Cerebrovascular diseases and headache
Cerebrovascular diseases (CVD) are one of the most pressing problems of modern medicine that clinicians of various profiles face in their daily practice. This is due to the wide prevalence of CVD and high social significance due to severe disability, especially in older age groups with a variety of comorbid pathology. In recent years, there have been some successes in the treatment of patients with acute cerebral circulatory disorders, which is associated with the introduction and improvement of medical care programs in Russia for this category of patients. At the same time, the percentage of chronic forms of vascular pathology is steadily increasing, including among younger people, which necessitates earlier diagnosis and adequate treatment of patients with the initial manifestations of chronic CVD, traditionally referred to as chronic brain ischemia (HIGM).
Among all the existing variants of pain syndrome, headache (GB) occupies one of the leading positions: about 90% of the population has experienced GB at least once in their life, and in 25-40% of cases it is chronic. With complaints of GB patients with cerebrovascular disease are treated more often by General practitioners, physicians primary outpatient centres and neurologists, whose main task is to establish a correct diagnosis and to appoint effective treatment. These comorbid disorders are in the area of special attention of doctors of different specialties.
Headache and HIGM
There are several clinical scenarios for a patient with complaints of GB and a diagnosis of HIGM. The initial stage of a chronic progressive form of cerebrovascular pathology caused by multi-focal or diffuse brain damage is clinically characterized by various and non-specific complaints, the leading ones are hypertension, dizziness, noise in the head and ears, distraction, decreased performance and fatigue. Despite the fact that patients with HIGM, especially in the initial stages, usually focus the doctor's attention on various and polymorphic GB or non-systemic vertigo, it is the increasing decline in cognitive and then motor functions that determines the degree of maladaptation and the severity of the patient's condition. General weakness, fatigue, and GB concern up to 75% of patients with HIGM, dizziness and balance disorders - up to 88%, and in half of cases, neurological examination does not reveal any confirmation.
Heterogeneity and dynamism of the clinical picture of the HIGM are associated with various cognitive and affective disorders that develop against the background of pathology of small-diameter cerebral arteries (cerebral microangiopathy), primarily penetrating medullary arteries of the large hemispheres and the brain stem, and various in nature, degree and location of pathological changes in the brain parenchyma. Vascular cognitive impairment (CN) observed in patients with HIGM is characterized by impaired Executive functions, programming, and control with relative memory retention. This is manifested, especially in the early stages, by a decrease in the rate of cognitive processes, impaired concentration, increased fatigue when performing mental work, and difficulty switching attention between different activities. It is important to note that vascular CN at the initial stages of the development of CIG is considered as potentially reversible, so early diagnosis and adequate therapy of these disorders, as well as correction of vascular risk factors (primarily arterial hypertension, diabetes mellitus, and atherosclerosis) can significantly affect the quality of life of this category of patients.
A common scenario in clinical practice is the misdiagnosis of HIGM in patients with a primary form of GB, in particular with migraine, tension headache, or drug-induced GB, whose diagnosis and treatment present certain difficulties, primarily at the primary health care level. The clinical picture of a migraine attack is known to doctors of various specialties, but in practice, therapists, General practitioners and even neurologists mistakenly diagnose other pathologies in these patients, such as degenerative-dystrophic diseases of the cervical spine, venous dysfunction, etc. It is surprising that even after a correctly established diagnosis of "migraine", doctors do not prescribe adequate medications with proven effectiveness for the relief and prevention of attacks of hypertension.
You should pay attention to the fact that migraine is a potential risk factor for the development of the CEH, particularly transient ischemic attack, stroke, coronary heart disease and angina. This is due to common pathogenetic mechanisms, in particular endothelial dysfunction, prothrombotic and procoagulant conditions (hypercoagulation, platelet aggregation), mitochondrial dysfunction, genetic predisposition, use of non-steroidal anti-inflammatory drugs, and other factors. Young women, patients with migraines with aura, those who use oral contraceptives, and those who smoke are at the highest Cerebro - and cardiovascular risk. Several meta - analyses have shown an increased risk of ischemic stroke in patients with migraines with aura, and dissection of the internal carotid or vertebral arteries in patients with migraines without aura. Patients with migraine are characterized by comorbid diseases such as arterial hypertension, coronary heart disease, and other diseases that may later independently lead to the development of CVD or the progression of existing HIGM. On the other hand, in patients with migraine, according to magnetic resonance imaging (MRI), in 4-59% of cases, there is a lesion of the brain substance in the form of small multiple "mute" foci, hyperintensive in T2-weighted and FLAIR modes, which are located periventrically and in the deep parts of the frontal, parietal lobe or limbic region. This, against the background of existing comorbid pathology, may predispose to subsequent pathology of the brain parenchyma, microangiopathy of the cerebral arteries, and the development of HIGM. However, this issue requires further study.
In recent years, tension headache has been considered as a risk factor for the development of cerebral pathology, in particular CN. Thus, in a large-scale study for 6 years involving about 14 thousand patients with a diagnosis of primary GB and more than 50 thousand respondents in the comparison group, a significantly large representation of CN, including dementia, was demonstrated in patients with tension headache, especially in the female population and in the chronic form of GB. Thus, if patients have such primary variants of HD as migraines and tension headaches, more attention should be paid to this category of patients, especially if there are other risk factors for the development of CVD.
Another option is the combination of a patient with a symptom complex of HIGM and one of the primary forms of HD, which is important to consider when searching for diagnostics, choosing further treatment tactics, and determining preventive measures in terms of the progression of existing disorders in these patients.
Secondary GB is much less common, which is not always easy to diagnose, especially if pain is the only symptom of a potentially dangerous condition, as is possible with a number of CVS. Factors that negatively affect the detection of urgent pathology also include the lack of clear characteristics and the course of pain similar to the primary GB, which resembles a migraine attack, cluster headache, or tension headache; localization of pain and a positive response to painkillers.
Secondary GB can occur acutely, quickly reaching the maximum intensity of pain (as a "bolt from the blue"), for example, in subarachnoid hemorrhage (SAH), reversible cerebral vasoconstriction syndrome (SOCV), less often - in cerebral artery dissection (table 2). However, the characteristics and course of the pain syndrome may resemble the clinical manifestations of migraine, tension headache, or cluster headache, the appearance of the clinical picture of the latter is observed with dissection of the internal carotid and vertebral arteries, vascular malformations, or other pathology of the cerebral vessels.
Acute, high-intensity, thunderous GB caused by SAH is usually accompanied by impaired consciousness, vomiting, neck muscle rigidity, and photophobia. At the same time, in 15-95% of cases, GB may precede the actual hemorrhage for days or even weeks. In 30% of patients with SA, the only symptom of the disease may be GB, which often leads to an incorrect diagnosis, for example, migraines. The use of painkillers in 5% of cases can completely stop the pain syndrome for 24 hours, and in 10% - for 48 hours , which also contributes to the erroneous diagnosis of other diseases.
With intense and short-term GB in SOCV, vomiting, visual impairment and impaired consciousness are usually observed. Episodes of "thunderous" GB may occur for 2-4 weeks, but relapses of intense cephalgia are described even after 3-4 years. In 75% of cases, GB is the only symptom of SOCV associated with the development of ischemic stroke in 6-39% of patients. The occurrence of concomitant transient focal neurological symptoms that are phenomenologically similar to a transient ischemic attack or migraine aura against the background of a recurrent course of GB creates additional difficulties for the diagnosis of SOCV.
Dissection, or dissection, of the internal carotid and vertebral arteries develops in young people who consider themselves practically healthy. Spontaneous occurrence of an urgent condition is possible in about 60% of cases, and subsequent development of ischemic strokes - in 20-25% of young patients. GB may be the only symptom of this pathology in 15-20% of cases. Incorrect diagnosis leads migrenepodobna, at least - clostrophobia for GB (often preceding the main cerebrovascular event) for days, often months, intensity of pain syndrome - less than 5 points on a visual analogue scale, and the occurrence of bilateral or isolated intense pain in the neck.
The clinical picture of venous sinus thrombosis is quite variable, with GB occurring in 90% of cases, and in 25% it is the only symptom of the disease; it is more often subacute, increasing in intensity, and less often "thunderous". However, GB in this pathology may resemble a typical migraine attack, less often - an episode of tension headache. Localization, severity, nature and course of GB may differ, as a rule, there is no effect from analgesic therapy.
The high prevalence of this disease in women of reproductive age is probably due to pregnancy, the postpartum period and the use of estrogen-containing oral contraceptives. Despite the fact that a fatal outcome in cerebral vein and venous sinus thrombosis is possible in up to 30% of cases, timely treatment initiated in the early stages leads to a favorable prognosis in more than 90% of patients.
Clinical manifestations of a rare form of vasculitis - primary angiitis of the Central nervous system (PACNS) - are very heterogeneous and depend on the severity and localization of cerebral vascular damage. In a number of studies, the majority of patients with PNS showed subacute and progressive development of diffuse lesions of the Central nervous system (CNS), among which moderate HD and CN are most often noted at the onset of the disease (in 50-78% and 50% of cases, respectively), in the future, the severity of these symptoms progressively increases. In the later stages of PTSD, focal neurological symptoms develop, more often represented by hemiparesis due to stroke (in 40% of cases). The assumption that the patient has PTSD may occur with the gradual progressive development of General cerebral manifestations, including mild or moderate GB, which has a chronic course with periods of improvement, and impaired cognitive functions associated with focal neurological symptoms that later joined in combination with multi-focal lesions of the subcortical regions and deep parts of the brain, according to the diffusion-weighted MRI regime. However, an accurate diagnosis can only be established after histological examination of the brain biopsy.
GB is a common symptom in patients with intracranial vascular malformations, most commonly dural arteriovenous fistula (10-15%), cavernous angioma (10-15%), and arteriovenous malformation (AVM). Various GB may be the only manifestation of this pathology for many years, on the other hand, it is possible to accidentally detect vascular malformation in the patient during neuroimaging, in the absence of any symptoms or complaints.
Clinical manifestations of cavernous sinus syndrome caused by dural arteriovenous fistula may mimic the symptoms of trigeminal neuralgia, temporal arteritis, or cluster headache. The cause of the development of a similar symptom complex may also be cavernous angioma, described in patients with long - term pharmacoresistant GB. only in 6% of cases, the only symptom of unexploded AVM may be one-or two-sided GB of a non-specific nature, which is noted in the rupture of congenital vascular pathology up to 31% of cases. The occurrence of chronic migraine-like GB with visual aura caused by AVM in the parietal-occipital region is described.
Management of patients with cerebrovascular diseases and headache
The General principles of management of this category of patients are to determine the etiopathogenetic cause of existing disorders, a thorough diagnostic search to identify primary or secondary forms of HD, treatment of existing diseases, and modification of risk factors for the development of CVD and the progression of chronic circulatory disorders. In particular, glucose and blood pressure monitoring, adequate hypotensive therapy, correction of metabolic disorders, Smoking cessation, statins and antiplatelet therapy, and regular physical activity are necessary.
The choice of further treatment tactics in patients with HIGM is based on determining the nature and severity of existing disorders, reducing the degree and preventing the progression of detected disorders. Therapy of patients with HIGM should be directed, if possible, to the pathological mechanisms of the disease development, which is not always possible in real clinical practice. The most affordable drug treatment is symptomatic therapy, which reduces the severity of various disorders in the patient, especially at the earliest stages of the pathological process, thereby significantly improving the quality of life.
The initial stage of HIGM often occurs in fairly young patients of working age, in whom GB, dizziness, asthenic and vegetative manifestations, as well as CKN in the form of slowing down the pace of cognitive processes, reduced concentration and impaired Executive functions, significantly affect professional and, over time - household activities. In this case, the use of drugs with a multimodal mechanism of action that can effectively, safely and pathogenetically reasonably affect existing disorders is important for patients with HIGM.
One of these drugs is Vasobral (Chiesi pharmaceuticals LLC), which is a combination of a dihydrogenated ergot derivative ?dihydroergocryptine and improve the absorption of caffeine. Most of the universal effects of Vasobral are due to blockade ?-dihydroergocryptine ?1 - and ?2-adrenoreceptors of vascular smooth muscle cells and stimulating effect on dopamine and serotonin receptors. According to experimental data, when using Vazobral , platelet and red blood cell aggregation decreases, vascular wall permeability decreases, brain metabolism improves, and cerebral tissue resistance to hypoxia increases. The second component - caffeine has a direct stimulating effect on the Central nervous system, mainly on the neurons of the cerebral cortex, increases mental and physical performance, reduces fatigue and drowsiness, and increases bioavailability ?-dihydroergocryptine.
In one study involving 293 patients with early stages of HIM on the background of a 3-month use of the drug has Vazobral have shown a significant decrease in the expression of KN and the subjective manifestations in the form GB, dizziness, and other nonspecific symptoms, improving the quality of life of these patients. The authors of the study demonstrated the feasibility of long-term therapy with Vasobral , since the positive clinical dynamics increased during all 3 months of therapy and was more significant than after 1 month of using this drug. In addition, there was a high adherence of patients to therapy with Vasobral and its good tolerability in patients with HIGM in the presence of arterial hypertension, against the background of antihypertensive therapy.
In another open multicenter study of Vazobral in 1341 patients (average age-59 years) with stages I and II of HIGM for 1 month, a significant improvement was shown in the vast majority of patients - in 82.1% of cases. This was manifested in a decrease in the intensity and frequency of GB, improved concentration, memory, and increased mental performance. The best effect was observed when prescribing high doses of the drug, with good tolerability of treatment, no reported side effects or undesirable interactions with other drugs used by patients with HIGM.
A survey of 1189 patients with CEH host has Vazobral as a primary drug or in combination therapy, using a specially developed questionnaire found that the most valuable properties of the drug, in their opinion, was a positive influence on memory, thinking, dizziness and other symptoms disrupt their usual operations (75% of patients) and available rate (69%) and almost constant presence of the drug in pharmacies (70%). Similar testing by 419 neurologists showed that 22% of respondents consider this drug to be the most effective drug among other medications, especially in the initial stages of HIGM. The advantages of the drug included good tolerability of course treatment (18%), a wide range of indications and clinical effects observed in practice (17%).
Thus, timely diagnosis, effective treatment of higm and prevention of further progression of THE disease, taking into account vascular risk factors, is of strategic importance for this category of patients. If patients with migraines have a high risk of developing CVD or existing HIGM, when considering therapy, it is necessary to monitor vascular risk factors, take into account concomitant comorbid conditions and diseases, exclude triptans and ergots for the relief of HD attacks, as well as taking hormone replacement therapy. If a patient with migraine has arterial hypertension, it is advisable to use drugs from several groups: ?-blockers, angiotensin II receptor antagonists and angiotensin-converting enzyme inhibitors that have a high level of proven effectiveness in the preventive therapy of migraine, treatment of arterial hypertension, which will prevent the further development and/or progression of cerebrovascular pathology.
The wide therapeutic potential and acceptable safety profile make it possible to reasonably use Vazobral in the complex therapy of patients with HIGM and HD, which will help reduce the intensity and frequency of cephalgia, dizziness and other concomitant vegetative, asthenic and cognitive manifestations, while increasing the patient's adherence to long-term therapy and significantly improving the quality of life.