Migräne – Bewährtes und aktuelle Entwicklungen

Zusammenfassung

Migräne ist eine sehr häufige, mit hohem Leidensdruck einhergehende, attackenweise auftretende, primäre Kopfschmerzerkrankung. Trotz intensiven Forschungsbemühungen in den letzten Jahren bleiben immer noch mehrere pathophysiologische Aspekte ungeklärt. Einer veränderten kortikalen Adaptionsfähigkeit und dem Hirnstamm als Migränegenerator kommen wahrscheinlich in der Initiierung einer möglicherweise teils stummen „cortical spreading depression“ und kaskadenartiger Prozesse eine hohe Bedeutung zu, die letztlich die zu den Kopfschmerzen führende neurogene Entzündung an den Meningen auslösen. Zahlreiche Studien der letzten Jahre untersuchten zudem somatische (insbesondere zerebrovaskuläre) sowie psychische Komorbiditäten.

In der Akuttherapie rückten CGRP-Antagonisten als vielversprechende, nicht vasokonstriktiv wirkende Alternative zu den Triptanen in den Fokus der Forschung. Sie konnten jedoch aufgrund von Leberwerterhöhungen in den Sicherheitsstudien bislang keine Marktreife erlangen. Einen weiteren neuen, scheinbar nebenwirkungsarmen Ansatz ohne vasokonstriktive Aktivität stellen die selektiven 5-HT1F-Agonisten (insbesondere Lasmiditan) dar, wobei auch hier größere placebokontrollierte und Triptan-kontrollierte Studien noch abgewartet werden müssen.

Für die Prophylaxetherapie konnte eine vergleichbare Wirkung von Ausdauersport zu Topiramat nachgewiesen werden. Insbesondere die Kombination von medikamentösen und nicht medikamentösen Therapien (wie die Kombination eines Stressbewältigungstrainings mit einer Betablocker-Einnahme) erzielt eine hohe Wirksamkeit. Auch interdisziplinäre, multimodale tagesklinische und stationäre Therapieansätze stellen wichtige Optionen dar. Bezüglich der Prophylaxe der chronischen Migräne gelang mittels zweier großen multizentrischen Studien der Wirksamkeitsnachweis für Botulinumtoxin A. Neuromodulative und neurostimulative Verfahren sind potenziell zukünftige, derzeit allerdings noch eher experimentelle Therapieoptionen für Patienten mit therapierefraktärer Migräne.

Abstract

Migraine is a very common primary headache disorder associated with intermittent attacks and great suffering. Despite extensive research efforts in the recent years, many pathophysiological aspects remain unclear. An altered cortical adaptability and the brainstem as a migraine generator are probably involved in the initiation of a (silent) cortical spreading depression and other processes that lead to neurogenic inflammation of the meninges causing the headache. Numerous studies in the last years have examined somatic, especially cerebrovascular and also psychological comorbidities. For attack therapy, CGRP antagonists have emerged as promising non-vasoconstrictive acting alternatives for triptans. However, they were so far not approved due to liver enzyme elevations in safety studies. Another new approach without vasoconstrictive action are the selective 5-HT1F agonists (especially Lasmiditan). Large placebo-controlled and triptan-controlled trials need to be awaited. For migraine prophylaxis, a comparable effect of sports and pharmacological prophylaxis using topiramate could be found. Particularly the combination of drug and non-drug therapies (such as the combination of stress management training with a beta-blocker treatment) achieves high efficacy. Also interdisciplinary, multimodal treatment approaches are important options. Two large multicentre studies have demonstrated the efficacy of botulinum toxin A as a prophylactic treatment for chronic migraine. Neuromodulative and neurostimulative procedures are promising but still experimental treatment options for patients with refractory migraine.

Schlüsselwörter

Migräne - Kopfschmerz - Therapie - Pathophysiologie

Key words

migraine - headache - therapy - pathophysiology

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