CME 201-Strategi Pengobatan Migren Akut PDF
CME 201-Strategi Pengobatan Migren Akut PDF
ABSTRAK
Migren menimbulkan nyeri kepala sedang hingga berat disertai foto-fonofobia, mual, muntah, dan aktivitas rutin umumnya memperparah
gejala-gejala tersebut, sering kali berdampak nyata. Mengingat keparahan, durasi, dan disabilitas yang menyertainya, terapi akut serangan
migren menjadi hal krusial. Tujuan pengobatan akut adalah sebagai terapi cepat yang cost-effective dengan reduksi disabilitas yang konsisten
tanpa kekambuhan nyeri kepala. Sekurang-kurangnya ada tiga jenis strategi pengobatan akut yang telah diperkenalkan: stepped care across
attacks, stepped care within attacks, dan stratified care.
Kata kunci: migren, patofisiologi, pengobatan akut
ABSTRACT
Migraine produces moderate to severe pain associated with photo-phonophobia, nausea, and vomiting, and routine activity typically worsens
the symptoms, often resulting in profound impact. Because of the severity, duration, and associated disability, acute treatment of migraine attacks
becomes crucial. The goals of acute treatment are rapid and cost-effective treatment, consistent reduction of disability without recurrence of
headache. At least three different acute treatment strategies have been proposed: stepped care across attacks, stepped care within attacks, and
stratified care. Isti Suharjanti. Strategies for Acute Migraine Therapy.
Key words: migraine, pathophysiology, acute treatment
PENDAHULUAN
Migren adalah nyeri kepala heterogen dengan
nyeri hebat dan durasi lama dibandingkan
dengan nyeri kepala lain. Walaupun
kebanyakan penderita migren dilaporkan
nyerinya sedang sampai berat selama
serangan, pengobatan terbanyak adalah
dengan menggunakan obat-obatan over-thecounter (OTC).1
World
Health
Organization
(WHO)
menyatakan bahwa migren adalah salah satu
dari 20 penyakit terbanyak yang menimbulkan
gangguan aktivitas kehidupan seseorang,
selain itu juga menjadi beban biaya yang
cukup tinggi setelah epilepsi, stroke, sindrom
Parkinson, sklerosis multipel dan penyakit
Alzheimer.2 Karena berat, lama dan gejala yang
menyertai migren cukup berat, pengobatan
saat serangan migren menjadi penting.
Tujuan utama pengobatan akut adalah onset
cepat, cukup efektif, secara konsisten dapat
menurunkan nyeri tanpa menimbulkan
Alamat korespondensi
email: isti.suharjanti@gmail.com
87
88
Nama obat
Dosis (mg)
Level of evidence
Efek samping
1.000, oral
Saluran cerna
1.000, IV
Saluran cerna
Ibuprofen
200-800, oral
Saluran cerna
Naproksen
500-1.000, oral
Saluran cerna
Diklofenak
50-100 oral
Saluran cerna
Parasetamol
500-1.000
ASA+parasetamol+kafein
250+250+50
Saluran cerna
Metamizol
1.000, oral
1.000, iv
Agranulositosis
Fenazon
1.000, oral
Hipotensi
Asam tolfenamat
200, oral
89
Nama Obat
Dosis
Dosis Maksimal
Level of Evidence
Sumatriptan
Rizatriptan
200 mg
5, 10 mg
30 mg
Zolmitriptan
2,5, 5 mg
10 mg
Naratriptan
1, 2,5 mg
5 mg
Almotriptan
12,5mg
25 mg
Frovatriptan
Eletriptan
2,5mg
7,5 mg
20, 40 mg
80 mg
Nama Obat
Metoklopramid
Dosis
Level of Evidence
10-20 mg (po)
20 mg (supp)
Efek Samping
Domperidon
20-30 mg (po)
Stratified Care
Pemilihan awal pengobatan berdasarkan
pengobatan yang dibutuhkan oleh pasien
dengan mengevaluasi beratnya disabilitas dari
serangan migrennya dan kemudian diberikan
pengobatan spesifik untuk menghindari
kelanjutan
disabilitasnya.
Pendekatan
disabilitas ini sebagai petanda beratnya suatu
penyakit.3,12,13
16
Obat-Obat Spesifik
Triptan (agonis 5-HT1B/1D)
Digunakan pada migren sedang sampai
berat atau migren ringan sampai sedang
yang tidak responsif terhadap analgesik atau
NSAID. Sumatriptan subkutan lebih efektif
karena cepat mencapai efek terapeutik (15
menit) pada 70-82% penderita. Penderita
harus mencoba satu macam obat untuk 2-3
kali serangan sebelum menukar dengan jenis
triptan lain.15,16
Efek samping yang umum terjadi pada
penggunaan semua jenis triptan: dada rasa
tertekan, nausea, parestesi distal, fatigue.
Kontraindikasi umumnya pada hipertensi
arterial yang tidak diobati, penyakit jantung
koroner, penyakit serebrovaskuler, penyakit
Raynaud, kehamilan dan laktasi, usia di bawah
18 tahun (kecuali sumatriptan nasal spray)
DAFTAR PUSTAKA
1.
Sumelahti ML, Mattila K, Sillanmaki L, Sumanen M. Prescription pattern in preventive and abortive migraine medication. Cephalalgia. 2011;31(16);1659-63.
2.
Chang M, Rapoport AM. Acute treatment of migraine headache. Techniques in Regional Anesthesia and Pain Management. 2009;13:9-15.
3.
Tepper SJ, Spears RC. Acute treatment of migraine. Neurol Clin. 2009;27:417-27.
4.
Lance JW, Goadsby PJ. Migraine pathophysiology. In: Lance JW, Goadsby P, editors. Mechanism and management of headache. 7th ed. Philadelphia; 2005. p. 87-121.
90
Mathew NT. Migraibe. In Evans RW, Mathew NT. Handbook of headache. 2nd ed. Philadelphia; 2005. p. 28-59.
6.
International Headache Society. The international classification of headache disorders. 2nd ed. Cephalalgia. 2004;24(Suppl 1):24-5.
7.
Sheftell F, Cady R. Migraine without aura. In: Lipton RB, Bigal ME, editors. Migraine and other headache disorders. New York; 2006. p. 173-87.
8.
Lance JW, Goadsby PJ. Migraine: Varieties. In: Lance JW, Goadsby P, editors. Mechanism and management of headache. 7th ed. Philadelphia; 2005. p. 41-58.
9.
Kalra AA, Elliott D. Acute migraine: Current treatment and emerging therapies. Her Clin Risk Manag. 2007;3(3):449-59.
10. Silberstein SD, Saper JR, Freitag FG. Migraine: Diagnosis and treatment. In: Silberstein SD, Lipton AB, Dalessio DJ, Wolff S. Headache and other head pain. 7th ed. Oxford University Press;
2001. p. 121-238.
11. Rapoport AM. Pharmachologic treatment of acute migraine. In: Levin M, editor. Comphrehensive review of headache medicine. New York; 2008. p. 209-29.
12. Methew NT. Treatment of acute attacks of migraine. In: Evans RW, Mathew NT, editors. Handbook of headache. 2nd ed. Philadelphia; 2005. p. 60-87.
13. Lipton RB, Stewart WF, Stone AM. Stratified care vs step care strategies for migraine. The disability in strategies of care (DISC) study: A randomized trial. JAMA. 2000;294(20):2599-2606.
14. Konsensus Nasional III Diagnostik dan Penatalaksanaan Nyeri Kepala. Kelompok Studi Nyeri Kepala PERDOSSI. 2010.
15. Gilmore B, Michael M. Treatment of acute headache. Am Fam Physician. 2011;83(3):271-80.
16. Kelley NE, Tepper DE. Rescue therapy for acute migraine. Part 1. Triptan, dehidroergotamin, and magnesium. Headache. 2012;52(1):114-28.
17. Pardutz A, Schoenen J. NSAID in acute treatment of migraine: A review of clinical and experimental data. Pharmaceutical. 2010;3:1966-87.
11. Australia New Zealand Food Standards. Initial assessment report application A594 Addition of lutein as nutritive substance in infant formula [Internet]. [cited 2007 Apr 27]. Available from:
http://www.foodstandards.gov.au/standardsdevelopment/.
12. Trumbo PR, Ellwood KC. Lutein and zeaxanthin intakes and risk of age - related macular degeneration and cataracts: an evaluation using the ood and Drug Administrations evidence based review system for health claims. Am J Clin Nutr. 2006;84:971-4.
13. Zaripheh S, Erdman JW. Factors that influence the bioavailability of Xantophylls. J Nutr. 2002;132:531s-4s.
14. Mc. Eligot AJ, Rock CL, Shanks TG, Flatt SW, Newman V, Faerber S, Pierce JP. Comparison of serum carotenoid responses between women consuming vegetable juice and women
consuming raw f cooked vegetables. Cancer Epidemiol Biomark. Prev J. 1999;8:227-31.
15. Roodenburg AJC, Leenen R, van het Hof KH, Westrate JA, Tijburg LBM. Amount of fat in the diet affects bioavailibility of lutein esters but not of - carotene, - carotene, and vitamin E in
humans. Am J Clin Nutr. 2000;71:1187-93.
16. Bowen PE, Herbst - Espinosa SM, Hussain EA, Stacewics Saputzakis M. Esteri- fication does not impair lutein bioavalibility in humans. J Nutr. 2002; 132:3668-73.
17. Hininger IA, Meyer-Wenger A, Moser U, Wright A, Southon S, Thurnham D, et al. No significant effects of lutein, lycopene or -carotene supplementation on biological markers of oxidative
stress and LDL oxidizability in healthy adult subjects. J Am Coll Nutr. 2001;20:232-8.
18. Lyle BJ, Mares-Perlman JA, Klein BE, Klein R, Greger JL. Antioxidant intake and risk of incident age-related nuclear cataracts in the Beaver Dam Eye Study. Am J Epidemiol. 1999;149:801-9.
19. Richer , Stiles W, Statkute L, Pulido J, Frankowski J, Rudy D, et al. Double- masked, placebo - controlled, randomized trial of lutein and antioxidant supplementation in the intervention of
trophic age-related macular degeneration: The Veteran LAST study (Lutein Antioxidant Supplementation Trial). Optometr. 2004;75:216-30.
20. Bahrami H, Melia M, Dagnelie G. Lutein supplementation in retinitis pigmentosa: PC-based vision assessment in a randomized-masked placebo-controlled clinical trial. BMC Ophtalmology
2006;6:23.
21. Falsini B, Piccardi M, Iarossi G, Fadda A, erendino E, Valentini P. Influence of short - term antioxidant supplementation on macular function in age-related maculo- pathy: A pilot study
including electrophysiologic assessment (abstract). Ophtalmology. 2003;110:51-60.
22. Hammond BR, Johnson EJ, Russel RM, Krinsky NI, Yeum KJ, Edwards RB, et al. Dietary modification of human macular pigment density. Invest Ophthalmol Vis Sci. 1997;38:1795-1801.
23. Evans JR. Antioxidant vitamin and mineral supplements for slowing the progression of age-related macular degeneration. Cochrane Database of Systematic Reviews 2006, Issue 2. Art.
No.:CD000254. DOI:10.1002/14651858.CD000254.pub2.
91