Migraine: Treatment

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Migraine: Treatment

I. Diagnostics of migraine

Accurate diagnosis is the cornerstone of effective treatment of migraine. Self -diagnosis is often ineffective and can lead to improper treatment. A professional assessment by a doctor, neurologist, or headache, a specialist is necessary to confirm the diagnosis and exclude other possible causes of headache.

A. Anamnesis: A detailed history of the anamnesis is the first and critical step. The doctor will ask questions about:

1. The nature of the headache: The type of pain (pulsating, pressing, drilling, etc.), intensity (light, moderate, strong), localization (one -sided, bilateral, occipital, frontal, etc.). The pain is usually produced on a visual analogue scale (yours) from 0 to 10, where 0 is the lack of pain, and 10 is the most severe pain that the patient can imagine.

2. Duration: The duration of a headache attack (from several hours to several days). It must be borne in mind that an absurd migraine can last from 4 to 72 hours.

3. Frequency: The frequency of headache attacks (the number of days with a headache per month). Migraine is considered episodic if the number of days with a headache per month is less than 15, and chronic, if 15 or more.

4. Related symptoms: The presence of nausea, vomiting, photophobia (photophobia), sound (phonophobia), osmophobia (sensitivity to smells), dizziness, visual disorders (aura), weaknesses, difficulties with concentration, irritability. It is important to note what symptoms precede headaches (prodromal symptoms), occur during a headache (accompanying symptoms) or remain after a headache (postrome symptoms).

5. Triggers: Identification of possible headache triggers, such as:

   • Food and drinks (sustained cheeses, chocolate, red wine, treated meat, caffeine, artificial sweeteners).
   • Stress (both physical and emotional).
   • Weather changes (pressure drops, temperature, humidity).
   • Disorders of sleep (lack of sleep, excess sleep, irregular sleep mode).
   • Hormonal changes (menstruation, pregnancy, menopause).
   • Bright light, loud sounds, pungent odors.
   • Missed meals.
   • Exercise.
   • Medicines (for example, oral contraceptives).

6. Family history: The presence of migraines for family members (parents, brothers, sisters). Migraine has a hereditary predisposition.

7. Medical history: The presence of other diseases (arterial hypertension, depression, anxiety disorders, epilepsy), which can be associated with migraine or influence its treatment.

8. Taken medicines: A list of all drugs taken, including prescription, over -the -counter drugs and food supplements. Some drugs can cause headache or interact with drugs for the treatment of migraine.

B. Physical examination: General physical examination, including the measurement of blood pressure, pulse and body temperature. A neurological examination is necessary to assess the neurological status and exclude other possible causes of headache.

1. Neurological examination: Evaluation:
   • Hodo-brain nerves (vision, hearing, smell, taste, eye movement, face, swallowing).
   • Motor function (strength, tone, coordination).
   • Sensitive function (tactile, pain, temperature sensitivity).
   • Reflexes (deep and superficial).
   • Gait and balance.
   • Mental status (attention, memory, speech).

C. Diagnostic criteria: The diagnosis of migraine is established on the basis of the diagnostic criteria for the international classification of headaches (ICHD-3). The criteria include:

1. Migraine without aura: At least five attacks that meet the following criteria:

   • The duration of the attack is from 4 to 72 hours (in the absence of treatment or ineffective treatment).
   • The headache has at least two of the following characteristics: one -sided localization, pulsating, moderate or strong intensity, intensifies with ordinary physical activity or is avoided by it (for example, walking or climbing the stairs).
   • During the headache, there is at least one of the following symptoms: nausea and/or vomiting, photophobia and phonophobia.
   • Headache is not related to another disease.

2. Migraine with aura: At least two attacks that meet the following criteria:

   • The presence of aura (usually visual, sensory or speech).
   • Aura of reversible.
   • At least one of the following signs:
     • At least one symptom of the aura develops gradually for more than 5 minutes.
     • At least two symptoms of aura occur sequentially.
     • Each symptom of the aura lasts from 5 to 60 minutes.
     • The aura is accompanied by a headache for 60 minutes (headache can begin before, during or after aura).
   • A headache meets the criteria of migraine without aura.
   • The aura is not related to another disease.

D. Instrumental research: Usually not required to diagnose migraines if the anamnesis and a neurological examination do not reveal any signs indicating another cause of headache. However, in some cases, they can be appointed:

1. MRI of the brain: To exclude structural anomalies, such as tumors, aneurysms or arteriovenous malformations. MRI is a more sensitive method than CT to detect diseases of the brain.

2. CT brain: It can be prescribed in emergency cases when it is necessary to quickly eliminate hemorrhage in the brain or other acute conditions.

3. Blood test: To exclude systemic diseases, such as infections, inflammatory processes or anemia.

4. Lumbal puncture: It can be prescribed to exclude meningitis or other infections of the central nervous system, if there is a suspicion of these diseases.

II. Treatment of acute migraine attacks

Treatment of acute migraine attacks is aimed at relieving pain and concomitant symptoms (nausea, vomiting, photophobia, sound) and restoration of normal function. The choice of the drug depends on the intensity of headaches, related symptoms, preceding the experience of treatment and the presence of concomitant diseases.

A. Non -specific analgesics: Usually effective for migrants of migraine.

1. Nonsteroidal anti -inflammatory drugs (NSAIDs): Ibuprofen, steady, ketoprofen, diclofenac. They have an anti -inflammatory and analgesic effect. It is recommended to take as soon as possible after the start of a headache. Caution should be observed with prolonged use due to the risk of side effects from the gastrointestinal tract (ulcers, bleeding) and the cardiovascular system.

2. Paracetamol: It has an anesthetic and antipyretic effect. Less effective than NSAIDs, but can be used for contraindications to NSAIDs. It is not recommended to exceed the maximum daily dose (4 grams) due to the risk of liver damage.

3. Combined drugs: Contain a combination of analgesics (for example, paracetamol and ibuprofen) and sometimes caffeine. Caffeine can enhance the analgesic effect of analgesics. Caution should be observed with frequent use of combined drugs due to the risk of drug-induced headache.

B. Specific drugs: More effective than non -specific analgesics, with moderate and strong migraine attacks.

1. TRIPTA: Selective agonists of serotonin receptors 5-HT1B/1D. The blood vessels of the brain are narrowed and block the release of neuropeptides involved in the development of migraines. Available in various forms of release: tablets, nasal sprays, subcutaneous injections. Examples: summptor, risatriptan, naratriptan, zolmitriptan, frutriptan, ethletripan, al -Praisipritan. Contraindicated to patients with coronary heart disease, a history of stroke, uncontrolled arterial hypertension. Caution should be observed with the simultaneous use of antidepressants (selective inhibitors of the reverse capture of serotonin-SIOOS, selective inhibitors of the reverse capture of serotonin and norepinephrine-SIOOSN) due to the risk of serotonin syndrome.

2. Dihydroergotamin (DGE): The non-chronic agonist of serotonin and alpha-adrenergic receptors. It has a vasoconstrictor effect. Available in the form of intravenous and intramuscular injections, as well as in the form of a nasal spray. It is used to treat heavy, long -term migraine attacks. It is contraindicated in patients with coronary heart disease, a history of stroke, uncontrolled arterial hypertension, and diseases of peripheral vessels. It can cause nausea and vomiting.

3. Hypers (CGRP Antagonists): Antagonists of the receptor of the general-tied peptide calcitonin (CGRP). The vessels do not narrow, which makes them suitable for use in patients with cardiovascular diseases. Examples: Rimegepant, Ubrogeepant.

4. Ditans (selective agonists 5-HT1F receptors): Lasmiditan. Also do not have a vasoconstrictor effect.

C. Anti -rate drugs: They are used to facilitate nausea and vomiting, which often accompany migraine attacks.

1. Metoclopramide: Enhances the peristalsis of the gastrointestinal tract and has anti-excavation effects. It can cause extrapyramidal side effects (dystonic reactions).

2. DOMPERON: Blocks dopamine receptors in the brain and has anti -excavation effects. Extrapyramidal side effects are less likely than metoclopramide.

3. Cool reuperezin: Blocks dopamine receptors in the brain and has anti -revolutionary and sedative effects. It can cause extrapyramidal side effects.

D. Additional measures:

1. Rest in a dark, quiet room: A decrease in sensory stimulation can help relieve headache.

2. Cold compress on the forehead or whiskey: It can help reduce pain.

3. Abundant drink: Dehydration can aggravate a headache.

4. The use of caffeine (in moderation): Caffeine can enhance the analgesic effect of analgesics, but its excessive consumption can lead to a drug-induced headache.

III. Preventive treatment of migraines

Preventive treatment of migraines is aimed at reducing the frequency, intensity and duration of headache attacks. It is recommended for patients who have:

• Migraines attacks often occur (4 or more days a month).
• Migraine attacks significantly violate everyday life.
• Sharp drugs are ineffective or poorly tolerated.
• There is a risk of developing drug-induced headache.

A. Medicines:

1. Beta blockers: Propranolol, metoprolol, Atenolol. Reduce blood pressure and heart rate. The mechanism of action for migraine is not completely studied, but it is believed that they stabilize the vascular tone. Contraindicated to patients with bronchial asthma, bradycardia, hypotension.

2. Antidepressants:

   • Tricyclic antidepressants (TCA): Amititriptylin, NORTRIPTILIN. Increase the level of serotonin and norepinephrine in the brain. They have an anesthetic and antidepressant effect. They can cause side effects, such as dry mouth, constipation, drowsiness.
   • Selective inhibitors of the reverse capture of serotonin and norepinephrine (SIOSSN): Venlafaxin, Dulcosetin. Increase the level of serotonin and norepinephrine in the brain. They have an anesthetic and antidepressant effect. Less likely to cause side effects than TCA.

3. Anticonvulsants:

   • Topiramate: Blocks sodium channels and enhances the GABA-ergic neurotransmission. It can cause side effects, such as weight loss, paresthesia (a tingling sensation in the limbs), a violation of concentration.
   • Valproic acid: Enhances the GABA-ergic neurotransmission and blocks sodium channels. It can cause side effects, such as weight gain, hair loss, impaired liver function. It is contraindicated in pregnant women due to the risk of congenital defects in the fetus.

4. Calcium channel blockers: Flunarizin. Blocks calcium channels in the cells of the brain. Improves blood supply to the brain and reduces the excitability of neurons. It can cause side effects, such as weight gain, drowsiness, depression.

5. Monoclonal antibodies to CGRP or its receptor (CGRP monoclonal antibodies): Erenumab, Freanzumab, Galkanzumab, Eptynesumab. They are an innovative class of drugs specially designed for the prevention of migraine. Block the action of CGRP, which plays an important role in the pathogenesis of migraines. They are introduced subcutaneously or intravenously. Usually well tolerated.

6. Botulinoxin Type A (Botox): Botox injections in the muscles of the head and neck. Blocks the release of neurotransmitters participating in the development of migraines. Effective for the treatment of chronic migraine.

B. Non -drug methods:

1. Life change change:

   • Regular sleep: Compliance with the regular sleep regime (to go to bed and wake up at the same time every day) can help reduce the frequency of migraine attacks.
   • Healthy nutrition: Regular nutrition and avoiding missing meals can help prevent migraine attacks. Products and drinks should be avoided, which are headache triggers.
   • Regular physical exercises: Moderate physical exercises (for example, walking, swimming, cycling) can help reduce stress and improve the overall health. Intensive physical exercises should be avoided, which can provoke a migraine attack.
   • Stress management: Stress management techniques (for example, meditation, yoga, breathing exercises) can help reduce the frequency of migraine attacks.

2. Biological feedback (BOS): A method that allows patients to learn how to control physiological functions (for example, heart rate, muscle voltage, skin temperature) using special sensors and feedback. Bos can help reduce the frequency and intensity of migraine attacks.

3. Acupuncture: The method of traditional Chinese medicine, which consists in introducing thin needles into certain points on the body. Acupuncture can help reduce the frequency of migraine attacks.

4. Cognitive-behavioral therapy (KPT): The type of psychotherapy that helps patients change negative thoughts and behavior that can contribute to the development of migraine. KPT can help reduce the frequency and intensity of migraine attacks, as well as improve the quality of life of patients.

5. Massage: Regular massage can help relax the muscles of the head and neck, reduce stress and improve blood circulation.

6. Food additives: Some studies show that some food additives can be useful for migraine prevention. These include:

   • Magnesium
   • Riboflavin (vitamin B2)
   • Coenzim q10
   • Melatonin
   • Burdok (white -skinned bark extract)
   • Ginger

IV. Treatment of special groups of patients

A. Migraine during pregnancy: Migraine treatment during pregnancy is a difficult task, since many drugs are contraindicated due to risk to the fetus.

1. Non -drug methods: The preferred treatment option during pregnancy. They include a change in lifestyle, bos, acupuncture, massage, kPT.

2. Medicines: It should only be used if non -drug methods are ineffective. Paracetamol is considered relatively safe during pregnancy. NSAIDs should be avoided in the third trimester of pregnancy due to the risk of premature closure of the arterial duct in the fetus. Triptans should be used with caution and only if the benefits for the mother exceeds the risk for the fetus. Preventive treatment of migraines during pregnancy should be carried out only in extreme cases and under the strict supervision of a doctor. First -line preparations for the prevention of migraine during pregnancy include magnesium and metoprolol (with caution).

B. Migraine in children and adolescents: Treatment of migraines in children and adolescents is similar to the treatment in adults, but it is necessary to take into account the characteristics of the child’s body.

1. Non -drug methods: The preferred treatment for children and adolescents. Include a change in lifestyle, BOS, KPT.

2. Medicines: Ibuprofen and paracetamol are safe and effective for the treatment of light and moderate migraine attacks in children and adolescents. Triptans can be used to treat moderate and strong migraine attacks in children and adolescents over 12 years old. Preventive treatment of migraines in children and adolescents should be carried out only if attacks occur often and significantly violate everyday life. First -line preparations for the prevention of migraine in children and adolescents include propranolol and topiramate.

C. Migraine in the elderly: Treatment of migraine in older people requires special attention due to the presence of concomitant diseases and increased risk of side effects of drugs.

1. Non -drug methods: The preferred treatment for the elderly. They include a change in lifestyle, bos, acupuncture, massage, kPT.

2. Medicines: It should be used with caution and in lower doses than that of young people. Paracetamol is relatively safe for the treatment of light and moderate migraine attacks in the elderly. NSAIDs should be avoided due to increased risk of side effects from the gastrointestinal tract and cardiovascular system. Triptans should be used with caution and only if there are no contraindications from the cardiovascular system. Preventive treatment of migraines in the elderly should be carried out only if attacks occur often and significantly violate everyday life. First -line preparations for the prevention of migraine in the elderly include propranolol (with caution) and amitriptylin (in low doses).

V. A drug-induced headache (leggl)

LEGB is a chronic headache that develops as a result of frequent medications for the treatment of headaches. Frequent use of analgesics, triptans, ergotamins or combined drugs can lead to leggings.

A. Diagnosis: The diagnosis of leggings is established on the basis of the following criteria:

1. Headache occurs 15 or more days a month.

2. Regular use of drugs for the treatment of headaches for 3 or more months:

   • Simple analgesics (paracetamol, NSAID) – 15 or more days a month.
   • Triptans, ergotamins, combined drugs – 10 or more days a month.

3. The headache develops or significantly deteriorates during frequent administration of drugs.

B. Treatment: The basic principle of the treatment of leggings is the abolition of drugs that caused headache.

1. The abolition of drugs: Should be carried out under the supervision of a doctor. The abolition of drugs can lead to an increase in headaches for several days or weeks. In some cases, hospitalization may be required for detoxification.

2. Treatment of cancellation symptoms: To relieve symptoms of cancellation, can be prescribed:

   • Nonsteroidal anti -inflammatory drugs (NSAIDs).
   • Anti -rate drugs.
   • Corticosteroids (for example, prednisone).

3. Preventive treatment: After the cancellation of drugs and the relief of the symptoms of cancellation, preventive treatment of migraine can be prescribed.

VI. New directions in the treatment of migraines

Research in the field of migraine continues, and new treatment methods are being developed, which can be more effective and safe than existing ones.

A. CGRP Antagonists of small molecules (Hever): Rimgeepant, Ubrogeepant. They are accepted orally and can be used both for the treatment of acute migraine attacks and for prevention.

B. Selective agonists 5-HT1F receptors (ditans): Lasmiditan. They are accepted orally and used to treat acute migraine attacks. Do not cause a vasoconstrictor effect.

C. Transcranial magnetic stimulation (TMS): The non -invasive method of stimulation of the brain using magnetic impulses. It can be used to treat acute migraine attacks and for prevention.

D. Transcanated trigeminal stimulation (TSTTN): The non -invasive method of stimulation of the trigeminal nerve using electrical impulses. Can be used to prevent migraine.

E. Digital therapeutic means: Applications for smartphones and other digital tools that help patients track headaches, determine triggers, receive education and support, as well as manage their symptoms.

VII. A comprehensive approach to the treatment of migraines

Effective treatment of migraine requires an integrated approach, which includes:

1. Accurate diagnostics: To exclude other possible causes of headache and determine the type of migraine.

2. Individual treatment plan: Given the characteristics of the patient, such as headaches intensity, accompanying symptoms, preceding experience in treatment, the presence of concomitant diseases and preferences.

3. Patient training: The patient should be trained in recognition of headache triggers, self -help methods and the proper use of drugs.

4. Regular observation: It is necessary to regularly visit a doctor to evaluate the effectiveness of treatment and correction of the treatment plan if necessary.

5. Support: It is important that the patient receives support from the family, friends and medical workers.

Properly selected treatment can significantly improve the quality of life of people with migraines.