil.

Dirceu Arcoverde State Hospital, Parnaíba,

Brazil.

Education and Research Israelite Institute

Albert Einstein, Brazil; Institute of Psychiatry,

HCFMUSP, Brazil.

*Correspondence

R. P. Silva-Néto

Federal University of Delta of Parnaíba,

Avenida São Sebastião, 2819, Fátima,

Parnaíba, PI 64001-020, Brazil. E-mail:

neurocefaleia@terra.com.br

Received: December 15, 2019.

Accepted: December 22, 2019.

Intracranial lipomas represent 0.1% to 0.5% of all intracranial tumors.

Approximately half of the patients are asymptomatic. In symptomatic patients,

headache is the most common symptom. We describe the case of a 71-year-old

woman with history of generalized seizures and episodic migraine for about

30 years. In recent months, there has been a change in the characteristics of

headache. She was admitted to the emergency room with muscle weakness

in left hemibody and intense headache onset approximately four hours ago.

Neuroimaging exams revealed a median frontal expansive lesion suggestive of

intracranial lipoma.

Keywords: Migraine; Epilepsy; Intracranial lipoma.

Lipomas intracranianos representam 0,1% a 0,5% de todos os tumores

intracranianos. Cerca de metade dos pacientes portadores dessa rara formação

são assintomáticos. Naqueles sintomáticos, a cefaleia é o principal sintoma. Nós

descrevemos o caso de uma mulher de 71 anos com história de convulsões e

migrânea episódica há cerca de 30 anos. Nos últimos meses, houve mudanças

nas características da dor. Ela foi admitida na emergência com fraqueza

muscular no hemicorpo esquerdo e intensa cefaleia, com início há cerca de

quatro horas. Os exames de imagem revelaram uma lesão expansiva frontal

mediana sugestiva de lipoma intracraniano.

Intracranial lipoma

Santos PEMS, et al.

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We describe the case of a 71-year-old woman with

history of generalized seizures and episodic migraine

for about 30 years. Headache presented pressure

characteristics, worsening in the last two months. Before,

she had three headache attacks a week, but in recent

months, headache occurs daily. Headache attacks don’t

remit with simple analgesics. Recently, she was admitted

to the emergency room with muscle weakness in left

hemibody and intense headache onset approximately

four hours ago. Her neurologic examination was normal.

Diagnostic hypothesis of stroke was considered.

She underwent a CT scan of the skull that showed an

interhemispheric hypodense mass. MRI revealed a

median frontal expansive lesion suggestive of intracranial

lipoma (Figure 1).

Intracranial lipomas (IL) represent 0.1% to 0.5% of all

intracranial tumors and are located mainly in the area of

corpus callosum

. A retrospective study with 17 patients

diagnosed with IL was conducted at a tertiary center.

He showed that 47% of these patients complained of

headache

. There is another study stating that half of the

cases of IL was asymptomatic. In the other half, the main

symptoms were seizures, headache and muscle weakness

Surgical intervention is rarely required, because

there may be vascular structures near or within the

lipomas and complications may develop due to surgical

excision

. Thus, the best therapeutic option for IL

symptoms remains unclear.

REFERENCES

1. Ben Elhend S, Belfquih H, Hammoune N, Athmane EM,

Mouhsine A (2019) Lipoma withagenesis of corpus

callosum: 2 case reports and literature review. World

Neurosurg, 125:123–125.

2. Seidl Z, Vaneckova M, Vitak T (2007), Intracranial lipomas:

A retrospective study. Neuroradiol J, 20(1):30–36.

3. Piovesan EJ, Tatsui CE, Kowacs PA, Prazeres RF, Lange

MC, Antoniuk SA, et al (2000), Lipoma do corpo caloso

associado a hipertroa do corpo caloso: Relato de caso.

Arq Neuropsiquiatr, 58(3B):947–951.

Figure 1. (A) CT. (B) Axial RNM T1W. (C) Coronal RNM T2W. (D) Axial RNM T2W. (E) Sagittal RNM T1W.Frontal median lesion of fat

content measuring about 6.6 x 4.5 x 3.5 cm associated with signs of corpus callosum dysgenesis and colpocephalic aspect of the

lateral ventricles.

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ABSTRACT

RESUMO

Descritores: Martelo; Neurologia; História; Reexos.

IMAGES

The neurologist’s hammer

O martelo do neurologista

duardo Nogueira

Yara Dadalti Fragoso

Neurologist’s hammer

*Correspondence

Yara Dadalti Fragoso

E-mail: yara@bsnet.com.br

Received: December 12, 2019.

Accepted: December 20, 2019.

From the obscurity of 18

century wineries to the hands of the greatest

neurologists in history, the percussion hammer has a fascinating history. The

rst famous percussion hammer was created in 1841 by the German physician

Max Wintrich and was initially used for thoracic percussion. In 1875, Erb and

Westphal both published simultaneous articles with the results from research

that they had conducted separately, from which they conrmed that percussive

objects were useful for stimulating deep tendon reexes, especially patellar

reexes. The percussion hammer, however, was not yet ideal. It was designed to

strike the thorax rather than the tendons, so it did not have the right weight or

ideal length, and even its shape was not practical. New modied versions of the

instrument subsequently emerged, and the hammer became the characteristic

symbol of the neurologist.

Keywords: Hammer; Neurology; History; Reexes.

Da obscuridade das adegas do século XVIII às mãos dos maiores neurologistas

da história, o martelo de percussão tem uma história fascinante. O primeiro

martelo de percussão a ganhar notoriedade foi criado em 1841 pelo médico

alemão Max Wintrich, sendo inicialmente usado para percussão torácica. Em

1875 Erb e Westphal publicaram em conjunto um artigo com os resultados de

suas pesquisas, que foram realizadas separadamente, conrmando o uso dos

objetos de percussão para o estímulo dos reexos tendíneos profundos, em

especial o patelar. O martelo de percussão, contudo, ainda não era o ideal.

Por ter sido desenvolvido para percutir o tórax e não os tendões, ele não tinha

o peso certo, o comprimento ideal e nem mesmo um formato prático. Novas

versões modicadas do instrumento foram surgindo até que o martelo se

tornasse o símbolo característico do médico neurologista.

Headache is one of the

neurological complaints that leads

a patient to seek urgent care more

often. Although it seems a common

issue the patient should be submitted

through a very careful and detailed

physical examination (including

neurological examination) so redag

symptoms and secondary causes of

headache can be excluded.

For that matter the percussion

hammer is an indispensable tool

for the neurologist and general

practitioner.

Percussion is an aid to medical

diagnosis. The delicate percussion

hammer neurologists use daily has

its origins in the dark wine cellars

of 18

century Austria, where young

Leopold Auenbrugger routinely

struck casks of wine in order to

check the level of uid

. As a music

admirer, he had sensitive ears and

wrote the axiom “the thorax of

a healthy person sounds, when

struck”. Auenbrugger favored

thumping his patients’ chest directly

with his own ngers, as most doctors

still do today

The rst percussion hammer

for medical use was created by

Max Wintrich, in 1841. This German

doctor presented the scientic

world with his gadget made of

steel and rubber, for use in thoracic

percussion (Fig 1)

. However, it was

only in 1875, when Carl Westphal was

the Editor of Archiv für Psychiatrie

The neurologist’s hammer

Nogueira, E, et al.

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und Nervenkrankheiten (“Archive for Psychiatry and

Nerve Sickness”), that the hammer for eliciting reexes

was created. While reviewing a paper by his colleague

Wilhelm Erb, Westphal was astonished to see that

Erb had reached conclusions that were rather like his

own. Separate articles from Erb and Westphal were

published in the same issue of Archiv für Psychiatrie und

Nervenkrankheiten

3, 4

Erb wrote: “If one rmly holds and supports the

leg to be examined, slightly bent at the hip and knee

joint with all the muscles relaxed, and then lightly and

elastically taps the region of the ligamentum patellae

with the nger or with the percussion hammer […] each

tap is immediately followed by a slight but signicant and

evidently reex contraction of the quadriceps; […] and it

is extremely difcult to suppress this reex voluntarily”.

Westphal wrote that the idea of tendon percussion was

given to him by one of his patients who said that when

he sat on a chair and lightly tapped the area below

the kneecap of the affected leg, it moved forwards

with a sudden jerk. While Erb described in detail how

to elicit the patellar reex with a percussion hammer,

Westphal described nger percussion, but mentioned

that a precision hammer would be more effective in this

maneuver

Thus, Westphal and Erb started the history of the

neurological percussion hammer. This history continued

with the arrival of different models of this tool for

neurological examinations. New modied versions of the

instrument emerged over the course of the nal years of

the 19

century

. Schematic images of some percussion

hammers are shown in 1.

Some of these hammers gained small gadgets like

a needle with sharp and blunt points inserted into the

handle, a small brush, or even a ruler or Wartenberg

wheel. In 1888, John Taylor introduced the rst reex

hammer with a triangular shaped head made of rubber

circled by a metal band. It had a metal handle nishing in

a loop and was manufactured to order by the Snowdon

Brothers Instruments Company

. Around 1920, the

loop was replaced by solid metal, giving this percussion

hammer the shape that we all know so well.

In 1894, William Christopher Krauss devised a model

that had two rounded pieces attached to a metal. The

large piece was designed to be used for the knee jerk

and the small one for the biceps jerk. The warm rubber

handle, the cold metal head, the sharp and blunt pin

heads and the brush would help in testing sensitivity

Ernst LO Trömner introduced the metal handle tapering

to a thin end, in order to test cutaneous reexes as well.

The Vernon hammer consisted of a rubber disk around a

metal sphere.

The Queen Square Hospital and Babinski hammers

followed, comprising a rubber disk around a at metal

disk

. The main difference between these lies in their

ease of carrying, since Queen Square is rigid, while

Babinski is smaller and telescopic, with a shorter handle.

Even if some consider these to be similar, Queen Square

is almost 150 grams heavier than Babinski

. The Queen

Square Hospital hammer was developed by Miss Wintle,

a nurse at the hospital.

The Rabiner hammer has a rubber disk that can be

used in parallel with or perpendicular to the handle, as well

as an inserted brush and needle for supercial reexes

Figure 1. Drawings from different neurologist’s hammers

The neurologist’s hammer

Nogueira, E, et al.

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and sensitivity assessment. The history of the Rabiner

hammer is quite peculiar. Babinski and Rabiner had an

argument about the physiology behind the Babinski

reex. The argument occurred during a black-tie dinner

in Vienna and the two neurologists became physical,

pushing and shoving each other to the amazement of the

dinner guests. The dispute was settled and, as a token of

respect and apology, Babinski gave his own percussion

hammer to Rabiner who returned to New York and

modied its shape and appearance

2, 7

With the rubber disk attached to the handle at 90

degrees, the Berliner hammer looks like a throwing axe.

The Stookey hammer is collapsible and is accompanied

by a camel hairbrush and two sharp pins for testing

supercial sensitivity, including two-point discrimination.

In addition, the Stookey hammer has a rough structure

to test the plantar response

6, 8

. The ve-in-one hammer

includes a tuning fork and a Waterberg wheel. The

Dejerine hammer features a hollow metal handle with

inserted hick brush and needle, and a double rubber

head. Imaginative improvements to this tool continue to

be made. Neuropediatric wards nowadays have a variety

of animal-shaped and colorful percussion hammers.

Although the hammer was initially developed for

percussion of the thorax and abdomen in medical practice,

it has now become the hallmark of the neurologist.

Purists among the practitioners of the art of neurological

examination will favor one hammer or another. The

present authors have their favorite ones as well, but we

do not feel like arguing about this. Use of a percussion

hammer is a matter of personal taste and experience: one

of these situations in which there is no right or wrong.

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Watenberg (1887-1956). Med Hist. 1967;11:75–85.

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1989;39:1542-1549.

3. Westphal CO. Über einige Bewegungs-Erscheinungen an

gelähmten Gliedern. Arch für Psych und Nervenkrankh

1875;5:803–834.

4. Erb WH. Über Sehnenreexe bei Gesunden und

Rückenmarkskranken. Archiv für Psychiat und Nervenkrankh

1875;5:792–802.

5. Louis. ED. Erb and Westphal: Simultaneous discovery of the

deep tendon reexes. Seminars in neurology 2002;22:385-

389.

6. Bhattacharyya KB. Deep tendon reex: The background

story of a simple technique. Neurol India 2017;65:245-249

7. Pinto F. A short history of the reex hammer. Pract Neurol

2003;3:366-371.

8. Schiller F. The reex hammer. Med Hist 1967;11:75-85.

9. Bynum B, Bynum H. Reex hammer. The Lancet

2017;390:641.