Cefaleea: Ghid de diagnostic si tratament in structurile de primire ...
Cefaleea: Ghid de diagnostic si tratament in structurile de primire ...
Cefaleea: Ghid de diagnostic si tratament in structurile de primire ...
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<strong>Cefaleea</strong>: <strong>Ghid</strong> <strong>de</strong> <strong>diagnostic</strong> <strong>si</strong> <strong>tratament</strong> <strong>in</strong><br />
<strong>structurile</strong> <strong>de</strong> <strong>primire</strong> urgente<br />
Timisoara 2009<br />
Mihai Bujor Grecu , Daniela Stefania Grecu<br />
Introducere<br />
Numarul mare <strong>de</strong> prezentari <strong>in</strong> <strong>structurile</strong> <strong>de</strong> <strong>primire</strong> urgente a pacientilor<br />
cu cefalee (pana la 4% d<strong>in</strong> totalul prezentarilor (1) ) impune o abordare clara<br />
<strong>si</strong> <strong>si</strong>stematizata a acestui tip <strong>de</strong> patologie neurologica atat d<strong>in</strong> punct <strong>de</strong><br />
ve<strong>de</strong>re <strong>diagnostic</strong> <strong>si</strong> terapeutic <strong>in</strong> urgenta, cat <strong>si</strong> d<strong>in</strong> cel al managementului<br />
ulterior al pacientului.<br />
<strong>Cefaleea</strong> se imparte <strong>in</strong> general <strong>in</strong> doua categorii:<br />
- Primara: care nu este <strong>in</strong> legatura cu vreo patologie subiacenta <strong>si</strong> care<br />
<strong>in</strong>clu<strong>de</strong>: migrena, cefaleea <strong>de</strong> tip ten<strong>si</strong>une <strong>si</strong> cefaleea cluster (2).<br />
- Secundara: <strong>in</strong> care <strong>si</strong>ndromul cefalalgic este datorat unei alte stari patologice<br />
<strong>si</strong> <strong>in</strong>clu<strong>de</strong>: cefaleea d<strong>in</strong> afectiunile <strong>in</strong>fectioase, neoplazice, vasculare<br />
sau <strong>in</strong>dusa <strong>de</strong> adm<strong>in</strong>istrarea <strong>de</strong> medicamente (2).<br />
Preocuparea pr<strong>in</strong>cipala a medicului <strong>de</strong> urgenta este i<strong>de</strong>ntificarea patologiilor<br />
amen<strong>in</strong>tatoare <strong>de</strong> viata care se exprima pr<strong>in</strong> cefalee, dar <strong>si</strong> tratarea<br />
prompta a durerii.<br />
Semne <strong>si</strong> <strong>si</strong>mptome<br />
1. <strong>Cefaleea</strong> primara<br />
1.1. Migrena<br />
Migrena este cea mai frecventa cefalee primara, prevalenta ei fi<strong>in</strong>d cupr<strong>in</strong>sa<br />
<strong>in</strong>tre 5 <strong>si</strong> 10% pentru barbati <strong>si</strong> 17 – 22% pentru femei (1,2).<br />
<strong>Cefaleea</strong> <strong>in</strong> migrena este caracteristica:<br />
Medic Primar Medic<strong>in</strong>a <strong>de</strong> Urgenta, UPU, Spital Cl<strong>in</strong>ic <strong>de</strong> Urgenta Ju<strong>de</strong>tean Timisoara<br />
Sef <strong>de</strong> lucrari, Catedra <strong>de</strong> Biochimie UMF „Victor Babes” Timisoara<br />
Autor-corespon<strong>de</strong>nt: Mihai Bujor Grecu, tel. +40 748331150, email: mihai.grecu@<br />
urgentatm.ro, b-dul Io<strong>si</strong>f Bulbuca, nr.10, Timisoara<br />
3
4<br />
- Unilaterala<br />
- Pulsatila<br />
- Se <strong>in</strong>staleaza <strong>in</strong> m<strong>in</strong>ute pana la ore<br />
- Inten<strong>si</strong>tate mo<strong>de</strong>rata spre severa<br />
- Se asociaza cu:<br />
• Greata <strong>si</strong>/sau varsaturi<br />
• Sen<strong>si</strong>bilitate la lum<strong>in</strong>a <strong>si</strong>/sau sunet<br />
• Agravata <strong>de</strong> activitatea fizica (3)<br />
Migrena se cla<strong>si</strong>fica <strong>in</strong> functie <strong>de</strong> prezenta sau absenta aurei. Aura tipica<br />
cupr<strong>in</strong><strong>de</strong> modificari vizuale <strong>si</strong>/sau ale senzoriului <strong>si</strong>/sau tulburari <strong>de</strong> limbaj<br />
care sunt total rever<strong>si</strong>bile. Ele pot fi pozitive (ex. Fosfene, parestezii) sau<br />
negative (pier<strong>de</strong>rea ve<strong>de</strong>rii, hipoestezie). Simptomele se <strong>de</strong>zvolta <strong>in</strong>tr-o perioada<br />
<strong>de</strong> peste 5 m<strong>in</strong>ute <strong>si</strong> se remit <strong>in</strong> 60 <strong>de</strong> m<strong>in</strong>ute <strong>si</strong> pot aparea <strong>in</strong> succe<strong>si</strong>une.<br />
Trebuie avut <strong>in</strong> ve<strong>de</strong>re un acci<strong>de</strong>nt ischemic tranzitor <strong>in</strong> <strong>si</strong>tuatia <strong>in</strong> care<br />
aceste <strong>si</strong>mptome se <strong>in</strong>staleaza rapid <strong>si</strong> mai <strong>de</strong>graba <strong>si</strong>multan <strong>de</strong>cat <strong>in</strong> succe<strong>si</strong>une,<br />
daca aura este em<strong>in</strong>amente constituita d<strong>in</strong> <strong>si</strong>mptome negative sau<br />
este foarte scurta. Aura poate fi prelungita <strong>in</strong> <strong>si</strong>tuatia cefaleelor secundare.<br />
Frecventa medie <strong>de</strong> aparitie a atacurilor migrenoase se con<strong>si</strong><strong>de</strong>ra a fi <strong>de</strong> 1<br />
– 2 pe luna. Se con<strong>si</strong><strong>de</strong>ra migrena cronica migrena care se manifesta <strong>in</strong> 15<br />
sau mai multe zile pe luna pe o perioada <strong>de</strong> cel put<strong>in</strong> trei luni.<br />
Jumatate d<strong>in</strong> pacientii cu migrena sunt gre<strong>si</strong>t <strong>diagnostic</strong>ati, cel mai frecvent<br />
fi<strong>in</strong>d <strong>in</strong>cadrati ca cefalee episodica tip ten<strong>si</strong>une. Anamneza corecta <strong>si</strong><br />
studierea jurnalelor pacientilor etichetati cu cefalee episodica tip ten<strong>si</strong>une<br />
a <strong>de</strong>term<strong>in</strong>at re<strong>in</strong>cadrarea <strong>diagnostic</strong>a a 82% ca fi<strong>in</strong>d migrena sau probabil<br />
migrena. Aproximativ 75% d<strong>in</strong>tre pacientii cu migrena <strong>de</strong>scriu durere la nivelul<br />
gatului asociata atacului migrenos. D<strong>in</strong>tre pacientii cu migrena 50%<br />
<strong>de</strong>scriu cefaleea ca nefi<strong>in</strong>d pulsatila, 40% ca fi<strong>in</strong>d bilaterala, iar varsaturile<br />
apar la o treime d<strong>in</strong>tre acesti pacienti (5).<br />
Studierea unor grupuri <strong>de</strong> pacienti a i<strong>de</strong>ntificat anumite elemente <strong>de</strong><br />
anamneza care pot ajuta la diferentierea migrenei <strong>de</strong> alte tipuri <strong>de</strong> cefalee:<br />
• Cefalee episodica severa care provoaca disabilitate<br />
• Greata<br />
• Sen<strong>si</strong>bilitate la lum<strong>in</strong>a <strong>in</strong> cursul atacului migrenos<br />
• Sen<strong>si</strong>bilitate la lum<strong>in</strong>a <strong>in</strong>tre atacuri<br />
• Sen<strong>si</strong>bilitate la zgomot<br />
• Aura tipica (la 15-33% d<strong>in</strong>tre pacienti)<br />
• Exacerbarea <strong>si</strong>mptomatologiei la activitate fizica<br />
• Istoric familial <strong>de</strong> migrena (2)<br />
Recomandări şi Protocoale în Anestezie, Terapie Inten<strong>si</strong>vă şi Medic<strong>in</strong>ă <strong>de</strong> Urgenţă
Nu toate caracteristicile <strong>de</strong> mai sus trebuie sa fie prezente pentru <strong>diagnostic</strong>ul<br />
<strong>de</strong> migrena. Atunci cand sunt comb<strong>in</strong>ate cu evaluarea tulburarilor<br />
functionale caracteristicile care au cea mai mare specificitate <strong>si</strong> sen<strong>si</strong>bilitate<br />
pentru <strong>diagnostic</strong>ul <strong>de</strong> migrena sunt greata <strong>si</strong> sen<strong>si</strong>bilitatea la lum<strong>in</strong>a.<br />
C Pacientii care se prez<strong>in</strong>ta cu episoa<strong>de</strong> recurente <strong>de</strong> cefalee severa<br />
disabilitanta asociata cu greata <strong>si</strong> sen<strong>si</strong>bilitate la lum<strong>in</strong>a <strong>si</strong> care au<br />
un examen neurologic normal trebuie <strong>in</strong>cadrati ca avand migrena.<br />
2.1.2 <strong>Cefaleea</strong> tip ten<strong>si</strong>une<br />
Este cel mai frecvent tip <strong>de</strong> cefalee primara avand o prevalenta globala<br />
<strong>de</strong> 42% pentru barbati <strong>si</strong> 49% pentru femei (6). Durerea este <strong>in</strong> general mai<br />
put<strong>in</strong> severa <strong>de</strong>cat <strong>in</strong> cazul migrenei. Este <strong>de</strong> obicei bilaterala cu caracter<br />
<strong>de</strong> pre<strong>si</strong>une sau cu caracter constrictiv, <strong>de</strong> <strong>in</strong>ten<strong>si</strong>tate usoara sau medie.<br />
Nu este prezenta greata <strong>si</strong> cefaleea nu este accentuata <strong>de</strong> activitatea fizica.<br />
Poate fi asociata o senzatie <strong>de</strong> disconfort sau durere pericraniana, sen<strong>si</strong>bilitate<br />
la lum<strong>in</strong>a sau la zgomot.<br />
<strong>Cefaleea</strong> tip ten<strong>si</strong>une episodica apare cu frecventa <strong>si</strong> durata variabile.<br />
<strong>Cefaleea</strong> tip ten<strong>si</strong>une cronica surv<strong>in</strong>e <strong>in</strong> mai mult <strong>de</strong> 15 zile pe luna pentru<br />
mai mult <strong>de</strong> trei luni.<br />
<strong>Cefaleea</strong> tip ten<strong>si</strong>une episodica <strong>de</strong> <strong>in</strong>ten<strong>si</strong>tate mare, disabilitanta este rara,<br />
iar pacientii <strong>de</strong>obicei nu se adreseaza medicului <strong>de</strong> familie sau structurilor<br />
<strong>de</strong> <strong>primire</strong> urgente.<br />
C Diagnosticul <strong>de</strong> cefalee tip ten<strong>si</strong>une trebuie con<strong>si</strong><strong>de</strong>rat la un pacient<br />
care se prez<strong>in</strong>ta cu cefalee bilaterala care nu este disabilitanta <strong>in</strong><br />
conditiile unui examen neurologic normal.<br />
2.1.3 <strong>Cefaleea</strong> trigem<strong>in</strong>ala autonoma (vegetativa)<br />
<strong>Cefaleea</strong> trigem<strong>in</strong>ala autonoma este rara <strong>si</strong> este caracterizata pr<strong>in</strong> accese<br />
<strong>de</strong> durere severa unilaterala <strong>in</strong> teritoriul <strong>de</strong> distributie al trigemenului <strong>si</strong> este<br />
asociata cu fenomene vegetative marcate ip<strong>si</strong>lateral.<br />
<strong>Cefaleea</strong> <strong>de</strong> tip cluster este cea mai comuna cefalee trigem<strong>in</strong>ala autonoma.<br />
Prevalenta ei se con<strong>si</strong><strong>de</strong>ra a fi <strong>de</strong> 1:1000.<br />
<strong>Cefaleea</strong> paroxistica este probabil sub-<strong>diagnostic</strong>ata, prevalenta ei fi<strong>in</strong>d<br />
estimata la 1:50.000.<br />
<strong>Cefaleea</strong> <strong>de</strong> tip cluster (<strong>in</strong> ciorch<strong>in</strong>e) provoaca o durere severa, strict unilaterala.<br />
Ea este <strong>si</strong>tuata <strong>in</strong>tr-una sau <strong>in</strong>tr-o comb<strong>in</strong>atie <strong>de</strong> localizari: orbital,<br />
supraorbital sau temporal <strong>si</strong> este <strong>in</strong>sotita <strong>de</strong> manifestari vegetative ip<strong>si</strong>lateral<br />
(conjunctive <strong>in</strong>jectate cu sau fara lacrimare, congestie nazala cu sau<br />
fara r<strong>in</strong>oree, transpiratii ale fruntii sau fetei, mioza <strong>si</strong>/sau ptoza palpebrala).<br />
Fiecare acces <strong>in</strong>cepe <strong>si</strong> se term<strong>in</strong>a brusc, durand <strong>de</strong> la 15 m<strong>in</strong>ute pana la<br />
Timisoara 2009
trei ore, pacientul fi<strong>in</strong>d nel<strong>in</strong>istit pe <strong>in</strong>treaga perioada a accesului dureros.<br />
Frecventa acestor accese variaza <strong>de</strong> la unul pe zi pana la opt pe zi. Intre paroxismele<br />
dureroase poate exista o durere <strong>de</strong> fond putand fi observate <strong>si</strong> caracteristici<br />
ale migrenei. Frecvent se poate observa o ritmicitate circadiana<br />
a acceselor, acestea aparand zilnic la aceea<strong>si</strong> ora, iar “agregarea” atacurilor<br />
apare <strong>in</strong> aceea<strong>si</strong> perioada a anului. Majoritatea pacientilor 80 – 90% prez<strong>in</strong>ta<br />
episoa<strong>de</strong> <strong>de</strong> cefalee <strong>de</strong> tip cluster <strong>in</strong>tre care sunt a<strong>si</strong>mptomatici. Doar 10<br />
– 20% au cefalee cronica <strong>de</strong> tip cluster – fara remi<strong>si</strong>une pe perioada unui an<br />
sau cu remi<strong>si</strong>une cu durata sub o luna (3).<br />
Hemicrania paroxistica are caractere <strong>si</strong>milare cu ale cefaleei <strong>de</strong> tip cluster,<br />
dar accesele sunt mai scurte (2 – 45 m<strong>in</strong>), sunt mai frecvente (pana la 40<br />
pe zi) <strong>si</strong> sunt mai frecvente la femei. Majoritatea pacientilor prez<strong>in</strong>ta mai<br />
curand forma cronica <strong>de</strong>cat cea episodica. Cele mai multe accese sunt spontane<br />
<strong>in</strong>sa 10% mecanic pr<strong>in</strong> flexia sau rotatia capului.<br />
Tabelul 1. Comparatia caracteristicilor cefaleelor trigem<strong>in</strong>ale autonome cu migrena<br />
Tipul <strong>de</strong> cefalee Durata Debut Frecventa Nel<strong>in</strong>iste<br />
sau<br />
agitatie<br />
<strong>in</strong><br />
timpul<br />
accesului<br />
Migrena<br />
<strong>Cefaleea</strong> tip<br />
cluster<br />
Hemicrania<br />
paroxistica<br />
Manifestari<br />
vegetative<br />
ip<strong>si</strong>laterale<br />
4 – 72 ore Treptat In medie 1 – 2/zi Nu Ocazional<br />
15 m<strong>in</strong> – 3 ore Rapid 1/ doua zile – 8/zi Toate Evi<strong>de</strong>nte<br />
2 – 45 m<strong>in</strong> Rapid 1 – 40/zi 50% Evi<strong>de</strong>nte<br />
D Atunci cand un pacient se prez<strong>in</strong>ta cu cefalee frecventa <strong>de</strong> scurta durata,<br />
unilaterala <strong>in</strong>sotita <strong>de</strong> manifestari vegetative ip<strong>si</strong>laterale trebuie<br />
luat <strong>in</strong> con<strong>si</strong><strong>de</strong>rare <strong>diagnostic</strong>ul <strong>de</strong> cefalee trigem<strong>in</strong>ala autonoma.<br />
D Pacientii cu o cefalee noua suspectati <strong>de</strong> cefalee trigem<strong>in</strong>ala autonoma<br />
trebuie evaluati <strong>de</strong> catre neurolog.<br />
Recomandări şi Protocoale în Anestezie, Terapie Inten<strong>si</strong>vă şi Medic<strong>in</strong>ă <strong>de</strong> Urgenţă
2.1.4 Hemicrania cont<strong>in</strong>ua<br />
Hemicrania cont<strong>in</strong>ua este o cefalee cu caracter strict <strong>de</strong> hemicranie care<br />
creste <strong>si</strong> sca<strong>de</strong> <strong>in</strong> <strong>in</strong>ten<strong>si</strong>tate fara sa dispara complet. Pot exista episoa<strong>de</strong><br />
scurte <strong>de</strong> durere penetranta, ascutita care se supraadauga peste cefaleea<br />
cont<strong>in</strong>ua <strong>si</strong> pot fi <strong>in</strong>sotite <strong>de</strong> manifestari vegetative unilaterale. De<strong>si</strong> este<br />
rara, <strong>diagnostic</strong>ul trebuie luat <strong>in</strong> con<strong>si</strong><strong>de</strong>rare, dat fi<strong>in</strong>d raspunsul absolut la<br />
<strong>in</strong>dometac<strong>in</strong>.<br />
Asemanarea cu <strong>si</strong>mptomatologia d<strong>in</strong> cefaleea secundara este frecventa<br />
<strong>si</strong> <strong>de</strong> aceea trebuie exclus un <strong>diagnostic</strong> <strong>de</strong> cefalee secundara <strong>in</strong>a<strong>in</strong>te <strong>de</strong> a<br />
<strong>in</strong>cadra pacientul ca avand hemicranie cont<strong>in</strong>ua primara. Raspusul favorabil<br />
la <strong>in</strong>dometac<strong>in</strong> nu exclu<strong>de</strong> o cefalee secundara.<br />
D Hemicrania cont<strong>in</strong>ua trebuie luata <strong>in</strong> con<strong>si</strong><strong>de</strong>rare ca <strong>diagnostic</strong> la pacientii<br />
care se prez<strong>in</strong>ta cu cefalee cronica cu caracter <strong>de</strong> hemicranie<br />
(strict unilateral).<br />
D Pacientii suspectati a avea hemicranie cont<strong>in</strong>ua cu <strong>de</strong>but recent trebui<br />
evaluati <strong>de</strong> catre neurolog.<br />
2.2 <strong>Cefaleea</strong> secundara<br />
Cefaleile secundare (cefalei cauzate <strong>de</strong> o alta stare patologica) trebuie<br />
luate <strong>in</strong> con<strong>si</strong><strong>de</strong>rare la pacientii care se prez<strong>in</strong>ta cu cefalee recent <strong>in</strong>stalata<br />
sau la care se schimba caracterul durerii. Studii observationale au scos <strong>in</strong><br />
evi<strong>de</strong>nta urmatoarele semne <strong>de</strong> alarma pentru cefaleile secundare care nece<strong>si</strong>ta<br />
o evaluare pr<strong>in</strong> <strong>in</strong>vestigatii suplimentare:<br />
• Aparitia recenta sau schimbarea caracterului durerii la pacienti cu varsta<br />
peste 50 <strong>de</strong> ani<br />
• Caracter fulgerator: durerea at<strong>in</strong>ge rapid <strong>in</strong>ten<strong>si</strong>tatea maxima (secun<strong>de</strong><br />
– 5 m<strong>in</strong>ute)<br />
• Simptome neurologice <strong>de</strong> focar (slabiciune la nivelul unui membru, aura<br />
cu durata sub 5 m<strong>in</strong> sau peste o ora)<br />
• Simptome neurologice non-focale (tulburari cognitive)<br />
• Modificari ale frecventei, caracterului sau asocierea <strong>de</strong> noi <strong>si</strong>mptome<br />
episoa<strong>de</strong>lor <strong>de</strong> cefalee<br />
• Examen neurologic modificat<br />
• <strong>Cefaleea</strong> care se modifica <strong>in</strong> functie <strong>de</strong> pozitie<br />
• <strong>Cefaleea</strong> care il trezeste pe pacient (atentie la migrena care este cea mai<br />
frecventa cauza <strong>de</strong> cefalee mat<strong>in</strong>ala)<br />
• <strong>Cefaleea</strong> accentuata <strong>de</strong> activitatea fizica sau <strong>de</strong> manevra valsalva (tuse,<br />
ras, stranut)<br />
• Pacientii cu risc crescut <strong>de</strong> tromboza a <strong>si</strong>nusurilor venoase cerebrale<br />
• Tulburari vizuale<br />
Timisoara 2009
• Redoare <strong>de</strong> ceafa<br />
• Debut recent al unei cefalei la un pacient cu istoric <strong>de</strong> <strong>in</strong>fectie HIV<br />
• Debut recent al unei cefalei la un pacient cu istoric <strong>de</strong> neoplasm<br />
D Pacienti care se prez<strong>in</strong>ta cu cefalee <strong>si</strong> care au un semn <strong>de</strong> alarma al<br />
unei cefalei secundare trebuie evaluati <strong>de</strong> catre neurolog<br />
La pacientii cu un caracter stabil al cefaleei exam<strong>in</strong>area neurologica este<br />
normala cu exceptia ptozei palpebrale <strong>in</strong> timpul <strong>si</strong> dupa un acces <strong>de</strong> cefalee<br />
<strong>de</strong> tip cluster. Prezenta <strong>si</strong>mptomelor focale sau non-focale <strong>si</strong>/sau un examen<br />
neurologic modificat creste semnificativ riscul existentei unei patologii<br />
subiacente <strong>si</strong>ndromului cefalalgic. Un examen cl<strong>in</strong>ic corespunzator, un examen<br />
neurologic care sa <strong>in</strong>cluda <strong>si</strong> examenul <strong>de</strong> fund <strong>de</strong> ochi <strong>si</strong> <strong>de</strong>term<strong>in</strong>area<br />
ten<strong>si</strong>unii arteriale sunt esentiale la prima prezentare a pacientului.<br />
D Pacientii care se prez<strong>in</strong>ta cu cefalee pentru prima data sau cu cefalee<br />
cu caracter modificat comparativ cu cefaleea pe care o prez<strong>in</strong>ta <strong>in</strong> mod<br />
obisnuit trebuie sa beneficieze <strong>de</strong> examen cl<strong>in</strong>ic, examen neurologic<br />
<strong>in</strong>clu<strong>si</strong>v al fundului <strong>de</strong> ochi <strong>si</strong> <strong>de</strong> <strong>de</strong>term<strong>in</strong>area ten<strong>si</strong>unii arteriale.<br />
Exam<strong>in</strong>area neurologica trebuie sa cupr<strong>in</strong>da:<br />
• Examenul <strong>de</strong> fund <strong>de</strong> ochi<br />
• Evaluarea nervilor cranieni, <strong>in</strong> special a pupilelor, a campului vizual,<br />
miscarile globilor oculari, sen<strong>si</strong>bilitatea <strong>si</strong> motricitatea faciala <strong>si</strong> functiile<br />
bulbare (palatul moale <strong>si</strong> miscarea limbii)<br />
• Evaluarea tonusului, fortei musculare, a reflexelor <strong>si</strong> coordonarii tuturor<br />
celor patru membre<br />
• Reflexul plantar<br />
• Evaluarea mersului, <strong>in</strong>clu<strong>si</strong>v mersul calcai-varf<br />
La nevoie exam<strong>in</strong>area neurologica poate fi facuta mai amanuntit <strong>in</strong> functie <strong>de</strong><br />
datele <strong>de</strong> anamneza. Ea trebuie adaptata pentru a <strong>in</strong>clu<strong>de</strong> orice <strong>si</strong>mptom focal.<br />
2.2.1 <strong>Cefaleea</strong> fulgeratoare<br />
<strong>Cefaleea</strong> fulgeratoare poate fi primara sau secundara. Ea este <strong>de</strong>f<strong>in</strong>ita ca<br />
fi<strong>in</strong>d o cefalee cu <strong>in</strong>ten<strong>si</strong>tate mare <strong>si</strong> <strong>in</strong>stalare rapida mimand o hemoragie<br />
subarahnoidiana pr<strong>in</strong> ruptura <strong>de</strong> anevrism, cu at<strong>in</strong>gerea unui maximum <strong>de</strong><br />
<strong>in</strong>ten<strong>si</strong>tate <strong>in</strong> mai put<strong>in</strong> <strong>de</strong> un m<strong>in</strong>ut. La majoritatea pacientilor cefaleea se<br />
<strong>in</strong>staleaza <strong>in</strong>stantaneu. Au existat studii <strong>in</strong> care la 19 % d<strong>in</strong>tre pacientii cu<br />
hemoragie subarahnoidiana durerea a crescut <strong>in</strong> <strong>in</strong>ten<strong>si</strong>tate progre<strong>si</strong>v (<strong>in</strong><br />
pana la 5 m<strong>in</strong>ute). <strong>Cefaleea</strong> severa cu <strong>de</strong>but brusc poate aparea <strong>si</strong> <strong>in</strong> cazul<br />
activitatii sexuale sau a exercitiului fizic (3).<br />
Alte cauze <strong>de</strong> cefalee fulgeratoare pot fi: hemoragia <strong>in</strong>tracerebrala, tromboza<br />
<strong>de</strong> <strong>si</strong>nus venos cerebral, disectia arteriala <strong>si</strong> apoplexia pituitara.<br />
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Nu exista caracteristici specifice care sa diferentieze cefaleea fulgeratoare<br />
primara <strong>de</strong> cea secundara, iar hemoragia subarahnoidiana se poate prezenta<br />
cu un <strong>de</strong>but brusc dar <strong>de</strong> <strong>in</strong>ten<strong>si</strong>tate mo<strong>de</strong>rata (7). Aproximativ 11% d<strong>in</strong>tre<br />
pacientii cu cefalee fulgeratoare au fost <strong>diagnostic</strong>ati ca avand hemoragie<br />
subarahnoidiana. Atunci cand pacientii se prez<strong>in</strong>ta pentru prima data cu<br />
cefalee severa <strong>si</strong> <strong>in</strong>stalare rapida ei trebuie evaluati <strong>in</strong> ve<strong>de</strong>rea <strong>de</strong>pistarii unei<br />
cauze secundare, <strong>in</strong> special a hemoragiei subarahnoidiene (<strong>in</strong>clu<strong>si</strong>v <strong>in</strong> cazul<br />
prezentarilor <strong>in</strong>tarziate) (7).<br />
Daca rezultatele sunt negative atat <strong>in</strong> cazul tomografiei computerizate<br />
cat <strong>si</strong> a punctiei lombare cu analiza lichidului cefaloarhidian <strong>in</strong>tr-un <strong>in</strong>terval<br />
<strong>de</strong> doua saptamani <strong>de</strong> la <strong>in</strong>stalarea cefaleei, hemoragia subarahnoidiana<br />
poate fi exclusa ca <strong>diagnostic</strong>.<br />
D Pacientii care prez<strong>in</strong>ta pentru prima oara o cefalee fulgeratoare trebuie<br />
evaluati neurologic <strong>in</strong> aceea<strong>si</strong> zi.<br />
2.2.2 <strong>Cefaleea</strong> pr<strong>in</strong> abuz <strong>de</strong> medicatie<br />
Utilizarea <strong>in</strong> exces a medicatiei pentru cefalee, <strong>in</strong>clu<strong>si</strong>v analgeticele <strong>si</strong>mple<br />
sau comb<strong>in</strong>ate poate <strong>de</strong>term<strong>in</strong>a cefaleea pr<strong>in</strong> abuz <strong>de</strong> medicatie (3).<br />
2.2.3 <strong>Cefaleea</strong> cervicogena<br />
Contributia afectiunilor coloanei vertebrale cervicale la migrena <strong>si</strong> la cefaleea<br />
tip ten<strong>si</strong>une este <strong>in</strong>suficient <strong>in</strong>teleasa. Intre 14 <strong>si</strong> 18% d<strong>in</strong> cefaleile<br />
cronice au orig<strong>in</strong>e cervicogena <strong>si</strong> sunt <strong>de</strong>term<strong>in</strong>ate <strong>de</strong> disfunctii musculoscheletale<br />
la nivelul coloanei vertebrale cevicale (8).<br />
<strong>Cefaleea</strong> cervicogena consta <strong>in</strong>tr-o durere uni sau bilaterala localizata la<br />
nivelul gatului <strong>si</strong> a regiunii occipitale <strong>si</strong> se poate proiecta la nivelul capului<br />
<strong>si</strong>/sau fetei. Aparitia durerii poate fi precipitata sau agravata <strong>de</strong> anumite<br />
miscari ale gatului sau <strong>de</strong> atitud<strong>in</strong>i prelungite ale regiunii cervicale <strong>si</strong> este<br />
asociata cu pozitii sau miscari modificate ale gatului <strong>si</strong> modificari ale tonusului<br />
<strong>si</strong> contractura musculaturii paravertebrale.<br />
D Exam<strong>in</strong>area gatului trebuie efectuata la toti pacientii care se prez<strong>in</strong>ta<br />
cu cefalee, <strong>in</strong>cluzand:<br />
• Pozitia gatului<br />
• Mobilitatea<br />
• Tonusul musculaturii<br />
• Sen<strong>si</strong>bilitatea musculara<br />
2.2.4 Hiperten<strong>si</strong>unea <strong>in</strong>tracraniana<br />
<strong>Cefaleea</strong> asociata cu hiperten<strong>si</strong>une <strong>in</strong>tracraniana este accentuata <strong>de</strong> <strong>de</strong>cubit<br />
<strong>si</strong> poate trezi pacientul d<strong>in</strong> somn. Poate fi precipitata <strong>de</strong> manevra val-<br />
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salva (ex. tuse, stranut, ras), activitate sexuala sau exercitiu fizic. Tulburarile<br />
vizuale tranzitorii aparute la schimbarea pozitiei pacientului pot sugera o<br />
crestere a pre<strong>si</strong>unii lichidului cefalorahidian. Oricare d<strong>in</strong>tre aceste semne<br />
impun o evaluare neurologica imediata.<br />
Tumorile <strong>in</strong>tracraniene produc rar cefalee pana cand volumul lor este relativ<br />
mare mai ales <strong>in</strong> regiuni neurologic “mute” cum ar fi lobii frontali. Tumorile<br />
pituitare <strong>si</strong> <strong>de</strong> fosa posterioara reprez<strong>in</strong>ta <strong>in</strong>sa o exceptie. Hemoragia<br />
<strong>in</strong> tumora poate <strong>de</strong>term<strong>in</strong>a <strong>in</strong>stalarea unei cefalei bruste <strong>si</strong> severe dar <strong>de</strong><br />
obicei acesti pacienti se prez<strong>in</strong>ta pentru convul<strong>si</strong>i sau <strong>si</strong>mptome <strong>si</strong> semne<br />
neurologice (tulburari cognitive, hemianop<strong>si</strong>e homonima, hemipareza). Exista<br />
un mare grad <strong>de</strong> suspiciune mai ales daca este cunoscuta existenta unui<br />
proces neoplazic un<strong>de</strong>va <strong>in</strong> organism.<br />
Un studiu efectuat pe un lot <strong>de</strong> 324 <strong>de</strong> pacienti a relevat faptul ca cefaleea<br />
a fost primul <strong>si</strong>mptom la 23% d<strong>in</strong>tre ei, dar la momentul prezentarii a<br />
fost <strong>si</strong>ngurul <strong>si</strong>mptom la doar 0,2% d<strong>in</strong>tre pacienti, restul prezentand semne<br />
<strong>si</strong> <strong>si</strong>mptome focale. Convul<strong>si</strong>ile au reprezentat cel mai comun <strong>si</strong>mptom focal<br />
(la 21% d<strong>in</strong>tre pacienti).<br />
Hiperten<strong>si</strong>une <strong>in</strong>tracraniana idiopatica are o <strong>in</strong>ci<strong>de</strong>nta <strong>in</strong> populatia generala<br />
<strong>de</strong> 1–3/100.000, dar este mai frecventa la femei cu varsta cupr<strong>in</strong>sa<br />
<strong>in</strong>tre 15 <strong>si</strong> 45 <strong>de</strong> ani (21/100.000) (9). Acesti pacienti se prez<strong>in</strong>ta cu semne <strong>si</strong><br />
<strong>si</strong>mptome <strong>de</strong> hiperten<strong>si</strong>une <strong>in</strong>tracraniana dar <strong>in</strong>vestigatiile neuroimagistice<br />
sunt normale (<strong>in</strong>clu<strong>si</strong>v tomografia computerizata <strong>si</strong> rezonanta magnetica<br />
nucleara), iar pre<strong>si</strong>unea lichidului cefalorahidian este crescuta. <strong>Cefaleea</strong> este<br />
<strong>in</strong>itial episodica pentru ca apoi sa progreseze <strong>in</strong> saptamani, <strong>de</strong>ven<strong>in</strong>d zilnica<br />
cu caracterele hiperten<strong>si</strong>unii <strong>in</strong>tracraniene. Alte semne <strong>si</strong> <strong>si</strong>mptome asociate<br />
pot fi: tulburari vizuale tranzitorii, t<strong>in</strong>nitus pulsatil, pareza <strong>de</strong> nerv cranian<br />
VI, largirea petei oarbe <strong>si</strong> e<strong>de</strong>m papilar. Etiologia este neclara, dar trebuie<br />
avute <strong>in</strong> ve<strong>de</strong>re cauze secundare cum ar fi tromboza <strong>de</strong> <strong>si</strong>nus venos cerebral,<br />
diferite medicamente (tetracicl<strong>in</strong>ele <strong>si</strong> ret<strong>in</strong>oizii), <strong>in</strong>flamatia, <strong>in</strong>fectiile<br />
<strong>si</strong> malignitatea.<br />
In cazul <strong>in</strong> care pacientul prez<strong>in</strong>ta alaturi <strong>de</strong> cefalee <strong>si</strong> febra, redoare <strong>de</strong><br />
ceafa, semne focale sau convul<strong>si</strong>i trebuie avuta <strong>in</strong> ve<strong>de</strong>re <strong>in</strong>fectia la nivelul<br />
<strong>si</strong>stemului nervos central. Aceasta poate fi difuza (men<strong>in</strong>gita sau encefalita)<br />
sau localizata (abces cerebral), iar suspiciunea este majora <strong>in</strong> cazul unui istoric<br />
<strong>de</strong> <strong>in</strong>fectie HIV sau imunosupre<strong>si</strong>e.<br />
D Pacientii cu cefalee asociata cu caracteristici ale hiperten<strong>si</strong>unii <strong>in</strong>tracraniene<br />
trebuie evaluati <strong>de</strong> urgenta <strong>de</strong> catre neurolog.<br />
D Pacientii cu cefalee asociata cu caracteristici ale <strong>in</strong>fectiei <strong>si</strong>stemului<br />
nervos central trebuie evaluati imediat <strong>de</strong> catre neurolog.<br />
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2.2.5 Hipoten<strong>si</strong>une <strong>in</strong>tracraniana<br />
La pacientii cu pre<strong>si</strong>une scazuta a lichidului cefalorahidian exista o componenta<br />
posturala clara a cefaleei. Aceasta <strong>de</strong>buteaza sau se agraveaza imediat<br />
dupa adoptarea pozitiei ortostatice <strong>si</strong> dim<strong>in</strong>ua sau dispare dupa plasarea<br />
pacientului <strong>in</strong> <strong>de</strong>cubit. Dupa ce <strong>de</strong>v<strong>in</strong>e cronica acest caracter dispare <strong>de</strong><br />
obicei.<br />
Sca<strong>de</strong>rea pre<strong>si</strong>unii lichidului cefalorahidian se datoreaza scurgerii acestuia<br />
fie secundar unei punctii rahidiene, fie spontan (mai greu <strong>de</strong> recunoscut).<br />
D Hipoten<strong>si</strong>unea <strong>in</strong>tracraniana trebuie avuta <strong>in</strong> ve<strong>de</strong>re la pacientii cu<br />
cefalee care apare sau se <strong>in</strong>ten<strong>si</strong>fica la adoptarea pozitiei ortostatice.<br />
2.2.6 Arterita temporala cu celule gigante<br />
Arterita cu celule gigante trebuie luata <strong>in</strong> co<strong>si</strong><strong>de</strong>rare la toti pacientii peste<br />
50 <strong>de</strong> ani care se prez<strong>in</strong>ta cu cefalee. Aceasta este mai <strong>de</strong>graba difuza <strong>de</strong>cat<br />
localizata temporal, poate fi severa <strong>si</strong> este <strong>de</strong>obicei per<strong>si</strong>stenta. Sen<strong>si</strong>bilitatea<br />
scalpului este <strong>de</strong> obicei prezenta dar nu are o valoarea predictiva scazuta<br />
a unei biop<strong>si</strong>i pozitive a arterei temporale. Claudicatia maxilara este un predictor<br />
mult mai puternic, dar nu este <strong>in</strong>tot<strong>de</strong>auna prezenta. Orice pacient<br />
care are cefalee asociata cu claudicatie maxilara trebuie con<strong>si</strong><strong>de</strong>rat a avea<br />
arterita cu celule gigante pana la <strong>de</strong>monstrarea contrariului. Urmatorul factor<br />
predictiv sunt tulburarile vizuale. La examenul fizic, semnul cu valoarea<br />
predictiva cea mai mare este existenta unei artere temporale proem<strong>in</strong>ente,<br />
cu calibru neregulat sau crescut. Valoarea normala pentru viteza <strong>de</strong> sedimentare<br />
a hematiilor face <strong>diagnostic</strong>ul improbabil dar nu il exclu<strong>de</strong>.<br />
D Arterita cu celule gigante trebuie suspicionata la toti pacientii cu<br />
varsta peste 50 <strong>de</strong> ani cu cefalee noua sau cu caractere modificate.<br />
Acestia trebuie evaluati urgent <strong>de</strong> catre neurolog.<br />
2.2.7 Glaucomul cu unghi <strong>in</strong>chis<br />
Glaucomul cu unghi <strong>in</strong>chis este rar la pacientii cu varsta sub 45 – 50 <strong>de</strong><br />
ani. Factorii <strong>de</strong> risc recunoscuti sunt istoricul familial, sexul fem<strong>in</strong><strong>in</strong> <strong>si</strong> hipermetropia.<br />
Simptomatologia la prezentare este variata. Pacientul poate<br />
avea o pupila mo<strong>de</strong>rat dilatata <strong>si</strong> ochiul rosu cu afectarea acuitatii vizuale,<br />
<strong>in</strong>dicand o crestere acuta a pre<strong>si</strong>unii <strong>in</strong>traoculare. Pe <strong>de</strong> alta parte pacientul<br />
se poate prezenta pentru cefalee nespecifica, durere oculara, halouri <strong>in</strong> jurul<br />
obiectelor lum<strong>in</strong>oase sau cefalee mimand migrena cu aura.<br />
D Glaucomul cu unghi <strong>in</strong>chis trebuie suspicionata la pacientii cu cefalee<br />
asociata cu un ochi rosu, halou sau tulburari unilaterale <strong>de</strong> ve<strong>de</strong>re<br />
<strong>si</strong> trebuie evaluati imediat <strong>de</strong> catre oftalmolog.<br />
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2.2.8 Intoxicatia cu monoxid <strong>de</strong> carbon<br />
Simptomatologia <strong>in</strong>toxicatiei subacute cu monoxid <strong>de</strong> carbon <strong>in</strong>clu<strong>de</strong> cefalee,<br />
greata, varsaturi, ameteala, slabiciune musculara <strong>si</strong> ve<strong>de</strong>re <strong>in</strong>cetosata.<br />
3. Investiugatii<br />
3.1 Neuroimagistica<br />
Cand este necesara?<br />
Investigatiile trebuie evitate <strong>in</strong> pr<strong>in</strong>cipiu daca nu conduc la o modificare<br />
a conduitei, a managementului pacientului sau daca este improbabil sa<br />
evi<strong>de</strong>ntieze anomalii relevante. Ocazional, <strong>in</strong>dividualizat, neuroimagistica<br />
poate fi necesara la anumiti pacienti care prez<strong>in</strong>ta o frica <strong>in</strong>validanta <strong>de</strong> a<br />
nu avea o patologie severa.<br />
Marea majoritate a pacientilor cu cefalee primara nu nece<strong>si</strong>ta evaluare<br />
neuroimagistica. Intr-un studiu prospectiv <strong>in</strong> care pacienti cu cefalee <strong>de</strong> mai<br />
mult <strong>de</strong> patru saptamani au fost evaluati imagistic au fost <strong>de</strong>scoperite anomalii<br />
semnificative la doar 0,4% d<strong>in</strong>tre cei cu migrena, 0,8% d<strong>in</strong>tre cei cu<br />
cefalee tip ten<strong>si</strong>une <strong>si</strong> 5% d<strong>in</strong>tre cei cu cefalee cluster (10). O metaanaliza a<br />
<strong>in</strong>vestigatiilor neuroimagistice a estimat o prevalenta <strong>de</strong> 0,2% a anomaliilor<br />
semnificative la pacientii cu migrena fara <strong>si</strong>mptome neurologice.<br />
Neuroimagistica, la pacientii cu cefalee <strong>si</strong> examen neurologic modificat,<br />
este susceptibila sa <strong>de</strong>scopere anomalii semnificative <strong>in</strong> special <strong>in</strong> sensul evi<strong>de</strong>ntierii<br />
cauzelor cefaleelor secundare. Investigatii suplimentare sunt necesare<br />
<strong>in</strong> cazul <strong>in</strong> care cefaleea este <strong>in</strong>sotita <strong>de</strong> semne <strong>de</strong> alarma.<br />
Anomalii <strong>de</strong>scoperite <strong>in</strong>tamplator<br />
Atat tomografia computerizata cat <strong>si</strong> rezonanta magnetica nucleara pot<br />
i<strong>de</strong>ntifica la pacienti anomalii neurologice fara legatura cu <strong>si</strong>mptomatologia<br />
<strong>de</strong> prezentare, fapt care va creste anxietatea pacientului <strong>si</strong> ne<strong>si</strong>guranta<br />
medicului. Un studiu prospectiv efectuat pe un lot <strong>de</strong> 2000 <strong>de</strong> voluntari cu<br />
o varsta medie <strong>de</strong> 63,3 ani (<strong>in</strong>tervalul fi<strong>in</strong>d 45 – 96 <strong>de</strong> ani) a relevat anomalii<br />
neurologice la 13,5% d<strong>in</strong>tre acestia.<br />
Rea<strong>si</strong>gurarea pacientului<br />
Un studiu controlat randomizat efectuat pe un numar <strong>de</strong> 150 <strong>de</strong> pacienti<br />
cu cefalee cronica zilnica a aratat ca pacientii care au beneficiat <strong>de</strong> rezonanta<br />
magnetica nucleara au prezentat o sca<strong>de</strong>re a anxietatii la 3 luni, dar<br />
aceasta sca<strong>de</strong>re nu s-a ment<strong>in</strong>ut <strong>si</strong> la un an. Pacientii cu un scor mare pe<br />
scara <strong>de</strong> anxietate/<strong>de</strong>pre<strong>si</strong>e care nu au beneficiat <strong>de</strong> evaluare pr<strong>in</strong> rezonanta<br />
magnetica nucleara au avut costuri semnificativ mai mari <strong>in</strong> ceea ce priveste<br />
a<strong>si</strong>stenta medicala <strong>in</strong> general pr<strong>in</strong> utilizarea mai multor resurse cum ar fi<br />
serviciile <strong>de</strong> p<strong>si</strong>hiatrie <strong>si</strong> p<strong>si</strong>hologie comparativ cu pacientii care au beneficiat<br />
<strong>de</strong> scanare.<br />
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Tomografia computerizata versus rezonanta magnetica nucleara<br />
Pentru exclu<strong>de</strong>rea cauzelor secundare <strong>de</strong> cefalee, rezonanta magnetica<br />
nucleara este mai sen<strong>si</strong>bila <strong>de</strong>cat tomografia computerizata i<strong>de</strong>ntificand<br />
leziunile <strong>de</strong> substanta alba <strong>si</strong> <strong>de</strong>zvoltarea anomaliilor venoase. Exista op<strong>in</strong>ii<br />
conform carora rezonanta magnrtica nucleara este mai sen<strong>si</strong>bila <strong>de</strong>cat<br />
tomografia computerizata <strong>in</strong> i<strong>de</strong>ntificarea unor anomalii nesemnificative,<br />
dar nu este mai sen<strong>si</strong>bila <strong>de</strong>cat tomografia computerizata <strong>in</strong> i<strong>de</strong>ntificarea<br />
patologiei cl<strong>in</strong>ic semnificative relevate pentru cauzele <strong>de</strong> cefalee (11).<br />
D Neuroimagistica nu este necesara la pacientii cu un istoric clar <strong>de</strong><br />
migrena, fara prezenta unor semne <strong>de</strong> alarma pentru o cefalee secundara<br />
<strong>si</strong> cu un examen neurologic normal.<br />
D tomografia computerizata trebuie efectuata la pacientii cu cefalee care<br />
prez<strong>in</strong>ta semne neurologice neexplicate, cu exceptia <strong>si</strong>tuatiei <strong>in</strong> care<br />
istoricul sugereaza ca este <strong>in</strong>dicata rezonanta magnetica nucleara.<br />
3.1.1 Tomografia computerizata <strong>si</strong> cefaleea fulgeratoare<br />
Tomografia computerizata (CT) <strong>si</strong> examenul lichidului cefalorahidian (LCR) trebuie<br />
efectuate <strong>in</strong>aite <strong>de</strong> a pune <strong>diagnostic</strong>ul <strong>de</strong> cefalee fulgeratoare primara.<br />
Atunci cand se suspicioneaza o hemoragie subarahnoidiana CT cerebral<br />
trebuie efectuat cat mai rapid pentru a-i mari sen<strong>si</strong>bilitatea. Aceasta este <strong>de</strong><br />
98% la 12 ore <strong>si</strong> sca<strong>de</strong> la 93% la 24 <strong>de</strong> ore (12). Un rezultat CT normal este<br />
<strong>in</strong>suficient pentru a axclu<strong>de</strong> o hemoragie subarahnoidiana fi<strong>in</strong>d necesara o<br />
punctie lombara <strong>si</strong> examenul LCR.<br />
D La pacientii cu cefalee fulgeratoare CT cerebral nativ trebuie efectuat<br />
cat mai rapid po<strong>si</strong>bil, <strong>de</strong> preferat <strong>in</strong> primele 12 ore <strong>de</strong> la <strong>de</strong>but.<br />
3.1.2 Rezonanta magnetica nucleara<br />
Op<strong>in</strong>ia expertilor sugereaza ca rezonanta magnetica nucleara (RMN) trebuie<br />
luata <strong>in</strong> con<strong>si</strong><strong>de</strong>rare la pacientii cu cefalee cluster, hemicrania paroxistica,<br />
sau la cei cu cefalee <strong>de</strong> scurta durata unilaterala neuralgiforma cu<br />
<strong>in</strong>jectie conjunctivala <strong>si</strong> lacrimare.<br />
Pacientii cu cefalee la tuse <strong>si</strong> care este precipitata <strong>si</strong> nu agravata <strong>de</strong> accesul<br />
<strong>de</strong> tuse, ras sau stranut pot fi <strong>diagnostic</strong>ati ca cefalee primara doar<br />
dupa exclu<strong>de</strong>rea leziunilor structurale pr<strong>in</strong> neuroimagistica. Acesti pacienti<br />
trebuie <strong>in</strong>vestigati pr<strong>in</strong> RMN pentru a exclu<strong>de</strong> leziunile <strong>de</strong> fosa posterioara.<br />
3.2 Punctia lombara <strong>in</strong> hemoragia subarahnoidiana<br />
Punctia lombara <strong>si</strong> examenul LCR sunt <strong>in</strong>dicate la pacientii cu cefalee fulgeratoare<br />
<strong>si</strong> exam<strong>in</strong>are neuroimagistica normala pentru a exclu<strong>de</strong> hemoragia<br />
subarahnoidiana.<br />
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Un studiu prospectiv a aratat ca 21% d<strong>in</strong>tre pacientii cu CT cerebral normal<br />
au avut punctia lombara pozitiva pentru hemoragia subarahnoidiana<br />
(7).<br />
Deoarece xantocromia LCR poate fi <strong>de</strong>pistata doar la peste 12 ore <strong>de</strong> la<br />
<strong>de</strong>butul cefaleei, punctia lombara <strong>si</strong> examenul LCR trebuie amanate pana<br />
la trecerea acestui <strong>in</strong>terval <strong>de</strong> timp. La pacientii care se prez<strong>in</strong>ta mai tarziu<br />
punctia lombara poate fi relevanta pana la doua saptamani <strong>de</strong> la <strong>de</strong>but<br />
(12).<br />
Metoda recomandata <strong>de</strong> exam<strong>in</strong>are a LCR este spectrofotometria. Ea trebuie<br />
efectuata la ultima proba <strong>de</strong> LCR recoltat. Dupa punctia lombara, prezenta<br />
bilirub<strong>in</strong>ei LCR este rezultatul cheie sugestiv pentru hemoragia subarahnoidiana<br />
<strong>si</strong> este <strong>in</strong>sotita <strong>de</strong> obicei <strong>de</strong> oxihemoglob<strong>in</strong>a.<br />
Pre<strong>si</strong>unea <strong>de</strong> <strong>de</strong>schi<strong>de</strong>re trebuie masurata <strong>de</strong> rut<strong>in</strong>a la toate punctiile lombare.<br />
La pacientii la care se suspicioneaza hemoragia subarahnoidiana evaluarea<br />
neuroimagistica trebuie efectuata <strong>in</strong>a<strong>in</strong>tea punctiei lombare.<br />
3.3 Alte <strong>in</strong>vestigatii<br />
Viteza <strong>de</strong> sedimentare a hematiilor, prote<strong>in</strong>a C-reactiva <strong>si</strong> vascozitatea<br />
plasmei sunt <strong>in</strong>dicate <strong>in</strong> <strong>diagnostic</strong>ul arteritei temporale cu celule gigante,<br />
fi<strong>in</strong>d <strong>de</strong> obicei crescute. Folo<strong>si</strong>rea comb<strong>in</strong>ata a acestor teste creste specificitate<br />
<strong>si</strong> sen<strong>si</strong>bilitatea <strong>diagnostic</strong>a.<br />
Hemoleucograma completa – nu exista date asupra beneficiului la pacientii<br />
cu cefalee.<br />
Radiografia <strong>de</strong> coloana vertebrala cervicala – nu exista date asupra beneficiului<br />
la pacientii cu cefalee.<br />
4.Tratament<br />
4.1 Migrena<br />
4.1.1 Tratamentul acut<br />
Tratamentul acut al atacului <strong>de</strong> migrena trebuie <strong>in</strong>dividualizat pentru fiecare<br />
pacient <strong>in</strong> parte t<strong>in</strong>and cont <strong>de</strong> frecventa <strong>si</strong> severitatea atacurilor,<br />
<strong>de</strong> celelalte <strong>si</strong>mptome asosciate, <strong>de</strong> prefer<strong>in</strong>tele pacientului precum <strong>si</strong> <strong>de</strong><br />
<strong>tratament</strong>ele aplicate anterior. Se poate utiliza o abordare terapeutica <strong>in</strong><br />
trepte, <strong>in</strong>cepand cu antalgice <strong>si</strong> antiemetice <strong>si</strong> cont<strong>in</strong>u<strong>in</strong>d cu adm<strong>in</strong>istrarea<br />
<strong>de</strong> triptani la nevoie. Se pot asocia <strong>si</strong> anti<strong>in</strong>flamatoare nesteroidiene <strong>in</strong> cazul<br />
acceselor rezistente la triptani.<br />
Anti<strong>in</strong>flamatoarele nesteroidiene <strong>si</strong> paracetamolul<br />
A Acidul acetilsalicilic este recomandata <strong>in</strong> doza <strong>de</strong> 900 mg la pacienti<br />
<strong>in</strong>diferent <strong>de</strong> severitatea atacului migrenos<br />
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A Ibuprofen 400mg este <strong>in</strong>dicat pentru <strong>tratament</strong>ul acut al pacientilor<br />
cu migrena. Pot fi folo<strong>si</strong>te <strong>si</strong> alte medicamente anti<strong>in</strong>flamatoare nesteroidiene<br />
(diclofenac, naproxen, acid tolfenamic)<br />
B Paracetamol 1000mg este <strong>in</strong>dicat <strong>in</strong> migrenele <strong>de</strong> severitate mo<strong>de</strong>rata<br />
sau usoara<br />
Triptanii<br />
Triptanii ofera o actiune antalgica semnificativa la pacientii cu atacuri<br />
acute <strong>de</strong> migrena. Comparativ cu aspir<strong>in</strong>a (1000mg) <strong>si</strong> ibuprofenul (400mg)<br />
efectul sumatriptanului (50mg) este aproximativ <strong>si</strong>milar <strong>in</strong> ceea ce priveste<br />
reducerea severitatii cefaleei la doua ore <strong>de</strong> la adm<strong>in</strong>istrare, dar este net<br />
superior <strong>in</strong> ceea ce priveste numarul <strong>de</strong> pacienti fara durere la doua ore.<br />
Triptanii sunt contra<strong>in</strong>dicati la pacientii cu boala cardiaca ischemica, <strong>in</strong>farct<br />
miocardic <strong>in</strong> antece<strong>de</strong>nte, spasm coronarian sau hiperten<strong>si</strong>une necontrolata.<br />
Triptanii trebuie utilizati cu precautie <strong>in</strong> migrena hemiplegica.<br />
A Adm<strong>in</strong>istrarea orala a triptanilor este <strong>in</strong>dicata <strong>in</strong> <strong>tratament</strong>ul acut al<br />
migrenei <strong>in</strong>diferent <strong>de</strong> severitate daca atacuri anterioare <strong>de</strong> migrena<br />
la acesti pacienti nu au putut fi controlate cu analgetice <strong>si</strong>mple.<br />
A Triptanii recomandati pentru <strong>tratament</strong>ul acut al migrenei sunt Almotriptan<br />
12,5 mg, eletriptan 40-80 mg sau rizatriptan 10 mg.<br />
B Daca pacientul nu raspun<strong>de</strong> la adm<strong>in</strong>istrarea unui triptan se va utiliza<br />
un triptan alternativ.<br />
D Triptanii trebuie adm<strong>in</strong>istrati la <strong>de</strong>butul sau imediat dupa <strong>de</strong>butul<br />
fazei cefalalgice a migrenei.<br />
Antiemeticele<br />
D Antiemeticele cu adm<strong>in</strong>istrare orala sau <strong>in</strong>trarectala se pot utiliza<br />
<strong>in</strong> <strong>tratament</strong>ul pacientilor cu migrena pentru a reduce <strong>si</strong>ptome ca<br />
greata <strong>si</strong> varsatura <strong>si</strong> pentru a favoriza golirea stomacului<br />
B Se pot utiliza comb<strong>in</strong>atii fixe <strong>de</strong> analgetice <strong>si</strong> antiemetice <strong>in</strong> <strong>tratament</strong>ul<br />
pacientilor cu atac acut migrenos.<br />
B Metoclopramidul adm<strong>in</strong>istrat <strong>in</strong>travenos se poate utiliza <strong>in</strong> <strong>tratament</strong>ul<br />
acut al pacientilor cu migrena.<br />
Ergotam<strong>in</strong>a<br />
Ergotam<strong>in</strong>a este superioara ca eficacitate comparativ cu placebo, dar mai<br />
put<strong>in</strong> eficienta <strong>de</strong>cat triptanii, anti<strong>in</strong>flamatoarele nesteroidiene sau opioi<strong>de</strong>le<br />
<strong>in</strong> <strong>tratament</strong>ul migrenei, chiar <strong>si</strong> <strong>in</strong> asociere cu cafe<strong>in</strong>a. Poate fi <strong>in</strong>sotita<br />
<strong>de</strong> reactii adverse cum ar fi greata, varsaturi, crampe abdom<strong>in</strong>ale sau musculare<br />
<strong>si</strong> nu trebuie utilizata la pacienti cu patologie cerebrovasculara sau<br />
cardiovasculara.<br />
Timisoara 2009
A Ergotam<strong>in</strong>a nu este recomandata <strong>in</strong> <strong>tratament</strong>ul cu migrena acuta.<br />
Cafe<strong>in</strong>a<br />
Efectul terapeutic al cafe<strong>in</strong>ei nu a fost evaluat separat, ci doar <strong>in</strong> diferite<br />
comb<strong>in</strong>atii cu alte medicamente.<br />
Alte terapii<br />
Nu exista date cu privire la eficacitatea utilizarii <strong>in</strong>hibitorilor <strong>de</strong> ciclooxigenaza-2,<br />
a corticoizilor, a <strong>in</strong>dometac<strong>in</strong>ului sau a opioi<strong>de</strong>lor (2).<br />
D Analgeticele opioi<strong>de</strong> nu trebuie utilizate <strong>de</strong> rut<strong>in</strong>a pentru <strong>tratament</strong>ul<br />
pacientilor cu migrena acuta datorita po<strong>si</strong>bilei aparitii a cefaleei<br />
pr<strong>in</strong> abuz <strong>de</strong> medicatie.<br />
4.1.2 Profilaxia farmacologica<br />
In profilaxia farmacologica a migrenei sunt utilizate urmatoarele clase <strong>de</strong><br />
medicamente:<br />
• Betablocante<br />
• Antiepileptice<br />
• Anti<strong>de</strong>pre<strong>si</strong>ve<br />
Alte medicamente utilzate cu rezultate variabile <strong>in</strong> profilaxie: pizotifen,<br />
methysergi<strong>de</strong>, flunariz<strong>in</strong>e, can<strong>de</strong>sartan, aspir<strong>in</strong>a, montelukast, acetazolamida,<br />
buspirone, oxigenul hiperbar.<br />
4.2 <strong>Cefaleea</strong> tip ten<strong>si</strong>une<br />
4.2.1 Tratamentul acut<br />
Adm<strong>in</strong>istrarea <strong>de</strong> aspir<strong>in</strong>a 1000mg <strong>in</strong> cefaleea <strong>de</strong> tip ten<strong>si</strong>une <strong>de</strong>term<strong>in</strong>a<br />
o rata mare <strong>de</strong> raspuns favorabil <strong>in</strong> ceea ce priveste disparitia durerii la<br />
doua ore. Acela<strong>si</strong> raspuns s-a observat <strong>si</strong> la adm<strong>in</strong>istrarea <strong>de</strong> paracetamol<br />
1000mg, iar amandoua au avut efecte superioare comparativ cu adm<strong>in</strong>istrarea<br />
<strong>de</strong> placebo.<br />
A Aspir<strong>in</strong>a <strong>si</strong> paracetamolul sunt recomandate pentru <strong>tratament</strong>ul acut<br />
al pacientilor cu cefalee tip ten<strong>si</strong>une.<br />
4.2.2 Profilaxia farmacologica<br />
In profilaxia cafaleei tip ten<strong>si</strong>une sunt recomandate urmatoarele clase <strong>de</strong><br />
medicamente:<br />
• Antihiperten<strong>si</strong>ve (antagonistii <strong>de</strong> receptori <strong>de</strong> angioten<strong>si</strong>na II)<br />
• Antiepilepticele<br />
• Anti<strong>de</strong>pre<strong>si</strong>vele (anti<strong>de</strong>pre<strong>si</strong>vele triciclice)<br />
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4.3 <strong>Cefaleea</strong> trigem<strong>in</strong>ala autonoma<br />
4.3.1 Tratamentul acut al cefaleei cluster (<strong>in</strong> ciorch<strong>in</strong>e)<br />
Triptanii<br />
Injectarea subcutana <strong>de</strong> sumatriptan 6 mg <strong>de</strong>term<strong>in</strong>a disparitia durerii la<br />
73-96% d<strong>in</strong> cazuri <strong>in</strong>tr-un <strong>in</strong>terval <strong>de</strong> 15 m<strong>in</strong>ute. Adm<strong>in</strong>istrarea <strong>de</strong> 20 mg<br />
sumatriptan ca spray <strong>in</strong>tranazal <strong>de</strong>term<strong>in</strong>a disparitia durerii la 57% d<strong>in</strong>tre<br />
pacienti <strong>in</strong> 30 <strong>de</strong> m<strong>in</strong>ute.<br />
A Prima optiune terapeutica la pacientii cu cefalee cluster este <strong>in</strong>jectarea<br />
<strong>de</strong> 6 mg sumatriptan subcutanat.<br />
A La pacientii care nu tolereaza adm<strong>in</strong>istrarea subcutanata a sumatriptanului<br />
se <strong>in</strong>dica adm<strong>in</strong>istrarea nazala <strong>de</strong> sumatriptan sau zolmitriptan.<br />
Oxigenul<br />
Adm<strong>in</strong>istrarea <strong>de</strong> oxigen 100% cu un <strong>de</strong>bit <strong>de</strong> 7 – 12 l/m<strong>in</strong> trebuie con<strong>si</strong><strong>de</strong>rata<br />
ca optiune terapeutica pentru pacientii cu cefalee cluster. Utilizarea<br />
oxigenului hiperbar pentru profilaxie nu <strong>si</strong>-a dovedit eficacitatea la acesti<br />
pacienti.<br />
Lidoca<strong>in</strong>a<br />
La pacientii la care cefaleea nu se amelioreaza satisfacator la adm<strong>in</strong>istrarea<br />
<strong>de</strong> sumatriptan <strong>si</strong> oxigen 100% se poate lua <strong>in</strong> con<strong>si</strong><strong>de</strong>rare adm<strong>in</strong>istrarea<br />
<strong>de</strong> lidoca<strong>in</strong>a 10% picaturi <strong>in</strong>tranazal <strong>in</strong> ve<strong>de</strong>rea accelerarii rezolutiei<br />
durerii.<br />
4.3.2 Profilaxia farmacologica<br />
Medicamentele utilizate <strong>in</strong> profilaxia cefaleei cluster:<br />
• Blocantele canalelor <strong>de</strong> calciu (verapamil 240-960 mg)<br />
• Litiul (800mg)<br />
• Antiepilepticele<br />
• Steroizii<br />
Au mai fost luate <strong>in</strong> discutie: ergotam<strong>in</strong>a, methysergite, melaton<strong>in</strong>a<br />
4.3.3 Tratamentul hemicraniei paroxistice <strong>si</strong> hemicraniei cont<strong>in</strong>ue<br />
Respon<strong>si</strong>vitatea celor doua tipuri <strong>de</strong> cefalee la <strong>tratament</strong>ul cu <strong>in</strong>dometac<strong>in</strong><br />
este <strong>in</strong>tegral. Indometac<strong>in</strong>ul se adm<strong>in</strong>istreaza <strong>in</strong> doze <strong>de</strong> pana la 225<br />
mg/zi <strong>si</strong> este eficient <strong>in</strong> profilaxia hemicraniei paroxistice <strong>si</strong> a hemicraniei<br />
cont<strong>in</strong>ue.<br />
Timisoara 2009
5. Situatii speciale<br />
5.1 <strong>Cefaleea</strong> pr<strong>in</strong> abuz <strong>de</strong> medicatie<br />
Se <strong>de</strong>f<strong>in</strong>este ca fi<strong>in</strong>d cefaleea care este prezenta mai mult <strong>de</strong> 15 zile pe<br />
luna <strong>si</strong> care a aparut sau s-a <strong>in</strong>rautatit <strong>in</strong> cursul adm<strong>in</strong>istrarii unei medicatii<br />
<strong>si</strong>mptomatice.<br />
Cl<strong>in</strong>icienii trebuie avertizati <strong>de</strong> faptul ca pacientii care utilizeaza orice <strong>tratament</strong><br />
acut sau <strong>si</strong>mptomatic prez<strong>in</strong>ta risc sa <strong>de</strong>zvolte acest tip <strong>de</strong> cefalee.<br />
Pacientii cu migrena, cefalee frecventa precum <strong>si</strong> cei care utilizeaza medicatie<br />
cu cont<strong>in</strong>ut opioid sau abuzeaza <strong>de</strong> <strong>tratament</strong>ul cu triptani se <strong>in</strong>cadreaza<br />
<strong>in</strong>tr-o clasa <strong>de</strong> risc crescut.<br />
Tratamentul consta <strong>in</strong> <strong>in</strong>treruperea medicatiei <strong>in</strong>crim<strong>in</strong>ate. In cazul <strong>in</strong> care<br />
aceasta medicatie este reprezentata <strong>de</strong> triptani sau analgetice <strong>si</strong>mple <strong>in</strong>treruperea<br />
adm<strong>in</strong>istrarii se face brusc, majoritatea acestor pacienti putand fi<br />
tratati ambulator. In cazul <strong>in</strong> care medicatia <strong>in</strong>crim<strong>in</strong>ata este reprezentata<br />
<strong>de</strong> substante opioi<strong>de</strong> sevrajul se va face gradat. Pacientul <strong>si</strong> medicul trebuie<br />
sa fie avertizati <strong>de</strong> faptul ca <strong>in</strong>treruperea brusca a medicatiei va <strong>de</strong>term<strong>in</strong>a<br />
<strong>in</strong>itial o <strong>in</strong>rautatire a cefaleei (2).<br />
5.2 Sarc<strong>in</strong>a, contraceptia <strong>si</strong> menstruatia<br />
Sarc<strong>in</strong>a<br />
Acolo un<strong>de</strong> este po<strong>si</strong>bil utilizarea medicatiei trebuie evitata <strong>in</strong> special <strong>in</strong><br />
timpul primului trimestru. Paracetamolul a fost utilizat <strong>in</strong> toate perioa<strong>de</strong>le<br />
sarc<strong>in</strong>ii fara a fi <strong>de</strong>pistate efecte nedorite <strong>si</strong>, <strong>in</strong> cazul <strong>in</strong> care este necesara<br />
terapia medicamentoasa, paracetamolul este medicamentul recomandat <strong>in</strong><br />
doza <strong>de</strong> 1000 mg. Daca adm<strong>in</strong>istrarea paracetamolului este <strong>in</strong>suficienta, <strong>in</strong><br />
primele doua trimestre <strong>de</strong> sarc<strong>in</strong>a se poate asocia aspir<strong>in</strong>a 300 mg sau ibuprofen<br />
400 mg.<br />
Aspir<strong>in</strong>a este contra<strong>in</strong>dicata <strong>in</strong> trimestrul trei <strong>de</strong> sarc<strong>in</strong>a, iar ibuprofenul <strong>in</strong><br />
adm<strong>in</strong>istrare prelungita creste riscul complicatiilor fetale.<br />
Contraceptia orala<br />
Migrena <strong>si</strong> contraceptivele comb<strong>in</strong>ate orale reprez<strong>in</strong>ta factori <strong>de</strong> risc <strong>in</strong><strong>de</strong>pen<strong>de</strong>nti<br />
pentru acci<strong>de</strong>ntul vascular cerebral<br />
B Femeile care prez<strong>in</strong>ta migrena cu aura nu trebuie sa utilizeze contraceptive<br />
comb<strong>in</strong>ate orale.<br />
D Pacientele care prez<strong>in</strong>ta migrena fara aura cu varsta peste 35 <strong>de</strong> ani<br />
nu trebuie sa utilizeze contraceptive comb<strong>in</strong>ate orale.<br />
Menstruatia<br />
Frecventa <strong>si</strong> severitatea migrenei pot creste <strong>in</strong> jurul perioa<strong>de</strong>i menstruale.<br />
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A Pacientele cu migrena acuta menstruala pot fi tratate cu acid mefenamic<br />
sau cu o comb<strong>in</strong>atie <strong>de</strong> aspir<strong>in</strong>a, paracetamol <strong>si</strong> cafe<strong>in</strong>a.<br />
A Sumatriptanul, zolmitriptanul, naratriptanul <strong>si</strong> rizatriptanul sunt recomandate<br />
pentru <strong>tratament</strong>ul acut al pacientelor cu migrena menstruala.<br />
6. Alti factori <strong>si</strong> terapii complementare<br />
6.1 Stilul <strong>de</strong> viata:<br />
• Dieta<br />
• Evitarea triggerului<br />
• Exercitiul fizic<br />
• Somnul<br />
• Managementul stresului<br />
6.2 Terapiile p<strong>si</strong>hologice<br />
6.3 Terapiile fizice:<br />
• Terapiile manuale (au efect documentat <strong>in</strong> cefaleea cervicogena <strong>si</strong> presupus<br />
<strong>in</strong> cefaleea tip ten<strong>si</strong>une)<br />
• Masajul<br />
• Stimularea electrica transcutanata a nervilor<br />
• Acupunctuta (se poate avea <strong>in</strong> ve<strong>de</strong>re <strong>in</strong> <strong>tratament</strong>ul profilactic al pacientilor<br />
cu migrena)<br />
6.4 Terapii complementare<br />
• Homeopatia (nu <strong>si</strong>-a dovedit eficacitatea)<br />
• Reflexoterapia (nu <strong>si</strong>-a dovedit eficacitatea)<br />
• M<strong>in</strong>eralele, vitam<strong>in</strong>ele <strong>si</strong> plantele (nu <strong>si</strong>-au dovedit eficacitatea)<br />
BIBLIOGRAFIE<br />
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limba romana, ed. ALPH MDN, 2008, vol. II, p. 418 - 425.<br />
2. SIGN. Diagnostic and management of headache <strong>in</strong> adult, A national cl<strong>in</strong>ical gui<strong>de</strong>l<strong>in</strong>e, Eliot House,<br />
Ed<strong>in</strong>burgh, nov.2008.<br />
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Cephalalgia 2004; 24(suppl 1):8-160.<br />
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Study. Headache 2004; 856-64.<br />
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6. Stovner L, Jensen R, Katsarava Z, Lipton R, Scher A, et al. The global bur<strong>de</strong>n of headache : a documentation<br />
of headache prevalence and disability worldwi<strong>de</strong>. Cephalalgia 2007; 27(3):193-210.<br />
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8. Russell MB, Fenger K, Olesen J. The family history of migra<strong>in</strong>e. Direct versus <strong>in</strong>direct <strong>in</strong>formation.<br />
Cephalalgia 1996;16(3):156-60.<br />
9. Skau M, Brennum J, Gjerris F, Jensen R, What is new about idiopathic <strong>in</strong>tracranial hyperten<strong>si</strong>on? An<br />
updated review of mechanism and treatment. Cephalalgia 2006; 26(4):384-99.<br />
10. Sempere AP, Porta-Etessam J, Medrano V, Garcia Morales I, Conception L, Ramos A, et al. Neuroimag<strong>in</strong>g<br />
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patients with nonacute headache [cited 16 oct 2008]. Available from url: http://www.americanheadachesociety.org/proffe<strong>si</strong>onalresources/<br />
USHeadacheConUSHeadacheConsort.asp<br />
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333(7561):235-40.<br />
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