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 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
( 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 40-160 mg/day 3-4 atenolol B II 50-100 mg/daypropranolol (calcium channel blocker, CCB) flunarizine 290 家庭醫學與基層醫療 第七期
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 240-480 mg/day (cluster headache) verapamil (AV block) (antiepileptic drug, AED) topiramate A I 5 0-2 0 0 m g / d a y (paresthesia) topiramate topiramate topiramate topiramate valproic acid A I sodium valproate ER (500 mg/day) divalproex sodium (500-1000 mg/day) valproic acid (300-1800 mg/day) Convulex ( ) Category D (FDA) 2008 0.43%0.22% (antidepressants) amitriptyline A I 10-75 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
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) 2010 10 15 3 1 5 155 3 (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 6 292 家庭醫學與基層醫療 第七期
預防性非藥物治療 B2(Riboflavin, 400 mg/day) (butterbur, 50-75 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) 3/4 2006 (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;1:658-60. 2. - 2010 42-4 3. D Andrea G, Leon A: Pathogenesis of migraine: from neurotransmitters to neuromodulators and beyond. Neurol Sci 2010;31:S1-7. 4. Sprenger T, Goadsby PJ: Migraine pathogenesis and state of pharmacological treatment options. BMC Med. 2009; 7:71. 5. Dodick D, Silberstein S: Central sensitization theory of migraine: clinical implications. Headache 2006;46:S182-91. 6. Treatment Guidelines for Preventive Treatment of Migraine. Acta Neurol Taiwan 2008;17:132-48. 7. 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 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;84:422-35. 9. Goadsby PJ, Sprenger T: Current practice and future directions in the prevention and acute management of migraine. Lancet Neurol 2010;9:285-98. 10. 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. 11. Shuhendler AJ, Lee S, Siu M, et al: Efficacy of 家庭醫學與基層醫療 第七期 293
botulinum toxin type A for the prophylaxis of episodic migraine headaches: a meta-analysis of randomized, double-blind, placebo-controlled trials. Pharmacotherapy 2009;29:784-91. 12. 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;50:921-36. 15 (Migraine Prevention Questionnaire 5, MPQ-5) 1 4-7 8 1 ( ) 3 3 1 4-7 8 9-11 12 9-11 12 9-11 12 15 16-29 30 資料來源 : 參考資料 8 294 家庭醫學與基層醫療 第七期
2 資料來源 : 參考資料 7 台灣頭痛學會 http://www.taiwanheadache.com.tw 家庭醫學與基層醫療 第七期 295