偏頭痛藥物治療的新進展

Recent Advances in Pharmacological Treatment of Migraine

偏頭痛一直在全球各種疾病所致失能中名列前茅，然而所受到的關注長期不足，許多病患也一直沒有得到足夠的治療。根據發作頻率以及病程長短，偏頭痛可分為陣發性偏頭痛以及慢性偏頭痛。在台灣頭痛學會最近發表的治療指引中，急性治療的第一線口服用藥包括偏頭痛專一性的triptan類以及非專一性的乙醯胺酚、ibuprofen、naproxen及diclofenac，而注射劑型的prochlorperazine也是選項之一。較新的偏頭痛專一性藥物以5-HT1F受體為標的的ditan類和以降鈣素相關胜肽（calcitonin gene-related peptide, CGRP）受體為標的的gepant類。第二線用藥為其他非固醇性抗發炎用藥，注射劑型的ketorolac和metoclopramide。急性治療建議採取分層照護的策略，中重度的發作可及早使用偏頭痛專一性藥物治療。若病患發作頻率較高、失能較嚴重或是對於急性藥物療效不佳或有禁忌症時，需考慮預防治療以減少發作頻率。對於陣發性偏頭痛而言，第一線用藥包括propranolo、ltopiramate，以及flunarizine，而第二線用藥則有amitriptyline、valproic acid和CGRP單株抗體。在慢性偏頭痛方面，第一線用藥為topiramate、flunarizine、onabotulinumtoxinA以及CGRP單株抗體，其他也能用在陣發性偏頭痛的預防藥物則為二線用藥。OnabotulinumtoxinA和CGRP單株抗體和傳統口服預防藥物相較，作用較長且耐受性較佳。這些新藥的面世，對於偏頭痛的治療正產生革命性的影響，預期將能顯著改善偏頭痛病患的治療預後以及生活品質。

Migraine has been one of the leading causes of disease-related disability globally, and has been underrecognized and under-treated. Migraine can be divided into episodic migraine (EM) and chronic migraine (CM) based on the headache frequency and disease duration. According to the recently published guidelines by the Taiwan Headache Society, first-line oral agents for acute treatment consist of migraine-specific agents, namely triptans, and non-specific agents, namely acetaminophen, ibuprofen, naproxen and diclofenac, and parenteral prochlorperazine is also recommended. Newer migraine-specific medications target 5-HT1F receptor, i.e. ditans, or calcitonin gene-related peptide (CGRP) receptor, i.e. gepants. Second-line agents include ergots, other nonsteroidals, and parenteral ketorolac and metoclopramide. Stratified care is a recommended approach in the acute treatment, and migraine-specific medications should be considered first for patients with moderate to severe attacks. For patients with higher headache frequencies, greater functional disabilities, or failure or contraindications for acute treatment, preventive treatment should be considered to reduce the attack frequency. First-line agents for EM include propranolol, topiramate, and flunarizine, whereas second-line agents are amitriptyline, valproic acid, and CGRP monoclonal antibodies. On the other hand, topiramate, flunarizine, onabotulinumtoxinA, and CGRP monoclonal antibodies are first-line agents for CM, and other agents commonly used in the preventive treatment of EM are second-line agents. OnabotulinumtoxinA and CGRP monoclonal antibodies, when compared with oral preventive medications, are characterized by longer duration and better tolerability. The availability of these newer agents is revolutionizing the management of migraine, and is expected to significantly improve the treatment outcome and quality of life of migraine patients.