migraine 偏 头 痛

Chongqing University of Medical Science

Migraine is manifested by headache that isa recurrence, usually unilateral and frequently pulsatile in quality 搏动性 ; it is often associated with nausea, vomiting, photophobia 畏光 , phonophobia 惧声 and lassitude 乏力 . Visual or other neurologic auras 神经学先兆 occur in about10% of patients. The onset is early in life approximately 25%beginning during the first decade, 55% by 20 years of age, more than 90% before age 40.

A.Cause and pathogenesis The real causes and the pathogenesis andpathophysiologic course of migraine is unknown. 1.Certain foods: tyramine 酪胺 -containing cheeses,meat,such as hot dogs or bacon,with nitrite 亚硝酸 preservatives, chocolate containingbut not chocolate alone. Food additives: monosodium glutamate 谷氨酸一钠； Fasting 禁食 ; Emotion 情绪 ; Menses 月经 ; Drugs:especially oral contraceptive agents;vasodilators (nitriglycerin 硝酸甘油 )

Brights lights may also trigger or precipitateattacks.

2. Genetics: About 60% patients of migrainehave families . Three genetic loci for familial hemiplegic migraine （偏瘫型 )have been identified 3. Endocrine factor 内分泌异常 Gender: women> men (2/3 to 3/4 of casesoccur in women); Headache mostly occursbefore or menacme 月经期 in women , and the headache becomes reduction or stopping in preg

nancy and after menopause 绝经 . The migraine also stops in men of after cli

macterium 更年期 .

4. vasomotor and autonomic 血管运动和自律神经

Intracranial vasoconstriction and extracranial vasodilatation have long been held to be the respective causes of the aura and headache phases of migraine. But the study of CBF 脑血流

can’t confirm. 5. spreading depression 扩布性抑制

More recent studies of rCBF 局部脑血流 during migraine attacks have demonstrated a reductionin regional flow, which begins in the occipital region and then towards with 1 cm/s velocity during the aura phase.

6. Neurotransmitter （神经递质） Serotonin 血清素 in platelets decreases and urinary serotonin increases durin

g the acute phase of a migraine attack . Depletion of serotonin by reserpine 利

血平may precipitate migraine and decreas

edby serotonin antagonists (sumatriptan, 英明格 )

B. The classification of migraine

1. classic migraine （典型偏头痛） 2. common migraine （普通型偏头痛） 3. special type: a. ophthalmoplegic M. （眼肌麻痹型偏头痛）

b. hemiplegic M. （偏瘫型偏头痛） c. basilar artery M. （基底动脉型偏头痛 ) d. late-life M. （晚发性偏头痛） e . migraine Equivalents （偏头痛等值症） :

C. Clinic figures 临床表现 1. Migraine with Aura (Classic migraine 典型偏头痛 ) 1) Auras （先兆） : visual alteration,particularly hemianopic ( 偏盲 ) field

defects (视野缺损） and scotomas （黑朦 ), hemiparansthesia ( 半身麻木 ) 。

2)Headache: 50% of patients experience no more than once attack per week, the duration of episodes is greater than 2 hours and less than 1 day in most patients. Usually unilateral and frequently pulsatile in quality;Although hemicranial pain is a hallmark 标志 of classic migraine,headache can also be bifrontal 双前额 ,lesscommonly localized to the occipital or vertex 头顶 ofthe Skull.

3)company symptoms 伴随症状 :

The nausea( 恶心 ),vomiting( 呕吐 ),photophobia( 畏光 ),phonophobia( 惧声 ), irritability( 激惹 ), and lassitude ( 倦怠 ) are common. Uncommonly, migraine are associated with frankneurologic deficits 明显神经学缺陷 that accompany orpersist beyond resolution of the pain phase.Those May include hemiparesis, hemisensory loss 偏身感觉丧失 , speech dysfunction 语言功能障碍 , or visual disturbance 视觉紊乱 . Same patients have vertigo 眩晕 ,ataxia 共济失调 , or altered consciousness 意识 .

2. Migraine without Aura (common mig.) a.This is the most frequent type of migraine(over

80%). The symptoms and signs are similarity the

classic migraine, but lacks the aura. b.Headache ： bilateral( or unilateral), periorbital aching or

throbbing in quality ； longer times; often occurs on weekend and holidays 。 An useful bedside test for both common and classic

migraine is reducing headache severity by compressing

the ipsilateral carotid or superficial temporal artery.

3. special type: a. ophthalmoplegic M. （眼肌麻痹型偏头痛） During or after migraine attack occur ocular nerve paralysis,

ptosis ,pupil dilation ,ets.and persists hours or months.

b.hemiplegic M. （偏瘫型偏头痛） with hemiplegia; last 10m.~days~wk.; children,less in adult.

c.basilar artery migraine(基底动脉型偏头痛） most common in children and youthful women; visual

alteration:field defects and scotomas, ataxia,vertigo,tinnitus耳鸣， diplopia 复视， nystagmus 眼震， dysarthria 构音障碍， bilateral limbs numb and weak,impairment of recognize and consciousness,and nausea,vomiting,ets.

d. migraine Equivalents （偏头痛等值症）:

abdominal pain腹痛 , thorax, pelvis骨盆 and limbs pain, bouts fever周期性发热 , attacks of tachycardia心动过速 , benign paroxysmal vertigo良性发作性眩晕 , cyclic edema, and so on. episodic, recurrence, excluded from other systemic diseases by history and examinations.

D . Diagnosis of migraine According to the International associate o

f headache recomm- ended a programme in 1988,the diagnosis of migraine will be in keeping with below criterion.

a. Migraine with aura 1. Have 2 subjects of below,break out 2 at least; 2. Have below characteristic at least 3 subjects: 1) More than 1 time aura of functional disturbance in focal cort

ex or brainstem 2) An aura at least gradual development and persist more t

han 4 min.,or have 2 auras； 3） The aura persists less than 60 min.; 4) There is not an interval time between the aura and heada

che; 3. Have one of below at least ： 1)No evidence of organic diseases by history and examination； 2） A possible of organic diseases by history and examination,

but was deny by test； 3） Although have some organic diseases,but the 1st migraine

attack have not relation with it.

典型（有先兆）偏头痛诊断标准 1. 符合以下 2项 ,发作至少两次； 2. 有以下特征至少 3项 : 1) 有局限性脑皮质或 / 和脑干功能障碍的大于 1次以上的先兆； 2 ）至少有一个先兆症状逐渐发展、持续 4分钟以上，或先后有两个以上的先兆； 3 ）先兆症状持续的时间小于 60分钟； 4 ）先兆症状与头痛间无间歇期。 3. 至少有下列之一： 1) 病史和体检不提示有器质性疾病证据； 2 ）病史和体检提示有某种器质性疾病可能，但经检查被否定；

3 ）虽有某种器质性疾病，但首次偏头痛发作与该疾病无密切关系。

b. Migraine without aura 1 . Have 2- 4 subjects of below,break outmore than 5 times at least ; 2 . If not treat, it continues 4-72 h. a seizure,;

3.Have below characteristic at least 2 subjects: 1)unilateral; 2)pulsatile(throbbing) ； 3)middle-serious degree,daily life

limited; 4)Headache serious after act ； 4. Have one of below: 1)nausea & vomiting; 2)photophobia,phonophobia ； 5.Without other known similar diseases , andexclude other diseases of the body.

普通型（无先兆）偏头痛诊断标准 1 . 符合下述 2-4 项 , 发作至少 5 次以上 ; 2 . 如果不治疗 , 每次发作持续 4-72 小时 ; 3. 有以下特征至少两项 :1)单侧型 ;2)搏动型；3)中 -重度头痛 ,日常活动受限 ;4)活动后头痛加重； 4. 发作期间有下列之一 :1)恶心和呕吐 ;2)畏光和惧声； 5. 无其他已知的类似疾病 :病史和躯体的其他方面正常。

C . Difference diagnosis: 1. cluster headache( 丛集性头痛） 2. tension-type headache(TTH, 紧张型头痛） 3. other vascular pain （其他血管性头痛） 4. Painful ophthalmoplegia （痛性眼肌麻痹） 5. carotidynia （颈动脉痛）

1) Cluster headache ( 丛集性头痛） men > women ;(4 ～ 5 ： 1 ） 20-50 yr.; recurrent; several or many times daily for several days or weekes; Prodromes 先兆 are uncommon, Ictal 发作 and stop suddenly; periorbital strong pain with congestion of the conjunctivae,lacrimation 流泪 , occasiona

lptosis 上睑下垂 of the eyelids and sweating;

2 ） Tension-type headache 紧张型头痛 Tension-type headache is a chronic diso

rder that most patients begins after age 20. Frequent (often daily) attacks , nonthro

bb- ing, bilateral occiptal or front, even all head pain, Sometimes likened to a press ,tight band around the head, ictal or persist months or years.

Not associated with nausea, vomiting, or prodromal visual disturbance.

Many patients have sleep disorders(insomnia 失眠 , a lot of dreams 多梦 ), anxious, depression and nervous 神经质 .

E . Treatment 偏头痛的治疗 The aim of treatment is stopping and controlling headache quickly. keep quiet and state darken room.1. Acute treatment 发作期治疗

mild-middle degree: It may respond to simple analgesics 止痛药 .Acetaminophen ( 乙酰氨基酚 ): 0.5-1.0 g,PO;

Aspirin( 阿司匹林 ): 0.6-1.0 g,PO; Naproxen( 萘普生 ): 0.5-0.75mg,PO Indomethacin( 吲哚美辛 ) ： 25mg Po, tid Flunarizine ( 氟桂利嗪 , Sibelium 西比灵） : 5-10mg, qn

Seriously ill (in severe cases with vomiting,nauseafrequently)subcutaneous,nosal,intravenous or intramuscularis used for drugs. Dihydroergotamine mesylate( 酒石酸二氢麦角胺 ): 0.25-1.0mg, im. or iv. Ergotamine （麦角胺 ): 0.6-1.0mg ， take orally or 2mg sublingual or by recta Sumatriptam( 英明格 ): 25-50mg, take orally (the 5-HT agonist ) or 6mg subcutaneous injection Pethidine( 哌替啶 ): 50-150mg, im. Chlorpromazine( 氯丙嗪 ): 10mg, intravenous inj

ection Codeine( 可待因 ): 1 5-60mg, PO When giving the drugs you have to tell the clinical side effe

cts for patient .

2 . Prophylactic treatment 预防性治疗 PT is indicated for patients who have frequent attacks –especially more than once a week, ets.

Propranolol( 普萘洛尔（心得安） :-receptor blocker 10 － 40mg, bid-qid/d ；Flunarizine ( 氟桂利嗪 ;Sibelium 西比灵 ,nicardepine

尼卡的平） : Calcium channel antagonists 5-10mg,qnCyproheptadine( 赛庚啶 ): 0.5-4mg,bid-qid/d; Valproate( 丙戊酸 ): 0.2g, tid/d ；Fluoxetine( 氟西汀 )Topiramate （托吡酯）Naproxen （萘普生）Pizptifen( 苯噻啶 )： 0.5-3mg/d

Key point It is necessary to understandand hold the Diagnostic criterionof migraine with aura and migrainewithout aura.

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