Prise en charge des céphalées chroniques

Il s’agit d’un problème important de Santé Publique puisque 30% de la population fran?aise se plaint de céphalées répétitives. La prise en charge comporte trois étapes successives qui ont chacune leur importance. Le diagnostic correct, dépassant les approximations énoncées, repose avant tout sur l’interrogatoire et un examen clinique soigneux. On peut ainsi individualiser trois groupes d’importance différente: Pathologie migraineuse et affections apparentées (cluster headache), céphalées de tension et céphalées sympt?matiques dont la fréquence est souvent surestimée. Une compréhension pysiopathologique fine est nécessaire pour aborder une thérapeutique adaptée mais elle servira aussi de base aux explications données au malade. Celles-ci sont essentielles pour lever la nosophobie si fréquente chez les céphalalgiques. Lorsque les céphalées ne sont pas fréquentes, on privilégiera le traitement symptomatique. Les traitements de fond choisis en fonction du diagnostic et du terrain seront également explicités afin d’obtenir une bonne observance thérapeutique, dans une relation de confiance, gage indispensable d’une prise en charge correcte.     

Psychopathologie et céphalées

Résumé  L’association entre céphalées et troubles psychiatriques a de tout temps été soulignée par les cliniciens. Les migraineux en particulier ont été décrits comme des sujets atteints fréquemment d’anxiété et de dépression. En ce qui concerne les patients souffrants de céphalées de tension, l’impact de l’anxiété et de la dépression a été jugé si important que le terme de céphalées psychogènes était employé jusqu’à récemment. Aujourd’hui, la classification de l’International Headache Society (1988) reconna?t l’anxiété et la dépression comme des étiologies possibles aux céphalées de tension. Cette revue de la bibliographie a pour objectif de préciser l’état actuel des connaissances au sujet de l’association entre les troubles psychiatriques et les céphalées. On verra qu’il existe une importante comorbidité entre migraines d’une part et troubles anxieux et dépressifs d’autre part. Cela est moins clair pour les céphalées de tension ce qui remet en cause la place prépondérante occupée traditionnellement par la psychopathologie dans l’étiologie de ces dernières. Les céphalées chroniques sont, elles, associées très fréquemment à la souffrance anxio-dépressive, qui pourrait jouer un r?le étiologique dans la chronicisation des céphalées. L’examen des rapports entre anxiété, dépression et céphalées est particulièrement riche tant sur le plan théorique en ce qui concerne les causes possibles des comorbidités, qu’en ce qui concerne les conséquences pratiques que ces associations peuvent avoir sur la prise en charge des patients. Certains traitements médicamenteux sont particulièrement intéressants dans ces cas là, efficaces à la fois sur les céphalées et sur les troubles affectifs; enfin et surtout, une prise en charge psychologique adaptée doit être proposée, à défaut de quoi la souffrance risque d’envahir le sujet et de devenir un mode de vie. Outre la relaxation, dont l’efficacité a été démontrée, l’impact de certaines interventions inspirées des théories comportementalo-cognitives a été étudié de fa?on rigoureuse chez les patients céphalalgiques.

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Summary  Clinicians have always stressed the association between psychiatric disorders and headaches. Migraineurs particularly have been described as anxious and depressed people. Concerning tension type headaches, the impact of anxiety and depression is so strong that until recently they used to be called ?psychogenic headaches? until recently. Now, anxiety and depression are aetiological items for tension type headaches in the International Headache Classification. This review deals with recent data regarding the association between psychiatric disorders and headaches. We shall see that some evidences suggest that there is a strong association between migraine on the one hand, and anxiety and mood disorders on the other hand. On the opposite, no evidence can be retained in favour of an association between those psychiatric disorders and tension type headaches. This fact challenges the hypothesis of a psychogenic aetiology. It also suggests that chronic headaches frequently are associated with an increased anxiety and depressive level, which could play an aetiological role in the chronicisation of headaches, However we cannot assert for the moment the aetiological role of anxiety and depression in the occurrence of headaches with chronic substance use. Some psychotropic treatments are of particular interest in those cases because of their efficiency in anxiety and mood disorders as well as in chronic headaches. This should not conceal the importance of the psychological intervention. Some evidences allowed us to think that relaxation have efficiency on migraines just as on tension type headaches. Cognitive behavioural therapy as well has been evaluated in these indications: it is effective in reducing the fear of pain anxiety and even pain intensity.

     

Psychopathologie et céphalées

L’association entre céphalées et troubles psychiatriques a de tout temps été soulignée par les cliniciens. Les migraineux en particulier ont été décrits comme des sujets atteints fréquemment d’anxiété et de dépression. En ce qui concerne les patients souffrants de céphalées de tension, l’impact de l’anxiété et de la dépression a été jugé si important que le terme de céphalées psychogènes était employé jusqu’à récemment. Aujourd’hui, la classification de l’International Headache Society (1988) reconna?t l’anxiété et la dépression comme des étiologies possibles aux céphalées de tension. Cette revue de la bibliographie a pour objectif de préciser l’état actuel des connaissances au sujet de l’association entre les troubles psychiatriques et les céphalées. On verra qu’il existe une importante comorbidité entre migraines d’une part et troubles anxieux et dépressifs d’autre part. Cela est moins clair pour les céphalées de tension ce qui remet en cause la place prépondérante occupée traditionnellement par la psychopathologie dans l’étiologie de ces dernières. Les céphalées chroniques sont, elles, associées très fréquemment à la souffrance anxio-dépressive, qui pourrait jouer un r?le étiologique dans la chronicisation des céphalées.     

éducation thérapeutique : expérience de prise en charge des migraines et céphalées par la relaxation

Within the scope of chronic pain recommendations at Périgueux hospital, four patients suffering with migraines were offered group-based relaxation treatment for a year, with one session a week, in accordance with Progressive Autogenic Training. A group dynamic soon formed amongst these patients, with lots of mutual understanding, progress and a discussion of thoughts and ideas concerning feelings; information was being shared. Speaking about oneself was possible for some, but there was a sense of self-censorship when it came to expressing intimate details. Patients with emotional needs received individual support at the end of the session. Patient feedback at the end of the treatment period is a good indicator of the change process resulting from this experience and the degree of take-up of the method. Assessment reports at one and two years reveal a reduction in migraine problems for the patient, a decrease in the length and intensity of the attacks, with the disease having less of an impact on the daily lives of those around them. In all cases, relaxation has been integrated into the migraine management process.     

Céphalées chroniques quotidiennes, céphalées par abus médicamenteux Définitions, épidémiologie

Résumé  La nosologie des céphalées chroniques quotidiennes (CCQ) est, pour le non-spécialiste, quelque peu complexe: la publication récente de la deuxième version des critères diagnostiques IHS des céphalées rend plus précise la réalisation des études en recherche clinique, mais complexifie notre travail d’enseignement des céphalées aux non-spécialistes. La définition actuelle des céphalées par abus médicamenteux (CAM) est comportementale, en nombre de jours avec prise d’un traitement de crise, alors qu’elle était auparavant plus quantitative, en poids de médicaments utilisés quotidiennement ou par mois. Ces CAM sont présentes dans un tiers des cas de CCQ, ellesmêmes présentes chez 3% de la population générale. La connaissance de l’affection par les professions médicales, paramédicales, et par la population générale elle-même doit s’améliorer, permetant de prévenir le développement des céphalées par abus médicamenteux, pas toujours réversibles.      

Prise en charge des troubles du rythme en réanimation

Arrhythmias are frequent in intensive care unit patients, subsequent to hypoxia, hypokaliemia or acidosis. Specific treatment is required if correction of such disturbances is not sufficient. Electrical or pharmacological cardioversion is mandatory in case of a life-threatening arrhythmia. Thereafter, it is a challenge to maintain sinus rhythm and prevent recurrences. Skill in anti-arrhythmic therapy is essential to avoid proarrhythmias and other deleterious effects.     

Prise en charge en urgence des corps étrangers ingérés

Foreign body (FB) ingestion is frequent in children. FB can pass through spontaneously in around 80% of cases during the first week, but 20% of them require endoscopic removal, and <1% need surgery. Severe complications (perforation, abscess, fistula, massive haemorrhage) were reported. Radiographs of the neck, chest and abdomen, with anteroposterior and lateral views, are recommended to diagnose and to locate FB. The risk that FB > 2 cm in diameter or > 5 cm in size block in the esophagus, at the pylorus, duodenal curve, ligament of Treitz, Meckel diverticulum, ileocecal valve, appendix and rectosigmoid junction, is important. Like sharp and pointed FB, their endoscopic removal should be performed in emergency. Disk batteries should be removed from the esophagus during the first 2 hours because of the damages they can quickly induce. Concerning magnet ingestion, it is to note that one magnet can pass through spontaneously, but several magnets can attract themselves across intestinal loop inducing necrosis, then perforation or fistula. Esophageal food impaction can be associated with stenosis, motility disorder, or eosinophilic esophagitis that requires endoscopic biopsies for its diagnosis. Patients with small, blunt objects located at the lower third of the esophagus or in the stomach could be observed at home; radiograph should be performed 3 to 4 weeks later if the FB was not found in faeces. In children, it is recommended to perform FB extraction by endoscopy under general anaesthesia and tracheal intubation, using several accessories. This gives good success rate, reduces perendoscopic complications, and enables to diagnose mucosal lesions.     

Prise en charge psychologique des personnes atteintes de sclérose en plaques

Psychological troubles in patients with multiple sclerosis (MS), already acknowledged when the disease was first described but underestimated, are in fact frequent, heterogeneous, and occur early in the disease course. They include cognitive deterioration that affects memory, attention, executive functions, and the speed of information processing, and also mood disturbance and emotional troubles. They induce difficulties for familial, social, and professional adaptation. They are a major source of impoverished quality of life for patients and caregivers. Therefore, it is necessary to systematically screen and evaluate them in order to organize rehabilitation strategies.     

Hypothèse veineuse et céphalées

The alterations of the cerebral venous circulation are a rare but clinically important cause of headache. The most frequent cause is a cerebral venous thrombosis but idiopathic intracranial hypertension and headaches related to exercise may be related to alteration of the cerebral venous circulation. The pathogenesis of these disorders has not been clearly established and several possibilities involving the cerebral circulation are discussed.     

Prise en charge des troubles neurovisuels de la sclérose en plaques

Visual impairment is one of the most common symptoms in multiple sclerosis (MS). Hard to describe, visual disturbances may be present even with a normal visual acuity. Prevalence of chronic visual impairment is little known in this pathology, while the impact on the quality of life is not negligible. Low vision seems to be a reality in MS. Associated with other symptoms, the impact on daily living activities and quality of life is very important. A multidisciplinary approach is essential and has to be especially focused on reducing the comorbidity of visual impairment and motor involvement in this pathology.     

Prise en charge diagnostique et thérapeutique des embolies gazeuses

Gas embolism is a largely iatrogenic clinical entity responsible for serious morbidity and mortality in many varied medical specialties and one of the most serious problems in diving medicine. Depending on the mechanism of gas entry and where the emboli ultimately lodge, two broad categories of gas embolism can be differentiated: venous gas embolism (by the entry of gas into the systemic venous system) and arterial gas embolism (through the entry and passage of air into the arterial system). It is important to note that any venous embolism can become an arterial one due to a paradoxical embolism. Treatment of gas embolism is to avoid further entry of gas. In certain cases, aggressive cardiopulmonary resuscitation must be performed. Adequate oxygenation is required by using a significant increase in the oxygen concentration of the inspired gas. In arterial gas embolism, oxygen should be administered in as high a concentration as possible and the treatment with hyperbaric oxygen is the first line treatment of choice, thus, transfer to a hyperbaric oxygen facility should be accomplished without delay.     

Prise en charge chirurgicale des mains brul��es complexes au stade aigu

Burns of the hands are relatively common because of their exposure and the risk of accidents occurring during their use. Among these cases, the management of complex burns in the acute stage continues to present a difficult problem. In this article we first define which clinical situations might correspond to the idea of the ??complex hand??, and we then review the therapeutic options which are available. We try to clarify the indications for skin grafts, treatment by negative pressure, artificial dermis and skin flaps. It seems that two situations need to be distinguished: the isolated complex burn of the hand and the complex burn of the hand in a patient with third-degree burns. The problems in managing a patient in the latter situation and the therapeutic possibilities that flow from this are then examined. Finally, and after a study of the literature, it appears that there is no real consensus or clearly established protocol.     

Prise en charge du traumatisme crânien cérébral grave

Management of severe traumatic brain injury (TBI) is based on early resuscitation — aiming to avoid hypoxia and hypotension, the rapid patient transfer to specialised neuroscience centers with neurosurgical availability, early surgical evacuation of acute cerebral lesions and invasive monitoring of intracranial pressure in TBI patients with abnormal admission CT-scan (contusions, hemorrhage, hematoma). Upon intensive care unit admission, treatment will be focused on the prevention/attenuation of secondary brain injuries of intra-cerebral (intracranial hypertension, cerebral ischemia, non-convulsive seizures) and sytemic (hyperthermia, hyperglycemia) etiology, according to a standardised algorithm. The application of such standardised therapeutic strategy has been shown by several studies to improve TBI prognosis and overall care of head-injured patients.     

Prise en charge des infections sur cathéters à chambre implantable

Totally implantable port is a device composed of a silicone catheter related to a reservoir inserted under the skin. These catheters have a lower rate of infection, compared with tunnelised central venous catheters, only when they are used in sequential infusions. Higher rates of infection are associated with more frequent handling of the catheter. Removal of the device associated to a systemic antibiotherapy is the standard treatment for catheter related infection, especially when the patient’s status is severe or when the infection is due to Staphylococcus aureus or Candida sp. Since few years, a treatment has been developed based on maintenance of the device using antibiotic lock technique, associated or not to a systemic antibiotherapy. Studies evaluating efficacy of this alternative in the treatment of tunnelised catheter-related infection show a rate of cure without relapse of 82%. Efficacy of this technique, however, seems less reliable in the treatment of totally implantable port-related infections, varying from 30 to 80%. The presence of fibrin clots inside the reservoir of the device limits the penetration of antibiotics explaining the persistence of micro-organisms and the higher rate of failure. Controlled studies to assess the use of urokinase associated to antibiotic lock technique might improve the efficacy of this technique and might favour the conservative treatment.     

Prise en charge des hépatites fulminantes d’origine toxique en réanimation

Toxin-related liver diseases are a common cause of acute and fulminant liver failure. Numerous substances may be involved. The diagnosis is important because in some cases specific treatment with an antidote is required. Other therapeutic interventions such as supportive measures, liver assist devices and transplantation are discussed.     

Prise en charge en médecine physique et de réadaptation des patients présentant des douleurs neuropathiques

Physical and rehabilitation medicine (PRM ) teams are involved in patients with neuropathic pain. This neuropathic pain can be associated with other kind of pain. The teams have to look for it, evaluate and treat it, and even more prevent it if possible. Treatment requires physical therapy and pharmacological interventions to operate on nociceptive, neuropathic, and emotional components of pain.