364.4 📋 章末速蚘 Summary

364.4.1 🔑 䞀句話瞜結

Headache = #2 ED visit + leading global disability (migraine ~ 12% prevalence); primary headaches = migraine + tension-type + cluster + other TACs (trigeminal autonomic cephalalgias); secondary headaches = vascular (SAH, dissection, GCA, RCVS, CVST) + infectious (meningitis, encephalitis) + neoplastic + IIH + low-pressure + MOH; red flags SNOOP10 = Systemic + Neurologic deficit + Onset sudden (thunderclap → SAH) + Older > 50 (GCA) + Pattern change + Positional + Precipitated by Valsalva + Papilledema + Pregnancy + Posttraumatic + Painful eye autonomic + Painkillers overuse; migraine ICHD-3 criteria — without aura ≥ 5 attacks + 4-72 hr + ≥ 2 of (unilateral, pulsating, moderate-severe, aggravated) + ≥ 1 of (N/V, photo + phono); with aura ≥ 2 attacks + ≥ 1 aura (visual most common, sensory, speech, motor hemiplegic, brainstem, retinal) + 5-60 min; phases prodrome → aura → headache → postdrome; acute migraine treatment — mild-moderate NSAIDs/acetaminophen + combo (ASA + caffeine), moderate-severe triptans (5HT-1B/1D — contraindicated CAD/HTN/stroke/hemiplegic), gepants ubrogepant/rimegepant (also prevention)/zavegepant nasal Zavzpret FDA 2023, lasmiditan Reyvow ditan (5HT-1F no vasoconstriction safe in CAD), rescue IV metoclopramide/prochlorperazine/ketorolac/DHE/Mg; preventive (≥ 4 days/mo or severe) — traditional topiramate + propranolol + amitriptyline + valproate + onabotulinumtoxinA (PREEMPT chronic migraine) + CGRP-targeted revolution 2018-2024: anti-CGRP mAbs erenumab Aimovig (anti-receptor SC monthly) + fremanezumab Ajovy (anti-ligand SC monthly/quarterly) + galcanezumab Emgality (SC monthly, also cluster) + eptinezumab Vyepti (IV quarterly) + oral gepants for prevention atogepant Qulipta + rimegepant Nurtec; chronic migraine ≥ 15 days/mo for > 3 mo with ≥ 8 migrainous → onabotulinumtoxinA + anti-CGRP + withdrawal of overused medication; tension-type bilateral pressing not pulsating mild-moderate not aggravated; cluster headache severe unilateral periorbital/temporal + 15-180 min + cluster periods (weeks-months) + remission + circadian/circannual + restless + cranial autonomic (lacrimation, conjunctival injection, ptosis, miosis, rhinorrhea) + alcohol trigger → acute high-flow O2 12-15 L/min via NRM 15-20 min + SC sumatriptan 6 mg fast onset + preventive verapamil (high doses) + galcanezumab FDA 2019 cluster + lithium; paroxysmal hemicrania + hemicrania continua absolute response to indomethacin; SUNCT/SUNA very brief; IIH young obese women + papilledema + LP > 25 cm H2O + acetazolamide; low pressure postural after LP/dural tear → epidural blood patch; MOH identify + withdraw + bridge + preventive; GCA age > 50 + ↑ ESR/CRP + temporal artery biopsy + urgent steroids (vision loss risk!) + tocilizumab refractory; trigeminal neuralgia carbamazepine first-line。

364.4.2 💊 治療粟芁

  • migraine acute mild-moderate: NSAIDs (naproxen 500-1000 mg, ibuprofen 400-800, ketorolac IM) + acetaminophen + combo
  • migraine acute moderate-severe: triptans sumatriptan PO/SC/nasal/rizatriptan/zolmitriptan/eletriptan; gepants ubrogepant 50-100 mg/rimegepant 75 mg ODT/zavegepant nasal 10 mg; lasmiditan 50-200 mg; SC sumatriptan + DHE for severe
  • migraine acute CV contraindicated: gepants or lasmiditan (no vasoconstriction)
  • migraine prevention traditional: topiramate 50-200 mg/d + propranolol 80-240 mg/d + amitriptyline 25-100 mg + valproate 500-1500 mg + onabotulinumtoxinA 155-195 U q12 weeks (chronic migraine PREEMPT)
  • migraine prevention CGRP-targeted: erenumab 70-140 mg SC monthly + fremanezumab 225 mg SC monthly or 675 mg quarterly + galcanezumab 240 mg load then 120 mg SC monthly + eptinezumab 100-300 mg IV q3 months + atogepant 10-60 mg PO daily + rimegepant 75 mg PO every other day
  • cluster acute: high-flow O2 12-15 L/min via non-rebreather mask × 15-20 min + SC sumatriptan 6 mg (fast onset, max 2 doses/day) + nasal sumatriptan or zolmitriptan + lidocaine intranasal
  • cluster preventive bridge: prednisone 60-100 mg taper × 2-3 weeks + greater occipital nerve block
  • cluster preventive maintenance: verapamil titrate to 240-720 mg/d (ECG monitoring) + galcanezumab 300 mg SC monthly (FDA 2019 cluster) + lithium + topiramate
  • paroxysmal hemicrania + hemicrania continua: indomethacin 25-75 mg TID (absolute response diagnostic)
  • IIH: weight loss + acetazolamide 1-4 g/d + topiramate + LP + optic nerve sheath fenestration + VP shunt for vision-threatening
  • GCA: urgent prednisone 40-60 mg/d (1 mg/kg, do not wait for biopsy) + biopsy + tocilizumab refractory
  • trigeminal neuralgia: carbamazepine 200-1200 mg/d + oxcarbazepine + microvascular decompression

364.4.3 🎯 盧醫垫的考前提醒

  1. SNOOP10 red flags (memorize for any new/changed headache): Systemic + Neurologic + Onset sudden (thunderclap < 1 min → SAH urgent CT + LP if neg) + Older > 50 (GCA) + Pattern change + Positional + Precipitated Valsalva + Papilledema + Pregnancy + Posttraumatic + Painful eye autonomic + Painkillers overuse
  2. Migraine without aura criteria: ≥ 5 attacks + 4-72 hr + ≥ 2 of (unilateral, pulsating, moderate-severe, aggravated) + ≥ 1 of (N/V, photo + phono)
  3. CGRP revolution (huge in 2018-2024): anti-CGRP mAbs for prevention (erenumab/fremanezumab/galcanezumab/eptinezumab) + gepants for acute (ubrogepant/rimegepant/zavegepant nasal FDA 2023) or prevention (atogepant/rimegepant) + lasmiditan ditan (5HT-1F, no vasoconstriction, safe in CAD)
  4. Triptans contraindications: CAD, uncontrolled HTN, stroke, hemiplegic/basilar migraine, within 24 hr of ergot → use gepants or lasmiditan instead
  5. Cluster acute: high-flow O2 12-15 L/min via NRM × 15-20 min (works in minutes!) + SC sumatriptan 6 mg (oral too slow for cluster); preventive verapamil + galcanezumab (FDA 2019 cluster) + lithium
  6. Indomethacin-responsive headaches: paroxysmal hemicrania + hemicrania continua = absolute response (diagnostic); primary cough/exertion/hypnic also respond
  7. Thunderclap headache differential: SAH (top, rule out — CT then LP xanthochromia) + RCVS (postpartum, recurrent) + cervical dissection + CVST + pituitary apoplexy + PRES
  8. GCA: age > 50 + new headache + scalp tenderness + jaw claudication + PMR + ↑ ESR > 50 + CRP → urgent prednisone (do not wait for temporal artery biopsy if suspicious — vision loss risk) + tocilizumab refractory
  9. IIH (pseudotumor cerebri): young obese women + daily headache + papilledema + vision loss + pulsatile tinnitus + LP > 25 cm H2O normal CSF composition + acetazolamide + weight loss + VP shunt/optic nerve sheath fenestration for vision-threatening
  10. Medication overuse headache (MOH): triptans ≥ 10 days/mo + simple analgesics ≥ 15 + opioids/combos ≥ 10 → withdraw offending agent + bridge therapy (steroids, NSAIDs) + initiate preventive (CGRP-mAbs particularly helpful)