(1) Neurotic headache: Headache mainly caused by mental and emotional factors or various pressures, such as common neurosis headache, hysteria headache, depression headache, tension headache (also called muscle contraction headache), anxiety headache, etc. This kind of headache is often accompanied by various neuropsychiatric symptoms, such as palpitation, shortness of breath, anxiety, insomnia and forgetfulness. This kind of headache has a long course, and it lasts for years. The headache lasts longer than the painless time, but the degree of headache is mild and moderate. See the web page of nervous headache.
(2) Migraine: that is, a vascular headache. Migraine is a common type of headache, which is paroxysmal neurovascular dysfunction and is characterized by recurrent migraine or bilateral headache. About 60% patients have a family history, and those who start to get sick after adulthood have less positive family history. The prevalence rate is more than 0/0% of the population/kloc-0, and women are more than men. The frequency of seizures varies from one to several times a year to one to several times a month. In addition to genetic factors, migraine is also related to cerebral blood flow, platelets and biochemical factors, diet, endocrine factors, etc., and emotional tension, hunger, lack of sleep, noise, strong light and climate change can all induce attacks. According to its manifestations, it can be divided into three types: typical migraine, common migraine and special migraine. Typical migraine is the most common type, accompanied by other symptoms, such as nausea and vomiting. Special types of migraine include ophthalmoplegia, hemiplegia, basilar artery and so on. See migraine webpage.
(3) Cluster headache: Also known as histamine headache, it is a kind of nerve-blood vessel dysfunction manifested as eye socket and head pain. Although it has similarities with migraine, it also has more differences: this disease is mainly seen in male patients, and the onset age is late, mostly between 30 and 50 years old. And the headache is without warning. Headache suddenly begins as a series of intensive headache attacks, which mostly start from one eye socket and its surroundings, spread to the ipsilateral temporal top and ear and nose, and also spread to the occipital top; The pain is drilling pain or pulsating disease, which is particularly severe. When the headache reaches its peak, the patient is often agitated and can't sit or lie quietly, but just walks back and forth in distress. Some patients have conjunctival congestion, tears, nasal congestion and runny nose, facial flushing, eyelid edema, nausea, anorexia, photophobia, etc. A few people (20%) may have homolateral Horner's sign (small eye fission, enophthalmos, miosis and anhidrosis on the same side). Seizures are most common after a nap and in the early hours of the morning, which can make patients wake up from sleep. Each headache lasts for half an hour to two hours, and then disappears quickly, and most of them can immediately resume their work before the headache. During the headache attack, almost every day 1 to several times, the time and place are very fixed, so it lasts for weeks to months; After months or years of remission, it can recur, often on the original side. Occasionally, the headache attack can last for 1 to several years, which is called chronic cluster headache.
(4) Headache after brain injury: Headache is the main symptom, but there are also dizziness, fatigue, insomnia, nervousness, excitability, inattention and memory loss. Headache is mostly on the injured side and can be accompanied by tenderness. Headache can be pulsating in nature or heavy pressure, mostly persistent pain, and is often intensified by mental factors, physical labor, sound, noise and light. The patient's performance is very similar to that of an excited depressive patient. There is no parallel relationship between the severity and duration of headache and the degree of head injury. The neurological examination was normal, and no abnormalities were found in EEG, CT and MRI scans. It may be related to fright, fear, and ideological concerns.
(5) Headache in children: Recurrent headache in children mainly includes neuropathic headache, vascular headache and muscle contraction headache, as well as headache after brain injury, sinusitis headache, brain tumor, epilepsy in children, headache caused by vision loss, etc., but headache caused by systemic diseases is more common. See the children's headache website.
(6) chronic daily headache: Chronic daily headache (CHD for short) refers to the frequent onset of headache for more than 15 days per month and the headache lasts for more than 4 hours every day. There are two types: primary and secondary. Primary CHD refers to having a headache for more than 15 days a month without organic or systemic diseases. A survey shows that 4-5% of the total population in the United States, Europe and Asia suffer from primary CHD, and chronic tension headache (that is, nervous headache) accounts for the first place in CHD, and chronic vascular migraine is the main one who goes to the clinic. See the relevant chapter for details. Secondary CHD refers to the patient suffering from organic diseases such as brain tumor and fever, which is beyond the scope of this site.
(7) Other types of organic headache:
Headache caused by cerebral hemorrhage or subarachnoid hemorrhage: Sudden headache with nausea, vomiting and disturbance of consciousness may cause cerebral hemorrhage or subarachnoid hemorrhage, which is more common in middle-aged and elderly people.
Headache caused by glaucoma: the headache is mostly located in the upper part of the orbit or around the eyeball, and is often accompanied by visual impairment.
Headache caused by brain tumor: those with dull headache and progressive aggravation accompanied by increased intracranial pressure such as nausea, vomiting and diplopia should be alert to the possibility of brain tumor.
Trigeminal neuralgia: People with severe lightning-like pain on one side of the face are often the characteristics of trigeminal neuralgia.
Other causes: benign cough headache, cold irritation headache and "sexual headache" related to sexual activities, etc. These headaches are mostly related to environmental, mental or emotional factors.
Therapeutic drug
① Specific drugs
A triptans (5-HT 1b/ 1d receptor agonists): Naletriptan, Rizatriptan, Sumatran, Zoletriptan and other drugs are safe and effective, and they are the first choice for moderate and severe migraine attacks without contraindications (Grade A); Non-specific drugs can be the first choice for migraine patients with poor curative effect and no contraindications (grade C); Patients with migraine with nausea and vomiting can be given sumatan intranasally/subcutaneously (grade C).
B ergotoxine: Dihydroergotimine (DHE) nasal spray is safe and effective, and it is the first choice for the treatment of moderate and severe migraine attacks (Grade A); DHE intramuscular injection/subcutaneous injection can be used for moderate and severe migraine attack, and static massage (DHE+ antiemetic) can be used for the treatment of severe migraine attack (grade B); DHE subcutaneous/intravenous injection/intramuscular injection/transanal administration can treat migraine attack with nausea and vomiting (Grade C), DHE subcutaneous/intramuscular injection/transanal administration can be used for any migraine patient with poor curative effect of non-specific drugs (Grade C); Ergotamine oral/anal administration or combined with caffeine can treat some moderate and severe migraine attacks (grade B).
② Nonspecific drugs
A antiemetic drugs: oral antiemetic drugs are auxiliary drugs for migraine treatment (grade C); Metoclopramide intramuscular injection/intravenous massage can be used only to relieve headache (grade B); The anal administration of mepiquat chloride can be used as an auxiliary drug for migraine attacks with nausea and vomiting (Grade C), and the intramuscular injection/intravenous injection/anal administration of mepiquat chloride and intravenous injection of chlorpromazine can be used for some moderate and severe migraine attacks (Grade B). 5-HT3 receptor blockers are ineffective in migraine attack alone (Grade B), but can be used to control nausea and vomiting during migraine attack (Grade C).
B Non-steroidal anti-inflammatory drugs (NSAIDs): NSAIDs or their caffeine complexes are the first-line drugs for mild to moderate migraine attacks and severe migraine attacks that have been effectively used in the past (Grade A); Acetaminophen can treat migraine attack (grade B); Paracetamol alone is not suitable for migraine attack (grade B); Ketorolic acid intramuscular injection can be used for migraine attack (grade C) under the guidance of a doctor.
C Analgesics containing isobutyric barbital: Due to the adverse reactions such as addiction, withdrawal reaction and drug-induced headache, the clinical use of this kind of drugs should be restricted or prescribed (Grade B).
D opioid analgesics: parenteral opioids or oral opioid analgesics combined with other drugs can treat migraine attacks without contraindications, such as butorphanol nasal spray for migraine attacks (Grade A); After weighing the risks of intensive sedation and drug overuse, parenteral opioids can be used as emergency drugs for migraine attacks (Grade B), such as butorphanol as emergency drugs for migraine attacks (Grade C). Because butorphanol is widely used in clinic, we must be alert to drug overdose and dependence.
E Other drugs: Isooctylamine alone or isooctylamine combined with other drugs can control mild to moderate migraine attacks (Grade B); Corticosteroids (dexamethasone/hydrocortisone) can be used for migraine status quo (grade C); At present, there is insufficient evidence of lidocaine nasal administration/intravenous massage in the treatment of migraine attack (grade B).
③ Evidence and recommendation of drugs for migraine attack (see Table 3 and Table 4).
Table 3 Evidence table of therapeutic drugs in migraine attack period
medicine
Level of evidence
Statistical efficiency
Clinical efficacy
side effect
serviceable range
Triptans:
Shumatriptan PR
A
+ + +
+ + +
Occasionally
Moderate and severe migraine patients who need non-oral administration and mild migraine patients who are ineffective with non-opioid drugs.
Triptan oral drugs:
Mild migraine patients with moderate to severe and non-opioid drugs ineffective
Nala qutan
A
+ +
+ +
seldom seen
Rizatriptan
A
+ + +
+ + +
Occasionally
sumatriptansuccinate
A
+ + +
+ + +
Occasionally
Zoli Qutan
A
+ + +
+ + +
Occasionally
Shumatriptan SC
A
+ + +
+ + +
common
Ergot drugs:
DHE IV
B
+ +
+ + +
common
Patients with low recurrence rate
DHE SC/ IM
B
+ + +
+ + +
Occasionally
Homotriptan oral drugs
DHE IV+antiemetic
B
+ + +
+ + +
common
Emergency medicine for migraine status quo
DHE PR
A
+ +
+ +
Occasionally
Patients with oral triptan and low recurrence rate
ergotamine
B
+
+ +
common
Some moderate and severe migraine attacks
Ergotamine caffeine
Antiemetic:
Chlorpromazine IM/ IV
C/ B
+ +
+ +
Mild to moderate
Adjuvant drugs for migraine attack
Metoclopramide IM
B
+
+
Even/common
be the same as the above
Metoclopramide PR/ IV
B
+ +
/ + +
be the same as the above
be the same as the above
Mepivalopramine
IV/ IM is a first-line adjuvant therapy in emergency, and PR is also an adjuvant therapy.
PR/ IM
B
+ + +
+ / + +
Occasionally
IV
B
+ + +
+ + +
common
NSAIDS and other non-opioids
Painkillers:
Panadol
B
+
seldom seen
Migraine during pregnancy
Ketorolic acid IM
B
+
+ +
seldom seen
Emergency medication
Oral NSAIDS:
Occasionally
First-line drugs for mild to moderate migraine attacks
Aspirin
A
+ +
+ +
Dichloramine phenylethyl ester
B
+ +
+ +
Potassium acid
Chlorobiphenyl propionic acid
B
+
+ +
Isobutyl phenylacetic acid
A
+ +
+ +
naproxen
B
+
+ +
Naproxen sodium
A
+ +
+ +
Combined use of painkillers:
Paracetamol, Ace.
A
+ + +
+ + +
First-line medication
Aspirin, caffeine
Barbiturates:
Isobarbital,
C
+ + +
Occasionally
Occasionally, limited use in
ASA, caffeine
Severe headache attack
Isobarbital,
B
+ +
+ + +
ASA, caffeine, codeine
Opioid drugs:
Butorphanol NS
A
+ + +
+ + +
common
Limited to moderate and severe migraine
Combined use of oral opioids:
Codeine,
A
+ +
+ +
Occasionally
be the same as the above
Panadol
Parenteral opioids:
B
+ +
+ +
common
Limited for emergency treatment of headache.
Butorphanol IM
Demerol IM/ IV
Meisantong IM
Other drugs:
Corticosteroids:
C
+
+ +
seldom seen
Status migraine
IV+antiemetic
dexamethasone
hydrocortisone
Isooctylamine complex
B
+
+ +
seldom seen
Mild to moderate headache attack
LidocaINe in
B
+ +
common
need to be decided or settled
Note: Refer to Table 1, Table 2, Table 7 and Table 8 for the explanations of evidence level, research level, statistical efficacy and clinical efficacy respectively; ? = I don't know; PR = Per rectum, administered through anus; SC = Subcuta-neous, subcutaneous administration; NS = Nasal Spray, nasal spray; IN = Intra nasal, administered by nose; NSAIDs = nonsteroidal anti-inflammatory drugs, non-steroidal anti-inflammatory drugs; ASA
= Acetylsalicylic acid, sodium acetylsalicylate;
Table 4 Recommended drugs for migraine attack
1 group
2 zu
3 zu
4 zu
5 zu
Specific drugs:
Paracetamol+codeine PO
Isobarbital, aspirin,+codeine PO
Paracetamol PO
Dexamethasone IV
Nala qutan PO
Isobarbital, aspirin, caffeine+codeine PO
Ergotamine PO
Chlorpromazine IM
Hydrocortisone IV
Rizatriptan PO
Butorphanol IM
Ergotamine+caffeine
Granisetron IV
sumatriptansuccinate
Chlorpromazine IV
Metulin IM ,PR
Lidocaine IV
SC ,IN ,PO
Zolitan PO
Dichloroamine POtassium phenylacetate po
Dihydroergotamine SC
Ergotamine+caffeine+
,IM ,IV ,IN
Pentobarbital+Bellafoline PO
Dihydroergotamine IV+antiemetic
Chlorobiphenyl propionic acid PO
Nonspecific drugs:
Isooctylamine complex
Paracetamol,
PO
Aspirin,
Ketorolic acid IM
Caffeine PO
LidocaINe in
Aspirin PO
Demerol IM ,IV
Butorphanol IN
Meisantong IM
Isobutyl phenylacetic acid PO
Metoclopramide IV
Naproxen sodium PO
Naproxen PO
Mepiropropane IV
Mepiprazole IM ,PR
Note: 1 group: at least 2 RCTs are confirmed to be effective; Group 2: at least 1 RCT is proved to be effective; Group 3: The conclusions of clinical studies are inconsistent or even mutual.
Contradictions; Group 4: it has been proved invalid; Group 5: The existing evidence is insufficient.
2.3 drug prevention of migraine
2.3. 1 target
Reduce the frequency and severity of headache and shorten the attack period; Enhance the sensitivity of patients to treatment during the attack; Improve function and reduce disability.
2.3.2 Consider the indications of drug prevention and treatment.
(1) Patients whose migraine still seriously affects their quality of life after treatment during the attack; (2) frequent migraine attacks; (3) those who overuse or contraindicate the use of therapeutic drugs during the attack, and those who are ineffective in the treatment of drugs during the attack; (4) those with severe side effects during the attack; (5) The cost of treatment and prevention; (6) the choice of patients; (7) Rare types of migraine: hemiplegic migraine, basal migraine and migraine cerebral infarction.
2.3.3 principle
(1) drug selection: the effective drugs are preferred; Adhere to the principle of low dose and increasing treatment; Each drug is tried for 2 to 3 months to fully judge its clinical efficacy; Avoid interfering with medication (excessive use of acute treatment drugs); Long-acting preparations are preferred.
(2) Evaluation of curative effect: Headache diary is used to monitor the change of patients' headache, and the drug can be reduced or stopped only after the headache is completely relieved for 3-6 months.
(3) Drug use for complications: Some complications (stroke, myocardial infarction, Raynaud's syndrome, epilepsy, emotional disorder, anxiety, etc.) may be opportunities for treatment, and may also limit the choice of therapeutic drugs, which should be fully considered. The principles of medication for complications are as follows: try to choose drugs that are effective for migraine and complications; Do not choose contraindicated drugs for complications; Ensure that the therapeutic drugs for complications do not induce/aggravate migraine; Pay attention to drug interaction; Patients who are pregnant or about to become pregnant should be treated with drugs with little side effects on the fetus.
(4) Evidence and recommendation form of migraine preventive drugs (see tables 5 and 6).
Table 5 Evidence Table of Prophylactic Drugs for Migraine
medicine
Level of evidence
Statistical efficiency
Clinical efficacy
side effect
group
Antiepileptic drugs:
carbamazepine
B
+ +
Even/common
five
Sodium divalproex/sodium valproate
A
+ + +
+ + +
Even/common
1
Gaba spray ding
B
+ +
+ +
Even/common
2
Tuotai
C
+ +
Even/common
three
Antidepressants:
Tricyclic antidepressants:
Amitriptyline
A
+ + +
+ + +
common
1
Nortriptyline
C
+ + +
common
3a
Plotyline
C
+ +
common
3a
Doxepin, imipramine
C
+
common
3a
Selective 5 -HT reuptake inhibitor (SSRI):
Aminophenyl chloride propylamine
B
+
+
Occasionally
2
Fluvoxamine
C
+
Occasionally
3a
Paroxietine
C
+
Occasionally
3a
Sutling
C
+
Occasionally
3a
Monoamine oxidase inhibitor:
phenelzine
C
+ + +
common
3b
Other antidepressants:
C
+
Occasionally
3a
Aminophenone
Mirtazepine
Clopiprazone
Beta blockers:
atenolol
B
+ +
+ +
Rare/occasional
2
Metoprolol
B
+ +
+ + +
Rare/occasional
2
Naloxoprofen
B
+
+ + +
Rare/occasional
2
propranolol
A
+ +
+ + +
Rare/occasional
1
Timolol
A
+ + +
+
Rare/occasional
1
Calcium channel blockers:
Thiazolidone
C
Rare/occasional
3a
Nimodipine
B
+
+ +
Rare/occasional
2
verapamil
B
+
+ +
Rare/occasional
2
NSAIDs :
Aspirin
B
+
+
seldom seen
2
Phenoxyphenylpropionic acid
Fluoxyphenylpropionic acid
Methamic acid
Isobutyl phenylacetic acid
C
+
seldom seen
3a
Ketophenylpropionic acid
B
+
+
seldom seen
2
Naproxen/naproxen sodium
B
+
+
seldom seen
2
5 -HT receptor blockers:
Cypheptyline
C
+
common
3a
Dimethyl ergonovine
A
+ + +
+ + +
common
four
Other drugs:
Feverfew
B
+ +
+
seldom seen
2
Magnesium agent
B
+ +
+
seldom seen
2
VitB2
B
+ + +
+ +
seldom seen
2
Note: Refer to Table 1, Table 2, Table 7 and Table 8 for the explanations of evidence level, research level, statistical efficacy and clinical efficacy respectively; Refer to Table 6 for the explanation of grouping; ? = I don't know; PR = Per rectum
Anal administration; SC = Subcutaneous, subcutaneous administration; NS = Nasal Spray, nasal spray; IN = Intra nasal, administered by nose; NSAIDS = non-steroidal anti-inflammatory drugs; ASA = sodium acetylsalicylate.
Table 6 Recommended preventive drugs for migraine
1 group
2 zu
3 zu
4 zu
5 zu
Amitriptyline
Beta blockers:
A: antidepressants:
Dimethyl ergonovine
Acetobutyryl propranolol
Sodium divalproex
atenolol
Aminophenone
carbamazepine
propranolol
Metoprolol
Doxepin
clomipramini hydrochloridum
Timolol
Naloxoprofen
Fluvoxamine
Clonazepam
Calcium channel blockers:
imipramine
clonidine hydrochloride
Nimodipine or verapamil
Mirtazepine
Indomethacin
NSAIDs :
Nortriptyline
Nicardipine
Aspirin
Proxetine
nifedipine
Phenoxyphenylpropionic acid
Plotyline
pindolol
Fluoxyphenylpropionic acid
Sutling
Ketophenylpropionic acid
Clopiprazone
Methamic acid
Venlafaxine
naproxen
Other antidepressants:
Naproxen sodium
Cypheptyline
Aminophenyl chloride propylamine
Thiazolidone
Gaba spray ding
Isobutyl phenylacetic acid
Other drugs:
Tuotai
Feverfew
B: (drugs with side effects)
Magnesium agent
phenelzine
VitB2
Note: 1 group: sufficient evidence, high efficiency and mild to moderate side effects; Group 2: the evidence is insufficient or the curative effect is lower than the first 1 group, with mild to moderate side effects; Group 3: Validity based on American College of Neurology.
Members agree on drugs; Group 4: sufficient evidence, moderate to high efficacy, but obvious side effects; Group 5: Drugs with similar efficacy to placebo.
2.4 Non-drug control
2.4. 1 Non-drug control principles
Non-drug therapy includes behavioral therapy and physical therapy. Behavioral therapy includes relaxation therapy, biofeedback therapy and cognitive behavioral therapy, while physical therapy includes acupuncture, neck exercises and exercise. Most migraine patients want to try out non-drug treatment before regular drug treatment, so the American Headache Alliance suggests that the following patients can consider non-drug prevention and treatment: (1) Patient selection; (2) drug intolerance; (3) those who have drug contraindications; (4) The drug is ineffective or ineffective; (5) Patients who are about to be pregnant, pregnant and lactating; (6) Frequent, excessive and long-term use of painkillers; (7) Persistent headache-induced tension and anxiety.
2.4.2 Recommendations for non-drug prevention and treatment
Behavioral/physical therapy is mainly used to prevent headache, rather than to alleviate the symptoms of headache attack, so it is often used in combination with drugs to prevent migraine recurrence. The recommendations of American Headache Association on migraine behavioral/physical therapy are as follows: (1) Relaxation therapy, biofeedback therapy such as relaxation therapy and heating/electricity, and cognitive behavioral therapy are recommended to prevent migraine recurrence, but there is no evidence for specific patients to choose which method is better (Grade A); (2) The combination of drugs and cognitive behavioral therapy is better than single drug (Grade B); (3) At present, there is insufficient evidence of physical therapy such as hypnosis, acupuncture, maxillofacial orthopedics and hyperbaric oxygen to prevent and treat migraine.
3 Conclusion
Evidence-based guidelines for migraine are recommendations on the role of migraine neuroimaging examination, the effectiveness and safety of intervention measures, and most of the recommendations are well-founded and convincing.
The American Headache Alliance states that the evidence-based guide to migraine is one of the series of educational materials for migraine diagnosis and treatment in American College of Neurology, and its suggestions are given after a systematic evaluation of the existing evidence. This guideline does not exclude other reasonable intervention measures and treatment recommendations, nor does it exclude other scientific guidelines. The treatment of specific patients should be comprehensively selected by both doctors and patients according to specific conditions and guidelines.