Migraine偏頭痛(中英雙語(yǔ)版)

migraine

偏頭痛

ChongqingUniversityofMedicalScience

Migraineismanifestedbyheadachethatisarecurrence,usuallyunilateralandfrequently

pulsatile

inquality

搏動(dòng)性;itisoftenassociatedwithnausea,vomiting,photophobia畏光,phonophobia懼聲andlassitude乏力.Visualorotherneurologicauras神經(jīng)學(xué)先兆

occurinabout10%ofpatients.

Theonsetisearlyinlifeapproximately25%beginningduringthefirstdecade,55%by20yearsofage,morethan90%beforeage40.

A.Causeandpathogenesis

Therealcausesandthe

pathogenesisandpathophysiologiccourse

ofmigraineisunknown.

1.Certainfoods:

tyramine酪胺-containingcheeses,meat,suchashotdogsorbacon,withnitrite亞硝酸preservatives,chocolatecontainingbutnotchocolatealone.Foodadditives:monosodiumglutamate谷氨酸一鈉；

Fasting禁食;Emotion情緒;Menses月經(jīng);

Drugs:especiallyoralcontraceptiveagents;vasodilators(nitriglycerin硝酸甘油)Brightslightsmayalsotriggerorprecipitateattacks.

2.Genetics:About60%patientsofmigrainehave

families.Threegeneticlociforfamilialhemiplegic

migraine（偏癱型)havebeenidentified3.Endocrinefactor內(nèi)分泌異常

Gender:women>men(2/3to3/4ofcasesoccurinwomen);Headachemostlyoccursbeforeormenacme月經(jīng)期

inwomen,andtheheadachebecomesreductionorstoppinginpregnancyandaftermenopause絕經(jīng).Themigrainealsostopsinmenofafterclimacterium更年期.

4.vasomotorandautonomic

血管運(yùn)動(dòng)和自律神經(jīng)

Intracranialvasoconstrictionandextracranialvasodilatationhavelongbeenheldtobetherespectivecausesoftheauraandheadachephasesofmigraine.ButthestudyofCBF腦血流

can’tconfirm.5.spreadingdepression擴(kuò)布性抑制

MorerecentstudiesofrCBF局部腦血流

duringmigraineattackshavedemonstratedareductioninregionalflow,whichbeginsintheoccipitalregionandthentowardswith1cm/svelocity

duringtheauraphase.

6.Neurotransmitter（神經(jīng)遞質(zhì)）

Serotonin血清素

inplateletsdecreases

andurinaryserotoninincreasesduringtheacutephaseofamigraineattack.Depletionofserotoninbyreserpine利血平mayprecipitatemigraineanddecreasedbyserotoninantagonists(sumatriptan,英明格)B.Theclassificationofmigraine

1.classicmigraine

（典型偏頭痛）

2.common

migraine

（普通型偏頭痛）

3.specialtype:

a.ophthalmoplegicM.

（眼肌麻痹型偏頭痛）

b.hemiplegicM.

（偏癱型偏頭痛）

c.

basilarartery

M.

（基底動(dòng)脈型偏頭痛)

d.

late-lifeM.（晚發(fā)性偏頭痛）

e.migraineEquivalents

（偏頭痛等值癥）:

C.Clinicfigures

臨床表現(xiàn)

1.MigrainewithAura

(Classicmigraine典型偏頭痛)

1)

Auras（先兆）:

visualalteration,particularlyhemianopic

(偏盲)

fielddefects

(視野缺損）andscotomas（黑朦),

hemiparansthesia

(半身麻木)。

2)Headache:

50%ofpatientsexperiencenomorethanonceattackperweek,thedurationofepisodesisgreaterthan2hoursandlessthan1dayinmostpatients.Usuallyunilateralandfrequentlypulsatile

inquality;Althoughhemicranialpainisahallmark標(biāo)志

ofclassicmigraine,headachecanalsobebifrontal雙前額,lesscommonlylocalizedtotheoccipitalorvertex頭頂

oftheSkull.

3)companysymptoms伴隨癥狀:

Thenausea(惡心),vomiting(嘔吐),photophobia(畏光),phonophobia(懼聲),irritability(激惹),andlassitude

(倦怠)arecommon.Uncommonly,migraineareassociatedwithfrankneurologicdeficits明顯神經(jīng)學(xué)缺陷

thataccompanyorpersistbeyondresolutionofthepainphase.ThoseMayincludehemiparesis,hemisensoryloss偏身感覺(jué)喪失,speech

dysfunction語(yǔ)言功能障礙,or

visualdisturbance視覺(jué)紊亂.Samepatientshavevertigo眩暈,ataxia共濟(jì)失調(diào),oralteredconsciousness意識(shí).

2.MigrainewithoutAura

(commonmig.)a.Thisisthemostfrequenttypeofmigraine(over80%).Thesymptomsandsignsaresimilaritytheclassicmigraine,butlackstheaura.

b.Headache：

bilateral(orunilateral),periorbital

achingorthrobbinginquality；longertimes;oftenoccursonweekendandholidays。

Anusefulbedsidetestforbothcommonandclassicmigraineisreducingheadacheseveritybycompressingtheipsilateralcarotidorsuperficialtemporalartery.

3.specialtype:

a.ophthalmoplegicM.

（眼肌麻痹型偏頭痛）

Duringor

aftermigraineattackoccur

ocularnerveparalysis,ptosis,pupildilation,ets.andpersistshoursormonths.b.hemiplegicM.

（偏癱型偏頭痛）

withhemiplegia;last10m.~days~wk.;children,lessinadult.

c.basilararterymigraine(基底動(dòng)脈型偏頭痛）

mostcommoninchildrenandyouthfulwomen;visualalteration:fielddefects

andscotomas,

ataxia,vertigo,tinnitus耳鳴，diplopia復(fù)視，nystagmus眼震，dysarthria構(gòu)音障礙，bilaterallimbsnumbandweak,impairmentofrecognizeandconsciousness,andnausea,vomiting,ets.

d.migraineEquivalents

（偏頭痛等值癥）:

abdominalpain腹痛,thorax,pelvis骨盆

andlimbspain,boutsfever周期性發(fā)熱,attacksoftachycardia心動(dòng)過(guò)速,benignparoxysmalvertigo良性發(fā)作性眩暈,cyclicedema,andsoon.

episodic,recurrence,excludedfromothersystemicdiseasesbyhistoryandexaminations.D.Diagnosisofmigraine

AccordingtotheInternationalassociateofheadacherecomm-endedaprogrammein1988,thediagnosisofmigrainewillbeinkeepingwithbelowcriterion.

a.Migrainewithaura1.Have2subjectsofbelow,breakout2atleast;2.Havebelowcharacteristicatleast3subjects:

1)Morethan1timeauraoffunctionaldisturbanceinfocalcortexorbrainstem2)Anauraatleastgradualdevelopmentandpersistmorethan4min.,orhave2auras；

3）Theaurapersistslessthan60min.;4)Thereisnotanintervaltimebetweentheauraandheadache;

3.

Haveoneofbelowatleast：

1)Noevidenceoforganicdiseasesbyhistoryandexamination；

2）Apossibleoforganicdiseasesbyhistoryandexamination,butwasdenybytest；

3）Althoughhavesomeorganicdiseases,butthe1stmigraineattackhavenotrelationwithit.

典型（有先兆）偏頭痛診斷標(biāo)準(zhǔn)

1.符合以下2項(xiàng),發(fā)作至少兩次；

2.有以下特征至少3項(xiàng):1)有局限性腦皮質(zhì)或/和腦干功能障礙的大于1次以上的先兆；

2）至少有一個(gè)先兆癥狀逐漸發(fā)展、持續(xù)4分鐘以上，或先后有兩個(gè)以上的先兆；

3）先兆癥狀持續(xù)的時(shí)間小于60分鐘；

4）先兆癥狀與頭痛間無(wú)間歇期。

3.

至少有下列之一：

1)病史和體檢不提示有器質(zhì)性疾病證據(jù)；

2）病史和體檢提示有某種器質(zhì)性疾病可能，但經(jīng)檢查被否定；

3）雖有某種器質(zhì)性疾病，但首次偏頭痛發(fā)作與該疾病無(wú)密切關(guān)系。

b.Migrainewithoutaura

1.Have2-4subjectsofbelow,breakoutmorethan

5timesatleast

;2.

Ifnottreat,itcontinues4-72h.aseizure,;3.Havebelowcharacteristicatleast2subjects:1)unilateral;2)pulsatile(throbbing)

；

3)middle-seriousdegree,dailylifelimited;4)Headacheseriousafteract

；

4.Haveoneofbelow:1)nausea&vomiting;2)photophobia,phonophobia；

5.Withoutotherknownsimilardiseases,andexcludeotherdiseasesofthebody.

普通型（無(wú)先兆）偏頭痛診斷標(biāo)準(zhǔn)

1.符合下述2-4項(xiàng),發(fā)作至少5次以上;2.如果不治療,每次發(fā)作持續(xù)4-72小時(shí);3.有以下特征至少兩項(xiàng):1)單側(cè)型;2)搏動(dòng)型；3)中-重度頭痛,日?；顒?dòng)受限;4)活動(dòng)后頭痛加重；

4.發(fā)作期間有下列之一:1)惡心和嘔吐;2)畏光和懼聲；

5.無(wú)其他已知的類(lèi)似疾病:病史和軀體的其他方面正常。

C.Differencediagnosis:

1.clusterheadache(叢集性頭痛）

2.tension-typeheadache(TTH,緊張型頭痛）

3.othervascularpain（其他血管性頭痛）

4.Painfulophthalmoplegia（痛性眼肌麻痹）

5.carotidynia（頸動(dòng)脈痛）

1)Clusterheadache

(叢集性頭痛）

men>women;(4～5：1）

20-50yr.;recurrent;severalormanytimesdailyforseveraldaysorweekes;Prodromes先兆

areuncommon,Ictal發(fā)作

andstopsuddenly;periorbitalstrongpainwithcongestionoftheconjunctivae,lacrimation流淚,occasionalptosis上瞼下垂

oftheeyelidsandsweating;

2）Tension-typeheadache

緊張型頭痛

Tension-typeheadacheisachronicdisorderthatmostpatientsbeginsafterage20.Frequent(oftendaily)attacks,nonthrobb-ing,bilateralocciptalorfront,evenallheadpain,Sometimeslikenedtoa

press,tightbandaroundthehead,ictal

orpersistmonthsoryears.

Notassociatedwithnausea,vomiting,orprodromalvisualdisturbance.

Manypatientshavesleepdisorders(insomnia失眠,

alotofdreams多夢(mèng)

),anxious,depressionandnervous神經(jīng)質(zhì).

E.Treatment

偏頭痛的治療

Theaimoftreatmentisstoppingandcontrollingheadachequickly.

keepquietandstatedarkenroom.1.

Acutetreatment

發(fā)作期治療mild-middledegree:Itmayrespondtosimpleanalgesics止痛藥.Acetaminophen(乙酰氨基酚):0.5-1.0g,PO;

Aspirin(阿司匹林):0.6-1.0g,PO;

Naproxen(萘普生mg,PO

Indomethacin(吲哚美辛)：25mgPo,tid

Flunarizine

(氟桂利嗪,Sibelium西比靈）:

5-10mg,qnSeriouslyill(inseverecaseswithvomiting,nauseafrequently)subcutaneous,nosal,intravenousorintramuscularisusedfordrugs.Dihydroergotaminemesylate(酒石酸二氫麥角胺):mg,im.oriv.

Ergotamine（麥角胺，takeorally

or

2mgsublingualorbyrectaSumatriptam(英明格):25-50mg,takeorally(the5-HTagonist)

or

6mgsubcutaneousinjectionPethidine(哌替啶):50-150mg,im.Chlorpromazine(氯丙嗪):10mg,intravenousinjectionCodeine(可待因):

15-60mg,PO

Whengivingthedrugsyouhavetotelltheclinicalsideeffectsforpatient.2.

Prophylactictreatment

預(yù)防性治療

PTisindicatedforpatientswh