Wheeler Steve D
Ryan Wheeler Headache Treatment Center, Miami, Florida 33143, USA.
Neurologist. 2009 Mar;15(2):59-70. doi: 10.1097/NRL.0b013e318165eb94.
Satisfactory prevention of migraine and other headaches is fraught with difficulties in the real world. Tolerability and safety issues are of concern just as is effectiveness or efficacy and all often seem to be patient-dependent. Maximizing migraine prevention and getting treatment right the first time ought to result in improved patient outcomes. Identifying headache phenotypes recognizes that clinical phenomenology may define or approximate genotypes that may predict specific preventive treatments.
The concept of phenotype-driven headache and migraine prevention relies heavily on the indomethacin-responsive headache experience wherein specific treatment is dictated by headache phenotype. Herein are described several additional headache phenotypes: migraine with typical and atypical aura, dopaminergic migraine, new daily-persistent headache, migraine with cluster or sinus features, short-lasting unilateral neuralgiform headache with conjunctival injection and tearing, hypnic headache, thunderclap headache, and imploding headache. Phenotype-driven preventive strategies are described that may offer reasonable first treatment choices, appropriate second choices, or choices when other treatments have failed.
These headache preventive recommendations are based on the best available evidence; however, all reports are observational. Perhaps some of these choices will be tested in prospective, randomized, blinded and controlled trials in the future, but historically clinical medicine has relied on clinical observations. The observations reported herein may help define specific, effective treatments for some patients or simply inspire further discussion and research about patient-specific preventive treatment regimens.
在现实世界中，要令人满意地预防偏头痛及其他头痛存在诸多困难。耐受性和安全性问题与有效性或疗效一样令人关注，而且所有这些往往似乎都取决于患者。最大限度地预防偏头痛并首次就正确进行治疗应能改善患者的治疗效果。识别头痛表型认识到临床现象学可能定义或近似可预测特定预防性治疗的基因型。
表型驱动的头痛和偏头痛预防概念在很大程度上依赖于对消炎痛反应性头痛的经验，其中特定治疗由头痛表型决定。本文描述了几种其他头痛表型：伴有典型和非典型先兆的偏头痛、多巴胺能性偏头痛、新发性每日持续性头痛、伴有丛集性或鼻窦特征的偏头痛、伴有结膜充血和流泪的短暂性单侧神经痛样头痛、睡眠性头痛、霹雳样头痛和爆裂样头痛。描述了表型驱动的预防策略，这些策略可能提供合理的初始治疗选择、合适的二线选择或其他治疗失败时的选择。
这些头痛预防建议基于现有最佳证据；然而，所有报告均为观察性的。也许其中一些选择未来会在前瞻性、随机、双盲和对照试验中进行检验，但从历史上看，临床医学一直依赖于临床观察。本文报告的观察结果可能有助于为一些患者确定具体、有效的治疗方法，或者仅仅激发关于针对患者的预防性治疗方案的进一步讨论和研究。
