1. MIGRAINE 偏头痛 Yin Mei Department of Neurology The No.2 Hospital Affiliated Kunming Medical College

2. NEW WORDS Migraine 偏头痛 Migraine 偏头痛 Throbbing pain 搏动样疼痛 Throbbing pain 搏动样疼痛 Aura 先兆 Aura 先兆 Teichopsia 闪光暗点 Teichopsia 闪光暗点

3. OUTLINE Definition Definition Triggers Triggers Pathophysiology Pathophysiology Clinical features Clinical features Diagnosis Treatment

4. Migraine - Definition “Migraine is a familial disorder characterized by recurrent attacks of headache widely variable in intensity, frequency and duration. Attacks are commonly unilateral and are usually associated with anorexia, nausea and vomiting” -World Federation of Neurology -World Federation of Neurology

5. Migraine Facts Migraine is one of the common causes of recurrent headaches Migraine is one of the common causes of recurrent headaches According to IHS, migraine constitutes 16% of primary headaches According to IHS, migraine constitutes 16% of primary headaches Migraine afflicts 10-20% of the general population Migraine afflicts 10-20% of the general population

6. 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:

7. 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

8. Migraine Facts Migraine greatly affects quality of life. The WHO ranks migraine among the world’s most disabling medical illnesses Migraine greatly affects quality of life. The WHO ranks migraine among the world’s most disabling medical illnesses

9. Migraine Facts More than 2/3 of migraine sufferers either have never consulted a doctor or have stopped doing so

10. Causes of Migraine Increased excitability of CNS Meningeal blood vessel dilation Activation of perivascular sensory trigeminal nerves

11. Causes of Migraine Vasoactive neuropeptides contain: substance P calcitonin gene-related peptide (CGRP) neurokinin A

12. Causes of Migraine Pain impulses Combination of increased pain sensitivity, tissue and vessel swelling, and inflammation

13. Triggers and Risk Factors 诱发因素 Migraine headaches are often triggered by specific things

14. MIGRAINE - PATHOPHYSIOLOGY VASCULAR THEORY 血管学说 Intracerebral blood vessel constriction – aura 血管收缩 — 先兆 Intracranial/Extracranial blood vessel dilation – headache 血管扩张 — 头痛

15. 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

16. 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

17. The Stages of a Migraine Attack

18. PRODROME 前驱症状 Premonitory symptoms begin from 12 to 36 hours before the aura and headache Premonitory symptoms begin from 12 to 36 hours before the aura and headache Symptoms include Symptoms include Yawning 哈欠 Yawning 哈欠 Irritability 易激惹 Irritability 易激惹 Depression 情绪低落 Depression 情绪低落 Lethargy 思睡 Lethargy 思睡 Craving or distaste for various foods Craving or distaste for various foods Duration – 15 to 20 min

19. AURA 先兆 Aura is a warning or signal before onset of headache Symptoms include Visual field defects 视野缺损 Visual field defects 视野缺损 Teichopsia 闪光暗点 Teichopsia 闪光暗点 Zig-zag lines 视物变形 Zig-zag lines 视物变形 Duration : 15-30 min

20. HEADACHE Headache is generally unilateral and throbbing 偏侧搏动样头痛 Headache is generally unilateral and throbbing 偏侧搏动样头痛 Repeated attacks of headache Repeated attacks of headache Moderately or severely painful Moderately or severely painful Frequent or infrequent Frequent or infrequent Duration is 4-72 hrs Duration is 4-72 hrs

21. 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

22. What Else You Might Experience During an Attack Nausea 恶心 Nausea 恶心 Vomiting 呕吐 Vomiting 呕吐 Diarrhea 腹泻 Diarrhea 腹泻 Sweating 出汗 Sweating 出汗 phonophobia 恐声 phonophobia 恐声 photophobia 恐光 photophobia 恐光 Pale color 面色苍白 Pale color 面色苍白 Cold hands 肢冷 Cold hands 肢冷

23. 52% 39% 9% Need bed rest Can 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

24. POSTDROME (RESOLUTION PHASE) Following headache, patient complains of Fatigue 疲倦 Fatigue 疲倦 Depression 情绪低落 Depression 情绪低落 Severe exhaustion 极度疲乏 Severe exhaustion 极度疲乏 Duration: Few hours or up to 2 days

25. MIGRAINE – CLASSIFICATION According to Headache Classification Committee of the International Headache Society, Migraine has been classified as: According to Headache Classification Committee of the International Headache Society, Migraine has been classified as: Migraine without aura ( common migraine) 75% Migraine without aura ( common migraine) 75% Migraine with aura ( classic migraine ) 20% Migraine with aura ( classic migraine ) 20% Specific migraine 5% Specific migraine 5% Status migrainosus Status migrainosus

26. Migraine Subtypes Specific migraine hemiplegic migraine 偏瘫型偏头痛 hemiplegic migraine 偏瘫型偏头痛 Unilateral motor and sensory symptoms that may persist after the headache. Complete recover

27. Migraine Subtypes Specific migraine basilar migraine 基底动脉型偏头痛 basilar migraine 基底动脉型偏头痛 Dysarthria, vertigo, diplopia, tinnitus, decreased hearing, ataxia, bilateral paresthesias, altered consciousness. Simultaneous bilateral visual symptoms. No muscular weakness

28. Migraine Subtypes Specific migraine complicated migraine 复杂型偏头痛 complicated migraine 复杂型偏头痛 migraine equivalents 偏头痛等值症 migraine equivalents 偏头痛等值症

29. MIGRAINE: DIAGNOSIS Medical History Headache diary Migraine triggers Investigations (only to exclude secondary causes) EEG Brain CT MRI

30. 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

31. THE TREATMENT APPROACH TO MIGRAINE

32. 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 the disorder 健康教育 Improving the patient’s quality of life 提高病人生活质量

33. 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

34. Regular sleep Regular meals Regular exercise Biofeedback Healthy lifestyle Protective Factors

35. DrugDoseRoute Aspirin100-300 mgOral Paracetamol 扑热息痛 250 mg-2 gOral MIGRAINE: ABORTIVE THERAPY 中止发作治疗 Non-specific treatment Ibuprofen 布罗芬 100- 200 mgOral Diclofenac 双氯芬酸 25-100 mgOral/IM Naproxen 萘普生 250-750 mgOral

36. ABORTIVE THERAPY FOR MIGRAINE DrugDoseRoute Ergot alkaloids 麦角碱 Ergotamine 麦角胺 1-2 mg/d; max-6 g/dOral Dihydroergotamine0.75-1 mgSC 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 2.5-5mgOrally Rizatriptan 利佐普坦 10 mgOrally Specific treatment

37. DrugDose (mg)/dRoute Domperidone 多潘立酮 10-80 mgOral Metoclopramide 甲氧氯普胺 5-10 mgOral/IV Promethazine 异丙嗪 50-125 mgOral/IM Chlorpromazine 氯丙嗪 10-25 mgOral/IV ANTI-NAUSEANT DRUGS FOR MIGRAINE TREATMENT 对症治疗

38. WHY THE NEED FOR PROPHYLAXIS 预防 ? Abortive drugs should not be used more than 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

39. 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

40. 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 migraine or attacks with a risk of permanent neurologic injury Patient preference

41. DrugsDose (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 10-20 120-480 3. TCAs Amitriptyline 阿米替林 10-20 4. SSRIs Fluoxetine 氟西汀 20-60 PREVENTIVE THERAPY FOR MIGRAINE 预防治疗

42. DrugsDose (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.)

43. Summary Recurrent attacks of headache Unilateral and throbbing pain Associated with anorexia, nausea and vomiting