Nervenheilkunde 2011; 30(12): 972-976
DOI: 10.1055/s-0038-1628458
Schwabinger Neuro-Seminar
Schattauer GmbH

Neue Entwicklungen in der Behandlung der Migräne

New strategies in migraine therapy
M. Keidel
1   Klinik für Neurologie, Bezirkskrankenhaus Bayreuth
› Author Affiliations
Further Information

Publication History

Eingegangen am: 04 October 2011

angenommen am: 06 October 2011

Publication Date:
22 January 2018 (online)

Zusammenfassung

Die Substanzklasse der Triptane ist bei fehlenden Neuentwicklungen nicht erweitert worden. Es liegen jedoch neue Applikationsformen vor. In Deutschland ist ein nadelfreier Injektor zur subkutanen Sumatriptanapplikation zugelassen. In den Vereinigten Staaten befindet sich eine transdermale Applikationsform des Sumatriptans mittels Pflaster in dem Zulassungsverfahren. Erprobt werden fixe Kombinationen eines Triptans mit einem nicht steroidalen Antiphlogistikum in einer Tablette, insbesondere zur Reduktion der Wahrscheinlichkeit eines Migräne-Wiederkehrkopfschmerzes, z. B. Rizatriptan mit Paracetamol oder Koffein. Als Mischpräparat ist Sumatriptan mit Naproxen in den USA zugelassen. Als Substanzen ohne direkte vasokonstriktorische Nebenwirkung werden in klinischen Studien Serotonin-5-HT-1F-Rezeptoragonisten und Calcitonin gene-related peptide (CGRP) Rezeptorantagonisten untersucht. Von einer zeitnahen Zulassungs- und klinischen Anwendungsreife der CGRP-Antagonisten ist nicht auszugehen. Eine mögliche Renaissance ergibt sich für Dihydroergotamin nach oraler Inhalation, da die pulmonale Absorption nebenwirkungsärmer als die gastroenterale oder i.m.-Gabe ist. Zur Durchbrechung schwerer Migräneattacken ist die i.v.-Gabe von Valproat der i.v.-Gabe von ASS bezüglich der Wirksamkeit vergleichbar. Therapeutische Ansätze zur Durchbrechung der Migräneaura über eine Inhibition der kortikalen spreading depression mittels transkranieller Magnetstimulation, Gleichstromstimulation oder Verabreichung eines Gap-Junktion-Modulators werden in Tierversuchen als auch klinischen Studien verfolgt. Genetische Assoziationsstudien weisen auf eine besondere Rolle von Glutamat in der Auraentstehung hin. Zur Prävention der Migränechronifizierung einer episodischen Migräne sollten Komorbiditäten anamnestiziert und mitbehandelt werden. Eine Kombinationsbehandlung von Topiramat mit Propranolol ist in der Behandlung der chronischen Migräne der alleinigen Gabe von Topiramat nicht überlegen. Amitriptylin ist bei chronischer Migräne wirksam; Levetiracetam ist nicht wirksam. Bei medikamentöser Therapierefraktärität der chronischen Migräne kann die lokale i.m.-Infiltration mit Botulinumtoxin Typ A in spezifische Kopf-/Nackenmuskelbereiche eine zugelassene Therapieoption darstellen. Die Anwendung eines invasiven neuromodulatorischen Verfahrens mit bilateraler N. occipitalis major Stimulation sollte bei sehr strenger Indikationsstellung unter konsequenter Beachtung sämtlicher Ausschlusskriterien lediglich spezialisierten Zentren vorbehalten bleiben.

Summary

Currently there are no clinical investigations of novel triptans. However, innovative delivery systems of triptans are under study. In the USA a novel formulation of sumatriptan which is delivered using an iontophoretic transdermal patch is submitted to approval. A needle-free drug delivery system to subcutaneously administer sumatriptan for the acute treatment of migraine is approved. A fixed-dose tablet of sumatriptan and naproxen sodium is approved by the FDA. Other fixed combinations of triptans with NSAIDs or caffeine or acetaminophen are being tested. Amitriptyline is effective in chronic migraine; levetiracetame is not. The combination of topiramate and propranolol is not superior to a monotherapy of chronic migraine with topiramate. For treatment of acute migraine attacks valproate given intravenously is just as well effective as acetylsalicylic acid. Calcitonin gene-related peptide (CGRP) receptor antagonists, 5-HT 1F receptor agonists, glutamate receptor antagonists, nitric oxide syntase inhibitors and gap junction modulators, which do not have direct vasoconstrictor effects, are targets for acute antimigraine drugs. Oral inhalation of dihydroergotamine as a novel route of administration improving pulmonary systemic absorption is under investigation. Targeting the cortical spreading depression and neuromodulatory brainstem structures transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS) or the application of drugs inhibiting neuronal-glial gap junctions are analysed in clinical trials and animal experiments. Intramuscular injections of OnabotulinumtoxinA across seven specific head/neck muscle areas are approved to treat chronic migraine refractory to oral medication. The significance of neuromodulatory techniques (e. g. occipital nerve block) in the treatment of chronic migraine is a matter of debate. This therapeutic option should be restricted to special centers. To prevent chronic migraine possible comorbidities should be diagnosed and treated.

 
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