Pregunta sobre cefaleas?

NEUROSAE 2018 ANNUAL MEETING EDITION (VOLUME 10, ISSUE 3)
QUESTION 2 OF 100

2.



A right-handed, 59-year-old woman presents with a 31-year history of headache and sinus pressure, characterized by throbbing, sharp, stabbing pain and pressure sensations. She reports having episodes about nine times a month and sometimes upon awakening. The headaches occur at any location but typically start on one side and usually are accompanied by lightheadedness and sensitivity to light, noise, and smell. Although the pattern of headaches has not changed, she believes the frequency has increased within the past few years. Acetaminophen or naproxen provide some relief. The patient has a history of heart palpitations, chest pain or tightness, and hypertension. She has a stent in place due to coronary artery disease and requires a CPAP device to address sleep apnea. Vital signs are as follows: BP 135/64 mm Hg, HR 73 beats/min, RR 16 breaths/min. She is 5′ 4″ tall, weighs 177 lb., and has a BMI of 30.38 kg/m2. Results of neurologic examination are within normal limits. Current medications include losartan, amlodipine, carvedilol, aspirin, and atorvastatin. MRI scans of the brain are shown. Which of the following is the most appropriate management strategy?

A. Abortive treatment with diclofenac potassium oral solution and preventive treatment with topiramate
B. Abortive treatment with diclofenac potassium oral solution and preventive treatment with propranolol
C. Abortive treatment with sumatriptan and preventive treatment with topiramate
D. Abortive treatment with sumatriptan and preventive treatment with propranolol
E. Referral to neurosurgery for urgent surgical intervention

A. Abortive treatment with diclofenac potassium oral solution and preventive treatment with topiramate  **
B. Abortive treatment with diclofenac potassium oral solution and preventive treatment with propranolol
C. Abortive treatment with sumatriptan and preventive treatment with topiramate
D. Abortive treatment with sumatriptan and preventive treatment with propranolol
E. Referral to neurosurgery for urgent surgical intervention
** = Your answer

The patient fulfills ICHD-3 Beta criteria for migraine without aura and requires both abortive and preventive treatments.
Seven triptans (multiple forms) and one NSAID (buffered diclofenac potassium for oral solution) currently are available and approved by the FDA for acute care of migraines. Triptans are contraindicated in patients with a history of coronary artery disease. Soluble formulation of diclofenac potassium is a nontriptan alternative for the acute treatment of migraine, with a fast onset of action, sustained efficacy, a favorable safety profile, and no triptan-type side effects.
Topiramate is a good option for this patient as it is an FDA-approved preventive treatment for migraine and may help with weight loss, which is one of its side effects. Although propranolol is an FDA-approved preventive medication, the patient currently takes the beta blocker carvedilol; this probably is not a good combination/option.
The increasing availability and use of modern diagnostic imaging modalities for the brain has made discovery of incidental meningiomas fairly common, which has created a dilemma among neurosurgeons, neurologists, and radiologists. In this situation, MRI was ordered but not indicated based on the patient’s history. The MRI scans show two homogeneously enhancing extra-axial tumors, consistent with meningioma. Referral to neurosurgery is not indicated because most asymptomatic incidental meningiomas can be monitored with serial imaging studies and clinical follow-up.
A reasonable approach to management is clinical follow-up 3 to 4 months from the time of diagnosis to rule out growth of an aggressive lesion. Follow-up appointments can then be scheduled at 6 to 9 months and then annually thereafter. In one large clinical series of 603 patients with asymptomatic meningiomas, lesion size did not increase in 63% patients, and only 6% of patients eventually developed symptoms (mean follow-up, 3.9 years).
References
* International Classification of Headache Disorders 3 Beta
* Rapoport AM. The therapeutic future in headache. Neurol Sci. 2012 May;33(Suppl 1):S119-S125.
* Spasic M, Pelargos PE, Barnette N, et al. Incidental meningiomas: management in the neuroimaging era. Neurosurg Clin N Am. 2016 Apr;27(2):229-238.
* Yano S, Kuratsu J, Kumamoto Brain Tumor Research Group. Indications for surgery in patients with asymptomatic meningiomas based on an extensive experience. J Neurosurg. 2006 Oct;105(4):538-543.

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