Paroxysmal headaches. Paroxysmal hemicrania and other headaches. Diagnostic criteria are presented below.

Paroxysmal hemicrania presents with attacks with pain characteristics and associated symptoms similar to those of cluster headache. Distinctive symptoms are the short duration of attacks and their high frequency. Paroxysmal hemicrania is more commonly observed in women, usually the disease begins in adulthood, but cases have also been described in children. A specific sign of this form of cephalalgia is the effectiveness of indomethacin.

Diagnostic criteria are presented below.

3.2. Paroxysmal hemicrania (ICHD-4)
A. At least 20 seizures fulfilling criteria B-D.
B. Attacks of intense unilateral pain of orbital, supraorbital or temporal localization lasting 2-30 minutes.
C. Headache accompanied by at least one of the following symptoms:
1) ipsilateral conjunctival injection and/or lacrimation;
2) ipsilateral nasal congestion and/or rhinorrhea;
3) ipsilateral swelling of the eyelids;
4) ipsilateral sweating of the forehead and face;
5) ipsilateral miosis and/or ptosis.
D. The predominant frequency of seizures is more than five times a day, sometimes somewhat less frequently.
E. Seizures are completely prevented by taking indomethacin at a therapeutic dose.
F. Not related to other causes (violations).

As with cluster headache, episodic (with remissions of 1 month or more) and chronic forms of paroxysmal hemicrania are distinguished, in which stupas are repeated for more than 1 year without remissions or with remissions for less than 1 month. There are cases of paroxysmal hemicrania, combined with trigeminal neuralgia (the so-called paroxysmal hemicrania-tic syndrome).

Treatment

Specific therapy for paroxysmal hemicrania is the use of indomethacin (orally or rectally at a dose of at least 150 mg / day or at least 100 mg as an injection). For maintenance therapy, lower doses are often effective.

Anyone who has ever experienced severe headaches knows what hemicrania is. But still it is worth examining this disease and ways to deal with it in more detail. This is a condition in which there are paroxysmal pains in one side of the head. The attack is accompanied by nausea and vomiting. Hemicrania is more common in women. The disease actively manifests itself between the ages of 25 and 60, after which the attacks become less frequent or disappear altogether.

Before the onset of an attack, patients often experience thirst, hunger, lethargy or a sharp change in the emotional background. Sometimes a headache precedes visual aura: a person observes moving points, lines, etc. before his eyes.

Pain in hemicrania occurs in one half of the head, usually in the temple area. The pain throbs, accompanied by nausea and vomiting. After a person vomits, the pain begins to fade. An attack can last from a couple of hours to several days.

Features of the paroxysmal form

If the patient has chronic paroxysmal hemicrania, there may be such a sign as a short duration of the attack, which is almost always accompanied by severe nausea.

Paroxysmal hemicrania usually occurs in women, and the first attacks occur after reaching adulthood. However, a number of cases of the appearance of symptoms of hemicrania in children have been described.

In the paroxysmal form of the disease, attacks can occur several times a day, they last from 2 minutes to half an hour. Timely intake of Indomethacin helps to prevent an attack.

Hemicrania is not related to other pathologies of the human body and is not a manifestation of chronic diseases.

Allocate chronic and episodic forms of the disease. In the chronic form, attacks occur regularly throughout the year, with periods of remission lasting up to 1 month. Sometimes hemicrania is observed in combination with neuralgic disorders.

Patients claim that the pain is localized in the temple or postorbital space. Usually pain occurs only on one side, while localization, as a rule, does not change throughout the patient's life. Pain may radiate to the arm or shoulder.

Hemicrania continua

This form of hemicrania is quite rare, and in most cases in women. The pain is felt either in the eye area or in the temple. Pain does not go away, ranging from barely perceptible to pronounced. The intensity of pain increases with time.

The frequency of seizures can vary from multiple repetitions within one week to 2-3 times per month. As the frequency of seizures increases, so does the intensity of pain. Additional symptoms may occur during an attack, such as increased lacrimation, nasal congestion, omission of the eyelid on the affected side.

This form of migraine is accompanied by the characteristic symptoms of a migraine: vomiting, nausea, and intolerance to bright light. Patients' eyelids may swell and twitch severely.

During an attack of vomiting, some patients develop auras and visual hallucinations.

First aid

As a rule, patients suffering from hemicrania, at the first sign of an approaching attack, take painkillers. In this case, the drugs give only temporary relief and do not relieve the attack. However, as practice shows, a more pronounced result can be achieved folk methods of treatment ailment.

As soon as the patient feels the approach of an attack, he should stop physical and intellectual activity. He should lie down and relax. It is necessary to put a cool compress on the person’s forehead and tighten it as tightly as possible around the head.

During an attack, it is preferable to stay in a cool, well-ventilated dark room. In no case should there be noise near the patient: you need to turn off the TV, radio, cover the windows. As soon as the patient falls asleep, the attack will stop.

Alternating cool and warm compresses can help alleviate hemicrania. You can put a cool compress on the forehead, and place a warm compress on the back of the head. Compresses should be changed every 2 minutes. It is recommended to carry out the procedure 4 to 6 times during the day.

Excellent results allows you to get self-massage. For some patients, a few minutes of self-massage is enough to prevent unbearable pain.

Treatment with herbs and folk methods

These simple methods will help prevent a painful attack and quickly return to normal life. Consult with your doctor before starting treatment in one way or another folk way.

Very little is known about the origin and mechanism of this disease. Several hypotheses have been developed, according to which the causes of the appearance of pathology are associated with a decrease in blood flow velocity in the middle cerebral artery. Scientists believe that paroxysmal hemicrania is a condition characterized by short-term paroxysmal pains concentrated in one half of the head. Most often, it is observed in women of the age category from 25 to 60 years. Some experts compare the malaise with cluster attacks in men.

Causes of the disease

Some doctors are of the opinion that the main cause of hemicrania is a violation of intracranial blood flow. The rest believe that this is a pathology of platelets or even the influence of serotonin, which causes severe vasoconstriction. While a person drinks coffee or pills containing serotonin, its plasma concentration decreases, and it enters the urine, the vessels dilate sharply, causing sharp pains.

It is important! Additional reasons include: severe stress, overheating in the sun, fatigue, eating foods provoking an attack, dehydration.

Episodic paroxysmal hemicrania

Attacks of paroxysmal hemicrania occur in periods that last from one week to a year. Periods of headache are replaced by remission, when symptoms are absent. Remissions can last from one month or more.

Diagnostic criteria:

C. At least two periods of headache attacks lasting 7-365 days separated by pain-free remission periods of at least 1 month.

Chronic paroxysmal hemicrania

Attacks of paroxysmal hemicrania occur for more than a year without remissions. Painful periods are punctuated by pain-free periods of remission lasting one month or more.

Diagnostic criteria:

A. Seizures fulfilling criteria A-F for 3.2. Paroxysmal hemicrania.

B. Attacks recur for more than 1 year without remissions or with remissions that last less than 1 month.

Paroxysmal form of the disease, its differences

Paroxysmal hemicrania makes itself felt through attacks of acute pain, accompanied by additional manifestations. The distinguishing symptoms of the lesion include: a short duration of attacks, which are characterized by the presence of nausea.

This form of pathology is more common in women and begins already in adulthood, but some cases of infection in children are known.

Symptoms of the disease are also characterized by the fact that the frequency of pain attacks can reach up to 5 times a day and they last 2 to 30 minutes. An attack can be prevented by taking indomethacin at a therapeutic dose. Pathology does not correlate with other disorders in the work of the human body.

Episodic and chronic paroxysmal hemicrania is classified when a person suffers from attacks for one year or longer with remissions lasting up to one month. There are cases when the disease is combined with the trigeminal form of neuralgia.

Headaches are usually localized in the ear or a little further than the eye. The pain is one-sided and only in rare cases does the affected side change. Sometimes the pain radiates to the shoulder.

It is important! A typical attack lasts from two to thirty minutes and some patients complain of mild pain during the interval between attacks. Attacks can recur many times throughout the day, and the time of painful attacks cannot be predicted.

Treatment of paroxysmal hemicrania is based on the organization of indomethacin therapy - it is administered orally or rectally at least 150 and 100 mg, respectively. For preventive therapy, lower dosages of the drug also bring efficiency.

The pain is removed by indomethacin unpredictably. And the lack of pain control sometimes makes doctors doubt the correctness of the final diagnosis.

The dosage of indomethacin, which allows you to take control of pain, varies from 75 mg to 225 mg and is divided into three doses throughout the day. The pain-relieving effect of this drug usually lasts for many years of life.

Given the fact that the disease is chronic, the long-term use of the drug can provoke disruption of the intestines and kidneys.

Preventive therapy brings results only for a subset of patients. Other agents and occipital nerve block have also been shown to have positive results in selected patients.

Diagnostics

In accordance with the international classification of headaches, the diagnosis of paroxysmal hemicrania is made on the basis of the following diagnostic criteria:

A. At least 20 attacks that meet the following criteria:

B. Attacks of severe unilateral headache in the orbital, supraorbital and/or temporal region, always on the same side, lasting 2 to 30 minutes.

C. The pain is accompanied by at least one of the following symptoms on the side of the pain:

conjunctival injection
lacrimation
Nasal congestion
Rhinorrhea
Ptosis or miosis
Edema of the eyelids
Sweating on half of the face or forehead

D. The frequency of seizures is more than 5 times a day, sometimes less frequently.

E. Absolute efficacy of indomethacin (150 mg daily or less).

F. Not related to other causes.

Hemicrania continua and its distinctive features

Hemicrania continua is a rare disease that mainly affects the female body. The pain is localized in the temple or near the eye. The pain is not passing, only its intensity changes - from mild to moderate. Pain is unilateral and rarely can change the side of the lesion, and the intensity most often increases.

The frequency of attacks of pain varies from multiple for one week to single cases for a month. During an increase in the frequency of seizures, the pain becomes moderate or very severe. During this period, it is supplemented by symptoms similar to cluster head pain - drooping of the upper eyelid, lacrimation, nasal congestion, as well as symptoms characteristic of migraine itself - sensitivity to bright light, nausea with vomiting. Symptoms may also be accompanied by swelling and twitching of the eyelid.

Some patients develop migraine-like auras during severe pain. The time of pain intensification can drag on from several hours to several days.

It is important! Predictions and timing of onset of primary headaches remain unknown. Approximately 85% of patients suffer from chronic forms without remissions. Due to the fact that the correct diagnosis is not always carried out, the exact prevalence of pathology remains unknown.

Symptoms

Paroxysmal hemicrania is manifested by daily, extremely severe attacks of burning, boring, rarely pulsating, always one-sided pain in the orbital and frontotemporal regions.

Associated symptoms are the same as in cluster cephalgia: Horner's syndrome, facial flushing, conjunctival injection, lacrimation, nasal congestion.

Thus, this form of vascular headache is similar to chronic cluster cephalgia in terms of intensity, localization of pain, and autonomic manifestations. The main difference is a significant increase in the frequency of attacks (from two to ten times more often), a shorter duration of a painful attack, and a predominance among sick women. In addition, there is no response to anti-cluster prophylactic agents, and, most characteristically, there is a very rapid cessation of attacks with indomethacin, with long-term pain attacks disappearing 1-2 days after the start of treatment.

Sensitivity to indomethacin can serve as an important differential diagnostic feature.

Patient examination and prevention

Recurring headaches should definitely cause a visit to a neurologist. Diagnosis consists in questioning and examining the patient. But hemicrania may indicate the formation of a tumor in the brain and other serious disorders. For this reason, it is necessary to organize a thorough neurological diagnosis in order to exclude malignant processes. You will also need to go to a specialist ophthalmologist who examines a person’s visual fields, visual acuity, conducts computed tomography and MRI, and examines the fundus. Subsequently, the neurologist will prescribe specific medications to help prevent an attack and relieve pain.

Drug prophylactic therapy for hemicrania is developed taking into account all the provoking factors of the pathology. Concomitant diseases and emotional and personal qualities of a person are also taken into account. For prevention, various blockers, antidepressants, serotonin antagonists and other medications are used.

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Diagnostic measures

To diagnose this disease, the neurologist sends the patient to a CT scan (computed tomography) or MRI (magnetic resonance imaging) of the brain. Although the survey data do not determine the true causes of acute pain attacks, the results obtained play an auxiliary role in differential diagnosis with severe diseases of the central nervous and vascular system (tumor, cyst, stenosis of the neck vessels, giant cell arteritis).

Mandatory to be carried out:

Patient Interview, in which complaints are clarified, provoking factors are established, the frequency and duration of the pain syndrome are determined.
visual inspection, which allows to identify autonomic disorders: a decrease in tactile or pain sensitivity, allodynia from the side of the lesion.
Examination by an ophthalmologist, which assesses the condition of the fundus, measures intracranial pressure, evaluates the boundaries and visual acuity.

Differential diagnosis is carried out with other vegetative attacks of headache: cluster, KONKS syndrome. Paroxysmal hemicrania completely stops after taking a therapeutic dose of the non-steroidal anti-inflammatory drug Indomethacin, which makes it possible to distinguish it from other cephalalgias with similar symptoms.

Chronic paroxysmal (paroxysmal) hemicrania requires additional studies: blood tests, angiography of the vessels of the head and neck.

Disease pathogenesis

The process of the origin of hemicrania has not been sufficiently studied, only some assumptions have been made about the mechanism of its appearance. In favor of vasomotor disorders, the data of transcranial dopplerography of cerebral vessels speak. They determine the slowing of blood flow in the pools of the middle cerebral artery on the side where the headache is felt.

Involvement in the process of the hypothalamic-pituitary system is proved by the bilateral activity of the posterior part of the hypothalamus during a pain attack. The disorder of the trigeminal system is fixed during the electrophysiological analysis - the data indicate a decrease in the flexor reflex and the early component of the blink reflex.

Disorder of the activity of the autonomic nervous system during an attack is expressed in changes in intraocular pressure and temperature of the cornea, increased sweating of the forehead from the side of pain. The development of symptoms indicates the connection between the causes of seizures and neurogenic activation of functionally combined suprasegmental areas of the autonomic nervous and nociceptive systems.

Signs of the disease

Before the onset of severe headaches, a person feels weakness and severe hunger. There are drastic mood swings. Bags or folds appear under the eyes, vision deteriorates. Unpleasant sensations with hemicrania are localized on one side, most often in the forehead. Signs of illness include nausea and vomiting. Pain of a throbbing nature subsides slightly after vomiting. Experts do not recommend enduring discomfort, since prolonged soreness will lead to a significant increase in intracranial pressure.

Conclusion

Paroxysmal hemicrania interferes with the usual way of life for every person. It causes severe pain and discomfort that cannot be tolerated. Only on the basis of the results of laboratory tests, the specialist prescribes treatment. Alternative methods of treatment can only temporarily mask the pain. Before taking any drug or infusion, you should consult a specialist. According to doctors, the best pain reliever is No-shpa. Tablets eliminate severe pain and spasms, while they have practically no side effects. The tablet should be taken no more than twice a day. To get rid of the disease for a long time, you need to responsibly approach the treatment process.

Hemicrania

The first mention of migraine appeared long before the birth of Christ: this is evidenced by ancient Egyptian papyri describing migraine headaches and ways to combat this disease. Ancient people prepared decoctions of herbs and made potions; tied the skin of a young crocodile to a sick head. The term "hemicrania", that is, "a disease in which half of the skull hurts," was suggested by the famous ancient physician Galen. Over time, as a result of the truncation of the first syllable, the concept of “micrania” developed, which later transformed into the modern “migraine”.

Despite the fact that mankind has been studying this disease for several millennia, it has not yet been possible to fully unravel its pathogenesis. Pharmaceutical companies spend millions of dollars on the synthesis and production of new anti-migraine drugs, despite the fact that migraine is incurable due to its hereditary nature.

Epidemiology

According to world statistics, about 14% of the population suffers from migraine (women are 2.5-3 times more likely than men: in women, the prevalence of this disease reaches 20%, in men only 6%). About 20 million people suffer from migraine in Russia.

Migraine headache is a disease of young people: the onset of the disease in the majority occurs before the age of 20 years, and the occurrence after 50 years is not typical. In childhood, migraine is detected in 4% of children, and until puberty, there are no gender differences in its prevalence.

It is known that only 1/6 of patients suffering from migraine go to the doctor, the rest do not consider migraine to be a serious disease and self-medicate. Most appeals fall on the most able-bodied age from 35 to 45 years, this is due to the fact that it is at this age that the disease is more difficult to tolerate: attacks become more frequent and become resistant to conventional analgesics.

According to the WHO, for women, migraine ranks 12th, and for men, 19th place in the list of diseases that have the most important impact on human health.

Classification and diagnosis of migraine

The international classification of headache distinguishes two main forms of migraine:

migraine without aura, which accounts for about 80% of all cases;
migraine with aura - 20%.

Diagnostic criteria are purely clinical in nature, however, neurological and paraclinical studies are necessary to rule out an organic lesion of the CNS (Fig. 1). The criteria for migraine without aura relate to a painful attack, the criteria for migraine with aura include the clinical symptoms of the aura itself, as the most characteristic manifestation of migraine. Migraine headache with aura can be typically migraine-like in nature, as well as resembling a tension headache or completely absent - "headless migraine".

Migraine headache is paroxysmal in nature: the intensity increases rapidly and also decreases rapidly, the patient can name the hours and minutes of the beginning and end of the attack. This distinguishes a migraine headache from a tension headache, the beginning and end of which are blurred. The duration of a migraine attack is on average about 24 hours, without the use of analgesics or with ineffective treatment with them. Unilateral pain or hemicrania is detected in 60% of attacks; as a rule, there is a "favorite" side from which the pain occurs more often and more strongly. Less often, there may be an alternation of the sides of localization of pain or bilateral pain. In most patients with migraine, the pain is pulsating, of moderate to severe intensity, and is exacerbated by the slightest exertion or even movement of the head.

Migraine aura is a complex of local reversible neurological symptoms. They are characterized by a duration of no more than an hour - in typical cases, 15–20 minutes; sequential development: visual disturbances occur first, then in 45% of patients visual disturbances are followed by sensory disturbances, in 10% - by motor ones, and motor aphasia, memory impairment by the type of transient global amnesia, etc. can rarely develop. If there is a “light interval", it lasts no more than an hour, otherwise these are unrelated events.

Characteristic of migraine is the presence of a special functional state of the patient, which occurs before the development of a migraine attack - prodrome and continues after its completion - postdrome. The prodrome occurs within 2-3 hours in approximately 60% of migraine attacks and is characterized by irritability, depressed mood, drowsiness, anxiety, hyperactivity, impaired concentration, photo- and phonophobia, hunger, anorexia, fluid retention, thirst and other symptoms. The presence of a prodrome allows patients to differentiate migraine from other types of headache in advance. For the postdrome, which is noted in 90% of attacks and lasts up to a day, a violation of concentration, a feeling of fatigue, weakness, muscle weakness, hunger, and less often euphoria are typical.

The most important for practical medicine is the differential diagnosis of migraine with secondary headaches, which are symptoms of another disease. So, for migraine, a differential diagnosis with an unruptured aneurysm, malformation of cerebral vessels, transient ischemic attack, and epilepsy is relevant. Danger signals are distinguished, if at least one of them is present in the clinical picture, a thorough examination should be carried out (Fig. 2), first of all, a neurological examination with a study of the motor, sensory and coordination spheres, as well as a paraclinical study. Magnetic resonance imaging (MRI) of the brain and MR angiography have the highest resolution. An ultrasound examination of the vessels, functional radiography of the cervical spine, an electroencephalogram (EEG), an examination of the fundus, visual fields, intraocular pressure, and other methods may be important.

Differential diagnosis with other primary headaches (tension headache, cluster headache) is carried out by analyzing the characteristic clinical symptoms of the disease.

Etiology and pathogenesis

Migraine is a hereditary disease. In the 90s of the twentieth century, genetic studies were carried out that identified several genes that control the function of ion channels, determine the excitability of the brain and are responsible for the inheritance of migraine headache.

The pathogenesis of migraine is extremely complex and many of its mechanisms are not fully understood. Modern researchers believe that cerebral mechanisms are leading in the occurrence of a migraine attack. In patients with migraine, it is assumed that there is a genetically determined limbic-stem dysfunction, leading to a change in the relationship between the noci- and antinociceptive systems, with a decrease in the influence of the latter. Before an attack, there is an increase in the level of brain activation, followed by a decrease in it during a pain attack. At the same time, the trigemino-vascular system is activated from one side or the other, which determines the hemicranic nature of pain.

According to the theory of Moskowitz M.A., the final link in the complex processes that occur during a migraine attack in the brain is the activation of the trigeminovascular system: vasodilatation of the meninges, penetration through the atonic vascular wall into the perivascular space of algogenic substances from the blood plasma (neurogenic inflammation) and, as a result, a strong throbbing pain.

Significant advances in the study of the pathophysiology of migraine serve as the basis for modern pharmacotherapy of migraine headaches.

Migraine treatment

A patient suffering from recurrent headaches of considerable intensity, accompanied by nausea and vomiting, especially when the attacks become more frequent and longer, usually has serious health concerns, suggesting that the cause is a tumor, vascular aneurysm, or some other fatal disease. The most important task of the doctor is to conduct an informational conversation about what a migraine headache is, about the course, a favorable prognosis of the disease and the absence of a fatal organic disease in the patient. Such a conversation is aimed at relieving distress, normalizing the mental state of the patient and is important for the success of future treatment. At the same time, the patient should be informed that migraine is an incurable disease due to its hereditary nature. In this regard, the main goal of treatment is to maintain a high quality of life in a patient with migraine by teaching him how to quickly, effectively and safely relieve migraine headache, as well as by taking a number of measures aimed at reducing the frequency, intensity and duration of attacks.

A necessary condition for this goal is the cooperation of the doctor and the patient, as well as the active participation of the latter in their own treatment. The patient is recommended to keep a headache diary, where within 2-3 months (for the period of examination and treatment) it is necessary to record the frequency, intensity, duration of headache, the drugs used, the day of the menstrual cycle, as well as provoking factors and accompanying symptoms. In the process of treatment, the diary can clearly and reliably demonstrate its effectiveness.

Migraine patients are hypersensitive to a wide variety of external and internal factors: hormonal fluctuations, food, environmental factors, sensory stimuli, stress.

Provoking factors - migraine triggers:

food (hunger, alcohol, supplements, certain foods: chocolate, cheese, nuts, citrus, etc.);
chronobiological (sleep: too little or too much);
hormonal changes (menstruation, pregnancy, menopause, HRT, contraceptives);
environmental factors (bright light, smell, altitude, change in weather);
physical influences (exercise, sex);
stress and anxiety;
head injury.

Identifying patient-specific triggers and avoiding them can go a long way in reducing the frequency of seizures.

Analysis of comorbidity is one of the most important moments in the development of therapeutic tactics. On the one hand, comorbid disorders, along with the underlying disease, can significantly affect the patient's quality of life, which must be taken into account in complex therapy, on the other hand, they can determine indications or preferences, as well as contraindications when choosing certain drugs and routes of their administration. . The presence of a patient with cardiovascular disorders, especially labile, arterial hypertension, angina pectoris or coronary heart disease is a contraindication for the use of triptans and ergotamine preparations. When migraine is combined with epilepsy and stroke, valproates have an advantage. The presence of comorbid conditions such as Raynaud's syndrome, depression, anxiety or panic in a patient with migraine determines the preferred choice of antidepressants.

The most recent, but undoubtedly the most important steps are the choice of a remedy for the treatment of an attack and the appointment, if necessary, of prophylactic therapy.

The main goal of treating a migraine attack is not only to eliminate the headache and associated symptoms, but also to quickly restore the patient's capacity and improve his quality of life.

For the treatment of migraine attacks (abortion therapy), drugs are used with both non-specific and specific mechanisms of action. Drugs with a nonspecific mechanism of action can reduce pain and associated symptoms not only in migraine, but also in other pain syndromes. Drugs with a specific mechanism - ergotamine derivatives and triptans - are effective only for migraine headaches. Along with this, combined preparations containing analgesics of both non-specific action (caffeine) and specific action (ergotamine), as well as antiemetic adjuvants, are used.

Choosing the right drug for the treatment of an attack is a complex task and depends on the intensity and duration of the attack itself, the accompanying symptoms, concomitant diseases, past experience with the drugs, and finally, their cost. There are two methodological approaches to drug selection: stepwise and stratified. With a stepwise approach, treatment begins with the cheapest and least effective drugs: the first step is conventional analgesics (paracetamol or Aspirin) and non-steroidal anti-inflammatory drugs (NSAIDs). If the trial treatment was ineffective or the drugs ceased to be effective after some time, then they proceed to the second stage: combined drugs (Spazmalgon, Pentalgin, Kaffetin, Kafergot, etc.). The third step is specific anti-migraine treatment using both selective 5HT1 receptor agonists - triptans, and non-selective 5HT1 receptor agonists - ergotamine preparations. It should be noted that with frequent and long-term use of analgesics and especially combined drugs, addiction and the formation of analgesic dependence occur, which leads to chronification of the pain syndrome and the transformation of migraine into a chronic form. It is a stepwise approach with unreasonably long and almost daily use due to the low effectiveness of analgesics and combined drugs that can lead to abuse headache. The second danger of a stepwise approach to treatment is the fact that for patients with severe attacks, accompanied by nausea and vomiting, a gradual selection of drugs is generally unacceptable. Such treatment will be obviously ineffective, the patient and the doctor will remain dissatisfied with the results of treatment, and the search for and constant replacement of the drug will make the treatment also expensive. In this regard, a stratified approach is proposed for the selection of treatment. According to this approach, the severity of the attack is initially assessed based on the analysis of the intensity of pain and the degree of disability. In patients with milder attacks, it is highly likely that first-line drugs will be effective. Patients with severe attacks should start treatment immediately with higher levels of drugs, such as triptans. In many cases, this will avoid calling an ambulance, quickly restore the ability to work, increase the patient's level of self-control, and reduce the feeling of fear and helplessness before another attack. Patients with prolonged severe attacks, migraine status need hospitalization and treatment in a neurological hospital or intensive care unit.

The action of selective 5HT1b and 5HT1d receptor triptan agonists is based on both neurogenic and vascular effects. Triptans inhibit the release of vasoactive substances from the peripheral endings of the trigeminal nerve, causing vasodilation and stimulation of pain receptors of the trigeminal nerve endings, and also cause contraction of the vessels dilated during an attack, which prevents exudation and irritation of pain receptors by algogenic substances penetrating from the blood plasma into the perivascular space.

Sumatriptan was the first selective 5HT1b/d agonist. Its clinical use began in 1990. Subsequently appeared: zolmitriptan, naratriptan, rizatriptan, eletriptan, almotriptan, frovatriptan (in the medical literature, this class of drugs is called "triptans").

at the Headache Clinic. Academician Alexander Vein conducted an open study of the Russian sumatriptan - Amigrenin on 60 patients suffering from migraine without aura. Relief or complete regression of headache after 2 hours using 50 mg and 100 mg of Amigrenin was noted by 60% and 63.3% of respondents, respectively (p< 0,005). Сопутствующие симптомы регрессировали постепенно, через 2 часа они отмечались менее чем у половины больных, а через 4 часа фото- и фонофобия исчезли полностью. Возврат головной боли составлял при приеме 50 мг и 100 мг Амигренина 33,3% и 36,6% приступов, и рецидив успешно купировался приемом второй таблетки препарата. В основном Амигренин хорошо переносился пациентами. Побочные эффекты были легкими и умеренными, их отметили 6 пациентов. Симптомы появлялись вскоре после приема Амигренина, длились не более 15–20 минут и проходили спонтанно, не требуя дополнительной коррекции. Побочные эффекты «укладывались в рамки так называемого «триптанового синдрома», который могут вызывать любые триптаны. Это покалывание, онемение, ощущение жара или холода, чувство тяжести, сдавления или стягивания головы, шеи, грудной клетки. Как было показано в многочисленных зарубежных исследованиях, побочные эффекты, возникающие при приеме этих препаратов, не являются опасными и не требуют отмены лечения при условии соблюдения правил назначения. Основными противопоказаниями к назначению триптанов является наличие сердечно-сосудистых заболеваний: ишемической болезни сердца (ИБС), перенесенного инфаркта миокарда или инсульта, неконтролируемой артериальной гипертензии, заболеваний периферических сосудов. Учитывая молодой возраст большинства пациентов с мигренью, можно с уверенностью сказать, что перечисленные противопоказания выявляются в исключительно редких случаях.

Preventive treatment of migraine

Preventive treatment of migraine is carried out daily for several months (usually three months), then take a break and repeat after six months. In the case of resistance, prophylactic treatment is carried out for a longer time, trying to choose the most effective course for this patient. The most common mistake is the appointment of prophylactic therapy for 1-2 weeks and its subsequent cancellation in the absence of a clear effect.

The main objective of preventive treatment is to reduce the frequency, intensity and duration of seizures.

Indications for the appointment of preventive treatment:

two or more seizures per month;
seizures that last three or more days and cause severe maladjustment;
contraindications to abortive treatment or ineffectiveness of symptomatic therapy;
hemiplegic migraine or other rare headache attacks during which there is a risk of permanent neurological symptoms.

The most popular means of preventive treatment of migraine include: beta-blockers, antidepressants, anticonvulsants, calcium channel blockers and other drugs (NSAIDs, botulinum toxin).

It is suggested that beta-blockers modulate the activity of central antinociceptive systems and prevent vasodilation. In the periphery, beta-blockers are able to block catecholamine-induced platelet aggregation and release of serotonin from them. The most effective for migraine are adrenoblockers that do not have partial sympathomimetic activity. The presence of a cardioselective property does not significantly affect the treatment of migraine. In patients with arterial hypertension, beta-blockers have an advantage over other anti-migraine prophylactic agents. Their combination with antidepressants (amitriptyline) significantly increases the effectiveness of treatment, which allows you to reduce the doses of both drugs and reduce the likelihood of side effects. In clinical practice, for the prevention of migraine, both non-selective beta-blockers (propranolol 40 mg - 120 mg per day) and selective beta-blockers (atenolol from 50 mg to 200 mg per day) are most often used.

Antidepressants of various classes are prescribed for prophylactic treatment of migraine: tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), selective noradrenergic and serotonergic antidepressants. Antimigraine action of antidepressants does not depend on their psychotropic action. Antidepressants are widely used to treat chronic pain, both due and unrelated to depression. The analgesic effect of antidepressants is primarily associated with their serotonergic effect, develops earlier in time than antidepressant, and is due to modulation of the activity of serotonergic receptors in the CNS. Clinical and experimental studies indicate an increased sensitivity of 5HT2-type serotonin receptors and a reduced level of serotonin in the interictal period in migraine. Antidepressants of various classes are able to increase the content of serotonin and modulate the sensitivity of serotonin receptors.

Currently, the latest generation of anticonvulsants are used in the treatment of migraine: valproate (600–1000 mg/day), topiramate (75–100 mg/day) and gabapentin (1800–2400 mg/day). Previously used for this purpose, carbamazepine and much less often clonazepam did not show their advantages over other antimigraine drugs and placebo. The mechanism of action of anticonvulsants is not fully understood. Several mechanisms of action of each drug are discussed. Valproate, topiramate and gabapentin are able to influence nociception by modulating gamma-aminobutyric acid (GABA) and/or glutamatergic transmission. All three anticonvulsants enhance GABAergic inhibition. Valproate and gabapentin affect the metabolism of GABA, preventing its conversion to succinate, and topiramate potentiates GABAergic inhibition, having an excitatory effect on GABA receptors. In addition, topiramate is able to directly act on glutamate receptors, reducing their activity. Valproate, gabapentin and topiramate reduce the activity of sodium ion channels (stabilization of neuronal membranes occurs). All three anticonvulsants modulate the activity of calcium ion channels. Valproate blocks the T-type calcium ion channels; topiramate inhibits high-voltage L-type calcium ion channels, and gabapentin binds to the alpha-2-delta subunit of L-type ion channels. The therapeutic effect of anticonvulsants, therefore, is based on their effect on ion channels, biochemical modulation of neuronal excitability, as well as a direct effect on nociceptive systems. Anticonvulsants are currently the most promising means of migraine prevention and, according to multicenter studies, they are in the first line of migraine prevention.

Calcium, in combination with calcium-binding protenins such as calmodulin or troponin, regulates many functions in the body - muscle contraction, the release of neurotransmitters and hormones, and enzyme activity. Extracellular calcium concentration is high, intracellular, on the contrary, low. This difference in concentration (concentration gradient) is maintained by the membrane pump. There are two types of calcium channels - channels through which calcium enters the cell, and channels through which calcium is released from cellular organelles into the cytoplasm. It is suggested that calcium channel blockers prevent neuronal hypoxia, vascular smooth muscle contraction, and inhibit calcium-dependent peptides involved in prostaglandin synthesis, preventing neurogenic inflammation. In addition, these drugs can block the release of serotonin. In the preventive therapy of migraine, verapamil is used from 80 to 240 mg/day, nifedipine from 20 to 100 mg/day, nimodipine 30–60 mg/day, flunarizine 5–10 mg/day. The side effects of calcium channel blockers differ with different drugs; the most frequent are: depression, constipation, orthostatic hypotension, bradycardia, edema.

Combinations of drugs are often used in the treatment of refractory migraine. Some combinations are preferred, such as antidepressants and beta-blockers, the following should be used with caution - beta-blockers and calcium channel blockers, others are strictly contraindicated - MAO inhibitors and SSRIs. Clinical observations have also shown that the combination of antidepressants (TCAs or SSRIs) and beta-blockers works synergistically. The combination of methysergide and calcium channel blockers reduces its side effects. Valproate in combination with antidepressants has been successfully used for refractory migraine in combination with depression or bipolar disorders.

It is important to note that abortive therapy (both non-specific analgesics and specific ones - triptans) is well combined with any means of preventive therapy. Their combined use allows maintaining a high quality of life for a patient with migraine.

For literature inquiries, please contact the editor.

E. G. Filatova, doctor of medical sciences, professor MMA named after I.M. Sechenov, Moscow

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Causes of hemicrania

Sometimes it is difficult to determine for what reason pain occurs with paroxysmal hemicrania, reviews of real people cannot always answer the question. Many factors can cause severe headaches. Among the most common:

strong feelings or stress;
heavy physical labor;
overheating of the body;
cold;
pregnancy;
poisoning;
heredity;
abrupt change in weather conditions;
ovulation and menstruation;
antibiotics.

If a person has a systematic headache, then the patient can already roughly determine which factors cause discomfort. But it is not always possible to limit their influence. It's important to listen to your body. Since close attention to oneself is not the main method of diagnosis, it is necessary to undergo a complete medical examination.

Features of the disease

After conducting numerous studies, doctors concluded that hemicrania occurs due to the appearance of disorders associated with intracranial pressure. Drugs and drinks that contain serotonin in their composition have a bad effect on the concentration of plasma in the blood. The substance enters the urine, due to which vasoconstriction occurs. As a result, a strong and sharp headache. As medical practice shows, this disease most often worries people whose activities are directly related to mental activity. For those who lead an active lifestyle, unpleasant sensations appear much less frequently.

Causes

The causes of the disease are not known for certain, factors that can provoke attacks of hemicrania have been identified. Such provocateurs include sharp turns of the head, alcoholic drinks, stressful situations, mental and emotional experiences, a relaxing phase after severe stress.

It is known that pain can occur as a response to prolonged visual load, taking certain medications. Women notice seizures during menstruation. The relationship of headache attacks with organic pathologies of the central nervous system has not been identified. But it should be noted that a similar clinical picture can be observed in patients after a stroke, traumatic brain injury, as well as in those suffering from arteriovenous anomalies in the posterior cranial fossa and neurofibromatosis.

Ways to relieve pain

People who are bothered by this disease often take painkillers to relieve headaches. By such actions, a person only masks unpleasant sensations, so such treatment gives a temporary effect. Medications do not always stop attacks of paroxysmal hemicrania. To alleviate the general condition of the patient, it is necessary:

Before the attack approaches, reduce physical and mental activity.
Lie on the sofa and take a comfortable position.
Use cold compresses as this improves circulation.
Ventilate the room.
Turn off the TV and lights.

It is advisable to get some sleep. After sleep, a person feels much better. You need to put aside urgent matters and just relax. Nervous tension and stress will only worsen the patient's well-being.

Varieties of hemicrania

There are several types of chronic hemicrania, depending on the signs and well-being of the patient. Namely:

A simple view is characterized by the occurrence of pain in the forehead or eyes. Localized on one side only. At the temples, the arteries expand, and the patient feels a pulsation. The skin turns pale, and bags form under the eyes. Often there is dizziness, impaired speech, pain in the abdomen and nausea. If the pain is too strong, then vomiting appears, after which relief comes. The session lasts approximately 2 hours.
During an ocular migraine, vision is impaired, flies and lines appear before the eyes. The patient may become temporarily blind as the disorder affects the eyes. In this case, the visual analyzer is not able to fully function.
Less often, pain is localized in the neck and temples. Such pain seems unbearable for the patient. Often accompanied by weakness and profuse vomiting.

Only a doctor can correctly analyze the clinical picture and prescribe treatment. Symptoms of paroxysmal hemicrania often indicate the presence of other diseases, so you should not self-medicate.

To get rid of severe pain, doctors recommend massaging the back of the head and forehead. With a massage of the collar zone, pain is reduced. It is important to know that Analgin is a dangerous drug used by ambulance staff in cases of emergency. These pills can cause a lot of side effects. Therefore, if there are serious diseases of other organs, it is better not to take it. Unfortunately, not everyone knows about it. To improve your overall health, you need to eat right, exercise, and visit your doctor regularly. As practice shows, such people are less likely to have headaches.

First aid

As a rule, patients suffering from hemicrania, at the first sign of an approaching attack, take painkillers. In this case, the drugs give only temporary relief and do not relieve the attack. However, a more pronounced result, as practice shows, can be achieved by alternative methods of treating the disease.

Excellent results allows you to get self-massage. For some patients, a few minutes of self-massage is enough to prevent unbearable pain.

Hemicrania is simply a migraine, that is, sharp pains in the head, accompanied by a strong pulsation, radiating to one of the hemispheres of the brain. This pathology can drag on for three days and deliver a lot of suffering to the patient.

Migraines are classified into two types, namely:

Ordinary migraine, which usually affects the temple, the crown, the eyeball, and then spreads to the entire half of the head. An artery begins to protrude at the temple, which pulsates strongly, and the skin on the face becomes very pale. The pain is often accompanied by short-term immobilization of the eyeball, double images, dizziness, speech disorders, as well as abdominal pain, vomiting with nausea.
Ophthalmic migraine - this type of pathology occurs occasionally and accounts for approximately 10% of all such lesions. Associated signs should be considered: visual disturbances, namely blurring of the image, blurring and short-term blindness. Bright lights, too loud sounds, sneezing and coughing provoke pain.

Causes of the disease

It is important! Additional reasons include: severe stress, overheating in the sun, fatigue, eating foods provoking an attack, dehydration.

Paroxysmal form of the disease, its differences

This form of pathology is more common in women and begins already in adulthood, but some cases of infection in children are known.

Headaches are usually localized in the ear or a little further than the eye. The pain is one-sided and only in rare cases does the affected side change. Sometimes the pain radiates to the shoulder.

It is important! A typical attack lasts from two to thirty minutes and some patients complain of mild pain during the interval between attacks. Attacks can recur many times throughout the day, and the time of painful attacks cannot be predicted.

The pain is removed by indomethacin unpredictably. And the lack of pain control sometimes makes doctors doubt the correctness of the final diagnosis.

Given the fact that the disease is chronic, the long-term use of the drug can provoke disruption of the intestines and kidneys.

Preventive therapy brings results only for a subset of patients. Other agents and occipital nerve block have also been shown to have positive results in selected patients.

Hemicrania continua and its distinctive features

Some patients develop migraine-like auras during severe pain. The time of pain intensification can drag on from several hours to several days.

It is important! Predictions and timing of onset of primary headaches remain unknown. Approximately 85% of patients suffer from chronic forms without remissions. Due to the fact that the correct diagnosis is not always carried out, the exact prevalence of pathology remains unknown.

Patient examination and prevention

For citation: Shtok V.N. TREATMENT OF MIGRAINE AND SOME FORMS OF PAROXYSMAL MIGRAINE-LIKE HEADACHE OF VASCULAR GENESIS // BC. 1998. No. 20. S. 2

The tactics of treatment of migraine, cluster headache, chronic paroxysmal hemicrania, migraine of the lower half of the face and "cervical migraine" are described. Each section contains characteristic clinical signs of different types of migraine and other paroxysmal forms of vascular headache.

The paper describes treatment policy for migraine, cluster headache, chronic paroxysmal hemicrania, lower facial and cervical migraine is described. Each section outlines the characteristic clinical signs of different types of migraine and other paroxysmal vascular headaches.

V.N. Stock - d.m.s., prof., head. Department of Neurology, Russian Medical Academy of Postgraduate Education

V.N. Shtok - prof., MD, Head, Department of Neurology, Russian Medical Academy of Postgraduate Training

To The group of paroxysmal headache of vascular genesis includes various forms of migraine itself, cluster (cluster) headache, chronic paroxysmal hemicrenia, migraine of the lower half of the face. In all these cases, the pathogenesis is based on hereditary or congenital inferiority of neurohumoral regulation and/or endocrine homeostasis. Standing apart is "cervical migraine" of vertebrogenic origin.

Migraine

Migraine is manifested by attacks of pain (usually pulsating) in the fronto-temporal-orbital region, extending to half of the head (hemicrania). It begins more often in the time interval from puberty to the beginning of the third decade of life.
The further course is unpredictable: attacks may end with the end of puberty or continue with varying frequency throughout life. In the latter case, the frequency of attacks is influenced by various factors: an unhealthy lifestyle, household or industrial stress, a change in the usual climatic conditions, food, medicinal and other allergens.
For different types of migraine, the following signs are characteristic: localization of pain, often one-sided, duration of an attack for several hours, photo- or phonophobia, nausea or vomiting at the height of the attack. During an attack, the patient is unable to work, and the usual household activity decreases. The patient seeks to retire, go to bed, fall asleep. It should be emphasized the individual stereotyping of the course of an attack in each patient.
According to the proposals of the International Commission of Experts on the Classification and Diagnosis of Headache, migraine without aura and migraine with aura are distinguished within the framework of migraine itself.
Migraine without aura (former name - simple, ordinary) is characterized by the onset of an attack without any pronounced disorders immediately before its onset. However, patients may experience dysphoria, irritability, changes in appetite, water retention within a few hours before an attack (more often women pay attention to this). The combination of these symptoms is called precursors.
migraine with aura It is characterized by the appearance of an aura more often before, less often simultaneously or against the background of an unfolding attack of pain. This type includes migraine, formerly called classical (ophthalmic), in which the aura manifests itself either as sparkling dots, zigzags or partial loss in any quadrant or half of both fields of vision, which indicates discirculation in the cortical branches of the posterior cerebral artery supplying the visual analyzer . Distinguished from the ophthalmic type retinal (retinal) migraine , in which visual impairment in one eye (the vision of the other eye is usually not impaired) is manifested by blurring, the impression of falling flakes, or the movement of black flies. These disorders are caused by discirculation in the central retinal artery.
Usually the visual aura in both cases precedes the onset of pain.
The duration of the aura is individual - from a few seconds to several minutes. Sometimes after the end of the aura before the onset of pain there is a short "light" interval.
Another form of aura (formerly known as associated migraine) is distinguished by the occurrence before or at the beginning of a painful attack of various neurological disorders - hemiparesis, hemidyshesthesia, aphasia, vestibulocerebellar symptoms, mental (dysphrenia), which indicates discirculation in different areas of the cortex or brain stem, or the appearance somatic symptoms (pain in the chest or abdomen) as signs of transient disorders of the regulation of the function of internal organs.
Seizures recurring without interruption for 2-5 days called migraine status . If associated symptoms are observed within a few days or hours after an attack, they speak of complicated migraine. In such cases, a more in-depth examination is necessary to exclude arterial or arteriovenous aneurysms of cerebral vessels. If all or most of the attacks occur during menstruation, such a migraine is called catamineal (menstrual).
Treatment for a migraine attack. The most effective means are 5-HT1 agonists - serotonin receptors - sumatriptan, zolmitriptan.
Sumatriptan during an attack is prescribed orally in tablets of 0.1 g no more than twice a day, or 6 mg of the drug is injected subcutaneously (6 mg of sumatriptan succinic salt are dissolved in 0.5 ml of distilled water in an ampoule) also no more than twice a day. Inside and in injections, sumatriptan is not used at the same time, they are not combined with ergotamine preparations. The drug is contraindicated in pregnancy, angina and intermittent claudication.
Another effective tool is ergotamine hydrotartrate which has a vasoconstrictor effect. Once, you should not prescribe more than 2 mg of the drug orally or 4 mg in a suppository (no more than 8-10 mg / day). With the rapid development of the pain phase, 0.25-0.5 ml of a 0.05% solution of ergotamine is injected into a muscle or vein. Overdose leads to the development of ergotism. Ergotamine is part of such medicines as ginergin, gynofort, neogynofort, ergomar, secabrevin, belloid, akliman. Among ready-made drugs, caffeamine has proven itself well - a combination of ergotamine with caffeine.
Drugs should be taken at the first signs of an attack, because gastric stasis develops later, and drugs taken orally are not absorbed. Metoclopramide (intramuscularly, orally or in suppositories a few minutes before taking an analgesic or ergotamine) accelerates the evacuation of the contents of the stomach and the absorption of the analgesic.
Access can be stopped dihydroergotamine- inside, 5-20 drops of a 0.2% solution (0.002 g in 1 ml), or subcutaneously, 0.25-0.5 ml of a 0.1% solution (0.001 g in 1 ml) 1-2 times a day, or nasal spray (1 dose in each nostril - a maximum of 4 doses during an attack). You can add antihistamines, sedatives and hypnotics.
With individual selection of effective agents for the treatment of an attack, the following combinations of ergotamine with analgesics are recommended: ergotamine + amidopyrine + acetylsalicylic acid; ergotamine + caffeine + indomethacin; ergotamine + paracetamol + codeine phosphate + caffeine. In such combinations, each of the drugs is prescribed in half the average therapeutic single dose.
Treatment for migraine status carried out in a neurological hospital. Intravenous (drip) administration of 50-75 mg of a soluble preparation of prednisolone - prednisolone hemisuccinate (the contents of the ampoule - 0.025 g - is dissolved in 5 ml of water for injection, preheated to 35-37 ° C; for drip administration, the resulting solution is diluted in 250-500 ml isotonic sodium chloride solution, 5% glucose solution or polyglucin), dihydroergotamine or injectable acetylsalicylic acid aspizol (contains 1 g of dry matter in 1 ampoule - 0.9 g of lysine monoacetylsalicylate, 0.1 g of aminoacetic acid and corresponds to 0.5 in activity g of acetylsalicylic acid, in another ampoule 5 ml of solvent - water for injection). A freshly prepared solution of aspizol is injected slowly into a vein or deep into a muscle. For drip intravenous infusion, this solution is diluted with 250 ml of isotonic sodium chloride solution or in 5% glucose or polyglucin solution. Assign sumatriptan or ergotamine (avoid overdose!). Apply dehydrating agents (furosemide), neuroleptics (chlorpromazine, haloperidol, thioridazine), diazepam, antihistamines, hypnotics and antiemetics. For local anesthesia, infusions into a vein of a 0.25% solution of bupivacaine hydrochloride (0.1-0.2 mg / kg) are offered in a 10% glucose solution (for 30 minutes). Good results are obtained by a combination of intravenous injections of aminophylline with glucose, dehydrating and antihistamines. Due to the increase in the level of lactate in the cerebrospinal fluid during migraine status, drip infusions of sodium bicarbonate are recommended. Narcotic analgesics usually have no effect, but often increase vomiting.
Interictal treatment of migraine prescribed for frequent (at least 1 per week) and severe attacks, leading to temporary disability.
The most recognized are the so-called antiserotonin agents. One of these drugs, cyproheptadine (12 mg/day), pizotifen (1.5 mg/day), methysergide (6 mg/day), or iprazochrome (7.5 mg/day), is given daily. It is advisable to start treatment on interictal days. The duration of the course is 3-6 months, depending on the effectiveness, presence and severity of adverse reactions. Termination or a sharp decrease in the frequency and severity of attacks is observed in 50-70% of patients.
Antidepressants have serotonergic properties.
Doses of amitriptyline recommended for course treatment range from 10 to 175 mg / day. Monoamine oxidase inhibitors for prolonged courses are not used due to toxicity and adverse reactions.
Effective b - blockers: treatment with propranolol at a dose of 120-240 mg / day reduces the frequency and severity of seizures in 80% of patients. b-blocker nadolol can be taken once a day (20-80 mg). The effectiveness of oxprenolol and pindolol is significantly lower than that of propranolol. Selective b-blockers are usually ineffective. The effectiveness of propranolol is increased when used in combination with pizotifen, and the dose of each of the drugs can be halved. Given that b-blockers and ergotamine cause peripheral vasoconstriction, they should not be administered simultaneously.
The action of clonidine is similar to that of b - blockers. With course treatment, clonidine at a dose of 0.150-0.235 mg / day reduces the frequency and severity of seizures in 52-61% of patients. Treatment b -blockers and clonidine should be used in patients with hypertension.
For interictal treatment, non-steroidal anti-inflammatory drugs (NSAIDs) are used - acetylsalicylic acid (15 mg / kg per day), ketoprofen (100-200 mg / day), piroxicam (20 mg / day), naproxen (550 mg / day), mefenamic, flufenamic and tolfenamic acids (respectively 250-500, 400 and 300 mg/day); dihydrated ergot derivatives - dihydroergotamine (1 mg / day), dihydroergotoxin at a dose of 4.5 mg / day, nicergoline - 15 mg / day orally for 2-3 months; calcium antagonists: cinnarizine (225 mg/day), flunarizine (9 mg/day), verapamil (80-160 mg/day), diltiazem (180 mg/day), nimodipine (120 mg/day). Course duration 8-15 weeks.
For menstrual migraine a good effect is given by the appointment 3-5 days before the start of menstruation of courses of treatment with NSAIDs in the above doses or bromocriptine (2.5-5 mg / day). Bromocriptine is contraindicated in patients with syncopal migraine. If such treatment is ineffective, progestogen preparations are used: 2.5% solution of progesterone in oil, 1 ml per muscle every other day 10-14 days before menstruation, or 6.5% (12.5, 25%) oily solution of oxyprogesterone capronate of prolonged action 1 ml per muscle 1 time 10 days before menstruation.
Sometimes it is effective to take pregnin 0.01 g 2 times a day for 6-7 days. In resistant cases, testosterone propionate is prescribed at a dose of 0.05 g 2 times a day.
Patients in whom interictal migraine treatment fails should undergo electroencephalography.
When epileptiform activity is detected on the EEG, anticonvulsants are used for interictal treatment: finlepsin 0.2 g 2 times a day or phenobarbital 0.05 g 2 times a day, sodium valproate 0.6 g 2 times a day (optimal plasma concentration 700 mmol/l).
The choice of agents for interictal treatment should be guided by pharmacotherapeutic logic. So, young patients suffering only from migraine are prescribed pizotifen or iprazochrome, in the presence of orthostatic episodes and arterial hypotension - dihydroergotamine; with concomitant arterial hypertension - clonidine or b-blockers, dihydroergotoxin, calcium antagonists; with depressive syndromes - antidepressants, with menstrual migraine - NSAIDs or bromocriptine (especially with an increase in plasma prolactin levels); with paroxysmal changes in the EEG - anticonvulsants (phenobarbital, carbamazepine).
The condition of patients in the interictal period can be different: from almost complete health to almost daily manifestations of various forms of vegetovascular dystonia. Among the latter, the headache of venous insufficiency is most often observed - arching pain (heaviness) in the back of the head or the entire head, which requires the appointment of xanthine drugs. The choice of drugs for the treatment of interictal manifestations of vegetovascular dystonia is determined individually. In most cases, it is advisable to combine them with tranquilizers.
In all cases, for successful relief of seizures and inter-ictal treatment, it is necessary that the patient maintain a healthy lifestyle, avoid mental and physical overload, as well as exposure to provoking factors.

Cluster (bundle) headache
(cluster head)

Of the former names - Horton's syndrome, erythromegaly of the head, group attacks of pain - Harris's periodic migraine neuralgia can be considered more accurate in describing the symptom complex.
The disease often begins between the ages of 25 and 30. About 70% of patients are men.
An attack of pain occurs suddenly in the periorbital region and behind the eye ("the eye protrudes"), radiates to the frontotemporal, zygomatic region, sometimes throughout the entire half of the face, to the neck; the pain is burning, cutting, bursting. Patients scream, moan, cry, there is psychomotor agitation. On the pain side, the skin of the face turns red, injection of scleral vessels, Horner's symptom are noted, the eye is watery, half of the nose is blocked. There are no harbingers or auras.
The duration of the attack ranges from 15 to 30 minutes, usually does not exceed 2 hours. There are several attacks during the day, and at least one at night. Periods of exacerbations occur mainly in spring or autumn. The duration of exacerbation ranges from 4 to 10 weeks, after which it disappears spontaneously. Light intervals between exacerbations range from six months to several years. During such intervals, patients are practically healthy. Seizures can be triggered by any factor that causes vasodilation. Cases of chronic cluster pain without light gaps have been described, although it is possible that in these cases we are talking about an intermediate form close to chronic paroxysmal hemicrania (see below).
For the treatment of seizures during periods of exacerbation, inhalations of 100% oxygen (7 l / min for 3-5 minutes) are prescribed in combination with oral administration of 2 mg of ergotamine and local anesthesia of the pterygopalatine node with 4% lidocaine solution or 5-10% cocaine hydrochloride solution. For course treatment of episodic seizures, it is advisable to use prednisilone (0.02-0.0 4 g) and pizotifen in combination with a single dose of 2 mg of ergotamine at night. With frequent attacks, a combination of lithium carbonate (0.3 - 0.6 g / day) with prednisolone is preferable; also use the H2-receptor blocker cimetidine (0.6 - 1.2 g / day). There is evidence of the effectiveness of ketotifen, prescribed at 3 mg / day for 8 weeks, as well as a combination of cofergot (caffeine + ergotamine) with triamcinolone (4 mg). This combination of drugs is prescribed 3-4 times a day, after a week the dose of triamcipolone is gradually reduced during the week and the next week the patient takes only ergotamine with caffeine. The use of interictal treatment of ordinary migraine (see above) gives rare, but sometimes amazing results, the exacerbation can be stopped on the 5-7th day.
In some cases, for treatment it is necessary to try all the means recommended in the treatment of migraine status (see above).
One way or another, after the exacerbation period, which is individually quite definite in duration, cluster pain disappears spontaneously. The patient must be informed about this feature, which calms him to a certain extent.

Chronic paroxysmal hemicrania

Chronic paroxysmal hemicrania is characterized by the fact that attacks resembling a simple migraine are usually short-lived (up to 40-60 minutes), but repeated many times a day and occur daily for many months. There is a high sensitivity to treatment with indomethacin. Hence the name "indomethacin-sensitive headache (hemicrania)." Sometimes chronic hemicrania lasting for months resolves after 1-2 days of treatment with indomethacin. The drug is prescribed 25 mg 3 times a day. After the cessation of seizures, they switch to a maintenance dose of 12.5-25 mg / day. In the absence of contraindications to the use of NSAIDs, multi-month treatment is recommended, since seizures resume after short courses.
The issue of a "transitional" form between cluster periodic pain and chronic paroxysmal pain - chronic cluster pain - remains debatable. For treatment, indomethacin is prescribed first, and if the effect is insufficient, it is necessary to use funds for the treatment of cluster headache.

Migraine of the lower half of the face

Migraine of the lower half of the face (carotidinia, carotidymonic syndrome, facial angioedema) is manifested by bouts of pulsating pain in the lower half of the face with irradiation to the orbit, temple, and neck. The carotid artery in the neck is painful on palpation. The duration of the attack is from several hours to 3 days. It can appear in two forms. In young and middle-aged patients, the onset is acute. It is believed that this form of infectious-allergic etiology, although the effectiveness of steroid and antihistamines in these cases has not been confirmed.
Prescribe analgesics. The other form occurs in the elderly and bears a strong resemblance to simple migraine. Anti-migraine drugs are effective.
Differential diagnosis with different forms of facial pain (prosopalgia) - cranial neuralgia and / or ganglioneuralgia - can be difficult. In these cases, the use of drugs prescribed for neuralgia is justified: antiepileptic (carbamazepine, ethosuxemide, trimetine, clonazepam, morpholep) in combination with neuroleptics or tranquilizers, as well as with analgesics.

cervical migraine

Other names for this form: posterior cervical sympathetic syndrome, vertebral artery syndrome, Barre-Lieu syndrome. The syndrome is caused by irritation of the sympathetic plexus of the vertebral artery, which passes in the canal formed by holes in the transverse processes of the cervical vertebrae, pathologically altered cervical spine with its osteochondrosis and deforming spondylosis, as well as with excessive mobility (pathological instability) of the cervical vertebrae even in the absence of osteochondrosis. These changes are detected by radiography, in particular on lateral radiographs during flexion and extension of the head.
The name "migraine" is due to the hemicranic localization of an attack of throbbing pain, starting from the cervical-occipital region and spreading to the entire half of the head. Retroorbital pain is characteristic, visual disturbances may resemble the aura of ophthalmic migraine. These disorders, as well as concomitant cochleovestibular and cerebellar disorders (hearing loss, noise and ringing in the ears, systemic and non-systemic dizziness, staggering when walking) are caused by discirculation in the vertebrobasilar zone. Attacks can be short ("small"), lasting several minutes, and long ("large"), lasting several hours.
The structure of subjective and objective symptoms individually varies widely. Attacks are provoked by flexion or extension of the head.
The awkward position of the head and neck in bed causes nocturnal attacks that wake the patient ("alarm clock" headache).
In the treatment of vertebrogenic cervical migraine, orthopedic measures are of great importance: wearing removable collars, using special orthopedic pillows for night sleep, gentle massage and therapeutic exercises that strengthen the "muscle corset" in the cervical region.
Drug treatment includes tranquilizers to relieve psycho-emotional stress and muscle relaxation, antidepressants - to correct depression. With frequent attacks, a combination of indomethacin is prescribed to inhibit pathological impulses from the structures of the cervical spine and an a-blocker (nicergoline or dihydroergotoxin). The drugs are prescribed 1 tablet 3 times a day. In case of insufficient effect, other vasoactive agents are successively tried: vinpocetine, cinnarizine, calcium antagonist nimodipine.
With pathological "stagnant" muscle tension in the cervical-occipital region, local blockades with novocaine (5-10 ml of a 0.5-1% solution) and hydrocortisone are recommended.
As the exacerbation subsides and the frequency of attacks subsides, physiotherapeutic procedures are prescribed: UV, ultrasound, sinusoidal and diadynamic currents, mud applications (35-36 ° C) on the paravertebral zones on the neck.
When a stable orthopedic defect (subluxation of the cervical vertebra) is detected, manual therapy is performed with great care, involving a highly qualified specialist.
Surgical treatment with decompression of the vertebral artery is indicated in cases where the progression of the disease leads to disability of the patient, and conservative treatment has no effect.

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