los operadores con PSM
III.5.3.4 Obligación de transparencia
Episodic migraine can change its clinical features over months to years, evolving into a chronic headache syn- drome with nearly daily pain. The headache often loses its classic migrainous features. Obesity, prior headache fre- quency, and caffeine use are associated risk factors. A com- mon subgroup of chronic migraine is that of headache from medication overuse.
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▲figure 6-10. Successive maps of scintillating scotoma (blind spot) to show the evolution of fortification figures (jagged edges) and associated scotoma in a patient with classic migraine. As the fortification moves laterally, a region of transient blindness remains.
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▲figure 6-11. Distribution of pain in migraine. Hemicranial pain (the pattern shown) is most common, but the pain can also be holocephalic, bifrontal, or uni- lateral frontal in distribution or, less commonly, local- ized to the occiput or the vertex of the skull.
Time (min)
15 30
0
Pain
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table 6-7. Acute (Abortive) Treatment of Migraine Headache.
Drug route1 strength recommended Dose Comments
Simple analgesics
Aspirin PO 325 mg 650 mg q4h May cause gastric pain or bleeding and rebound headache if used frequently.
Naproxen sodium PO 250, 375, 500 mg 500–1,000 mg at onset, then 250–500 prn after 1 hour Ibuprofen PO 200, 400, 600, 800 mg 800-1,200 mg at onset, then 600-800 mg q4–8h Ketoprofen PO 25, 50, 75, 100, 150, 200 mg 75-150 mg q6h Acetaminophen PO PR 325, 500 mg 650-1,000 mg at onset,
then q4h Acetaminophen/isometheptene/dichloralphena-zone is marketed as Midrin. (If analgesics ineffective, switch to triptans for next headache.)
Triptans Sumatriptan∗∗ Rizatriptan∗ Zolmitriptan∗∗ Almotriptan∗∗ Eletriptan∗ Frovatriptan∗∗∗ Naratriptan∗∗∗ NS PO SC PO PO NS PO PO PO PO 20 mg/spray 25, 50, 100 mg 6 mg 5, 10 mg 2.5, 5 mg 5 mg/spray 6.25, 12.5 mg 20, 40 mg 2.5 mg 1, 2.5 mg 20 mg 50-100 mg 6 mg 10 mg 2.5-5 mg 5 mg 6.25-12.5 mg 40 mg 2.5 mg 2.5 mg
May repeat once after 2 hours for partial response. May cause nausea and vomiting; contraindicated by pregnancy, coronary or peripheral vascular disease, concurrent treat- ment with monoamine oxidase inhibitors, and possibly hemiplegic or basilar migraine. Common side effects: chest tightness, extremity parasthesias
∗Onset of effect 30 minutes ∗∗Onset of effect 45-60 minutes
∗∗∗ Require 4 hrs for effect but are long acting
Triptan response rate 60-80%. Faster-acting triptans have more frequent headache recur- rence which can be attenuated by NSAID co-administration.
Ergot alkaloids (not to be combined with triptans) Ergotamine/
caffeine (Cafergot)
PR 2 mg/100 mg 1/4-2 suppositories, up to 5 per week
May cause nausea and vomiting; contraindicated in pregnancy and coronary or peripheral vas- cular disease.
Dihydroergotamine (DHE)
NS 0.5 mg/spray 1 spray to each nostril, up to 5 times per week
Repeat after 15 minutes. May cause nausea and vomiting; contraindicated in pregnancy and coronary or peripheral vascular disease. SC 1 mg/mL 1-2 mg Repeat 1 mg q12h, up to 6 mg IV 0.75-1.25 mg IV Narcotic analgesics Codeine/aspirin PO 15, 30, 60/325 mg 30-120 mg codeine Meperidine PO IM 50, 100 mg 50-200 mg
Butorphanol NS 10 mg/mL (1 mg/spray) 1 spray every 3-4 hours as needed
(continued )
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(Continued )
table 6-7. Acute (Abortive) Treatment of Migraine Headache.
Drug route1 strength recommended Dose Comments
Antiemetics
Prochlorperazine PO 5, 10, 15 mg 25 mg q6h
Adjunctive treatment to reduce nausea and improve enteric absorption of antimigraine drugs. Extrapyramidal side effects may occur. PR 2.5, 5, 25 mg 25 mg q12h IM, IV 5 mg/mL 10 mg (with 10 mg diphenhydramine) Chlorpromazine IM 25 mg/mL 50 mg IV 25 mg/mL 0.1 mg/kg drip over 20 minutes Promethazine PO, PR 12.5, 25, 50 mg 25-50 mg q6h Metoclopramide PO 5, 10 mg 5-20 mg tid
1bid, twice daily; hs, at bedtime; IM, intramuscular; IV, intravenous; NS, nasal spray; PO, oral; PR, rectal; prn, as needed; q, every; qd, every
day; qod, every other day; SC, subcutaneous; tid, three times daily.
Overuse of medications used to treat migraine or other forms of headache can lead to a chronic daily headache syndrome. Most patients have migraine as their underlying problem and have overused simple analgesics or triptans, but patients with other types of headache and those using other classes of drugs are also susceptible. Most patients are women. Headache is characteristically present at least 15 days per month for at least 3 months. Treatment involves tapering or withdrawal of the offending medica- tions, and beginning prophylactic therapy (Table 6-8). Corticosteroids may be useful for “bridge therapy” attenu- ating drug withdrawal exacerbation of headache.
Dodick DW. Chronic daily headache. N Engl J Med. 2006; 354:158-165.
PReCiPitAtinG fACtoRS
Migraine attacks can be precipitated by certain foods (tyramine-containing cheeses; meat, such as hot dogs or bacon, with nitrite preservatives; chocolate containing phenylethylamine but not chocolate alone) and by food additives such as monosodium glutamate, a commonly used flavor enhancer. Fasting, emotion, menses, drugs (especially oral contraceptive agents and vasodilators such as nitroglycerin), and bright lights may also trigger attacks.
tReAtMent
Tables 6-7 and 6-8 summarize treatment options in
migraine, which can be divided into measures used to abort attacks in progress (abortive) and to prevent future episodes (prophylactic).
Acute migraine attacks often respond to simple analge- sics or, if these are ineffective, serotonin 5-HT1B/D receptor agonists (triptans) or ergot alkaloids (eg, dihydroergota- mine). A new class of antimigraine drugs—calcitonin gene-related peptide receptor antagonists (eg, telcagepant, olcegepant)—may also prove to be useful for this purpose. Drugs for acute (abortive) treatment (Table 6-7) must be taken at the onset of symptoms to be maximally effective. Rapidly absorbed parenteral formulations are superior to oral preparations. Nausea, a prominent feature of migraine, is also a common side effect of some antimigraine drugs, so that administration by other than the oral route or con- comitant administration of an antiemetic (Table 6-8) may be necessary. Ergot alkaloids and triptans are contraindi- cated in patients with hypertension or other cardiovascular disease and should not be used together.
Prophylactic treatment should be used in patients with two or more headaches per week or those in whom abor- tive treatment is inadequate. Tricyclic antidepressants, β-blockers, anticonvulsants, and calcium channel blockers can be tried in that order, unless concurrent illnesses or medications dictate differently (see Table 6-8).
Migraine during pregnancy should be treated only with narcotic analgesics, although sumatriptan is safe in the first trimester. Acetaminophen is sometimes helpful but other antimigraine drugs may be teratogenic or cause complica- tions in pregnancy. Precipitating factors should be avoided. Goadsby PJ, Goldberg J, Silberstein SD. Migraine in pregnancy.
BMJ. 2008;336:1502-1504.
Goadsby PJ, Sprenger T. Current practice and future directions in the prevention and acute management of migraine. Lancet Neurol. 2010;9:285-298.
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table 6-8. Prophylactic Treatment of Migraine Headache
Drug route1 strength recommended Dose Comments
Anti-inflammatory agents
Aspirin PO 325 mg 325 mg qod May cause gastric pain or bleeding Naproxen sodium PO 275, 550 mg 550-825 mg bid
Tricyclic antidepressants
Amitriptyline PO 10, 25, 50, 75, 100, 150 mg
10-300 mg hs May cause dry mouth or urinary retention. Begin with lowest dose and increase slowly. Adding an anticon- vulsant may increase efficacy.
Nortriptyline PO 10, 25, 50, 75 mg 10-150 mg hs Desipramine PO 10, 25, 50, 75, 100 mh 25-300 mg qhs Protriptyline PO 5, 10 mg 15-40 md/d in 3-4
doses Protriptyline is less sedating than other tricyclics but dry mouth and constipation may be problematic β-Receptor antagonists Propranolol* PO PO (long acting) 10, 20, 40, 60, 80, 90 mg 60, 80, 120, 160 mg 20-120 mg bid
60-320 mg qd Listed in descending order of efficacy. Symptomatic bradycardia may occur at high doses.
Contraindicated in asthma and congestive heart fail- ure and in patients on calcium channel blockers. To discontinue, taper over 1-2 weeks.∗ most effective
Timolol* PO 10, 20 mg 10-30 mg qd Metoprolol* PO 50, 100 mg 100-200 mg qd Nadolol PO 40, 80, 120, 160 mg 40-240 mg qd Atenolol PO 50, 100 mg 50-200 mg qd Anticonvulsants Valproic acid PO 125, 250, 500 mg; 500 mg extended release 250-500 mg bid or 1,000 mg qhs as single dose with extended release
Begin with lowest dose. Contraindicated in women of childbearing age.
Topiramate PO 25, 50, 100, 200 mg 25-200 mg qd Start 25 mg hs and increase by 25 mg/d every 7 days as tolerated. Optimal dose 100 mg/d. Paresthesias in 50%. Altered mental state may require lowering dose. Rare: nephrolithiasis, angle-closure glaucoma. Gabapentin PO 100, 300, 400,
600, 800 mg 1800-2,400 mg qd Less effective than other anticonvulsants. Sedating. Calcium channel antagonists
Verapamil PO 40, 80, 120 mg 80-160 mg tid Contraindicated by severe left ventricular dysfunction, hypotension, sick sinus syndrome without artificial pacemaker, second- or third-degree AV nodal block, and in patients on β-blockers. Constipation is most common side effect. Verapamil ineffective in migraine without aura.
Flunarizine PO (long acting) 240 mg 240 mg qd-bid PO 5, 10 mg 5-15 mg/day Other agents2 Riboflavin (vitamin B2)
PO Various 400 mg/d May require 4-8 weeks for onset and increased effect over 3-6 months. Urine turns dark.
Onabotulinum
toxin A IM 100 units/vial 100-250 units Not effective in episodic but very effective in chronic migraine. Injected into head and neck muscles.
1bid, twice daily; hs, at bedtime; IM, intramuscular; IV, intravenous; NS, nasal spray; PO, oral; PR, rectal; prn, as needed; q, every; qd, every
day; qod, every other day; SC, subcutaneous; tid, three times daily.
2Other agents reported as effective include magnesium 200-1200 mg/d, coenzyme Q10 150 mg tid, feverfew 6.25 mg tid, butterbur
75 mg bid, and memantine 5-20 mg tid.
HEADACHE & FACIAL PAIN
157
agents. Melatonin (10 mg/d) can also be helpful. Drugs used for maintenance prophylaxis are discontinued at the end of the cluster.
C. transitional Prophylaxis
Administration of prednisone at the beginning of a cluster cycle can be abortive, when given as 40 to 80 mg/d orally for 1 week, and then discontinued by tapering the dose over the following week. Intravenous methylprednisolone or dihydroergotamine may be useful as well.
▲
▲figure 6-13. Ptosis of the right eye during acute cluster headache. Other components of Horner syn- drome (pupillary miosis, and regional anhydrosis) may also occur.
▲
▲figure 6-12. Distribution of symptoms and signs in
cluster headache. Nasal stuffiness and discharge Tearing Ptosis, miosis Pain
CLustEr HEADACHE & trIgEmINAL
AutoNomIC CEPHALALgIAs
CliniCAl finDinGS
Cluster headache presents as clusters of brief, very severe, unilateral, constant, nonthrobbing headaches that last from 15 minutes to 3 hours. Unlike migraine headaches, cluster headaches are always unilateral and usually recur on the same side in any given patient. They occur most often at night, awakening the patient from sleep, and recur daily, often at nearly the same time of day (circadian peri- odicity), for a cluster period of weeks to a few months. Patients may pace restlessly during attacks. Between clus- ters, the patient may be free from headaches for months or years. The cause is unknown, but functional MRI during attacks has shown hypothalamic activation.
Cluster headache occurs much more frequently in men than in women and typically begins at a somewhat later age than migraine (mean onset at 25 years). There is rarely a family history.
The headache may begin as a burning sensation over the lateral aspect of the nose or as pressure behind the eye (Figure 6-12). The pain is throbbing, sharp, or stabbing. Ipsilateral conjunctival injection, lacrimation, nasal stuffi- ness, and Horner syndrome (Figure 6-13) are commonly associated with the attack. Episodes may be precipitated by the use of alcohol or vasodilating drugs, especially if used during a cluster siege.
tReAtMent
At the onset of a headache cluster, treatment involves mea- sures both to abort the acute attack and to prevent subse- quent ones.
A. Acute treatment
Prompt relief of pain is achieved by inhalation of 100% oxygen (7-12 L/min for 15-20 minutes) or subcutaneous administration of sumatriptan (6 mg, repeated once per attack if necessary) (see Table 6-7). Alternative abortive treatments include intranasal sumatriptan, zolmitriptan, or lidocaine; subcutaneous octreotide; intravenous, intramus- cular, subcutaneous, or intranasal dihydroergotamine; and oral zolmitriptan.
B. Maintenance Prophylaxis
Several drugs used in the treatment of migraine (see Table 6-8), are also useful for preventing recurrent symp- toms during an active bout of cluster headache (mainte- nance prophylaxis). The most widely used drug is verapamil (80 mg three times daily or sustained-release 240 mg/d; doses of 720 mg/d may be required). Anticonvulsants such as valproic acid (500-2,000 mg/d), gabapentin (300-3,600 mg/d), and topiramate (50-200 mg/d) are second-line
CHAPtEr 6
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D. Cluster Headache variants
Chronic rather than episodic cluster headaches may occur. A bilateral variant is hypnic headache, which lacks the autonomic components of cluster headache and occurs in the elderly. Multiple, brief 10 to 20 minutes episodes of recurrent pain for approximately five days are called parox- ysmal hemicrania. These are more common in women. Each of these syndromes responds dramatically to indo- methacin 25 to 50 mg three times daily.