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Headache：美国头痛学会AHS 急性偏头痛的药物治疗

2015-02-05 高晓方 译 医学论坛网

美国头痛学会急性偏头痛药物治疗
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美国头痛学会(AHS)对急性偏头痛治疗进行了重新评估，这是自2000年以来的第一次更新，将以此作为新指南的基础。专家组利用美国神经病学会指南规程对近期研究进行了详细评阅，并对相关内容做出了循证性说明。全文于1月20日在线发表于《头痛》(Headache)杂志。 以下是撰写专家Marmura博士在接受记者采访时的建议。 1、布托啡诺鼻喷剂因接受随机试验评估而被升高至A级推荐药

美国头痛学会(AHS)对急性偏头痛治疗进行了重新评估，这是自2000年以来的第一次更新，将以此作为新指南的基础。专家组利用美国神经病学会指南规程对近期研究进行了详细评阅，并对相关内容做出了循证性说明。全文于1月20日在线发表于《头痛》(Headache)杂志。

以下是撰写专家Marmura博士在接受记者采访时的建议。

1、布托啡诺鼻喷剂因接受随机试验评估而被升高至A级推荐药物。

2、美沙酮注射剂则因有效性基于陈旧试验而被降至C级。

3、阿片类药物在有效性方面可能为A或B级，但由于副作用和潜在成瘾性而不适宜作为一线治疗药物。

4、曲普坦类将成为主要一线治疗药物，因其有效性证据充分且不良事件可接受。

另外一名撰写专家Silberstein博士也同意将曲普坦类作为主要一线治疗药物，他表示，曲普坦类药物在2/3的情况下都有效，如无效，他将尝试用具有A级证据水平的非甾体类抗炎药(NSAID)或双氢麦角胺(DHE)类药物。

5、如果在偏头痛发作早期(起病后1小时内)应用，大多数药物都具有良好疗效，但在偏头痛迁延(已发病1周并转至急诊室)的患者中情况则与之相反。对于极重度病例，丙氯拉嗪和DHE注射剂可能为最佳选择，即使这些药物推荐级别为B级。

药物级别

1、确定有效的A类药物包括扑热息痛、阿司匹林、萘普生、布托啡诺鼻喷剂、曲坦类和联合治疗。

2、大致有效的B类药物包括麦角胺、其他DHE类药物、酮洛芬、肌肉注射或静脉输注酮咯酸、氟比洛芬和静脉用镁剂(先兆性偏头痛)，以及异美汀化合物组合、可待因/对乙酰氨基酚、曲马多/对乙酰氨基酚。

此外，止吐药丙氯拉嗪、氟哌利多、氯丙嗪和甲氧氯普胺可能有效(B级)。

3、可能有效的C类药物包括布他比妥和其合剂、安替比林、静脉用曲马多、美沙酮，不妥菲诺或哌替啶、鼻腔内使用利多卡因和皮质类固醇激素。

4、奥曲肽被列为“很可能无效”，酮洛酸鼻喷剂、静脉用对乙酰氨基酚、氯丙嗪和格拉斯琼均被列为“可能无效”。

附表 药物治疗（A级证据，已知在至少两项严格的研究中被证明是有效的）

Category

Treatments

Analgesics

Acetaminophen 1000 mg (for nonincapacitating attacks)

Ergots

DHE nasal spray 2 mg and pulmonary inhaler 1 mg

NSAIDs

Aspirin 500 mg

Diclofenac 50, 100 mg

Ibuprofen 200, 400 mg

Naproxen 500, 550 mg

Opioids

Butorphanol nasal spray 1 mg

Triptans

Almotriptan 12.5 mg

Eletriptan 20, 40, 80 mg

Frovatriptan 2.5 mg

Naratriptan 1, 2.5 mg

Rizatriptan 5, 10 mg

Sumatriptan oral 25, 50, 100 mg; nasal spray 10, 20 mg; patch 6.5 mg; subcutaneous injection 4, 6 mg

Zolmitriptan nasal spray 2.5, 5 mg; oral 2.5, 5 mg

Combinations

Acetaminophen/aspirin/caffeine 500/500/130 mg

Sumatriptan/naproxen 85/500 mg

本文只包括偏头痛急性发作治疗。AHS与美国神经病学会最近还发布了预防偏头痛发作联合指南。

原始出处：

Marmura MJ1, Silberstein SD, Schwedt TJ.The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmacotherapies.Headache. 2015 Jan;55(1):3-20. doi: 10.1111/head.12499.

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  1. [GetPortalCommentsPageByObjectIdResponse(id=1991763, encodeId=8e501991e6312, content=<a href='/topic/show?id=a69b521933a' target=_blank style='color:#2F92EE;'>#急性偏头痛#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52193, encryptionId=a69b521933a, topicName=急性偏头痛)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d784426, createdName=isabellayj, createdTime=Mon Mar 02 08:39:00 CST 2015, time=2015-03-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=17213, encodeId=42141e2135e, content=不错的文章，学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=151, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=36a81612921, createdName=xiaoai5777, createdTime=Sat Feb 28 11:00:00 CST 2015, time=2015-02-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=15910, encodeId=4fee15910fb, content=已阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=78, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c68e1614119, createdName=windmilL1989, createdTime=Mon Feb 16 14:42:00 CST 2015, time=2015-02-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1264528, encodeId=da951264528bc, content=<a href='/topic/show?id=150f19229c' target=_blank style='color:#2F92EE;'>#ADA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1922, encryptionId=150f19229c, topicName=ADA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ad9f79, createdName=般若傻瓜, createdTime=Sat Feb 07 00:39:00 CST 2015, time=2015-02-07, status=1, ipAttribution=)]
    2015-03-02 isabellayj

    #急性偏头痛#

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=1991763, encodeId=8e501991e6312, content=<a href='/topic/show?id=a69b521933a' target=_blank style='color:#2F92EE;'>#急性偏头痛#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52193, encryptionId=a69b521933a, topicName=急性偏头痛)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d784426, createdName=isabellayj, createdTime=Mon Mar 02 08:39:00 CST 2015, time=2015-03-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=17213, encodeId=42141e2135e, content=不错的文章，学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=151, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=36a81612921, createdName=xiaoai5777, createdTime=Sat Feb 28 11:00:00 CST 2015, time=2015-02-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=15910, encodeId=4fee15910fb, content=已阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=78, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c68e1614119, createdName=windmilL1989, createdTime=Mon Feb 16 14:42:00 CST 2015, time=2015-02-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1264528, encodeId=da951264528bc, content=<a href='/topic/show?id=150f19229c' target=_blank style='color:#2F92EE;'>#ADA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1922, encryptionId=150f19229c, topicName=ADA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ad9f79, createdName=般若傻瓜, createdTime=Sat Feb 07 00:39:00 CST 2015, time=2015-02-07, status=1, ipAttribution=)]
    2015-02-28 xiaoai5777

    不错的文章，学习了

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=1991763, encodeId=8e501991e6312, content=<a href='/topic/show?id=a69b521933a' target=_blank style='color:#2F92EE;'>#急性偏头痛#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52193, encryptionId=a69b521933a, topicName=急性偏头痛)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d784426, createdName=isabellayj, createdTime=Mon Mar 02 08:39:00 CST 2015, time=2015-03-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=17213, encodeId=42141e2135e, content=不错的文章，学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=151, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=36a81612921, createdName=xiaoai5777, createdTime=Sat Feb 28 11:00:00 CST 2015, time=2015-02-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=15910, encodeId=4fee15910fb, content=已阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=78, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c68e1614119, createdName=windmilL1989, createdTime=Mon Feb 16 14:42:00 CST 2015, time=2015-02-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1264528, encodeId=da951264528bc, content=<a href='/topic/show?id=150f19229c' target=_blank style='color:#2F92EE;'>#ADA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1922, encryptionId=150f19229c, topicName=ADA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ad9f79, createdName=般若傻瓜, createdTime=Sat Feb 07 00:39:00 CST 2015, time=2015-02-07, status=1, ipAttribution=)]
    2015-02-16 windmilL1989

    已阅

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1991763, encodeId=8e501991e6312, content=<a href='/topic/show?id=a69b521933a' target=_blank style='color:#2F92EE;'>#急性偏头痛#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52193, encryptionId=a69b521933a, topicName=急性偏头痛)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d784426, createdName=isabellayj, createdTime=Mon Mar 02 08:39:00 CST 2015, time=2015-03-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=17213, encodeId=42141e2135e, content=不错的文章，学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=151, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=36a81612921, createdName=xiaoai5777, createdTime=Sat Feb 28 11:00:00 CST 2015, time=2015-02-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=15910, encodeId=4fee15910fb, content=已阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=78, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c68e1614119, createdName=windmilL1989, createdTime=Mon Feb 16 14:42:00 CST 2015, time=2015-02-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1264528, encodeId=da951264528bc, content=<a href='/topic/show?id=150f19229c' target=_blank style='color:#2F92EE;'>#ADA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1922, encryptionId=150f19229c, topicName=ADA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ad9f79, createdName=般若傻瓜, createdTime=Sat Feb 07 00:39:00 CST 2015, time=2015-02-07, status=1, ipAttribution=)]
    2015-02-07 般若傻瓜

    #ADA#

    0