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

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1 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 toxin, quality of life 1 ( ) 3 mm/min 2~3 mm/ min (cortical spreading depression, CSD) 2~3 mm/min (spreading oligemia) (PET) / (Triptans) / 家庭醫學與基層醫療第七期 289

2 ( CSD C S Da u r a) (calcitonin gene related peptides[cgrp], substance P[SP]) (neurogenic inflammation ) (peripheral sensitization) (Triptans) 5HT 1B 5HT 1D ( ) (central sensitization) (cutaneous allodynia) 預防性藥物 A ~( ) B C D E 5 (Migraine Prevention Questionnaire 5, MPQ-5, 1) (beta blocker) propranolol A I mg/day 3-4 atenolol B II mg/daypropranolol (calcium channel blocker, CCB) flunarizine 290 家庭醫學與基層醫療第七期

3 A I 5-10 mg/day 5mg 1 0 m g 5mg D r u g - I n d u c e d Parkinsonism (DIP) flunarizine verapamil B II mg/day (cluster headache) verapamil (AV block) (antiepileptic drug, AED) topiramate A I m g / d a y (paresthesia) topiramate topiramate topiramate topiramate valproic acid A I sodium valproate ER (500 mg/day) divalproex sodium ( mg/day) valproic acid ( mg/day) Convulex ( ) Category D (FDA) %0.22% (antidepressants) amitriptyline A I mg/day ( )( ) (tension-type headache) amitriptyline imipramine doxepin S S R I, S N R I, D N R I, MAOIamitriptyline (botulinum toxin type A) (episodic migraine headache) 家庭醫學與基層醫療第七期 291

4 Phase III REsearch Evaluating M i g r a i n e P r o p h y l a x i s T h e r a p y w i t h Botulinum Toxin Type A [PREEMPT] (chronic migraine) (FDA) (8.7%) a n g i o t e n s i n c o n v e r t i n g e n z y m e inhibitor, ACEI; angiotensin receptor blocker, ARB lisinopril candesartan ACEI ARB (comorbidities, 1) 4-6 1(comorbidities) (Depression) TCA Beta-blocker, flunarizine (Anxiety) (Sleep disturbance) TCA, beta-blocker TCA (Overweight) Topiramate TCA, gabapentin, valproate (Bipolar disorder) Valproate, topiramate TCA Topiramate, valproate TCA (Raynaud s phenomenon) CCB Beta-blocker, ergotamine CCB, valproate, topiramate, ARB, ACEI TCA, beta-blocker TCA: tricyclic antidepressant; CCB: calcium channel blocker; ARB: angiotensin receptor blocker; ACEI: angiotensin converting enzyme inhibitor. 資料來源 : 參考資料家庭醫學與基層醫療第七期

5 預防性非藥物治療 B2(Riboflavin, 400 mg/day) (butterbur, twice daily) (feverfew 6.25mg three times daily) ( a c u p u n c t u r e ) (behavioural techniques, biofeedback, relaxation, cognitive therapy) 結語 ( / / ) (2) 3/ (over-the-counter, OTC) 參考資料 1. Weiller C, May A, Limmroth V, et al: Brain stem activation in spontaneous human migraine attacks. Nat Med. 1995;1: D Andrea G, Leon A: Pathogenesis of migraine: from neurotransmitters to neuromodulators and beyond. Neurol Sci 2010;31:S Sprenger T, Goadsby PJ: Migraine pathogenesis and state of pharmacological treatment options. BMC Med. 2009; 7: Dodick D, Silberstein S: Central sensitization theory of migraine: clinical implications. Headache 2006;46:S 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 : / / 8. Buse DC, Rupnow MF, Lipton RB: Assessing and managing all aspects of migraine: migraine attacks, migraine-related functional impairment, common comorbidities, and quality of life. Mayo Clin Proc. 2009;84: 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: Shuhendler AJ, Lee S, Siu M, et al: Efficacy of 家庭醫學與基層醫療第七期 293

6 botulinum toxin type A for the prophylaxis of episodic migraine headaches: a meta-analysis of randomized, double-blind, placebo-controlled trials. Pharmacotherapy 2009;29: Dodick DW, Turkel CC, DeGryse RE, et al: OnabotulinumtoxinA for treatment of chronic migraine: pooled results from the doubleblind, randomized, placebo-controlled phases of the PREEMPT clinical program. Headache 2010;50: (Migraine Prevention Questionnaire 5, MPQ-5) ( ) 資料來源 : 參考資料家庭醫學與基層醫療第七期

7 2 資料來源 : 參考資料 7 台灣頭痛學會家庭醫學與基層醫療第七期 295

<4D6963726F736F667420506F776572506F696E74202D2032303134C4EA20CDB7CDB420C2EDB4BAC0B4A3A8C9BEBCF5B0E6A3A92E707074205BBCE6C8DDC4A3CABD5D>

<4D6963726F736F667420506F776572506F696E74202D2032303134C4EA20CDB7CDB420C2EDB4BAC0B4A3A8C9BEBCF5B0E6A3A92E707074205BBCE6C8DDC4A3CABD5D> 头痛马春来复旦大学附属华山医院药剂科 Nov 2014 学习目标头痛的流行病学定义了偏头痛的病理生理学基础治疗药物的药理作用急性和预防偏头痛治疗的一般原则为偏头痛患者制定个性化的治疗计划治疗药物的禁忌症和不良反应