Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
Headache. 2017 Oct;57(9):1471-1481. doi: 10.1111/head.13089. Epub 2017 May 26.
Chronic migraine is common, affecting approximately 1% of the general population, and causes significant disability.
To summarize optimal involvement of primary care physicians in chronic migraine care, and to provide algorithms to assist them in the diagnosis and management of patients with chronic migraine.
An analysis of diagnostic and treatment needs in chronic migraine, based on a synthesis of the medical literature and clinical experience.
Chronic migraine represents the more severe end of the migraine spectrum, usually arises out of previous episodic migraine, and is characterized by headache on 15 days a month or more. Importantly, the headache needs to meet migraine diagnostic criteria on only 8 days a month in order to meet chronic migraine diagnostic criteria. When acute medication overuse is present, a second diagnosis of medication overuse headache should be made. If patients meet criteria for chronic migraine, this excludes a diagnosis of chronic tension-type headache. Acute therapy of chronic migraine is similar to episodic migraine, except that medication overuse is a much greater risk in chronic migraine and must be addressed. All patients should be considered for pharmacological prophylaxis, and the behavioral aspects of therapy should be emphasized. The two prophylactic drugs with the best evidence for efficacy in chronic migraine are topiramate and onabotulinumtoxinA. Given the disability caused by chronic migraine, these should both be available to patients as necessary.
Management of chronic migraine is complex, and many patients are relatively refractory to therapy. Specialist referral will often be required and should not be unduly delayed. On the other hand, the primary care physician should be able to make the diagnosis, initiate therapy, and manage some less refractory patients without referral. The timing of referral should depend both on the expertise of the primary care physician in headache management and the patient's response to initial therapy.
慢性偏头痛较为常见，影响约 1%的普通人群，且可导致严重残疾。
总结初级保健医生在慢性偏头痛治疗中的最佳参与方式，并提供相关算法以协助他们诊断和管理慢性偏头痛患者。
基于对慢性偏头痛的诊断和治疗需求的分析，综合了医学文献和临床经验。
慢性偏头痛代表偏头痛谱中更严重的一端，通常由先前的阵发性偏头痛发展而来，其特征为每月头痛 15 天或以上。重要的是，即使每月头痛满足偏头痛诊断标准的天数仅为 8 天，也可满足慢性偏头痛的诊断标准。当存在急性药物过度使用时，应做出药物过度使用性头痛的第二诊断。如果患者符合慢性偏头痛标准，则排除慢性紧张型头痛的诊断。慢性偏头痛的急性治疗与阵发性偏头痛相似，但药物过度使用是慢性偏头痛的一个更大风险，必须加以解决。所有患者均应考虑药物预防治疗，并应强调治疗的行为方面。在慢性偏头痛中，具有最佳疗效证据的两种预防药物是托吡酯和肉毒杆菌毒素 A。鉴于慢性偏头痛所致的残疾，必要时应向患者提供这两种药物。
慢性偏头痛的管理较为复杂，许多患者对治疗的反应相对较差。通常需要专科转诊，且不应延迟。另一方面，初级保健医生应能够在无需转诊的情况下做出诊断、启动治疗并管理一些对治疗反应较好的患者。转诊时机应取决于初级保健医生头痛管理的专业知识以及患者对初始治疗的反应。
