Arq Neuropsiquiat r 2004;62(4):1090-1091
Headache Invest igat ion Sect or of Universidade Federal Fluminense, Nit erói RJ, Brazil (UFF): 1Neurologist , M D, PhD; 2Neurologist , M D, PhD, Adjunct Prof essor, Neurology, UFF; 3Neurologist , M D; 4Adjunct Prof essor, Vascular Surgery, UFF; 5Int ernist .
Received 1 April 2004, received in f inal f orm 3 June 2004. Accept ed 20 July 2004.
Dr. Jano Alves de Souza - Rua Ot ávio Carneiro 143/609 - 24230-190 Nit erói RJ - Brasil. E-mail: janoasouza@t erra.com.br
REM ISSION OF REFRACTORY CHRONIC CLUSTER
HEADACHE AFTER WARFARIN ADM INISTRATION
Case report
Jano Alves de Souza
1, Pedro Ferreira M oreira Filho
2, Carla da Cunha Jevoux
3,
Geraldo Fort una M art ins
4, André Bet t ini Pit ombo
5ABSTRACT - Isolat ed report s of a possible posit ive eff ect of ant i-coagulant drugs, among t hem heparin, w arf arin and acenocumarol, in migraine prophylaxis are f ound in t he lit erat ure. We report t he case of a 37 years old man suffering from refractory chronic cluster headache that presented remission with the admin-ist rat ion of w arf arin f or t he t reat ment of deep venous t hrombosis associat ed t o art erial t hrombosis. We did not f ound any case like t hat in t he lit erat ure.
KEY WORDS: clust er headache, w arf arin.
Remissão de cefaléia em salvas crônica refratária após administração de varfarina: relato de caso
RESUM O - Alguns relat os isolados na lit erat ura ref erem-se a um possível ef eit o prof ilát ico de drogas ant i-coagulant es, ent re elas a heparina, varf arina e acenocumarol na prof ilaxia da migrânea. Apresent amos o caso de um homem de 37 anos com cef aléia em salvas crônica ref rat ária que obt eve remissão t ot al das crises após a administ ração de varf arina para o t rat ament o de t rombose venosa e art erial. Não encont ramos nenhum relat o semelhant e na lit erat ura consult ada.
PALAVRAS-CHAVE: cef aléia em salvas, varf arina.
Isolat ed report s of a possible posit ive eff ect of
ant icoagulant drugs, among t hem heparin, w arf
a-rin and acenocumarol, in migraine prophylaxis
1-5are
f ound in t he lit erat ure. We do not know ref erences
t o a prophylact ic act ion of t hese same drugs on
clust er headache. We report t he case of a pat ient
suff ering f rom chronic clust er headache, up t o t his
point ref ract ory t o t he t reat ment and t hat present
-ed remission with the administration of warfarin for
t he t reat ment of deep venous t hrombosis associat
-ed t o art erial t hrombosis.
CASE
A 37 years old w hit e man, salesman, searched med-ical care due t o headache complaint , f or t he f irst t ime, on December 1997. At t hat t ime, he report ed t hat t he headache had st art ed about t w o mont hs ago and, since t hen, he experienced pain w it h a f requency of one t o t w o crises a day. Headache w as described as very st rong, obligat ing t he pat ient t o int errupt all and any act ivit y. The pain w as invariably locat ed on t he lef t orbit , perior-bit al and t emporal regions, and never changed side.
dival-Arq Neuropsiquiat r 2004;62(4) 1091
proat e sodium (up t o 1,500 mg/day); t opiramat e (up t o 200mg/day); met hysergide (up t o 4mg/day); indomet acin (up to 150mg/day), naratriptan (up to 5,0 mg/day), ergota-mine (up t o 4 mg/day), how ever, complet e remission of t he crises w as never achieved. There w ere periods w hen t he crises became less f requent and ot hers w hen t here w as a recrudescence of t he pain, ret urning t o t he origi-nal f requency of one t o t w o crises a day. For t he acut e care, the best result was achieved with oxygen and patient got used t o ut ilize it at t he f irst sign of pain. A magnet -ic resonance image of t he brain perf ormed w as com-plet ely normal.
The sit uat ion remained unchanged unt il July, 2002, w hen, in spit e of t he use of mult iple drugs, t here w as a new increase of t he crises f requency t hat , by t hat t i-me, st art ed responding less t o t he use of oxygen and sumat ript ane. We prescribed again prednisone, in t he dose of 60 mg, w hat gave him a signif icant relief . Any t ry t o reduce prednisone, how ever, caused t he ret urn of t he pain w it h an int olerable f requency and t he pat ient became cort icoid-dependant . On December 2002, w e suggest ed t he surgical t reat ment , but t his w as not pos-sible due t o personal reasons, and t he pat ient cont in-ued t he self -medicat ion w it h t he cort icoid, in addit ion to keep the use of verapamil and divalproate sodium with medical prescript ion. He ret urned t o our off ice in M arch, 2003, in a deplorable psychological st at us, st ill having f requent crises of headache and w it h several side eff ect s of cort icot herapy: cushingoid aspect ; syst emic blood hy-pert ension and diabet es mellit us. We suggest ed again t he surgical t reat ment and he agreed.
During t he w eeks prior t o surgery, t he pat ient broke t he lef t ankle in an accident and evolved w it h deep ve-nous t hrombosis and acut e art erial occlusion in t he sa-me sa-member, being admit t ed in t he hospit al in M ay 23, 2003, w hen enoxaparine st art ed t o be given in t he dose of 80 mg each 12 hours. While he w as at t he hospit al, prednisone (60 mg/day) verapamil (720 mg/day) and di-valproat e sodium (1,500 mg/day) w as maint ained and, spit e of t he many analgesic used f or t he t reat ment of pains relat ed t o art erial occlusion (codein, t ramadol, me-peridine and inject able ant iinf lammat ory medicat ions), t he crises kept occurring, and relief w as only part ialy achieved w it h oxigen inhalat ion. He w as submit t ed t o an embolectomy in May 30, 2003 and, once again, in June 04, due t o reocclusion of t he vessel. From July 07 on, w ar-f arin st art ed t o be given, in t he init ial dose oar-f 5 mg/day. Wit h t he st art of oral ant icoagulant , t here w as a reduc-tion in the frequency of cluster headache crises. They were no longer daily, but t he complet e remission w as not achieved. On July 11, as t he INR w as st ill of 1.8, w arf arin w as increased t o 10 mg/day, obt aining a INR ≥2.5. From then on, the patient did not present headache. Prednisone and divalproat e sodium w ere gradually reduced and, f inally, discont inuat ed, and verapamil (480 mg/day) w as maint ained w it h no recurrence of t he crises.
On Oct ober, 2003, t he pat ient present ed art erial oc-clusion again, requiring anot her vascular surgery. During hospit al t ime, w arf arin w as replaced by heparin, and crises compat ible w it h clust er headache ret urned. Af t er t he new surgery, t he use of w arf arin w as reest ablished, and t he remission of crises w as achieved again. Now (M arch, 2004) more t han f our mont hs af t er t he ret urn t o w arf arin, t he pat ient t akes no longer prednisone or divalproat e sodium. He t akes verapamil 240 mg/day as ant i-hypert ensive drug and has no longer crises. INR has been kept around 2.5.
DISCUSSION
In t he present case, it is necessary t o consider t he
possibilit y of coincidence, but t he pat ient had
pre-sent ed clust er headache crises f or more t han six
years, with no effective control, spite of being in use
of suitable medications. With the use of warfarin and
achievement of INR 2.5, t here w as t he remission of
crises. When it was necessary to replace warfarin with
heparin, t he crises ret urned and, once more, t hey
have ceased w it h t he ret urn t o oral ant icoagulant .
An import ant dat um is t hat t he pat ient w as a
smoker, and consumed about 20 cigaret t es a day,
and t he relief during t he f irst hospit al admission
could be at t ribut ed t o t he smoking habit int
errup-t ion. How ever, during errup-t he second hospierrup-t al
admis-sion, w hen t he w arf arin suspension produced t he
ret urn of crises, t he pat ient had not smoked f or
mont hs and t he crises remit t ed only w hen t he use
of w arf arin w as ret urned.
Our evaluat ion is t hat , as it occurs f or some
pa-t ienpa-t s w ipa-t h migraine, w arf arin may have a
preven-t ive ef f ecpreven-t on preven-t he cluspreven-t er headache.
This is t he f irst case in t he lit erat ure, as f ar as
we know, of a patient with chronic cluster headache
ref ract ory t o t reat ment present ig complet e
remis-sion of t he crises f ollow ing administ rat ion of w
ar-f arin ar-f or anot her purpose.
REFERENCES
1. Fragoso YD. Reduction of migraine attacks during the use of warfarin. Headache 1997;37:667-668.
2. Suresh CG, Neal D, Coupe MO. Warfarin treatment and migraine. Postgrad Med J 1994;70:37-38.
3. Van Puijenbroek EP, Egberts JF, Trooster JF, Zomerdijk J. Reduction of migrainous headaches during the use of acenocoumarol. Headache 1996;36:48.
4. Morales-Asin F, Iniguez C, Cornudella R, Mauri JA, Espada F, Mostacero EE. Patients with acenocoumarol treatment and migraine. Headache 2000;40:45-47.
