1、 migraine 偏 头 痛Chongqing University of Medical Science Migraine is manifested by headache that isa recurrence, usually unilateral and frequently pulsatile in quality 搏动性搏动性; it is often associated with nausea, vomiting, photophobia畏光畏光, phonophobia惧声惧声 and lassitude乏力乏力. Visual or other neurologic a
2、uras神经学神经学先兆先兆 occur in about10% of patients. The onset is early in life approximately 25%beginning during the first decade, 55% by 20 years of age, more than 90% before age 40. A.Cause and pathogenesis The real causes and the pathogenesis andpathophysiologic course of migraine is unknown. 1.Certain
3、 foods: tyramine酪胺-containing cheeses,meat,such as hot dogs or bacon,with nitrite亚硝酸preservatives, chocolate containingbut not chocolate alone. Food additives: monosodium glutamate谷氨酸一钠； Fasting禁食; Emotion情绪; Menses月经; Drugs:especially oral contraceptive agents;vasodilators (nitriglycerin硝酸甘油) Brigh
4、ts lights may also trigger or precipitateattacks. 2. Genetics: : About 60% patients of migrainehave families . Three genetic loci for familial hemiplegic migraine（偏瘫型偏瘫型)have been identified 3. Endocrine factor 内分泌异常内分泌异常 Gender: women men (2/3 to 3/4 of casesoccur in women); Headache mostly occursb
5、efore or menacme月经期月经期 in women , and the headache becomes reduction or stopping in pregnancy and after menopause绝经绝经. The migraine also stops in men of after climacterium更年期更年期. 4. vasomotor and autonomic 血管运动和自律神经血管运动和自律神经 Intracranial vasoconstriction and extracranial vasodilatation have long bee
6、n held to be the respective causes of the aura and headache phases of migraine. But the study of CBF脑血流脑血流 cant confirm. 5. spreading depression 扩布性抑制扩布性抑制 More recent studies of rCBF局部脑血流局部脑血流 during migraine attacks have demonstrated a reductionin regional flow, which begins in the occipital regio
7、n and then towards with 1 cm/s velocity during the aura phase. 6. Neurotransmitter（神经递质）（神经递质） Serotonin血清素血清素 in platelets decreases and urinary serotonin increases during the acute phase of a migraine attack . Depletion of serotonin by reserpine利血平利血平may precipitate migraine and decreasedby seroto
8、nin antagonists (sumatriptan, 英明格英明格)B. The classification of migraine 1. classic migraine （典型偏头痛） 2. common migraine （普通型偏头痛） 3. special type: a. ophthalmoplegic M. （眼肌麻痹型偏头痛） b. hemiplegic M. （偏瘫型偏头痛） c. basilar artery M. （基底动脉型偏头痛) d. late-life M. （晚发性偏头痛） e . migraine Equivalents （偏头痛等值症）: C. Cl
9、inic figures 临床表现临床表现 1. Migraine with AuraMigraine with Aura (Classic migraine 典型典型偏头痛偏头痛) 1)1) Auras（先兆）: visual alteration,particularly hemianopic (偏盲偏盲) field defects (视野缺损视野缺损）and scotomas（黑朦黑朦), hemiparansthesia (半身麻木半身麻木)。 2)2)Headache: 50% of patients experience no more than once attack per
10、week, the duration of episodes is greater than 2 hours and less than 1 day in most patients. Usually unilateral and frequently pulsatile in quality;Although hemicranial pain is a hallmark标志 of classic migraine,headache can also be bifrontal 双前额,lesscommonly localized to the occipital or vertex头顶 oft
11、he Skull. 3)3)company symptoms伴随症状: The nausea(恶心),vomiting(呕吐),photophobia(畏光),phonophobia(惧声), irritability(激惹), and lassitude (倦怠) are common. Uncommonly, migraine are associated with frankneurologic deficits明显神经学缺陷明显神经学缺陷 that accompany orpersist beyond resolution of the pain phase.Those May inc
12、lude hemiparesis, hemisensory loss偏身感觉偏身感觉丧失丧失, speech dysfunction语言功能障碍语言功能障碍, or visual disturbance视觉紊乱视觉紊乱. Same patients have vertigo眩晕,ataxia共济失调, or altered consciousness意识. 2. M2. Migraine without Auraigraine without Aura ( (common mig.) ) a.This is the most frequent type of migraine(over 80%
13、). The symptoms and signs are similarity the classic migraine, but lacks the aura. b.HeadacheHeadache： bilateral( or unilateral), periorbital aching or throbbing in quality； longer times; often occurs on weekend and holidays。 An useful bedside test for both common and classicmigraine is reducing hea
14、dache severity by compressing the ipsilateral carotid or superficial temporal artery. 3. special type: a a. ophthalmoplegic M. （眼肌麻痹型偏头痛） During or after migraine attack occur ocular nerve paralysis, ptosis ,pupil dilation ,ets.and persists hours or months. b b.hemiplegic M. （偏瘫型偏头痛） with hemiplegia
15、; last 10m.dayswk.; children,less in adult. c c.basilar artery migrainemigraine(基底动脉型偏头痛） most common in children and youthful women; visual alteration:field defects and scotomas, ataxia,vertigo,tinnitus耳鸣，diplopia复视，nystagmus眼震，dysarthria构音障碍，bilateral limbs numb and weak,impairment of recognize an
16、d consciousness,and nausea,vomiting,ets. d. d. migraine Equivalents Equivalents （偏头痛等值症）: abdominal pain腹痛, thorax, pelvis骨盆 and limbs pain, bouts fever周期性发热, attacks of tachycardia心动过速, benign paroxysmal vertigo良性发作性眩晕, cyclic edema, and so on. episodic, recurrence, excluded from other systemic dis
17、eases by history and examinations. D . Diagnosis of migraine According to the International associate of headache recomm- ended a programme in 1988,the diagnosis of migraine will be in keeping with below criterion. a. Migraine with aura 1. 1. Have 2 subjects of below,break out 2 at leastHave 2 subje
18、cts of below,break out 2 at least; ; 2. 2. Have below characteristic at least 3 subjectsHave below characteristic at least 3 subjects: : 1) More than 1 time aura of functional disturbance in focal cortex or brainstem 2) An aura at least gradual development and persist more than 4 min.,or have 2 aura
19、s； 3）The aura persists less than 60 min.; 4) There is not an interval time between the aura and headache; 3. 3. Have one of below at leastHave one of below at least： 1)No evidence of organic diseases by history and examination； 2）A possible of organic diseases by history and examination, but was den
20、y by test； 3）Although have some organic diseases,but the 1st migraine attack have not relation with it. 典型（有先兆）偏头痛典型（有先兆）偏头痛诊断标准诊断标准 1. 1.符合以下符合以下2 2项项, ,发作发作至少两次；至少两次； 2. 2.有以下特征至少有以下特征至少3 3项项: : 1) 1)有局限性脑皮质或有局限性脑皮质或 / / 和脑干功能障碍的和脑干功能障碍的大于大于1 1次以上的先兆；次以上的先兆； 2 2）至少有一个先兆症状逐渐发展、）至少有一个先兆症状逐渐发展、持续持续4
21、4分钟以分钟以上，或先后有两个以上的先兆上，或先后有两个以上的先兆； 3 3）先兆症状持续的时间）先兆症状持续的时间小于小于6060分钟分钟； 4 4）先兆症状与头痛间无间歇期。）先兆症状与头痛间无间歇期。 3. 3. 至少有下列之一：至少有下列之一： 1)1)病史和体检不提示有器质性疾病证据；病史和体检不提示有器质性疾病证据； 2 2）病史和体检提示有某种器质性疾病可能，但）病史和体检提示有某种器质性疾病可能，但经检查被否定；经检查被否定； 3 3）虽有某种器质性疾病，但首次偏头痛发作与）虽有某种器质性疾病，但首次偏头痛发作与该疾病无密切关系。该疾病无密切关系。 b. Migraine wi
22、thout aura 1 . 1 . Have 2- 4 subjects of below,break outmore than 5 times at least ; ; 2 . 2 . If not treat, it continues 4-72 h. a seizure,; ,; 3.Have below characteristic at least 2 subjects: : 1) 1)unilateral; ; 2) 2)pulsatile(throbbing) ； 3)3)middle-serious degree,daily life limited; middle-seri
23、ous degree,daily life limited; 4) 4)Headache serious after actHeadache serious after act ； 4. 4. Have one of below Have one of below: : 1) 1)nauseanausea & & vomitingvomiting; ; 2) 2)photophobia,phonophobia； 5 5.Without other known similar diseases , andexclude other diseases of the body. 普通型（无先兆）偏头
24、痛普通型（无先兆）偏头痛诊断标准诊断标准 1 . 1 . 符合下述符合下述2-42-4项项,发作至少发作至少5 5次以上次以上; ; 2 . 2 . 如果不治疗如果不治疗,每次发作每次发作持续持续4-724-72小时小时; ; 3.有以下特征至少两项有以下特征至少两项:1):1)单侧型单侧型;2);2)搏动型搏动型；3)3)中中- -重度头痛重度头痛, ,日常活动受限日常活动受限;4);4)活动后头痛加活动后头痛加重；重； 4. 4.发作期间有下列之一发作期间有下列之一:1):1)恶心和呕吐恶心和呕吐;2);2)畏畏光和惧声；光和惧声； 5. 5.无其他已知的类似疾病无其他已知的类似疾病: :
25、病史和躯体的其他病史和躯体的其他方面正常。方面正常。 C . Difference diagnosis: 1. cluster headache(丛集性头痛） 2. tension-type headache(TTH,紧张型头痛） 3. other vascular pain（其他血管性头痛） 4. Painful ophthalmoplegia（痛性眼肌麻痹） 5. carotidynia （颈动脉痛） 1) Cluster headache ( (丛集性头痛丛集性头痛） men women ;(45：1） 20-50 yr.; recurrent; several or many time
26、s daily for several days or weekes; Prodromes先兆先兆 are uncommon, Ictal发作发作 and stop suddenly; periorbital strong pain with congestion of the conjunctivae,lacrimation流泪流泪, occasionalptosis上睑下垂上睑下垂 of the eyelids and sweating; 2）Tension-type headache 紧张型头痛紧张型头痛 Tension-type headache is a chronic disord
27、er that most patients begins after age 20. Frequent (often daily) attacks , nonthrobb- ing, bilateral occiptal or front, even all head pain, Sometimes likened to a press ,tight band around the head, ictal or persist months or years. Not associated with nausea, vomiting, or prodromal visual disturban
28、ce. Many patients have sleep disorders(insomnia失眠失眠, a lot of dreams多梦多梦 ), anxious, depression and nervous神经质神经质. E . Treatment 偏头痛的治疗偏头痛的治疗 The aim of treatment is stopping and controlling headache quickly. keep quiet and state darken room.1. Acute treatment 发作期治疗发作期治疗mild-middle degree: It may re
29、spond to simple analgesics止痛药止痛药.Acetaminophen (乙酰氨基酚乙酰氨基酚): ): 0.5-1.0 g,PO;0.5-1.0 g,PO; Aspirin( (阿司匹林阿司匹林): 0.6-1.0 g,PO; ): 0.6-1.0 g,PO; Naproxen( (萘普生萘普生): 0.5-0.75): 0.5-0.75mg,PO,PO Indomethacin(吲哚美辛吲哚美辛)： 25mg Po, tid Flunarizine ( (氟桂利嗪氟桂利嗪, , Sibelium西比灵西比灵）: : 5-5-10mg, qnSeriously ill
30、(in severe cases with vomiting,nauseafrequently)subcutaneous,nosal,intravenous or intramuscularis used for drugs. Dihydroergotamine mesylate(酒石酸二氢麦角胺酒石酸二氢麦角胺): 0.25-1.0mg, im. or iv. Ergotamine（麦角胺麦角胺): 0.6-1.0mg，take orally or 2mg sublingual or by recta sublingual or by recta Sumatriptam(英明格英明格): 2
31、5-50mg, take orally (the 5-HT agonist ) or 6mg subcutaneous injection Pethidine(哌替啶哌替啶): 50-150mg, im. Chlorpromazine(氯丙嗪氯丙嗪): 10mg, intravenous injection Codeine(可待因可待因): 1 5-60mg, PO When giving the drugs you have to tell the clinical side effects for patient . 2 . 2 . Prophylactic treatment 预防性治疗
32、预防性治疗 PT is indicated for patients who have frequent attacks especially more than once a week, ets.Propranolol( (普萘洛尔（心得安普萘洛尔（心得安）: : -receptor blocker-receptor blocker 101040mg, bid-qid/d40mg, bid-qid/d；Flunarizine ( (氟桂利嗪氟桂利嗪; ;Sibelium西比灵西比灵, ,nicardepine 尼尼卡的平卡的平）: Calcium channel antagonists :
33、Calcium channel antagonists 5-10mg,qn5-10mg,qnCyproheptadine( (赛庚啶赛庚啶) ): : 0.5-4mg,bid-qid/d;0.5-4mg,bid-qid/d; Valproate(丙戊酸丙戊酸) ): : 0.2g, tid/d0.2g, tid/d；Fluoxetine(氟西汀氟西汀)Topiramate（托吡酯托吡酯）Naproxen（萘普生萘普生）Pizptifen( (苯噻啶苯噻啶) )： 0.5-3mg/d0.5-3mg/d提问与解答环节Questions And Answers谢谢聆听 学习就是为了达到一定目的而努力去干, 是为一个目标去战胜各种困难的过程,这个过程会充满压力、痛苦和挫折Learning Is To Achieve A Certain Goal And Work Hard, Is A Process To Overcome Various Difficulties For A Goal
