Koreshkina Marina Igorevna - Ph.D., Head of the Headache Center, International Clinic MEDEM, St. Petersburg
Among primary headaches, migraine is the most important condition that occurs in adults in more than 11% of the population (16). Migraine is included in the WHO list of the top 20 diseases causing significant disability in the population and the top 10 diseases causing severe disability among women (10). Unfortunately, the treatment of migraine has not reached a satisfactory state in many countries of the world, including Russia.
Economic losses from various types of headaches are made up of several indicators: loss of working days, reduced efficiency at work or school. Economic losses from migraine were studied in the United States and European countries based on population studies, according to which 14% of the population of these countries suffers from migraine. Both studies analyzed the cost of migraine, both in direct costs and indirect costs. For example, in the United States, the total cost of 22 million migraine patients aged 20 to 65 years was analyzed, and the total amount was $ 14.4 billion per year (14). Direct costs (drugs, consultations, research, and hospitalization) were about $ 1 billion. Whereas the indirect costs exceeded $ 3 billion. For women with migraines, 80% of both direct and indirect funds were spent.
In Europe, the total amount spent on 1 migraine attack was 579 euros, or 27 billion euros for 41 million losses from days of incapacity for work, but, just as importantly, they counted the decrease in activity at work or school, when a person seems to be at work. place, but cannot work or study fully due to a headache.
Migraine and its manifestations are found in the descriptions of the suffering of literary characters quite often and vividly. Let us recall at least the figurative description of hemicrania by Pontius Pilate in M. Bulgakov's novel The Master and Margarita. There is still controversy about the book by Lewis Carroll "Alice in Wonderland" - that it is a children's book or a manual on migraines. It is not for nothing that Alice's illustrations are often used for clarity when describing migraine symptoms.
But these are works of past centuries. There are also more modern literary images of migraines. So in the article "Harry Potter and the Course of Headache" ("Harry Potter and the school of migraine") Fred Sheftell, Timothy J. Steiner, Hallie Thomas in the magazine "Headache. The Journal of Head and Face Pain, Volume 47, Number 6, 2007, used test pieces from various Harry Potter books to illustrate the diagnosis of migraine according to the II Edition of the International Headache Classification. Considering the descriptions of headache attacks, the authors tried to make a diagnosis by analyzing each complaint according to the classification points. At the end of the article, the authors concluded that Harry Potter had migraines without an aura.
Epidemiology of migraine
Migraine is a chronic illness with attacks of unilateral or bilateral headache, usually of a pulsating character, with moderate to severe intensity, and decreased functional activity. Associated symptoms are nausea and / or vomiting, photophobia and phonophobia. On average, migraine in the population is 12%, 18% in women and 6% in men (11). About 20-30% of migraine patients suffer from migraine with aura. The aura is characterized by recurrent episodes of reversible focal neurological symptoms that usually develop in 5–20 minutes and last for 60 minutes. Various forms of aura are classified as transient neurological deficits that can precede, accompany, or exceed the duration of a headache.
Migraine frequency
The most frequent is the frequency of attacks 2-4 times a month (13). But more than 11% of patients have more than 1 seizure per week, that is, more than 4 seizures per month, which leads to a sharp decrease in efficiency and maladjustment of patients (Fig. 1).
The frequency of migraine varies not only between different patients, but also in the same patient at different periods of life: the frequency of attacks can vary from two to three per year, to two to three per week. At the same time, the clinical characteristics of an attack may also differ in the same patient.
Chronic migraines, in which attacks take more than 15 days a month, are a complication of migraines. This form is very often worsened by abusal headache, in which analgesics are used for more than 10-15 days a month, regardless of the dose used daily for relief. At the same time, analgesics do not have their analgesic effect, but, at the same time, the patient cannot refuse them on his own. This type of headache is the most difficult to treat, especially in outpatient practice.
Interesting are the data on the frequency of migraine attacks depending on the day of the week (Winner P. Headache 2003; 45: 451-7) (Fig. 2). The diagram notes that it is Monday that is the most difficult day, and on Saturday, the least attacks develop in a week.
Also, statistics of hours of onset of migraine attacks is of practical importance, which may reflect the effect of various provoking factors on the development of an attack (Fig. 3) (Winner P. Headache 2003; 45: 451-7).
Migraine diagnostics
The first International Classification of Headache appeared in 1998, in 2003. The Classification Committee of the International Headache Society adopted the 2nd edition of the ICGB. This classification not only distributes all headaches into groups and subgroups, but includes diagnostic criteria that allow a clear and correct diagnosis.
The classification identified 14 large groups of headache, each of which is divided into subgroups and further into more detailed subgroups (ICGB scheme).
The first 4 groups are primary headaches (GB), the next 10 are secondary. The name "secondary HD" reflects the essence of these pains - headaches are the result of some other disease.
The first place in the classification is given to migraine - the most striking and characteristic primary headache (Table 1).
In the ICGB II for migraine, the diagnostic criteria are prescribed (diagram of the diagnostic criteria - Table 2). Let's consider them in order.
Point A - there must be at least 5 attacks that meet the criteria B-D - means that a diagnosis of migraine cannot be made based on 1-2 attacks.
Point B - duration. A headache attack within 20 minutes or within a week is not a migraine.
Point C is very important - you must have at least 2 characteristics of the four listed. Unfortunately, many doctors are adhered to the old term "hemicrania" and believe that with a migraine there can be no bilateral headache. According to the points listed, the localization of the headache in the frontal, temporal or occipital regions does not play a diagnostic role. But on the basis of the ICGB criteria, it is possible to diagnose migraine, for example, if the headache is bilateral and pressing in nature, if it is pronounced (item C3) and intensifies with physical exertion (item C4). Strict adherence to the diagnostic criteria allows avoiding errors on the one hand and making a diagnosis of migraine in case of not very typical patient complaints.
The next point D includes the most typical complaints for migraine - nausea, reaching in severe cases to vomiting, as well as photo- and phonophobia. At present, taking into account the large% of patients with intolerance to odors during a migraine attack, the inclusion of "osmophobia" in the next edition of the ICGB is also being considered.
Important in importance, although it ranks last locally in the list, item E - the absence of other causes of headache - thus, we must exclude the secondary nature of the headache.
On the one hand, "migraine" is a clinical diagnosis based on compliance with the above criteria. On the other hand, at various international conferences and congresses dedicated to headache problems (Congress of the European Headache Federation (EHF) in Valencia - 2006, International Congress of the Headache Research Society (IHS) - Stockholm 2007, 9 Congress of the European Headache Federation , Migraine Trust 2008 - London) have repeatedly demonstrated the results of MRI of patients who have been treated for a long time with a diagnosis of migraine. This list of diseases includes arteriovenous malformations, multiple sclerosis, brain tumors, etc.
Differential diagnosis of migraine
Despite the existence of clear criteria for the diagnosis of migraine, presented in the International Classification of Headache II edition, there is a need for differential diagnosis with various types of secondary headache.
Absolute indications for neuroimaging in patients with headache:
- New-onset headache in patient> 50 years of age
- Acute intense headache
- Changed headache pattern
- Increased intensity and / or frequency of attacks
- Cancer history
But not only in these cases, it is necessary to carry out an MRI of the brain. Clinical cases obtained in the practice of the Headache Center confirm the need for a full examination of patients.
Example No. 1.
A patient with migraine sends her mother for consultation to a neurologist, who has also been suffering from typical headache attacks in the left frontal region for many years, accompanied by nausea, photophobia and phonophobia, reaching 6-7 points on the VAS, at a frequency of 1 time per month. During MRI of the brain, the patient was found to have a meningeoma in the left frontal region (Fig. 4)
Example No. 2
A 40-year-old patient is admitted to the clinic with a headache up to 10 points on the VAS, nausea, vomiting, severe photo and phonophobia. Similar attacks disturbed for several years, but were extremely rare - 1-2 times a year, but the intensity of the headache was less pronounced. MRI of the brain and MRI of the vessels using the GE Signa HDx3T high-resolution MRI machine revealed an aneurysm of the MCA. The patient was transferred to a specialized neurosurgical department and successfully operated on (Fig. No. 4)
The literature describes cases of differential diagnosis with multiple sclerosis (Fig. No. 6)
It is important that primary secondary headaches can be, and most often are, less intense than with primary headaches. The intensity, duration of the headache cannot be a criterion - whether a given headache is dangerous for the patient's life and health, or not.
The European Headache Federation, although it does not consider it mandatory for every patient to perform such methods of neuroimaging as MRI of the brain, but at numerous conferences, congresses (8th EHF Valencia Congress, 2006, 9th EHF & Migraine Trust Congress - London 2008), educational programs encourages, at the slightest doubt, to conduct an MRI of the brain as a method to exclude secondary headache.
Migraine provocateurs
Migraine is a hereditary, genetically determined disease, and a number of genes have already been identified that are responsible for the inheritance of migraine. Various provocateurs of migraine attacks play an important role in the development of the disease (Table 3). These include - first of all - stress and emotional tension, overwork. Sleep disorders play a huge role - lack of sleep and, which is typical for migraines, oversleeping.
For example, a patient came to the clinic with weekly intense migraine attacks that developed on Saturday and lasted all weekends, dramatically reducing the quality of life and having a negative impact on family relationships. Taking into account the more rare development of seizures on Saturday time (19), the patient was asked in detail about the peculiarities of her life schedule on workdays and weekends. It turned out that, in contrast to working days, the patient woke up on Saturdays later than 11 a.m. The patient was advised to shift the ascent time to an earlier time and after 1.5 months the number of attacks significantly decreased, after 3 months of adherence to this regimen, the patient had only one migraine attack per month, associated with the onset of menstruation, of lower intensity than previous and well-controlled taking a triptan.
Thus, only by observing the individual regimen of the day, it was possible to significantly reduce the frequency of migraine attacks per month without additional drug therapy.
The provoking factors also include atmospheric changes and food products. A study conducted in Austria on 300 patients with migraine showed the following risks of developing a migraine attack: menstruation, muscle tension in the cervical spine, overwork the day before the development of migraine, holidays, changes in atmospheric pressure (19). Migraine attacks associated with weather conditions, unfortunately, do not lend themselves to any correction, but the diet can play a role in the treatment of migraines, especially chronic ones.
In the literature, there is a description of a large number of food and drinks that are provocateurs of migraine attacks, but the information is different (4).
At the headache treatment center, patients with chronic migraine undergo a blood test - ImuPro 300. Imu - immunological, Pro - profile, 300 - the number of allergens detected in food.
All reactions to food that are not associated with exposure to toxins can be divided into two categories: immune and non-immune. The basis of reactions not related to the immune system is the action of biologically active substances contained in food, a deficiency of certain enzymes, or other mechanisms. Immune reactions to food can be fundamentally divided into two types: IgE antibody-mediated (classic food allergy) and IgG antibody-mediated (true food intolerance).
Characteristic manifestations of food allergies are sudden and usually pronounced reactions, such as hives and other sudden skin rashes, swelling of the lips, eyelids, larynx, and difficulty breathing. These symptoms appear almost immediately after contact with a causally significant allergen. IgE antibodies are responsible for this type of reaction.
The situation with food intolerance looks completely different. Manifestations of food intolerance are non-specific. They can resemble allergies, but they can also be represented by symptoms such as headache, changes in skin condition, itching, stool disorders, arthritis, depression, etc. Moreover, clinical manifestations of intolerance do not appear immediately, but after several hours or even days from the moment the use of the "guilty" product. A causal relationship in this case is almost impossible to establish. Therefore, many people who have food intolerances to certain foods are unaware of this. IgG antibodies are involved in the formation of true food intolerance, the level of which to individual food antigens is determined using the ImuPro test.
The study was carried out in a laboratory at CTL-Labor GmbH Schulstrasse 9/26160 Bad Zwischenahn, Germany. An IgG ELISA was performed to detect intolerances out of 300 foods. As a result of the examination, the patient received - a list of foods that are well tolerated by the body and a list of foods that are not tolerated. The degree of intolerance was determined from 1 to 4 points. 1 point meant that the product can be consumed periodically, and 4 points - that the product should be completely excluded from the diet for 3-4 months, with its further rare use.
The analysis was carried out in patients with frequent and severe migraine, more than 8 attacks per month. The results of the analyzes were so individual that it was impossible to carry out a statistical analysis of the most common foods. So, in one patient, all the listed seafood and all fish were included in the list of prohibited products, and in the other, the most pronounced intolerance was to dairy and sour milk products. It drew attention to the fact that patients with the most severe form of migraine, poorly amenable to preventive therapy and having more than 12-15 migraine attacks per month, had an intolerance to food additives, dyes and stabilizers, which are extremely difficult to exclude from the diet, due to their ubiquitous presence (yoghurts , confectionery, baked goods).
Patients received not only a list of foods that should be reduced in consumption and elimination (Fig. 11), but also a whole book, which explained in what form they can find certain foods, how they can be replaced without a drastic change in lifestyle and nutrition. Also, as a result of the survey, recommendations were made on completing the food ration in the context of the exclusion of prohibited products. Thus, the patient received not only a list of products, but also dietary recommendations developed by German specialists.
After receiving this examination result, the patients began a new diet with the exception of prohibited foods. The dietary results were positive. Drug therapy remained the same, but patients supplemented it with an individually tailored diet. After 3 months of adherence to the diet, there was a significant decrease in the frequency of headache attacks. The patients also noted an improvement in general well-being, an increase in working capacity, and a decrease in fatigue.
Thus, an individually selected diet can be an additional effective non-drug method for preventing migraine attacks and, taking into account the possibility of carrying out this blood test not only in Germany, but also in various clinics in St. Petersburg and Moscow, can be used more widely in the treatment of chronic forms of migraine.
The most important provoking factors, especially in women, are hormonal changes. In most patients, the first migraine attacks appear in puberty, during pregnancy there is a decrease in the number of attacks, at the beginning of the climacteric period - an increase - an increase in the frequency and intensity of migraine attacks.
The majority of patients with migraine (24-80%) note menstruation as a trigger for the development of an attack, especially migraine with aura. Attacks can develop before, during, and after bleeding, and these attacks are usually more severe and lasting (up to 72 hours).
The use of a number of contraceptives can also worsen the course of migraine and is contraindicated in patients with migraine with aura. Therefore, the interaction of doctors of various specialties in the practice of managing patients with migraine is very important - neurologists, ophthalmologists, general practitioners, gynecologists, endocrinologists, etc. Analysis of various provoking factors, individual for each patient, allows you to improve the quality of life, reducing the frequency and intensity of attacks migraines without increasing the drug load.
Migraine and stroke
Migraine with different auras, retinal or ophthalmoplegic migraine, familial hemiplegic migraine, or basilar migraine can mimic a transient ischemic attack (TIA) or stroke. Migraine with aura is associated with a higher risk of stroke. If symptoms of a migraine aura last for more than 24 hours, a migraine-induced stroke may be suspected.
Numerous studies have established a link between the presence of migraine and the development of stroke (5). Data from the Women's Health Study, which included a study of 39,000 healthy women 45 and older, showed a 1.7-fold increased risk of ischemic stroke in women with migraine with aura, as opposed to women without migraine. was not associated with the risk of ischemic stroke. Another study, the Stroke Prevention in Young Women Study (12), showed a 1.5 times higher risk of stroke in women with visual aura during migraine. The risk increased up to 2.3 times if developed more than 12 times a year, as well as for those who developed migraine for the first time in their life (6.7 times). If smoking or the use of oral contraceptives were added to the migraine with a visual aura, the risk increased 7 times.
Thus, migraine is one of the factors in the development of ischemic strokes in the presence of other risk factors.
The most important risk factors for migraine patients are (7) - tab. 4.
With frequent migraines, the risk of ischemic events, whether transient ischemic attack (TIA) or stroke, increases in line with the frequency of migraine attacks per month (8) (Fig. 7).
In various studies on migraine, focal changes in the white matter of the brain were recorded, most often detected in the hemisphere on the side of the headache and contralateral to sensory disturbances during the aura. Diagnosis of migraine infarction is based on MRI (6).
Important for the choice of treatment tactics for patients is not only the presence or development of ischemic strokes, but also the identification of discirculatory changes in the brain that are a consequence of migraine (4).
When examining patients with migraine, with and without aura, with episodic and chronic migraine, on a 3.0 Tesla apparatus (GE HDx) at the Headache Center of the international clinic MEDEM, St. Petersburg, the following changes were revealed (Table 5).
Thus, migraine, especially its chronic form, is not only a serious disease leading to a decrease in the ability to work and a decrease in the quality of life of patients, but is an independent risk factor for the development of ischemic changes in the brain, even at a young age (9).
Treatment
In recent years, international standards for the treatment of migraines have been developed. The European Federation of Neurological Societies established standards for the treatment of migraine in 2006.
The standards for the treatment of the most common headaches were developed by the European Headache Federation in 2007. in close contact with WHO, which organized a campaign to reduce the burden of migraine for patients (17).
The modern approach to the selection of migraine therapy consists of the following stages
- Identification of provocateurs of the appearance of migraine attacks and their gradual decrease: normalization of sleep patterns, reduction of the influence of stressful situations (auto-training, classes with a psychotherapist, etc.), an individually selected diet, an increase in rest periods (many patients with chronic migraine did not have a full vacation during several years)
- Selection of a drug that relieves migraine attacks
- If necessary, the selection of preventive treatment (with a frequency of attacks of more than 4-6 per month)
Migraine treatment should include more than just headache therapy. The clinical heterogeneity of this disease determines the need for the formation of a treatment approach, taking into account the needs of each individual patient. The goals of the therapeutic strategy are (13):
- Raise the level of knowledge of patients about their disease and provoking factors
- Reduce the frequency, intensity and duration of migraine attacks
- Interrupt an attack of headache and accompanying symptoms as early as possible
- Prevent the development of recurrent pain
- Reduce the number of analgesics taken
- Prevention of disease chronicity
- Improve the patient's quality of life
- Reduce patient disability
- Reduce the cost of treating a disease
To achieve such difficult tasks, the main rules should be the following (3):
- Establish an understanding between doctor and patient
- Explain to the patient the biological mechanisms of the development of migraine and the possibility of a toxic effect from excessive use of analgesic drugs
- Dispel the existing myths about migraine (connection with sinusitis, cervical osteochondrosis, poor digestion, etc.)
- Instill in the patient realistic expectations of treatment options
- Draw up a treatment plan with the patient
- Draw up a program of drug treatment, relief of migraine attacks and preventive treatment
- Outline sequential steps for non-drug therapy: lifestyle changes, sleep and rest, diet, computer work, etc.
In the treatment of migraine, it is very important to distinguish between the relief of migraine attacks, which are suitable only for the relief of one attack, and preventive therapy, which is the treatment of the disease itself.
Currently, there is a so-called stratified approach to the treatment of each seizure (10). This means that not only the drug for the relief of migraine attacks is individually selected for each patient, but the nature and intensity of the headache during the development of attacks in the same patient is taken into account. The stratified approach assumes that the best criteria for successful selection of migraine treatment are: the intensity of pain and the degree of disability.
What does this mean in practice?
The first drug of choice for the relief of a migraine attack are drugs of the NSAID group. Their use is justified in the development of mild migraine attacks, without a pronounced decrease in performance.
If a migraine attack leads to maladjustment of the patient, then the use of triptans, modern drugs specially designed for the treatment of migraine, is justified (1).
A few simple guiding principles must be explained to patients in order to obtain successful results in the use of drugs for the relief of migraine attacks:
- Use adequate doses
- Start treatment as early as possible. If nausea or vomiting is concerned, a nasal spray or suppository is preferred
- Use monotherapy for unexpressed headache
- With a pronounced degree of pain, a combination of NSAIDs and triptans is possible
- Use additional methods (rest in silence and darkness, etc.)
The emergence of new drugs for the treatment of migraine - triptans - has opened a new page in the effective treatment of migraine (15).
Sumatriptan (Imigran) was the first among the trypatins to appear on the pharmaceutical market. It is still the "gold standard" among triptans, especially due to its intensity of action. Imigran occupies a worthy place among the entire group of triptans, not only because of its effectiveness, but also due to the widest range of forms presented.
Imigran exists in tablet form - tablets 50 × 100 mg, which allows you to make the treatment more individual, depending on the intensity of the developing migraine attack. An innovative form of use of the drug is a 20 mg nasal spray.
Imigran - nasal spray is the fastest-acting form of the drug, allows a lower dose (20 mg, as opposed to 50 × 100 mg tablets) to achieve a pronounced effect - complete relief of the attack, which includes not only the removal of pain, but also a significant reduction or complete disappearance of nausea, photo and phonophobia, restoration of functional activity.
Nasal spray is the only possible way to use triptans in the presence of severe nausea and / or vomiting, due to the impossibility of using either NSAIDs or tableted triptans in this situation.
Also an indispensable remedy for the relief of severe migraine attacks Igran - a nasal spray is in the presence of nocturnal attacks - developing at night or in the early morning. In this case, the patient wakes up already with a pronounced intensity of headache, when due to sleep, time is lost for a quick and complete relief of a migraine attack by taking peraprat in tablets. The nasal spray allows you to get fast and effective relief of headache and accompanying nausea, photo and phonofboia for night attacks. Also, the nasal spray can be used in the drug supply arsenals of ambulance and emergency vehicles, as it is the fastest and most effective remedy for the relief of severe migraine attacks.
The use of the nasal spray has received approval in a large number of patients with predominantly nocturnal attacks and attacks accompanied by severe nausea.
It is very important to explain to patients the need to stop each migraine attack in a timely manner. Since, an uncropped migraine attack or an attack that was only suppressed by the use of simple analgesics, retains significant changes in the state of the vessels. In the headache center, a Doppler study of extra- and intracranial vessels was performed in all patients with migraine.
It was found that not only during a migraine attack, but also in the interictal period, there is a tendency towards pronounced dilatation of the vessels. Thus, an incompletely arrested migraine attack retains vasodilatation, which can lead to the development of another migraine attack with minor provoking factors, for example, when atmospheric pressure changes.
On the contrary, sequential treatment of each attack leads to the normalization of vascular tone, and is also accompanied by a significant decrease in the frequency of migraine attacks without the use of prophylactic drug therapy (Fig. 10).
It should be noted that there is a difference in the use of tripatns, including Imigran, in the presence of migraine with aura. The drug is taken only after the end of all the symptoms of the aura and at the beginning of the onset of the headache. This limitation is associated with the pathogenetic mechanisms of the development of a migraine attack with aura. During the aura, vasoconstriction develops, therefore, the use of triptans, one of the mechanisms of action of which is vasoconstriction, is not advisable. But at the onset of a headache, when vasoconstriction is replaced by vasodilation, triptan begins its positive effect.
It is extremely important to determine the goals that the patient sets for the doctor (Table 6).
The data presented in the table are important for understanding the goals and objectives that patients pose to a doctor who selects a drug to relieve a migraine attack.
Draws attention to the fact that it is important for patients not only to relieve the headache, but also to all accompanying symptoms - nausea, photophobia, phonophobia, as well as the absence of repeated attacks during the day.
An immigrant has important advantages in all of the following areas:
- Imigran - nasal spray most quickly stops a migraine attack (A. V. Amelin et al. Migraine (pathogenesis, clinical picture and treatment) St. Petersburg, 2001; Winner P, Mannix L, Putnam DG, et al. 2003) - Fig. 12
- The immigrant has a low percentage of recurrent headache (PeikertA, et al 1999)
- The immigrant relieves not only the headache, but also the accompanying symptoms - nausea, photo and phonophobia (Diamond S, et al. 1998) fig. 13
- Imigran nasal spray is the only possible use of triptan in the event of severe nausea and / or vomiting, in which taking any pills is not possible (Ryan R et al. 1997)
It should be noted one more of the possibilities of using Imigran in the form of a nasal spray. These are situations related to emergency and urgent care, as well as the work of ambulance teams. In Russia, no injectable forms of any of the drugs in the triptan group have been registered. Therefore, the question arises - what can be applied in the case of a severe migraine attack or a more rare variant - migraine status?
There is only one answer - the use of a nasal spray - Imigran is a quick and complete solution to this problem.
Among patients with migraine, the number of patients with severe and protracted - up to 72 hours - attacks is not so great and, according to various sources, ranges from 1 to 3%. But what do these numbers mean in practice? These modest percentages equate to 5,000 severe migraine patients in St. Petersburg and 10,000 in Moscow.
Medical experts from one of the leading insurance companies in St. Petersburg complained about large financial losses in the provision of emergency care to patients with severe migraine. The monthly and sometimes multiple visits of the ambulance team to patients with severe migraine attacks turn into serious costs. Timely and planned examination and treatment of this category of patients gives not only relief to the patient or patient, but also significant economic benefits for insurance companies.
But if, nevertheless, the patient could not cope with the attack on his own or he did not have the necessary drug on hand on time, the use of the nasal spray by the ambulance specialists can quickly and fully solve the situation Imigran Nasal Spray can stop a severe migraine attack, even if from it it took a long time to start. The task of the ambulance specialists is not only to introduce this drug to the patient, but also to teach him how to use such a spray in the future.
The use of the spray is not a difficult event, each package contains the drug with detailed instructions for use, there are also special leaflets distributed by the manufacturer for doctors. By issuing such a leaflet to a patient when prescribing a drug, the doctor saves a significant amount of time required to instruct the patient.
Having such a leaflet, the patient studies it in a calm home environment in the absence of an attack and can further use the drug without any difficulties (link to the picture is a copy of the leaflet on the use of the spray).
Prophylaxis
Before embarking on prophylactic migraine therapy, which condemns the patient to daily medication for a long period of time, it is very important to educate and instruct the patient properly on other ways to prevent the development of attacks.
Of course, all these conversations require a significant amount of time from both the patient and the doctor. Unfortunately, a regular doctor's appointment cannot provide this opportunity. But it must be remembered that the prevention and treatment of migraines provides enormous economic benefits for the whole society and, in particular, for each patient.
If the frequency of migraine attacks per month exceeds 4-6 (different options depending on different authors), it is necessary to carry out prophylaxis: medication and non-medication.
Non-drug methods include lifestyle changes, elimination of diets, long breaks in food intake, avoidance of physical fatigue, normalization of sleep patterns, and stress prevention (1). Oral contraceptives should be avoided in the presence of migraine with aura.
Drug therapy based on daily intake of drugs should be selected individually for each patient, taking into account his preferences and specific tasks, in a balance between the effectiveness of treatment and the severity of side effects, as well as contraindications (2).
The choice of preventive therapy should be carefully discussed with the patient, keeping in mind the following points:
- Quality of life is significantly affected by migraine attacks
- The frequency of attacks per month is more than 2
- Symptomatic therapy is not effective
Preventive therapy has in its arsenal the following groups of drugs:
- Beta blockers
- Antidepressants
- Anticonvulsants
Various new techniques such as electrical stimulation of the occipital nerve, the use of botulinum toxin injections, and vagus nerve stimulation are under study and development.
Conclusion and conclusions
In order for a headache and migraine in particular to cease being "terra incognita", it is necessary:
- To improve the educational level of doctors of various specialties - neurologists, general practitioners, therapists, who are most often approached by patients with headache complaints - it is necessary not only to know the International Classification of Headaches, the criteria for diagnosing various primary and recurrent headaches, but also to be able to put and timely diagnosis
- Treats headache as an independent complaint
- To inform patients about the possibilities of modern medicine - diagnosis and treatment of various types of headaches
- Inform doctors about modern medicinal products existing in practice and available on the Russian pharmaceutical market, their indications, contraindications, possibilities of application, use of various existing forms of medicinal products (tableted, injectable, nasal sprays, soluble forms, suppositories, lingual tablets, etc.). ) for various types of headaches and various types of migraines.
In conclusion, we can say that it is in our power to make the diagnosis of migraine not a sentence, but only the beginning, the first step towards solving this problem.
Fig. 1. Frequency of migraine attacks per month
Drawing. 2. Development of migraine attacks depending on the days of the week
Figure 3. Development of seizures depending on the time of day
Table 1. International Classification of Headache II edition 2003
Migraine
- Migraine without aura
- Migraine with aura
- Recurrent childhood syndromes, usually preceding migraines
- Retinal migraine
- Complications of migraine
- Possible migraine
Table 2. Criteria for diagnosing migraine without aura
| Criteria | |
|---|---|
| A. | The presence of at least 5 seizures that meet the requirements of items G-D |
| B. | A headache attack lasts from 4 to 72 hours |
| V. | A headache has at least two of the following characteristics:
|
| G. | A headache is accompanied by one of the 2 listed symptoms:
|
| D. | One of the characteristics:
|
Figure 4. MRI of a patient with frontal lobe meningeoma
Figure 5. MR - angiography of a patient with MCA aneurysm
Figure 6. MRI of a patient with multiple sclerosis. Demyelination foci in the brain and cervical spinal cord.
Table 3. Trigger factors for migraine (4)
| Trigger factors | |
|---|---|
| Psychological |
|
| Hormonal factors |
|
| Environmental factors |
|
| Diet, food, drinks |
|
| Medications |
|
| Other factors |
|
Table 4. Risk factors for stroke
- Female
- Smoking
- Arterial hypertension
- Having a migraine with an aura
- Oral contraceptive use
Figure 7. Frequency of "silent" ischemic strokes depending on the frequency and nature (with or without aura) of migraine attacks per month (10)
Table 5. Identification of ischemic foci in the white matter of the brain in patients with episodic and chronic MO and MA according to MRI of the brain on a GE 3.0 Tesla tomograph
| The nature of migraine in patients | The total number of patients examined | Identification of foci of ischemia of the white matter of the brain | Expansion of Virchow's perivascular spaces | Associated finds, changes |
|---|---|---|---|---|
| MO episodic | 28 | 13 | 17 | Cyst -3, meningeoma |
| MO chronic | 16 | 16 | 8 | |
| MA episodic | 7 | 4 | 3 | Cyst -2 |
| MA chronic | 5 | 5 | 3 |
Figure 8. MRI of the brain of a 42-year-old patient suffering from chronic migraine without aura (more than 15 attacks per month, more than 3 months). Left - multiple foci of ischemic origin in the white matter of the frontal lobes, more pronounced on the side of pain. On the right is a tractography. No pathological changes were found.
Figure 9. MRI of a 30-year-old female patient, MO, episodic form. Left - a single ischemic focus on the side of the pain. Right - Perfusion-weighted study with contrast - changes in blood flow in the interictal period.
Figure 10. Decrease in the frequency of migraine attacks against the background of therapy for each attack with the use of tab. Imigran 100 mg
Table 6. What patients want from their migraine treatment (4)
Figure 11. The result of laboratory diagnostics of ImuPro 300 in a 32-year-old patient with chronic MO
Figure 12. Relief of migraine headache over a period of 2 hours with the use of Imigran nasal spray - 20 mg versus placebo
Figure 13. Effect of Imigran nasal spray on symptoms associated with migraine
Bibliography
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The prevalence of M in the world averages 14%, it is more common in women. According to a Russian population study, the prevalence of M in the Russian Federation for 1 year was 20.8%, which significantly exceeds the world indicators.
Usually M first appears at the age of 10 to 20 years, at 30–45 years the frequency and intensity of M attacks reach a maximum, after 55–60 years M, as a rule, stops. In some patients, typical M seizures persist beyond age 50.
Etiology and pathogenesis
In 60–70% of patients, M is hereditary. It has been shown that patients with M are characterized by increased excitability of neurons in the cerebral cortex and the spinal nucleus of the trigeminal nerve, which increases when exposed to endogenous and exogenous migraine triggers. Migraine hypertension is based on neurogenic inflammation and secondary vasodilation, which develop as a result of the release from the perivascular fibers of the trigeminal nerve of pain peptides-vasodilators (including calcitonin-gene-related peptide (CGRP)), and activation of pain receptors in the walls of blood vessels (primarily Pain impulses enter the sensory cortex of the brain, which creates a sensation of pulsating pain.The mechanism of migraine aura is associated with the propagation in the direction from the visual cortex to the somatosensory and frontotemporal regions of the wave of neuronal depolarization (spreading cortical depression (CDD), the speed and topography of which determine the rate, nature and sequence of the symptoms of the aura.
Classification
According to the International Classification of Disorders with Headache and Facial Pain (International Classification of Headache, 3rd revision, ICGB-3 beta, 2013, www.headache-society.ru , www.painrussia.ru , www.paininfo.ru , www.ihs-headache.org ), migraine refers to primary (benign) cephalalgias, which are not associated with organic damage to the brain, cerebral vessels and other structures located in the head and neck.In ICGB-3, there are 3 main forms of migraine: M without aura, M with aura, chronic M (HM); as well as complications M, possible M and episodic syndromes that can be combined with M. The most common are M without aura (up to 80% of cases) and M with aura (up to 20% of cases).
M without aura(formerly simple M) is manifested by recurrent seizures with the typical characteristics of hypertension described above and accompanying symptoms (Table 1).
M with aura(formerly classic M) is characterized by the presence of an aura followed by a GB phase. The aura is more often represented by one-sided, completely reversible visual, less often sensitive and other cerebral symptoms (for example, speech impairment), which develop gradually, on average, 10-30 minutes before the GB phase and / or accompany it. At the same time, HD and accompanying symptoms meet the criteria for M without aura (items B, C, D, the second column of Table 1). In ICGB-3, 4 subtypes of M with aura are distinguished: M with a typical aura, M with a stem aura, hemiplegic and retinal M.
M with a typical aura. The aura is represented by visual and / or sensory and / or speech disorders, but without muscle weakness; with gradual development and duration of each symptom no more than 1 hour. If HD does not occur during or after a typical aura, then such a subtype is classified as "typical aura without HD."
M with stem aura(earlier - M basilar type, basilar M). The aura is distinguished by the stem symptoms of the aura (dysarthria, dizziness, tinnitus, hypoacusia, double vision, ataxia, decreased level of consciousness), but without muscle weakness. At the same time, symptoms of a typical aura are almost always present.
Hemiplegic M... The aura is characterized by fully reversible muscle weakness and typical aura symptoms; stem symptoms are possible. Sporadic and familial hemiplegic M are distinguished (4 types - depending on the type of gene in which the mutation / CACNA1A, ATP1A2, SCN1A is found and with mutations in other genes).
Retinal M. The aura manifests itself as a monocular visual disorder in the form of scintillations (blinking), scotoma, blindness.
Chronic M(formerly the transformed M). It manifests itself as daily or almost daily GB (more than 15 days a month for more than 3 months), of which at least 8 days a month correspond to migraine GB; can develop in patients with M both without aura and with an aura. An important auxiliary criterion for the diagnosis of HM is the presence of typical attacks of episodic M at the onset of the disease (criterion B).
Diagnostic criteria for chronic migraine
A. GB (migraine-like and / or HDN-type) ≥15 days per month ≥3 months, meeting criteria B and C ..B. History of ≥5 attacks of M without aura (1.1 according to criteria B – D) and / or M with aura (1.2 according to criteria B – C).
C. ≥8 days per month for ≥3 months. meets 1 or more of the following criteria:
- M without aura (1.1 according to criteria C and D) (Table 1, right column);
- M with aura (1.2 according to criteria B and C) (Table 1, left column);
- in the patient's opinion, there was an M attack interrupted or relieved by triptan or ergotamine.
D. GB does not correspond to a greater extent to another diagnosis from ICGB-3 beta.
HM and drug abuse. With the uncontrolled and frequent use of analgesics, ergotamine preparations and triptans in patients with M, the formation of drug-induced headache (LHB, or abusus GB) is possible. LHB is characterized by the occurrence of GB for 15 or more days a month for more than 3 months. with excessive use of any means for the relief of hypertension and is usually relieved after the abolition of the "guilty" anesthetic drug. The greatest clinical significance in Russia is "GB with excessive use of analgesics or combined analgesics."
For the diagnosis of LHB, the main diagnostic parameter is “number of days per month with pain relievers” (≥15 days per month for simple analgesics / NSAIDs and ≥10 days for triptans, combined analgesics, ergotamine derivatives and opiates). One of the characteristic symptoms of LHB is the patient's awakening from hypertension at night with the need to take another dose of an analgesic. When determining the criteria for LHB in a patient with HM, a dual diagnosis should be established, for example: "Chronic M. Drug-induced hypertension associated with the use of combined analgesics and triptans."
Possible M. A GB attack meets all diagnostic criteria M without aura or M with aura (Table 1), except one. In such a situation, additional examinations should be carried out to exclude the symptomatic nature of M.
Episodic syndromes that may be associated with migraine(formerly - children's periodic syndromes, periodic childhood syndromes). The section includes 3 groups of syndromes: recurrent gastrointestinal disorders in the form of a syndrome of cyclic vomiting and abdominal M; benign paroxysmal dizziness; benign paroxysmal torticollis.
Provoking factors
Attack M can be provoked by a number of endogenous and exogenous factors, possibly a combination of several triggers.Factors provoking a migraine attack
Diet: hunger, irregular meals, delayed, skipped or insufficient meals, certain foods (cheese, chocolate, nuts, smoked meats, chicken liver, avocados, citrus fruits, foods containing caffeine, or refusal to eat them regularly, dehydration).Alcohol (especially red wine)
Hormonal: menstruation, ovulation, estrogen hormone replacement therapy, combined oral contraceptives.
Psychological: stress, anxiety, depression, fatigue, relaxation after stress.
Weather changes.
Exercise stress.
Lack or excess of sleep at night.
Others: stuffiness, odors, visual stimuli (bright or flickering light), noise, staying at an altitude, vestibular stress, air travel with the intersection of several time zones, sexual activity.
Complications of migraine
There are 4 complications M: migraine status, persistent aura without a heart attack, migraine infarction, epileptic seizure caused by a migraine aura. In clinical practice, these complications are relatively rare.Diagnostics
The diagnosis of M is exclusively clinical and is based on the history data, a thorough analysis of the characteristics of hypertension and their compliance with the diagnostic criteria of the ICHD. The diary of GB has diagnostic value, which allows one to distinguish an attack of M from an attack of HDN and other GB; specify the frequency of M (HD ≤ 15 days / month - episodic M / episodic attacks M without aura or M with aura; HD ≥ 15 days / month - chronic M), and also identify the abuse of painkillers (drug abuse).At questioning In patients with M, attention should be paid to possible comorbid disorders (CI), which significantly impair the quality of life of patients in the interictal period, contribute to the chronicity of M and require treatment. The most common CDs: depression, anxiety-phobic disorders (including panic attacks), nighttime sleep disturbance, episodic HDN, drug abuse, and other pain syndromes. Severe mental disorders and drug abuse are indications for referring the patient to a cephalgologist (specialist in the diagnosis and treatment of hypertension).
Objective examination. As a rule, no organic changes are detected in the somatic and neurological status. If they are found, additional examinations should be carried out to exclude the symptomatic nature of GB.
Additional research. In patients with M, as in other primary hypertension, most research methods (EEG, USDG and DS of the vessels of the head and neck, X-ray of the skull, MRI / CT, examination of the fundus) are uninformative; their implementation is impractical, since none of the methods reveals changes specific to M. Laboratory and instrumental studies should be carried out only if there is a suspicion of the symptomatic nature of hypertension in the following cases: an atypical clinical picture, changes in the neurological status, or the presence of "danger signals".
The list of warning symptoms ("danger signals") in patients with hypertension:
GB, which first appeared after 50 years, or GB, which has changed its course;"Thundering GB" (GB, increasing up to 10 points on the VAS (visual analogue scale of pain) for 1–2 s);
strictly one-sided GB;
progressively worsening hypertension without remission;
sudden onset, unusual for the patient, GB;
atypical migraine aura (with unusual visual, sensory, or motor impairment and / or duration> 1 hour);
changes in consciousness (stunnedness, confusion, amnesia) or mental disorders (delirium, hallucinations, etc.);
focal neurological signs, symptoms of a systemic disease (fever, skin rash, stiff neck muscles, arthralgia, myalgia);
signs of intracranial hypertension (increased hypertension with coughing and physical exertion), morning hypertension;
swelling of the optic nerve head;
HIV infection, cancer, endocrine and other systemic disease or head trauma in history;
debut of GB during pregnancy or in the postpartum period;
ineffectiveness of adequate treatment.
The diagnostic algorithm of patients with a complaint of hypertension is shown in Figure 1. In typical cases, if the clinical picture corresponds to the diagnostic criteria M and in the absence of suspicion of the symptomatic nature of hypertension, a diagnosis of one of the forms of M should be established, if necessary, the diagnosis should include actual comorbid disorders and immediately, without additional examinations, prescribe treatment for the patient.
Treatment
Treatment with M is primarily aimed at alleviating the course of the disease (attacks of hypertension and interictal period), improving the quality of life of patients and preventing the chronicity of the disease. Treatment M includes: 1) relief of a painful attack; 2) preventive therapy; 3) patient education (behavioral therapy).Treatment of patients with uncomplicated M can be carried out at the primary care stage by both a neurologist and a GP. Patients with a severe course of M, including those with HM, multiple comorbid disorders, drug abusus should be optimally observed in specialized centers of hypertension.
Treatment of an attack is aimed at reducing the intensity, duration of the painful episode and associated symptoms, as well as restoring the general condition of the patient. To relieve an attack of M, analgesics and / or NSAIDs (preferably uncombined), triptans, and less often ergotamine-containing drugs are used (Tables 2, 3). Treatment of an attack should be started as early as possible (within the first 30 minutes of an attack). In patients with a short history of M and mild seizures, simple analgesics have a good effect (Table 2).
It is permissible to use monocomponent analgesics for no more than 14 days a month in order to avoid the development of abusal hypertension. Due to the high risk of LHB, the use of combined analgesics containing caffeine, codeine and barbiturates should be limited (no more than 9 days a month), and in patients with a frequency of pain episodes of 5 or more per month, the use of drugs of this group is not recommended. Due to the risk of agranulocytosis, the use of drugs containing metamizole sodium (analgin) is not recommended.
In a number of patients, lornoxicam at a dose of 8 mg at the beginning of an attack of M may be effective (included in the Russian standard of primary health care for M).
With severe nausea and vomiting 10-15 minutes before taking analgesics, it is advisable to use antiemetics: metoclopramide and domperidone, which reduce gastrostasis and improve the absorption of pain medications.
The most effective and high level of evidence (A) are specific drugs - agonists of serotonin receptors like 5HT1 triptans (Table 3), the indication for which is the relief of an attack of M. Triptans have an advantage in patients with initially severe seizures and severe maladjustment, as well as with a long history of M, when the effectiveness of analgesics is significantly reduced.
With M without aura, triptans should be taken at the beginning of the attack (in the first 30 minutes), with M with aura - at the end of the aura phase / at the very beginning of the GB phase. If one triptan is ineffective, others should be tried, but to assess the effectiveness of each triptan, the drug must be used for at least 3 attacks. If one or more triptans are taken regularly for ≥10 days per month for ≥3 months. there is a high risk of developing abusal (triptan) hypertension.
Contraindications for the appointment of triptans are associated with their potential constrictive effect on arteries: ischemic heart disease (IHD) (including myocardial infarction and postinfarction cardiosclerosis), occlusive peripheral vascular disease, stroke or a history of transient ischemic attack.
Derivatives of ergotamine (ergot alkaloids), including in the form of combined agents, are less effective and safe.
Preventive treatment indicated for patients with frequent episodic and chronic forms of M. Preventive treatment is aimed at reducing the frequency and severity of attacks, overcoming the abuse of drugs for the relief of hypertension, treating comorbid disorders and improving the quality of life of patients and is recommended in the following cases:
≥3 intense M attacks within a month and ≥8 days per month with hypertension with adequate relief of M attacks;
severe and prolonged auras, even with a low frequency of M attacks;
ineffectiveness or poor tolerance of drugs for the relief of seizures;
chronic M (number of days with GB> 15 per month);
severe comorbid disorders (depression, anxiety disorders, drug abuse, etc.);
M subtypes posing a risk of brain damage (stroke): migraine infarction or migraine status in history, M with stem aura, hemiplegic M;
the patient himself prefers preventive therapy to alleviate the course of M and restore the quality of life.
Prophylactic treatment is considered effective if within 3 months. therapy, the number of days with GB decreases by 50% or more from the initial level (Table 4).
In patients with episodic attacks of M, beta-blockers (metoprolol, propranolol), candesartan, anticonvulsants (valproic acid, topiramate), as well as antidepressants (amitriptyline and venlafaxine), which, along with antidepressant and V). In particular, venlafaxine blocks the reuptake of the most important pain neurotransmitters serotonin and norepinephrine, thereby disrupting the transmission of pain impulses and increasing the pain threshold. A prolonged dosage form of venlafaxine with a constant and uniform release of the active substance (Newvelong® 75 and 150 mg), which increases patient adherence to treatment, has clinical advantages in terms of antidepressant and analgesic effects.
The drugs with the level of persuasiveness of recommendations C include: acetylsalicylic acid, coenzyme Q10, riboflavin, gabapentin and some other drugs (Table 4). In particular, it has been shown that a special dosage form of coenzyme Q10, which penetrates the blood-brain barrier, idebenone (Noben®), due to the replenishment of coenzyme Q10, has a positive effect on the function of mitochondria of nerve cells: it restores ATP synthesis, increases blood supply and the volume of incoming oxygen, in including in the neurons of the pain matrix structures. In clinical studies, long-term therapy with idebenone (at a dose of 300 mg / day for 4 months and at a dose of 90 mg / day for 3 months) led to a significant decrease in the number of days with headache per month, the duration of migraine attacks and the intensity of headache. , as well as the need for taking painkillers. Noben® (at a dose of 60–90 mg / day for 3-4 months) can be used as an additional component of preventive therapy M along with drugs of the first choice (beta-blockers, antidepressants, anticonvulsants), especially in patients with concomitant mild cognitive impairment and decreased performance.
Principles of preventive drug treatment M:
The duration of the course of treatment is from 3 to 12 months. (on average, 4–6 months for M with episodic attacks, 12 months for HM), then an attempt is made to gradually withdraw the drug (s) or reduce their dosage.
Treatment begins with monotherapy with a drug with proven efficacy; with insufficient effectiveness of monotherapy, a combination of 2 or even 3 drugs of different pharmacological groups may be more effective, also with proven efficacy, starting with the minimum recommended doses.
When choosing a prophylactic agent, concomitant / comorbid diseases should be taken into account. The preferred choice is a drug that is also effective in treating comorbidities (eg, a beta-blocker in a patient with M and hypertension, an antidepressant in a patient with M and comorbid depression).
The drug must be taken with a minimum dose, increasing it to an adequate therapeutic dose for a time sufficient for the development of a clinical effect (the initial effect is usually achieved after 1 month of treatment in an adequate dose, the maximum - after 2-3 months) or until side effects appear.
To minimize side effects, it is advisable to slowly increase the dose.
If the therapeutic effect is not obtained within 2-3 months. therapy, then the drug is replaced with another or a combination of drugs.
It is necessary to avoid situations that lead to excessive use of pain medications: due to insufficiently effective prophylaxis (due to an incorrectly selected drug or an insufficient dose) and / or the effect of therapy for a concomitant disease (for example, taking NSAIDs due to concomitant back pain may increase drug abuse and contribute to the chronization of M).
To improve the effectiveness of treatment, patients should follow recommendations for lifestyle modification, first of all, exclude potential triggers of M attacks and factors of chronicity of the disease (abuse of analgesics, stress, excessive consumption of caffeine).
Non-drug methods. Biofeedback (BFB) and cognitive-behavioral therapy (CBT), aimed at overcoming stress, correcting pain behavior, and teaching psychological and muscle relaxation, are moderately effective (evidence level B-C). CBT is primarily indicated for patients with emotional-personality, somatoform, and senesto-hypochondriacal disorders; in severe cases, consultation and supervision of a psychiatrist is necessary.
For patients with M and severe dysfunction of the pericranial muscles, post-isometric relaxation, massage of the collar zone, manual therapy, remedial gymnastics, acupuncture (level C) are recommended. Corticosteroid and local anesthetic blockade of the large occipital nerve using corticosteroids and local anesthetics is recommended as an adjunctive therapy in combination with other therapies (grade B).
Neuromodulation... Transcranial direct electrical stimulation and transcranial magnetic stimulation (TMS) (level B) are possible as additional methods of treatment, including for forms that are resistant to all types of drug therapy (refractory HM); stimulation of the occipital, supraorbital, and less often the vagus nerves (level C).
Behavioral therapy is a necessary stage in the effective management of patients with M, should be carried out during a conversation with the patient and include: clarification of the benign nature and mechanisms of M, dissuasion in the presence of an organic cause of hypertension and the inappropriateness of additional research, discussion of the role of seizure provocateurs and the need to avoid them, risk factors chronicity of M (drug abuse, stress, mental and other comorbid disorders), as well as a brief justification for the choice of treatment tactics (mechanisms of action of the prescribed prophylactic agents).
HM treatment. Due to the severe course of the disease and multiple comorbid disorders, optimal management of patients with HM should be carried out in the conditions of specialized hypertension centers; the duration of treatment should be at least 1 year.
Topiramate and botulinum toxin type A (BTA) have proven efficacy in HM, including in patients with drug abuse (level A). Topiramate is prescribed for a long course (12 months) with dose titration of 25 mg per week, starting from 25 mg to 100 mg / day.
BTA is associated with the interruption of neurogenic inflammation, which leads to sensitization of peripheral nociceptors and, subsequently, to central sensitization. The drug is injected intramuscularly according to a special PREEMPT protocol into 7 muscle groups of the head and neck ( mm. frontalis, mm. corrugator supercilii, m. procerus, mm. temporalis, mm. occipitalis, mm. trapezius and mm. paraspinalis cervicis); the total dose for 1 procedure is 155-195 U. The analgesic effect develops gradually over the course of 1 month. after injections and persists for at least 3 months; to achieve stable improvement, at least 3 repeated injections are recommended 1 time per 3 months. ...
Forecast
Patients with M and other primary hypertension after the appointment of treatment should be under medical supervision for 4-12 months. (depending on the severity of GB). Repeated visits to assess the effectiveness of therapy should be carried out 1 time in 2-3 months. In most patients, timely and correct behavioral therapy, effective relief of M seizures and adequate preventive treatment within 2–3 months. can significantly reduce the number of days with hypertension, the use of pain medications, the severity of comorbid disorders and improve the quality of life.Migraine is a widespread disease that occurs in 6% of men and 18% of women (Rasmussen B. K. et al., 1991). Despite the fact that migraine therapy is well developed (according to the American Association for the Study of Headache, the effectiveness of correct treatment can reach 95%), more than 70% of patients are not satisfied with the treatment result (Lipton R. B., Stewart W. F., Simon D ., 1998). This is partly to blame for the patients themselves, who do not go to the doctor, self-medicate, ignore the recommendations received. However, in many cases, the low effectiveness of therapy is the result of inadequate medical care. Some doctors continue to treat migraine patients based on outdated information, without considering the possibilities of modern migraine treatments. However, the difficulty in treating headaches is not only due to the “correctness” of the choice of the drug. Migraine is a complex neurobiological disorder with a multifactorial pathogenesis, and the problem of its treatment cannot be solved with the help of any one, even a new and effective drug. In order to be successful, it is necessary to consider a number of aspects, both purely medical and psychological.
In the treatment of migraine, three tasks can be distinguished - the prevention of attacks, their treatment and prevention.
Teaching the patient to identify precursors, identify migraine triggers, and avoid situations that trigger migraines can prevent or significantly reduce the number of attacks without medication.
Treatment of seizures... Many patients with migraine are maladjusted by the fear associated with anticipating an attack. In this regard, it is very important to work out together with the patient the tactics of treatment for various scenarios of the development of migraine.
If migraine attacks are frequent (more than 2 times a week) and / or if behavioral and pharmacological measures are ineffective, it is necessary to raise the issue of preventive treatment. Indications for prophylactic treatment are also some special forms of migraine: hemiplegic migraine or migraine with aura with persistent neurological deficit.
Preventing migraine attacks
The success of treatment depends largely on the ability of the doctor to teach the patient to recognize triggers and avoid situations that provoke migraines. According to our research, at the first story, about 30% of patients who visit a doctor note the connection between the onset of headache and any factors (Danilov A.B., 2007). With careful questioning using a special questionnaire, which lists all possible triggers of headache, the detection rate of such factors rises to 85%.
The difficulty of detecting provoking factors can be explained by the fact that some of them never cause a migraine attack in some patients, while in others they do, but not always. For example, many alcohol-sensitive patients notice that if they are in a good mood, relaxed, follow a low-carb diet, then a moderate amount of white wine does not lead to negative consequences. If these patients are tense and eat a lot of sweets, then the same wine can cause them a severe migraine attack. When the presence of migraine triggers is not obvious, it is advisable to use a headache diary, which helps to recognize the factors provoking the development of migraine.
In a study conducted at our department, it was shown that in some patients a migraine attack occurred not at the height of emotional stress, but at the end of a stressful situation: after a responsible speech, after signing a difficult contract, at the beginning of a vacation ("migraine of the day off"), after receiving a promotion, etc. Chronic stress (family conflicts, overload at work) contributed to an increase not only in the frequency of attacks, but also in the intensity of headaches. At the same time, the strength of the provoking factor depended on the importance that the patient attached to events in accordance with his attitudes and coping strategies - the situation became / did not become “stressful” depending on the patient's individual reaction to it. It was noted that men were more inclined to attach importance to problems related to professional activities, while women were more concerned about their social relations at work and at home (Danilov, 2007).
In susceptible individuals, food can cause headaches. Most often, such triggers are meat (pork, game), as well as animal organs (liver, kidneys, goiter, brains), sausages and sausages, herring, caviar and smoked fish, vinegar, salted and pickled foods, some types of cheese (cheddar, "Brie"), foods containing yeast (especially fresh bread), chocolate, sugar and foods containing it, citrus fruits (if consumed in large quantities), cream, yoghurts, sour cream, legumes, flavor enhancers such as monosodium glutamate, caffeine ( black tea, coffee), alcohol, especially red wine. It should also be borne in mind that the development of a migraine attack can also provoke skipping meals.
Other triggers of migraine are strong odors (and even pleasant ones, such as perfume, cigar smoke), vestibular stress, bright light, noise, smoking. In women, in addition, the development of headache can be triggered by certain days of the menstrual cycle or by the start of taking oral contraceptives.
Physical activity can also be a trigger for migraines. According to our research, 7% of women and 21% of men associate headaches with exercise. Migraine attacks can provoke exhausting physical exercises (for women - fitness, dancing, for men - running, football, fitness). Sports activities without physical exhaustion do not lead to headaches (Danilov, 2007).
In 10% of cases, migraine attacks occur during intercourse (Evans R. W., 2001). The cause of a headache that develops during sexual activity may not be migraine, but secondary dangerous disorders - aortic aneurysm and others, therefore, in this case, it is advisable to undergo a thorough examination. Fortunately, secondary headaches are rare. However, sexual activity can also help reduce or even stop migraine attacks. In a study by Couch J. R. and Bearss C. (1990), which included 82 women suffering from migraines, having sex when migraines appeared reduced the severity of headaches and other symptoms in every third patient, and in 12% of women, sex completely stopped the attack ... The effect was more pronounced in those women who experienced orgasm. The authors explain the observed phenomenon by the influence of antinociceptive opiate systems, which are activated during sex and contribute to the reduction or cessation of headache.
A number of migraine triggers, such as changes in the weather, certain days of the menstrual cycle, cannot be avoided. In these cases, it is important to simply be aware of the possible threat of migraine development and be prepared for the onset of an attack. Most of the other triggers can be controlled and should be communicated to the patient. So, for many patients, it may be an unexpected discovery that not only insufficient sleep and overwork, but also excessive sleep, the situation of getting out of a period of stress, overload can provoke a migraine attack.
Currently, many devices are proposed in order to reduce or avoid the influence of provoking factors of migraines, for example, special light-protective glasses, fluorescent lamps instead of "yellow" ones, earplugs, eye masks, special pillows. It's also important to be able to relax. There are special techniques that help to relax and prevent the development of headaches in cases where a stressful situation could not be avoided.
Treatment of seizures
Behavioral activities
Preparing for a likely attack. Achieving a feeling of control over the headache is an important factor in the success of treatment: pain can be exacerbated by anxiety gripping the patient waiting for a new attack, and the feeling of helplessness that occurs if the patient does not know how to cope with the attack. In the case when it is impossible to prevent the influence of a trigger or provoking situation, or when the patient fails to follow the doctor's recommendations, it is important to teach him what to do if the development of a headache is unavoidable.
First of all, it is necessary to help the patient learn to distinguish between the onset of a migraine. Many patients (usually with many years of experience with migraines) unmistakably distinguish migraines from other types of headaches. For the rest, the doctor's explanations about the features of migraine attacks (the presence of precursors, auras, impaired concentration, nausea, etc.) will be very valuable. The education of the patient in this case is of direct importance in the choice of drugs for arresting an attack. If a migraine of moderate to severe intensity is expected, then a drug from the triptan group is likely to be the best remedy in this situation. If the development of a headache of mild intensity is expected or the patient feels that in this case he is developing an episode of tension headache, then in this situation it is advisable to use a conventional analgesic or a drug from the group of non-steroidal anti-inflammatory drugs (NSAIDs).
It is important to select in advance a drug for arresting an attack, taking into account previous experience with the use of drugs (efficacy, the presence of adverse reactions), the patient's preferences and expectations, and the severity of the intended attack. The tactic of "waiting" is today recognized as wrong. Migraine attacks can last up to 72 hours, and the longer it takes from the onset of the first migraine symptoms, the worse the response to treatment. If you take the medicine as early as possible after the first signs of migraine appear, it is often possible to completely prevent or significantly reduce the intensity and duration of the headache and quickly return to social or work activity.
Providing conditions for a comfortable experience of an attack ... A number of behavioral interventions can enhance the effectiveness of drugs. If a migraine attack begins, it is advisable to stop exposure to irritating stimuli (bright light, loud speech, working at a computer monitor, activities that require physical or mental stress). Understanding of others is very important here. It makes sense for the patient to warn in advance his family members or co-workers and the authorities that he has migraine attacks, which can make him unable to work for 24 hours or more. They should be told that giving the patient the opportunity to stop work, take the medicine and sit in silence will dramatically increase the likelihood that they will be able to return to their normal activities after 2 hours, having successfully dealt with the attack.
Drug therapy
To date, many methods have been developed for the treatment of migraine, ranging from tea from wild rosemary branches to drugs of the triptan series. What is the best treatment? The best treatment is the one that is tailored to the individual needs of the individual patient.
Until recently, a stepwise approach was adopted in the treatment of migraines, according to which, initially, to stop an attack, it was proposed to use simple analgesics or drugs from the NSAID group. With insufficient effect, they switched to combined drugs. If the tried remedies proved to be ineffective, it was suggested to use drugs of the "upper stage" - triptans. Thus, triptans were used only in resistant cases.
This approach has often frustrated patients who would rather have a doctor prescribe an effective medication right away. With a stepwise approach, the patient, on average, had time to try about 6 drugs before finding the optimal remedy (Lipton R. B., 2000). It should be borne in mind that another failure in taking a new drug seriously undermines the patient's faith in the possibility of the success of therapy, increases anxiety, contributes to the development of depression and maladjustment, which worsens the prognosis of therapy.
The stratified approach to the treatment of migraine has proven to be extremely convenient for clinical use. It is based on the assessment of the impact of migraine on the patient's daily activity using the MIDAS (Migraine Disability Assessment Scale). The severity of a migraine is determined based on the answers to five simple questions about wasted time due to headaches in three main areas of life (study and work, housework and family life, sports or social activity). The MIDAS scale divides patients into 4 groups, where group I corresponds to minimal disruption of daily activity and low intensity of headache, and group IV is characterized by severe maladjustment and severe headache (Lipton R. B., Stewart W. F., 1998). Different drugs are offered for each group.
Treatment of seizures of mild intensity that practically do not worsen the quality of life of patients. Patients in this group rarely go to the doctor, because they are helped by physical methods of dealing with pain (heat, cold), numerous "folk" methods (cabbage leaf, lemon peel, peeled, etc.). From pharmacological agents for rare attacks of unexpressed headache, as a rule, simple analgesics (Analgin), paracetamol or drugs from the NSAID group are effective: ibuprofen (Ibuprofen, MIG 400, Nurofen), naproxen (Naproxen), indomethacin (Indomethacin), diclofenac (Voltaren ), etc. The choice of the drug should be made depending on the patient's preferences, taking into account the past experience of using drugs and the risk of gastrointestinal complications (table).
Treatment of moderate seizures. For moderate pain, NSAIDs are indicated. Combined analgesics containing codeine or caffeine (Caffetin, Solpadein, Tetralgin, Pentalgin) are more effective. These drugs can be purchased without a prescription. Many patients, unfortunately, become overly addicted to them, believing that it is necessary to be careful only when using prescription drugs. It should be remembered that over-use over-the-counter drugs can become ineffective and sometimes even cause an abusal headache, that is, a headache caused by overuse of the drug.
In case of severe maladjustment of patients with moderate intensity of headache, it may be advisable to start therapy with a triptan drug. The use of triptans can reduce the number of drugs that are taken by patients for symptomatic treatment of migraine and prevent chronic headache.
Treatment of high intensity seizures. With a high intensity of headache, it is recommended to immediately prescribe a drug from the triptan group. In some cases, the use of opioid analgesics is advisable. Clinical studies have shown high efficacy for the relief of migraine attacks of the combined drug "Zaldiar", which includes the weak opioid analgesic tramadol and the analgesic and antiperetic agent paracetamol. Thanks to this combination, it is possible to achieve high efficiency with a low number of side effects (Ekusheva E.V., Filatova E.G., 2007). Zaldiar does not belong to the group of narcotic analgesics, and any doctor can prescribe him on the prescription form No. 147.
Severe headache attacks are often accompanied by severe nausea and vomiting. In this case, it is advisable to use antiemetics: metoclopramide (Metoclopramide, Cerucal, Ceruglan), domperidone (Domperidone, Motilak, Motilium), chlorpromazine (Chlorpromazine, Aminazine). Some experts recommend using an antiemetic drug 20 minutes before taking an NSAID or triptan medication. If the attack is accompanied by nausea, it is advisable to use a nasal spray with triptan (Imigran) (table).
For very severe persistent migraine attacks, the use of corticosteroids (dexamethasone 8-12 mg intravenously or intramuscularly) is necessary.
In some studies, a good effect (“on the needle” effect) of Kormagnesin has been demonstrated for the relief of migraines of moderate or severe intensity (Danilov A.B. et al., 2004). There are other medical methods for stopping migraines, for example, leech therapy, injections of novocaine into trigger points, etc. These methods are very effective in the hands of those specialists who have developed them or have extensive experience in their use. Non-traditional approaches to headache treatment can be welcomed if they are effective, but they cannot be recommended for mass use without evidence-based research.
Features of drugs of the triptan series ... Sumatriptan is the gold standard for migraine therapy. The efficacy and safety of sumatriptan has been studied in 300,000 attacks (more than 60,000 patients) in clinical trials and in 200 million attacks in clinical practice over 15 years of its use. Patient satisfaction with this drug is 63% and significantly exceeds the satisfaction with drugs of other classes that are used to relieve migraines (Pascual J., 2007). Sumatriptan is more effective in patients with slow onset of headache. In our country, sumatriptan is produced in the form of tablets under the trade name Amigrenin, Imigran, Sumamigren, in the form of a spray - Imigran and in the form of Trimigren candles. Studies of generics of sumatriptan (Amigrenin, Sumamigren), conducted in our country, have confirmed its high efficiency (Vein A.M., Artemenko A.R., 2002; Tabeeva G.R., Azimova Yu.E., 2007).
Naratriptan (Naramig), zolmitriptan (Zomig), eletriptan (Relpax) belong to the second generation of triptans and have a greater selectivity of action compared to sumatriptan, which leads to fewer side effects and greater efficiency in some indicators. The use of these drugs is advisable when sumatriptan is ineffective.
The following recommendations have been developed for the use of drugs from the triptan group for the relief of a migraine attack. After the patient feels that he is developing a migraine attack of severe or moderate intensity, 1 tablet of the drug should be taken (minimum dose). If the pain disappears after 2 hours, the patient can return to normal activities. If after 2 hours the pain has decreased, but has not completely disappeared, it is recommended to take another dose (tablet) of the drug. Next time, you can immediately take a double dose of the drug (2 tablets).
If after 2 hours after administration there was no effect, the drug is considered ineffective. In this case, the question of replacing it should be raised. Some headache specialists suggest trying the drug 3 times before giving it up. Other doctors think that a new drug should be used on the next attack. We adhere to the second point of view, i.e. if the drug was taken in a timely manner during a correctly recognized migraine attack and after 2 hours the intensity of the headache did not change at all, then another drug should be taken at the next attack (triptan of another group or another manufacturer). Note that there is a pronounced variability in the effectiveness of the drug, including within the triptan series, depending on individual sensitivity. It is important to patiently select from the available arsenal the remedy that will be effective for a given patient.
Once an effective drug is found, one should not experiment with others. Encourage the patient to carry the medication with them at all times. You should not be afraid of addiction if the drug is used no more than 2 times a week. More frequent use of triptans can lead to side effects, including triptan abusal headache (headache caused by overuse of drugs to treat it). Also, do not exceed the maximum daily dose. There are contraindications to the use of triptans, such as the presence of hypertension and other cardiovascular disorders (for a complete list of contraindications, see the instructions for use). The choice of the drug should be carried out jointly by the doctor and the patient, taking into account the pharmacochemical characteristics, the presence of contraindications and individual sensitivity.
Preventive treatment for migraine
Prescribing preventive treatment is a demanding task that requires careful preliminary discussion with the patient. Preventive treatment is associated with side effects due to long-term drug use and requires patience from the doctor and patient. However, the lack of prophylactic treatment can lead to the abuse of analgesics and the development of abusal headache. Frequent migraine attacks are the basis for the onset of chronic migraine, as well as risk factors for vascular damage to the brain.
For the prevention of migraine, various pharmacological agents are used, including those for which this indication is not yet in the recommendations. Monotherapy is preferable; in difficult cases, combined treatment is allowed taking into account concomitant diseases. The drugs of choice are beta-blockers - propranolol (Anaprilin, Obzidan). Antidepressants and anticonvulsants, which occupy a leading position in the effectiveness of preventive treatment, still do not have this indication in the instructions for use. The most effective anticonvulsants are valproate and the new anticonvulsant topiramate. Clinical studies have shown that topiramate effectively prevents migraine attacks by significantly reducing their frequency. Its effect develops rather quickly - during the first month of therapy, there is a persistent long-term decrease in the number of attacks without the development of resistance. In comparison with other anticonvulsants, topiramate has a favorable tolerance profile (Brandes J. L., 2004).
Antidepressants have long been used to treat migraines. The basis for their use is the information accumulated in the treatment of chronic pain. Antidepressants reduce the accompanying symptoms of depression, which is either initially present in the patient or develops in connection with frequent migraine attacks. Antidepressants potentiate the action of analgesics and triptans, and some of them have independent antinociceptive or analgesic activity. The most favorable efficacy / safety ratio is observed in the new generation of antidepressants - venlafaxine (Velafax, Velaxin), duloxetine (Simbalta), milnacipran (Ixel).
Prospects for migraine treatment
A second phase of research is currently underway in Europe with a CGRP receptor antagonist, olcegepant, which, when administered intravenously, prevents intracranial vascular dilatation that occurs during migraine attacks. Research is also being conducted on the first tablet form of a CGRP receptor antagonist, MK-0974, to relieve a migraine attack (Doods H. et al., 2007).
A group of American scientists from the Ohio University Medical Center conducted research on the use of transcranial magnetic stimulation to interrupt migraine attacks with aura. According to the current theory, the development of migraine begins with an increase in electrical activity in the occipital lobe, after which the electrical impulse spreads throughout the brain, causing symptoms of a migraine aura. The essence of the technique is to interrupt this electrical activity using an electromagnetic pulse. More than two-thirds of patients treated with transcranial magnetic stimulation reported that two hours after the procedure, they either experienced no pain at all, or the pain was of moderate intensity. Less than half of the patients reported the same effect in the placebo group (Clarke B. M. et al., 2006).
Currently, clinical trials of a new drug, aerosol for migraine headaches, are underway. To supply the active substance, the patented technology for the manufacture of Stockatto inhalers is used, which has a number of features. The device has a built-in battery, which, when the piston is pressed, heats up one dose of a solid medicinal substance, turning it into an aerosol. The aerosol particle size - 1-3 micrometers - is optimal for deep irrigation of the lungs, where the drug is quickly absorbed and at a rate comparable to intravenous injections, it enters the circulatory system. The new drug, code-named AZ-001, is the Stockcato system with prochlorperazine, a drug used to treat symptoms such as nausea and vomiting. Recently, the results of studies were published that showed that when administered intravenously, this substance is effective for migraines. Thus, if clinical trials are successful, Stockcato Prochlorperazine will have undeniable advantages over tablets and intravenous injections, since it will combine the effectiveness of an intravenous drug with the convenience and ease of use, which will allow the inhaler to be used at home (Alexza news release, 2007).
Non-pharmacological aspects of migraine treatment
Despite the fact that advances in the field of pharmacology play a huge role in the treatment of migraine, the skill of the doctor is no less important, and first of all, his ability to build a dialogue with the patient. Here are the factors that are considered the most important by clinicians who are successful in migraine treatment.
Cooperation with the patient. Especially important is the doctor's sincere attitude towards the patient, which is manifested through non-verbal communication (intonation, facial expressions, gestures). The patient will immediately feel if the doctor tries to hide his irritation behind encouraging remarks because the patient wastes his time with his questions, when the diagnosis is clear and the patient has long been given a leaflet with prescriptions.
Involvement of the patient in the treatment process. It is necessary to explain to the patient the essence of the problem, the possibilities of treatment and involve him in the choice of therapeutic agents, taking into account past experience, preferences and expectations. The time spent on explaining the essence of the problem pays off with the high adherence of patients to treatment and, as a result, higher rates of effectiveness of the therapy.
Patient education and training. Many patients are frustrated by the fact that different doctors and numerous examinations do not reveal the physical cause of their headache. In this situation, it is advisable to spend time explaining the pathogenesis of migraine. It is also important to educate the patient to identify triggers and avoid situations that trigger migraines.
Assessment of the severity of the migraine. The severity of a migraine is determined not only by clinical manifestations, but also by how much the disease interferes with the patient's life.
Critically assess the patient's past experiences, attitudes and expectations. Often, patients who have already tried all known drugs and have not received the desired effect turn to a doctor. In these cases, it is important to carefully question the patient about previous experience with the drug in order to understand what the lack of effectiveness may be due to.
Conclusion
Thus, the treatment of migraine is a complex complex task that requires erudition from the doctor, a sensitive attitude towards the patient, good communication skills and patience. Currently, not only modern drugs have been developed, but also new approaches to treatment, which make it possible to select it based on objective criteria. However, a physician confronted with migraine treatment cannot be a simple performer of the proposed algorithms. In order for the therapy to be effective and safe, it is necessary to be creative in the choice of methods, taking into account the individual characteristics of the patients. It is also very important to create a trusting and at the same time business relationship with the patient, his education and active involvement in the treatment process. If the doctor manages to cope with all the listed tasks, the treatment will allow not only to stop the symptoms of the disease, but also to improve the patient's quality of life by eliminating or mitigating his social and labor maladjustment, that is, to achieve exactly what the patient comes to the doctor for.
For literature questions, please contact the editorial office
A. B. Danilov, Doctor of Medical Sciences MMA them. I. M. Sechenova, Moscow
Migraine is one of the most common neurological diseases, the main manifestation of which is repeated attacks of intense, throbbing and usually unilateral headache. It is believed that about 70% of all people have suffered at least one migraine paroxysm during their life.
Usually migraine develops between the ages of 18 and 30, the onset of the disease in childhood and, especially, in the elderly is much less common. The highest prevalence rates of migraine are typical for middle-aged people in the range from 30 to 48 years. Women suffer from this type of headache, as a rule, 2-3 times more often than men.
According to the results of modern epidemiological studies, carried out mainly in the most developed countries of the world, the prevalence of migraine in the population ranges from 3 to 19%. Migraines occur annually in 17% of women, 6% of men and 4% of children. The trend towards a steady increase in morbidity has been stable in recent years.
The very attacks of intense migraine headache, as well as the constant expectation of the possible occurrence of a new attack, significantly disrupt the ability of patients to productive work and good rest. The annual financial losses from reduced labor productivity due to migraines and the direct costs of treatment are many billions of dollars.
In the last decade, the concept of migraine has undergone significant changes, due to a certain breakthrough in the study of the subtle mechanisms of the development of the disease using genetic, neurophysiological, neurochemical and immunological methods. This opened up new possibilities for the effective treatment of migraine attacks and the prevention of their recurrence.
Migraine diagnostics
The official international classification of headaches considers migraine as a nosological form and along with tension headache and cluster headache refers it to the so-called primary headaches... Currently, the second edition of this classification has been adopted.
Migraine classification (ICHD-II, 2003)
1. Migraine
1.1. Migraine without aura
1.2. Migraine with aura
1.2.1. Typical migraine headache aura
1.2.2. Typical non-migraine headache aura
1.2.3. Typical aura without headache
1.2.4. Familial Hemiplegic Migraine (FHM)
1.2.5. Sporadic hemiplegic migraine
1.2.6. Basilar migraine
1.3. Periodic syndromes of childhood - precursors of migraine
1.3.1. Cyclic vomiting
1.3.2. Abdominal migraine
1.3.3. Benign paroxysmal vertigo
1.4. Retinal migraine
1.5. Complications of migraine
1.5.1. Chronic migraine
1.5.2. Migraine status
1.5.3. Persistent aura without heart attack
1.5.4. Migraine infarction
1.5.5. Migraine - an epileptic seizure trigger
1.6. Possible migraine
1.6.1. Possible migraine without aura
1.6.2. Possible migraine with aura
1.6.3. Possible chronic migraine
The diagnosis of migraine is established when the characteristics of the headache are consistent with clinical diagnostic criteria with the exclusion of the secondary nature of the pain syndrome. In this aspect, special attention should be paid to headache danger symptoms:
- the onset of the first attacks after 50 years;
- change in the typical nature of the pain syndrome;
- a significant increase in pain;
- persistent progressive course;
- the appearance of neurological symptoms.
Assistance in diagnosis is provided by taking into account the risk factors that provoke attacks of migraine headache.
Major risk factors for migraine attacks
| Hormonal | Menstruation; ovulation; oral contraceptives; hormone replacement therapy. |
| Dietary | Alcohol (dry red wines, champagne, beer); food rich in nitrites; monosodic glutamate; aspartame; chocolate; cocoa; nuts; eggs; celery; aged cheese; missed meals. |
| Psychogenic | Stress, post-stress period (weekend or vacation), anxiety, anxiety, depression. |
| Wednesday | Bright light, sparkling lights, visual stimulation, fluorescent lighting, smells, weather changes. |
| Sleep-related | Lack of sleep, oversleeping |
| Diverse | Traumatic brain injury, physical stress, overwork, chronic diseases |
| Medications | Nitroglycerin, histamine, reserpine, ranitidine, hydralazine, estrogen. |
The leading characteristic of migraine is its paroxysmal course - pain attacks are clearly separated by headache-free intervals. The most common clinical form of the disease is migraine without aura(up to 75-80% of all observations).
Diagnostic criteria for migraine without aura (ICHD)
A. At least 5 seizures meeting criteria B-D.
B. Attacks of headache lasting from 4 to 72 hours.
C. The presence of at least 2 of the following characteristics of pain:
1) one-sided localization;
2) pulsating character;
3) moderate to strong intensity;
4) increases with normal physical activity.
D. During a headache, at least one of the following occurs:
1) nausea and (or) vomiting;
2) photo and (or) phonophobia.
At migraines with aura the pain attack is preceded by an aura - a complex of focal neurological symptoms preceding the pain attack. The appearance of the aura is associated with transient ischemia of the cortex or brain stem. The nature of clinical manifestations depends on the predominant participation in the pathological process of a particular vascular basin. More often than others (up to 60-70%) there is an ophthalmic (or typical) aura.
Diagnostic criteria for migraine with aura (ICHD)
A. At least 2 seizures meeting point B.
B. At least 3 of the following 4 criteria:
1) complete reversibility of one or more aura symptoms indicative of focal cerebral cortical and (or) brainstem dysfunction;
2) at least one symptom of the aura gradually develops over 4 minutes, or two or more symptoms appear one after the other;
3) no aura symptom lasts more than 60 minutes;
4) the duration of the light interval between the aura and the onset of the headache is 60 minutes or less (the headache can begin before the aura or simultaneously with it).
C. The nature of the headache attack meets the general criteria for migraine cephalalgias.
For migraines with typical aura characteristic:
A. Meets the general criteria for migraine with aura.
C. Along with motor weakness, one or more aura symptoms of the following type occur:
1) homonymous visual disorder;
2) unilateral paresthesia and (or) anesthesia;
3) aphasia or unclassified speech difficulties.
Family history is important in the diagnosis of migraine. Approximately 70% of people with migraines have a positive family history. It was found that if both parents had migraine attacks, then the risk of morbidity in offspring reaches 80-90%, if only the mother suffered from migraine, then the risk of morbidity is about 72%, if only the father is 20-30%. It was also shown that in men with migraine, mothers suffered from this disease 4 times more often than fathers. In monozygous twins, migraine pain syndrome developed significantly more often than in dizygotic twins.
The differential diagnosis of migraine is usually carried out with the following conditions:
- aneurysm of cerebral vessels and its rupture;
- arterial hypertension;
- temporal arteritis;
- inflammatory lesions of the brain and its membranes;
- cluster headache;
- cranial neuralgia;
- brain tumor;
- acute disorders of cerebral circulation;
- acute sinusitis;
- paroxysmal hemicrania;
- psychology;
- vertebral artery syndrome;
- episodic tension headache.
Migraine pathogenesis
In the onset of migraine, genetic factors are of undoubted importance. One of the proofs of this is the existence of a monogenic form of the disease - family hemiplegic migraine... It was found that chromosome 19p13 is responsible for the appearance of this pathology. Currently, most specialists in the field of headache study believe that the mechanisms of development of various forms of migraine are determined by dysfunction of many genes, and environmental influences play an important role in its clinical manifestation.
According to modern concepts in the pathogenesis of migraine, as well as other paroxysmal conditions, the leading role belongs to nonspecific systems of the brain, namely, imbalance in the activating and synchronizing systems. The activating system includes the reticular formation of the midbrain and the limbic system. The synchronizing system includes the reticular formation of the medulla oblongata and the pons, as well as the nonspecific nuclei of the thalamus. The imbalance of the processes of excitation and inhibition, namely, the relative insufficiency of inhibitory influences creates conditions for the occurrence in various parts of the nervous system generators of pathologically enhanced excitation(GPUV). According to G.N. Kryzhanovsky (1997), they are the structural basis of neurogenic pain syndromes and represent an aggregate of interacting sensitized neurons with impaired inhibitory mechanisms and increased excitability. GPPV are capable of developing long-term self-sustaining pathological activity both under the influence of afferentation from the periphery and without its direct participation. Such generators arise mainly in structures that conduct and process nociceptive signals at different levels of the spinal cord and brain stem.
The results of neurophysiological studies of evoked potentials and reflex polysynaptic responses confirm the deficit in inhibition and characterize the insufficiency of the structures of the antinociceptive system in migraine.
The data obtained using positron emission tomography during a paroxysm of migraine pain made it possible to localize the area of metabolic and blood flow changes, which anatomically corresponds to the functionally important structures of the antinociceptive system - the dorsal nucleus of the suture and the blue spot. It is believed that this may indicate the presence of a "migraine generator" in the central nervous system.
Against the background of an imbalance in the processes of excitation and inhibition, excessive activation of the trigeminal nerve system occurs. This leads to the release of algogenic and vasodilating neuropeptides from its afferent endings (substance P, peptide associated with the calcitonin gene, neurokinin A). These neuropeptides dilate blood vessels, increase mast cell degranulation, platelet aggregation, vascular wall permeability, sweating of plasma proteins, blood cells, edema of the vascular wall and adjacent areas of the dura mater. This whole process is defined as aseptic neurogenic inflammation... In its development, the deficiency of peripheral noradrenergic influences (neuropeptide Y) and the activation of parasympathetic terminals secreting vasoactive intestinal peptide also play a role.
Aseptic neurogenic inflammation is a factor of intense irritation of the nociceptive terminals of the afferent fibers of the trigeminal nerve located in the vascular wall, which leads to the development of typical migraine pain.
An important role in the implementation of these mechanisms belongs to the serotonergic neurotransmitter system. In the central nervous system, it is represented by the nuclei of the central gray matter, the suture of the trunk and midbrain. This system modulates the tone of cerebral vessels and the functioning of the endogenous opioid and monoaminergic systems of the brain. A decrease in the level of serotonergic influences in the central nervous system contributes to the development of chronic pain and the obligatory accompanying emotional-affective disorders.
The neurotransmitter serotonin (5-hydroxytryptamine or 5-HT) implements its effects through a class of specific receptors, which, according to the modern classification, are subdivided into 7 populations. Of these, 5-HT1 and 5-HT2 receptors are of primary importance in the pathogenesis of migraine.
There are several subtypes of the 5-HT1 receptor.
5-HT1A - receptors are located in the central nervous system and, when activated, reduce vegetative (nausea, vomiting) and psychoemotional symptoms of migraine.
5-HT 1B - receptors are postsynaptic receptors of intracranial vessels. Their activation induces voosoconstriction.
5-HT 1D - receptors are localized in the endings and caudal nucleus of the trigeminal nerve. Stimulation of these receptors leads to a decrease in the release of vasoactive polypeptides and, thereby, helps to reduce the degree of neurogenic inflammation, and also reduces the excitability of neurons in the caudal nucleus of the trigeminal nerve, which is a relay station that controls the passage of ascending nociceptive streams to the optic tubercle.
The subtypes of 5-HT 2B / 2C receptors are widely represented in the central nervous system and are responsible for the transmission and control of nociceptive information. They are also located on the vascular endothelium, are associated with the function of nitrite oxide synthetase and regulate the local release of NO. Stimulation of the receptors activates the lipoxygenase and cyclooxygenase pathways of inflammation, leads to a decrease in the pain threshold, and the development of hyperalgesia. It is believed that the prodromal phase of migraine is caused by the activation of 5-HT 2B / 2C. Antagonists of this type of receptor are effective in the prevention of migraine.
Migraine treatment
Treatment of migraine consists of arresting the attack and course therapy in the interictal period, aimed at preventing new paroxysms of headache. The main requirements for modern treatments are efficiency, safety and speed of action. Financial aspects should also be recognized as important, since, as experience shows, the high cost of many pharmacological drugs significantly complicates the access of the vast majority of patients to effective therapy.
Relief of a migraine attack
The use of remedies for the relief of a migraine attack is aimed at eliminating headaches, accompanying painful vegetative and emotional-affective manifestations. Currently, the list of these funds is quite wide and the doctor's task is to select the optimal method of relief, taking into account the severity of paroxysms, as well as the somatic and psychological state of the patient.
Analgesics, non-steroidal anti-inflammatory drugs
This group of drugs is indicated for mild and moderate seizures. Their effectiveness is quite high, especially with early application. Use acetylsalicylic acid, paracetamol, combined analgesics, naproxen, ibuprofen, diclofenac... The action of this group of drugs is aimed at reducing neurogenic inflammation, suppressing the synthesis of pain modulators (prostaglandins, kinins, etc.), activating antinociceptive mechanisms with the involvement of the descending inhibitory serotonergic system.
Acetylsalicylic acid appoint inside at 500-1000 mg / day. Side effects from the gastrointestinal tract (nausea, vomiting, gastralgia, mucosal ulceration, bleeding), allergic rhinitis, conjunctivitis, Vidal's syndrome (rhinitis, polyposis of the nasal mucosa, bronchial asthma, urticaria), Reye's syndrome in children under 12 years of age (toxic encephalopathy, fatty degeneration of internal organs).
The therapeutic effect can be enhanced when combined with caffeine(400 mg / day orally), which potentiates the action of analgesics and causes vasoconstriction.
Paracetamol use 500 mg orally or rectally, the maximum dose is up to 4 g / day. With migraine, it is somewhat inferior acetylsalicylic acid by effectiveness, which is associated with its weak anti-inflammatory effect. The drug has practically no side effects on the gastrointestinal tract, allergic reactions are possible, and long-term administration of large doses causes a hepatotoxic effect.
Less commonly used naproxen(up to 500 mg / day) and ibuprofen(up to 800 mg / day) inside, diclofenac(50-100 mg / day) by mouth or rectally. With regular use, complications from the gastrointestinal tract, allergic manifestations, thrombocytopenia, anemia, liver and kidney damage are possible.
Long-term use of pain relievers can lead to the development abusal, i.e. drug-dependent headache. So, for aspirin the likelihood of such a transformation is significant with a total dose of more than 40 g per month. If the patient has a drug-dependent headache, it is necessary to cancel analgesics and prescribe antidepressant therapy. According to our data, in case of abusal headache, a good therapeutic effect is achieved using reflexology methods.
Dopamine antagonists and prokinetic agents
This group of drugs refers to adjuvants and is designed to relieve nausea and vomiting, the occurrence of which is due to the activation of the dopaminergic system during the initial phases of migraine. Use metoclopramide(10-20 mg by mouth, rectally or IV), domperidone(10-20 mg orally), levomepromazine(10-50 mg orally, 12.5-25 mg i / m). Gastroparesis, which develops during an acute migraine attack, leads to a decrease in the absorption of medications. Prokinetic agents such as metoclopramide enhances gastric motility and increases absorption.
Non-selective 5-HT 1 receptor agonists
The group includes ergot alkaloids ergotamine and dihydroergotamine(DHE), having a wide range of affinities and outside the 5-HT 1 -receptor system. They also bind to dopamine and adrenergic receptors.
Ergotamine administered orally or rectally at 0.5-1 mg (no more than 4 mg / day). Contraindicated in ischemic heart disease, arterial hypertension and obliterating diseases of peripheral arteries. Side effects due to the effect on dopamine and adrenergic receptors are manifested by nausea, vomiting, diarrhea, chest pain and paresthesia in the extremities.
Combined drug coffergot, includes as main components ergotamine(1 mg) and caffeine(100 mg ) ... The first dose is taken in a dose of 1-2 tablets, then 1 tablet every 30 minutes, but not more than 4 tablets per day and 10 tablets per week.
Dihydroergotamine(DHE) is an effective treatment for migraine attacks and is ergotamine differs in less frequency and severity of adverse reactions. It is not recommended to appoint patients with ischemic heart disease and severe arterial hypertension.
A convenient route of administration is intranasal spray inhalation diidergot... At the beginning of the attack, one standard dose (0.5 mg) is injected into each nasal passage. The second dose (0.5 or 1 mg) is administered no earlier than 15 minutes after the first. The maximum daily dose is not more than 4 mg, and the maximum weekly dose is not more than 12 mg.
For severe attacks, the solution dihydroergotamine injected subcutaneously, intramuscularly or intravenously at a dose of 0.5-1.0 mg, but not more than 3 mg / day.
Selective 5-HT 1 receptor agonists
This class triptans- the most effective drugs for the relief of severe migraine attacks . It includes highly affinity agonists for the 5-HT 1B and 5-HT 1D receptors.
Everything triptans contraindicated in patients with ischemic heart disease, arrhythmias, arterial hypertension. Taking drugs, especially parenteral administration, may be accompanied by discomfort and a feeling of heaviness in the chest and throat, paresthesias in the head, neck and extremities, anxiety, irritability, drowsiness, asthenia, difficulty breathing, etc.
Sumatriptan (amigrenin) is the first drug of this group introduced into clinical practice. The initial dose for oral administration is 50 mg (not more than 300 mg / day), the dose of the nasal spray is 20 mg, 6 mg is injected subcutaneously (not more than 12 mg / day).
Zolmitriptan belongs to the second generation of selective 5-HT1 receptor agonists. Due to its ability to penetrate the blood-brain barrier, it has both peripheral and central effects. The initial dose of the drug is 2.5 mg, repeated administration of 2.5-5 mg is permissible after 2 hours, the daily dose is not more than 15 mg.
Choosing a treatment for a migraine attack
Choosing the right way to treat a migraine attack is a challenge. The severity of the headache, the presence of comorbidities, the past experience of successful or unsuccessful use of anti-migraine drugs, as well as the availability of certain drugs, including the financial capabilities of patients to purchase them, should be taken into account.
There are two fundamental approaches to choosing a method for stopping an attack - stepwise and stratified.
Stepwise approach involves a sequential ascent from simple to complex, from cheap to expensive - from drugs of the first stage, including analgesics, nonsteroidal anti-inflammatory drugs, antiemetics, to selective agonists of 5-HT 1 receptors.
This strategy provides a sufficient individualization of the methods of therapy, however, it is not without its drawbacks, since in the case of a severe course of the disease, the sequential overcoming of all stages with the use of ineffective means delays the achievement of treatment success, leads to mutual misunderstanding between the doctor and the patient and to the refusal to continue therapy with this specialist. ...
Stratified approach based on an assessment of the severity of migraine attacks. A quantitative assessment of the severity of the disease based on taking into account the intensity of pain and the degree of disability is carried out using a special questionnaire MIDAS (Migraine Disability Assessment). Patients with mild seizures that do not interfere with their activities, whose therapeutic needs are significantly lower, can be treated with simple analgesics or use non-drug methods. For those with severe seizures, “specific medications with proven effectiveness” are prescribed.
Unfortunately, this approach is also not without its drawbacks, since it is based on the subjective opinion of patients about their condition. Therefore, high severity according to the questionnaire may be due, for example, to emotional-affective disorders, personality traits of the patient, or even emerging behavioral disorders (pain behavior, cognitive impairment). All this can lead to the fact that in a particular patient, obviously effective and very expensive drugs with a high therapeutic effect proven in special conditions will not give the desired result.
In practical terms, a stepwise and stratified approach should be rationally combined, guided by the logic of clinical thinking and relying, if possible, on objective criteria for assessing the severity of the disease.
Relief of migraine status
Migraine status occurs in 1-2% of cases and is a series of severe seizures following each other, or less often one very severe and prolonged seizure. All symptoms increase steadily over the course of a day or even several days. The headache becomes diffuse, bursting. There is repeated vomiting, leading to dehydration of the body, disruption of the water-electrolyte and acid-base balance, severe weakness, weakness develops, and convulsions may appear. In some patients, severe cerebral symptoms develop due to hypoxia, edema of the brain and its membranes.
A patient with a migraine status should be hospitalized urgently. The following set of activities is carried out:
- sumatriptan 6 mg s / c (up to 12 mg / day) or dihydroergotamine IV 0.5-1.0 mg (up to 3 mg / day);
- prednisolone 50-75 mg or dexamethasone 12 mg IV drip;
- lasix 2 ml / m;
- seduxen 2-4 ml in / in a jet slowly in 20 ml of 40% glucose solution;
- haloperidol 1-2 ml with indomitable vomiting;
- correction of water-electrolyte and acid-base balance.
Narcotic analgesics for migraine status are usually not used, because often do not give the expected effect, but may increase vomiting.
Migraine therapy in the interictal period
It should be noted that despite the significant amount of research carried out and a huge arsenal of drug and non-drug methods of treatment, the problem of effective therapy for migraine in the interictal period, aimed at preventing the development of new paroxysms, is still far from being resolved. This is largely due to insufficient knowledge of the pathogenesis of migraine in general and significant individual variability of the pathological process in different patients.
When deciding on the appointment of treatment in the interictal period, the following generally accepted indications are used:
- 2 attacks or more within 1 month, which lead to disability within 3 days or longer;
- the presence of contraindications or ineffectiveness of drugs for the relief of migraine attacks;
- the use of drugs to relieve seizures more often than 2 times a week;
- development of complications of migraine.
The results of our own research, experience in the practical treatment of headaches of various origins and analysis of the literature data allowed us to supplement this list with several more points:
- insufficiency of inhibition processes in the central nervous system according to neurophysiological studies of polysynaptic reflexes;
- the presence of actual emotional-affective disorders;
- concomitant chronic pain syndrome of other localization.
The preventive treatment of migraine in the interictal period should be started with the establishment of proper contact between the doctor and the patient. The clinician needs to help the patient define realistic expectations of the treatment by discussing the different therapeutic approaches and their advantages and disadvantages. It can be especially helpful to involve patients in the treatment process, for example through keeping a diary. The diary should record the frequency, severity, duration of migraine attacks, the degree of disability, the effectiveness of a particular type of therapy, side effects from the treatment.
In the process of analyzing the disease, the doctor must identify the main factors provoking migraine paroxysms in this patient, and teach him the main methods of preventing attacks. The objectives of interictal migraine treatment should first of all be achieved by changing lifestyle, behavior, interpersonal communication, diet, and only secondarily by prescribing one or another method of therapy. In this aspect, I would like to especially emphasize the value of non-drug treatment, since most migraine patients for many years have been forced to use pharmacological drugs to relieve headache paroxysms and additional drug load is simply unsafe for them.
Rational, group and suggestive psychotherapy, autogenous training are used as non-drug methods of migraine treatment; biofeedback, reflexology, physiotherapy, massage, exercise therapy, water procedures, spa treatment, etc.
Pharmacotherapy in the interictal period is based on the use of the following groups of medicines: 1) β -adrenergic blockers, 2) antidepressants, 3) antagonists of 5-HT 2B / 2C -receptors, 4) Anticonvulsants, 5) calcium channel blockers, 6) non-steroidal anti-inflammatory drugs.
Typically, pharmacotherapy begins with the use of small doses, followed by its gradual increase, since this tactic reduces the risk of developing adverse reactions and the likelihood of developing tolerance to the drug. Monotherapy is preferable, but sometimes it is safer to take 2 drugs, but at a lower dose. Patients often stop taking the medication after 1-2 weeks, considering it ineffective. It is important to make it clear to the patient that the desired result can only be achieved within a few weeks. If the headaches are well controlled, then a drug-free day can be taken, followed by a gradual dose reduction and withdrawal. The drug is replaced if a positive result is not obtained within 2-3 months. The total duration of preventive treatment should be at least 6 months.
β-blockers
Traditionally considered first-line drugs for the prevention of migraines. The biological basis of the effect of β-blockers in migraine includes 5-HT 2B antagonism, blockade of nitric oxide activity, followed by inhibition of dilatation of cranial arteries and arterioles. The clinical efficacy of β-blockers does not correlate with their ability to penetrate the central nervous system and β-receptor selectivity. Due to the possible hypotensive effect, this group of drugs is considered especially effective for the prevention of migraine, occurring against the background of arterial hypertension. With their anxiolytic effect, they are also effective in patients with severe anxiety.
The most commonly used drug is propranolol (anaprilin). Typically, treatment begins with 10-20 mg 2 times a day and within 1-2 weeks reach an average dose of 80-120 mg per day in 3-4 doses. Of the other β-blockers, nadolol is used at 40-160 mg / day once, atenolol - 50-100 mg / day, metoprolol - 50-100 mg / day in several doses.
The main side effects of β-blockers are increased fatigue, drowsiness and depression, memory impairment, impotence, orthostatic hypotension, and bradycardia also occur. Patients should be warned of the possibility of developing these symptoms so that they are recognized as early as possible. Patients who are engaged in physical activity or have a rare pulse (up to 60 beats per minute) should be notified of a decrease in heart rate. Perhaps some increase in body weight due to the ability of drugs in this group to cause hypoglycemia, which contributes to an increase in appetite.
The main contraindications for the use of β-blockers are bronchial asthma, heart failure, atrioventricular conduction disturbances, arterial hypotension, insulin-dependent diabetes, depression.
Antidepressants
Antidepressants are widely used to prevent migraines. It has been established that the effectiveness of antidepressants in migraine does not depend only on their psychotropic action.
Amitriptyline is one of the most commonly used antidepressants. Its therapeutic dose for migraine is 75-100 mg / day. The dose should be increased gradually to avoid excessive sedation. It is recommended to give two thirds of the dose at night. In addition to the antidepressant, this drug also has a sedative effect, which is important in the treatment of concomitant anxiety disorders.
The biological basis of its action in migraine is antagonism to 5-HT 2 -receptors. In experimental studies, it has been shown that it reduces the frequency of discharges in the spinal nucleus of the trigeminal nerve.
Antidepressants of the first generation (amitriptyline, clomipramine, maprotiline, etc.) differ in non-selectivity of neurochemical action, influence on many neurotransmitter systems, which not only take part in the implementation of the therapeutic effect, but also form many side reactions due to effects on cholinergic and histamine systems, a- and b - adrenergic receptors. Clinically, this can manifest itself as dry mouth, weakness, drowsiness, sinus tachycardia, slowing of intracardiac conduction, increased intraocular pressure, weight gain, etc. This limits the use of these drugs in patients taking MAO inhibitors, suffering from heart disease, glaucoma, prostate adenoma, bladder atony, etc.
Fluoxetine belongs to the group of selective serotonin reuptake inhibitors. It is prescribed at a dose of 20 mg / day in the morning. Other representatives of this group are sertraline(50 mg / day before bedtime), paxil(20 mg / day, in the morning).
It is assumed that the anti-migrenous activity of such drugs is based on an increase in the descending inhibitory serotonergic effects on the structures of the trigeminal nerve.
Side effects of selective serotonin reuptake inhibitors are manifested by agitation, akathisia, anxiety, insomnia (overstimulation of 5-HT 2 receptors) and nausea, stomach discomfort, diarrhea, headache (overstimulation of 5-HT 3 receptors). Contraindications for their use are pregnancy, lactation, severe liver and kidney disorders, simultaneous administration of MAO inhibitors, convulsive syndrome.
In the presence of severe anxiety-phobic disorders in migraine patients, it is recommended to prescribe antidepressants with sedative and anti-anxiety effects ( amitriptyline, Lerivona, fluvoxamine). With the predominance of depressive disorders and asthenic manifestations, it is preferable melipramine, fluoxetine, aurorix and etc.
Antagonists of 5-HT 2B / 2C -receptors
Vasobral is a combined preparation containing α- dihydroergocriptine(2 mg) and caffeine(With 20 mg). The effectiveness of the drug in the interictal period of migraine is determined by the ability of the ergot alkaloid dihydroergocriptine block 5-HT type 2 receptors. The dose is 1-2 tablets or 2-4 ml 2 times a day, the duration of treatment until the appearance of a clinical effect is at least 3 months. The combination is also effective dihydroergotamine(10 mg per day) with aspirin(80 mg per day).
Side effects include dizziness, drowsiness, tachycardia, decreased blood pressure, dyspeptic disorders. Contraindications are severe arterial hypotension, myocardial infarction, impaired liver and kidney function, the first trimester of pregnancy, lactation.
Metisergide is a derivative of ergotamine. It is an antagonist of type 2 5-HT receptors and histamine H1 receptors. This drug inhibits the vasoconstrictor and pressor effects of serotonin. The recommended dose is 4-8 mg / day.
Side effects are manifested by dyspeptic disorders, nausea, vomiting, weakness, drowsiness, sleep disturbances, irritability, and sometimes hallucinations. Long-term use can lead to the development of retroperitoneal, pleural, endocardial fibrosis, which usually regresses after discontinuation of the drug. To prevent fibrosis, it is recommended to take 3 week breaks in treatment every 6 months.
Anticonvulsants
Currently anticonvulsants are increasingly used in the preventive treatment of migraines. This is due to their influence on the leading links in the pathogenesis of the disease, in particular, insufficient inhibition in the central nervous system, hyperactivity of sensory neurons of the trigeminal system. These drugs enhance GABAergic inhibition, activate the action of endogenous antinociceptive systems, and reduce the pain sensitivity of vascular wall receptors.
Valproic acid used in doses from 800 to 1500 mg / day. While taking the drug, the frequency of attacks decreases by about 2 times, but the intensity of the headache during an attack does not decrease.
Side effects are manifested by drowsiness, dyspeptic symptoms, weight gain, alopecia, possibly a toxic effect of the drug on the liver and the hematopoietic system. Their frequency is over 10%. It is recommended to monitor blood levels of the drug and liver enzymes every three months.
Topiramate a dose of 50 to 100 mg per day is prescribed. The duration of the course of treatment is 3-6 months.
Levetiracetam it is used in the range from 250 mg / day to 500 mg / day. The drug was taken once in the evening. The duration of the course of treatment is at least 3 months.
General contraindications for the appointment of anticonvulsants for migraine are pregnancy and lactation, chronic hepatic and / or renal failure.
Calcium channel blockers
The use of calcium channel blockers is considered appropriate for migraine disorders accompanied by neurological manifestations, such as basilar migraine, hemiplegic migraine, migraine with persistent aura. Calcium channel blockers inhibit serotonin release, alter slow potential shifts, and prevent the development of pervasive cortical depression. The drug of choice is verapamil... Usually it is used in a daily dose of 120-200 mg, it is also relatively effective. flunarizine(10 mg per day) and nimodipine(60-120 mg per day).
Dizziness, increased fatigue, nervousness can be observed as side effects. Contraindications to the use of this group of drugs are bradycardia, atrioventricular block, Wolff-Parkinson-White syndrome, chronic heart failure.
Non-steroidal anti-inflammatory drugs (NSAIDs)
The mechanism of action of NSAIDs in migraine consists of two components - peripheral, which is due to the anti-inflammatory activity of drugs, and central, associated with the effect on the thalamic centers of transmission of afferent pain impulses.
The most studied and effective in the prevention of migraine is naproxen, which is used in a dose of 275 to 375 mg twice a day. There is evidence of successful application indomethacin and diclofenac... The widespread use of NSAIDs in migraine is limited by the high frequency of side effects from the gastrointestinal tract, as well as the likelihood of developing a drug headache. The need for long-term treatment significantly increases the risk of these complications. In this regard, drugs of this class are recommended to be prescribed for 5-7 days for the preventive treatment of menstrual migraine.
Thus, the treatment of migraine is a complex problem that requires taking into account the leading factors of the pathogenesis of the disease and the use of differentiated methods of treatment based on this. In our opinion, preventive therapy for migraine should be a priority. According to various authors, only about 10% of patients with migraine receive systematic therapy in the interictal period, while more than 52% of all patients suffering from this disease need it. The basis of therapeutic measures should be non-drug methods of exposure, which, if necessary, can be supplemented by the use of the most effective and safe medicines, among which a special place belongs to 5-HT2 receptor antagonists, modern anticonvulsants and antidepressants.
A.A. Yakupova
Kazan State Medical University
Department of Neurology and Neurosurgery, FPDO (Head of Department, Prof. V.I.Danilov)
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