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Transcript of MIGRAINE 偏头痛 Yin Mei Department of Neurology The No.2 Hospital Affiliated Kunming Medical...
MIGRAINE偏头痛
Yin Mei Department of Neurology
The No.2 Hospital Affiliated Kunming Medical College
NEW WORDS MigraineMigraine 偏头痛偏头痛 Throbbing pain Throbbing pain 搏动样疼痛搏动样疼痛 AuraAura 先兆先兆 Teichopsia Teichopsia 闪光暗点闪光暗点
OUTLINE
Definition Definition Triggers Triggers PathophysiologyPathophysiology Clinical featuresClinical features Diagnosis Treatment
Migraine - Definition
““Migraine is a familial disorder characterized Migraine is a familial disorder characterized
by by recurrent attacks of headacherecurrent attacks of headache widely widely
variable in intensity, frequency and duration. variable in intensity, frequency and duration.
Attacks are commonlyAttacks are commonly unilateral unilateral and are and are
usually associated with anorexia, nausea and usually associated with anorexia, nausea and
vomiting”vomiting”
-World Federation of Neurology-World Federation of Neurology
Migraine Facts Migraine is one of the common causes of Migraine is one of the common causes of
recurrent headachesrecurrent headaches According to IHS, migraine constitutes According to IHS, migraine constitutes
16% of primary headaches16% of primary headaches Migraine afflicts 10-20% of the general Migraine afflicts 10-20% of the general
populationpopulation
How Migraine Stacks Up Against Other Common Diseases
From the Centers for Disease Control and Prevention, the US Census Bureau, and the Arthritis Foundation.
1%
5%6%
7%
12%
Rheumatoid arthritis
风湿性关节炎
Asthma哮喘
Diabetes糖尿病
Osteoarthritis骨关节炎
Migraine
Affected Americans:
In the past 3 months...
9 million
14 million
21 million
18 million
16 million Missed family or leisure activity
Functioned less than half as well at household
Were unable to do household work
Functioned less than half as well at work/school
Missed Work or School
Migraine Takes Time Out From Your Life
Migraine Facts
Migraine greatly affects qualitMigraine greatly affects quality of life . The WHO ranks migy of life . The WHO ranks migraine amongraine among the world’s mothe world’s most disabling medical illnessest disabling medical illnessess
Migraine Facts
More than 2/3 of migraine sufferers either have never consulted a doctor or have stopped doing so
Causes of Migraine Increased excitability of CNS Meningeal blood vessel dilation Activation of perivascular
sensory trigeminal nerves
Causes of Migraine
Vasoactive neuropeptides contain: substance P calcitonin gene-related peptide
(CGRP) neurokinin A
Causes of Migraine
Pain impulses Combination of increased pain
sensitivity, tissue and vessel swelling, and inflammation
Triggers and Risk Factors诱发因素
Migraine headaches are often tMigraine headaches are often triggered by riggered by specific thingsspecific things
MIGRAINE - PATHOPHYSIOLOGY
VASCULAR THEORY 血管学说Intracerebral blood vessel constrict
ion – aura 血管收缩—先兆 Intracranial/Extracranial blood vesse
l dilation – headache 血管扩张—头痛
MIGRAINE - PATHOPHYSIOLOGY
SEROTONIN 五羟色胺 THEORY Decreased serotonin levels linked
to migraine 五羟色胺水平降低与偏头痛相关
Specific serotonin receptors found in blood vessels of brain
MIGRAINE - PATHOPHYSIOLOGY
PRESENT UNDERSTANDING Neurovascular process, in which
neural events result in activation of blood vessels, which in turn results in pain and further nerve activation
The Stages of a Migraine Attack
PRODROME 前驱症状 Premonitory symptoms begin from 12 to 36 Premonitory symptoms begin from 12 to 36
hours before the aura and headachehours before the aura and headache Symptoms includeSymptoms include
Yawning Yawning 哈欠哈欠 Irritability Irritability 易激惹易激惹 Depression Depression 情绪低落情绪低落 Lethargy Lethargy 思睡思睡 Craving or distaste for various foods Craving or distaste for various foods
Duration – 15 to 20 minDuration – 15 to 20 min
AURA 先兆Aura is a warning or signal beforeAura is a warning or signal before
onset of headacheonset of headache
Symptoms includeSymptoms include
Visual field defects Visual field defects 视野缺损视野缺损 Teichopsia Teichopsia 闪光暗点闪光暗点 Zig-zag lines Zig-zag lines 视物变形视物变形Duration : 15-30 minDuration : 15-30 min
HEADACHE
Headache is generally unilateral anHeadache is generally unilateral and throbbing d throbbing 偏侧搏动样头痛偏侧搏动样头痛
Repeated attacks of headache Repeated attacks of headache Moderately or severely painfulModerately or severely painful Frequent or infrequentFrequent or infrequent
Duration is 4-72 hrs Duration is 4-72 hrs
1.2% 18.4%
47.2%
33.2%
Mild
Moderately severe
Severe
Extremely severe
Most Patients’ Headaches Are Severe or Extremely Severe
National Headache Foundation. American Migraine Study II: Migraine in the United States: Burden of Illness and Patterns of Treatment
What Else You Might Experience During an Attack
Nausea Nausea 恶心恶心 Vomiting Vomiting 呕吐呕吐 Diarrhea Diarrhea 腹泻腹泻 Sweating Sweating 出汗出汗
phonophobiaphonophobia 恐声恐声 photophobiaphotophobia 恐光恐光 Pale color Pale color 面色苍面色苍
白白 Cold hands Cold hands 肢冷肢冷
52%39%
9%
Need bed restCan work with some difficulty
Can work as normal
Migraine Takes Quality Time Out From Your Life
National Headache Foundation. American Migraine Study II: Migraine in the United States: Burden of Illness and Patterns of Treatment
POSTDROME (RESOLUTION PHASE)
Following headache, patient complains ofFollowing headache, patient complains of
Fatigue Fatigue 疲倦疲倦 Depression Depression 情绪低落情绪低落 Severe exhaustion Severe exhaustion 极度疲乏极度疲乏Duration: Few hours or up to 2 daysDuration: Few hours or up to 2 days
MIGRAINE – CLASSIFICATION
According to Headache Classification Committee of According to Headache Classification Committee of
the International Headache Society, Migraine has beethe International Headache Society, Migraine has bee
n classified as:n classified as:
Migraine without auraMigraine without aura ((common migraine) common migraine) 75%75%
Migraine with auraMigraine with aura ((classic migraineclassic migraine) ) 20%20%
Specific migraineSpecific migraine 5%5%
Status migrainosusStatus migrainosus
Migraine Subtypes
Specific migraineSpecific migraine
hemiplegic migraine hemiplegic migraine 偏瘫型偏头痛偏瘫型偏头痛 Unilateral motor and sensory symptoms that
may persist after the headache. Complete recover
Migraine Subtypes
Specific migraineSpecific migraine
basilar migraine basilar migraine 基底动脉型偏头痛基底动脉型偏头痛 Dysarthria, vertigo, diplopia, tinnitus, decreased he
aring, ataxia, bilateral paresthesias, altered consciousness.
Simultaneous bilateral visual symptoms. No muscular weakness
Migraine Subtypes
Specific migraineSpecific migraine
complicated migrainecomplicated migraine 复杂型偏头痛复杂型偏头痛
migraine equivalentsmigraine equivalents 偏头痛等值症偏头痛等值症
MIGRAINE: DIAGNOSIS Medical History Headache diary Migraine triggers Investigations (only to exclude secondary causes)
EEG Brain CT MRI
DIFFERENTIATING COMMON PRIMARY HEADACHES
Strictly unilateral
Tension headaches: Do not have the associated features like nausea, vomiting, photophobia, phonophobia. The muscle contraction leads to headache. Headache quality is of a tightening (non-pulsating) quality. Usually bilateral. Intensity is mild or moderate
Cluster headaches: Severe unilateral pain. Headache associated with lacrimation, nasal congestion, rhinorrhea, facial sweating or eyelid edema. Pain lasts for 15 to 180 minutes. More common in men
THE TREATMENT
APPROACH TO
MIGRAINE
LONG-TERM TREATMENT GOALS FOR THE MIGRAINE SUFFERER
Reducing the attack frequency and severity
减少头痛发作的频率和严重程度 Avoiding escalation of headache medication
避免过度使用止痛药 Educating and enabling the patient to manage t
he disorder健康教育 Improving the patient’s quality of life
提高病人生活质量
MIGRAINE MANAGEMENT Non-pharmacological treatment 非药物治疗
Identification of triggers Relaxation training Psychotherapy
Pharmacotherapy 药物治疗 non-specific
Abortive therapy specific Preventive therapy
Regular sleep Regular meals Regular exercise Biofeedback Healthy lifestyle
Protective Factors
Drug Dose Route
Aspirin 100-300 mg Oral
Paracetamol 扑热息痛
250 mg-2 g Oral
MIGRAINE: ABORTIVE THERAPY中止发作治疗
Non-specific treatment
Ibuprofen 布罗芬 100- 200 mg Oral
Diclofenac 双氯芬酸 25-100 mg Oral/IM
Naproxen 萘普生 250-750 mg Oral
ABORTIVE THERAPY FOR MIGRAINE
Drug Dose Route
Ergot alkaloids 麦角碱Ergotamine 麦角胺 1-2 mg/d; max-6 g/d Oral
Dihydroergotamine 0.75-1 mg SC
5-HT receptor agonists
Sumatriptan琥珀酸舒马普坦 , 尤舒
25-300 mg
6 mg
Orally
SC
Zolmitriptan
佐米普坦2.5-5mg Orally
Rizatriptan 利佐普坦 10 mg Orally
Specific treatment
Drug Dose (mg)/d Route
Domperidone 多潘立酮 10-80 mg Oral
Metoclopramide
甲氧氯普胺5-10 mg Oral/IV
Promethazine 异丙嗪 50-125 mg Oral/IM
Chlorpromazine 氯丙嗪 10-25 mg Oral/IV
ANTI-NAUSEANT DRUGS FOR MIGRAINE TREATMENT
对症治疗
WHY THE NEED FOR PROPHYLAXIS预防 ?
Abortive drugs should not be used more th
an 2-3 times a week Long-term prophylaxis improves quality of life
by reducing frequency and severity of attacks
80% of migraineurs may require prophylaxis
WHEN IS PROPHYLAXIS INDICATED?
According to the US Headache Consortium Guidelines, indications for preventive treatment include:
Patients who have very frequent headaches (more than 2 per week)
Attack duration is > 48 hours Headache severity is extreme Migraine attacks are accompanied by
prolonged aura
WHEN IS PROPHYLAXIS INDICATED
Unacceptable adverse effects occur with acute migraine treatment
Contraindication to acute treatment Migraine substantially interferes with the patient’
s daily routine, despite acute treatment Special circumstances such as hemiplegic migrain
e or attacks with a risk of permanent neurologic injury
Patient preference
Drugs Dose (mg/d)
1. Betablockers Propranolol 普萘洛尔 40-320
2. Calcium Channel Blockers Flunarizine 氟桂利嗪 Verapamil 维拉帕米
10-20
120-4803. TCAs
Amitriptyline 阿米替林 10-204. SSRIs
Fluoxetine 氟西汀 20-60
PREVENTIVE THERAPY FOR MIGRAINE 预防治疗
Drugs Dose (mg/d)
5. Anti-convulsant Sodium valproate
丙戊酸钠600-1200
6. Anti-histaminic Cyproheptadine
赛庚啶4-8
PREVENTIVE THERAPY FOR MIGRAINE (CONTD.)
Summary
Recurrent attacks of headacheRecurrent attacks of headache
Unilateral and throbbing painUnilateral and throbbing pain
Associated with anorexia,Associated with anorexia,
nausea and vomitingnausea and vomiting