Recomendações para o tratamento da crise migranosa - Um consenso brasileiro
Neste artigo um grupo de especialistas no tratamento de cefaleia da Sociedade Brasileira de Cefaleia através de um consenso elaborou medidas estratérgicas para tratar uma crise de migrânea tanto na criança como no adulto. Uma enfase particular foi dada no tratamento da migranea na mulher, incluindo gravidez, lactação e período perimenstrual.
cefaleia; enxaqueca; tratamento; analgésico; crise
| Symptomatic Treatment | Miniprophylaxis |
|---|---|
| Strong Evidence of Effectiveness* in the NSAIDs | Menstrual Migraine |
| NSAIDs | |
| Mefenamic acid 500 mg 3 x d | Naproxen sodium 550 mg 2 x d |
| Nimesulid 100 mg 2-3 x d | Minerals and Supplements |
| Triptans | Magnesium 360 mg/d |
| Naratriptan 2.5 mg | Vitamin E 400 IU/d (especially for photophobia, phonophobia and nausea) |
| Rizatriptan 10 mg | Triptans |
| Sumatriptan 50-100 mg | Naratriptan 1 mg 2xd |
| Zolmitriptan 2.5 mg | Sumatriptan 25mg 3xd |
| Hormones | |
| Percutaneous estradiol Gel 1.5 mg (-5 to +2 of menstruation) Estradiol patch 100µ (-4 to +4 of menstruation) | |
| Limited evidence or clinical suggestive experience | of the menstrual migraine efficacy |
| NSAIDs (others) | Ketoprofen 25-50 mg 3 x d |
| Magnesium 360 mg/d | |
| Mefenamic Acid 500 mg 3-4xd |
| Nonsteroidal Anti-inflammatory Drugs (NSAIDs) |
|---|
| Naxoprene sodium 550 mg 2 x/day, starting two days before date of menstruation (expected) for 5 to 7 days or 500 mg 2x/day, starting 7 days before menstruation to day 6 of the cycle (prophylactic - Level I) |
| Ibuprofen: 200-400mg - 2-3x/day, starting 7 days before menstruation, to day 6 of the cycle (prophylactic - Level I) |
| Ketoprofen: 25-50mg – 3x/day, starting 7 days before menstruation to day 6 of the cycle (prophylactic – Level I) |
| Mefenamic acid: 500 mg – 3-4x/day, starting 2 to 3 days before menstruation to its end (preventive – Level II) |
| Tolfenamic acid, other NSAIDs, selective inhibitors of cyclooxygenase-2 (COX2) (Celecoxib) may also be used. |
| Use of NSAIDs does not exclude triptans employment for acute crises that may rise. |
| Triptans and ergotaminics |
| Sumatriptan: 25 mg 3x/day – 2 to 3 days before headache onset, for 5 days (preventive – Level I) |
| Naratriptan: 1 mg (level I) to 2.5 mg (low evidence) – 2x/day – 2 days before headache onset, for 5 days |
| Triptans and ergominics exclude triptans for crises, but not the use of anti-inflammatory drugs. |
| Minerals and supplements |
| Magnesium: 360 mg, chelated a day, from day 15 after the menstruation onset to the following cycle |
| Vitamin E: 400 UI a day, for 5 days (-2 to +3 from the menstruation onset) |
| Estrogen gel |
|---|
| Percutaneous estradiol gel: 1.5 mg, two days before menstruation for seven days (evidence level II). -5 to 2 days after the beginning of menstruation (1) |
| Estradiol transdermal patch (TD) 100 µg every two days, for five to seven days (level of evidence II) (three patches), the first three days before menstruation, the second at the first day of menstruation, and the third, two days after the menstruation. If the woman is using contraceptive pills, a patch on pill 20, one on day 23 of the interval and one on day 26 of the interval (2); or a patch on pill 21 and one on day 25 of the interval (two patches). |
| Category | Risk |
|---|---|
| A | Controlled studies in humans show no risks |
| B | No evidence of risk in humans, but there are no controlled human studies |
| C | Risk in humans has not been proven |
| D | Presence risk of evidence in humans, in animal and/or human experiments |
| X | Contraindicated during pregnancy |
| Pregnancy | Lactation | |
|---|---|---|
| Simple analgesics | ||
| Aspirin | C (D) | Warning |
| Acetaminophen | B | Warning |
| Caffeine | B | Compatible |
| Dipyrone | C | Compatible |
| NSAIDs | ||
| Ibuprofen | B (D) | Compatible |
| Indomethacin | B (D) | Compatible |
| Naproxen | B (D) | Compatible |
| Narcotics | ||
| Codeine | C (D) | Compatible |
| Meperidine | B (D) | Compatible |
| Tramadol | C | Contraindicated |
| Ergotamine and serotonergic agonists | ||
| Ergotamine | X | Contraindicated |
| Dihydroergotamine | X | Contraindicated |
| Sumatriptan | C | Probably compatible |
| Corticosteroids | ||
| Dexamethasone | C | Probably compatible |
| Prednisone | B | Probably compatible |
| Neuroleptics | ||
| Chlorpromazine | C | Warning |
| Promethazine | C 1st Quarter B 2nd and 3rd Quarter | Probably compatible |
| Haloperidol | C | Warning |
| Metoclopramide | B | Warning |
| Drug | Age | Dose | Route |
|---|---|---|---|
| Paracetamol | No restriction | 15 mg/kg/dose Up to 6 doses/day | PO |
| Ibuprofen | > 6 months | 10 mg/kg/dose Up to 4 doses/days | PO |
| Naproxen and naproxen sodium | > 2 years | 2.5-5 mg/kg/dose Up to 4 doses/day | PO |
| Acetylsalicylic acida | > 12 years | 7-10 mg/kg/dose Up to 6 doses/day | PO |
| Dipyrone | < 6 years 6-12 years > 12 years | 6-10 mg/kg/dose Up to 1 g/day Up to 2 g/day Up to 3 g/day | PO IR IM EV |
| Metoclopramide b | > 1 year | 0.1-0.2 mg/kg/dose Up to 3 doses/day | PO IM EV IR |
| Domperidone | > 1 year | 0.3 mg/kg/dose Up to 3 doses/day | PO |
| Sumatriptanc | > 12 years > 18 years | 10 mg 10-20 mg | IN |
| Zolmitriptan | > 12 years | 2.5 mg/dose | PO |
| Rizatriptan | > 12 years | 5-10 mg/dose | PO |
| Naratriptan | > 12 years | 2,5 mg/dose | PO |
| Sumatriptan in combination with naproxene or naproxene sodium | > 12 years | 25-50 mg/dose 250-500 mg/dose 275-550 mg/dose | PO |
| Isometheptene (association) | > 1 year | 1 drop/kg/dose | PO |
| Chlorpromazine d | > 2 years | 0.25 mg/kg/dose up to 6 doses 0.5 mg/kg/dose up to 4 doses | PO EV |
| Dexamethasone | > 2 years | 0.25 mg/kg/dose up to 4x day | EV |
| Medications already used | None | Common analgesics | Ergotics/isometheptene | Triptans |
|---|---|---|---|---|
| Options | Sumatripthane SC Dipyrone IV NSAID IV | Sumatripthane SC Dipyrone IV NSAID IV | Dipyrone IV NSAID IV | Dipyrone IV NSAID IV |
| If nausea, vomiting | Antiemetics Hydration | Antiemetics Hydration | Antiemetics Hydration | Antiemetics Hydration |
| If refractory crisis | Dopamine antagonists Valproate sodium IV | Dopamine antagonists Valproate sodium IV | Dopamine antagonists Valproate sodium IV | Dopamine antagonists Valproate sodium IV |
