Therapie und Versorgung bei chronischer Migräne

Expertenempfehlung der Deutschen Migräne- und Kopfschmerzgesellschaft/Deutsche Gesellschaft für Neurologie sowie der Österreichischen Kopfschmerzgesellschaft/Schweizerischen Kopfwehgesellschaft

Therapy and care of patients with chronic migraine

Expert recommendations of the German Migraine and Headache Society/German Society for Neurology as well as the Austrian Headache Society/Swiss Headache Society

Zusammenfassung

Die chronische Migräne (CM) ist eine erst in der 2. Auflage der IHS (International Headache Society)-Klassifikation 2004 neu abgegrenzte Verlaufsform der Migräne. Dabei berichten die Patienten über Kopfschmerzen im Durchschnitt an mehr als 15 Tagen im Monat, davon an mindestens 8 Tagen über migränetypische Kopfschmerzen und es besteht kein begleitender Medikamentenübergebrauch (MOH, revidierte Klassifikation der IHS 2006). In der Praxis berichtet die Mehrzahl der Patienten über einen Medikamentengebrauch an mehr als 10 bis 15 Tagen im Monat und die einfache Unterscheidung in CM mit oder ohne begleitenden MOH ist in der Praxis häufig nicht möglich. Es finden sich bei der Mehrzahl der Patienten häufig weitere Komorbiditäten wie Depression, Angsterkrankungen und andere Schmerzerkrankungen. Eine erfolgreiche Therapie muss dieser Komplexität Rechnung tragen und besteht multimodal neben der Pharmakotherapie auch aus Verhaltenstherapie, Entspannungsverfahren und Sporttherapie. In der Akuttherapie der Kopfschmerzen ergeben sich keine Abweichungen zu der Therapie der Kopfschmerzen im Rahmen einer episodischen Migräne. Die Schmerzmitteleinnahme sollte unbedingt an weniger als 15 Tagen (für Monoanalgetika) und an weniger als 10 Tage für Triptane und Schmerzmittelmischpräparate erfolgen. In der Prophylaxe können, den nur begrenzt vorliegenden Studiendaten nach, in erster Linie Topiramat und Onabotulinumtoxin A (155–195 Units) eingesetzt werden, begrenzte Evidenz aus Studien gibt es auch für Valproinsäure und Amitriptylin. Experimentell ist eine Neuromodulation, z. B. durch die Stimulation des N. occipitalis major, möglich. Der Einsatz dieser Verfahren sollte zum jetzigen Zeitpunkt nur innerhalb von Studien erfolgen.

Summary

Chronic migraine (CM) was first defined in the second edition of the International Headache Society (IHS) classification in 2004. The definition currently used (IHS 2006) requires the patient to have headache on more than 15 days/month for longer than 3 months and a migraine headache on at least 8 of these monthly headache days and that there is no medication overuse. In daily practice the majority of the patients with CM also report medication overuse but it is difficult to determine whether the use is the cause or the consequence of CM. Most the patients also have other comorbidities, such as depression, anxiety and chronic pain at other locations. Therapy has to take this complexity into consideration and is generally multimodal with behavioral therapy, aerobic training and pharmacotherapy. The use of analgesics should be limited to fewer than 15 days per month and use of triptans to fewer than 10 days per month. Drug treatment should be started with topiramate, the drug with the best scientific evidence. If there is no benefit, onabotulinum toxin A (155–195 Units) should be used. There is also some limited evidence that valproic acid and amitriptyline might be beneficial. Neuromodulation by stimulation of the greater occipital nerve or vagal nerve is being tested in studies and is so far an experimental procedure only.

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Straube, A., Gaul, C., Förderreuther, S. et al. Therapie und Versorgung bei chronischer Migräne. Nervenarzt 83, 1600–1608 (2012). https://doi.org/10.1007/s00115-012-3680-9

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Schlüsselwörter

  • Chronische Migräne
  • Multimodal
  • Pharmakotherapie
  • Topiramat
  • Onabotulinumtoxin A

Keywords

  • Chronic migraine
  • Multimodal therapy
  • Drug therapy
  • Topiramate
  • Onabotulinumtoxin A