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