Burstein Rami, Collins Beth, Jakubowski Moshe
Departments of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Ann Neurol. 2004 Jan;55(1):19-26. doi: 10.1002/ana.10786.
For many migraine patients, triptan therapy provides complete pain relief in some attacks but not in others. Here, we tested whether the success of triptan therapy is hindered in the presence of cutaneous allodynia (pain resulting from a nonnoxious stimulus to normal skin), a phenomenon we previously described develop gradually during the course of the migraine attack in more than 70% of patients. We studied migraine patients repeatedly on three visits to the clinic: in the absence of migraine (baseline), within the first hour of one attack, or at 4 hours from onset of another attack. Presence or absence of allodynia was determined based on differences between migraine and baseline pain thresholds to mechanical and thermal stimulation of periorbital skin. In 31 patients, we studied 34 migraine attacks that were associated with allodynia at the time of triptan treatment and 27 attacks that were not. Within 2 hours of triptan treatment, patients were rendered pain-free in 5 of 34 (15%) of allodynic attacks versus 25 of 27 (93%) of nonallodynic attacks. Treating migraine attacks 1 hour (early) or 4 hours (late) after the onset of pain was equally ineffective in inducing a pain-free state in the presence of allodynia, and equally effective in the absence of allodynia. For patients susceptible to allodynia during the attack, triptan therapy was by far more likely to provide complete pain relief if administered before rather than after the establishment of cutaneous allodynia. Patients who never developed allodynia were highly likely to be rendered pain-free by triptan therapy anytime after the onset of pain. We conclude that the probability of consistent pain-free outcome increases drastically if triptan therapy is vigilantly timed to precede any signs of cutaneous allodynia.
对于许多偏头痛患者而言，曲坦类药物治疗在某些发作中能完全缓解疼痛，但在另一些发作中则不然。在此，我们测试了在存在皮肤异常性疼痛（对正常皮肤的非伤害性刺激所导致的疼痛）的情况下，曲坦类药物治疗的成功率是否会受到阻碍，我们之前描述过这种现象在超过70%的患者偏头痛发作过程中会逐渐出现。我们对偏头痛患者进行了三次门诊复诊：在无偏头痛时（基线期）、在一次发作的第一小时内，或在另一次发作开始后4小时。根据偏头痛发作时与基线期对眶周皮肤进行机械和热刺激的疼痛阈值差异来确定是否存在异常性疼痛。在31名患者中，我们研究了34次在曲坦类药物治疗时伴有异常性疼痛的偏头痛发作以及27次不伴有异常性疼痛的发作。在曲坦类药物治疗后2小时内，34次伴有异常性疼痛发作中有5次（15%）患者疼痛缓解，而27次不伴有异常性疼痛发作中有25次（93%）患者疼痛缓解。在存在异常性疼痛的情况下，在疼痛发作1小时（早期）或4小时（晚期）后治疗偏头痛发作，诱导无痛状态的效果同样不佳；在不存在异常性疼痛的情况下，效果则同样良好。对于在发作期间易出现异常性疼痛的患者，如果在皮肤异常性疼痛形成之前而非之后给予曲坦类药物治疗，那么该治疗更有可能提供完全的疼痛缓解。从未出现异常性疼痛的患者在疼痛发作后的任何时间接受曲坦类药物治疗都极有可能实现疼痛缓解。我们得出结论，如果曲坦类药物治疗能谨慎地在出现任何皮肤异常性疼痛迹象之前进行，那么持续无痛结局的可能性将大幅增加。
