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Migreeni
Käypä hoito -suositus |  Julkaistu: 04.09.2015   | Tila: voimassa  |  Aihepiiri(t): Kliininen farmakologia, Neurologia, Työterveyshuolto, Yleislääketiede
Mikä on Käypä hoito -suositus?
Suomalaisen Lääkäriseuran Duodecimin ja Suomen Neurologinen yhdistys ry:n asettama työryhmä
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Migreeni

Käypä hoito
4.9.2015
Suomalaisen Lääkäriseuran Duodecimin ja Suomen Neurologinen yhdistys ry:n asettama työryhmä

Opi ja ota käyttöön

Koosteet

Potilaalle

Muut suositukset

Keskeinen sisältö

  • Lievän migreenikohtauksen hoidoksi sopivat tulehduskipulääkkeet joko yksinään tai metoklopramidiin yhdistettynä.
  • Vaikeissa tai invalidisoivissa kohtauksissa kannattaa käyttää triptaania heti eikä vasta kohtauksen alussa otetun tulehduskipulääkkeen osoittauduttua tehottomaksi. Eri triptaanien välillä ei suositeltuja annoksia käytettäessä ole havaittu kliinisesti merkitseviä tehoeroja.
  • Lasten migreenikohtausten hoidossa parasetamoli tai ibuprofeeni ovat suositeltavimmat lääkkeet. Myös sumatriptaaninenäsuihketta voi käyttää.
  • Estohoitoon suositellaan ensisijaisesti ei-ISA-vaikutteisia beetasalpaajia tai kandesartaania ja amitriptyliiniä.

Tavoite ja kohderyhmät

  • Suosituksessa esitetään migreenin kohtaus- ja estohoidon näyttöön perustuvat vaihtoehdot. Jatkotutkimukset ja diagnostiikka kuvataan lyhyesti.
  • Suositus on tarkoitettu migreenipotilaiden hoitoon sekä perusterveydenhuollossa että erikoissairaanhoidossa.

Määritelmä ja esiintyvyys

Taulukko 1. Auraton migreeni – ICHD-3-kriteerit.
- ICHD = The International Classification of Headache Disorders; IHS = International Headache Society
- Lähde: Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (beta versio). Cephalalgia. 2013;33:629–808 «Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013;33:629-808 »1
A Potilaalla on ollut ainakin viisi kohtausta, jotka täyttävät kriteerit B–D
B Päänsärkykohtaus kestää 4–72 tuntia (ilman hoitoa tai jos hoito ei tehoa).
C Ainakin kaksi seuraavista neljästä päänsäryn piirteistä täyttyy:
1 Särky on toispuoleista.
2 Särky on sykkivää.
3 Särky on kohtalaista tai kovaa.
4 Tavanomainen ruumiillinen rasitus (esim. kävely tai portaiden nousu) pahentaa päänsärkyä, tai päänsärky johtaa sen välttämiseen.
D Päänsäryn aikana on ainakin toista seuraavista:
1 pahoinvointia tai oksentelua
2 valo- ja ääniarkuutta.
E Muu ICHD-3-diagnoosi ei selitä oireistoa paremmin (www «http://www.ihs-headache.org/ichd-guidelines»3).
Taulukko 2. Migreenin ja jännityspäänsäryn erot.
Migreeni Jännityspäänsärky
Ennakko-oireet Ei ennakko-oireita
Rasitus pahentaa Liikunta helpottaa
Oksentelu Ei oksentelua
Valonarkuus Ei valonarkuutta
Kova särky Kohtalainen särky
Alkoholi aiheuttaa Alkoholi voi auttaa
Alkaa öisinkin Alkaa päiväsaikaan
Kohtauksittainen Jatkuva, tasainen

Aikuisten migreenin hoito

  • Migreenin hoidon kulmakivet ovat oikea diagnoosi ja siihen liittyvä luottamuksellinen potilas-lääkärisuhde. Ne edellyttävät huolellista anamneesia ja kohtausten kuvausta sekä potilaan elämäntapojen ja elämäntilanteen selvittämistä «Ferrari MD. Migraine. Lancet 1998;351:1043-51 »3.

Migreenikohtauksen hoito

Ärsykkeiden välttäminen

  • Migreenipotilaat tunnistavat usein selvästi ärsykkeitä, jotka laukaisevat tai pahentavat kohtauksia. Niitä välttämällä osa kohtauksista saattaa helpottua tai estyä, mutta luotettavaa näyttöä asiasta ei ole.
    • Kirkas valo lienee tavallisin migreenin ärsyke.
    • Muita tavallisia ärsykkeitä ovat alkoholi, hajut, hormonaaliset tekijät, kuumuus, lämpötilan huomattavat vaihtelut, valvominen, veren glukoosipitoisuuden huomattavat vaihtelut, vuorokausirytmin muutokset ja mahdollisesti eräät ruoka-aineet.

Kipu- ja pahoinvointilääkkeet

  • Suuri osa migreenikohtauksista on hoidettavissa tavallisella kipulääkkeellä tai kipu- ja pahoinvointilääkkeen yhdistelmällä.
  • On suositeltavaa ottaa riittävän iso lääkeannos (taulukko «Aikuisen migreenikohtauksen lääkehoito. »3) heti ensioireiden ilmaantuessa.
  • Ennen kipulääkkeen ottoa tai samanaikaisesti sen kanssa voi käyttää metoklopramidia.
  • Lähes kaikkia myynnissä olevia kipulääkkeitä on käytetty ja käytetään edelleen migreenikohtausten hoitoon, vaikka tutkimusnäyttö niistä on niukkaa.
Taulukko 3. Aikuisen migreenikohtauksen lääkehoito.
Päänsäryn voimakkuus ja lääke Annos (mg)
Vaikea tai invalidisoiva päänsärky
TRIPTAANIT
almotriptaani 12,5 p.o.
eletriptaani 40–80 p.o.
frovatriptaani 2,5 p.o.
naratriptaani 2,5–5 p.o.
risatriptaani 5–10 p.o.
sumatriptaani 50–100 p.o., 20 i.n., 25 p.r., 6 s.c.
tsolmitriptaani 2,5–5 p.o., 5 i.n.
Lievä tai kohtalainen päänsärky
TULEHDUSKIPULÄÄKKEET
asetosalisyylihappo 1 000 p.o.
parasetamoli 1 000 p.o./p.r.
diklofenaakki 50–75
ibuprofeeni 800–1 200
ketoprofeeni 100–200
naprokseeni 500–1 100
tolfenaamihappo 200
(Voidaan yhdistää kaikkiin yllämainittuihin)
PAHOINVOINTILÄÄKKEET
metoklopramidi 10–20 p.o./p.r.
proklooriperatsiini 10–25 p.o. (p.r. vain erikoisluvalla)

Asetyylisalisyylihappo ja parasetamoli

Muut tulehduskipulääkkeet

Huumaavat kipulääkkeet eli euforisoivat analgeetit

Pahoinvointilääkkeet

Triptaanit

Ritsatriptaani

Almotriptaani

Eletriptaani

Frovatriptaani

Yhteiskäyttö steroideihin kuulumattomien tulehduskipulääkkeiden (NSAID) kanssa

Lääkkeen valinta aikuisten migreenikohtauksen hoitoon

Kohtausten varhainen hoito jo kivun lievässä vaiheessa ja herkistymisen esto

Lääkepäänsärky

Migreenin estohoito aikuisilla

Hoitomuodon valinta

Lääkkeetön hoito

Lääkehoito

Taulukko 4. Migreenin estohoitolääkkeet ja aikuisten annokset.
Annos (mg/vrk) Teho
Reniini-angiotensiini-järjestelmään vaikuttavat lääkkeet
Kandesartaani 8–32 ++
Lisinopriili 5–20 +
Beetasalpaajat
Propranololi 40–240 ++
Metoprololi 47,5–190 ++
Atenololi 50–150 ++
Bisoprololi 5–10 ++
Kalsiumsalpaajat
Verapamiili 16–320 +/-
Trisykliset masennuslääkkeet
Amitriptyliini 10–50 ++
Nortriptyliini 10–50 +
Muut masennuslääkkeet
Venlafaksiini 37,5–150 +
Neuromodulaattorit
Natriumvalproaatti 500–1500 ++
Topiramaatti 50–200 ++
Botuliinitoksiini
Episodinen migreeni 50–200 Tehoton
Krooninen migreeni 155–195 yksikköä ++

Beetasalpaajat

Reniini-angiotensiinijärjestelmään vaikuttavat lääkkeet

Trisykliset masennuslääkkeet

Epilepsialääkkeet

Steroideihin kuulumattomat tulehduskipulääkkeet.

Botuliinitoksiini A

Hoidon porrastus

  • Yleensä migreeni- ja päänsärkypotilaat voidaan tutkia ja hoitaa perusterveydenhuollossa ja työterveyshuollossa.
  • Toisinaan tarvitaan kuitenkin pään kuvantamista tai erikoislääkärin konsultaatiota. Jäljempänä esitetään suuntaviivoja päänsärky- tai migreenipotilaan jatkotutkimuksiin ohjaamiseksi.
  • Jos epäillään lukinkalvonalaista verenvuotoa tai keskushermoston infektiota, potilas tulee lähettää päivystystapauksena erikoissairaanhoitoon.

Jatkotutkimuksiin lähettämisen aiheet

  • Päänsärkypotilaan päivystyksellisen lähettämisen perusteet ovat
    • kohonnut kallonsisäinen paine
    • enkefaliittiepäily
    • meningiittiepäily
    • tuoreet, aiemmin esiintymättömät fokaalioireet tai kliiniset löydökset
    • uudentyyppinen päänsärky ja yleisoireet (esim. kuume)
    • varfariini- tai AK-hoitopotilaalla uudentyyppinen päänsärky
    • tuore pään trauma tai SAV-epäily (lähete neurokirurgille)
    • Hortonin särky ja trigeminusneuralgia, jos tavanomaisista hoidoista huolimatta särky ei ole hallinnassa tai siedettävää.
  • Huom. Lähettäminen tulee perustella «S2NOOP4»9.

Päänsärkypotilaan neurologisen konsultoinnin perusteet

  • Potilas lähetetään ajanvarauspoliklinikalle, jos kyseessä ei ole päivystyksellisen lähettämisen aihe mutta
    • päänsärky on päivien ja viikkojen kuluessa paheneva
    • päänsärky liittyy yskimiseen tai ponnistamiseen
    • päänsärkyyn liittyy aiempi (> 1–2 vkoa) fokaalioire, joka ei sovi migreeniauraksi
    • päänsärkyyn liittyy endokriininen häiriö
    • potilaalla on asentoriippuvainen päänsärky
    • tarvitaan triptaanin, ergotamiinin tai särkylääkkeiden vieroitushoitoa
    • potilaalla tai hänen suvussaan on neurofibromatoosia tyyppi 2.
  • Migreeni- tai tensiosärkypotilas lähetetään vain, jos hän oireilee usein ja tavanomaiset hoidot on kokeiltu tai on syntymässä pitkittyvä työkykyongelma.

Lasten päänsäryn lähettämisen perusteet

  • Päänsärkyä ja oksentelua esiintyy öisin ja heti ylös noustessa.
  • Päänsäryn yhteydessä esiintyy tajunnanhäiriöitä.
  • Äkillinen fyysinen ponnistus tai yskiminen pahentaa voimakkaasti päänsärkyä.
  • Päänsärky on säännönmukaisesti toispuolinen sykkivä, paheneva tai hoitoresistentti.
  • Lapsen luonne tai käytös muuttuu.
  • Normaali kehitys tai kasvu hidastuu.
  • Pään kasvu kiihtyy.
  • Lapsella todetaan poikkeavia neurologisia löydöksiä tai poikkeava kehitys.
  • Alle 5-vuotiaat tulee lähettää herkästi.

Migreenin hoito raskauden ja imetyksen aikana

Migreeni ja kardiovaskulaaririski sekä yhdistelmäehkäisytabletit ja hormonikorvaushoito

Lasten migreenin diagnoosi

Lasten migreenin hoito

Kohtaushoito (akuuttihoito)

Estohoito

Suomalaisen Lääkäriseuran Duodecimin ja Suomen Neurologinen yhdistys ry:n asettama työryhmä

Migreeni-suosituksen historiatiedot «Migreeni, Käypä hoito -suosituksen historiatiedot»10

Puheenjohtaja:

Markus Färkkilä, LKT, professori, ylilääkäri; HYKS:n neurologian klinikka

Jäsenet:

Hannele Havanka, LKT, aluehallintoylilääkäri; Pohjois-Suomen aluehallintovirasto

Mirja Hämäläinen, LT, erikoislääkäri; HYKS:n lasten ja nuorten sairaala

Mikko Kallela, LKT, dosentti; HYKS:n neurologian klinikka

Eero Mervaala, LT, professori; Helsingin yliopiston lääketieteellisen tiedekunnan farmakologian osasto, Käypä hoito -toimittaja

Markku Sumanen, LT, yleislääketieteen apulaisprofessori; Tampereen yliopiston lääketieteen yksikkö

Marja-Liisa Sumelahti, LT, dosentti, erikoislääkäri; Tampereen yliopiston lääketieteen yksikkö

Sidonnaisuudet

Markus Färkkilä: Asiantuntijapalkkio (Amgen, Biogen Idec, Novartis, Sanofi-Aventis, Genzyme, Merck-Serono), luentopalkkio (Biogen Idec, Genzyme, FCG-koulutus, Novartis, Finva, Merck-Serono), muu palkkio (Alexion, Actelion, Amgen, BiogenIdec, BioHit, Novartis, Merck-Serono), kliininen tutkija useissa lääketeollisuuden (Alexion, Actelion, Amgen, BiogenIdec, BioHit, Novartis, Merck-Serono) rahoittamissa tutkimuksissa

Hannele Havanka: Ei sidonnaisuuksia

Mirja Hämäläinen: Ei sidonnaisuuksia

Mikko Kallela: Asiantuntijapalkkio (Allergan, Allerganin advisory boardin jäsen, Leiras, Teva, MSD:n Advisory Board), johtokunnan tms jäsenyys (Helsingin Päänsärkykeskus Oy ), työsuhde (HPK), luentopalkkio (AGA, Allergan, AstraZeneca, Bayer, Boehringer-Ingelheim, Genzyme, GlaxoSmithKline, Janssen-Cilaq, Leiras, MSD, Meda, Menarini, Novartis, Orion, Pfizer, Sandoz, Teva), osakeomistus (Helsingin Päänsärkykeskus Oy), koulutus/kongressikuluja yrityksen tuella (Allergan, Biogen, Genzyme, Novartis, TEVA)

Eero Mervaala: Asiantuntijapalkkio (Kustannus Medicina Oy), Työsuhde (Yhtyneet Medix Laboratoriot)

Markku Sumanen: Ei sidonnaisuuksia

Marja-Liisa Sumelahti: Asiantuntijapalkkio (A. Menarini Suomi Oy, Novartis), luentopalkkio (Novartis, Useita), koulutus/kongressikuluja yrityksen tuella (Novartis, Teva, Biogen, Bayer, Merck-Serono, Sanofi)

Vastuun rajaus

Käypä hoito -suositukset ovat parhaiden asiantuntijoiden laatimia yhteenvetoja yksittäisten sairauksien diagnostiikan ja hoidon vaikuttavuudesta. Ne eivät korvaa lääkärin tai muun terveydenhuollon ammattilaisen omaa arviota yksittäisen potilaan parhaasta mahdollisesta diagnostiikasta ja hoidosta hoitopäätöksiä tehtäessä.

Tiedonhakukäytäntö

Systemaattinen kirjallisuushaku on hoitosuosituksen perusta. Lue lisää artikkelista khk00007

Kirjallisuutta

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