Chronic migraine poses a significant personal, social and economic burden and is characterized by headache present on 15 or more days per month for at least three months, with at least eight days of migrainous headache per month. It is frequently associated with analgesic or acute migraine medication overuse and this should not be overlooked. The present consensus was elaborated upon by a group of members of the Brazilian Headache Society in order to describe current evidence and to provide recommendations related to chronic migraine pharmacological and nonpharmacological treatment. Withdrawal strategies in medication overuse headache are also described, as well as treatment risks during pregnancy and breastfeeding. Oral topiramate and onabotulinum toxin A injections are the only treatments granted Class A recommendation, while valproate, gabapentin, and tizanidine received Class B recommendation, along with acupuncture, biofeedback, and mindfulness. The anti-CGRP or anti-CGRPr monoclonal antibodies, still unavailable in Brazil, are promising new drugs already approved elsewhere for migraine prophylactic treatment, the efficacy of which in chronic migraine is still to be definitively proven.

Background Migraine affects 1 billion people worldwide and > 30 million Brazilians; besides, it is an underdiagnosed and undertreated disorder. Objective The need to disseminate knowledge about the prophylactic treatment of migraine is known, so the Brazilian Headache Society (SBCe, in the Portuguese acronym) appointed a committee of authors with the objective of establishing a consensus with recommendations on the prophylactic treatment of episodic migraine based on articles from the world literature as well as from personal experience. Methods Meetings were held entirely online, with the participation of 12 groups that reviewed and wrote about the pharmacological categories of drugs and, at the end, met to read and finish the document. The drug classes studied in part II of this Consensus were: antihypertensives, selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, calcium channel blockers, other drugs, and rational polytherapy. Results From this list of drugs, only candesartan has been established as effective in controlling episodic migraine. Flunarizine, venlafaxine, duloxetine, and pizotifen were defined as likely to be effective, while lisinopril, enalapril, escitalopram, fluvoxamine, quetiapine, atorvastatin, simvastatin, cyproheptadine, and melatonin were possibly effective in prophylaxis of the disease. Conclusions Despite an effort by the scientific community to find really effective drugs in the treatment of migraine, given the large number of drugs tested for this purpose, we still have few therapeutic options.

The Brazilian Headache Society (Sociedade Brasileira de Cefaleia, SBCe, in Portuguese) nominated a Committee of Authors with the aim of establishing a consensus with recommendations regarding prophylactic treatment for episodic migraine based on articles published in the worldwide literature, as well as personal experience. Migraine affects 1 billion people around the world and more than 30 million Brazilians. In addition, it is an underdiagnosed and undertreated disorder. It is well known within the medical community of neurologists, and especially among headache specialists, that there is a need to disseminate knowledge about prophylactic treatment for migraine. For this purpose, together with the need for drug updates and to expand knowledge of the disease itself (frequency, intensity, duration, impact and perhaps the progression of migraine), this Consensus was developed, following a full online methodology, by 12 groups who reviewed and wrote about the pharmacological categories of the drugs used and, at the end of the process, met to read and establish conclusions for this document. The drug classes studied were: anticonvulsants, tricyclic antidepressants, monoclonal anti-calcitonin gene-related peptide (anti-CGRP) antibodies, beta-blockers, antihypertensives, calcium channel inhibitors, other antidepressants (selective serotonin reuptake inhibitors, SSRIs, and dual-action antidepressants), other drugs, and polytherapy. Hormonal treatment and anti-inflammatories and triptans in minimum prophylaxis schemes (miniprophylaxis) will be covered in a specific chapter. The drug classes studied for part I of the Consensus were: anticonvulsants, tricyclic antidepressants, monoclonal anti-CGRP antibodies, and beta-blockers.

Introdução ZFA, sexo feminino, 55 anos, hipertensa e diabética, com histórico de migrânea sem aura desde a infância, com bom controle. Apresentou mudança do padrão das crises em 2014, descritas como cefaleia estritamente em hemicrânio esquerdo, forte intensidade, duração 1-2 horas, recorrente, 3-4 ataques/dia, associada a hiperemia conjuntival e congestão nasal ipsilateral. Exame neurológico e Ressonância magnética de encéfalo sem alterações. Realizado teste com indometacina, sem resposta. Tratamento agudo com sumatriptano nasal (boa resposta). Tentado tratamento profilático com diversas medicações, tais quais: prednisona e bloqueio do nervo occipital (boa resposta por curto período), verapamil(resposta parcial), Lítio (sem resposta), melatonina (pouca resposta), clomifeno (resposta parcial). Após refratariedade ao tratamento, optado por iniciar varfarina, com redução significativa das crises. Por último, iniciado Ácido Valpróico (boa resposta) mantendo 1 ataque a cada 2 meses.  Objetivo Relatar um caso de cefaleia em salvas crônica. Material e métodos Revisão bibliográfica em comparação ao relato de caso. Resultados A cefaleia em salvas é a mais comum das cefaleias trigeminoautonômicas. Tem prevalência 4-15,6/100000 habitantes, preferencialmente homens adultos jovens. Pode ser episódica ou apresentar-se de forma crônica, com pouca remissão e alta refratariedade terapêutica. Houve necessidade de terapia combinada com várias drogas, sendo a Varfarina uma droga chave, com redução de mais de 50% no controle dos ataques. A Varfarina é indicada apenas nos casos refratários, tem ação como antagonista da vitamina K no metabolismo dos dendritos e neurônios, no ritmo circadiano do hipotálamo e na inflamação neurogênica do óxido nítrico. Conclusões A cefaleia em Salvas possui diagnóstico clínico peculiar, sendo cada vez melhor reconhecida e diagnosticada, sendo que o conhecimento e instituição do tratamento precocepode melhorar a qualidade de vida dos pacientes.

Cluster headache is the most common of trigeminal autonomic cephalalgia, with variable prevalence. It can be episodic or chronic, with few remission and high therapeutic failure. The case refers to a 55-year-old female patient, hypertensive and diabetic, with a history of migraine without aura with pain management. In 2014, the patient began to present a new headache pattern, with a diagnosis of Chronic Cluster Headache. Pain management to nasal sumatriptan as an acute treatment. For the prophylactic treatment, she presented therapeutic failure to several medications, with pain management with the use of warfarin. Associated with valproic acid to control migraine. There are few cases described in the literature about the use of warfarin, and its mechanism is still unclear. Warfarin was a key drug, with more than a 50% reduction in attack control. There is a need for more clinical trials randomly that support it. Cluster headache has peculiar clinical diagnosis, being increasingly well recognized and diagnosed. Knowledge and institution of treatment can significantly improve the quality of life of patients, helping to recover the functionality of patients affected by treatment failure.