Migraine

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Migraine is a chronic episodic primary headache disorder. The symptoms typically last 4-72 hours, and can be fierce. The pain is often one-sided, throbbing, worse on exertion and is accompanied by symptoms such as nausea and hypersensitivity to light, sound or smell. An aura occurs in approximately 25% of patients, usually just before, but sometimes after the headache. The diagnosis is made clinically. Treatment is with triptans, dihydroergotamine, antiemetics, and analgesics. Prophylactic treatment approaches include changes in lifestyle (eg. As the sleeping or eating habits) and drugs (such. As Betaezeptorenblocker, amitriptyline, topiramate, divalproex).

Migraine is a chronic episodic primary headache disorder. The symptoms typically last 4-72 hours, and can be fierce. The pain is often one-sided, throbbing, worse on exertion and is accompanied by symptoms such as nausea and hypersensitivity to light, sound or smell. An aura occurs in approximately 25% of patients, usually just before, but sometimes after the headache. The diagnosis is made clinically. Treatment is with triptans, dihydroergotamine, antiemetics, and analgesics. Prophylactic treatment approaches include changes in lifestyle (eg. As the sleeping or eating habits) and drugs (such. As Betaezeptorenblocker, amitriptyline, topiramate, divalproex).

(See also examination of headache patients.) Migraine is a chronic episodic primary headache disorder. The symptoms typically last 4-72 hours, and can be fierce. The pain is often one-sided, throbbing, worse on exertion and is accompanied by symptoms such as nausea and hypersensitivity to light, sound or smell. An aura occurs in approximately 25% of patients, usually just before, but sometimes after the headache. The diagnosis is made clinically. Treatment is with triptans, dihydroergotamine, antiemetics, and analgesics. Prophylactic treatment approaches include changes in lifestyle (eg. As the sleeping or eating habits) and drugs (such. As Betaezeptorenblocker, amitriptyline, topiramate, divalproex). Epidemiology Migraine is the most common cause of recurrent moderate to severe headaches. The one-year prevalence is 18% in the US in women and in men 6%. Most often the migraine begins during adolescence or young adulthood and varies in frequency and severity during subsequent years; they usually decreases after age 50. Studies show a family history of migraine. On an assessment of veterans of the Iraq and Afghanistan conflict based evidence suggests that migraine can often develop after mild traumatic brain injury. Pathophysiology migraine as neurovascular pain syndrome with altered central neural processing (activation of the nuclei in the brain stem cortical hyperexcitability and propagating cortical attenuation) with participation of the trigeminovascular system (triggers the release of neuropeptides which cause a painful inflammation in the brain vessels and the dura mater ) Roger that. Many potential triggers have been identified for migraine; they include the following: consumption of red wine skipping meals Excessive afferent stimuli (eg, flashing lights, strong smells.) weather changes trigger sleep deprivation Stress Hormonal factors, especially menstrual Certain foods head trauma, neck pain or craniomandibular dysfunction (myofascial syndrome) or exacerbate sometimes a migraine. Changing levels of estrogen are a strong migraine triggers. For many women, the migraine begins with menarche, during menstruation (menstrual migraine) occur severe attacks of pain, and it may be a deterioration during menopause occur. In most women, the migraine forms during pregnancy back (but sometimes there is an exacerbation during the 1st or 2nd trimester), it gets worse after birth, when estrogen levels decline rapidly. Oral contraceptives and other hormone treatments can sometimes trigger a migraine or worsen; They were taken with insults in women who have migraine with an aura in conjunction. Familial hemiplegic migraine, a rare migraine subtype associated with genetic defects on chromosomes 1, 2 and 19th The role of genes in the most common forms of migraine is currently being explored. Symptoms and complaints often prodromal announces (a feeling of incipient migraine) to the attacks. The prodromal symptoms may include mood swings, loss of appetite, nausea, or a combination thereof. An aura is preceded by the attacks of pain in approximately 25% of patients. Auras are transient neurological disorders, which can affect the sensation, balance, muscle coordination, speech or vision; they last for minutes to up to an hour. The aura may persist after the onset of the headache. Most frequently include visual auras to symptoms (Fortifikationsspektren-z. B. flashes in the visual field, sheets of flickering light, bright zigzag patterns and scotoma). Paresthesia and numbness (which typically start in one hand and the ipsilateral arm and face hike), speech disorders and temporary dysfunction of the brain stem (the z. B. ataxia, confusion or even consciousness clouding cause) are less common than visual auras. Some patients have an aura with light or without headache. The headache varies from moderate to severe, and last for the attacks of 4 hours to a few days. They typically disappear during sleep. The pain is often one-sided, but it may also be on both sides, most commonly in frontotemporal localization, and is typically described as a pulsating or throbbing. Migraine is more than just a headache. Accompanying symptoms such as nausea (and occasionally vomiting), photophobia, noise and odor sensitivity are outstanding. Patients report difficulty concentrating during the attacks of pain. Routine physical activities usually intensify the migraine. This effect brings along with photophobia and phonophobia, most patients to lie down during the headache attacks in a dark, quiet room. Severe pain attacks can make unfit and thus interfere with the family and working life to patients. The attacks of pain vary considerably in frequency and severity. Many patients have different types of headaches, including lighter pain attacks without nausea and photophobia. they can recall tension headache, but a blurred form of migraine. Chronic migraine patients with episodic migraine can develop chronic migraine. These patients have an ? 15 days a month headaches. This headache disorder was formerly known as combination or mixed headache because it has both features of migraines and the tension-type headache. This headache often occurs in patients with überstiegertem use of drugs for acute Kopfschmerzbehandlung.Weitere symptoms Other, rare forms of migraine can cause other symptoms: The basilar generates a combination of dizziness, ataxia, visual field defect, sensory disorders, focal weakness and altered level of consciousness. Hemiplegic migraine, which can be sporadic or familial caused sided weakness. Diagnosis Clinical Evaluation The diagnosis of migraine is based on the characteristic symptoms and a normal result of the physical examination that includes a thorough neurological examination. Among the findings with warning signs that speak for an alternative diagnosis (also in patients with known migraine), include the following: pain, which reach their maximum intensity within a few seconds or faster ( “thunderclap headache”). Beginning Persistent after age 50 headache, which increase anamnesis with cancer (brain metastases) or immunosuppressive disorder (z. B. HIV infection, AIDS) fever, neck stiffness, consciousness changes, or a combination thereof over weeks or longer related. Intensity or frequency focal neurological deficits papilledema Significant change in an established headache pattern patients with characteristic symptoms and no warning signs do not need any tests. Patients with warning signs often require brain imaging and sometimes a spinal tap. Common misdiagnoses are the following: It is not considered that migraine often causes bilateral pain and is not always described as throbbing A migraine is misdiagnosed because of their autonomous and visual symptoms as sinus headache or eyestrain It is believed all of the headaches in patients with known migraines are another migraine attack (a “thunderclap headache” or a change in its current headache pattern may indicate a new, potentially more serious condition) a migraine with aura is mistaken in the elderly for a transient ischemic attack, v. a. when the aura occurs without headache is diagnosed as migraine a “thunderclap headache” because a triptan acts relief (a triptan can also be a headache due to a subarachnoid hemorrhage alleviate) Several unusual disorders can mimic migraine with aura: carotid dissection or vertebral cerebral vasculitis Moyamoya disease CADASIL (cerebral autosomal dominant eArteriopathie with subcortical infarcts and leukoencephalopathy) MELAS (mitochondrial encephalopathy, lactic acidosis and stroke-like episodes) syndrome prognosis for some patients is a rare migraine, tolerable discomfort. For others, it is an excruciating disease that attracts the frequent periods of disability, lost productivity and greatly reduced quality of life for themselves. Treatment Beseitiung Triggers For stress: behavioral interventions For mild headaches. Acetaminophen or NSAIDs For severe attacks, triptans or dihydroergotamine plus an antiemetic dopamine antagonists A thorough explanation of the disorder image helps to understand the patient, that although there is no cure for migraine they can still be controlled. This enables them to better participate in the treatment. Patients should necessarily keep a headache diary to document the number and the timing of the attacks of pain, possible triggers and the response to treatment. Identified Trigger be eliminated if possible. The Paitenten should be encouraged to avoid triggers, and doctors recommend behavior therapy (biofeedback, stress management, psychotherapy) for dealing with migraines when stress is an essential trigger or when analgesics are used in excess. The treatment of acute migraine headache is made based on the frequency, duration and severity of pain attacks. It can analgesics, antiemetics, triptans, and / or dihydroergotamine include (1). Mild to moderate pain attacks There NSAIDs or acetaminophen can be used. Opioid-containing analgesics, caffeine or butalbital (. N. D Übers .: In Germany not allowed) are helpful in the rare incident, slight pain attacks. However, there is the tendency to take these drugs in excess, which sometimes leads to some form of daily headache, is called a syndrome that headache by pain medication overuse. An antiemetic may alone be used to light or moderately severe migraines to lindern.Schwere pain attacks When developing mild pain attacks to severe migraine attacks or from the outset are heavy, triptans are used. Triptans are selective serotonin 1B, 1D receptor agonists. They do not affect analgesic per se, but specifically block the release of vasoactive neuropeptides that trigger migraine pain. Triptans are most effective if they are taken at the beginning of pain attack. You are in oral, nasal and subcutaneous application forms available (see table: drugs for migraine and cluster headache *). Subcutaneous preparations are more effective, but also have more adverse effects. Overuse of triptans can also lead to headaches by pain medication overuse. With significant nausea combining a triptan with an antiemetic at the beginning of pain attacks is effective. Iv Liquids (e.g., 1 to 2 l of a 0.9% physiological saline) can help alleviate headache and increase the feeling of well-being, v. a. in patients who are dehydrated from vomiting. The i.v. administration of dihydroergotamine with an anti-emetic dopamine antagonists (eg. As metoclopramide i.v. 10 mg, 5-10 mg prochlorperazine i.v.) carrying very heavy to end, persistent pain attacks in. Dihydroergotamine is also available in a s.c. formulation and as a nasal spray. A formulation of the active ingredient over the Linge is offered, is in development. Triptans and dihydroergotamine can cause constriction of the coronary arteries and therefore in patients with coronary heart disease or uncontrolled hypertension is contraindicated. In elderly patients and in the presence of vascular risk factors, these drugs must be used with care. A good response to dihydroergotamine or a triptan should not be understood as a diagnostic indication of a migraine because these drugs can improve headaches, which are caused by subarachnoid hemorrhage or other structural abnormalities. Prochlorperazine suppositories (25 mg) or tablets (10 mg) are an option for patients who do not tolerate other triptans and vasoconstrictors. (Editor’s note: prochlorperazine is not approved in Germany!) Opioids should be used in severe headaches as a last resort (rescue medication) when other measures ineffective waren.Chronische migraine For the treatment of chronic migraine are the same drugs used as for the prevention of episodic migraine , Also, there is strong evidence for OnabotulinumtoxinA and, to a lesser extent, topiramate. Medications for migraine and cluster headache drug dosage * Comments prevention amitriptyline 10-100 mg po bedtime use only in migraine has anticholinergic effects; causes weight gain helpful for patients with insomnia Small doses are often effective atenolol 25 to 100 mg po once a day metoprolol 50-200 mg po once daily nadolol 20-160 mg po once-daily propranolol 20-160 mg po twice daily timolol 5-20 mg p.o. 1 time / day (Editor’s note: timolol is not approved in Germany for the treatment of migraine!) For use only in migraine Only use of beta receptors beta-blockers without intrinsic sympathomimetic activity to be avoided in patients with bradycardia, hypotension, diabetes or asthma divalproex Normal drug release: 250-500 mg po 2 times daily Retardpräparation: 500-1000 mg po once daily Can alopecia, gastrointestinal irritation, liver dysfunction, thrombocytopenia, tremor and weight gain lead lithium 300 mg po 2 to 3 times a day use only cluster headache Can weakness, thirst, tremor and polyuria cause Periodic review of drug levels required OnabotulinumtoxinA – first-line drugs for chronic migraine topiramate 50-200 mg po 1 times a day Can weight loss and adverse effects in the CNS (eg. As confusion, depression) usually cause verapamil † 240 mg 1 to 3 times daily important benefit for patients with cluster headache. (Editor’s note:.! In the dt guidelines not named as prophylaxis for migraine) Can hypotension and constipation cause treatment dihydroergotamine 0.5-1 mg s.c. or iv 4 mg / ml nasal spray can cause nausea contraindicated in patients with hypertension or coronary heart disease can not be used simultaneously with triptans formulation for inhalation in development triptans ‡ almotriptan 12.5 mg p.o. Eletriptan 20-40 mg po Frovatriptan 2.5 mg p.o. Naratriptan 2.5 mg p.o. Rizatriptan 10 mg p.o. Sumatriptan 50-100 mg p.o., 5-20 mg nasal spray, 6 mg s.c. or 6.5 mg transdermal patch, followed -if required- by ??a second patch after 2 h (no more than 2 plaster in 24 h) Zolmitriptan 2.5-5 mg p.o. or 5 mg Nasal Spray Can redness, paresthesia and a feeling of pressure in the chest or throat cause If recurrent headache repeated doses up to 3 times / day possible contraindicated in patients with coronary heart disease, unadjusted hypertension, hemiplegic migraine or intracranial vascular use of injections or nasal spray at cluster headache valproate 500-1000 mg iv not tolerate commonly in patients taking triptans or vasoconstrictors can at long-term use to alopecia, gastrointestinal irritation, liver dysfunction, thrombocytopenia, tremor and weight gain lead * The drugs can be used for both types of headache, unless otherwise indicated. † In general, the formulation is used with normal release. ‡ triptans are given once and if necessary again. Treatment Note 1. Marmura MJ, Silberstein SD, Schwedt TJ: The acute treatment of migraine in adults: The American Headache Society evidence assessment of migraine pharmacotherapies. Headache 55 (1): 3-20, 2015. Prevention A daily prophylactic therapy is justified if disturb the patient’s activities despite acute treatment frequent migraine attacks. Some experts consider OnabotulinumtoxinA for the drug of choice. In patients who often take analgesics (. Eg> 2 days / week), especially patients with headaches painkiller overuse, the administration of prophylactic drugs should (see table: drugs for migraine and cluster headache *) with a Absetzprogramm the overly used analgesics are combined. The selection of drugs can be passed through comorbid disorders: a small amitriptyline dose at bedtime for patients with insomnia A Betaezeptorenblocker in patients with anxiety or coronary heart disease topiramate that can induce weight loss for obese patients or for patients who want to avoid weight gain Divalproex for patients with mania (Editor’s note: Divalproex is not available on the German market, active ingredient used here. valproic acid) Conclusion migraine is a common primary headache disorder with several potential triggers. Symptoms may include: one or both sides throbbing pain, nausea, sensitivity to sensory stimuli (. Eg light, sounds, smells), non-specific prodromal symptoms and transient neurological symptoms that precede the headache (auras). The diagnosis is based on clinical findings migraine; Patients should have findings with warning signs, often investigations are needed. Involve patients in their treatment with a by avoiding triggers and using biofeedback, stress management and psychotherapy. Treat the most headaches with analgesics, dihydroergotamine i.v. or triptans. If the pain attacks often and disrupt the activities, put a preventive therapy (for. Example OnabotulinumtoxinA. Amitriptyline, a beta-receptor blockers, topiramate, divalproex, OnabotulinumtoxinA).

Health Life Media Team

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