表 1 無預兆偏頭痛的診斷基準 exacerbated by activity, phonophobia P I N P I N (positive predictive value, PPV) 93% PIN 81% PPV P O U N D P u l s a t i l e quality

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1 陳彥宏 1 顏啟華 2 李孟智 3 孔勝琳 4 前言 (WHO) % 4.5% 3.2% 診斷 (70-90%) (10-30%) 1 中山醫學大學附設醫院家庭暨社區醫學部住院醫師 2 中山醫學大學附設醫院家庭暨社區醫學部主任 3 中山醫學大學附設醫院家庭暨社區醫學部教授 4 中山醫學大學附設醫院神經科主治醫師 migraine, screener, diagnosis, acute management 1. ( ) / ( ) 2. ( ) / ( ) 3. ( c l u s t e r headache) 2 POUND Pulsatile quality, duration 4-72 hours, Unilateral location, Nausea / vomiting, Disabling intensity POUND ( l i k e l i h o o d r a t i o, L R ) 2 4 POUND 24 ( 96%) PIN Photophobia, Inability to function (Disability), Nausea PIN pulsatile, unilateral, aura, moderate-to-severe pain, 99

2 表 1 無預兆偏頭痛的診斷基準 exacerbated by activity, phonophobia P I N P I N (positive predictive value, PPV) 93% PIN 81% PPV P O U N D P u l s a t i l e quality PIN Photophobia 無預兆偏頭痛的診斷基準 A 至少有 5 次能符合基準 B-D 的發作 5 5 attacks B 頭痛發作持續 4-72 小時 ( 未經治療或治療無效 ) C 頭痛至少具下列二項特徵 : 1. 單側 2. 搏動性 3. 疼痛程度中或重度 4. 日常活動會使頭痛加劇或避免此類活動 ( 如走路或爬樓梯 ) D 頭痛發作時至少有下列一項 : 噁心及 / 或嘔吐畏光及怕吵 E 非歸因於其他疾患急性治療藥物表 2 偏頭痛和叢發性頭痛的鑑別診斷 P U M A 1 N/V P+L 偏頭痛專一性藥物翠普登 (triptans) (serotonin, 5HT)1B/1D 5HT 1B 5HT 1D (neurogenic inflammation ) 口訣 4 hours 3 days = 72 hours 2 characteristics: Pulsating quality Unilateral location Moderate or severe intensity Aggravation by Activity 1 of the following: Nausea and/or Vomiting Phonophobia and Photophobia (Light) 偏頭痛 (migraine) 叢發性頭痛 (cluster headache) 盛行率女性常見男性常見部位 60% 單側 (40% 雙側 ) 單側, 眼眶周圍性質搏動性尖銳刺入鑽孔頻率陣發性, 不規律發作週期性發作 ( 每二日一次至每日八次 ) 持續時間 4-72 小時分鐘好發時刻清晨半夜 ( 患者常在睡眠中痛醒 ) 伴隨症狀噁心嘔吐畏光怕吵同側流眼淚結膜充血眼皮水腫眼皮下垂瞳孔縮小鼻腔充血流鼻水前額及臉部出汗 ( 有時也會噁心畏光怕吵 ) 緩解因子休息臥床躁動走來走去以緩解頭痛發作翠普登急性治療有效急性治療有效 100

3 s u m a t r i p t a n ( triptans) naproxen( NSAID) sumatriptan naproxen triptans NSAID 6 24 selective serotonin-reuptake inhibitors(ssri) (serotonin syndrome) category C 10 (medication overuse headache) 麥角胺 (ergotamine) (serotonin, 5HT)1B/1D (caffeine) 48 (>48 )/ category X 6 (medication overuse headache) 偏頭痛非專一性藥物非類固醇抗發炎藥物 (non-steroid antiinflammatory drugs, NSAID) 和阿斯匹靈 900mg-1000mg aspirin 50mg sumatriptan aspirin sumatriptan naproxen t r i p t a n s NSAID N S A I D m g naproxen 200mg-400mg (or 400mg m g ) i b u p r o f e n 5 0 m g m g diclofenac 75mg-150mg ketoprofen 101

4 200mg tolfenamic acid ketoprofen 30mg-60mg IM 30mg IV 單純止痛藥 (simple analgesics) (acetaminophen) 1000mg 15mg/kg / / (acetaminophen-aspirincaffeine, AAC tablet) caffeine 多巴胺拮抗劑 (anti-dopaminergics) / prochlorperazine metoclopramide / prochlorperazine 1 p r o c h l o r p e r a z i n e % metoclopramide 79.3% (extrapyramidal symptoms, EPS) NSAID ( ) 類固醇 (steroids) 2 4 steroids NSAID 48 鎂離子 (magnesium) (CSF) glutamate 31P NMR glutamate NMDA 臨床試驗中的藥物 calcitonin gene related peptides (CGRP) receptor antagonists 5HT 1B 5HT 1B 1/3 24 CGRP C G R P receptor antagonists( olcegepant 102

5 telcagepant) CGRP receptor antagonists 急性期治療策略 (stratified care) MIDAS 10 NSAID ( acetaminophen-aspirin-caffeine, AAC tablet) MIDAS 11 結語 PIN POUND (MIDAS) Act when Mild ( 1 ) 參考資料 1. The International Classification of Headache Disorders. 2nd edition (ICHD-II). Cephalalgia 2004;24: Niere K: The presence of four simple history features can diagnose migraine accurately. Aust J Physiother. 2006;52: Lanteri-Minet M: The role of general practitioners in migraine management. Cephalalgia 2008;28: Treatment Guidelines for Preventive Treatment of Migraine. Acta Neurol Taiwan 2008;17: T a i w a n H e a d a c h e S o c i e t y. h t t p : / / 7. Goadsby PJ, Sprenger T: Current practice and future directions in the prevention and acute management of migraine. Lancet Neurol 2010;9: Antonaci F, Dumitrache C, De Cillis I, Allena M: A review of current European treatment guidelines for migraine. J Headache Pain 2010;11: Goadsby PJ, Zanchin G, Geraud G, et al: Early vs. non-early intervention in acute migraine A c t w h e n M i l d ( Aw M ). A d o u b l e - blind, placebo-controlled trial of almotriptan. Cephalalgia 2008;28: Brandes JL: The migraine cycle: Patient burden of migraine during and between migraine attacks. Headache 2008;48:

6 附錄 1 臨床篩檢 / 診斷 / 治療 / 預防偏頭痛流程圖 Photophobia nability to function Nausea ( ) A 5 B-D B 4-72 ( ) C 1., 2.,, ( ) D 1. /, E 2. (M DA ) M DA - M DA - V ( 1 ) ( 11 ) N A D N A D ibuprofen Acetaminophen- Aspirin-Caffein umatriptan +Napro en ( N A D) ( ) prochlorpera ine, metoclopramide N A D A B C D E MP -5 ( DA2 1.1 ) MP -5 Migraine Prevention uestionnaire 5 1, 2, 3, 4, 5 104

7 附錄 2 偏頭痛失能評估問卷 (Migraine Disability Assessment, MIDAS) ( 1 ) ( 3 ) 0 A. ( ) B (0 10 ) Innovative Medical Research, Inc grade definition score I 0-5 minimal or infrequent disability II 6-10 mild or infrequent disability III moderate disability IV 21+ severe disability 5 ( / / ) 5 MIDAS A B 6,

( CSD C S Da u r a) (calcitonin gene related peptides[cgrp], substance P[SP]) (neurogenic inflammation ) (peripheral sensitization) (Triptans) 5HT 1B

( CSD C S Da u r a) (calcitonin gene related peptides[cgrp], substance P[SP]) (neurogenic inflammation ) (peripheral sensitization) (Triptans) 5HT 1B 1 2 3 4 前言 1/3 (frequent) (duration)(intensity) 致病機轉 5HT 1B 1 中山醫學大學附設醫院家庭暨社區醫學部住院醫師 2 中山醫學大學附設醫院家庭暨社區醫學部主任 3 中山醫學大學附設醫院家庭暨社區醫學部教授 4 中山醫學大學附設醫院神經科主治醫師 migraine, pathogenesis, preventive treatment, botulinum