陳彥宏 1 顏啟華 2 李孟智 3 孔勝琳 4 前言 (WHO) 19 2000 1 5 14.4% 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
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 4 3 2 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 15-180 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
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 )/ 2.55 8.52 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 7 5 0 m g naproxen 200mg-400mg (or 400mg- 8 0 0 m g ) i b u p r o f e n 5 0 m g - 1 0 0 m g diclofenac 75mg-150mg ketoprofen 101
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 5 7. 1 % 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
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;24:24-36. 2. Niere K: The presence of four simple history features can diagnose migraine accurately. Aust J Physiother. 2006;52:304. 3. Lanteri-Minet M: The role of general practitioners in migraine management. Cephalalgia 2008;28:1-8. 4. 2007 1-16 5. Treatment Guidelines for Preventive Treatment of Migraine. Acta Neurol Taiwan 2008;17:132-48. 6. 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 : / / www.taiwanheadache.com.tw 7. Goadsby PJ, Sprenger T: Current practice and future directions in the prevention and acute management of migraine. Lancet Neurol 2010;9:285-98. 8. Antonaci F, Dumitrache C, De Cillis I, Allena M: A review of current European treatment guidelines for migraine. J Headache Pain 2010;11:13-9. 9. 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;28:383-91. 10. Brandes JL: The migraine cycle: Patient burden of migraine during and between migraine attacks. Headache 2008;48:430-41. 103
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.,, 3. 4. ( ) 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
附錄 2 偏頭痛失能評估問卷 (Migraine Disability Assessment, MIDAS) 1. 2. 3. 4. 5. ( 1 ) ( 3 ) 0 A. ( ) B. 0 10 (0 10 ) Innovative Medical Research, Inc grade definition score I 0-5 minimal or infrequent disability II 6-10 mild or infrequent disability III 11-20 moderate disability IV 21+ severe disability 5 ( / / ) 5 MIDAS A B 6, 10 105