Overview
Migraine is a group of periodic attacks with a tendency to develop in families. It is characterized by episodes of migrainous throbbing headache with nausea, vomiting and shyness, followed by a period of interruption. The headache is relieved in a quiet, dark environment or after sleep. It may be accompanied by neurological and mental dysfunction before or during the onset of headache.
Diagnosis
The diagnosis is not difficult with a long history of recurrent headaches, all normal intervals, normal physical examination and family history of migraine. We need to exclude organic diseases if they are accompanied by focal neurological signs. Ocular muscle palsy can be caused by aneurysm, and arteriovenous malformation can also be associated with migraine, and a cranial CT scan or cerebral angiography should be performed to clarify the diagnosis. Complex migraine is often caused by organic diseases, and neuroimaging should be performed. Occipital or temporal lobe tumors may also present with visual field defects or other visual symptoms initially, but as the disease progresses, symptoms of increased intracranial pressure may eventually appear. Temporo-occipital headache in the elderly should be excluded from temporal arteritis, where the superficial temporal artery or occipital artery is thickened like a rope, and the pulsation is significantly weakened or absent, and the arterial biopsy shows characteristic multinucleated giant cell infiltration.
Treatment measures]
In addition to relieving the symptoms of acute headache attack, the aim of treatment is to prevent or reduce the recurrent attacks of headache as much as possible. Various triggering factors should be avoided. Drug therapy, psychotherapy, acupuncture and qigong are effective for some patients.
I. Treatment of acute attacks
Rest in a quiet and light-proof room. Mild cases can take general analgesics and tranquilizers (such as aspirin, ibuprofen, etc.), and most of them can be alleviated. Those with headache accompanied by nausea and vomiting can apply methotrexate.
Ergotamine system is effective in some patients. It is an agonist of 5-HT receptors and also has a direct vasoconstrictor effect. It mainly agonizes 5-HT1A receptors, but also has effects on dopamine and adrenergic receptors, so it has more side effects. Ergotamine caffeine tablets (each containing 100 mg of caffeine and 1 mg of ergotamine) are commonly used, and one to two tablets are taken immediately at the onset of aura or onset of vague pain. To avoid ergot toxicity, do not take more than 4 tablets for a single attack and do not exceed a total of 8 tablets per week. Alternatively, ergotamine tartrate 0.25 to 0.5 mg may be administered subcutaneously or intramuscularly. Ergot overdose can cause side effects such as nausea, vomiting, abdominal pain, myalgia and peripheral vascular spasm and ischemia. It is contraindicated in people with serious cardiovascular, liver and kidney diseases and pregnant women. It is also not indicated for hemiplegic, oculomotor paralysis and basal migraine.
Imodium is a 5-HT1D receptor agonist with a highly selective effect on cerebral blood vessels. Adults receive 100 mg orally, headache relief begins after 30 minutes, and optimal efficacy is achieved after 4 hours. Side effects are mild, with transient generalized fever, dry mouth, head pressure and joint pain. Occasionally, there is chest tightness, chest pain or palpitations.
Persistent migraine and severe migraine can be treated with oral or intramuscular chlorpromazine (1mg/kg) or intravenous ACTH 50 units (in 500ml glucose water), or oral prednisone 10mg 3 times a day. Patients with prolonged seizures should pay attention to appropriate rehydration and correction of water and electrolyte disorders.
II. Preventive treatment
Long-term prophylactic medication should be considered for patients with 2 to 3 headache attacks per month. This type of medication should be taken daily and the effect should be seen at least 2 weeks after taking the medication. If the effect continues for 6 months, then gradually reduce the dosage to stop.
1, propranolol; for beta-adrenergic receptor blocking agents. It is effective in about 50% to 70% of patients, and the number of seizures can be reduced by more than half in 1/3 of patients. The general dosage is 10 to 40mg, 3 times a day. The side effects are small, and the gradual increase in dosage can reduce nausea, ataxia and painful spasms of the limbs and other adverse effects.
2, benzothiazide; 5-HT antagonist, also has antihistamine, anticholinergic and anti bradykinin effects. The common dose is 0.5 mg once daily, slowly increasing to 3 times daily. Continuous treatment for 4 to 6 months resulted in improvement or cessation of headache attacks in 80% of patients. Side effects are drowsiness and fatigue, can increase appetite, long-term use will be fat.
3.Mesilagole; 5-HT antagonist, mainly has antagonistic effect on 5-HT2 receptors. Need to start taking small doses (0.5 to 1mg/day) and gradually increase to 1 to 2mg within a week, twice a day. It can cause side effects such as nausea, vomiting, dizziness, drowsiness, etc. Long-term use can lead to retroperitoneal tissue and pulmonary-pleural fibrosis. It must be discontinued for 1 month after 6 months of continuous administration. Consider trial only in the most recalcitrant patients.
4, calcium channel blockers; nimodipine and flunarizine common dose of nimodipine is 20 to 40 mg, 3 times a day. Drug side effects are small, but discomfort such as dizziness, head swelling, nausea, vomiting, insomnia or skin allergy may occur.
5.Sodium valproate; 100 to 400mg, 3 times a day.
6.Amitriptyline; it is a tricyclic antidepressant, which can block the re-uptake of 5-HT. It is mostly used for antidepressant and treatment of chronic pain, and is effective for migraine with tension headache. The common dose is 75 to 150mg/day.
7. Colistin; it can inhibit vasomotor center and has hypotensive effect. The effect of migraine prevention is weak, but a small amount of application without side effects. The commonly used dose is 0.078mg to 0.15mg, 2 to 3 times a day.
Etiology
The etiology is unclear, and about 60% of patients have a family history. Female patients tend to have migraine attacks before menstruation and fewer attacks after pregnancy, suggesting that the onset may be related to endocrine or water retention. Migraine attacks can be triggered by mental stress, overexertion, sudden climatic changes, bright light, sun exposure, hypoglycemia, application of vasodilators or reserpine, and consumption of high tyramine food and alcoholic beverages.
Wolff et al. explained the clinical manifestations of migraine by the vascular origin theory. In typical migraine, there is a constriction of intracranial arteries and a decrease in local cerebral blood flow, causing aura symptoms such as visual changes, sensory abnormalities or mild hemiparesis, followed by expansion of intracranial and external arteries and headache.
Clinical manifestations]
According to the international classification and diagnostic criteria of headache formulated by the International Headache Society in 1988, and combined with our clinical practice, they are summarized as follows.
I. Migraine without aura (generalized migraine) is the most common. The onset of moderate to severe throbbing headache, accompanied by nausea, vomiting or photophobia. The headache is aggravated by physical activity. The attack begins as a mild to moderate dull ache or discomfort and reaches a severe throbbing or throbbing pain after a few minutes to a few hours. About 2/3 of the headaches are unilateral, but they can also be bilateral, sometimes radiating to the upper neck and shoulders. The headache lasts 4 to 72 hours and is commonly relieved after sleep. There is a clear normal interval between attacks. If 90% of the attacks are closely related to the menstrual cycle, it is called menstrual migraine. The diagnosis can be made only after at least 5 episodes of the above-mentioned attacks, excluding various intracranial and extracranial organic diseases.
II. Migraine with aura (typical migraine) can be divided into two phases: aura and headache.
1.Aura phase; visual symptoms are most common, such as photophobia, flashes of light in front of the eyes, sparks, or complex visual hallucinations, followed by visual field defects, dark spots, hemianopia or transient blindness. A small number of patients may develop hemianesthesia, mild hemiparesis, or speech impairment. The aura mostly lasts for 5 to 20 minutes.
2. Headache phase; often occurs when the aura begins to subside. The pain mostly starts in the supraorbital, postorbital or frontotemporal region on one side, and gradually worsens and extends to half of the head, or even the whole head and neck. The headache is pulsating, throbbing or chisel-like, and gradually increases in severity to a constant pain. It is often accompanied by nausea, vomiting, photophobia and phonophobia. Some patients have flushed face, sweating profusely and conjunctival congestion; some patients are pale, depressed and anorexic. An attack can last from 1 to 3 days, and the headache is usually relieved significantly after sleeping, but the attack is followed by several consecutive days of lethargy and weakness. Everything is normal in the interictal period.
Third, the oculomotor paralysis type of migraine is extremely rare. The age of onset is mostly below 30 years. There is a history of headache attacks fixed on one side, and after an attack of more severe headache (orbital or retro-orbital pain), there is a paralysis of the eye muscles on the same side, most often with drooping of the upper face. The paralysis lasts for several days or weeks and then recovers. The first few episodes of palsy recover completely, but partial ocular muscle palsy may remain without recovery after multiple episodes. The neuroimaging does not Song body exclude intracranial organic lesions.
IV. Benign episodic vertigo in childhood (migraine equilibrium attack) has a family history of migraine but the child himself has no headache. It presents with multiple, transient episodes of vertigo, and may also present with episodic balance disorder, anxiety, with nystagmus or vomiting. Neurological and electroencephalographic examinations are normal. Everything is normal in the interval. Some children may turn to migraine in adulthood.
V. Migraine persistent state; migraine attacks lasting more than 72 hours (with a remission period of less than 4 hours) are called migraine persistent state.
Traditional Chinese medicine
I. External treatment of Chinese medicine.
1. Acupuncture point paste: certain specific drugs are used to treat migraine from outside of the body by means of paste application, etc., which can be effective
2.Acupoint injection: Acupoint injection is a kind of treatment method combining Chinese and Western medicine, that is, injecting certain drugs at the relevant acupuncture points or certain parts with positive reaction found through meridian palpation, and using the stimulation effect of acupuncture and medicinal liquid on acupuncture points to appear certain needle sensation to achieve the purpose of treating the disease.
3, acupuncture point buried wire method; acupuncture point buried wire therapy originated in the early 1960s acupuncture point buried method, it is the use of buried wire apparatus will be special drug-soaked protein magnetized wire implanted in the corresponding acupuncture points, through the drug and the wire body on the acupuncture points to produce a continuous effective stimulation effect (the wire in the body 15 days to 3 months naturally dissolved absorption), to achieve the purpose of treatment of disease. The acupuncture point buried thread therapy to make up for the short time to tie the needle, tie the needle more times, the curative effect is not lasting, the disease is not easy to consolidate after healing shortcomings. The biggest advantage of acupuncture point buried wire therapy is no side effects, safe and painless, easy for patients to accept, and the recurrence rate is very low.
4, acupuncture point cutting treatment method; acupuncture point cutting treatment method is based on the viewpoint of Chinese medicine meridian theory, evolved from acupuncture therapy, its function is to dredge the meridians, declare the coordination of qi and blood yin and yang, the purpose of fixing the mind and calming the spirit. Acupuncture point cutting treatment is based on the individual differences of patients, different symptoms, different causes of the disease to dialectical selection of points, and then cut on the acupuncture points can play a warming meridians, dispel cold and damp, adjust the internal organs of qi and blood and adjust the role of nerve function. Combined with the oral series of special drugs and acupuncture point cutting treatment for migraine, it can coordinate with each other and enhance the efficacy of treatment.
II. Acupuncture treatment; acupuncture has the effect of influencing various neurotransmitters and vasoactive substances, and according to the identification of Chinese medicine, the disease is divided into four types: hyperactivity of liver and yang, phlegm and turbidity, stagnation of qi and blood, and deficiency of liver and kidney, etc. The main acupuncture points of Baihui, Touwei, Fengchi and Sun and other supporting points are selected and treated with different acupuncture techniques. effect.
According to the theory of traditional Chinese medicine, “the head is the meeting of all the yang”, “the blood of the essence of the five organs and the qi of the clear yang of the six bowels are all meeting at the top”, where the evil of the six external disturbances on the top, the evil Qi stays and blocks the clear yang, the meridians are suppressed and the qi and blood Therefore, wind, cold, phlegm and stasis are the main causes of this disease. After identifying and examining the causes, the medicine includes: Chuanxiong, Angelica dahurica, white mustard seed, white peony, Yu Li Ren, Chai Hu, Hsiang Hsien, Xiang Shen, whole scorpion, centipede and roasted licorice, and the whole formula can dispel wind and cold, pass through the channels and dispel stasis, and remove phlegm and facilitate the orifice. Migraine headache has a long and lingering course and occurs when it is strained. Its onset is closely related to the liver, spleen and kidneys, so the treatment is based on angelica, atractylodes, chuanxiong, white peony, zedoary, poria, geranium and scorpion, and scutellaria is added if there is heat. The migraine is caused by imbalance in the flow of qi and blood, blockage of qi and inaccessibility of the veins, and the pain is mostly on the two sides of the head, where the Shaoyang meridians pass. Migraine belongs to “long-standing pain entering the luo”, so we can treat migraine by adding and subtracting Tonic Yang Returning Five Soup. The modern pharmacological effects of peach kernel, safflower, Chuanxiong and Salviae have the ability to dilate blood vessels and reduce blood viscosity, which is also in line with the TCM theory to activate blood circulation and remove blood stasis. Some researchers combined the viewpoints of Chinese medicine that “prolonged illnesses have more phlegm”, “prolonged illnesses enter the luo” and “prolonged illnesses have more blood stasis”, and this formula is used to nourish qi and blood, resolve phlegm and lower turbidity, resolve blood stasis and open the luo, and treat both the symptoms and the root cause. The formula is clinically effective in the treatment of migraine. If the liver has been diseased for a long time, the liver blood is insufficient, blood deficiency generates heat, fire moves and generates wind, which disturbs the clear orifices and causes blockage of the meridians, resulting in headache. The combination of all the medicines makes the yin and blood sufficient, the liver wood rise, and the headache can be eliminated by itself.
There are many other therapies that I will not go into here!