Migraine is a common and recurrent headacheheadacheThe disease is characterized by one or both sides of throbbing severe headache, often accompanied by nausea, vomiting, allergic to sound and light stimulation and other symptoms.Common types includeMigraine without aura, migraine with aura andchronic migraine Etc.The pathogenesis of migraine may be related to heredity, endocrine metabolism, environmental factors, mental factors, and often has a genetic background.Female patients are 2-3 times as many as male patients, most of whom start in adolescence, and a few can start in childhood.
In terms of symptoms, the typical symptom of migraine is severe headache, which may be pain in one side of the head, migration to the other side, and sensitivity to light, noise and smell.Common concomitant symptoms includenausea、vomit, stomach discomfort, abdominal pain, feeling very hot or cold, pale skin, etc.
In terms of treatment, migraine can not be eradicated at present, and most of the treatments are aimed at alleviating or terminating the headache attack, alleviating the accompanying symptoms, and preventing the recurrence of headache.includemedicationAnd non drug treatment, of which drug treatment is divided into paroxysmal treatment and preventive treatment.Non drug treatmentIt is mainly to strengthen propaganda and education, help patients maintain a healthy lifestyle, and find and avoid various factors inducing migraine.
As far as the impact is concerned, migraine has a great impact on the quality of life of patients, and can impose a heavy burden on society, economy and individuals.Therefore, although migraine is not fatal, it ranks third in the global disease burden and is a public health problem worthy of attention.
Migraine usually starts in adolescence, and a small part can occur in childhood. It reaches its peak in the middle and young age. This age group has frequent attacks and severe symptoms.Migraine has a special "preference" for women, and women patients are 2-3 times more than men.Migraine often has a genetic backgroundepilepsy、depression、asthma、anxiousMigraine is also more common in people with stroke and other neurogenetic diseases.
Goad (2002) investigated in the United States and Western Europe for one year, and the overall prevalence rate of migraine in the population was 11%.Among them, about 6% are male and 15%~18% are female.The lifetime prevalence of migraine was 18%.
A survey in 2013 showed that the prevalence rate of migraine in China was 9.3%, which was also very high worldwide.Therefore, this is a common disease ranking third in the global disease burden, or the sixth disabling disease, which can impose a heavy burden on society, economy and individuals.
By 2023, about 1.04 billion people worldwide will suffer from migraine, with a lifetime prevalence rate of about 10% for men and 22% for women.The annual prevalence rate of migraine in China is 9%, and the annual treatment cost of patients diagnosed with migraine exceeds 299.4 billion yuan.
Type of disease
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Academic circles have a very detailed classification of migraine, which is more used for academic research.According to the main clinical manifestations of headache, it is classified into migraine without aura, migraine with aura, chronic migraine, etc. The first two categories are detailed in the symptom section.
Chronic migraine refers to the attack that conforms to the characteristics of migraine for more than 15 days every month, lasting for 3 months or more, and at least 8 days every month.The diagnosis of this type of headache must exclude headaches caused by other reasons, especially those caused by excessive drugs.
There are also some rare migraine types:
Brainstem migraine aura
Also known as basal migraine, as the name implies, the precursor symptoms of this type of headache originate from the brain stem and can be very serious, such as sudden enunciation (dysarthria), dizziness, tinnitus, hearing or even hearing loss, inability to see clearly or see objects in part of the visual field (visual field defect), walking instability, ataxia, and even worse, sudden unconsciousness.But this kind of migraine usually has no symptoms of weakness.
Hemiplegic migraine
As its name implies, it has the same symptoms as "hemiplegia", one side of the body is weak in movement, and at least there are signs of abnormal vision, feeling and speech.
This kind of manifestation is a completely reversible monocular visual disorder that occurs repeatedly, including flicker, scotoma, and even blindness, but the ophthalmic examination is normal. The difference between this kind of migraine and brainstem migraine is that the visual symptoms are only limited to monocular.
pathogeny
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The etiology of migraine is still unclear, which may be related to heredity, endocrine metabolism, environmental factors and mental factors.
Pathogenesis
Genetic factor
Migraine has genetic susceptibility. About 60% of migraine patients have a family history. If a person suffers from migraine, the risk of migraine in their relatives is 3-6 times that of the general population.Some scholars have found a special mutant gene of migraine patients, and it has a certain autosomal dominant inheritance. This type of migraine is known as familial hemiplegic migraine (FHM) based on the performance of the attack.
Nerve cell excitability disorder
Other scholars found that there is a kind of excitability related gene mutation in the nervous system related to the common type of migraine, which infers that migraine is related to the excitability disorder of brain nerve cells.
Endocrine and metabolic factors
This factor is very obvious clinically, especially related to female hormone level. Migraine in women can reach three times that in men, especially in adolescent women,PregnancyormenopausePost seizure decreased or stopped.
Predisposing factors
diet
Migraine can be induced by cheese containing tyramine, meat containing nitrite, pickled food, chocolate containing phenylethylamine, food additives containing sodium glutamate and aspartame, wine and drinks with high caffeine content.In addition, skipping meals or fasting can also induce migraine.
Stress or stress
Migraine can be induced by pressure, tension, emotional instability, stress and relaxation after stress from work or life.
Sensory stimulus
Migraine can be induced by strong light, loud voice and strong smell (perfume, paint, second-hand smoke, etc.).
Changes in wake-up sleep mode
Insufficient or excessive sleep can induce migraine.
physical activity
Migraine may be induced by intense physical activity, including sexual activity.
environmental change
Some studies suggest that changes in weather or barometric pressure can also cause migraines.
medicine
Oral contraceptives and vasodilators (such as nitroglycerin) can aggravate migraines.
symptom
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The common symptoms of migraine include: headache, which is usually dull at the beginning, gradually becomes pulsatile pain, and becomes worse when moving. It can also be transferred from one side of the head to the other side, involving the front of the head or the whole head;Sensitive to light, noise and smell;Accompanied by nausea, vomiting, stomach discomfort, abdominal pain;Poor appetite;Feel very warm or cold;Pale skin;Fatigue;dizzy;Blurred vision;Diarrhea.Relatively rare symptoms include fever, which affects normal limb movement.
Most patients have headaches that last about 4 hours, but the severe ones last more than 3 days.The frequency of migraine varies from person to person. It is common to have 2 to 4 migraines per month, but some patients have migraines every few days, and some patients only have migraines once or twice a year.
Typical symptoms
Migraine attack can be divided into four stages: prodromal stage, aura stage, headache stage and recovery stage, but not all patients go through these stages.
Prodromal stage
A few hours or one or two days before the onset of migraine, the patient shows some predictive changes about migraine, including:
constipation
Emotional changes, from depression to excitement, or vice versa
appetite changes
stiff neck
Increased thirst and urination
Repeated yawn
Premonitory period
Precursors are neurological symptoms before or during the onset of migraine, manifested as visual abnormalities, sometimes sensory abnormalities, motor or language disorders.Precursory symptoms usually begin slowly and last for 20 to 60 minutes.Precursory symptoms may include:
Visual aura is the most common type of aura symptoms. Patients may have flashes, dark spots, or even blurred vision or vision loss in front of their eyes. Typically, there are zigzag and wavy linear flashes, which gradually expand to the periphery.
Sensory and neural aura, manifested as numbness of the face or one side of the body, tingling of the arms or legs, and even speech disorders, tinnitus or auditory hallucinations, uncontrollable twitching or other movements.The omen may be as short as a few minutes, or as long as an hour.
Migraine can be divided into two types according to whether there is aura or not:
Migraine without aura, which is the most common type of migraine, accounting for about 80%, has a high attack frequency, which can seriously affect normal work and life, and often requires frequent use of pain killers.This kind of migraine is often associated with menstruation.
Migraine with aura accounts for 10% of migraine patients. The aforementioned visual aura and sensory/neural aura will gradually worsen in 5 to 20 minutes, generally lasting no more than 60 minutes. Different auras may appear successively, followed by typical headache.Sleep in the premonitory period and rest in a dark environment can alleviate headache attacks.
Headache period
Migraine usually lasts 4 to 72 hours.The frequency of migraine varies from person to person. Some patients only have migraine occasionally, and some patients have migraine several times a month.
During the headache period, the patient may have the following symptoms:
Severe pulsatile pain
One side head or one eye is involved, sometimes bilateral headache is also shown
Sensitive to light and sound, and sometimes sensitive to smell and touch
Nausea and vomiting
Blurred vision
Dizziness or syncope
convalescence
This stage usually lasts about 24 hours, and patients may show:
Dilemma
be subject to changing moods
dizzy
weak
Sensitive to light and sound
Accompanying symptoms
Migraine patients are often accompanied by nausea, vomiting, photophobia or fear of sound, pallor, sweating, polyuria, fatigue and other symptoms.
Medical treatment
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The diagnosis of migraine is very dependent on the description of symptoms by the patient. Therefore, if the symptoms and signs of migraine attack often occur, the attack and treatment should be recorded and described to the doctor when seeking medical advice.For patients with a history of headache, if the headache mode changes or suddenly feels different from the past, they should seek medical advice as soon as possible.
Seek medical attention immediately if any of the following symptoms and signs occur:
Sudden and severe headache;
Headache with fever, stiff neck, mental disorder, epilepsy, diplopia, fatigue, numbness or speech disorder;
Headache after head injury, especially headache aggravation;
Headache worsens after coughing, fatigue, tension or exercise;
New onset headache over 50 years old.
Visiting department
Migraine patients can go to the neurology department or the headache clinic (center) set up in the hospital.
It focuses on nervous system examination. According to the premonitory symptoms and the nature of headache, it may check whether the consciousness is clear, the state of speech communication, eye activity, neck rigidity, etc., but once an experienced doctor judges that migraine, if the patient is still in the attack period, he may quickly tell the patient to rest quietly to avoid more serious headache attacks caused by too many examinations.
It is generally considered that blood examination is rarely carried out for migraine. When vascular disease, spinal cord or intracranial infection, and endocrine disease are suspected, relevant examinations may be arranged.
MRI can produce detailed images of the brain and blood vessels by using powerful magnetic fields and radio waves, which can help doctors eliminate brain tumors, stroke, cerebral hemorrhage, infection and other brain and nervous system diseases.
CT scanning uses a series of X-rays to create detailed cross-sectional images of the brain, which helps doctors rule out tumors, infections, brain injuries, cerebral hemorrhage and other diseases that may cause headaches.
Lumbar puncture
If intracranial infection, hemorrhage or other potential diseases are suspected, the doctor may recommend lumbar puncture.
differential diagnosis
Clinical diagnosis can usually be made according to the type of migraine attack, family history and neurological examination.Through brain CT, MRI and other examinations, cerebrovascular diseases, intracranial aneurysms, space occupying lesions and other intracranial organic diseases can be excluded.
Migraine should be differentiated from the following diseases.
Cluster headache
This is a relatively rare type of headache, with paroxysmal severe pain around one side of the orbit, lasting for 15 minutes to 3 hours, from once every other day to eight times a day.This disease has the characteristics of repeated and intensive attacks, but it is always unilateral headache, and is often accompanied by ipsilateral conjunctival congestion, tears, runny nose, forehead and facial sweating and Horner's sign.
Tension type headache
This type of headache is bilateral occipital or whole head constrictive or compressive headache, which is often persistent, rarely accompanied by nausea and vomiting. Some cases can also show paroxysmal and pulsatile headache.It is mostly seen in young and middle-aged women. Emotional disorders or psychological factors can aggravate headache symptoms.
Symptomatic migraine
Headache caused by head and neck vascular diseases, such as ischemic cerebrovascular diseases, cerebral hemorrhage, unruptured saccular aneurysms and arteriovenous malformations;Headache caused by non vascular intracranial diseases, such as intracranial tumors;Headache caused by intracranial infection, such as brain abscess, meningitis, etc.These secondary headaches can also be clinically manifested as migraine like headache, accompanied by nausea and vomiting, but there is no typical migraine attack process. Most cases have focal neurological deficit or irritation symptoms, and brain imaging can show the focus.
Headache caused by internal environment disorder, such as hypertensive crisis, hypertensive encephalopathy, eclampsia or preeclampsia, can be manifested as bilateral pulsating headache. Headache is closely related to the increase of blood pressure in the occurrence time. In some cases, neuroimaging examination can show reversible white matter damage.
Drug overuse headache
This type belongs to secondary headache.The occurrence of headache is related to the overuse of drugs. It can be a migraine like headache or a mixed headache with migraine and tension headache. The headache will be relieved or return to the original headache mode within 2 months after the drug is stopped.Drug overuse headache is ineffective for preventive treatment.
treatment
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Migraine cannot be eradicated, and its treatment purpose is to alleviate or stop the headache attack, alleviate the accompanying symptoms, and prevent the recurrence of headache.Treatment measures include medication and non medication.Drug therapy is divided into paroxysmal treatment and preventive treatment.Non drug treatment is mainly to strengthen propaganda and education, help patients establish scientific and correct prevention and treatment concepts and goals, maintain a healthy lifestyle, and find and avoid various migraine incentives;Non drug interventions include acupuncture, massage, physiotherapy, biofeedback therapy, cognitive behavioral therapy, etc.
medication
In clinical treatment of migraine, drugs should be taken immediately at the beginning of symptoms.Therapeutic drugs include nonspecific analgesics (such as nonsteroidal anti-inflammatory drugs, opioids) and specific drugs (such as ergot preparations, triptans).The choice of drugs should be based on the degree of headache, accompanying symptoms, previous medication and other comprehensive considerations, and individualized treatment should be carried out.
Mild to moderate headache
Single use of non steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, naproxen, ibuprofen, diclofenac, etc. is effective, and if it is ineffective, use the specific treatment drugs for migraine;
Opioid preparations, such as pethidine, are also effective in treating acute migraine attacks. Since they are addictive, routine use is not recommended;
For cases with ergot or triptolide contraindications, such as heart disease, peripheral vascular disease or migraine during pregnancy, pethidine can be given to stop the acute attack of migraine.
Moderate to severe headache
For severe attacks, migraine specific drugs can be directly used to improve symptoms as soon as possible. Some patients who have severe headache but have responded well to NSAIDs in previous attacks can still use NSAIDs.
Ergot preparations are suitable for patients with long attack duration, and compound preparations such as ergotamine caffeine mixture can treat some moderate to severe migraine attacks.
It should be noted that the adverse reactions of ergot and triptolide drugs include nausea, vomiting, palpitations, irritability, anxiety, and peripheral vasoconstriction. A large number of long-term applications can cause hypertension and limb ischemic necrosis.Severe hypertension, heart disease and pregnant women are contraindicated due to their strong vasoconstriction.In addition, excessive use of ergot and triptolide will cause headache due to drug overdose. It is recommended that the drug should not be used more than 2-3 days a week.
Treatment of accompanying symptoms
It is necessary to use antiemetics (such as metoclopramide 10 mg intramuscular injection) together for nausea and vomiting, and low-dose chlorpromazine can be given to patients with severe vomiting.Patients with dysphoria can be given benzodiazepines to promote sedation and sleep.
surgical treatment
The disease generally does not require surgical treatment.
TCM treatment
The TCM treatment of the disease is not supported by evidence-based medical evidence, but some TCM treatment methods or drugs can alleviate symptoms, so it is recommended to go to regular medical institutions and treat under the guidance of doctors.
Preventive treatment
Preventive treatment refers to medication when migraine has not occurred, and the scope of application for guidance of medication includes:
Frequent attacks, especially those patients who have serious impact on daily life and work more than once a week;
The acute phase treatment is invalid, or the acute phase treatment cannot be carried out due to side effects and contraindications;
Special variant migraine that may lead to permanent neurological deficit, such as hemiplegic migraine, basal migraine or migraine infarction.
The preventive treatment drugs for migraine are divided into the following categories, which should be started from small doses of single drugs, slowly added to appropriate doses under the guidance of doctors, and pay attention to side effects.The preventive treatment can be considered effective if the attack frequency of migraine is reduced by more than 50%.Effective preventive treatment lasts for about 6 months, after which the dosage can be slowly reduced or the drug can be stopped.
Cardiovascular drugs
Beta blockers can reduce the frequency and severity of migraine, for example, propranolol, metoprolol and timolol have been proved to be effective in preventing migraine;
Calcium antagonists can help prevent migraine and relieve symptoms, for example, verapamil can help prevent migraine with aura;
Angiotensin converting enzyme inhibitor lisinopril can reduce the onset time and severity of migraine.
Tricyclic antidepressants can reduce the frequency of migraine, and amitriptyline has been proved to be effective in preventing migraine.In addition, studies have shown that 5-hydroxytryptamine and norepinephrine reuptake inhibitor venlafaxine may help prevent migraine.However, selective serotonin reuptake inhibitors have not been proven to be effective in preventing migraine, and may even worsen or cause headache.
Some antiepileptic drugs, such as valproate and topiramate, can reduce the incidence of migraine.However, at high doses, these antiepileptic drugs may cause side effects. Sodium valproate may cause nausea, tremor, weight gain, hair loss and dizziness. Topiramate may cause diarrhea, nausea, weight loss, memory difficulties and inattention.
The psychotherapy of migraine is mainly based on behavioral therapy, including relaxation, biofeedback and cognitive therapy.The main purpose of relaxation therapy is to reduce the activation of various systems of the body and promote physical relaxation.Biofeedback can measure, amplify and feedback body information to patients by using various instruments to feel and measure muscle tension (electromyography biofeedback therapy), skin resistance (electrodermal biofeedback therapy) or ambient temperature (temperature biofeedback therapy), so as to achieve relaxation promoted by biofeedback.Cognitive therapy treats recurrent headaches by instructing patients to better deal with headache related stress reactions and other accompanying psychological disorders.
Behavioral therapy can usually be considered in the following situations:
Patients want to receive non drug treatment;
Patients cannot tolerate drug treatment or have drug contraindications;
Drug treatment is ineffective or ineffective;
Pregnancy, preparation for pregnancy or lactation;
Frequent or large dosage of analgesics or other therapeutic drugs in acute phase;
There are obvious life stress events or the patient lacks appropriate stress handling ability.
Frontier treatment
Transcutaneous electric stimulation therapeutic apparatus
The head transcutaneous electrical stimulation therapeutic apparatus is an electrical stimulation device, which has been approved by the US FDA for the treatment of migraine, especially for patients with adverse drug reactions.
Calcitonin gene related peptide (CGRP) inhibitor
Calcitonin gene related peptide (CGRP) is a molecule involved in migraine.In May 2018, the US FDA approved Erenumab, the first new CGRP inhibitor, to prevent adult migraine;In September of the same year, the second anti CGRP migraine drug Fremanezumab was approved, and the third anti CGRP migraine drug Galcanezumab was approved.This brings new treatment options for migraine patients.We are looking forward to the early launch of these drugs in China to benefit Chinese migraine patients.
botulism toxin A
Such drugs have been proved to be helpful in treating adult chronic migraine, but more clinical trials are needed before the drugs are approved for clinical use.
Mild anesthesia
The sphenopalatine ganglion nerve block can alleviate migraine. At present, the US FDA has approved three devices for this treatment.During the anesthesia process, the doctor inserted the catheter through the patient's nose under the guidance of X-ray equipment, and injected the anesthetic into the sphenopalatine ganglion and its surrounding area through the connected syringe.
prognosis
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The prognosis of most migraine patients is good.Migraine symptoms can gradually ease with age, and some patients can stop migraine attacks when they are 60 to 70 years old.
complication
Migraine status
The duration of migraine attack is more than or equal to 72 hours, and the pain is severe, but there may be a short remission period due to sleep or drug use.
persistent aura without infarction
Migraine patients with aura appear one or more aura symptoms in one attack, lasting more than 1 week, mostly bilateral;Other symptoms of this attack are similar to those of previous attacks;Neuroimaging is needed to exclude cerebral infarction.
In rare cases, ischemic infarction in the corresponding intracranial blood supply area occurs after the migraine aura. This aura usually lasts more than 60 minutes, and the ischemic infarction focus is confirmed by neuroimaging, which is called migraine cerebral infarction.
Seizures induced by migraine aura
In very few cases, migraine premonitory symptoms can trigger epileptic seizures, and epileptic seizures occur in the premonitory symptoms or within 1 hour after.
The common complications of migraine include asthma, chronic pain, fibromyalgia, depression, hypertension and cardiovascular and cerebrovascular disease risk, obesity, obstructive sleep apnea.
prevention
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Avoid headache inducing factors
To prevent the onset of migraine, first eliminate or reduce the incentives for migraine. In daily life, avoid direct stimulation of strong light, such as looking directly at the reflection of car glass, and avoid looking from dark indoors to bright outdoors.Avoid looking at neon lights with strong light.Avoid emotional tension, drugs such as vasodilators, red wine and foods containing cheese, coffee, chocolate, smoked fish, etc.
Drug preventive treatment
Preventive treatment is applicable to: ① patients who have frequent attacks, especially those who have attacks more than once a week that seriously affect their daily life and work; ②The acute phase treatment is invalid, or the acute phase treatment cannot be carried out due to side effects and contraindications; ③Special variant migraine that may lead to permanent neurological deficit, such as hemiplegic migraine, basal migraine or migraine infarction.Preventive drugs should be taken daily, and can take effect at least 2 weeks after use.If effective, continue to take it for 6 months, and then gradually reduce the dosage to discontinue the drug.Drugs used clinically for migraine prevention include: ① beta adrenergic receptor blockers, such as propranolol and metoprolol; ②Calcium antagonists, such as flunarizine and verapamil; ③antiepileptic, such asValproic acid、topiramate；④antidepressant, such asamitriptyline、fluoxetine；⑤5-HT receptor antagonists, such asBenzothiadine。Among them,PropranololAmitriptyline, amitriptyline and valproic acid, three drugs that are not related in structure, are the main preventive drugs. If one drug fails, another drug can be used.
daily
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At present, there is no specific treatment, which can eradicate migraine. The most effective treatment is to avoid inducing factors in the interval of migraine.The details are as follows:
Keep away from tyramine foods
Tyramine is the main inducement of vasospasm, which is easy to cause headache. Such foods include cheese, chocolate, citrus, pickled sardines, chicken liver, tomatoes, milk, lactic acid drinks, etc.
Reduce alcohol consumption
All alcoholic beverages can cause headaches, especially red wine, which contains more chemicals that can cause headaches.If you must drink, you'd better choose such colorless wine as vodka and white wine.
Learn to decompress
Relax, choose bubble warm water bath, do yoga and other relaxation exercises to avoid headaches.
Regular movement
For people with migraine, focus on breathing training and breath regulating exercises (such asyogaQigong) can help patients stabilize the autonomic nervous system, alleviate anxiety, muscle tightness and other symptoms.
Law of life
Create a quiet environment, maintain regular work and rest, and go to bed and get up regularly even on holidays.
Historical evolution
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Migraine originated 2500 years agoancient Greek, there is a doctor calledHippocratesIn his own medical career, he found that many headache patients often presented unilateral headache when they had attacks, that is, only the left side headache or the right side headache, and they can often have repeated attacks. The nature and attack process of headache at each attack are often very similar, showing pulsating headache at the temple outside the forehead, accompanied by nausea and vomiting,Sometimes cold sweats can appear on the head, and visual symptoms are often accompanied before and during the attack.He called this type of headache "migraine", which is still used today.
