- 期刊
叢發性頭痛治療準則
Treatment Guidelines for Acute and Preventive Treatment of Cluster Headache
摘要
本小組針對台灣目前臨床使用的叢發性頭痛急性治療、預防用藥與國外手術治療方式，以實證醫學的方式，評估其研究品質、證據等，並參考其他國家的治療準則，歷經多次討論與意見整合，對該藥物與治療方式在叢發性頭痛的角色、推薦等級、臨床療效與不良反應等使用時注意事項提出共識。國人叢發性頭痛大多屬於陣發性，極少患者會發展成慢性叢發性頭痛。治療可分爲急性治療與預防治療。叢發性頭痛發作時，在短時間內達到極痛程度，並伴隨同側自主神經症狀，所以及時的治療能爲患者帶來相當大的幫助。台灣可用於叢發性頭痛急性發作的治療方式中，以高流速純氧吸入的證據等級與效果最佳，其次爲鼻噴劑型的翠普登類藥物，皆建議作爲第一線治療。口服翠普登類藥物建議作爲二線治療考慮。過渡預防用藥中，口服類固醇可爲優先選擇。麥角鹼類藥物則建議爲二線治療考慮。維持預防用藥中，verapamil證據等級最佳，建議作爲第一線治療。Lithium、melatonin、valproic acid、topiramate、gabapentin等藥物建議作爲二線治療考慮。至於手術治療方面（包括枕神經刺激術、深腦刺激手術、蝶？神經節射頻阻斷、經皮射頻脊髓根切斷術、三叉神經戴斷），由於屬侵入性治療，長期的療效與副作用仍無定論，台灣目前尚未有經驗可供參考。年。療效與不良反應等使用時之注意事項提出共識藥物預防用藥選擇，依照病患個人狀況，可同時使用過渡預防用藥與維持預防用藥。等待維持預防用藥發揮作用後，逐漸停用過渡預防藥物。過渡預防藥物中之類固醇的使用儘量不要超過兩星期。維持預防藥物則應依照病人情況，等待叢發期結束後逐漸停藥。
並列摘要
The Treatment Guideline Subcommittee of the Taiwan Headache Society evaluated both the acute and the preventive treatments for cluster headache now being used in Taiwan, based on the principles of evidence-based medicine. We assessed the quality of clinical trials and levels of evidence, and referred to other treatment guidelines proposed by other countries. Throughout several panel discussions, we merged opinions from the subcommittee members and proposed a consensus on the major roles, recommended levels, clinical efficacy, adverse events and cautions of clinical practice regarding acute and preventive treatments of cluster headache.The majority of Taiwanese patients have episodic cluster headaches, because chronic clusters are very rare. Cluster headache is characterized by severe and excruciating pain which develops within a short time and is associated with ipsilateral autonomic symptoms. Therefore, emergency treatment for a cluster headache attack is extremely important. Within the group of acute medications currently available in Taiwan, the subcommittee determined that high-flow oxygen inhalation has the best evidence of effectiveness, followed by intranasal triptans. Both are recommended as first-line medical treatments for acute attacks. Oral triptans were determined to be second-line medications. For transitional prophylaxis, oral corticosteroids are recommended as the first-line medication, and ergotamine as the second-line choice. As for maintenance prophylaxis, verapamil has the best evidence and is recommended as the first-line medication. Lithium, melatonin, valproic acid, topiramate and gabapentin are suggested as the second-line preventive medications. Surgical interventions, including occipital nerve stimulation, deep brain stimulation, radiofrequency block of the sphenopalatine ganglion, percutaneous radiofrequency rhizotomy and trigeminal nerve section, are invasive and their long-term efficacy and adverse events are still not clear in Taiwanese patients; therefore, they are not recommended currently by the subcommittee.The transitional and maintenance prophylactic medications can be used together to attain treatment efficacy. Once the maintenance prophylaxis achieves efficacy, the transitional prophylactic medications can be tapered gradually. We suggest the corticosteroids be used within two weeks, if possible. The duration of maintenance treatment depends on the individual patient's clinical condition, and the medications can be tapered off when the cluster period is over.