Forty to 78% of the patients using sumatriptan for the acute treatment of migraine may present recurrence at least occasionally. The concomitant use of a NSAID (nonsteroidal anti-inflammatory drug) has been recommended to decrease the recurrence rate. Sixty seven patients that treated successfully 8 migraine attacks with 100 mg of sumatritpan PO and presented recurrence in at least 5 attacks were studied prospectively. The patients received 100 mg of sumatriptan and 550 mg of naproxen sodium PO to treat 4 consecutive moderate or severe migraine attacks. The recurrence rate, once at least 62.5% (5 out of 8 attacks), decreased to 14.2% (38 out of 268 attacks) with the combination of compounds (p<0.0001). We then studied two groups of 13 patients made randomicaly from the 67 initially evaluated, that were given sumatriptan 100 mg plus naproxen sodium 550 mg or placebo, in a double-blind design, to treat 3 other consecutive migraine attacks. Each group of patients treated 39 attacks. The recurrence among the patients taking sumatriptan plus placebo was 59% (23 out of 39 attacks) and the recurrence presented by the group taking sumatriptan plus naproxen was 25.5% (10 out of 39 attacks) (p<0.0003). We concluded that the combination of sumatriptan plus naproxen sodium decreases significantly migraine recurrence presented by patients taking sumatriptan alone.

Chronic daily headache and chronic (transformed) migraine (TM) patients represent more than one third of the subjects seen in specialized headache centers. Most of these patients may overuse symptomatic medications (SM) taken on a daily basis to relieve headache and associated symptoms. The conversion to the daily or near-daily pattern of headache presentation is thought to be related to the medication overuse. The aim of this study was to evaluate the profile of SM consumption among transformed migraine patients attending a tertiary center. One hundred thirty three consecutive patients (22 men and 111 women, ages 17 to 80) with TM and overuse of SM according to the proposed criteria of Silberstein et al (1994, 1996) were prospectively studied. None of the patients were under treatment for other conditions. Among them, 73 (54.9%) were using one category of SM, while 55 (41.3%) and 5 (3.8%) patients were taking simultaneously two and three categories of SM respectively. The categories of overused symptomatic medications varied from simple analgesics to narcotics, triptans and combinations of ergot derivatives and caffeine and of analgesics and caffeine. The average intake per patient per day was of 3 to 4 tablets and mostly of the patients overused simple analgesics (isolated or in combination with other substances) (75.2%), caffeine containing drugs (71.4%), drugs containing ergotamine derivatives (26.1%), triptans (alone or combined) (15.5%), drugs with narcotics or ansiolitics (13%) and anti-inflammatory drugs (3.7%). The mechanisms by which the overuse of symptomatic medications may play a role in this transformation are uncertain but despite of the necessity of controlled trials to demonstrate the real role of such compounds in the development of transformed migraine, this study emphasizes the necessity for more rigorous prescribing guidelines for patients with frequent headaches.

Chronic daily headache (CDH) refers to a group of non-paroxysmal daily or near-daily headaches with peculiar characteristics that are highly prevalent in populations of neurological clinics and not uncommon among non-patient populations. Most of the patients with CDH had, as primary diagnosis, episodic migraine, which, with the time, presented a progressive frequency, pattern modification and loss of specific migraine characteristics. Other CDH patients had chronic tension-type headache, new daily persistent headache and hemicrania continua, which evolved thru the time to the daily or near-daily presentation. The objective of this study was to determine the primary headache diagnosis among a population of chronic daily headache patients attending a tertiary center for headache treatment. During a 5-year period 651 consecutive chronic daily headache patients attending a private subspecialty center were studied prospectively. The criteria adopted were those proposed by Silberstein et al (1994, revised 1996). Five hundred seventy four patients (88.1%) had episodic migraine as primary headache before turning into daily presentation, 52 (8%) had chronic tension-type headache, 14 (2.2%) had hemicrania continua and 11 patients (1.7%) had new daily persistent headache. CDH is quite frequent in patients from clinic-based studies suggesting a high degree of disability. Emphasis on education of patients suffering from frequent primary headaches with regard to measures that are able to decrease suffering and disability as well as better medical education directed to more efficient ways to handle these patients are necessary to improve outcome of such a prevalent condition.

Dentre as cefaléias primárias, pacientes com migrânea ou enxaqueca são os que mais procuram assistência médica. A sua prevalência é estimada em 12% da população sendo mais comum em mulheres com média de 18 a 20%, de 6% nos homens e de 4 a 8% nas crianças. O impacto econômico na produtividade e lazer é significativo, e as crises incapacitam o paciente para as atividades habituais. Com fisiopatologia complexa e ainda insuficientemente conhecida, a migrânea pode cursar com ataques de cefaléia intermitente, intensa e com características peculiares. A abordagem mais eficiente para o tratamento inclui o afastamento dos fatores deflagradores, tratamento medicamentoso preventivo, uso de medicamentos de resgate para os momentos de dor, e as terapias acessórias ou não medicamentosas. Para o tratamento profilático, objeto desta avaliação, utilizam-se várias classes de medicamentos que incluem os beta bloqueadores, antidepressivos tricíclicos (e mais recentemente inibidores seletivos da recaptação da serotonina), antagonistas dos canais de cálcio, antagonistas da serotonina, anticonvulsivantes e outros. Embora os seus mecanismos de ação nas migrâneas ainda sejam desconhecidos, parece que todos atuam nas funções serotoninérgica, noradrenérgica e gabaérgica centrais. Novas propostas de mecanismos de ação para algumas destas drogas incluem a inibição da formação do óxido nítrico e a ação específica de modulação em canais catiônicos neuronais. Quando individualizados e usados corretamente, estes medicamentos preventivos têm sido responsáveis por reduções importantes na frequência e intensidade dos episódios de migrânea, diminuindo assim o sofrimento e condutas duvidosas às quais os pacientes são usualmente submetidos.

Crises freqüentes de migrânea requerem tratamento preventivo. Alguns anticonvulsivantes têm sido preconizados baseado na importância progressiva da hiperexcitabilidade cortical na fisiopatologia da migrânea. O topiramato é um desses medicamentos e sua eficácia foi demonstrada em estudos recentes. O objetivo deste estudo foi avaliar a aderência e resposta ao uso do topiramato em pacientes em tratamento em uma clínica especializada. Durante dois anos todos os pacientes para os quais o topiramato foi prescrito deveriam ser avaliados após três meses. Grau de aderência, redução da freqüência da cefaléia superior a 50% e efeitos adversos foram avaliados. Entre 175 pacientes incluídos, 134 (76,6%) aderiram ao seu uso. Houve redução da freqüência >50% em 82 (61,2%) dos pacientes. Em 105 (78,4%) pacientes ocorreu emagrecimento médio de 3,4 Kg e os efeitos colaterais mais observados foram parestesias (39,6%); distúrbios emocionais (17,9%); distúrbios do raciocínio (12,7%); distúrbios da memória (12,7%) e alterações no paladar em 11,9% dos pacientes estudados. Concluímos que o topiramato foi eficaz e houve aderência ao seu uso na maioria dos pacientes. Além disso, sua tolerabilidade foi aceitável. Estudos controlados são necessários para confirmar estas observações.

BACKGROUND AND OBJECTIVE: Nonsteroidal anti-inflammatory drugs (NSAID) are effective to treat migraine attacks. Lysine clonixinate (LC) and dipyrone (metamizol) have been proven effective to treat acute migraine. The aim of this study was to evaluate the efficacy and tolerability of the intravenous formulations of LC and dipyrone in the treatment of severe migraine attacks. METHOD: Thirty patients (28 women, 2 men), aged 18 to 48 years with migraine according the International Headache Society (IHS) (2004) were studied. The patients were randomized into 2 groups when presenting to an emergency department with a severe migraine attack. The study was single-blind. Headache intensity, nausea, photophobia and side effects were evaluated at 0, 30, 60 and 90 minutes after the drug administration. Rectal indomethacin as rescue medication (RM) was available after 2 hours and its use compared between groups. RESULTS: All patients completed the study. At 30 minutes, 0% of the dipyrone group 13% of the LC group were pain free (p=0.46). At 60 and 90 minutes, 2 (13%) and 5 (33%) patients from the dipyrone group and 11 (73%) and 13 (86.7%) patients from the LC group were pain free (p<0.001). At 60 minutes, significantly more patients from the LC group were nausea-free (p<0.001). Regarding photophobia, there were no differences between groups at 60 minutes (p=0.11). The use of RM at 2 hours did not differ among groups (p=0.50). Pain in the site of the injection was reported by more patients of the LC group compared to the dipyrone group (p<0.0001). CONCLUSION: LC is significantly superior to dipyrone in treating severe migraine attacks. LC promotes significantly more burning at the site of the injection.

Objective To compare the adherence between monotherapy and politherapy in prophylactic migraine treatment. Method Five hundred consecutive patients with migraine from a tertiary center were retrospectively studied as to the number of preventive medications prescribed during the first visit. Adherence, defined as returning for the next consultation after 4 to 6 weeks and following the prescribed regimens, were also evaluated and compared between patients. Results 71.8% were women, and 6% of the patients did not receive any preventive medication, 11.4% received one drug, 22.2% two drugs, 41.4% three drugs, and 19% four drugs for the prevention of migraine. The overall adherence was 79.6%. Respectively, 73.7, 71.8, 82.6 and 86.3% of those who received the prescription of one, two, three and four drugs returned, complying with the treatment. Conclusion There is no difference in adherence to monotherapy or politherapy (one to four drugs) for the prophylaxis of migraine.