Zusammenfassung
Die Bedeutung des Themas Kopfschmerz wird durch neue epidemiologische Daten unterstrichen. Diese belegen die hohe Prävalenz von Kopfschmerzen auch in Deutschland sowie den hohen Bedarf an ärztlicher Versorgung, der bislang noch nicht ausreichend gedeckt ist. Bezüglich prädisponierender Risikofaktoren konnte für Erwachsene ein Zusammenhang zwischen Adipositas und chronischen Kopfschmerzen gezeigt werden, für Kinder auch eine Korrelation zwischen zunehmendem Körpergewicht und der Attackenzahl. Ob sich daraus therapeutische Implikationen ableiten lassen, ist noch nicht geklärt. Auffällig ist der Zusammenhang zwischen Schwindel und Migräne, die überzufällig zusammen auftreten. In der Akuttherapie muss die Bedeutung der Allodynie als Prädiktor einer verringerten Wirkung von Triptanen im Migräneanfall wohl revidiert werden, da sich die Befunde in doppelblinden Untersuchungen nicht reproduzieren lassen. In der Migräneprophylaxe gelang es nicht für Carisbamat eine Wirkung nachzuweisen. Valproat hatte in 2 großen Studien zur Migräneprophylaxe bei Kindern keine Überlegenheit gegenüber Placebo. Memantine zeigte keine eindeutige Wirksamkeit in der prophylaktischen Behandlung des chronischen Kopfschmerzes vom Spannungstyp. Das Dogma von der Unwirksamkeit von Migräneprophylaxen unter fortgesetztem Übergebrauch von Triptanen oder Analgetika lässt sich nicht mehr sicher aufrechterhalten. Es gibt Hinweise auf die Wirksamkeit nicht nur von Topiramat, sondern auch von anderen Prophylaktika bei weiterhin fortgesetztem Übergebrauch. In der Behandlung des chronischen, therapierefraktären Clusterkopfschmerzes bietet die bilaterale Nervus-occipitalis-Stimulation eine neue Therapieoption, für die zunehmend Daten zur Wirksamkeit publiziert werden. Auch die Radiofrequenzablation des Ganglion sphenopalatinum könnte eine weitere Therapieoption darstellen. Der Pseudotumor cerebri muss nicht zwangsläufig mit einer Stauungspapille einhergehen, im Zweifel ist eine Liquorpunktion bei chronischen Kopfschmerzen zum sicheren Ausschluss eines erhöhten Liquordruckes notwendig.
Abstract
The relevance of headache is highlighted by new epidemiological data, which show the high prevalence of headache in Germany and the need for additional medical care. Concerning predisposing risk factors, obesity shows a positive correlation with chronic daily headache in adults; for children additionally a correlation between number of attacks and extent of weight gain was shown. It remains unclear whether this may modify the therapeutic approach in chronic headache patients. Further striking evidence was shown for more than a coincidence of headache and dizziness syndromes. Allodynia was proposed as a barrier of effectiveness of acute migraine attacks. This could not be confirmed in double-blind treatment studies. Carisbamate failed to show effectiveness in migraine prophylaxis. Valproic acid failed to show effectiveness in migraine prophylaxis in children in two placebo-controlled clinical trials. Memantine has not a proven effect in prophylactic treatment of chronic tension type headache. The so-called dogma of ineffectiveness of prophylactic treatment in patients with medication overuse headache before withdrawal is becoming doubtful. There is growing evidence that topiramate as well as other prophylactics may work. In the treatment of chronic cluster headaches new therapeutic strategies are arising, e. g., bilateral stimulation of the occipitalis nerve and sphenopalatine ganglion radiofrequency ablation. However, both treatment options should be verified in placebo-controlled clinical trials. Idiopathic intracranial hypertension may occur without papilledema. Therefore, in any doubtful cases lumbar punction should be performed to prove or exclude this diagnosis in patients with chronic daily headache syndromes.
Schlüsselwörter
Migräne - chronischer Kopfschmerz - Clusterkopfschmerz - Prophylaxe
Keywords
migraine - chronic headache - cluster headache - prophylaxis
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Prof. Hans Diener
Klinik für Neurologie und Westdeutsches Kopfschmerz-Zentrum, Universitätsklinikum Essen
Hufelandstr. 55
45147 Essen
Email: h.diener@uni-essen.de
