Biomedical subjects
Publications and source records attributed to Carlos A Bordini.
The connection between headache and the cervical spine has been a theme of debate for decades. Cervicogenic headache is a headache related to the cervical spine that often is misdiagnosed and treated inadequately because of confusing and varying terminology. In this article, we discuss our experience in diagnosing and treating cervicogenic headache.
OBJECTIVE: In this study we compare the clinical features of migraine attacks occurring in the elderly (60 to 70 years) and in younger migraineurs (20 to 40 years). BACKGROUND: Studies comparing the clinical features of migraine at different ages are still lacking. These studies are important for a better comprehension of the natural history of migraine, as well as to refine our recognition of the disease. METHODS: We retrospectively assessed subjects seen from 1995 to 2000 in a university-based outpatient headache clinic in Brazil. We reviewed 144 charts from patients 60 to 70 years (mean = 66.4). We applied a questionnaire based on the first edition of the International Classification of Headache Disorders (criteria for episodic migraine remained unchanged in the second edition). Controls were migraineurs from 20 to 40 years (mean = 32.6). RESULTS: Migraine occurred in 25% of the elderly and 29% of younger migraineurs (NS). A lower proportion of migraine attacks in the elderly were unilateral (38% vs. 57%, P < .01), or with associated symptoms (nausea = 75% vs. 86%, P = .05; vomiting = 30% vs. 54%, P < .05, photophobia and phonophobia = 83% vs. 94%, P < .05). Other symptoms such as paleness (P = .0441), dry mouth (P = .0093), and anorexia (P = .05) were more common in the elderly. CONCLUSION: Migraine is less typical in the elderly and more frequently associated with vegetative symptoms. Therefore, the diagnosis of migraine in elderly subjects may be more challenging, and many seniors with this primary headache can be misdiagnosed.
The purpose of our study was to prospectively evaluate the impact of preventive drug treatment on the quality of life of patients with episodic migraine (EM). Quality of life evaluations can enhance traditional measures of therapeutic efficacy. Thirty-five consecutive EM without aura patients attending a tertiary care unit (Batatais Headache Clinic) entered the study. They were given a prescription for preventive medication and completed the validated Portuguese version of the generic instrument Short Form-36 (SF-36) questionnaire. Six months later, patients were given another SF-36. We compared the pre-treatment and post-treatment scores for the SF-36 and analysed the headache diaries. The mean age of the 35 patients (32 women and 3 men) was 40.2 years (range 18-60 years). All 35 patients completed the pretreatment and follow-up SF-36. The pre-treatment and post-treatment mean frequency of migraine attacks was 9.16 and 2.4 crises per month, respectively (p<0.05). After the six months of preventive treatment, six of the eight domains evaluated by the SF-36 (role physical, bodily pain, general health, vitality, social function and mental health) showed statistically significant (p<0.05) improvement. The preventive treatment of migraine leads to a significant improvement in the quality of life of patients with EM. This improvement was measurable by the general quality of life instrument SF-36.
OBJECTIVE: To evaluate the impact of ETTH on HRQoL in a sample of employees of a Brazilian public hospital. METHOD: Three hundred and sixty Mário Gatti Hospital employees were asked about headache occurrence in the previous 6 months and completed a SF-36 and a pain questionnaires concerning impact of pain (0 to 10 scale) on daily activities, work efficiency, leisure and social activities in previous six months. Two groups were studied: 1. Episodic Tension-type headache group: 127 employees -- 81 (63.8%) female and 46 (36.2%), male. 2. CONTROL GROUP: 124, 71 (57.3%) female and 53 (42.7%) male. RESULTS: ETTH had lowers scores than control in all domains of SF-36; in vitality and bodily pain the difference was statistically significant. CONCLUSION: Our results indicate that ETTH suffers have impact on HRQoL predominantly in vitality. Psychological factors associated to pain may explain this finding.
BACKGROUND: The pathophysiology of the explosive type of headache associated with sexual activity is not completely understood. Five reported cases of patients with thunderclap headache, precipitated by sexual activity, in association with concomitant cerebral arterial narrowing, were found in the literature. METHODS: A 44-year-old woman with both coital and masturbatory headaches during orgasm associated with segmental reversible cerebral artery vasospasm was investigated. Cerebral anatomy and eventual spasm was documented by magnetic resonance imaging or digital angiography before, during, and after resolution of the orgasmic headache-vasospasm clinical manifestation. CONCLUSION: Findings of cerebral arterial narrowing, presented by some patients shortly after orgasmic headache attacks, support the hypothesis that segmental vasospasm may exert a role in the pathogenesis of this uncommon type of headache. The literature is reviewed, and possible mechanisms underlying the development of orgasmic headache are discussed.
About 60% of women with migraine associate their headache attacks to the menstrual period. Regarding the non-migrainous headaches, this relationship is not so clear. The aim of this study is to present a clinical evaluation of menstrual headaches. Menstrual headache in our study was defined as the headache that begins in the interval of time from 2 days before menstruation until the last day of the menstrual period. The analyzed parameters were: intensity, character and localization of the pain, and associated symptoms. The headaches of 100 women (154 periods) whose ages ranged from 20 to 45 years were analyzed. Most headaches were classified as migraine without aura; the headaches had strong intensity in the first day of pain and reduced gradually until the last day of pain. The headaches were mostly of throbbing character and, in some moment of the menstrual period, referred as unilateral; the duration of these headaches was of longer duration than the migraine attacks reported in medical literature. Most part of the headaches began two days before the first day of the menstrual flow. Nauseas and/or vomiting were the most frequent associated symptoms. Finally, we found, among the menstrual headaches, 9 cases of tension type headache, 2 cases of cervicogenic headache and 1 case of stabbing headache.
The migraine-specific triptans have revolutionized the treatment of migraine and are usually the drugs of choice to treat a migraine attack in progress. Different triptans are available in different strengths and formulations including oral tablets, orally disintegrating tablets, nasal sprays and subcutaneous injections. In Europe, sumatriptan is also available as a suppository. Specific differences among the triptans exist as evidenced by different pharmacological profiles including T1/2, Tmax, Cmax, AUC, metabolism, drug-drug interaction profiles, amongst other parameters. How or whether these differences translate to clinical efficacy and tolerability differences is not well differentiated. Clinical distinctions among these agents are subtle and proper choice of triptan requires attention to the specific characteristics of each individual patient, knowledge of patient preference, accurate history of the efficacy of previous acute care medications as well as individual features of the drug being considered. Delivery systems may play an important role in the onset of action of triptans. The selection of an acute antimigraine drug for a patient depends upon the stratification of the patient's migraine attack by peak intensity, time to peak intensity, level of associated symptoms such as nausea and vomiting, time to associated symptoms, comorbid diseases, and concomitant treatments that might cause drug-drug interactions. The clinician has in his armamentarium an ever-expanding variety of medications, available in multiple formulations and dosages, with good safety and tolerability profiles. Continued clinical use will yield familiarity with the various triptans, and it should become possible for the interested physician to match individual patient needs with the specific characteristics of a triptan to optimize therapeutic benefit.
OBJECTIVE: To determine the prevalence and clinical characteristics of headache in patients undergoing hemodialysis and to compare the prevalence of headache prior to and following the beginning of a hemodialysis program. BACKGROUND: About 70% of patients receiving hemodialysis complain of headache. Despite this, headaches have not been well studied in this group of patients. METHODS: We evaluated a series of patients with chronic renal failure who attended 3 hemodialysis services in a Brazilian town from January of 1998 to December of 1999. Patients with headache were prospectively followed and classified according to the International Headache Society criteria. The headaches were also categorized according to their temporal profile relative to hemodialysis. RESULTS: Headache was reported by 87 (70.7%) of the 123 patients studied. Prior to beginning dialysis, 48% had migraine, 19% had episodic tension-type headache, and 8% had both. Headache related to arterial hypertension was the second most frequent headache diagnosis in these patients (25.4%). Fifty patients (57.5%) experienced headache during the session of hemodialysis. Thirty-four were classified as dialysis headache, 7 were classified as migraine, 7 as episodic tension-type headache, and 2 were unclassified. Twenty-four patients (27.6%) reported dramatic improvement of their headaches after the beginning of the dialysis program. CONCLUSIONS: Headache is common in patients undergoing hemodialysis. Classification of such headaches according to the International Headache society criteria may be difficult.
BACKGROUND: Dipyrone (Metamizol) has been used in the acute treatment of migraines in Brazil. Some investigators have found it to be a highly effective medication for migraine pain and associated symptoms. OBJECTIVE: To conduct a randomized, placebo controlled, double blind study to assess the effect of dipyrone on the pain and symptoms associated with migraine without aura or with aura and the adverse effect profile of this medication. METHODS: For the migraine without aura group, 44 patients were assigned at random to receive 1 g intravenous dipyrone, and 30 patients received 10 mL 0.9% physiological saline. For the migraine with aura group, 30 patients received both dipyrone or placebo. We used seven parameters of analgesic evaluation and an analog scale to assess nausea, photophobia, and phonophobia. RESULTS: Patients receiving dipyrone demonstrated a statistically superior improvement (P<.05 and P<.01) in pain and all associated symptoms compared with control subjects. CONCLUSIONS: Dipyrone is an effective drug for the relief of acute migraine pain and associated symptoms.
OBJECTIVE: To compare the intensity of pain and associated symptoms after placebo administration in patients with migraine with aura and migraine without aura. BACKGROUND: Studies that evaluate drugs used in the acute treatment of migraine ideally should include a placebo arm. The International Headache Society also recommends stratification according to age and sex but not by the presence versus absence of aura. METHODS: The study was conducted as part of a placebo controlled randomized survey comparing four active drugs against placebo in the acute treatment of migraine. Patients were blinded as to treatment received. Placebo consisted of 10 mL of normal saline (0.9%) intravenously. Pain intensity was evaluated by a 10-point analogical-verbal scale. Nausea, photophobia, and phonophobia were evaluated by a four-point analogical-verbal scale. For statistical analysis, unpaired t-test with Welch correction was used. RESULTS: After placebo administration, reduction of symptom intensity (pain, nausea, photophobia, and phonophobia) in patients with migraine without aura was significantly greater than that observed in patients with migraine with aura. CONCLUSIONS: Our findings suggest that studies comparing placebo against an active drug should use stratification according to the presence versus absence of aura.
In spite of the enormous amount of research regarding classification, epidemiology, diagnosis, pathophysiology and treatment of migraines, aura, one of its hallmarks, stays much less studied. The objective of this study is, therefore, to evaluate the evolution of aura in patients submitted to placebo and three different drugs available in Brazilian public health units. We studied 86 patients during an acute migrainous attack, with aura at the moment of the evaluation. Patients were randomized to receive one of the following substances, in a parenteral route: placebo, dipyrone, chlorpromazine and magnesium sulphate. Magnesium sulphate was superior to placebo (p <0,05) 30 and 60 minutes after its administration. Dipyrone and chlorpromazine reduced the duration of the aura, when compared to placebo, 60 minutes following their administration. Our findings make possible some speculations about the pathophysiology of migraine, as well as about the therapeutic approach of patients presenting migrainous aura.
The aim of this study is to assess, in a double blind fashion, the effect of diclofenac on the pain and associated symptoms in patients with acute migraine. 60 patients with migraine with aura and 60 patients with migraine without aura were assigned at random to receiving intramuscular diclofenac, 75 mg associated to intravenous physiological saline, 10 ml, or physiological saline alone. We used 3 parameters of analgesic evaluation and an analogical scale to asses associated symptoms. We also observed the recurrence and rescue medication percentiles. Patients receiving diclofenac showed a statistically significant improvement of pain 60 minutes after the administration in two of the three parameters(migraine without aura) and in all parameters (migraine with aura). They did not present difference, compared to placebo, on the intensity of associated symptoms. We observed a reduction on the recurrence and rescue medication utilization. Despite being an option to treat migraines attacks in the emergency room settings, diclofenac has a slow onset action and no effects on the associated symptoms.
A growing number of patients have been undergoing dialysis procedures all around the world. Around 70% of the patients receiving dialysis treatment complain about headaches. In spite of this, headache is not well studied in this group of patients. The aims of this study are: to evaluate possible triggering factors related to hemodialysis headache and to evaluate the analgesic treatments used under this situation. We prospectively studied 50 patients with chronic renal failure attending to three dialysis services from the town of Ribeirão Preto, State of São Paulo, Brazil, from January 1998 to December 1999. All of them presented headaches strictly related to the hemodialysis sessions. Headache occurred mainly in the second half of the hemodialysis (86%). Arterial hypertension (38%), arterial hypotension (12%) and changes in the weight during the hemodialysis sessions (6%) were the most consistently triggering situations. In 28% of the cases no factors were identified. Dipyrone was, by far (56%), the most frequently analgesic used. Despite being so common it noteworthy how scarce are studies in literature concerning headaches in patients with chronic renal failure. These patients, besides having to bear the burden of living with a painful and boring procedure to keep them alive, many of them have the additional burden, to live with a headache in most of the sessions. The identification of possible triggering factors and further evaluations of the treatment might increase our knowledge and contribute to reduce the burden of the headaches in patients with chronic renal failure.
BACKGROUND: The search for rationality in health expenses in developing countries collides with the lack of effectively conducted epidemiologic studies. PURPOSE: To present an estimate of the impact and costs of migraine in the Brazilian public health system and to estimate the impact on these costs and the effectiveness of a model of stratified care in the management of migraine. METHODS: An analytical model of utilization of the Brazilian public health system was constructed. Data refer to 1999 and were obtained in accordance with the following steps: (1) Brazilian demographic characteristics; (2) characteristics of the public health system related to its 3 hierarchical levels-primary, secondary, and tertiary care, the last being subdivided into emergency department and hospital care; and (3) estimation of the number of migraine consultations at each complexity level. In Brazil, migraineurs seen in the public health system are most often discharged with an acute treatment, usually a nonspecific medication. We compared this treatment with a proposed stratified care model that uses a triptan as an acute care medication. We have made the following assumptions: (1) 15% of the patients would fall into the Migraine Disability Assessment (MIDAS) grade I category, 25% would fall into the MIDAS grade II category, 30% into the grade III category, and 30% into the MIDAS grade IV category; (2) the mean number of migraine attacks per year are: MIDAS I, 7.49; MIDAS II, 8.02; MIDAS III, 12.22; and MIDAS IV, 27.01. The annual costs of the treatment were calculated according to the following equation: AC = P x N x C + P x Cp + P x Cat x AMA, where P is the number of patients; N, the number of consultations per patient; C, the cost of consultation per level; Cp, the cost of preventive drugs; Cat, the cost of acute therapy drugs; and AMA is the number of migraine attacks per year. Results.-The public health system resources included 55 735 ambulatory units (primary and secondary) and 6453 emergency department and public hospital units, with a corresponding budget of US $2 820 899 621.26. The estimated cost of a consultation on the primary care level was US $11.53; on the secondary care level, US $22.18; in the emergency department, $34.82; and for hospitalization, US $217.93. The total estimated public health system expenses for migraine were US $140 388 469.60. The proposed model would imply a cost reduction of 6.2% (US $7 514 604.40) with an improvement in the quality of the public health system from the actual 18.2% to an estimated 84.5%. CONCLUSION: Migraine seems to pose a huge burden on the Brazilian public health system. The implementation of a stratified care model of treatment that would include specific acute migraine therapies could result in a dramatic increase in the quality of migraine care and a significant reduction in cost.