Syncope is a condition often misdiagnosed as epileptic seizures. However, the differential diagnosis between both conditions can be quite difficult, even for well-trained physicians. Four cases of epilepsy and/or syncope are reported, to exemplify this situation. Each case is discussed individually, and the confounding factors are analyzed.

Descrição das características clínicas e do EEG de 53 pacientes de ambulatório atendidos no Setor de Investigação e Tratamento das Epilepsias da Escola Paulista de Medicina com diagnóstico de epilepsia rolândica. A média de idade (em anos) de início da epilepsia foi 5,5±3,2. As crises parciais simples motoras foram as mais frequentemente encontradas. Sete pacientes apresentaram déficit cognitivo. Observamos correlação clínico-EEG e manifestação clínica contralateral, nos focos localizados no hemisfério cerebral esquerdo; nos focos à direita, a manifestação clínica foi ipsilateral ao foco.

Abstract Objectives: The present study aims to evaluate the efficacy, tolerability and compliance of a fixed combination of dipyrone, isometheptene and caffeine versus paracetamol and placebo for the treatment of acute primary headache disorders. Method: A phase IV, multicentric, double-blind, placebo-controlled, randomized, crossover, prospective study was conducted. Approximately equal number of patients received dipyrone 300 mg, isometheptene 50 mg and caffeine 30 mg (combination therapy), paracetamol 200 mg/ml or placebo (oral drops). The primary efficacy endpoint was sustained pain-free (SPF) rate, defined as being headache-free at 120 minutes, without recurrences of any intensity or the use of rescue medication within 24 hours of treatment. Results: Among 99 subjects, most of them classified as having mild to moderate headache (96.0%), primary endpoint was achieved by 61.8%, 48.7% and 28.9% treated with combined therapy, paracetamol and placebo, respectively. A significative improvement in pain severity was observed with combined therapy at 30 and 90 minutes and in headache-related interference on daily activities after 30 minutes versus paracetamol. Both active treatments showed grater satisfaction levels versus placebo after 24 hours. No serious adverse events were registered. Conclusions: Substantial therapeutic gain was obtained with combined therapy on patients with mild to moderate acute primary headache episodes versus paracetamol and placebo. A favorable and tolerable safety profile was reported. Keywords: Headache disorders, primary; Dipyrone; Isometheptene; Caffeine; Acetaminophen; Clinical trial Resumo Fundamento: A associação de dipirona, isometepteno e cafeí­na tem sido utilizada no Brasil para o tratamento de cefaleias primárias agudas. Objetivo: O estudo teve como objetivo avaliar a eficácia, tolerabilidade e adesão de uma combinação fixa de dipirona, isometepteno e cafeí­na, em comparação com paracetamol e placebo, para o tratamento de cefaleias primárias agudas. Métodos: Foi realizado um estudo prospectivo, multicêntrico, randomizado, duplo-cego, cruzado, controlado por placebo e de fase IV. Um número aproximadamente igual de pacientes recebeu a combinação de dipirona 300 mg, isometepteno 50 mg e cafeí­na 30 mg (terapia combinada), paracetamol 200 mg/ml ou placebo (solução oral). O desfecho primário de eficácia consistiu na proporção de pacientes com ausência total da dor após 120 minutos, sem reincidências ou uso de medicamento de resgate por 24 horas. Resultados: Entre 99 pacientes, o desfecho primário foi alcançado por 61,8%, 48,7% e 28,9% dos pacientes tratados com terapia combinada, paracetamol e placebo, respectivamente. Melhora significativa foi observada na gravidade da dor com a terapia combinada em 30 e 90 minutos e na interferência da cefaleia nas atividades diárias após 30 minutos versus paracetamol. Ambos os tratamentos ativos apresentaram maiores ní­veis de satisfação versus placebo, após 24 horas. Nenhum evento adverso grave foi relatado. Conclusão: Obteve-se um ganho terapêutico substancial com a terapia combinada, em pacientes com episódios de cefaleia primária aguda leve a moderada versus paracetamol e placebo. Um perfil de segurança favorável e tolerável foi reportado. Descritores: Transtornos da cefaleia primários, Dipirona, Isometepteno, Cafeí­na, Acetaminofen, Ensaio clí­nico 

OBJECTIVE: Headache is a common condition not always managed satisfactorily by primary care providers (PCPs). In an effort to improve headache care, the Curitiba City Hall in consortia with Hospital de Clínicas da Universidade Federal do Paraná - Brazil developed an educational program directed to the PCPs. The goal of the project was to evaluate, to update and to train the PCP on headache knowledge and care. METHOD: The program was designed to have a theoretical phase and a practical phase. Knowledge on headache and medical care of headache were surveyed before and after the theoretical phase thorough a specific questionnaire. RESULTS: Significant improvement in post-CME scores on headache prevalence (p<0.001), migraine diagnosis (p<0.001) and management (p=0.01), secondary headache diagnosis (p=0.005) and management (p=0.005) was reached by the respondents. CONCLUSION: Improvement in post-CME scores confirms that the program had a significant immediate impact on the PCPs knowledge directly affecting the patient's health.

The Brazilian Lyme-disease-like illness (BLDLI) or Baggio-Yoshinari syndrome is a unique zoonosis found in Brazil. It reproduces all the clinical symptoms of Lyme disease except for the high frequencies of relapse and the presence of autoimmune manifestations. Two cases of borreliosis manifesting with unremitting headache, which is a symptom associated with late-stage BLDLI, were presented. Clinical, therapeutic, and prognostic aspects of the BLDLI and its associated headaches were showed and discussed in this article. BLDLI diagnosis requires additional attention by physicians, since the disease has a tendency to progress to the late, recurrent stage or the chronic form, and the associated headache can be confused with chronic primary headache or with analgesic-overuse one. Special attention should be paid to patients with headaches who have traveled to endemic areas.

OBJECTIVE: To determine the influence of the location of the irritative zone, and the number and the distribution of the intracranial calcifications in the severity of epilepsy associated with intracranial calcifications. METHOD: We studied 47 patients with epilepsy and intracranial calcifications, 24 with normal (Group A) and 23 with abnormal interictal EEGs (Group B), a control group (n=21) with abnormal interictal EEGs and normal CT-scans (Group C). Clinical, electroencephalographic and neuroradiological features were compared among groups. RESULTS: Temporal lobe interictal EEG abnormalities were found in 23/24 Group B patients, and in all Group C patients. Most Group B and Group C patients presented temporal lobe seizure symptomatology, whereas in most Group A patients symptomatology was rolandic (p=0.0001). Epilepsy was more severe in Group B and Group C patients than in Group A patients (p=0.0001 and p=0.0054). No relationship was found between the number of calcifications and epilepsy severity. CONCLUSION: An irritative zone at the temporal lobe is more relevant in determining the severity, symptomatology and frequency of seizures than the number and location of calcifications.

The case of a 70 year-old, previously healthy woman who developed a severe bleeding diathesis shortly after touching a Lonomia obliqua caterpillar and finally died from multiple intracerebral hemorrhages is described. Brain hemorrhages are the leading cause of death in patients envenomed by the Lonomia species. The pertinent literature is reviewed and the most relevant clinical features highlighted, with emphasis on diagnosis. The use of new therapeutic options such as anti-Lonomia serum is discussed.

ABSTRACT BACKGROUND AND OBJECTIVES: Chronic pelvic pain is a condition that lacks specific treatment and often is refractory to several therapeutic approaches. This study aims to report two patients in whom chronic pelvic pain was nearly completely controlled with thalidomide as an add-on therapy. CASES REPORT: The response to therapy of two postmenopausal women who presented to our service with a longstanding history of refractory chronic pelvic pain secondary to interstitial cystitis is reported. Due to their uncontrolled pain and consequent poor quality of life, these women were started on thalidomide at 25 mg/day as an add-on therapy. At one-month follow-up, the patients' pain was reduced in 80% and 70%, respectively. Subsequently, their pain increased, but was again relieved with higher doses of thalidomide. Notably, this medication was well tolerated by both patients. At one-year follow-up and eleven-month follow-up (respectively), their pain has remained controlled and their quality of life is significantly improved. CONCLUSIONS: These results suggest that thalidomide may have therapeutic value for chronic pelvic pain/interstitial cystitis. Based on previously published data, we hypothesize that suppression of TNF-alpha may be one of the mechanisms by which thalidomide controls pelvic pain. Our study may lead to a better understanding of the currently unclear pathogenesis of chronic pelvic pain. Lastly, we hope to encourage further studies to establish the efficacy and safety of thalidomide for CPP and other chronic pain conditions.