Tavis tkivilis marTva pirvelad jandacvaSi...2 Tavis tkivilis marTva pirvelad jandacvaSi 1. Tavis tkivilis definicia Tavis tkivili ewodeba tkivils Tavis areSi, romelic lokalizebulia

1

danarTi 1

Tavis tkivilis marTva

pirvelad jandacvaSi

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

damtkicebulia saqarTvelos Sromis, janmrTelobisa da socialuri dacvis ministris 2010 wlis 11 oqtombris

# 333/o brZanebiT

miRebulia “klinikuri praqtikis erovnuli rekomendaciebis (gaidlainebi) da daavadebaTa marTvis saxelmwifo

standartebis (protokolebi) SemuSavebis, Sefasebisa da danergvis erovnuli sabWos"

2009 wlis 30 dekembris #2 sxdomis gadawyvetilebis Sesabamisad

2

Tavis tkivilis marTva pirvelad jandacvaSi

1. Tavis tkivilis definicia

Tavis tkivili ewodeba tkivils Tavis areSi, romelic lokalizebulia Tvalebisa da yurebis zemoT, kefaSi an kisris zeda nawilis ukan. Tavis tkivili, gulmkerdis an zurgis areSi tkivilis msgavsad, mravalma mizezma SeiZleba gamoiwvios. mocemul gaidlainSi gamoyenebulia Tavis tkivilis saerTaSoriso klasifikaciis gansazRvrebebi, romlebsac gvTavazobs Tavis tkivilis saerTaSoriso sazogadoebis me-2 gadaxedva1 (ix. danarTi 1).

Tavis tkivili zogadad klasificirdeba, rogorc pirveladi an meoreuli, xolo aRniSnuli formebi ki SemdgomSi iyofa Tavis tkivilis specifiur tipebad. pirveladi Tavis tkivili ewodeba tkivils, romelic ar aris asocirebuli sxva gamomwvev paTologiasTan da igi moicavs Sakiks, daZabvisa da klasterul Tavis tkivils. meoreuli ewodeba Tavis tkivils, romelic ganpirobebulia romelime gamomwvevi paTologiuri mdgomareobiT da masSi Sedis infeqciuri, neoplaziuri, vaskuluri, medikamentebiT gamowveuli an idiopaTiuri warmoSobis Tavis tkivili. pacientTa umravlesobas aReniSneba pirveladi Tavis tkivilis romelime tipi, maSin roca seriozuli meoreuli mizezebi SedarebiT iSviaTia2.

cxrili 1. Tavis tkivilis saerTaSoriso klasifikacia3,*.

pirveladi 1. Sakiki, maT Soris:

1.1 Sakiki auris gareSe;

1.2 Sakiki auriT;

2. daZabulobis tipis Tavis tkivili, maT Soris:

2.1. iSviaTi epizoduri daZabulobis tipis Tavis tkivili;

2.2. xSiri epizoduri daZabulobis tipis Tavis tkivili;

2.3. qronikuli daZabulobis tipis Tavis tkivili.

3. klasteruli Tavis tkivili da sxva trigeminul-avtonomiuri cefalalgiebi, maT Soris:

3.1. klasteruli Tavis tkivili.

4. sxva pirveladi Tavis tkivili.

meoreuli 5. Tavis tkivili, romelic dakavSirebulia Tavis an kisris travmasTan, maT Soris:

5.2. qronikuli post-travmuli Tavis tkivili.

6. Tavis an kisris sisxlZarRvebis paTologiasTan

* cxrilSi CamoTvlilia klasifikaciaSi Sesuli is ZiriTadi paTologiebi, romlebic

yvelaze gavrcelebulia zogad saeqimo praqtikaSi.

3

dakavSirebuli Tavis tkivili, maT Soris:

6.2.2. Tavis tkivili, ganpirobebuli subaraqnoiduli hemoragiiT;

6.4.1. Tavis tkivili, ganpirobebuli giganturujreduli arteriitiT.

7. Tavis tkivili, ganpirobebuli arasisxlZarRvovani intrakraniuli paTologiiT, maT Soris:

7.1.1. idiopaTiur intrakraniul hipertenziasTan dakavSirebuli Tavis tkivili;

7.4. intrakraniuli simsivnuri warmonaqmniT ganpirobebuli Tavis tkivili.

8. Tavis tkivili, romelic dakavSirebulia sxvadasxva nivTierebebis moxmarebasa an maT moxsnasTan, maT Soris:

8.1.3. naxSirbadis monoqsidiT gamowveuli Tavis tkivili;

8.1.4. alkoholiT gamowveuli Tavis tkivili.

8.2. medikamentebis Warbi moxmarebiT gamowveuli Tavis tkivili:

8.2.1. ergotaminis Warbi moxmarebiT gamowveuli Tavis tkivili;

8.2.2. triptanebis Warbi moxmarebiT gamowveuli Tavis tkivili;

8.2.3. analgetikebis Warbi moxmarebiT gamowveuli Tavis tkivili.

9. infeqciiT ganpirobebuli Tavis tkivili, maT Soris:

9.1. intrakraniuli infeqciiT gamowveuli Tavis tkivili.

10. Tavis tkivili, ganpirobebuli homeostazis darRveveiT.

11. Tavis an saxis tkivili, ganpirobebuli qalas, kisris, yurebis, cxviris, sinusebis, kbilebis, piris Rrus an saxisa da qalas sxva struqturebis paTologiiT, maT Soris:

11.2.1. cervikogenuli Tavis tkivili;

11.3.1. Tavis tkivili, ganpirobebuli mwvave glaukomiT.

12. Tavis tkivili, ganpirobebuli fsiqiuri paTologiiT.

nevralgia da Tavis tkivilis sxva tipebi

13. kraniuli nevralgiebi da saxis tkivilis centraluri da pirveladi mizezebi, maT Soris:

13.1. trigeminuli nevralgia.

14. sxva tipis Tavis tkivili, kraniuli nevralgia, saxis centraluri an pirveladi tkivili.

mocemul gaidlainSi ganxilulia Tavis tkivili, romelic moicavs:

pirvelad Tavis tkivils (magaliTad, Sakiki, daZabulobis tipis Tavis tkivili);

meoreul Tavis tkivils (magaliTad, medikamentebis gadaWarbebul gamoyenebasTan dakavSirebuli).

SeniSvna: gaidlainSi ar aris Sesuli Tavis tkivili, gamowveuli iseTi paTologiebiT, rogoricaa magaliTad, trigeminuli nevralgia an meningiti.

4

gaidlainis samizne populacias warmoadgens mozrdili pacientebi pirveladi da meoreuli Tavis tkiviliT, xolo misi amocanaa mozrdilebSi Tavis tkivilis diagnostikisa da marTvis mtkicebulebebze dafuZnebuli rekomendaciebis mowodeba.

2. Tavis tkivilis epidemiologia

miuxedavad imisa, rom Tavis tkivilis sxvadasxva tipebis dokumenturi dasabuTeba mxolod nawilobriv xelmisawvdomia, am paTologiis erTad aRebuli SemTxvevebi Zalian farTod aris gavrcelebuli. populaciur kvlevebSi ZiriTadad Seswavlilia Sakiki, romelic miuxedavad imisa, rom kvlevis uxSires sagans warmoadgens, ar aris Tavis tkivilis yvelaze gavrcelebuli mizezi. Tavis tkivilis sxva tipebs, rogoricaa magaliTad, yvelaze gavrcelebuli daZabulobis tipis Tavis tkivili da yvelaze metad damainvalidebeli qronikuli yoveldRiuri Tavis tkivilis qvetipebi, kvlevebSi naklebi yuradReba eqceva. ganviTarebad qveynebSi Catarebuli populaciuri kvlevebis ricxvi Zalzed SezRudulia, radganac aseT qveynebSi dafinansebis simwire da Tavis tkivilis naklebi problematuroba sxva daavadebebTan SedarebiT aferxebs informaciis sistemur Segrovebas.

ganviTarebul qveynebSi calke aRebuli daZabulobis tipis Tavis tkivili aReniSneba mozrdili mamakacebis daaxloebiT or mesamedsa da qalebis 80%-s4. Sakikis gavrcelebis Semswavleli kvlevebidan miRebuli monacemebis safuZvelze savaraudoa, rom saerTo mosaxleobis yovel milionze yoveldRiurad viTardeba Sakikis 3000 Seteva. naklebad Seswavlilia qronikuli yoveldRiuri Tavis tkivilis gavrceleba: daaxloebiT 20-dan erT mozrdils aReniSneba Tavis tkivili yoveldRe an TiTqmis yoveldRiurad.

Tavis tkivili ara marto mtkivenuli, aramed damainvalidebeli paTologiacaa. jandacvis msoflio organizaciis (WHO) monacemebiT, calke aRebuli Tavis tkivili me-19 adgilzea uunarobiT gatarebuli wlebis (years lived with disability [YLDs]) yvela mizezs Soris. Tavis tkivilis gamomwvevi paTologiebi pacientebisaTvis mniSvnelovan tvirTs warmoadgens, rac moicavs gamoxatul individualur avadobas, sicocxlis xarisxis gauaresebasa da mniSvnelovan finansur danaxarjebs. Tavis tkivilis ganmeorebiTi Setevebi da xSirad mosalodneli Setevis SiSi moqmedebs ojaxur cxovrebaze, socialur urTierTobebsa da samuSaoze. magaliTad, socialuri aqtivoba da samuSaos Sesrulebis unari Semcirebulia TiTqmis yvela SakikiT daavadebulsa da daZabulobis tipis Tavis tkivilis mqone pacientTa daaxloebiT 60%-Si.

Tavis tkivilTan gamklavebis xangrZlivma mcdelobam SesaZlebelia gamoiwvios sxva daavadebebisadmi calkeuli pacientis winaswarganwyobis ganviTareba. magaliTad, depresia samjer ufro xSirad gvxdeba SakikiT an mZime Tavis tkiviliT daavadebul pacientebSi, vidre zogadad janmrTel populaciaSi.

5

pirvelad jandacvaSi Tavis tkivilis mqone pacientebis umravlesobas pirveladi Tavis tkivili aReniSneba5. pacients SesaZlebelia erTdroulad Tavis tkivilis ramdenime tipi hqondes (magaliTad, Sakiki auris gareSe da daZabulobis tipis Tavis tkivili), romelTaganac TiToeuls esaWiroeba mkurnaloba calk-calke. meoreuli Tavis tkivili SedarebiT iSviaTia.

3. Tavis tkivilis etiopaTogenezi

imis gamo, rom Tavis tkivilis tipebi sxvadasxva etiologiuri faqtorebis kombinaciiTa da paTogenezuri meqanizmebiT xasiaTdeba, mizanSewonilia etiopaTogenezis ganxilva calkeuli tipis Tavis tkivilisaTvis individualurad. Tavis tkivilis etiologiuri faqtorebi ixileT cxrili #1-Si.

Sakikis etiopaTogenezi

genetikuri faqtorebi

pacientTa daaxloebiT 70%-s yavs pirveli rigis naTesavebi Sakikis anamneziT. Sakikis riski 4-jer momatebulia im pacientTa naTesavebSi, visac aReniSneba Sakiki auriT. miuxedavad imisa, rom martivi Sakikis SemTxvevaSi genetikuri safuZveli dadgenili ar aris, zogadad savaraudoa dedismieri memkvidreobiTi gadacemis arseboba6,7.

Sakiki da ko-morbiduli mdgomareobebi

Sakiki asocirebulia epilefsiasTan, ojaxur dislipoproteinemiasTan, memkvidrul hemoragiul teleangieqtaziasTan, turetis sindromTan, memkvidrul esenciur tremorTan, memkvidrul cerebrul amiloidur angiopaTiasTan, iSemiur insultTan (Sakiki auriT warmoadgens risk-faqtors, romlis drosac Sansebis Tanafardoba utoldeba 6-s), SfoTvasTan, depresiasa da asTmasTan. epilefsiis dros Sakikis SefardebiTi riski 2,4-jer izrdeba.

Sakikis paTofiziologia

Sakikis paTofiziologiis axsnis ori ZiriTadi Teoria arsebobs. erT-erTi ufro Zvelia da mTlianad emyareba vaskularul mosazrebebs; SemdgomSi moxda am Teoriis ganviTareba da misi Canacvleba neirovaskularuli TeoriiT. amJamad naTelia, rom Sakiki cns-is qronikuli paTologiaa da am dros damaxasiaTebelia sisxlZarRvovani cvlilebebis ganviTareba.

vaskularuli Teoria

1940-1950-ian wlebSi Camoyalibda vaskularuli Teoria Sakikis paTofiziologiis asaxsnelad. Wolff da Tanaavtorebi Tvlidnen, rom Sakikis auris ganmapirobebelia intrakraniuli vazokonstriqcia, xolo misi momdevno vazodilatacia da perivaskularuli nocicepturi nervebis aqtivacia iwvevs Tavis tkivils. es Teoria emyareboda

6

dakvirvebas imaze, rom, (1) eqstrakraniuli sisxlZarRvebi farTovdeba da pulsirebs Sakikis Setevis periodSi; (2) intrakraniuli sisxlZarRvebis stimulacia mRviZare pirebSi iwvevs Tavis tkivils; da (3) vazokonstriqtorebis (magaliTad, ergotaminis preparatebis) miReba amsubuqebs Tavis tkivils, maSin roca vazodilatatorebi (magaliTad, nitroglicerini) iwvevs Setevis provocirebas. amJamad dadginda, rom am or movlenas Soris ar arsebobs mdgradi urTierTkavSiri da rom am SemTxvevaSi ganviTarebul Tavis tkivilis meqanizmi intra- da eqstrakraniuli faqtorebis rTuli erTobliobiTaa ganpirobebuli, rac savaraudod dakavSirebuli unda iyos sisxlZarRvebisa da maTi garemomcveli struqturebis sensibilizaciasTan. Sakikuri Tavis tkivilis ganviTarebaSi aseve garkveul rols asrulebs “steriluri anTeba”, romelsac iwvevs trigemino-vaksuluri sistemis (samwvera nervisa da mis mier inervirebuli sisxlZarRvebis) aqtivacia.

neirovaskuluri Teoria

amJamad arsebuli SexedulebiT Sakikis dawyebas iwvevs nervuli da sisxlZarRvovani rTuli seriuli cvlilebebi. am Sexedulebas neirovaskularuli Teoria ewodeba8.

Sakikis mqone pacients Tavidan aReniSneba Tavis tvinis, gansakuTrebiT ki kefis qerquli nivTierebis neironebis hiperagznebadoba. Sakikis aura dakavSirebulia qerqis rux nivTierebaSi ganviTarebuli neironuli agznebis talRis gavrcelebasTan warmoqmnis adgilidan 2-6 mm/wuTSi siCqariT. am gavrcelebas Tan sdevs analogiuri gziT ganviTarebuli neironuli supresiis talRa [qerquli gadacemis depresia (qgd)]. aRniSnul areSi xdeba erTdroulad sisxlZarRvebis dilatacia da Semdeg konstriqcia. amis gamo Sakikis aura warmoadgens qerqul movlenas, romelsac safuZvlad udevs gansazRvruli neiroeleqtruli procesi. rogorc ki Tavis tvinSi xdeba qgd-s ganviTareba, H+ da K+-is ionebi vrceldeba rbil garsSi da aaqtiurebs C-boWkovan meningealur nociceptorebs, saidanac xdeba proanTebiTi neiroqomiuri mediatorebis (magaliTad, kalcitoninis genTan dakavSirebuli peptidis) gamoyofa da viTardeba plazmis eqstravazacia. amis gamo adgili aqvs trigemino-vaskularuli kompleqsis sterilur neirogenul anTebas. trigeminuli sistemis aqtivacia iwvevs kraniuli sisxlZarRvebis dilatacias. mfeTqavi xasiaTis tkivilis ganviTarebis saboloo mizezi swored sisxlZarRvebis gafarToebaa. Sakikis epizodis ganmavlobaSi aseve adgili aqvs trigemino-Talamuri sistemis tkivilis meoreuli gzebis sensibilizacias, rac kutaneuri alodiniis fenomenis saxeliTaa cnobili9.

prodromuli simptomebis mravalferovneba (magaliTad, mTqnareba, agznebadoba, gulisreva, Rebineba) SesaZlebelia dofaminerguli stimulaciiT aixsnas. dofaminis antagonistebi, iseTi rogoricaa, magaliTad, proqlorperazini, mTlianad xsnis Sakikis mwvave SetevaTa daaxloebiT 75%-s10.

7

serotoninerguli Teoria

Sakikis Setevis dros serotoninis Semcvelobis cvlileba rogorc sisxlis plazmaSi, ise TrombocitebSi, safuZvels qmnis imis varaudisTvis, rom serotonini CarTuli unda iyos Sakikis paTogenezSi. Sakikis Setevis ganviTarebamde Trombocitebis aqtivaciis fonze adgili aqvs maT lizissa da serotoninis gamoyofas, ris fonzec plazmaSi serotoninis done izrdeba. aRniSnul movlenas Tans sdevs vazokonstriqcia, radganac rogorc cnobilia, serotonini mZlavr vazokonstriqtors warmoadgens. vazokonstriqciis Sedegad ganviTarebuli sisxlis nakadis Semcireba moiazreba Sakikis auris ganmapirobebeli meqanizmis saxiT. Sakikis Tavis tkivilis fazis ganviTarebis dros serotoninis plazmuri koncentracia mcirdeba, xolo misi metabolitebis eqskrecia SardTan erTad matulobs. serotoninis donis daqveiTebas mohyveba eqstrakraniuli arteriebis mniSvnelovani gafarToeba, rac Sakikis tkivilis ganviTarebis mizezs warmoadgens.

daZabulobis tipis Tavis tkivilis etiopaTogenezi

daZabulobis tipis Tavis tkivilis paTogenezi rTuli da multifaqtorulia da moicavs rogorc centraluri, ise periferiuli faqtorebis Tanamonawileobas. warsulSi arsebobda mosazrebebi sxvadasxva meqanizmebis, maT Soris, vaskuluri, kunTovani (kerZod, skalpis kunTebis gadaWarbebuli SekumSva) da fsiqogenuri faqtorebis Sesaxeb. amJamad miCneulia, rom aRniSnuli tipis Tavis tkivilis yvelaze savaraudo mizezi neironebis paTologiuri mgrZnobeloba da maT mier tkivilis xelSewyobaa da ara kunTebis gadaWarbebuli SekumSva.

perikraniuli miofasciuri qsovilebis tkiviliT gaxangrZlivebuli gaRizianebis Sedegad SesaZlebelia ganviTardes momatebuli sensibilizacia spinaluri dorsaluri rqis/samwvera nervis birTvis doneze, rasac mohyveba periferiuli meqanizmebis regulaciis cvlileba da perikraniuli kunTebis aqtivobis mateba an neirotransmiterebis gamoTavisufleba miofasciur qsovilebSi11. aRniSnuli centraluri sensibilizacia SesaZlebelia SenarCundes mas Semdegac ki, rac moxdeba sawyisi maprovocirebeli faqtorebis mocileba, rasac Tan sdevs daZabulobis tipis epizoduri Tavis tkivilis transformacia daZabulobis tipis qronikul Tavis tkivilad.

klasteruli Tavis tkivilis paTogenezi

vaskularuli Teoriis Tanaxmad warsulSi klasteruli Tavis tkivili ukavSirdeboda kavernozuli sinusis vaskulits, radganac es ukanaskneli warmoadgens erTaderT anatomiur adgilmdebareobas nervul sistemaSi, sadac paTologiis 3 wamyvani elementi erTmaneTTan mWidro siaxloveSi imyofeba. venuri vaskuliti iwvevs venuri drenaJis blokirebas da karotiduli wnulis simpaTikuri nervuli boWkoebis dazianebas. klasteruli Tavis tkivilis epizodis periodSi gadaRebul angiogramebze vlindeba Tvalbudis arteriis

8

vazodilatacia. sxva cvlilebebs miekuTvneba rqovanas momatebuli CaRrmaveba, TvalSida wnevisa da Tvalis irgvlivi kanis temperaturis momateba.

neirovaskularuli Teoriis Tanaxmad, klasteruli Tavis tkivilis mqone pacientebze tkivilis epizodis dros Catarebuli PET da funqciuri mrt-kvlevebiT dadginda, rom klasteruli Tavis tkivilis pirvelad generators hipoTalamusis ifsilateraluri struqturebi warmoadgens12. amgvar pacientebs aReniSnebaT endokrinul darRvevaTa farTo speqtri (magaliTad, testosteronisa da melatoninis dabali done). SemdgomSi hipoTalamusi iwvevs zeda salivatoruli birTvis aqtivacias, romelic astimulirebs parasimpaTikur meqanizmebs. parasimpaTikuri meqanizmebi warmoadgens cremldenis, rinoreis, koniunqtivis hiperemiisa da sxva vegetatiuri simptomebis mizezs. klasteruli Tavis tkivilis mqone pacientebSi Zalian maRalia vazoaqtiuri intestinuri peptidis done.

qronikuli yoveldRiuri Tavis tkivilis paTogenezi

qronikuli yoveldRiuri Tavis tkivilis paTogenezi kargad Seswavlili ar aris da arsebobs garkveuli mosazrebebi imis Sesaxeb, rom igi dakavSirebulia centralur meqanizmebTan, romelSic CarTulia Tavis tvinis Rerosa da hipoTalamusis serotoninerguli da monoaminerguli struqturebis paTologia.

qronikuli Tavis tkivilisa da obieqturi nevrologiuri gasinjvis normaluri monacemebis mqone pacientTa mxolod 1%-s aReniSneba paTologiuri gadaxra neirogamosaxviTi gamokvlevisas. neirogamosaxviTi kvleva rekomendebulia mxolod maSin, roca Tavis tkivili vlindeba atipiuri niSnebiT.

qronikuli yoveldRiuri Tavis tkivili asocirebulia komorbiduli mdgomareobebis momatebul sixSiresTan, maT Soris, depresiasTan, SfoTvasTan, bipolarul aSlilobasTan, panikur SetevebTan. oromandibulur disfunqciasTan, stressa da medikamentebis borotad gamoyenebasTan.

cervikogenuli Tavis tkivilis paTogenezi

aseTi tipis Tavis tkivilis dros tkivilis iradiacia xdeba kisris midamodan. mis anatomiur safuZvels warmoadgens trigemino-cervikaluri nucleus caudalis zurgis tvinis rux nivTierebaSi C1-C3

doneze, sadac xdeba gadakveTa nocicepturi meore rigis neironebisa, romlebic Rebuloben signalebs rogorc trigeminuli, ise cervikaluri struqturebidan.

9

4. klinikuri simptomatika

pirveladi Tavis tkivilis klinikuri simptomebi

Sakiki

Sakikis dros ganviTarebuli Tavis tkivilisTvis damaxasiaTebelia:

calmxrivi lokalizacia;

mfeTqavi xasiaTi;

gaZliereba wuTebidan saaTebamde drois periodSi;

saSualo xarisxis an Zlieri intensivoba;

asocirebulia gulisrevasa da/an RebinebasTan da/an momatebul mgrZnobelobasTan sinaTlis da/an xmauris mimarT;

fizikuri uunaroba;

damZimeba Cveuli fizikuri aqtivobis fonze.

Sakikis klasificireba xdeba auris arseboba-ararsebobis mixedviT. tipuri aura warmodgenilia srulad Seqcevadi vizualuri da/an sensoruli da/an disfaziuri metyvelebis simptomebiT. simptomebi SesaZlebelia iyos pozitiuri (magaliTad, sinaTlis cimcimi, zigzagisebri xazebi) da negatiuri (magaliTad mxedvelobis dakargva, dabuJeba). simptomebi Cveulebriv, Zlierdeba ≥ 5 wuTSi da qreba 60 wuTis ganmavlobaSi. momdevno periodSi SesaZlebelia ganviTardes gansxvavebuli auris simptomebi. gardamavali iSemiuri Seteva savaraudoa im SemTxvevaSi, roca aura Zalian swrafad iwyeba, gansxvavebuli auris simptomebi viTardeba erTdroulad da ara Tanmimdevrulad da aura wmindad negatiuri xasiaTis an Zalian xanmoklea13,14(III). aura SesaZlebelia ganviTardes Tavis tkivilis gareSec.

ganmeorebiTi Setevebi, romelTa xangrZlivobac 4-dan 72 saaTamdea, SeiZleba ganviTardes ufro iSviaTad, vidre weliwadSi erTxel, an yoveldRiurad. saSualo sixSire Seadgens TveSi erTidan or Setevas15(IV). qronikuli Sakiki ganisazRvreba, rogorc Sakiki, romelic viTardeba TveSi 15 an meti dRis ganmavlobaSi 3-ze meti Tvis manZilze. qronikuli Sakikis dros SesaZlebelia aRiniSnebodes simptomebi, romlebic metad damaxasiaTebelia daZabulobis tipis Tavis tkivilisaTvis.

Sakikis mqone pacientTa daaxloebiT 50%-s arasworad esmeba Tavis tkivilis sxva tipis diagnozi16(III). xSirad ismeba epizoduri daZabulobis tipis Tavis tkivilis araswori diagnozi. erT-erT kvlevaSi im pacientTa istoriebis prospeqtuli Seswavlisas, romelTac dasmuli hqondaT epizoduri daZabulobis tipis Tavis tkivilis diagnozi, eqimis diagnozebis 82% Seicvala SakikiT an savaraudo SakikiT.

Sakikis mqone pacientTa daaxloebiT 75% aRwers Sakikis SetevebTan asocirebul kisris tkivils. pacientebs SesaZlebelia erTdroulad Tavis tkivilis ramdenime tipi aReniSnebodes. Tavis tkivilis mizezebis saerTaSoriso klasifikaciis (ICHD-II) nebismieri calke

10

aRebuli kriteriumis gamoyenebiT SeiZleba pacientTa daaxloebiT 40%-is diagnozi gamogveparos. pacientTa 40% uCivis bilateralur tkivils, 50%-s aReniSneba ara-mfeTqavi xasiaTis tkivili, xolo Rebineba viTardeba pacientTa 33%-ze naklebSi14(III).

imis gaTvaliswinebiT, ramdenad Znelia auris gareSe mimdinare Sakikis diferenciuli diagnostika iSviaT epizodur daZabulobis tipis Tavis tkivilTan, ICHD-II-s mixedviT auris gareSe mimdinare Sakikis diagnozis dasmamde aucilebelia 5 Setevis arseboba, xolo auriT mimdinare Sakikis diagnozisaTvis ki saWiroa ori Seteva mainc. im pacientebisaTvis, romelTac erTdroulad Tavis tkivilis ramdenime tipi aReniSnebaT, Tavis tkivilis saerTaSoriso sazogadoeba (IHS) gvTavazobs ierarqiul diagnostikur strategias, romelic pirvel adgilze ayenebs ufro mZime Tavis tkivilis diagnozs.

kohortul da SemTxveva_kontrolis kvlevebSi dadginda anamnezuri niSnebi, romelTa meSveobiTac SesaZlebelia Sakikis diferencireba Tavis tkivilis sxva tipebisagan. diagnozis dasasmelad ar aris aucilebeli yvela maTganis arseboba:

epizoduri Zleri Tavis tkivili, romelic iwvevs uunarobas17,18(III);

gulisreva16,19(III);

Tavis tkivilis periodSi momatebuli mgrZnobeloba sinaTlis mimarT16,18(III);

momatebuli mgrZnobeloba sinaTlis mimarT Setevebs Soris periodSi20(III);

momatebuli mgrZnobeloba xmauris mimarT18;

tipuri aura (Sakikis mqone pacinetTa 15-33%-Si)18;

gamwvaveba fizikuri aqtivobis Sedegad18;

Sakikis ojaxuri anamnezi18,21(IV).

funqciuri dazianebis SefasebasTan kombinaciaSi gamoyenebisas Sakikis diagnostikis mizniT yvelaze specifiuri da mgrZnobiare simptomebia gulisreva da sinaTleze momatebuli mgrZnobeloba18.

rekomendacia (C):

Tuki pacienti uCivis Zlieri damainvalidebeli Tavis tkivilis ganmeorebiT epizodebs, romelic asocirebulia gulisrevasa da momatebul mgrZnobelobasTan sinaTlis mimarT, unda vivaraudoT Sakikis diagnozi.

daZabulobis tipis Tavis tkivilis simptomebi

daZabulobis tipis Tavis tkivili miekuTvneba yvelaze gavrcelebul pirvelad Tavis tkivils. am dros tkivilis intensivoba naklebia SakikTan SedarebiT.

tipur SemTxvevebSi tkivili bilateraluria, zewoliTi an moWeriTi xasiaTis da msubuqi an saSualo intensivobis. adgili ara aqvs

11

gulisrevas da ar xdeba Tavis tkivilis gauareseba fizikuri datvirTvis fonze. SesaZlebelia saxeze iyos perikraniuli struqturebis momatebuli mgrZnobeloba, sinaTlis an xmauris autanloba. epizoduri daZabulobis tipis Tavis tkivili viTardeba sxvadasxva sixSirisa da xangrZlivobis epizodebis saxiT. qronikuli daZabulobis tipis Tavis tkivili viTardeba TveSi 15-ze meti dRis ganmavlobaSi 3 Tveze meti drois manZilze.

damainvalidebeli epizoduri daZabulobis tipis Tavis tkivili iSviaTia. am paTologiis mqone pacientTa umravlesoba arc ki mimarTavs eqims22(III). daZabulobis tipis Tavis tkivilis diagnozi xSirad SecdomiT ismeba Sakikis sawyisi Sefasebisas.

rekomendacia (C):

Tuki pacients aReniSneba bilateraluri Tavis tkivili, romelic ar iwvevs fizikur uunarobas da nevrologiuri gamokvlevis Sedegebi normaluria, eqimma unda gaiTvaliswinos daZabulobis tipis Tavis tkivilis diagnozi.

trigeminul-avtonomiuri cefalalgiebis simptomatika

trigeminul-avtonomiur cafalalgiebs miekuTvneba: klasteruli Tavis tkivili, paroqsizmuli hemikrania, xanmokle calmxrivi nevralgiismagvari Tavis tkivilis Setevebi koniunqtivis SewiTlebiT da cremldeniT (SUNCT) da xanmokle calmxrivi nevralgiismagvari Tavis tkivilis Setevebi kraniuli vegetatiuri simptomebiT (SUNA).

trigeminuli vegetatiuri cefalalgiebi (tvc) iSviaTia da xasiaTdeba Zlieri unilateraluri tkiviliT samwvera nervis sainervacio zonaSi. igi asocirebulia TvalsaCino kraniul vegetatiur niSnebTan. klasteruli Tavis tkivili yvelaze gavrcelebul tvc-s miekuTvneba. paroqsizmuli hemikraniis diagnostika savaraudod saTanadod ar xdeba. xanmokle nevralgiuri Tavis tkivilis Setevebi koniunqtivis hiperemiiTa da cremldeniT (SUNCT) da xanmokle nevralgiuri Setevebi kraniuli vegetatiuri simptomebiT (SUNA) Zalian iSviaTia.

klasteruli Tavis tkivilis Setevebi iwvevs Zlier, mkveTrad unilateralur tkivils. tkivili lokalizebulia orbitul, supraorbitul an temporul areSi, an SesaZlebelia xasiaTdebodes kombinirebuli lokalizaciiT. ICHD-II klasifikaciis mixedviT aucilebelia SetevasTan erTad ifsilateraluri vegetatiuri simptomebis arseboba (ix. danarTi 1). TiToeuli Seteva iwyeba da wydeba uecrad, grZeldeba 15 wuTidan 3 saaTamde da Setevis periodSi pacienti mousvenaria. Setevebis sixSire cvalebadobs dReSi erTidan 8-mde. Setevebs Soris SesaZlebelia aRiniSnebodes mudmivi fonuri Tavis tkivili da SakikisaTvis damaxasiaTebeli simptomebi. xSirad adgili aqvs Setevebis cirkadul riTmulobas. isini viTardeba dRis erTsa da imave periodSi, xolo “klasterebi” ki aRiniSneba weliwadis erTsa da imave dros23(IV). pacientTa 80-90%-s aReniSneba epizoduri klasteruli Tavis tkivili, rodesac SetevaTa “klasteri” grZeldeba ramdenime kviridan ramdenime Tvemde, xolo maT Soris ki aRiniSneba Tavis

12

tkivilisagan Tavisufali periodi. darCenil 10-20%-s qronikuli klasteruli Tavis tkivili aqvs (remisiis ararseboba erTi wlis manZilze, an remisia grZeldeba erT Tveze naklebi drois ganmavlobaSi).

paroqsizmuli hemikrania klasteruli Tavis tkivilis analogiuri simptomebiT xasiaTdeba, magram Setevebi ufro xanmoklea (2-45 wuTi), ufro xSiri (dReSi 40-mdec ki) da igi ufro gavrcelebulia qalebSi. pacientTa umravlesobas aReniSneba qronikuli da ara epizoduri forma. SetevaTa umravlesoba spontanuria, magram SemTxvevaTa 10%-Si SesaZlebelia moxdes misi meqanikuri provocireba Tavis daxris an mobrunebis Sedegad. ICHD-II klasifikaciis mixedviT diagnozis dasasmelad aucilebelia tkivilis sruli gaqroba indometacinis miRebis Semdeg da Setevis periodSi ifsilateraluri vegetatiuri simptomebis arseboba (ix. danarTi 1).

SUNCT-s iseTive simptomebi axasiaTebs, rogorc klasterul Tavis tkivilsa da paroqsizmul hemikranias. Setevebi ufro xanmokle (2-250 wami) da xSiria (saaTSi 30-mdec ki). Seteva SesaZlebelia ganviTardes erTeuli, jgufuri an urTierTgadamfaravi (xerxiseburi) gamWoli tkivilis saxiT. SetevaTa rigi SesaZlebelia gagrZeldes erTidan 3 saaTamde. diagnozis dasasmelad aucilebelia koniunqtivis hiperemia da/an cremldena. Seteva SesaZlebelia ganviTardes spontanurad an trigeminuli (mag. saxeze Sexebis) an eqstratrigeminuli (magaliTad, fizikuri datvirTvis) maprovocirebeli faqtorebis zemoqmedebis Sedegad. recidivebi da remisiebi arakanonzomierad viTardeba24(III). SUNA warmoadgens im pacientTa mdgomareobis klasifikacias, romelTac aReniSnebaT SUNCT_isaTvis damaxasiaTebeli Tavis tkivili, magram gansxvavebuli kraniuli vegetatiuri niSnebi.

paroqsizmuli hemikraniis, SUNCT_isa da SUNA-s diagnozis dasmamde aucilebelia meoreuli mizezebis gamoricxva, romelTa simptomebic SesaZlebelia aRniSnuli paTologiebis msgavsi iyos. magaliTad, simptomuri klasteruli Tavis tkivilis SemTxvevebi aRwerilia infeqciis Semdeg, an sisxlZarRvovani da neoplaziuri paTologiebis fonze. paroqsizmuli hemikraniis SemTxvevaSi Sedegi indometacinze ar gamoricxavs meoreul mizezebs.

tvc-sa da Sakikis ganmasxvavebeli niSnebi CamoTvlilia cxrili #2-Si. trigeminuli vegetatiuri cefalalgiebis erTmaneTisagan da samwvera nervis nevralgiisagan ganmasxvavebeli niSnebi CamoTvlilia danarT 2-Si.

13

cxrili 2. tvc-sa da Sakikis ganmasxvavebeli niSnebi13,19

Tavis tkivilis tipi

SUNCT

paroqsizmuli hemikrania

klasteruli Tavis

tkivili Sakiki

xangrZlivoba 2-250 wm 2-45 wT 15 wT – 3 saaTi

4-72 saaTi

dasawyisi

swrafi swrafi swrafi TandaTanobiTi

sixSire 1/dReSi-30/sT_Si

1-40/dReSi dReSi 1-dan

8-mde

<1/weliwadSi-1/dReSi

(saSualod 1-2/TveSi)

mousvenroba Setevis periodSi

50% 50% 100% 0%

ifsilateraluri vegetatiuri niSnebi

TvalsaCinoa TvalsaCinoa TvalsaCinoa iSviaTia

rekomendacia (D):

Tuki pacients aReniSneba xSiri, xanmokle, unilateraluri Tavis tkivili vegetatiur simptomebTan erTad, unda gaviTvaliswinoT trigeminul-avtonomiuri cefalalgiis SesaZlebloba;

pacienti axlad ganviTarebuli saeWvo trigeminul-avtonomiuri cefalalgiiT SefasebisaTvis unda gaigzavnos specialistTan (nevrologTan).

uwyveti hemikraniis simptomatika

uwyveti hemikrania warmoadgens gamudmebul mkveTrad unilateralur Tavis tkivils, romlis intensivobac periodulad Zlierdeba an mcirdeba, magram sruli gaqroba ar aRiniSneba. periodulad SesaZlebelia adgili hqondes xanmokle gaelvebis tipis tkivilis wina planze wamowevas gamudmebul tkivilTan SedarebiT da agreTve, ifsilateralurad vegetatiuri simptomatikis arsebobas.

meoreuli SemniRbavi mizezebi sakmaod xSiria da amitom pirveladi uwyveti hemikraniis diagnozis dasmamde aucilebelia maTi gamoricxva. indometacinze dadebiTi pasuxi ar gamoricxavs meoreul mizezs.

rekomendacia (D):

rodesac pacients aReniSneba qronikuli yoveldRiuri Tavis tkivili, romelic mkveTrad unilateraluria, aucilebelia uwyveti hemikraniis diagnozis gaTvaliswineba;

pacienti axlad ganviTarebuli saeWvo uwyveti hemikraniiT SefasebisaTvis unda gaigzavnos specialistTan (nevrologTan).

14

axali yoveldRiuri mudmivi Tavis tkivili

Tavis tkivili, romelic yoveldRiuria da ar xasiaTdeba remisiiT dawyebisTanave, klasificirdeba, rogorc axali yoveldRiuri mudmivi Tavis tkivili. am paTologiis diagnozis dasmamde mniSvnelovania meoreuli mizezebis gamoricxva da samTviani periodis gavla. axal yoveldRiur mudmiv Tavis tkivils SesaZlebelia hqondes fenotipebi. mis gamomwvev meoreul mizezebs Soris gasaTvaliswinebelia subaraqnoiduli sisxlCaqceva, meningiti, intrakraniuli hipertenzia, Tav-zurgtvinis siTxis dabali wneva, giganturujreduli arteriiti da post-travmuli Tavis tkivili25(IV).

rekomendacia (D):

pacientebi axali yoveldRiuri mudmivi Tavis tkiviliT SefasebisaTvis gaagzavneT specialistTan (nevrologTan).

meoreuli Tavis tkivilis simptomebi

meoreuli Tavis tkivili (anu Tavis tkivili, romelsac iwvevs sxva mizezi) gasaTvaliswinebelia yvela pacientSi, romelsac aReniSneba axlad dawyebuli Tavis tkivili, an tkivilma icvala xasiaTi da gansxvavdeba manamde arsebuli Cveuli Tavis tkivilisagan. observaciuli kvlevebis safuZvelze gamovlinda potenciuri meoreuli Tavis tkivilis qvemoT CamoTvlili gamafrTxilebeli niSnebi anu “wiTeli droSebi”, romelTa drosac saWiroa damatebiTi gamokvlevebis Catareba:

“wiTeli droSis” niSnebi:

axlad dawyebuli Tavis tkivili an misi xasiaTis cvlileba 50 wels zeviT asakis pacientebSi26(III);

“mexis dacemismagvari“ Tavis tkivili: Tavis tkivili piks aRwevs Zalian swrafad (wamebidan 5 wuTamde)27;

fokaluri nevrologiuri simptomatika (magaliTad, kidurebis sisuste, aura <5 wuTze da >1 saaTze)28(III);

ara-fokaluri nevrologiuri simptomatika (magaliTad, cnobierebis darRveva)29(IV);

Tavis tkivilis xasiaTis, sixSirisa an asocirebuli simptomebis cvlileba30;

obieqturi nevrologiuri gamokvlevisas gamovlenili paTologia31;

Tavis tkivili, romelic icvleba poziciis cvlilebisas32;

Tavis tkivili, romelic aRviZebs pacients (Sakiki dilis Tavis tkivilis mizezebs Soris yvelaze xSiria)33;

Tavis tkivili, romelic mwvavdeba fizikuri aqtivobis fonze an valsalvas manevris Sesrulebisas (magaliTad, xvelis, sicilis, gazmorebis dros)34;

pacientebi cerebruli venuri Trombozis risk-faqtorebiT35;

ybis saxsris paTologia an vizualuri dazianeba36;

kisris daWimuloba37;

15

cxeleba37;

axlad ganviTarebuli Tavis tkivili adamianis imunodeficitis virusiT (aiv) inficirebul pacientSi27;

axlad ganviTarebuli Tavis tkivili pacientSi, romelsac anamnezSi aReniSneba kibo38.

rekomendacia (D):

pacientebi, romelTac aReniSnebaT Tavis tkivili da potenciuri meoreuli paTologiis “wiTeli droSis” niSnebi Semdgomi SefasebisaTvis unda gaigzavnon specialistTan (nevrologTan).

Tavis tkivilis stabiluri maxasiaTeblebis mqone pacientebSi nevrologiuri gasinjvis Sedegebi normaluria, garda ftozis iSviaTi SemTxvevebisa klasteruli Tavis tkivilis periodSi an mis Semdeg. fokaluri an ara-fokaluri simptomebisa da/an paTologiuri nevrologiuri niSnebis arseboba mniSvnelovnad zrdis sxva daavadebis Sanss27. pacientis Tavdapirveli konsultaciisas aucilebelia Sesabamisi klinikuri gamokvleva, nevrologiuri gasinjva, fundoskopia da arteriuli wnevis gazomva.

rekomendacia (D):

pacientebs, romelTac pirvelad mogmarTes Tavis tkivilis gamo, an Tuki Tavis tkivilma icvala Cveuli xasiaTi, unda CautardeT klinikuri gamokvleva, nevrologiuri gamokvleva, fundoskopia da arteriuli wnevis gazomva;

nevrologiuri gamokvleva pacientebSi axlad ganviTarebuli Tavis tkiviliT unda moicavdes:

fundoskopias; kraniuli nervebis Sefasebas, gansakuTrebiT, gugebis,

mxedvelobis velis, Tvalebis moZraobis sifarTis, saxis kunTebis Zalisa da mgrZnobelobis da bulbaruli funqciebis (rbili sasis, enis moZraobis) gamokvlevas;

oTxive kiduris tonusis, Zalis, refleqsebisa da koordinaciis Sefasebas;

plantarul refleqsebs; siarulis, maT Soris quslebsa da fexis wverebze siarulis

unaris Sefasebas.

ufro detaluri Sefaseba saWiroa im SemTxvevaSi, Tuki amaze miuTiTebs anamnezuri monacemebi. gasinjva specialurad mimarTuli unda iyos fokaluri nevrologiuri simptomebis aRmoCenisaken.

pirveladi “mexis dacemismagvari” Tavis tkivili

“mexis dacemismagvari” Tavis tkivili SesaZlebelia iyos pirveladi an meoreuli. ICHD-II klasifikaciiT igi ganisazRvreba, rogorc Zlieri intensivobis Tavis tkivili, romelic emsgavseba Tavis tvinis anevrizmis gaskdomis Sedegad ganviTarebuli subaraqnoiduli sisxlCaqcevis Tavis tkivils da maqsimalur intensivobas aRwevs

16

wuTze nakleb periodSi. pacientTa umravlesobaSi “mexis dacemismagvari” Tavis tkivili piks aRwevs myisierad. SemTxvevaTa mcirericxovan seriul kvlevaSi subaraqnoiduli sisxlCaqcevis mqone pacientTa 19%-s aReniSneboda Tavis tkivili, romelic maqsimalur intensivobas aRwevda ufro TandaTanobiT (daaxloebiT 5 wuTSi)39(IV). uecari Zlieri Tavis tkivili SesaZlebelia aseve ganviTardes sqesobrivi aqtivobis an fizikuri datvirTvis dros.

uecari Zlieri Tavis tkivilis sxva mizezebia: intracerebruli sisxlCaqceva, cerebruli venuri sinusis Trombozi, arteriis gaxeTqva da hipofizis apopleqsia.

ar arsebobs sando niSnebi, romelTa mixedviTac SesaZlebeli iqneboda pirveladi da meoreuli “mexis dacemismagvari” Tavis tkivilis gansxvaveba, xolo subaraqnoiduli sisxlCaqceva ki SesaZlebelia ganviTardes Tavis tkivilis ufro msubuqi dawyebis SemTxvevaSic ki. “mexis dacemismagvari” Tavis tkivilis mniSvnelovani umciresoba meoreuli warmoSobisaa. SemTxvevaTa seriuli Seswavlis erT-erT kvlevaSi “mexis dacemismagvari” Tavis tkivilis mqone pacientTa daaxloebiT 11%-s aReniSneboda subaraqnoiduli sisxlCaqceva26. rodesac pacienti pirvelad mogvmarTavs uecari Zlieri Tavis tkivilis gamo, igi dauyovnebliv unda gaigzavnos meoreuli mizezis, gansakuTrebiT ki subaraqnoiduli sisxlCaqcevis gamosaricxad.

Tuki Tavis tvinis kompiuteruli tomografiisa da lumbaluri punqciis Sedegebi uaryofiTia “mexis dacemismagvari” tkivilis dawyebidan ori kviris ganmavlobaSi, SesaZlebelia subaraqnoiduli sisxlCaqcevis diagnozis gamoricxva.

rekomendacia (D):

“mexis dacemismagvari” Tavis tkivilis dawyebisTanave pacienti dauyovnebliv unda gaigzavnos specializirebul klinikaSi nevrologis mier Sefasebis mizniT.

medikamentebis Warbi moxmarebiT ganpirobebuli Tavis tkivili

mwvave Tavis tkivilis samkurnalo nebismieri medikamentis, maT Soris martivi da kombinirebuli analgetikebis gadaWarbebulma gamoyenebam SesaZloa gamoiwvios Tavis tkivili.

ICHD-II kriteriumebis mixedviT medikamentebis gadaWarbebuli gamoyenebiT gamowveuli Tavis tkivilis diagnozi gasaTvaliswinebelia im SemTxvevaSi, rodesac TveSi 10 dRis manZilze adgili aqvs triptanebis, ergotaminis preparatebis, opioidebisa da kombinirebuli analgeziuri saSualebebis an martivi analgetikebis TveSi 15 dRis ganmavlobaSi gamoyenebas160(IV).

zogad saeqimo praqtikaSi Catarebuli auditis safuZvelze gamovlinda, rom im pacientTa daaxloebiT 16,2%, romlebic moixmarden triptanebs, akmayofilebden triptanebis gadaWarbebul miRebasTan dakavSirebuli Tavis tkivilis ICHD-II kriteriumebs40(IV).

17

pacientebs qronikuli yoveldRiuri Tavis tkiviliT, romelic viTardeba epizoduri daZabulobis tipis Tavis tkivilis Semdeg da akmayofilebs medikamentebis Warbi moxmarebiT ganpirobebuli Tavis tkivilis kriteriumebs, xasiaTobrivi paTologiis arsebobis ufro maRali albaToba aReniSnebaT vidre maT, visac qronikuli daZabulobis tipis Tavis tkivili aqvs medikamentebis gadaWarbebuli miRebis gareSe. aseve aRmoCnda, rom Sakikis evoluciis Sedegad ganviTarebuli yoveldRiuri qronikuli Tavis tkivilis mqone pacientebs, romlebic akmayofileben medikamentebis Warbi moxmarebiT ganpirobebuli Tavis tkivilis kriteriumebs, xasiaTobrivi paTologiis, depresiis, SfoTvisa da obsesiur-kompulsiuri moSlilobis ufro maRali albaToba aReniSnebaT, vidre pacientebs qronikuli daZabulobis tipis Tavis tkiviliT medikamentebis Warbad gamoyenebis gareSe, maTSi aseve mniSvnelovnad ufro maRalia damokidebulebiTi qcevis sixSire41(III).

rekomendacia:

medikamentebis Warbi moxmarebiT ganpirobebuli Tavis tkivili unda gamoiricxos yvela pacientSi qronikuli yoveldRiuri Tavis tkiviliT (Tavis tkivili ≥ 15 dReze TveSi > 3 Tvis manZilze) [D];

klinicistebma unda icodnen, rom pacientebi, romlebic xmaroben Tavis tkivilis mwvave Setevebis an simptomuri mkurnalobis nebismier saSualebas, imyofebian medikamentebis Warbi moxmarebiT ganpirobebuli Tavis tkivilis ganviTarebis riskis qveS (D):

medikamentebis Warbi moxmarebiT ganpirobebuli Tavis tkivilis diagnozis dasmisas gasaTvaliswinebelia fsiqiatriuli komorbiduli mdgomareobis an damokidebulebiTi qcevis arseboba (C);

medikamentebis Warbi moxmarebiT ganpirobebuli Tavis tkivilis mqone pacientebSi, romelTac aReniSnebaT fsiqiatriuli komorbiduli paTologia an damokidebulebiTi qceva, am mdgomareobebis mkurnaloba saWiroa damoukideblad. unda gaviTvaliswinoT fsiqiatrTan an fsiqologTan gagzavnis saWiroeba (C).

cervikogenuli Tavis tkivili

xerxemlis kisris nawilis paTologiebis wvlili Sakikisa da daZabulobis tipis Tavis tkivilis ganviTarebaSi mkafiod gaazrebuli ar aris. qronikuli Tavis tkivilis 14-18% cervikogenuli warmoSobisaa, anu gamowveulia xerxemlis kisris nawilis ConCx-kunTovani disfunqciiT42.

cervikogenuli tkivili warmodgenilia unilateraluri an bilateraluri tkiviliT, romelic lokalizebulia kisrisa da kefis areSi da SesaZlebelia iradirebdes Tavis da/an saxis mimarTulebiT. tkivilis provocireba SeiZleba moxdes kisris garkveuli moZraobis an

18

xangrZlivi fiqsirebuli poziciis fonze da Tan axldes kisris iZulebiTi poza, moZraobis SezRudva, kunTebis kontraqtura an maTi mtkivneuloba43(IV). diagnostikaSi SesaZlebelia dagvexmaros manualuri gasinjva, romlis saSualebiTac xdeba saxsrebis mobilurobis, kunTTa tonusisa da moZraobis sifarTis dadgena. Tavis tkivili aseve SeiZleba cervikogenuli warmoSobis iyos im SemTxvevaSi, Tuki klinikuri, laboratoriuli da/an gamosaxviTi kvlevis safuZvelze arsebobs xerxemlis kisris nawilis paTologiis an dazianebis mtkicebuleba (ICHD-II).

rekomendacia (D):

Tavis tkivilis mqone yvela pacients unda Cautardes kisris gasinjva, romelic moicavs Semdegi elementebis Sefasebas: kisris poza; moZraobis sifarTe; kunTovani tonusi; kunTTa mtkivneuloba.

intrakraniuli hipertenzia

intrakraniul hipertenziasTan dakavSirebuli Tavis tkivili Cveulebriv, uaresdeba maSin, roca pacienti wevs da tkivilma SesaZloa gaaRviZos kidec. tkivilis provocireba aseve SeiZleba moxdes valsalvas manevris (magaliTad, xvelis, sicilis, gazmorebis), sqesobrivi aqtivobis an fizikuri daZabulobis Sedegad. mxedvelobis dabindva da mxedvelobis gardamavali cvlilebebi poziciis Secvlis an valsalvas sinjis dros Tav-zurgtvinis siTxis momatebul wnevaze gvafiqrebinebs. am simptomebidan nebismieris gamoCena unda warmoadgendes mizezs specialistTan saswrafo Sefasebis mizniT gagzavnisTvis.

intrakraniuli simsivneebis fonze Tavis tkivili iSviaTad viTardeba manam, sanam igi ar miaRwevs garkveul zomas, gansakuTrebiT, nevrologiurad “munj” areebSi (rogoricaa, magaliTad Sublis wili) lokalizaciis SemTxvevaSi. am wesidan gamonakliss warmoadgens hipofizisa da qalas ukana fosos simsivneebi. simsivneSi sisxlCaqcevam SesaZloa uecari Zlieri Tavis tkivili gamoiwvios, Tumca, aseT pacientebSi ufro xSirad vlindeba krunCxvebi an nevrologiuri simptomebi (magaliTad, cnobierebis darRveva) da niSnebi (magaliTad, homonimuri hemianofisia, hemiparezi). eWvis safuZveli izrdeba im SemTxvevaSi, roca pacients anamnezSi aReniSneba kibo.

neirogamosaxviTi kvleviT dadasturebuli intrakraniuli simsivnis diagnozis mqone 324 pacientze Catarebuli auditis Sedegebma aCvena, rom Tavis tkivili warmoadgenda pirvel simptoms SemTxvevaTa 23%-Si, magram prezentaciis momentSi erTaderTi simptomi iyo pacientTa mxolod 0,2%-Si. yvela danarCen pacients aReniSneboda fokaluri nevrologiuri simptomebi da niSnebi. yvelaze gavrcelebuli fokaluri simptomi iyo krunCxvebi (21%)44. pirveladi jandacvis dawesebulebebSi, Tavis tvinis pirveladi simsivnis mqone pacientebze ganxorcielebul farTomasStabian SemTxveva-kontrolis kvlevaSi,

19

izolirebuli Tavis tkivilis, rogorc erTaderTi simptomis dadebiTi savaraudo Rirebuleba (PPV) Seadgenda 0,09%-s (95% CI 0,08-0,10). axlad ganviTarebuli krunCxvis PPV ki iyo 1,2% (95% CI 1,0-1,4)45(III).

idiopaTiuri intrakraniuli hipertenziis dros (sixSire 1-3/100000 mosaxleze da 21/100 000 qalze 15-45 wlis asakSi) aRiniSneba simptomebi da niSnebi, romlebic momatebuli intrakraniuli wnevis analogiuria, tipur SemTxvevebSi neirogamosaxviTi kvlevis (kompiuteruli tomografiisa da venuri sinusis Trombozis gamoricxvis mizniT magnitur rezonansuli venografiis) Sedegebi normaluria, xolo Tav-zurgtvinis siTxis wneva ki momatebuli. dasawyisSi Tavis tkivili epizoduria, Tumca Semdeg ganicdis progresirebas yovelkvireulidan yoveldRiuramdec ki da xasiaTdeba simptomebiTa da niSnebiT, romlebic tipiuria momatebuli intrakraniuli wnevisTvis. sxva simptomebsa da niSnebs (romlebic am dros xSirad aRiniSneba), miekuTvneba mxedvelobis gardamavali dabindva, mfeTqavi xmauri yurebSi, meeqvse wyvili nervis parezi, brma xalis gadideba da mxedvelobis nervis dvrilis SeSupeba. es paTologia ufro xSiria reproduqciuli asakis msuqan qalebSi. SemTxvevaTa umravlesobaSi etiologia ucnobia, Tumca, meoreul mizezebs, romelTa gamoricxvac aucilebelia, miekuTvneba Tavis tvinis venuri sinusis Trombozi, sxvadasxva medikamentebi (magaliTad, tetraciklini da retinoidebi), Tav-zurgtvinis siTxis anTebiTi paTologia, infeqcia an avTvisebiani simsivne.

Tuki pacients aReniSneba Tavis tkivili da CamoTvlili simptomebidan erT-erTi an maTi kobinacia: (cxeleba, kisris daWimuloba, fokaluri niSnebi an krunCxvebi), unda gamoiricxos centraluri nervuli sistemis infeqcia. infeqcia SesaZloa iyos difuzuri (magaliTad, meningiti an encefaliti) an lokalizebuli (magaliTad, Tavis tvinis abscesi). eWvis safuZveli izrdeba im SemTxvevaSi, rodesac pacienti aiv-inficirebulia an adgili aqvs imunosupresias.

rekomendacia (D):

pacienti Tavis tkiviliTa da momatebuli intrakraniuli wnevisTvis damaxasiaTebeli niSnebiT saswrafod unda gaigzavnos Sefasebis mizniT nevrologTan;

pacienti Tavis tkiviliTa da cns-is infeqciaze saeWvo niSnebiT dauyovnebliv unda gaigzavnos specialistTan (nevrologTan, infeqcionistTan) Sefasebis mizniT.

Tav-zurgtvinis siTxis wnevis Semcirebis fonze damaxasiaTebelia Tavis tkivili mkafio posturaluri komponentiT. Tavis tkivili viTardeba an uaresdeba vertikaluri mdgomareobaSi.

mas Semdeg, rac tkivili ganicdis qronizacias, igi kargavs Tavis posturalur komponents. hipotenziuri Tavis tkivili gamowveulia cerebro-spinaluri siTxis JonviT, romlis uxSiresi mizezic aris diagnostikuri lumbaluri punqcia, Tumca, SesaZlebelia ganviTardes spontanuri duraluri Jonvac, romelic xSirad aradiagnostirebuli rCeba.

20

rekomendacia (D):

intrakraniuli hipotenziis diagnozis gamoricxva aucilebelia yvela pacientSi, romelTac aReniSnebaT Tavis tkivili vertikalur poziciaSi gadasvlisas.

giganturujreduli (temporaluri) arteriiti

giganturujreduli arteriitis diagnozi gasaTvaliswinebelia 50 wels zeviT asakis yvela pacientSi, romelsac aReniSneba Tavis tkivili. tkivili ufro xSirad difuzuri xasiaTisaa, vidre lokaluri. zogadad igi persistiulia da SesaZlebelia iyos sakmaod Zlieri. pacienti SeiZleba sistematurad iyos avad. skalpis mtkivneuloba sakmaod xSiri simptomia, Tumca misi prognozuli Rirebuleba dabalia safeTqlis arteriis biofsiis dadebiT SedegTan SedarebiT. safeTqel-qvedaybis saxsris disfunqcia yvelaze sando prognozuli niSania, magram igi SesaZloa yovelTvis ar iyos gamoxatuli. nebismier pacientSi, romelsac aReniSneba Tavis tkivili da safeTqel-qvedaybis saxsris disfunqcia, aucilebelia giganturujreduli arteriitis diagnozis gaTvaliswineba manam, sanam ar dadasturdeba sxva mizezi. vizualuri dazianeba rigiT meore yvelaze sando prognozul niSans warmoadgens. TvalsaCinod gamoxatuli, gafarToebuli an daklaknili temporaluri arteriebi yvelaze ukeTes prognozul fizikur niSans miekuTvneba. eriTrocitebis daleqvis dabali siCqare dignozis albaTobas amcirebs, magram ar gamoricxavs mas.

rekomendacia (D):

giganturujreduli arteriitis diagnozi unda gaviTvaliswinoT 50 wels zemoT asakis yvela pacientSi axlad dawyebuli Tavis tkivilis an misi xasiaTis cvlilebis SemTxvevaSi.

giganturujredul arteriitze eWvis SemTxvevaSi pacienti saswrafod unda gaigzavnos nevrologTan Sefasebis mizniT.

daxurul-kuTxovani glaukoma

daxurulkuTxovani glaukoma iSviaTia Suaxnis asakamde. mis cnobil risk-faqtorebs miekuTvneba ojaxuri anamnezi, mdedrobiTi sqesi da hipermetropia. klinikuri gamovlineba sxvadasxvagvaria. pacients SesaZloa aReniSnebodes gugis mciredi gafarToeba da Tvalis hiperemia mxedvelobis darRvevasTan erTad, rac TvalSida wnevis mwvave momatebaze miuTiTebs. alternatiulad daxurulkuTxovani glaukoma SesaZloa gamovlindes araspecifiuri Tavis tkivilis, Tvalis tkivilis, sinaTlis irgvlivi rgolebis an auriT mimdinare Sakikis msgavsi tkivilis saxiT46(IV). mwvave daxurulkuTxovan glaukomas SesaZloa win uswrebdes gardamavali daxurulkuTxovani glaukoma, xolo Tvalis siwiTle SesaZlebelia gamoxatuli ar iyos. diagnozi gasaTvaliswinebelia pacientebSi Tavis tkiviliTa da wiTeli TvaliT, sinaTlis irgvlivi rgolebiTa an unilateraluri vizualuri simptomebiT.

21

rekomendacia (D):

gaiTvaliswineT daxurulkuTxovani galukomis diagnozi pacientebSi Tavis tkiviliTa da wiTeli TvaliT, sinaTlis irgvlivi rgolebiTa da unilateraluri vizualuri simptomebiT.

mwvave daxurulkuTxovani glaukoma ofTalmologiur gadaudebel mdgomareobas warmoadgens, ros gamoc nebismieri pacienti am mdgomareobaze eWviT unda gaigzavnos ofTalmologTan.

naxSirbadis monoqsidiT mowamvla

naxSirbadis monoqsidiT qvemwvave mowamvlis simptomebs miekuTvneba Tavis tkivili, gulisreva, Rebineba, Tavbrusxveva, kunTebis sisuste da mxedvelobis dabindva.

5. Tavis tkivilis diagnozi

Tavis tkivilis diagnozi anamnezs, obieqturi gasinjvisa da laboratoriul-instrumentuli gamokvlevebis Sedegebs emyareba. Tavis tkivilis diagnozis dasmaSi daxmarebis mizniT SemuSavebulia mravalricxovani instrumentebi. cxrili #3-Si Sejamebulia instrumentTa garkveuli raodenoba, romlebic xelmisawvdomia internetis saSualebiT. klinikur praqtikaSi eqimi Cveulebriv, pacients usvams SekiTxvebs Tavis tkivilis simptomebis Sesaxeb. Tuki simptomi mniSvnelovania, misi zemoqmedebis Sesaxeb kiTxvebis meSveobiT SesaZlebelia Seicvalos eqimis warmodgena Tavis tkivilis an Sakikis simZimis Sesaxeb47. es informacia moqmedebs mkurnalobis meTodis arCevansa da meTvalyureobis saWiroebaze.

Tavis tkivilis diagnozi xSirad arasworad ismeba, rac SeiZleba gamowveuli iyos konsultaciis drois SezRudulobiT an pacientze xangrZlivi dakvirvebisa da ganmeorebiTi vizitebis organizebis SeuZleblobiT. diagnostikis gaumjobeseba SesaZlebelia ramdenime kviris ganmavlobaSi pacientis mier warmoebuli dRiuris ganxilviT. Tavis tkivilTan dakavSirebuli anamnezuri kiTxvebis magaliTi mocemulia danarT 3-Si, xolo yovelkvireuli dRiuris magaliTi ki - danarT 4-Si.

rekomendacia (D):

Tavis tkivilis diagnostikisa da marTvis gaumjobesebis mizniT praqtikosma eqimma unda gaiTvaliswinos Tavis tkivilis dRiurisa da Sefasebis adekvaturi kiTxvarebis gamoyeneba.

saqarTveloSi SemuSavebulia Tavis tkivilis dRiuri, romlis safuZvelzec Catarda saerTaSoriso epidemiologiuri kvlevebi, xolo monacemebi gamoqveynda JurnalebSi Headache, Cephalalgia, Neurology. amitom am dRiuris gamoyeneba savsebiT gamarTlebulia.

22

cxrili #3. Tavis tkivilis diagnostikisa da pacientze misi zegavlenis

Sesafasebeli instrumentebi†. instrumenti gamoyeneba/sar

gebeli

formati safuZveli limiti

Tavis tkivilis zegavlenis testi (Headache Impact Test - HIT/HIT 6)

www.headachetest.com/

Tavis tkivilis zegavlenis Sefaseba;

diagnozis gansazRvra;

mkurnalobaze pasuxis monitoringi48.

pacientebs maRali HIT6-quliT aReniSnebaT maTi ojaxis eqimis mier swori diagnozis dasmisa da mkurnalobis ufro maRali albaToba.

qronikuli Tavis tkivilis dros qula tipiur SemTxvevbSi Seadgens 57-63-s, SakikisTvis 54-59-s, xolo daZabulobis tipis Tavis tkivilisTvis 34-35-s49.

internet- kiTxvari

5/6 kiTxva

testirebis kompiuterizebuli sistema.

retrospeqtuli instrumenti, romelic emyareba pacientis gamocdilebas Tavis tkivilTan dakavSirebiT gasuli 4 kviris manZilze. misi saSualebiT fasdeba:

tkivili;

socialuri rolis SezRudva;

kognitiuri funqcia;

fsiqologiuri stresi;

sicocxlisunarianoba.

SezRuduli mgrZnobeloba tkivilis simZimis gansazRvris TvalsazrisiT.

SakikTan dkavSirebuli fizikuri uunarobis Sefaseba (Migraine

Disability Assessment - MIDAS)

www.mediamigraine.net/edu/question/De fault.asp

Tavis tkivilis zegavlenis Sefaseba;

mkurnalobaze pasuxis monitoringi.

qulebi Seesabameba eqimis mier pacientis samedicino anamnezis mixedviT dadgenili tkivilisa da fizikuri uunarobis dones50.

testi xasaiTdeba maRali

5-punqtiani kiTxvari

retrospeqtiuli instrumenti, romelic emyareba 3 saxis aqtivobaSi dakarguli drois Sefasebas gasuli 3 Tvis ganmavlobaSi:

samuSao an skola;

ojaxuri saqmianoba;

socialuri aqtivoba.

xSiri Tavis tkivilis mqone yvela pacientSi iZleva maRal qulebs; qulaTa specifiuri sistemis gamo Tavis tkivilis erTi tipis daTvla SesaZlebelia moxdes ramdenjerme

ar aris gaTvaliswin

† am kiTxvarebis gamoyenebisTvis saqarTveloSi saWiroa damatebiTi kvleva Cvens

sinamdvileSi maTi validurobis Sefasebis mizniT.

http://www.mediamigraine.net/edu/question/De

http://www.mediamigraine.net/edu/question/De

23

instrumenti gamoyeneba/sar

gebeli

formati safuZveli limiti

mdgradobiT, testireba-retestirebis sandoobiTa da gamoyenebis siioliT.

ebuli emociuri zegavlena.

Sakikis saidentifikacio kiTxvari (ID Migraine)

www.migraineclinic.org.uk/

diagnozis dadgena.

SakikisaTvis mgrZnobeloba Seadgens 0,81-s (95% CI 0,64-dan 0,84-mde), xolo dadebiTi savaraudo Rirebuleba 0,93-s (95% CI 0,90-dan 0,96-mde)

3-punqtiani skrininguli kiTxvari.

retrospeqtiuli instrumenti, romelic emyareba:

gastro-intestinaluri simptomebis arsebobas;

mgrZnobelobas sinaTlis mimarT;

funqciur uunarobas.

cru dadebiTi Sedegebis sixSire Seadgens 19%-s.

Tavis tkivilis diferenciuli diagnostikis dros gasaTvaliswinebelia Semdegi mizezebi:

1. Tavis tkivili Tavis tvinis organuli dazianebis an liqvorodinamiuri darRvevebis dros:

Tavis tvinis travmasTan dakavSirebuli Tavis tkivili;

Tavis tvinis moculobiT warmonaqmnTan dakavSirebuli tkivili;

Tavis tkivili anTebiTi daavadebebis dros (meningiti, meningoencefaliti da a. S.).

2. sisxlZarRvovani Tavis tkivili:

arteriuli hipertenzia.

3. fsiqogenuri Tavis tkivili:

SfoTvis, depresiis, qronikuli stresis fonze;

4. Tavis tkivili, romelic gamowveulia eqstrakraniuli mizezebiT:

Tavis tkivili eqstrakraniuli infeqciebis dros;

medikamentebis/qimiuri nivTierebebis zemoqmedeba (kombinirebuli oraluri kontraceptivebi, nitratebi, kofeini, alkoholi, benzoli, naxSirbadis oqsidi, inseqticidebi, tyvia);

metabolur darRvevebTan dakavSirebuli Tavis tkivili (hipoqsiis, hiperkapniis, dializis dros);

Tavis qalas, kisris, Tvalebis, Yyurebis, cxvirisa da misi danamati wiaRebis, piris Rrus, saxisa da qalas sxva struqturebis paTologiis gamo ganviTarebuli Tavis tkivili;

24

Tavis tkivilis xerxemlis kisris nawilis osteoqondrozisa da sxva paTologiebis dros.

6. gamokvlevebis sqema

neirogamosaxviTi gamokvleva

Tavis tkivilis dros zogadad gamokvlevebs Tavi unda avaridoT, Tuki mis safuZvelze ar aris mosalodneli marTvis gegmis cvlileba an Tu gamokvlevis saSualebiT Sesabamisi paTologiis aRmoCenis albaToba dabalia. Zalian iSviaTad, calkeul SemTxvevebSi SesaZlebelia saWiro iyos neirogamosaxviTi kveleva, Tuki pacients aReniSneba uunaroba seriozuli paTologiis SiSis gamo33.

Tavis tkivilis SemTxvevaTa umravlesobaSi neirogamosaxviTi kvleva saWiro ar aris. prospeqtul kvlevaSi, sadac 4 kviraze meti xangrZlivobis Tavis tkivilis mqone pacientebs CautardaT neirogamosaxviTi kvleva (Tavis tvinis kt, mrt an orive erTad), mniSvnelovani paTologia gamovlinda Sakikis mqone pacientTa 0,4%-Si, daZabulobis tipis Tavis tkivilis SemTxvevaTa 0,8%-sa da klasteruli Tavis tkivilis mqone pacientebis 5%-Si (yovel me-20 pacientSi). Tavis tkivilis mkafiod dadgenili tipis armqone 188 pacientis qvejgufSi mniSvnelovani intrakraniuli paTologia aRmoaCnda 3,7%-s51(III).

Sakikisa da normaluri nevrologiuri gasinjvis Sedegebis mqone pacientebze Catarebuli neirogamosaxviTi kvlevebis meta-analizis safuZvelze mniSvnelovani intrakraniuli paTologia daudginda aseT pacientTa 0,2%-s33. qronikuli Tavis tkivilisa da obieqturi nevrologiuri gasinjvis normaluri Sedegebis mqone 402 pacientze Catarebuli kvlevis retrospeqtulma mimoxilvam mrt-gamokvlevisas paTologia gamoavlina Sakikis SemTxvevaTa 0,6%-Si, daZabulobis tipis Tavis tkivilis 1,4%-sa da ”atipuri Tavis tkivilis” 14,1%-Si52(III). sxva retrospeqtul kvlevaSi mrt-Ti intrakraniuli paTologia gamovlinda qronikuli an ganmeorebiTi Tavis tkivilisa da nevrologiuri gasinjvis normaluri monacemebis mqone pacientTa 0,7%-Si53(III).

Tavis tkivilisa da nevrologiuri gasinjvis paTologiuri Sedegebis mqone pacientebis SemTxvevaSi neirogamosaxviTi kvlevis saSualebiT gamomwvevi mizezis gamovlenis albaToba mniSvnelovnad maRalia33. damatebiTi gamokvlevebi Tavis tkivilis meoreuli mizezebis gamosaricxad saWiroa im SemTxvevaSi, rodesac tkivils Tan axlavs ”wiTeli droSis” simptomebi.

SemTxveviTi anomaliebi

rogorc mrt, ise kt kvlevebiT SesaZlebelia gamovlindes SemTxveviTi nevrologiuri anomaliebi, romlebic ar Seesabameba pacientis Civilebs, magram iwvevs mis gadametebul SfoTvasa da klinikur gaurkvevlobas54(III). 2356 janmrTel axalgazrdaze Catarebulma kranialurma mrt-m SemTxveviTi anomaliebi gamoavlina 6,55%-Si55(III). 2000 moxaliseze Catarebul prospeqtul kohortul kvlevaSi (saSualo

25

asaki 63,3 weli; asakobrivi farglebi 45-96 weli) Tavis tvinis mrt-kvlevam SemTxveviTi anomaliebi gamoavlina 13,5%-Si.

pacientis darwmuneba

specializebul klinikaSi qronikuli yoveldRiuri Tavis tkivilis mqone 150 pacientze Catarebuli randomizebuli kontrolirebadi kvleviT dadginda, rom im pacientebs, romelTac CautardaT Tavis tvinis mrt-gamokvleva, aReniSnebodaT SfoTvis Semcireba 3 Tvis ganmavlobaSi, magram misi SenarCuneba ver xerxdeboda 1 wlis manZilze. SfoTvisa da depresiis maRali donis mqone pacientebi, romelTac ar CatarebiaT gamosaxviTi kvleva, zogadad mniSvnelovnad ufro met finansebs xarjavdnen janmrTelobis dacvasTan dakavSirebul momsaxurebaSi (rogoricaa, magaliTad, fsiqiuri an fsiqologiuri servisebi), vidre pacientebi, romelTac CautardaT gamosaxviTi kvleva56(I).

Tavis tvinis kt-sa da mrt-s SedarebiTi daxasiaTeba

Tavis tkivilis meoreuli mizezebis gamoricxvis mizniT Tavis tvinis mrt-kvleva kt-sTan SedarebiT ufro maRali mgrZnobelobiT xasiaTdeba TeTri nivTierebis dazianebebisa da venebis Tandayolili anomaliebis dadgenis TvalsazrisiT33. nevrologiur sazogadoebaTa evropis federaciis gaidlainebis mixedviT Tavis tvinis mrt-kvleva arCevis neirogamosaxviT gamokvlevas warmoadgens misi ufro maRali mgrZnobelobis gamo57(III). aSS-s Tavis tkivilis konsorciumis daskvniT mrt-kvleva SesaZlebelia kt-ze ufro mgrZnobiare meTodi iyos zogadad klinikurad mniSvnelovani paTologiebis dadgenis TvalsazrisiT, magram es ar exeba Tavis tkivilis gamomwvevi mizezisaTvis Sesabamisi klinikurad mniSvnelovani paTologiis gamovlinebas.

rekomendacia (D):

neirogamosaxviTi gamokvlevis Catareba ar aris rekomendebuli Sakikis TvalsaCino anamnezis mqone pacientebSi meoreuli Tavis tkivilis ”wiTeli droSis” niSnebis gareSe da nevrologiuri gasinjvis normaluri SedegebiT.

neirogamosaxviT kvlevaze gadawyvetilebis miRebisas klinicistma unda gaiTvaliswinos is faqti, rom rogorc Tavis tvinis kt-m, ise mrt-m SesaZloa gamoavlinos SemTxveviTi nevrologiuri anomaliebi, romelTac SesaZlebelia mohyves rogorc pacientis SfoTva, ise marTvasTan dakavSirebuli praqtikuli da eTikuri problemebi.

Tavis tvinis kt unda Cautardes Tavis tkivilis mqone pacientebs auxsneli paTologiuri nevrologiuri simptomebiT, Tuki klinikuri anamnezis safuZvelze ar aris naCvenebi mrt-kvleva.

26

Tavis tvinis kompiuteruli tomografia da mexis dacemismagvari

Tavis tkivili

ICHD-II klasifikaciis mixedviT pirveladi ”mexis dacemismagvari” Tavis tkivilis diagnozis dasmamde aucilebelia Tavis tvinis gamosaxviTi kvlevisa da Tav-zurgtvinis siTxis analizis normaluri Sedegebis arseboba.

subaraqnoidul sisxlCaqcevaze eWvis SemTxvevaSi Tavis tvinis kompiuteruli tomografia unda Catardes rac SeiZleba swrafad maqsimaluri mgrZnobelobis miRebis mizniT. kt-s mgrZnobeloba subaraqnoiduli sisxlCaqcevis pirvel 12 saaTSi 98%-ia, xolo 24 saaTSi ki – 93%.

Tavis tvinis kt-s normaluri Sedegi arasakmarisia subaraqnoiduli sisxlCaqcevis gamosaricxad da amisaTvis aucilebelia lumbaluri punqciis ganxorcileba im pacientebSi, visac normaluri tomografiuli monacemebi aReniSnebaT.

Tuki ”mexis dacemismagvari” Tavis tkivilis dawyebidan 2 kviris ganmavlobaSi rogorc kt-s, ise lumbaluri punqciis Sedegebi normaluria, SesaZlebelia tkivilis mizezebidan subaraqnoiduli sisxlCaqcevis gamoricxva.

uecari Zlieri Tavis tkivili, romlis provocirebasac iwvevs sqesobrivi aqtivoba, SesaZlebelia ganisazRvros, rogorc pirveladi, Tuki ver xerxdeba misi dakavSireba sxva paTologiasTan. amgvari Tavis tkivilis pirveli SemTxvevis ganviTarebisas Zalzed mniSvnelovania subaraqnoiduli sisxlCaqcevisa da arteriis kedlis gaxeTqvis gamoricxva58(IV).

rekomendacia (D):

”mexis dacemismagvari” Tavis tkivilis SemTxvevaSi Tavis tvinis kompiuteruli tomografia unda Catardes rac SeiZleba swrafad da sasurvelia, tkivilis dawyebidan 12 saaTis ganmavlobaSi.

magnitur-rezonansuli gamosaxviTi kvleva

eqspertTa mosazrebis Tanaxmad mrt-kvleva unda gaviTvaliswinoT klasteruli Tavis tkivilis, paroqsizmuli hemikraniis an SUNCT_is mqone pacientebSi meoreuli mizezebis farTo speqtris gamoricxvis mizniT.

31 SemTxvevis mimoxilvaSi, sadac trigeminuli vegetatiuri cefalalgiebi (tvc) an tvc-s msgavsi sindromi asocirebuli iyo struqturul dazianebasTan, xolo am dazianebis mkurnalobam gamoiwvia mniSvnelovani klinikuri gaumjobeseba, 31-dan 11 pacients aReniSneboda hipofizis adenoma. 31-dan mxolod 10-s hqonda prezentaciis atipuri simptomebi59(III). SUNCT_is mqone 43 da SUNA-s mqone 9 pacientze Catarebul prospeqtul kvlevaSi kraniuli gamosaxviTi gamokvleva Cautarda SUNCT-is mqone 36 da SUNA-s mqone 8 pacients. maTgan 12-s (11-s SUNCT_iT da 1-s SUNA-Ti) Tavis tvinis

27

gamosaxviTi kvlevis fonze gamouvlinda mniSvnelovani intrakraniuli paTologia24.

rekomendacia (D):

Tavis tvinis mrt-kvleva gasaTvaliswinebelia klasteruli Tavis tkivilis, paroqsizmuli hemikraniisa an SUNCT-is mqone pacientebSi.

retrospeqtul kvlevaSi, romelic Catarda pacientebSi xveliT gamowveuli (n=30), fizikur datvirTvasa (n=28) da sqesobriv aqtivobasTan dakavSirebuli Tavis tkiviliT (n=14), xvelasTan dakavSirebuli Tavis tkivilis mqone 30 pacientidan 17-s gamouvlinda kiaris tipis 1 malformacia; fizikuri datvirTviT gamowveuli Tavis tkivilis mqone 28 pacientidan 10-s hqonda subaraqnoiduli sisxlCaqceva, 1-s – sinusiti, xolo 1-s – metastazi Tavis tvinSi. xolo progresirebadi orgazmuli Tavis tkivilis mqone 13 pacientidan 1-s gamouvlinda subaraqnoiduli sisxlCaqceva60(III).

pirveladi xvelismieri Tavis tkivilis (valsalvas manevriT ganpirobebuli Tavis tkivilis) diagnozi, romlis provocirebac xdeba xveliT, siciliT an gazmorebiT, ismeba mxolod mas Semdeg, rac neirogamosaxviTi kvleviT gamoiricxeba struqturuli paTologia. xvelismieri Tavis tkivilis mqone pacientebs unda CautardeT Tavis tvinis mrt-kvleva qalas ukana fosos paTologiis gamoricxvis mizniT.

rekomendacia (D):

Tavis tvinis mrt-kvleva unda Cautardes pacientebs, romelTac aReniSnebaT Tavis tkivilis provocireba xvelis Sedegad.

fizikuri daZabulobis keTilTvisebiani Tavis tkivilis, rogorc pirveladi Tavis tkivilis diagnozi, romlis provocirebac xdeba fizikuri daZabviT, SeiZleba daisvas im SemTxvevaSi, Tuki igi ar aris asocirebuli sxva paTologiasTan. ICHD-II klasifikaciis Tanaxmad amgvari Tavis tkivilis dawyebis momentSi unda gamoiricxos subaraqnoiduli sisxlCaqceva an arteriis kedlis gaxeTqva. SemTxvevaTa seriebis Semswavlel or prospeqtul kvlevaSi keTilTvisebiani ”mexis dacemismagvari” Tavis tkivilisa da dadasturebuli subaraqnoiduli sisxlCaqcevis mqone pacientTa erTsa da imave procents aReniSneboda Tavis tkivilis provocireba fizikuri daZabviT, amdenad mxolod fizikur daZabulobaze dayrdnobiT SeuZlebelia subaraqnoiduli sisxlCaqcevis prognozireba41. eqspertTa mosazrebis Tanaxmad, fizikur daZabvasTan dakavSirebuli Tavis tkivilis mqone pacientebs unda CautardeT neirogamosaxviTi kvleva struqturuli an vaskuluri paTologiis gamoricxvis mizniT. Tuki Tavis tkivili grZeldeba ramdenime saaTis ganmavlobaSi, Tan sdevs nevrologiuri simptomatika an Rebineba, an pirvelad viTardeba 40 wels zemoT asakSi, Sesabamisi paTologiis dadgenis Sansi izrdeba56.

28

rekomendacia (D):

pacientebSi Tavis tkiviliT, romelic ufro metad provocirdeba, vidre mZimdeba fizikuri datvirTvis fonze, unda gaviTvaliswinoT damatebiTi gamokvlevebis Catarebis aucilebloba.

SemTxvevaTa sakontrolo mciremasStabian kvlevaSi, romelic Catarda zurgis tvinis mrt-s Sedegebis Sesaswavlad pacientebze lumbaluri punqciis Semdgomi Tavis tkiviliTa da sponatnuri intrakraniuli hipotenziiT, gakeTda daskvna, rom aseT pacientebSi venuri wnulis moculoba C2-doneze mniSvnelovnad aRemateboda analogiur maCvenebels sakontrolo jgufSi. spontanuri intrakraniuli hipotenziis mqone pacientTa 67%-sa da postpunqciuri Tavis tkivilis mqone pacientTa 73%-Si aRiniSneboda spinaluri higromebis arseboba, xolo sakontrolo jgufSi ki am movlenas adgili ar hqonia61(III).

SemTxvevaTa Semswavlel ramdenime kvlevaSi gamovlinda asociacia intrakraniul hipotenziasa da Tavis tvinis mrt-ze gadoliniumis difuzuri paqimeningealuri CarTvis momatebas Soris62(IV).

rekomendacia (D):

yvela pacienti intrakraniul hipotenziaze eWviT unda gaigzavnos specialistTan (nevrologTan) adekvaturi gamokvlevebis Catarebis mizniT.

lumbaluri punqcia subaraqnoiduli sisxlCaqcevis dros

lumbaluri punqcia Tav-zurgtvinis siTxis gamokvlevis mizniT saWiroa pacientebSi ”mexis dacemismagvari” Tavis tkiviliTa da neirogamosaxviTi kvlevis normaluri SedegebiT subaraqnoiduli sisxlCaqcevis diagnozis gamoricxvis mizniT63(III). erT-erT prospeqtul kvlevaSi gamovlinda, rom lumbaluri punqciis Sedegebi subaraqnoidul sisxlCaqcevaze miuTiTebden ”mexis dacemismagvari” Tavis tkivilis mqone im pacientTa 21%-Si (23 pacientidan 5-Si), romelTac aReniSnebodaT Tavis tvinis kt-kvlevis normaluri Sedegebi26.

SemTxvevaTa seriul kvlevaSi lumbaluri punqcia Cautarda 81-dan 40 pacients ”mexis dacemismagvari” Tavis tkiviliTa da Tavis tvinis kt-kvlevis normaluri SedegebiT. maTgan 15%-s Tav-zurgtvinis siTxis analizis Sedegi subaraqonidul sisxlCaqcevaze dadebiTi aRmoaCnda61.

imis gamo, rom Tav-zurgtvinis siTxeSi qsantoqromiis (bilirubinisa da oqsihemoglobinis) aRmoCena SesaZlebelia mxolod sisxlCaqcevidan 12 saaTis Semdeg, lumbaluri punqciisa da Tav-zurgtvinis siTxis analizi unda Catardes ”mexis dacemismagvari” Tavis tkivilis dawyebidan 12 saaTis gasvlis Semdeg64. im pacientebSi, romelTac samedicino dawesebulebas mimarTes mogvianebiT, lumbaluri punqcia SeiZleba informatiuli iyos ”mexis dacemismagvari” Tavis tkivilis dawyebidan 2 kviramde periodSi.

29

rekomendacia:

pacientebi ”mexis dacemismagvari” Tavis tkiviliTa da Tavis tvinis kt-kvlevis normaluri SedegiT unda gaigzavnon lumbaluri punqciis Casatareblad (C);

pacientebSi ”mexis dacemismagvari” Tavis tkiviliT, romelTac esaWiroebaT lumbaluri punqcia, Tav-zurgtvinis siTxis gamokvlevisas unda ganisazRvros oqsihemoglobinisa da bilirubinis Semcveloba (D);

pacientebSi saeWvo subaraqnoiduli sisxlCaqceviT neirogamosaxviTi kvleva unda Catardes lumbalur punqciamde (D);

subaraqnoidul sisxlCaqcevaze eWvis SemTxvevaSi pacientebs Tavis tvinis kt-s normaluri SedegiT, lumbaluri punqcia unda CautardeT simptomebis dawyebidan 12 saaTis gasvlis Semdeg SeZlebisdagvarad swrafad (D);

pacientis dagvianebuli momarTvis SemTxvevaSi lumbaluri punqciis Catareba SesaZlebelia ganxorcieldes simptomebis dasawyisidan 2 kviris ganmavlobaSi (D).

eriTrocitebis daleqvis siCqare, C-reaqtiuli cila da

plazmis siblante giganturujreduli arteriitis dros.

Sesabamisi simptomebis mqone pacientebSi eriTrocitebis daleqvis siCqare (eds) SesaZlebelia sasargeblo iyos giganturujreduli arteriitis arseboba-ararsebobis dadgenis mizniT. giganturujreduli arteriitis SemTxvevaSi eds-is saSualo mniSvneloba iyo 88 mm/sT, xolo pacientebSi giganturujreduli arteriitis gareSe – 10 mm/sT. gansxvaveba statistikurad mniSvnelovani ar yofila. pacientTa 4%-s temporaluri arteriebis biofsiis dadebiTi SedegiT hqonda normaluri eds65(III).

SemTxvevaTa seriebis retrospeqtul kvlevaSi Seiswavleboda 363 pacienti giganturujredul arteriitze eWviT, romelTac CautardaT safeTqlis arteriebis biofsia. am kvlevaSi dadginda, rom rogorc eds, ise C-reaqtiuli cila maRali mgrZnobelobiT xasiaTdeba giganturujreduli arteriitis gamovlenis TavalsazrisiT. C-

reaqtiuli cilis mgrZnobeloba ufro maRalia, vidre eds-is (Sesabamisad 100% da 92%). giganturujreduli arteriitis dros eds-isa da C-reaqtiuli cilis erTdrouli gansazRvra ufro maRal specifiurobas iZleva (97%), vidre calke aRebuli C-reaqtiuli cila (83% mamakacebSi da 79% qalebSi)66(IV).

rekomendacia (D):

pacientebs giganturujredul arteriitze eWviT unda CautardeT eds-is da/an C-reaqtiuli cilis gamokvleva (maqsimaluri specifiurobisa da mgrZnobelobis miRebis mizniT sasurvelia am diagnostikuri testebis kombinirebuli gamoyeneba).

30

plazmis siblantis gansazRvra gamoiyeneba giganturujreduli arteriitis diagnostikaSi, magram misi efeqturobis Sesaxeb Sesabamisi kvlevebi ar Catrebula.

sxva gamokvlevebi

Tavis tkivilis mqone pacientTa SemTxvevaSi sisxlis saerTo analizisa da xerxemlis kisris nawilis rentgenografiis sargebelis Sesaxeb mtkicebulebebi ar moipoveba.

31

Tavis tkivilis sadiagnozo algoriTmi

pacienti UuCivis

Tavis tkivils?

mniSvnelovani

pirveli nabijebi:

detaluri anamnezi;

fokusirebuli obieqturi gasinjva;

fokusirebuli nevrologiuri gasinjva.

eWvis mizezebi:

qvemwvave da/an progresirebadi Tavis tkivili Tveebis ganmavlobaSi;

axlad dawyebuli Tavis tkivili an misi saxecvlileba;

“yvelaze uaresi Tavis tkivili”;

dawyebisTanave maqsimaluri intensivobis nebismieri Tavis tkivili;

Tavis tkivilis dawyeba 50 wels zemoT asakSi;

sistemuri daavadebis simptomebi;

krunCxvebi;

nebismieri nevrologiuri niSani.

detaluri anamnezi:

Tavis tkivilis maxasiaTeblebi;

funqciuri uunarobis Sefaseba;

warsuli samedicino anamnezi;

Sakikis ojaxuri anamnezi;

mimdinare medikamenturi mkurnaloba (eqimis mier daniSnuli Tu TviT-mkurnaloba);

socialuri anamnezi;

organoTa sistemebis Sefaseba sistemuri daavadebis gamoricxvis mizniT.

saxezea

mizezebi

eWvisTvis?

akmayofilebs

pirveladi Tavis

tkivilis

kriteriumebs?

meoreuli Tavis

tkivili

gaiTvaliswineT

Tavis tkivilis

meoreuli

mizezebi

naCvenebia

specialis

tis kons.-

tacia?

Cvenebis SemTxvevaSi

CaatareT

diagnostikuri

gamokvleva

Sedegebi

metyvelbs

meoreul

Tavis

tkivilze?

gaagzavneT

specialistTan

pirveladi

Tavis

tkivilis

diagnozi

dadastur-

da?

SeafaseT pirveladi

Tavis tkivilis tipi;

daiwyeT pacientis

ganaTleba da

cxovrebis stilis

modificireba

Sakiki (ix.

Sakikis marTva)

daZabvis Tavis

tkivili (ix.

marTva)

klasteruli

Tavis tkivili

(ix. marTva)

meoreuli Tavis

tkivili (ix.

marTva)

sinusuri Tavis tkivili SakikTan asocirebuli simptomebis dros xSirad arasworad ismeba sinusuri

Tavis tkivilis diagnozi. amis Sedegia Sakikis arasaTanado diagnostireba da mkurnaloba.

Tavis tkivilis saerTaSoriso sazogadoebis (International Headache Society – IHS) definiciis mixedviT sinusuri Tavis tkivilis diagnozi ganisazRvreba Semdegi kriteriumebis safuZvelze: Cirqovani gamonadeni cxviridan, cxviris danamati wiaRebis paTologia gamosaxviTi kvlevisas, sinusitisa da Tavis tkivilis erTdrouli dawyeba, Tavis tkivili, romelic lokalizebulia sinusebisTvis specifiur saxisa da kranialur areebSi.

gansazRvreT

meoreuli Tavis

tkivilis mizezi

(ix. gaidlaini)

diax

diax

diax

diax

ara

ara

ara ara

32

7. Tavis tkivilis mkurnaloba

Sakikis mkurnaloba

Sakikis mkurnalobis mizania Semcirdes tkivilis intensivoba (simZime) da SetevaTa sixSire, gaizardos pacientis Sromisunarianoba da cxovrebis xarisxi. Sakikis mkurnaloba iyofa or kategoriad: abortuli (mwvave Setevebis) da profilaqtikuri (qronikuli) mkurnaloba.

Sakikis mwvave Setevis mkurnaloba

calkeuli pacientisTvis Sakikis mwvave Setevis mkurnaloba individualurad unda iqnes SerCeuli Setevis simZimis, sixSirisa da sxva simptomebis Sesabamisad. SeiZleba gamoyenebuli iqnes safexurebrivi midgoma, romelic iTvaliswinebs mkurnalobis dawyebas analgeziuri da Rebinebis sawinaaRmdego saSualebebiT (saWiroebisas) da gagrZelebas sxva samkurnalo saSualebebiT67(IV).

rekomendacia (D):

praqtikosma eqimma unda gaacnobieros is faqti, rom pacientis standartuli Terapia SesaZlebelia araTanmimdevruli efeqtiT xasiaTdebodes nebismieri Setevis dros. rezistentuli Setevebis marTvis strategia unda daigegmos pacientTan erTad;

Sakikis mwavve Setevis mkurnalobis dawyebisas aucilebelia pacientTan erTad medikamentebis borotad gamoyenebasTan dakavSirebuli Tavis tkivilis problemis ganxilva.

warmatebuli mkurnalobis klinikurad yvelaze Sesabamisi pirveladi maCvenebelia pacientTa is raodenoba, romelsac ar aReniSneba tkivili wamlis dozis miRebidan 2 saaTis ganmavlobaSi, Tumca idealuri efeqturobis maCvenebeli umtkivneulo periodis SenarCunebaa, kerZod, pacientTa is raodenoba, romelTac ar aReniSnebaT tkivili wamlis miRebidan 2 saaTSi da ar uvlindebaT saSualo an Zlieri intensivobis Tavis tkivili wamlis miRebidan 2-24 saaTSi, xolo Semamsubuqebeli medikamentebis miRebis saWiroeba ki ar aris68(II).

arasteroiduli anTebis sawinaaRmdego medikamentebi (aspirinis CaTvliT) da paracetamoli

aspirini, ibuprofeni da paracetamoli iaffasiani da advilad xelmisawvdomi pirveli rigis arCevis medikamentebia. aspirinisa da ibuprofenis gamoyenebas unda moveridoT im pacientebSi, romlebsac aqvT asTma da wylulovani daavadeba.

samma kargad organizebulma randomizebulma kontrolirebadma kvlevam

aCvena, rom Sakikis mwvave Setevisas tkivilma gaiara aspirinis 900-1000mg miRebidan 2 saaTSi SemTxvevaTa 48-52%-Si69,70,71(I). msubuqi an saSualo intensivobis Sakikis dros paracetamolis 1000mg-is, aspirinis 1000mg-isa da kofeinis 260 mg-is kombinacia SeiZleba ufro efeqturi iyos (84%-Si tkivilis Semsubuqeba 2 sT-Si), vidre mxolod aspirinis 500mg-is an sumatriptanis 50 mg-is miReba72(I).

33

erT-erT kontrolirebad randomizebul kvlevaSi ibuprofenis 200-400 mg-is miReba axdenda tkivilis Semsubuqebas 2 saaTSi pacientTa 41 %-Si, Tumca mZime pirveladi Tavis tkivilis Semsubuqeba SesaZlebeli iyo mxolod 400 mg-is miRebis fonze73(I). 400 mg ibuprofeni iseTive efeqturia, rogorc 1000 mg aspirini an 50 mg sumatriptani. 75-150 mg ketoprofeni agreTve uzrunvelyofs tkivilis Semsubuqebas 2 sT-Si pacientTa 62 %-Si74(I).

anTebis sawinaaRmdego arasteroidi tolfenamis mJavas swrafad moqmedi 200 mg-iani tabletebi licenzirebulia specifiurad Sakikis mwvave Setevebis mkurnalobisTvis. diklofenaki, flurbiprofeni, ibuprofeni da naproqseni agreTve gamoiyeneba Sakikis Setevis samkurnalod. gulisrevisa da Rebinebis mqone pacientebSi tkivilis Sesamcireblad SeiZleba gamoyenebul iqnes diklofenakis 100mg-iani sanTlebi.

erT-erT placebo-kontrolirebad kvlevaSi naCvenebi iqna, rom

paracetamolis 1000 mg-is miRebisas pacientTa 57.8%-s aReniSneba Sakikis Setevis saSualo (magram ara mZime) intensivobis tkivilis Semsubuqeba 2 sT-Si75(I).

rekomendacia:

900 mg aspirini rekomendebulia Sakikis mwvave Setevis mkurnalobis mizniT nebismieri intensivobis tkivilis SemTxvevaSi (A).

400 mg ibuprofeni rekomendirebulia Sakikis mwvave Setevis mkurnalobis mizniT (A).

Sakikis mwvave Setevis mkurnalobis mizniT SesaZlebelia anTebis sawinaaRmdego sxva arasteroidebis gamoyenebac (tolfenamis mJava,

diklofenaki, naproqseni, flurbiprofeni) (D).

Sakikis msubuqi da saSualo intensivobis Setevebis mkurnalobis mizniT rekomendebulia 1000 mg paracetamolis gamoyeneba (B).

triptanebi

Sakikis Setevisas triptanebis miReba uzrunvelyofs tkivilis mniSvnelovan Semsubuqebas miRebidan 2 saaTSi da aumjobesebs sicocxlis xarisxs76,77,78(I-II). triptanebis Sedarebam aspirinTan, paracetamolis, aspirinsa da kofeinis kombinaciasa da ergotaminis preparatebTan aCvena, rom maTi efeqturoba statistikurad aspirinisa da ibuprofenis eqvivalenturi iyo Tavis tkivilis simZimis Semsubuqebis TvalsazrisiT miRebidan 2 saaTSi, magram gacilebiT aRemateboda aspirins tkivilisgan Tavisufali periodis sixSiriT drois amave SualedSi (Sesabamisad, pacientTa 37,1% da 27,1%)69. analogiuri Sedegi aRiniSneboda ergotaminis preparatebTan Sedarebis SemTxvevaSic77. amJamad gamodis triptanebis sxvadasxva saxeobebi, romelTa Sedarebac ganxorcielda mravalricxovan kvlevebSi da am kvlevaTa meta-analizis safuZvelze SemuSavda rekomendaciebi maTi efeqturobis, umtkivneulo periodis SenarCunebis unarisa da amtanobis profilis Sesaxeb. triptanebis SedarebiTi daxasiaTeba mocemulia qvemoT moyvanil cxrilSi:

34

cxrili 4. peroraluri triptanebis efeqturobisa da amtanobis mTavari parametrebis maCveneblebi 100mg sumatriptanTan SedarebiT79.

Semsubuqeba

miRebidan 2 sT-Si

umtkivneulo periodis

SenarCuneba

efeqtis mdgradoba

amtanoba

sumatriptani 25 mg _ =/_ _ +

sumatriptani 50 mg = = =/_ =

zolmitriptani 2,5 mg = = = =

zolmitriptani 5 mg = = = =

naratiptani‡ 2,5 mg _ _ _ + +

rizatriptani‡ 5 mg = = = =

rizatriptani‡ 10 mg + + +(+) =

eletriptani 20mg _ _ _ =

eletriptani 40mg =/+ =/+ = =

eletriptani 80mg +(+) + = _

almotriptani‡12,5 mg = + + + +

= gansxvaveba 100 mg sumatriptanTan SedarebiT ar dgindeba;

+ ukeTesia 100 mg sumatriptanTan SedarebiT;

_ uaresia 100 mg sumatriptanTan SedarebiT.

triptanebis gamoyenebasTan dakavSirebuli rekomendaciebi

triptanebis gamoyeneba ukunaCvenebia pacientebSi, romelTac aReniSnebaT gulis iSemiuri daavadeba, gadatanili miokardiumis infarqti, koronaruli arteriebis spazmi an arakontrolirebadi an mZime hipertenzia. triptanebis gamoyenebisas hemiplegiuri Sakikis dros saWiroa sifrTxile80. calkeuli triptanebis mimarT reaqcia individualuria. pacientebSi, romelTac ar aReniSnebaT efeqti erTi saxis triptanze, SesaZlebelia am klasis medikamentebis sxva warmomadgenelze kargi Terapiuli efeqti miviRoT81(I).

rekomendacia:

oraluri triptanebis gamoyeneba rekomendebulia Sakikis nebismieri simZimis mwvave Setevis samkurnalod, Tuki ver xerxdeba misi kontroli martivi analgetikebis saSualebiT (A);

Sakikis mwvave Setevis mkurnalobis mizniT peroraluri triptanebidan upiratesoba eniWeba 12,5 mg almotriptanis, 40-80 mg eletriptanis an 10 mg rizatriptanis gamoyenebas§

(A);

‡ saqarTveloSi es preparatebi registrirebuli ar aris.

35

Tuki tkivilis Semsubuqeba ver xerxdeba erTi triptanis miRebiT, alternativis saxiT aucilebelia gansxvavebuli triptanis SeTavazeba (B);

triptanis miReba rekomendebulia Tavis tkivilis Setevis dawyebisTanave an dawyebidan rac SeiZleba male (D).

triptanebis nazaluri sprei/kanqveSa ineqcia‡

sumatriptanis nazaluri spreis gamoyeneba sargebels ar iZleva im SemTxvevaSi, rodesac Rebinebis gamo SeuZlebelia misi peroraluri miReba, radganac sumatriptanis bioSeRwevadoba damokidebulia saWmlis monelebaze, maSin roca zolmitriptanis nazaluri sprei SesaZlebelia sasargeblo iyos im SemTxvevaSi, rodesac ukve ganviTarda Rebineba, radganac misi 30%-is absorbcia xdeba cxviris lorwovani garsidan. swored es faqti ganapirobebs tkivilis Semsubuqebis ukeTes siCqaresa da xarisxs, Tumca, SesaZlebelia gverdiTi efeqtebis riskis zrda, ris gamoc misi gamoyeneba Semoifargleba pacientTa garkveuli jgufiT.

rekomendacia (D):

zolmitriptanis nazaluri spreis an sumatriptanis kanqveSa ineqciis gamoyeneba SesaZlebelia mZime Sakikis dros, rodesac Rebineba xels uSlis peroralur miRebas an rodesac oraluri triptanebi araefeqturia.

triptanebisa da aass kombinacia

or ormxrivad brma randomizebul kontrolirebad kvlevaSi 85 mg sumatriptanisa da 500 mg naproqsenis natriumis marilis fiqsirebuli kombinaciis efeqturoba da usafrTxoeba Sedarda placebosa da sumatriptanis suqcinatiT monoTerapias, romelSic dadginda kombinirebuli Terapiis upiratesoba monoTerapiasTan SedarebiT82(II).

rekomendacia (C):

50-100 mg sumatriptanisa da 500mg naproqsenis natriumis marilis kombinacia SeiZleba sasargeblo iyos Sakikis mwvave Setevebis samkurnalod, gansakuTrebiT gaxangrZlivebuli Setevebis SemTxvevaSi, romlebic asocirebulia recidivebTan.

qvemoT moyvanil cxrilSi CamoTvlilia triptanebis sxvadasxva saxeobebi, maTi dozireba da gverdiTi movlenebi.

§ saqarTveloSi es preparatebi registrirebuli ar aris

36

cxrili 5. triptanebis sxvadasxva saxeobebi, maTi dozireba da gverdiTi movlenebi

samkurnalo saSualeba

dozireba gverdiTi movlenebi

almotriptani oraluri: 6.25-12.5mg sawyisi doza. SeiZleba ganmeordes 2 sT-iani intervaliT maqsimum: 25mg/dReSi

xSirad: gulisrevis SegrZneba, Rebineba, Zilianoba, piris simSrale, sisuste, Tavbrusxveva, diarea, taqikardia, paresTezia, vazodilatacia. iSviaTad: ezofagospazmi, hipertenzia, hiperqolesterinemia, arTritebi, miopaTia, diplopia, mSrali Tvali,Sua yuris anTeba, laringiti, sinkope, nerwyvdenis gaZliereba.

eletriptaniO

oraluri: 20-40mg sawyisi doza. SeiZleba ganmeordes 2 sT-iani intervaliT maqsimum: 80mg/dReSi

flovatpiftani oraluri: 2.5mg sawyisi doza. SeiZleba ganmeordes 2 sT-iani intervaliT maqsimum: 7.5mg/dReSi

naratriptani

oraluri: 2.5mg sawyisi doza. SeiZleba ganmeordes 4 sT-iani intervaliT maqsimum: 5mg/dReSi

sumatriptani

oraluri: 50-100mg sawyisi doza.SeiZleba ganmeordes 2 sT-iani intervaliT maqsimum: 200mg/dReSi kanqveS: 6mg sawyisi doza. SeiZleba ganmeordes 1 sT-iani intervaliT; maqsimum: 12mg/dReSi intranazalurad: 20 mg SeiZleba ganmeordes 2 sT-iani intervaliT maqsimum: 40mg/dReSi D

rizatriptani

oraluri: 10mg sawyisi doza. SeiZleba ganmeordes 2 sT-iani intervaliT maqsimum: 30mg/dReSi

zolmitriptani

oraluri: 2.5-5mg sawyisi doza. SeiZleba ganmeordes 2 sT-iani intervaliT maqsimum: 10mg/dReSi intranazalurad: 5 mg SeiZleba ganmeordes 2 sT-iani intervaliT maqsimum: 10mg/dReSi

Rebinebis sawinaaRmdego saSualebebi

Rebinebis sawinaaRmdego saSualebebi, rogoricaa magaliTad proqlorperazinis 3-6 mg-iani bukaluri tabletebi an domperidonis 10 mg-iani oraluri da 30 mg-iani reqtaluri forma, gamoiyeneba im SemTxvevaSi, roca Sakiki Serwymulia gulisrevasa da RebinebasTan. 10mg metoklopramidis an 20mg domperidonis gamoyeneba aseve SesaZlebelia kuWidan sakvebis evakuaciisaTvis xelSewyobis mizniT.

37

rekomendacia (D):

oraluri da reqtaluri Rebinebis sawinaaRmdego saSualebebi gamoiyeneba Sakikis mwvave Setevisas, rodesac aRiniSneba gulisreva da Rebineba da kuWidan sakvebis evakuaciis xelSewyobis mizniT.

sistemurma mimoxilvam gamoavlina eqvsi ormagi brma randomizebuli kontrolirebadi kvleva, romlebSic fasdeboda Sakikis mwvave Setevebis mkurnalobaSi aspirinisa da metoklopramidis kombinacia83(II). metoklopramidis doza yvela SemTxvevaSi iyo 10 mg, aspirinis doza varirebda 650-900 mg-is farglebSi. oTx kvlevaSi kombinacia Seadares placebos, orSi - oralur sumatriptans (100mg), erTSi- dihidroergotaminis mezilats (5mg) da erTSi - mxolod aspirins (650mg). oTxive kvlevaSi miRebidan 2 saaTis Semdeg tkivilis Semsubuqebis TvalsazrisiT kombinacia mniSvnelovnad aRemateboda placebos. amave maCveneblis mixedviT erT kvlevaSi sumatriptani sjobda, xolo meoreSi ki eqvivalenturi iyo kombinirebuli preparatis gamoyenebisa. gulisrevis Semsubuqebis mxriv ar gamovlenila mniSvnelovani gansxvaveba. kombinacia mniSvnelovnad aRemateboda miRebidan 2 saaTis Semdeg tkivilis Semsubuqebis efeqtiT oralur dihidroergotamins. mxolod erT kvlevaSi, sadac erTmaneTs dardeboda ori preparatis kombinacia da mxolod aspirinis gamoyeneba, ar gamovlenila gansxvaveba 2 saaTSi tkivilis Semsubuqebis TvalsazrisiT. Tumca, am kvlevaSi monawile pacientebis raodenoba mcire iyo.

500mg paracetamolisa da 10mg domperidonis fiqsirebuli kombinaciis 50mg sumatriptanTan Sedarebaze Catarebulma jvaredinma randomizebulma kontrolirebadma kvlevam ver gamoavlina maT Soris mniSvnelovani gansxvaveba miRebidan 2 saaTSi tkivilis Semsubuqebis efeqturobis TvalsazrisiT. gulisrevis Semcireba erTnairi iyo mkurnalobis orive meTodis SemTxvevaSi, xolo gverdiTi efeqtebis sixSire ki naklebi – kombinirebuli Terapiis dros84(II).

sxvadasxva xarisxisa da dizainis randomizebuli kvlevebis meta-analiziT dadginda, rom metoklopramidis intravenuri ineqcia placebosTan SedarebiT meti efeqturobiT xasiaTdeba Sakikis mwvave Setevis dros tkivilis Semsubuqebis TvalsazrisiT, Tumca, igi ar aris licenzirebuli Sakikis dros tkivilis mkurnalobis mizniT85(II). Rebinebis sawinaaRmdego saSualebebis intravenuri gamoyeneba SesaZlebelia stacionarul pirobebSi im SemTxvevaSi, rodesac Sakikis Seteva ar emorCileba standartul Terapias.

rekomendacia:

aspirinisa da metoklopramidis kombinaciis gamoyeneba SesaZlebelia Sakikis mwvave Setevebis mkurnalobis mizniT (B).

analgeziuri/Rebinebis sawinaaRmdego saSualebebis fiqsirebuli kombinacia SeiZleba gamoyenebul iqnes mwvave Sakikis Setevis samkurnalod (B).

metoklopramidis intravenuri ineqciis gamoyeneba SesaZlebelia Sakikis mwvave Setevis mqone pacientebis marTvaSi (B).

38

ergotamini

ergotaminis efeqturoba aRemateba placebos, magram Sakikis mwvave Setevebis simptomebis Semsubuqebis TvalsazrisiT CamorCeba triptanebs, aass-s, izomeTeptensa an opioidebs. misi amtanobis profili aradamakmayofilebelia86(I). ergotaminisa da kofeinis kombinacia (kafergoti) aseve nakleb efeqturia, vidre eletriptani Tavis tkivilis Semsubuqebisa da umtkivneulo periodebis sixSiris mixedviT.

ergotaminma SeiZleba gamoiwvios iseTi gverdiTi efeqtebi, rogoricaa gulisreva, Rebineba, muclis tkivili da kunTovani “krampi”. misi preparatebi ar unda gamoviyenoT im pacientebSi, romelTac gul-sisxlZarRvTa an cerebro-vaskuluri daavadebebi aReniSnebaT.

rekomendacia (A):

ergotamini ar aris rekomendebuli pacientebSi Sakikis mwvave Setevebis dros.

kofeini

Tavis tkivilis mkurnalobis mizniT kofeinis gamoyenebaze mtkicebulebebi Semoifargleba mxolod sxva saxis TerapiasTan misi kombinaciis saxiT.

mwvave Setevebis sxva saxis Terapia

mtkicebulebebi Tavis tkivilis mkurnalobaSi cog-2 inhibitorebis, kortikosteroidebis, indometacinis an opioidebis efeqturobis Sesaxeb ar moipoveba. Sakikis mwvave Setevebis nebismieri tipis mkurnalobis dros arsebobs medikamentebis borotad gamoyenebis riski, romelic matulobs opioidebis Semcveli kombinirebuli tkivilgamayuCebeli preparatebis xmarebisas.

rekomendacia (D):

Sakikis mwvave Setevebis mkurnalobis mizniT ar aris rekomendebuli opioiduri analgeziuri saSualebebis rutinuli xmareba, medikamentebis borotad gamoyenebasTan dakavSirebuli Tavis tkivilis ganviTarebis potenciuri riskis gamo.

Sakikis farmakologiuri prevencia

prevenciuli Terapia unda Cautardes Sakikis mqone pacientebs, romelTac aReniSnebaT Sakikis ganmeorebiTi Setevebi, rac mniSvnelovnad zRudavs maT yoveldRiur rutinul saqmianobas, Sakikis mwvave Setevebis samkurnalo preparatebis mimarT ukuCvenebis, maTi warumatebeli an gadaWarbebuli gamoyenebis SemTxvevaSi da Sakikis iSviaTi formebis dros (hemiplegiuri Sakiki, Sakiki gaWianurebuli auriT, bazilaruli Sakiki). prevenciuli mkurnalobis mizania Setevebis sixSiris, simZimisa da xangrZlivobis Semcireba, Sakikis mwvave Setevis mkurnalobaze mgrZnobelobis gaumjobeseba da SakikTan asocirebuli Sromisuunarobis Semcireba.

39

prevenciuli medikamenturi Terapiis zogadi principebia:

gverdiTi efeqtebis minimumamde dayvanis mizniT prevenciuli medikamentebis umravlesobis doza nel-nela unda gaititros efeqtur an maqsimalur dozamde;

prevenciuli wamlis SerCeva unda moxdes Tanxmlebi daavadebebisa da gverdiTi movlenebis gaTvaliswinebiT;

prevenciuli medikamentis miReba saWiroa dozis titraciidan sul mcire, 6-8 kviris ganmavlobaSi;

6-dan 12 Tvemde xangrZlivobis efeqturi prevenciuli Terapiis Semdeg gasaTvaliswinebelia wamlis TandaTanobiTi moxsna87(II).

rekomendacia (D):

Sakikis prevenciuli Terapiisagan damoukideblad, pacientebisTvis aseve xelmisawvdomi unda iyos Sesabamisi medikamentebi Sakikis mwvave Setevebis samkurnalod.

cxrili 6. prevenciuli medikamentebi Sakikis mqone pacientebisTvis

prevenciuli medikamenti

sifrTxiliT gamoiyeneba Semdegi mdgomareobebis dros (CamonaTvali arasrulyofilia)

SesaZlebelia upiratesoba mieniWos

Semdegi mdgomareobebis dros

beta-blokerebi

asTma; diabeti; bradikardia; periferiuli sisxlZarRvebis daavadeba; depresiis Tanaarseboba.

SfoTvis Tanaarseboba

tricikluri antidepresantebi

daxurul-kuTxovani glaukoma

depresiis Tanaarseboba; daZabulobis tipis Tavis tkivilis Tanaarseoba; Zilis darRveva.

topiramati** TirkmelkenWovani daavadeba; daxurul-kuTxovani glaukoma; orsuloba.

simsuqnis Tanaarseboba

valproati

simsuqne; RviZlis daavadeba; orsuloba.

depresiis Tanaarseboba

** topiramati saqarTveloSi registrirebulia, magram misi fasis gamo naklebad

xelmisawvdomia.

40

rekomendacia (D):

Tuki reproduqciuli asakis qalebSi Sakikis prevenciuli Terapiis mizniT rekomendebulia antiepilefsiuri saSualebebis gamoyeneba, aucilebelia pacientis konsultireba da informaciis miwodeba am medikamentebis teratogenuli efeqtis Sesaxeb.

beta-blokerebi

propranololis 80-240 mg dReSi efeqturad amcirebs Sakikis sixSires, Tumca, tkivilis intensivobis Semcirebis TvalsazrisiT misi efeqti araTanmimdevrulia88(IV). kokreinis bazis sistemurma mimoxilvam gamoavlina, rom propranololi TiTqmis orjer efeqturia placebosTan SedarebiT Tavis tkivilis sixSiris Semcirebis TvalsazrisiT89(I).

propranololis daniSvnisas mwvave Setevebis mkurnalobis mizniT rizatriptanis xmarebis SemTxvevaSi pacients unda erCios misi dozis ganaxevreba da amis garda, rizatriptanis miReba propranololis miRebidan 2 saaTis ganmavlobaSi

Sakikis dros atenololis gamoyeneba prevenciuli Terapiis mizniT licenzirebuli ar aris.

rekomendacia:

Sakikis prevenciuli Terapiis mizniT β-blokerebis klasidan pirveli rigis medikamentis saxiT rekomendebulia dReSi 80-240 mg/ propranololis gamoyeneba (A);

Timololi, atenololi, nadololi da metoprololi SeiZleba gamoyenebul iqnes, rogorc propranololis alternativa Sakikis prevenciuli mkurnalobis mizniT (D).

antiepilefsiuri saSualbebi

kohreinis bazis mimoxilvam aCvena, rom antiepilefsiuri saSualebebis klass SeuZlia Sakikis sixSiris Semcireba 28 dReSi 1,4 SeteviT. placebosTan SedarebiT iseTi antikonvulsantebis moxmarebisas, rogoricaa topiramati, natriumis valproati da gabapentini, pacientebs Sakikis sixSiris 50%-iani Semcirebis 2,4-jer ufro maRali albaToba aReniSnebaT90(I).

Sakikis Setevebis sixSiris Semcirebis, mkurnalobaze pasuxis gaumjobesebisa da Semamsubuqebeli medikamentebis yoveldRiuri gamoyenebis gaiSviaTebis TvalsazrisiT dReSi 100mg topiramatis miReba 160 mg propranololiT mkurnalobis analogiuria91(I).

rekomendacia:

epizoduri da qronikuli Sakikis mqone pacientebSi dReSi 50-200 mg topiramatis miReba rekomendebulia Tavis tkivilis sixSirisa da simZimis Semcirebis mizniT (A);

epizoduri Sakikis mqone pacientebSi natriumis valproatis 800-1500 mg/dReSi rekomendebulia Tavis tkivilis sixSirisa da simZimis Semcirebis mizniT (A);

41

epizoduri da qronikuli Sakikis mqone pacientebs SeiZleba vumkurnaloT gabapentinis 1.200-2.400 mg/dReSi Tavis tkivilis sixSiris da simZimis Sesamcireblad (C).

antidepresantebi

qronikuli Tavis tkivilis mqone pacientebSi antidepresantebis gamoyenebaze Catarebuli 38 kvlevis meta-analizma aCvena, rom mxolod amitriptilinia Seswavlili pacientTa sakmaris raodenobaSi, raTa moxdes misi statistikurad mniSvnelovani efeqtis demonstrireba. misi xmarebis fonze adgili hqonda Tavis tkivilis indeqsis (Tavis tkivilis tvirTi, romelic gamoiTvleba sixSirisa da simZimis maCveneblebidan) Semcirebas rogorc daZabulobis tipis Tavis tkivilis, ise Sakikis SemTxvevaSi. serotoninis ukuSeboWvis seleqtiur inhibitorebze (SSRI) Catarebulma eqvsma kvlevam, romlebSic Seiswavleboda Tavis tkivilis tvirTi, am preparatebis mniSvnelovani sargebeli ver gamoavlina92(II).

venlafaqsinis prevenciuli efeqtis Sedareba ganxorcielda amitriptilinTan jvaredin randomizebul kvlevaSi da aRmoCnda, rom tkivilis parametrebis mniSvnelovan gaumjobesebas adgili hqonda pacientTa orive jgufSi93(I).

rekomendacia:

SSRI ar aris rekomendebuli Sakikis prevenciuli mkurnalobis mizniT (B);

amitriptilini 25-150mg/dReSi rekomendebulia pacientebisTvis, romelTac esaWiroebaT Sakikis prevenciuli mkurnaloba (B);

venlafaqsini 75-150mg/dReSi tricikluri antidepresantebis efeqturi alternativaa Sakikis profilaqtikis TvalsazrisiT (B).

sxva saxis prevenciuli Terapia

pizotifeni – pizotifeni did xnis ganmavlobaSi gamoiyeneba Sakikis prevenciis mizniT. pizotifenze kvlevaTa umravlesoba Catarebulia 1970-ian wlebSi. im pacientTa 30-50%, romlebic moixmardnen pizotifens, aRniSnavdnen SetevaTa ricxvis Semcirebas94(I). am kvelevebSi aseve dadginda, rom pizotifenis gamoyeneba SesaZlebelia umjobesi iyos im pacientebSi, romelTac aReniSnebaT TveSi oTxi an meti Seteva.

rekomendacia (D):

Sakikis prevenciis mizniT pizotifenis gamoyeneba garkveuli CvenebebiT Semoifargleba.

meTisergidi – meTisergidi erT-erTi pirveli preparati iyo, romelic gamoiyeneboda Sakikis prevenciis mizniT, magram misi xmareba SezRudulia imis gamo, rom xangrZlivi miRebisas xasiaTdeba retroperitoneuli fibrozis ganviTarebis riskiT. ramdenime placebo-kontrolirebad kvlevaSi meTisergidi placebosTan SedarebiT mniSvnelovani efeqturobiT gamoirCeoda88(IV).

42

rekomendacia (D):

meTisergidis gamoyeneba rekomendebulia mxolod specialistis (nevrologis) meTvalyureobis SemTxvevaSi.

flunarizini – 5-10 mg flunariziniT mkurnaloba Sedarda Sakikis prevenciis mizniT 160 mg propranololiT Terapias da aRmoCnda, rom igi iseTive efeqturi iyo, rogorc propranololi Sakikis Setevebis sixSiris Semcirebis TvalsazrisiT. usafrTxoebis mxriv mniSvnelovani gansxvaveba ar dafiqsirebula95(II).

botulotoqsini A – A botulotoqsinis efeqturoba epizoduri Sakikis prevenciis mizniT Seswavlili iqna multicentrul randomizebul kontrolirebad kvlevaSi da masSi ar gamovlenila botulotoqsinis mniSvnelovani sargebeli placebosTan SedarebiT.

rekomendacia (A):

botulotoqsini A-s gamoyeneba Sakikis prevenciuli Terapiis mizniT rekomendebuli ar aris.

kandesartani – erT-erTma mciremasStabianma kvlevam aCvena, rom kandesartaniT namkurnaleb pacientebs, placebosTan SedarebiT, 22%-iT naklebi dReebis ganmavlobaSi aReniSnebodaT Sakikis Seteva96(II).

aspirini – erTma kvlevam aCvena, rom aspiriniT mkurnaloba SesaZlebelia dakavSirebuli iyos Sakikis mcired prevenciul efeqtTan saSualo asakis qalebSi, magram es efeqti statistikurad mniSvenlovani ar yofila97(II).

acetazolamidi – Sakikis mqone pacientebis tolerantoba acetazolamidis mimarT cudia da igi ar iZleva raime saxis sargebels prevenciuli efeqtis TvalsazrisiT placebosTan SedarebiT98(II).

hiperbaruli oqsigenacia – Sakikis prevenciis TvalsazrisiT hiperbaruli oqsigenacia ar gamoiyeneba99(II).

buspironi – Sakikis mqone pacientebSi, romelTac aReniSnebodaT Tanmxlebi SfoTviTi aSliloba, buspironiT mkurnalobis fonze adgili hqonda Tavis tkivilis sixSiris Semcirebas 43,3%-iT. asociacia Tavis tkivilis moxsnasa da anqsiolitur efeqts Soris ar gamovlenila100(II).

daZabulobis tipis Tavis tkivilis (dTt) mkurnaloba

daZabulobis tipis Tavis tkivilis mkurnaloba moicavs daZabulobis tipis Tavis tkivilis epizodebis mkurnalobas, dTt-is profilaqtikas da aramedikamentur mkurnalobas.

43

daZabulobis tipis Tavis tkivilis Setevis mkurnaloba

cxrili 7. daZabulobis tipis Tavis tkivilis Setevis samkurnalo medikamentebi

samkurnalo saSualeba dozireba gverdiTi movlenebi

acetaminofeni 325-650 mg yovel 4-6 sT-

Si saWiroebisamebr maqsimum 4000 mg/dReSi

gulisreva, Rebineba, hepatotoqsikuria

aspirini

500 – 1000mg

dispefsia, gastrointestinuri

darRvevebi, gulisreva, diarea, nefropaTia

ibuprofeni 400 mg yovel 4-6 sT-Si

saWiroebisamebr maqsimum 3200 mg/dReSi



naproqseni 500 mg yovel 12-sT-Si

saWiroeisamebr maqsimum 1250 mg/dReSi



farTomasStaburma randomizebulma kontrolirebadma kvlevam (pacientTa ricxviT n=638) gamoavlina, rom aspirini gamoirCeva maRali efeqturobiT epizoduri daZabulobis tipis Tavis tkivilis dros (75%-1000mg; p=0.0009 da 70%-500mg; p=0.011). 1000 mg paracetamoli analogiuri procentuli maCvenebeliT xasiaTdeboda (71%-p=0.007)

101(I).

rekomendacia (A):

aspirini da paracetamoli rekomendebulia daZabulobis tipis Tavis tkivilis mwvave Setevebis mkurnalobis mizniT.

amerikis ojaxis eqimTa asociacia rekomendacias uwevs ibuprofens.

daZabulobis tipis Tavis tkivilis prevenciuli mkurnaloba

daZabulobis tipis Tavis tkivilis prevenciuli mkurnalobis mizniT gamoiyeneba tricikluri da SSRI (serotoninis ukuSeboWvis seleqtiuri inhibitorebi) antidepresantebi, epilefsiis sawinaaRmdego saSualebebi, anitihipertenziuli medikamentebi.

antidepresantebi - qronikuli Tavis tkivilis Semsubuqebis TvalsazrisiT tricikluri antidepresantebi serotoninis ukuSeboWvis seleqtiur inhibitorebze ufro efeqturia129,102(II).

rekomendacia (A):

Tuki qronikuli daZabulobis tipis Tavis tkivilis mqone pacients unda daeniSnos prevenciuli Terapia, tricikluri antidepresantebi, gansakuTrebiT ki amitriptilini 25-150 mg dReSi, rekomendebulia arCevis preparatis saxiT.

44

botulinis toqsini A - botulinis toqsini A-s gamoyeneba qronikuli daZabulobis tipis Tavis tkivilis prevenciis mizniT ar xasiaTdeba statistikurad mniSvnelovani efeqturobiT placebosTan SedarebiT. Tumca, erT-erT kvlevaSi dadasturda misi efeqturoba iseTi Tavis tkivilis samkurnalod, romelic dakavSirebulia kisris distoniasTan103(II).

rekomendacia (B):

botulinis toqsini A ar aris rekomendebuli qronikuli daZabulobis tipis Tavis tkivilis prevenciuli mkurnalobis mizniT.

antihipertenziuli medikamentebi - maRali arteriuli wneva rogorc wesi ar iwvevs Tavis tkivils, Tumca antihipertenziuli saSualebebiT mkurnalobis fonze SesaZlebelia Tavis tkivilis prevalentobis Semcireba104(II). kvlevebis meta-analizis safuZvelze gairkva, rom angiotenzin II receptorebis antagonistebi amcireben Tavis tkivilis sixSires. aseve, lizinoprili xasiaTdeba mniSvnelovani efeqtiT im dReebisa da saaTebis raodenobis Semcirebis TvalsazrisiT, rodesac pacienti aRniSnavs Sakiks an Tavis tkivils. am kvlevebSi ar momxdara Tavis tkivilis tipis specifikacia da agreTve, hipertenziis mqone pacientebis gamoyofa.

antiepilefsiuli saSualebebi – erT-erT randomizebul kvlevaSi gamovlinda gabapentinis dadebiTi efeqti qronikuli yoveldRiuri Tavis tkivilis mqone pacientebis prevenciul mkurnalobaSi, rac gamoixata Tavis tkivilisgan Tavisufali periodebis sixSiris 9,1%-iT matebiT105(I).

cxrili 8. daZabulobis tipis Tavis tkivilis prevenciuli samkurnalo

saSualebebi

samkurnalo

saSualeba dozireba gverdiTi movlenebi

amitriptilini 25 mg sawyisi; maqsimum 100 mg/dReSi

pirisa da Tvalebis simSrale, sedacia, wonaSi momateba, ariTmiebi,

TvalSida wnevis momateba. gulisreva, Rebineba, anoreqsia

beta blokerebi: atenololi nadololi propranololi

50-100 mg 1jer dReSi 40 mg 1jer dReSi 80 mg 1jer dReSi Tavidan 2-3 miRebaze gayofili;

gulisreva, diarea, bronqospazmi, hipotenzia, orTostatiuli

hipotenzia, civi kidurebi, dispnoe, bradikardia,

atrio-ventrikuluri gamtareblobis darRveva, kanze gamonayari

45

daZabulobis tipis Tavis tkivilis aramedikamenturi mkurnaloba

daZabulobis tipis Tavis tkivilis aramedikamenturi mkurnaloba moicavs: varjiSs, darwmunebas, relaqsacias, stresis daZlevis teqnikas, akupunqturas.

trigeminul-avtonomiuri cefalalgiebis mkurnaloba

klasteruli Tavis tkivilis mkurnaloba moicavs mwvave Setevisa da profilaqtikur mkurnalobas.

abortuli (mwvave Setevis simptomuri) mkurnaloba:

Jangbadi;

triptanebi;

prednizoloni;

dihidroergotamini;

ergotamini;

lidokaini;

procedurebi trigeminul nervul kvanZebze.

klasteruli Tavis tkivilis prevencia:

pacienti unda moeridos Semdeg maprovocirebel faqtorebs, rogoricaa: alkoholi, TvalismomWreli kaSkaSa ganaTeba, Zilis darRveva, stresi.

prevenciuli mkurnaloba, Cveulebriv, saWiroebs kombinirebul Terapias ori (verapamili da liTiumi, an verapamili da topiramati)

an sami medikamentiT (mag. verapamili, liTiumi da ergotamini).

gabapentini;

beta blokerebi;

valprois mJava;

amitriptilini, serotoninis ukumitacebis seleqtiuri inhibitori;

akupunqtura

fsiqologiuri Terapia, rogoricaa: relaqsacia, hipnozi.

klasteruli Tavis tkivilis mwvave Setevis mkurnaloba

triptanebi

6 mg sumatriptanis kanqveSa ineqcia iwvevs mwvave klasteruli tkivilis Semsubuqebas 15 wuTSi pacientTa 73-96%-Si106(I). N20 mg sumatriptanis nazaluri spreis saxiT miReba ufro nela moqmedebs da iwvevs tkivilis Semsubuqebas 30 wuTSi pacientT 57%-Si107(I).

5 mg da 10 mg nazaluri zolmitriptani iwvevs tkivilis Semsubuqebas 30 wT-Si pacientTa 50 da 63 %-Si. peroralurad 10 mg zolmitriptanis miReba mwvave Setevisas tkivilis Semsubuqebas iwvevs 30 wT-Si pacientTa 47%-Si108(I);

46

rekomendacia:

klasteruli Tavis tkivilis mwvave Setevis mkurnalobaSi 6 mg sumatriptanis kanqveSa ineqcia rekomendebulia, rogorc pirveli rigis arCevis medikamenti†† (A).

nazaluri sumatriptani da zolmitriptani‡‡ rekomendebulia mwvave klasteruli Tavis tkivilis dros im pacientebSi, romlebic ver itanen kanqveSa sumatriptans (A).

imis gamo, rom peroraluri triptanebis moqmedeba mogvianebiT iwyeba, rekomendebulia saineqcio an nazaluri triptanebis gamoyeneba (A).

cxrili 9. klasteruli Tavis tkivilis mwvave Setevis samkurnalo saSualebebi

samkurnalo


eletriptaniO


xSirad: gulisrevis SegrZneba, Rebineba, Zilianoba, piris simSrale, sisuste, Tavbrusxveva, diarea,

taqikardia, paresTezia, vazodilatacia. iSviaTad: ezofagospazmi, hipertenzia, hiperqolesterinemia, arTritebi, miopaTia, diplopia, mSrali Tvali,Sua yuris anTeba, laringiti,sinkope, nerwyvdenis gaZliereba.

naratriptani

oraluri: 2.5mg sawyisi doza. SeiZleba ganmeordes 4 sT-iani intervaliT maqsimum: 5mg/dReSi

sumatriptani

oraluri: 25-100mg sawyisi doza. SeiZleba ganmeordes 2 sT-iani intervaliT maqsimum: 200mg/dReSi intramuskularuli: 6mg sawyisi doza. SeiZleba ganmeordes 1 sT-iani intervaliT; maqsimum: 12mg/dReSi

rizatriptani


zolmitriptani

oraluri: 2.5-5mg sawyisi doza. SeiZleba ganmeordes 2 sT-iani intervaliT maqsimum: 10mg/dReSi

†† saqarTveloSi saineqcio sumatriptani registrirebuli ar aris.

‡‡ saqarTveloSi nazaluri triptanebi registrirebuli ar aris.

47

Jangbadi

klasteruli Tavis tkivilis mqone 52 randomulad SerCeul pacientze Catarebulma kvlevam aCvena, rom 100%-iani Jangbadis miwodebisas 7l/wT siCqariT isini aRniSnavden tkivilis mniSvnelovan Semsubuqebas Terapiis dawyebidan 15 wuTSi109(IV).

rekomendacia (D):

100%-iani Jangbadis 7-12 l/wT siCqariT miwodeba unda gaviTvaliswinoT klasteruli Tavis tkivilis mqone yvela pacientSi mwvave Setevis mkurnalobis mizniT§§.

cxrili 10. klasteruli Tavis tkivilis mwvave Setevis dros Jangbadis gamoyeneba


Jangbadi

100%-iani 7-12 litri/wuTSi, 10-15 wT-is gan-Si; niRbis

saSualebiT, win gadaxril mjdomare poziciaSi.

gulisreva, Tavbrusxveva, gonebis dakargva, krunCxva, xvela, substernaluri diskomforti.

lidokaini

erT-erT randomizebul kontrolirebad kvlevaSi naCvenebi iqna, rom 10%-iani lidokainis cxviris wveTebi klasteruli Tavis tkivilis mwvave Setevis SemTxvevaSi iZleoda tkivilis Semsubuqebas 37 wuTSi, maSin, roca placebos saxiT gamoyenebuli fiziologiuri xsnaris xmarebisas analogiuri efeqti miiReboda 59 wuTSi (p<0.001)110(II)

rekomendacia (D):

pacientebSi, romlebSic kanqveSa an intranazaluri triptanis da 100%-iani Jangbadis gamoyenebiT ver xerxdeba klasteruli Tavis tkivilis Setevis Semsubuqeba, Setevis moxsnis dasaCqareblad SeiZleba ganxilul iqnes 10%-iani lidokainis cxviris wveTebi.

cxrili 11. lidokaini klasteruli Tavis tkivilis mwvave Setevis dros


lidokaini

intranazaluri (4%-iani xsnari) 1 ml 2-jer SeiZleba ganmeordes 15 wT-Si

maqsimum: 8ml dReSi

gemos Secvla, enisa da piris Rrus lorwovanis dabuJeba.

§§ saqarTveloSi ojaxis eqimisTvis pjd doneze aRniSnulis ganxorcieleba dRevandel

pirobebSi naklebad mosaxerxebelia, ris gamoc mwvave klasteruli Tavis tkivilis

mqone pacientebi samkurnalod rekomendebulia gaigzavnon stacionarSi.

48

klasteruli Tavis tkivilis profilaqtikuri mkurnaloba

kalciumis arxebis blokatorebi

verapamili amcirebs klasteruli Tavis tkivilis sixSiresa da simZimes. verapamilis 360 mg-iT mkurnalobisas pacientTa 86%-s aReniSneboda Tavis tkivilis sixSiris >50%-ze Semcireba placebosTan SedarebiT111(I).

verapamilis didi doziT gamoyeneba (960 mg-mde dReSi) rekomendebulia klasteruli Tavis tkivilis prevenciuli mkurnalobis mizniT, magram am dros saWiroa ekg-s regularuli kontroli112(IV).

rekomendacia (B):

verapamilis 240-960 mg gamoiyeneba rogorc profilaqtikuri mkurnaloba klasteruli Tavis tkivilisas.

liTiumi

mcireOormag brma placebo-kontrolirebad kvlevaSi klasteruli Tavis tkivilisas gamoyenebuli liTiumis (800mg dReSi) miReba Sewyda adreulad, radganac placebosTan SedarebiT ar iqna gamovlenili misi upiratesoba113 (I).

ergotaminebi

ergotaminebi didi xania gamoiyeneba klasteruli Tavis tkivilis prevenciuli Terapiis mizniT, magram misi sargebelis Sesaxeb Sesabamisi mtkicebulebebi ar moipoveba.

5-HT (5-hidroqsitriptaminis receptorebis) inhibitorebi

klasteruli Tavis tkivilis SemTxvevaSi meTisergidis prevenciuli mizniT gamoyenebis Sesaxeb Tanmimdevruli placebo-kontrolirebadi kvlevebi naklebad moipoveba. mcire kvlevam aCvena pizotifenis efeqturoba klasteruli Tavis tkivilis dros, magram Semdgomi gadaxedviT gamovlinda, rom aRniSnuli efeqti minimaluria114(IV).

melatonini

mciremasStabur ormag brma kvlevaSi (klasteruli Tavis tkivilis mqone 20 pacienti) melatoninis fonze mniSvnelovnad Semcirda Tavis tkivilis sixSire placebosTan SedarebiT (p<0.03)

114(II).

antiepilefsiuri saSualebebi

ormag brma placebo-kontrolirebad kvlevaSi klasteruli Tavis tkivilis valproatiT mkurnalobisas ar gamovlinda sasargeblo efeqti. aRsaniSnavia, rom am kvlevaSi uCveulod maRali iyo placebos jgufSi efeqtis sidide115(II). Tavisufali dizainis ramdenime kvlevaSi dadginda gabapentinisa da topiramatis efeqturoba klasteruli Tavis tkivilis prevenciis mizniT23(IV).

steroidebi

erT-erT ormagi brma placebo-kontrolirebad kvlevaSi betametazonis kanqveSa ineqcia Sedarda placebos, ris fonzec gamovlinda, rom Tavis tkivilis mqone pacientTa 85%-s steroidis ineqciidan pirvel kviraSi aRar hqonda tkivili, maSin roca placebos jgufSi ar dafiqsirebula arc erTi umtkivneulo SemTxveva116(I). eqspertebis azriT oraluri

49

steroidebis gamoyeneba SesaZlebelia klasteruli Tavis tkivilis xanmokle prevenciuli Terapiis mizniT, miuxedavad imisa, rom ar moipoveba Tanmimdevruli mtkicebulebebi maTi saregebelis Sesaxeb.

cxrili 12. klasteruli Tavis tkivilis prevenciuli samkurnalo saSulebebi

samkurnalo


verapamili

oraluri: swrafi Semsubuqeba: 80 mg 3jer dReSi xangrZlivi Semsubuqeba 120-480mg/dReSi

simxurvalis SegrZneba, hiperemia, hipotenzia, gulis ukmarisobis simptomebi, Tavbrusxveva, bradikardia, gadaRliloba, gastroenteruli darRvevebi -xSirad yabzoba, gulisreva, zogjer gaRizianebadoba, nevrozuli mdgomareoba; - iSviaTad-eriTema, qavili, angionevrozuli SeSupeba

liTiumi oraluri: 300mg 4-jer dReSi maqsimaluri: 1200 mg/dReSi

gulisreva, diarea, gastroenteraluri darRvevebi, wonis momateba, siuste, vertigo, tremori, akne, fsoriazi, leikocitozi, hipoTireoidizmi, poliuria, ekg cvlilebebi

ergotamini

oraluri: 2 mg Setevisas,SeiZleba ganmeores 1 sT-iani intervaliT maqsimaluri 6 mg/dReSi an 10mg/kviraSi

gulisreva, Rebineba, vazokonstriqcia, paresTeziebi, vertigo, sisuste, qavili

antiepilefsiuri saSualebebi: valproati gabapentini topiramati

sawyisi 500 mg/dReSi, sawyisi: 300mg/dReSi; maqsimaluri:3600mg/dReSi sawyisi: 25-50 mg 1-2-jer maqsimaluri: 200 mg/dReSi

sedacia, gastroenteruli darRvevebi, wonis da madis momateba sedacia, sisuste, ataqsia, Tavbrusxveva sedacia, ataqsia, sisuste, Tavbrusxveva, paresTezia, mexsierebis daqveiTeba,

prednizoloni

oraluri(mwvave): 20 mg 3-jer dReSi mkurnalobis kursi: 14 dRe; oraluri (profilaqtika): 60-80 mg 1-jer dReSi mkurnalobis kursi: 7 dRe;

diarea, gulisreva, madis momateba, kuWisa da 12-goja nawlavis wyluli. wonis momateba, hirsutizmi, TvalSida wnevis momateba, imunosupresia, Tirkmelzeda jirkvlis qerqis funqciis daTrgunva.

50

paroqsizmuli hemikraniis, uwyveti hemikraniis da SUNCT-is mkurnaloba

indometacinze dadebiTi sapasuxo reaqcia paroqsizmuli da uwyveti hemikraniis sadiagnostiko kriteriumia. indometacini efeqturia paroqsizmuli da uwyveti hemikraniis SemTxvevaSi dReSi 225 mg-mde doziT.

lamotrijini SeiZleba efeqturi iyos SUNCT sindromis mkurnalobaSi114(IV).

rekomendacia (D):

indometacini dReSi 225 mg-mde doziT rekomendebulia paroqsizmuli hemikraniis da uwyveti hemikraniis prevenciuli Terapiis mizniT.

medikamentebis Warbi moxmarebiT ganpirobebuli Tavis tkivilis

mkurnaloba

medikamentebis gadaWarbebuli moxmarebiT ganpirobebuli Tavis tkivilis mqone pacientebis umravlesobisTvis arCevis pirveli rigis mkurnalobas warmoadgens xelSemwyobi agentis uecari moxsna117(III). im pacientebze Catarebulma dakvirvebam, romelTa SemTxvevaSic warmatebulad ganxorcielda wamlis moxsna, aCvena, rom recidivebis sixSire 1-4 wlis ganmavlobaSi Seadgenda 45%-s, xolo maTi 94% ki modioda moxsnis pirvel welze. recidivebis sixSire varirebs Tavis tkivilis tipis mixedviT (22% - SakikisTvis, 73% - daZabulobis tipis Tavis tkivilisTvis da 77% - Sereuli tipis Tavis tkivilisTvis). recidivebis yvelaze maRali sixSiriT xasiaTdeba analgeziuri saSualebebi (52%). triptanebis Warbad xmarebis SemTxvevaTa mxolod 17%-sa da ergotaminis preparatebis gadaWarbebeuli miRebis 22%-Si aRiniSneboda recidivebi118(III).

medikamentebis gadaWarbebul xmarebasTan dakavSirebuli Tavis tkivilis SemTxvevaSi moxsnis xangrZlivoba (swrafad an TandaTanobiTi moxsna) damokidebulia moxmarebuli medikamentebis tipze119(III). moxsna ufro swrafad aris SesaZlebeli da Sedegic ufro kargia im pacientebSi, romlebic Rebuloben triptanebs an ergotaminis preparatebs, vidre opioidebis, martivi an kombinirebuli analgeziuri saSualebebis miRebis SemTxvevaSi. moxsnis sindromis xangrZlivoba aseve ufro naklebia triptanebis moxmarebis dros.

medikamentebis uecari moxsna dasawyisSi iwvevs simptomebis gauaresebas120(IV). kvlevebi, romlebSic Sedardeboda medikamentebis uecari da TandaTanobiTi moxsnis efeqturoba, TiTqmis ar moipoveba. eqspertTa azriT opioidebis (agreTve, benzodiazepinebisa da barbituratebis) moxsna saWiroa ganxorcieldes TandaTanobiT122(IV).

im pacientebSi, romlebic borotad ar moixmaren opioidebs, struqturirebuli rCeva-darigeba medikamentebis gadaWarbebul gamoyenebis, maTi moxsnis sargebelisa da moxsnis simptomebis Sesaxeb iseTive dadebiTi efeqtiT xasiaTdeba, rogorc ambulatoriuli an stacionaruli dezintoqsikaciis programebi121(III).

51

rekomendacia:

medikamentebis gadaWarbebuli moxmarebiT ganpirobebuli Tavis tkivilis mqone pacientebSi saWiroa ganxorcieldes wamlis moxsnis mcdeloba (D);

pacientebs medikamentebis gadaWarbebul gamoyenebasTan dakavSirebuli Tavis tkiviliT, romlebic iReben martiv analgetikebs an triptanebs, unda erCioT ucbad Sewyviton am medikamentebis miReba. pacientTa umravelsobaSi aRniSnulis ganxorcieleba SesaZlebelia ambultoriulad struqturirebuli rCeva-darigebis fonze (C);

pacientebs, romelTa Tavis tkivilic gamowveulia opioidebiT da opioidebis Semcveli analgetikebis gadaWarbebuli miRebiT, unda erCioT am medikamentebis TandaTanobiTi Sewyveta (D).

sam mciremasStabur randomizebul kvlevaSi naCvenebi iqna topiramatis sargebeli medikamentebis gadaWarbebul miRebasTan dakavSirebuli Tavis tkivilis SemTxvevaSi. misi miRebis fonze 3,5±7,1-iT Semcirda Tvis ganmavlobaSi Sakikis SetevaTa dReebis raodenoba, imis miuxedavad, rom medikamentebis gadaWarbebuli xmareba grZeldeboda122(II). ramdenime kvlevaSi gamovlinda, rom amitriptilini da natriumis valproati amcirebs Tavis tkivilis intensivobas medikamentebis gadaWarbebuli miRebis uecari Sewyvetis SemTxvevaSi123(III). ergotaminis preparatebis Warbi xmarebiT gamowveuli Tavis tkivilis dros gamovlinda naproqsenis efeqturoba moxsnis sindromis Semsubuqebis TvalsazrisiT122(IV).

rekomendacia:

Tu simptomuri medikamentebis moxsnis Semdeg grZeldeba xSiri Tavis tkivili, SeiZleba efeqturi iyos da unda gavTvaliswinoT prevenciuli medikamentebis daniSvna (D);

medikamentebis gadaWarbebul gamoyenebasTan dakavSirebul Tavis tkivilis mqone pacientebSi SesaZlebelia topiramitis*** daniSvna, Tavis tkiviliT datvirTuli dReebis saerTo raodenobis Semcirebis mizniT (C).

orsuloba, kontraceptivebi, menstruacia da menopauza

orsuloba

orsulebSi, Tuki SesaZlebelia, Tavi unda avaridoT medikamentebis gamoyenebas, gansakuTrebiT – pirvel trimestrSi. Tumca, kvlevebma aCvena, rom mTeli orsulobis ganmavlobaSi Tavis tkivilis gamo paracetamolis rutinuli gamoyeneba ar iwvevda saziano efeqts nayofze124(IV).

Tuki orsulobis pirvel an meore trimestrSi saWiroa aass gamoyeneba, SesaZlebelia ibuprofenis an aspirinis daniSvna125(IV). aspirinis gamoyeneba ukunaCvenebia orsulobis me-3 trimestrSi80(IV). ar arsebobs sakmarisi mtkicebulebebi imis Sesaxeb, rom orsulobis 20 kviramde

*** saqarTveloSi am rekomendacias zRudavs medikamentis siZvire.

52

ibufrofenis gamoyeneba iwvevs nayofis defeqtebs an spontanur abortebs. ibuprofeniT mkurnaloba xangrZlivi periodis manZilze an misi maRali dozebiT gamoyeneba orsulobis mogvianebiT vadebSi dakavSirebulia nayofis mxriv garTulebebis riskis zrdasTan127(IV). orsulobis periodSi triptanebis gamoyenebis usafrTxoebis mxardasaWerad sakmarisi mtkicebulebebi ar moipoveba.

zogierTi Rebinebis sawinaaRmdego saSualeba orsulebSi sifrTxiliT iniSneba. mtkicebulebebi buklizinisa da ciklizinis teratogenuri moqmedebis Sesaxeb ar moipoveba80

(IV). proqlorperazini sifrTxiliT gamoiyeneba pirvel or trimestrSi.

rekomendacia:

orsulebSi Sakikis da daZabulobis tipis Tavis tkivilis dros 1000 mg paracetamoli arCevis pirveli rigis medikamentia im SemTxvevaSi, Tuki tkivilis intensivoba moiTxovs analgeziuri saSualebis gamoyenebas (D);

Tuki paracetamoli ver uzrunvelyofs adekvatur analgezias, orsulobis pirvel da meore trimestrSi SesaZlebelia 300 mg aspirinis an 400 mg ibuprofenis gamoyeneba (D).

oraluri kontraceptivebi

calke aRebuli Sakiki da kombinirebuli oraluri kontracepciuli saSualebebis gamoyeneba damoukideblad warmoadgens insultis ganviTarebis risk-faqtorebs. amdenad, Zalzed mniSvnelovania insultis riskis Sesaxeb Sakikis mqone im qalebis konsultireba, romelTac esaWiroebaT oraluri kontracepcia. iSemiuri insultis riskis zrda kombinirebuli oraluri kontraceptivebis (kok-ebis) gamoyenebis fonze doza-damokidebulia. sxvadasxva kvlevebis monacemebiT Sansebis Tanafardoba 2,08-dan (95% CI 1,55-2,80) 2,74-mde (95% CI 2,24-3,35) meryeobs126(II). qalebSi, romelTac aReniSnebaT Sakiki auriT da xmaroben kok-ebs, insultis ganviTarebis SefardebiTi riski 8,72-s aRwevs (95% CI 5,05-15,05)127(II).

rekomendacia:

qalebma, romelTac aReniSnebaT Sakiki auriT ar unda miiRon kombinirebuli oraluri kontraceptivebi (B);

35 wels zeviT asakis qalebma, romelTac aReniSnebaT Sakiki auris gareSe, ar unda miiRon kombinirebuli oraluri kontaceptivebi (D).

menstruacia

Sakikis mqone qalebis 50%-ze meti aRwers menzesis periodSi Sakikis Setevebis sixSirisa da simZimis matebas. mtkicebulebebis safuZvelze savaraudoa, rom aRniSnuli faqti ukavSirdeba menstrualuri ciklis gvian luTeinur fazaSi estrogenebis donis dacemas128(II). aseT SemTxvevaTa umravlesobaSi Sakikis mwvave Setevebis samkurnalo standartuli preparatebi efeqturad muSaobs129(I). zolmitriptanze, sumatriptanze, naratriptansa da riztriptanze Catarebulma kvlevebma aCvena, rom es preparatebi efeqturia menstrualuri Sakikis mwvave Setevebis mkurnalobaSi130(I). qalebis 10%-ze naklebi aRniSnavs Sakikis

53

Setevebs, romlebic “eqskluziurad” dakavSirebulia menstruaciis drosTan da ar vlindeba Tvis sxva periodSi.

rekomendacia:

menstruaciasTan dakavSirebuli Sakikis mwvave Setevebis mkurnalobis mizniT SesaZlebelia mefenamis mJavis an aspirinis, paracetamolisa da kofeinis kombinaciis gamoyeneba (A);

menstruaciasTan dakavSirebuli Sakikis mwvave Setevebis samkurnalod rekomendebulia sumatriptanisa da zolmitriptanis gamoyeneba (A).

menstrualuri Sakikis specifiuri prevenciuli Terapia unda Catardes mxolod im SemTxvevaSi, rodesac qals aReniSneba regularuli prognozirebadi menstrualuri ciklebi. ramdenime SemTxveva-kontrolis kvlevis meta-analizis safuZvelze dadginda, rom perimenstrualur periodSi estradioliT Terapiis fonze menstrualuri Sakikis riski mcirdeba (RR 0,78, 95% CI 0,62-dan 0,99-mde), magram mkurnalobis fazis CamTavrebis Semdeg SesaZlebelia adgili hqondes Sakikis Setevebis sixSiris `rikoSetul~ matebas (Sakikis Setevebis gaxSireba wamlis miRebis Sewyvetis Semdeg)131(IV). calke aRebuli es kvlevebi metad mcirea imisaTvis, rom rekomendacia gaewios estradiolis gamoyenebas menstrualuri Sakikis prevenciis mizniT.

kvlevebSi, sadac pacientebs eZleoda dReSi 2,5 mg frovatriptani an 1 mg naratriptani orjer, mniSvnelovnad Semcirda menstrualuri Sakikis riski, rodesac es preparatebi pacients eniSneboda menzesis dawyebamde 2 dRiT adre da maTi miReba grZeldeboda Semdgomi oTxi da xuTi dRis ganmavlobaSi Sesabamisad132,133(I).

rekomendacia (A):

frovatriptani 2.5 mg/dReSi an naratriptani 1 mg orjer dReSi SeiZleba gamoviyenoT menstrualuri Sakikis prevenciis mizniT menzesis dawyebamde ori dRiT adre, xolo Semdeg 4 an 5 dRis ganmavlobaSi.

menopauza

perimenopauza is periodia, rodesac auris gareSe mimdinare Sakikis gavrceleba qalebSi aRwevs piks134. Ges faqti gamowveulia estrogenebis meryeobiT, romelic dakavSirebulia menstruaciuli ciklis SewyvetasTan. Sakikis sixSire mcirdeba spontanuri menopauzis Semdeg qalebSi, romelTac aReniSnebaT momatebuli mgrZnobeloba hormonuli cvlilebebis mimarT, rac gvxvdeba premenstrualuri sindromis dros135. qalebSi, romelTac menopauza uviTardebaT qirurgiuli Carevis Semdeg, Sakikis momatebuli gavrceleba aRiniSneba137(IV).

perimenopauzis Sedegia klimaqteruli sindromi (mag. vazomotoruli simptomebi, rogoricaa: RamiT oflianoba, alebi da insomnia, mexsierebis gauareseba, guneba-ganwyobis Secvla), romelic SeiZleba gaumjobesdes hormonCanacvlebiTi Terapiis (HRT) fonze.

HRT-s gamoyeneba zrdis qalebSi insultis ganviTarebis risks136(II). HRT-s

fonze SesaZlebelia aRiniSnos Sakikis gauareseba, rac garkveuli

54

kvlevebis safuZvelze ufro metad gamoxatulia estrogenebis peroraluri miRebisas, vidre maTi Seyvanis transdermalur gzis gamoyenebis dros137(IV).

rekomendacia:

HRT SeiZleba dainiSnos Sakikis mqone pacientebSi menopauzisa da perimenopauzis dros (D).

Tuki hormonCanacvlebiTi Terapiis fonze pacients aReniSneba Sakikis gauareseba, HRT unda CaiTvalos mis gamomwvev SesaZlo mizezad (D).

Tuki peroraluri hormonCanacvlebiTi Terapiis fonze adgili aqvs Sakikis simptomebis gauaresebas, unda gaviTvaliswinoT misi daniSvnis transdermuli gza (D).

cxovrebis wesTan dakavSirebuli faqtorebi

dieta

miuxedavad imisa, rom pacientebi aRniSnaven sxvadasxva saxis sakvebis fonze Sakikis provocirebas, am mosazrebis mxardamWeri Sesabamisi xarisxis mtkicebulebebi ar moipoveba138(III). aseve ver moxerxda im mosazrebis mxardamWeri mtkicebulebebis dadastureba, rom Sakikis mqone pacientebis mier yvelisa da SokoladisTvis Tavis arideba, an sxva dieturi manipulaciebi prevenciuli efeqtiT xasiaTdeba139(III). eqspertTa SeTanxmebis safuZvelze savaraudoa, rom kvebis darRveuli reJimi an sakvebis gamotoveba SesaZlebelia zogierT SemTxvevaSi asocirebuli iyos Sakikis Setevis ganviTarebasTan. magaliTad, sauzmis gamotovebam SeiZleba dilis mogvianebiTi Setevis provocireba moaxdinos, ris gamoc pacients unda erCios regularuli kveba38(IV).

rekomendacia (D):

Sakikis mqone pacientebs unda erCioT, moeridon kvebis gamotovebas.

maprovocirebeli faqtorebis Tavidan acileba

Tavis tkivilis mqone pacientebze Catarebuli kvlevis safuZvelze gamoiTqva varaudi imis Sesaxeb, rom kofeinis miRebis Semcirebisa da Zilis mowesrigebis fonze SesaZlebelia Tavis tkivilTan dakavSirebuli uunarobis Semcireba140(III).

maRalxarisxiani mtkicebulebebi imis Sesaxeb, rom mobiluri telefonis gamosxiveba ukavSirdeba Tavis tkivilis simptomebs, ar moipoveba.

fizikuri varjiSi

cervikogenuli cefalalgiebis dros kisris varjiSi msubuqi datvirTviT da manualuri Terapia amcirebs Tavis tkivilis sixSiresa da intensivobas, Tumca ar moipoveba informacia damatebiTi statistikurad mniSvnelovani sargebelis Sesaxeb im SemTxvevaSi, rodesac adgili aqvs Terapiis am ori saxeobis kobinirebul gamoyenebas141(I).

Sakikis mqone pacientebSi mravalfunqciuri Careva, romelic moicavs samkurnalo varjiSs (stresis marTvasTan, relaqsaciur TerapiasTan,

55

dietur rCevebTan da masaJTan erTad) uzrunvelyofs Tavis tkivilis sixSiris, intensivobisa da xangrZlivobis Semcirebas da pacientis cxovrebis xarisxis gaumjobesebas142(I).

Zili

maRali xarisxis mtkicebulebebi im faqtze, rom arsebobs kavSiri Zilsa da Tavis tkivils Soris, ar moipoveba. SesaZlebelia arsebobdes garkveuli asociacia Zilis obstruqciul apnoesa da qronikul Tavis tkivils Soris, Tumca Catarebul kvlevebSi Tavis tkivili ar iyo CarTuli pirveladi simptomis saxiT143(III). Zilis Cveuli xangrZlivobis cvlileba, magaliTad ufro xangrZlivi Zili SabaT-kviras an stresis gamo Zilis darRveva SesaZloa ukavSirdebodes Sakikis ganviTarebas.

stresis menejmenti (marTva)

miCneulia, rom stresi da daZabuloba kavSirSia Tavis tkivilTan da Sesabamisad zrdis Sakikis ganviTarebis risks, maSin rodesac dasveneba da stresis Semdgomi relaqsacia am risks amcirebs 144(II).

rekomendacia (B):

stresis marTva ganxiluli unda iqnes rogorc kombinirebuli Terapiis nawili, pacientisTvis SakikTan dakavSirebuli Tavis tkivilis sixSirisa da intensivobis SemcirebaSi daxmarebis mizniT.

mkurnalobis sxva formebi

fsiqoTerapia – am sferoSi Catarebuli kvlevebi dakavSirebulia sxvadasxva problemebTan, ris gamoc Sesabamisi xarisxis mtkicebulebebis mopoveba sakmaod rTulia. aSS-s Tavis tkivilis konsorciumis gaidlainebis mixedviT relaqsaciuri varjiSi, Termuli bio-ukukavSiri, eleqtromiografiuli bio-ukukavSiri da kognitiur-qceviTi Terapia SesaZlebelia ganxilul iqnes Sakikis prevenciuli Terapiis erT-erTi alternativis saxiT145(IV).

qronikuli Tavis tkivilis fizikuri Terapia:

manualuri Terapia - cervikogenuli Tavis tkivilis dros manualur Terapiaze Catarebuli kvlevebis mimoxilvam aCvena, rom spinaluri manualuri Terapia masaJTan kombinaciaSi mniSvnelovnad amcirebs Tavis tkivilis intensivobas146(I). Sakikisa da daZabulobis tipis Tavis tkivilis SemTxvevaSi misi efeqturobis Sesaxeb mtkicebulebebi naklebad moipoveba.

rekomendacia (B):

spinaluri manualuri Terapia unda gaviTvaliswinoT cervikogenuli Tavis tkivilis mqone pacientebSi.

masaJi – Sakikis mqone pacientebSi masaJi, rogorc multidisciplinaruli Carevis nawili, sakmaod efeqturia tkivilis sixSiris, intensivobisa da xangrZlivobis Semcirebis TvalsazrisiT, Tumca misi rogorc calke aRebuli meTodis roli naklebad TvalsaCinoa. nervis transkutaneuri eleqtrostimulacia (TENS) – transformirebuli Sakikis mqone pacientebze Catarebul erT-erT randomizebul kvlevaSi

56

TENS-ma gamoiwvia Tavis tkiviliT datvirTuli dReebis Tviuri raodenobis statistikurad mniSvnelovani Semcireba (p<0,05), magram es sargebeli TvalsaCino ar iyo oTxi Tvis Semdeg147(II).

akupunqtura – qronikuli Tavis tkivilis, ZiriTadad ki Sakikis mqone pacientebze Catarebulma kargad organizebulma randomizebulma kontrolirebadma kvlevam daadgina, rom im pacientebSi, romelTac utardebodaT Terapia akupunqturiT, 12 Tvis Semdeg Tavis tkivilis intensivoba statistikurad mniSvnelovnad Semcirda standartul TerapiasTan SedarebiT148(II).

rekomendacia (B):

Sakikis mqone pacientTa SemTxvevaSi prevenciuli Terapiis mizniT unda gaviTvaliswinoT akupunqturis SesaZlebloba.

oraluri reabilitacia – mtkicebulebebi imis Sesaxeb, rom iseTi paTologiis dros, rogoricaa safeTqel-qvedaybis saxsris moSliloba (romelic moicavs saxsris tkacuns, tkivils saxis areSi da qvedaybis moZraobis SezRudvas) Tankbilvis okluziuri mkurnaloba amcirebs Tavis tkivilis intensivobas an xels uwyobs mis Tavidan acilebas, ar moipoveba149(II).

rekomendacia (B):

safeTqel-qvedaybis saxsris paTologiis samkurnalod Tankbilvis okluziuri Terapia rekomendebuli ar aris.

mtkicebulebebi Tavis tkivilis mkurnalobaSi homeopaTiis an refleqsoTerapiis efeqturobis Sesaxeb ar moipoveba.

mineralebi, vitaminebi da mcenareuli preparatebi – niacini (peroraluri an intravenuri) SeiZleba sasargeblo efeqtiT xasiaTdebodes Sakikis da daZabulobis tipis Tavis tkivilis dros150(IV). koxreinis bazis mimoxilvis safuZvelze gakeTda daskvna imis Sesaxeb, rom mtkicebulebebi mcenare piretrumis (kavkasiuri gvirilis) efeqturobis Sesaxeb Sakikis prevenciis TvalsazrisiT arasakmarisia151(I).

Sakikis mwvave Setevis dros magniumis sulfatis intravenuri gamoyenebis Sesaxeb Catarebuli kvlevis safuZvelze gamovlinda, rom mas iseTive analgeziuri efeqti aqvs, rogorc metoklopramids an placebos, Tumca, gverdiTi efeqtebis albaToba mniSvnelovnad aRemateba placebos152(II).

rekomendacia (B):

magneziis intravenuri ineqcia ar aris rekomendebuli Sakikis mwvave Setevebis mkurnalobis mizniT.

riboflavini doziT 200mg dReSi Sedarda placebos da aRmoCnda, rom SetevaTa sixSire misi miRebis SemTxvevaSi Semcirda 56%-iT (9% placebos jgufSi), xolo SakikiT datvirTuli dReebis saSualo raodenoba TveSi 59%-iT (15% placebos jgufSi)153(II). 400mg riboflavinis, 300mg magneziis da 100mg piretrumis kombinaciam ver gamoavlina ukeTesi efeqti placebosTan SedrebiT, romelic Seicavda 25 mg riboflavins154(II).

57

Sakikis profilaqtikuri mkurnalobis algoriTmi

pacienti akmayofilebs

Sakikis kriteriumebs

profilaqtikuri mkurnaloba

SeafaseT faqtorebi, romlebmac

SesaZloa gadawyvitos Sakikis pirveli

rigis mkurnaloba:

*medikamentebi

-beta-blokerebi

-tricikluri antidepresantebi

*antiepilefsiuri medikametebi

-divalproeqsi

-topiramati

-gabapentini

-verapamili

*gaanaTleT pacientis da miawodeT

informacia cxovrebis stilis Sesaxeb;

*mxedvelobaSi iqonieT sxva mkurnaloba

(bioukukavSiri, relaqsacia);

*gamoavlineT, xom ar aris depresia an

generalizebuli SfoTva.

warmatebulia?*

scadeT sxva pirveli rigis medikamenti an

igive jgufis sxva wamali

warmatebulia?*

beta-blokerebis da

tricikluri antidepresantebis

kombinacia

warmatebulia?*

mesame rigis profilaqtikuri

mkurnaloba an nevrologis

konsultacia

gaagrZeleT mkurnaloba 6-12

Tve da Semdeg ganmeorebiT

SeafaseT mdgomareoba

gaagrZeleT mkurnaloba 6-12 Tve

da Semdeg ganmeorebiT SeafaseT

mdgomareoba

gaagrZeleT mkurnaloba 6-12 Tve

da Semdeg ganmeorebiT SeafaseT

mdgomareoba

warmatebulia?

warmateba ganisazRvreba rogorc:

-Tavis tkivili mcirdeba 50%-T an

metad;

-misaRebi gverdiTi movlenebi;

diax

diax

diax

ara

ara

ara

ara

58

daZabulobis tipis Tavis tkivilis algoriTmi

mkurnaloba

warmatebulia?

daZabvis Tavis

tkivili

pacienti akmayofilebs

daZabvis Tavis

tkivilis kriteriumebs

pacienti

profilaqtikuri

mkurnalobis

kandidati aris?

profilaqtikuri mkurnaloba

*amitriptilini *ssva tricikluri antidepresantebi

*venlafaqsini XR

*tizanidini

*damatebiTi Terapia

mkurnaloba

warmatebulia?

rekomenda-

ciisgan

gansxvavebuli

mkurnaloba

damatebiTi mkurnaloba

*stresis marTva

*fsiqoTerapia

daubrundiT

diagnostikur

algoriTms

mwvave Setevis

mkurnaloba:

*acetaminofeni;

*aspirini;

*anTebis sawinaaRmdego

arasteroidebi;

*midrini (kombinirebuli

preparati: acetaminofeni,

izometepteni da

diqlorafenazoni);

*damatebiTi Terapia.

*mxedvelobaSi iqonieT sxva

mwvave an profilaqtikuri

mkurnaloba;

*gadaamowmeT diagnozi;

*mxedvelobaSi iqonieT

medikamentebis Warbad gamoyeneba;

*mxedvelobai iqonieT

specialistis konsultacia.

gaagrZeleT mkurnaloba

mkurnaloba

warmatebulia?

amJamad pacients

aReniSneba Tavis

tkivili?

ara

diax

ara

ara

ara

diax

diax

59

klasteruli Tavis tkivilis algoriTmi

klasteruli

Tavis tkivili

gaagrZeleT Terapia ciklis

ganmavlobaSi, Semdeg

SeamcireT.

akmayofilebs

klasteruli

tkivilis

kriteriumebs?

amJamad pacienti

imyofeba klasterul

ciklSi?

mwvave mkurnaloba:

*Jangbadi;

*sumatriptani;

*dihidroergotamini;

*daiwyeT profilaqtikuri

mkurnaloba.

profilaqtikuri mkurnaloba:

*moeridos alkoholis

miRebas klasteruli ciklis

dros;

*verapamili (pirveli rigis).

*verapamili – maRali

dozebi;

*steroidebi da sxvebi;

*liTiumi;

*depakoti;

*topiramati.

mkurnaloba

warmatebulia?

daubrundiT diagnostikur

algoriTms

*gaaZliereT pacientis

ganaTleba;

*mxedvelobaSi iqonieT pre-

klasterul ciklSi


*gaagrZeleT da SecvaleT

mwvave mkurnaloba;

*gaagrZeleT da SecvaleT

profilaqtikuri mkurnaloba;

*mxedvelobaSi iqonieT


mkurnaloba

warmatebulia?

?

mxedvelobaSi

iqonieT

specialistis

konsultacia/

rekomendaciisgan

gansxvavebuli

midgoma

ara

diax

diax

ara

ara

ara

ara

diax

diax

diax

diax

60

menstruaciasTan asocirebuli Sakikis mkurnaloba

menstruaciasTan asocirebuli Sakiki

menstrualuri Sakikis

diagnozi dasturdeba

menstruaciis CanaweriT?

daubrundiT Sakikis

mkurnalobis algoriTms

daubrundiT Sakikis

mkurnalobis algoriTms

mxolod menstrualuri:

*Tavis tkivili aRmocendeba mxolod

menzesis dasawyisidan ±2 dReSi

asocorebulia magram ar

Semoifargleba mxolod

menstruaciiT:

*TveSi 6-8 dReze metjer

*Tavis tkivili ≥3 dRis/TveSi

roca pacients utardeba

optimaluri mkurnaloba,

magram siptomebi mainc

Somisuunaros xdis.

ixileT Sakikis mkurnalobis

algoriTmi

mkurnaloba

warmatebulia?

gaagrZeleT

mkurnaloba

cikluri profilaqtika

*anTebis sawinaaRmdego

arasteroidebi;

*triptanebi;

*ergotebi.

mkurnaloba

warmatebulia?

gaagrZeleT

mkurnaloba

hormonuli profilaqtika:

*estradiolis plastirebi;

*estrogenis Semcveli kontraceptivebi;

*GnRH (gonadotropin rilizing

hormonis) agonistebi-

ixileT estrogenis Semcveli

kontraceptivebis Sakikis algoriTmi

gaagrZeleT

mkurnaloba

mkurnaloba

warmatebulia?

Tavis tkivilis

specialistTan konsultacia

diax

diax

diax

diax

ara

ara

ara

ara

61

perimenopauzuri da monopauzuri Sakikis algoriTmi

perimenopauzuri an

menopauzuri pacienti

aqtiuri Sakikis anamneziT

aris pacienti

hormonuli Terapiis

kandidati?

pacienti Tanaxmaa

daiwyos hormonuli

Terapia?

daubrundiT Sakikis

mkurnalobis

algoriTms

scadeT Terapia Sakikis

profilaqtikuri

mkurnalobis algoriTmis

mixedviT

warmatebulia?

gaagrZeleT

mkurnaloba

hormonuli Terapia

*oraluri an transdermuli estrogenebi;

*progestini Cvenebebis SemTxvevaSi;

*estrogenebis Semcveli kontraceptivebi.

ixileT ICSI-s menopauzis da hormonuli

Terapiis rekomendacias, aseve

estrogenebis Semcveli kontraceptivebis

Sakikis algoriTmi.

warmatebulia?

gaagrZeleT mkurnaloba da

dakvirveba

kidev erTxel

gaiTvaliswineT

hormonuli Terapia

warmatebulia?

*specialistis

konsultacia;

*daubrundiT

Sakikis

mkurnalobis

algoriTms.

gaiTvaliswineT

estrogenebis da

progestinis

miwodebis gzis

cvlileba an

medikamenturi

formis

Taviseburebebi

ara

ara

ara

diax

diax

diax

ara

ara diax

62

estrogenebis Semcvel kontraceptivebze myofi an estrogenebi

Semcveli kontraceptivebis kandidatebSi Sakikis algoriTmi

estrogenebis Semcvel kontraceptivebze myofi

an estrogenebis Semcveli kontraceptivebis

kandidatebi, visac aReniSneba Sakiki

iTvaliswinebT

araestrogenul

Sobadobis

kontrols?

SeafaseT insultis risk faqtorebi:

*Sakikis aura;

*hiperkoagulaciis laboratoriuli

niSnebi;

*gadatanili arteriuli

Tromboemboliuri daavadeba;

*Tambaqos moxmareba

*progestinuli meTodebi:

- mxolod progestinis Semcveli

kontraceptivebi

- depo-provera

*arahormonuli kontracefciis meTodebi;

*saSvilosnosSida mowyobilobebi,

barieruli meTodebi.

riskis qveS?

estrogenebis dabali

Semcvelobis kontraceptivebi

Tavis tkivili

gauaresda?

*gaxSirda

*gaZlierda

*ganviTarda aura

ganagrZeT profilaqtikuri

mkurnaloba

Tavistkivili

gauaresda?

*gaxSirda

*gaZlierda

*ganviTarda

aura

ganagrZeT

mkurnaloba

* mxedvelobaSi iqonieT

progestinebis Sewyveta;

* ganmeorebiT SeafaseT

gauaresebis mizezebi;

* mxedvelobaSi iqonieT

specialistis konsultacia;

* daubrundiT Sakikis

mkurnalobis algoriTms.

*mxedvelobaSi miiReT oraluri an transdermuli

estrogenebi placebos kviris ganmavlobaSi;

*SewyviteT estrogenebis Semcveli kontraceptivebi;

*mxedvelobaSi iqonieT progestinuli meTodebi an

arahormonuli kontracefciis meTodebi;

*ganmeorebiT SeafaseT gauaresebis mizezebi;

*mxedvelobaSi miiReT specialistis konsultacia.

ara

diax

diax ara

diax

diax ara

ara

63

8. meTvalyureoba/reabilitacia

qronikuli Tavis tkivilis mqone pacientebze meTvalyureoba iTvaliswinebs mwvave Setevebis mkurnalobasa da prevencias, pacientTa simptomebis Semsubuqebas, maTi Sromis unaris gazrdasa da sicocxlis xarisxis gaumjobesebas.

Sakikis, klasteruli Tavis tkivilisa da daZabulobis tipis Tavis tkivilis mqone pacientebze meTvalyureobis mizniT rekomendebulia maTi ambulatoriuli Semowmeba 6 TveSi erTxel.

prevenciuli Terapiis daniSvnis dros rekomendebulia pacientis ganmeorebiTi vizitis organizeba sawyisidan 6-8 kviraSi, medikamentis dozis titraciisa da saukeTeso efeqturi Terapiuli dozis SerCevis mizniT.

warmatebuli prevenciuli Terapiis SemTxvevaSi aucilebelia wamlis moxsnis mcdelobis ganxorcieleba 6-12 TveSi.

ganmeorebiTi vizitebis dros aucilebelia pacientis ganaTleba Semdeg sakiTxebze:

SeZlebisdagvarad Tavi aaridos stresul situaciebs;

daicvas Zilis regularuli reJimi;

regularulad ivarjiSos;

ikvebos balansirebulad;

Tavi aaridos arakomfortul poziciebs yoveldRiuri saqmianobis an Zilis dros;

Tavi aaridos Tvalebis gadaZabvas;

miewodos informacia bio-ukukavSirisa da relaqsaciis teqnikis Sesaxeb.

9. eTikur-samarTlebrivi rekomendaciebi

Tavis tkivilis marTva pirveladi jandacvis sistemaSi samedicino eTikis mTavari principebis dacviT unda ganxorcieldes. arsebiTi mniSvneloba aqvs pacientis avtonomiis dacvas da gadawyvetilebis miRebis procesSi mis CarTvas.

rekomendacia:

pacientebs Tavis tkiviliT, kerZod maT visac aReniSneba pirvelad ganviTarebuli tkivili da Sesabamisi risk-faqtorebi, unda miewodoT amomwuravi informacia Tavis tkivilis gamomwvevi SesaZlo mizezebisa da maTi marTvis gzebis, sadiagnostiko gamokvlevebTan da medikamentur mkurnalobasTan dakavSirebuli riskisa da sargeblis, agreTve medikamentebis gadaWarbebul miRebasTan dakavSirebuli Tavis tkivilis ganviTarebis SesaZlo riskisa da misi Tavidan acilebis gzebis Sesaxeb (D);

Tavis tkivilis dros rekomendebuli diagnostikuri gamokvlevebi da medikamenturi mkurnaloba unda dainiSnos pacientisaTvis

64

mosalodneli sargebelis, potenciuri riskisa da xarjebis gaTvaliswinebiT (D).

10. praqtikaSi adaptaciis da protokolis SemuSavebis

rekomendaciebi

gaidlainis praqtikaSi adaptaciisaTvis mniSvnelovania Semdegi RonisZiebebis ganxorcieleba:

gaidlainis dabeWdva da gavrceleba saqarTvelos pirveladi jandacvis qselSi;

gaidlainis eleqtronuli versiis ganTavseba Sromis, janmrTelobsa da socialuri dacvis saministrosa da saqarTvelos ojaxis eqimTa asociaciis veb-gverdebze;

gaidlainis safuZvelze uwyveti samedicino ganaTlebis programebis SemuSaveba da samedicino personalisTvis treiningebis organizeba;

gaidlainis praqtikaSi danergvis Sefaseba klinikuri auditebis saSualebiT.

gaidlainis implementaciis rekomendebuli meTodebi:

gaidlainis gavrceleba/xelmisawvdomobis uzrunvelyofa

gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT, asociaciis veb-gverdi, saministro da a.S.

gaidlainis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba.

ganaTleba da treiningi

gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi, maT Soris moklevadiani (gadamzadebis) programaSi;

gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba; aRniSnuli programebi xelmisawvdomi unda gaxdes ojaxis eqimebisa da sxva samedicino personalisaTvis;

Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba, rogorc calkeuli eqimebis, ise ganyofilebis doneze saqmianobis marTvisaTvis.

saxelmwifo sasertifikacio gamocda;

gaidlainze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~.

profesiuli konsensusis miRweva

erToblivi konferenciebis da klinikuri garCevebis organizeba ojaxis eqimebis, nevrologebisa da Tavis tkivilis marTvaSi CarTuli sxva specialistebis monawileobiT.

65

pirvelad jandacvaSi Tavis tkivilis marTvis SefasebisaTvis

rekomendebuli auditis kriteriumebi

klinikuri auditiT unda Sefasdes pirvelad jandacvaSi Tavis tkivilis diagnostikis, mwvave Setevebisa da prevenciuli Terapiis da meTvalyurobis etapebi. rekomendebulia Sefaseba Semdegi kriteriumebis safuZvelze:

struqturis auditi:

pirveladi jandacvis centrs gaaCnia Tavis tkivilis marTvis gaidlaini da lokaluri protokolebi;

ojaxis eqimebs/eqTnebs gavlili aqvT treiningi zemoT aRniSnuli problemis marTvaze.

procesis auditi:

Tavis tkivilis diagnozis dasmisas gamoyenebuli iqna standartuli anamnezuri kiTxvari (ix. danarTi 3);

diagnozi daisva ICHD-II klasifikaciis kriteriumebis safuZvelze;

Tavis tkivilis diagnozis dasmisas Sefasda saSiSroebis (“wiTeli droSis”) niSnebi;

“wiTeli droSis” niSnebis arsebobisas pacienti gaigzavna meoreuli donis dawesebulebaSi damatebiTi gamokvlevisa da specialistis konsultaciis mizniT;

pacients miewoda informacia qronikuli Tavis tkivilis mwvave Setevebisa da prevenciuli Terapiis Sesaxeb;

pacients miewoda informacia medikamentebis gadaWarbebul gamoyenebasTan dakavSirebuli Tavis tkivilis ganviTarebis riskis Sesaxeb;

pacients miewoda informacia medikamentebis gverdiTi efeqtebisa da maTi Tavidan aridebis gzebis Sesaxeb;

pacients miewoda informacia Tavis tkivilis mkurnalobaSi aramedikamenturi meTodebis rolisa da sargebelis Sesaxeb;

prevenciuli Terapiis saWiroebis SemTxvevaSi SerCeulia pirveli rigis medikamenti;

prevenciuli medikamentis dozis titraciis mizniT pacienti ganmeorebiT dabarebulia 6-8 kviraSi;

qronikuli Tavis tkivilis SemTxvevaSi ambulatoriuli vizitebis organizeba ganxorcielda 6 TveSi erTxel.

gamosavlis auditi:

qronikuli Tavis tkivilis warmatebulad marTuli SemTxvevebis raodenoba;

pacientTa raodenoba, romelTac mwvave Setevis samkurnalo medikamentebi ar esaWiroebaT TveSi 1-ze metad;

pacientTa raodenoba, romlebic sakonsultaciod gaigzavna specialistTan.

66

11. alternatiuli gaidlaini ar arsebobs

12. gaidlainis gadasinjvis da ganaxlebis vada

gaidlainis gadasinjva da ganaxleba sasurvelia ganxorcieldes danergvidan 2 weliwadSi.

13. gaidlainis miRebis xerxi/wyaro

gaidlaini SemuSavda saqarTvelos ojaxis eqimTa asociaciis mier. igi warmoadgens sxvadasxva gaidlainis (ix. literatura) Sejerebis da adaptaciis Sedegs. pirvel etapze, Tavis tkivilis diagnostikisa da marTvis Sesaxeb uaxlesi, mecnierulad dasabuTebuli mtkicebulebebis moZiebis mizniT samuSao jgufma Caatara literaturis Zieba internetis Sesabamisi programebis saSualebiT medlainis, kokreinisa da sxva monacemTa bazaSi sakvanZo sityvebis garSemo (Headache diagnosis, Headache risk

assessment, Headache treatment and management). moZiebuli 300-mde abstraqtidan SeirCa 160-mde naSromi, romelic yvelaze metad Seesabameboda sakvlev Temas da moicavda sarwmuno mecnierul mtkicebulebebs (msgavs Temebze did britaneTsa da aSS-Si SemuSavebuli gaidlainebi155,156, randomizebuli da ara-randomizebuli kvlevebi an maTi klinikuri mimoxilva da meta-analizi). gaidlainSi aseve gamoyenebulia Tavis tkivilis saerTaSoriso klasifikaciis qarTuli gamocema157. literaturis nusxa erTvis gaidlains.

mtkicebulebebis done da rekomendaciebis xarisxi

done mtkicebulebis done xaris-

xi rekomendaciis xarisxi

I

Zlieri mtkicebuleba, eyrdnoba minimum

erT sistemur mimoxilvas, romelic

efuZneba swori dizainis mqone

randomizebul kontrolirebad kvlevas

A

eyrdnoba I donis

mtkicebulebas da

Sesabamisad mtkiced

rekomendebulia

II

Zlieri mtkicebuleba, eyrdnoba minimum

erT swori dizainis mqone

randomizebul kontrolirebad kvlevas

B

eyrdnoba II donis

mtkicebulebas da

Sesabamisad

rekomendebulia

III

klinikuri kvleva randomizaciis gareSe,

kohortuli da SemTxveva-kontrolis

kvlevebi

C

eyrdnoba III donis

mtkicebulebas, SeiZleba

CaiTvalos Sesabamisad

IV araeqsperimentuli multicentruli

kvlevebi D

eyrdnoba IV da V donis

mtkicebulebas, saWiroebs

konsesuss

Vა avtoritetul profesionalTa mosazreba

Vბ klinikuri gamocdileba, aRwerilobiTi

kvlevebi an eqspertTa angariSi

67

14. danarTebi

danarTi 1 – Tavis tkivilis ICHD-II diagnostikuri kriteriumebi

Tavis tkivilis saerTaSoriso sazogadoebis klasifikaciis (ICHD-II) SerCeviTi diagnostikuri kriteriumebi158 (aq ar aris Sesuli klasifikaciis yvela erTeuli; Sesabamisad, numeraciis Tanmidevrulobac darRveulia).

1. Sakiki

1.1. Sakiki auris gareSe.

aRweriloba: Tavis tkivilis morecidive paTologia, romelic vlindeba 4-72 saaTis xangrZlivobis SetevebiT. Tavis tkivilis tipiuri damaxasiaTebeli niSania calmxrivi lokalizacia, mopulsire xasiaTi, saSualo an mZime xarisxis intensivoba, gauareseba Cveuli fizikuri aqtivobis Sedegad da Tanmxlebi Rebineba da/an fotofobia da fonofobia.

sadiagnostiko kriteriumebi:

A. sul mcire 5 Setevidan, erTi unda akmayofilebdes B-D sadiagnostiko kriteriumebs;

B. Tavis tkivilis Seteva grZeldeba 4-72 saaTis ganmavlobaSi (mkurnalobis ararsebobis an warumatebeli mkurnalobis pirobebSi);

C. Tavis tkivils axasiaTebs qvemoT CamoTvlilidan sul mcire ori niSani:

1. calmxrivi lokalizacia;

2. mopulsire (mfeTqavi) xasiaTi;

3. tkvilis intensivoba saSualo simZimis an mZimea;

4. gauareseba dakavSirebulia Cveul fizikur aqtivobasTan an tkivilis gamo xdeba fizikuri aqtivobisTvis (magaliTad, fexiT siarulis, an safexurebze asvlis) Tavis arideba.

D. Tavis tkivilis dros adgili aqvs qvemoT CamoTvlilidan sul mcire erT niSans mainc:

1. gulisreva da/an Rebineba;

2. fotofobia da fonofobia.

E. ar aris dakavSirebuli sxva paTologiasTan.

1.2. Sakiki auriT

aRweriloba: morecidive paTologia, romelic vlindeba Seqcevadi fokaluri nevrologiuri simptomebis Setevebis saxiT. Setevebi Cveulebriv, viTardeba TandaTanobiT 5-20 wuTis ganmavlobaSi da grZeldeba sul mcire, 60 wuTis manZilze. auris simptomebs Cveulebriv, Tan sdevs Tavis tkivilis ganviTareba, romelic xasiaTdeba auris gareSe mimdinare SakikisTvis damaxasiaTebeli niSnebiT. ufro iSviaTad Tavis tkivili moklebulia Sakikis maxasiaTeblebs, an igi saerTod ar vlindeba.


A. sul mcire 2 Seteva, romelic akmayofilebs B kriteriums;

B. Sakikis aura akmayofilebs 1.2.1-1.2.6 qvetipebis B da C kriteriumebs;

C. ar aris dakavSirebuli sxva paTologiasTan.

68

1.2.1. tipuri aura Sakikis tipis Tavis tkiviliT


A. sul mcire, 2 Seteva, romlebic akmayofilebs B-D kriteriumebs;

B. aura, romelic moicavs qvemoT CamoTvlilidan sul mcire, erT-erTs mainc, magram ara motorul sisustes:

1. srulad Seqcevadi vizualuri simptomebi, pozitiuri niSnebis (magaliTad, sinaTlis cimcimi, laqebi an xazebi) da/an negatiuri niSnebis (magaliTad, mxedvelobis dakargvis) CaTvliT.

2. srulad Seqcevadi sensoruli simptomebi pozitiuri (magaliTad, Cxvletisa da SerWobis SegrZneba) da/an negatiuri (magaliTad, dabuJebis) niSnebis CaTvliT;

3. metyvelebis srulad Seqcevadi disfaziuri darRveva.

C. qvemoT CamoTvlilidan xul mcire oris arseboba:

1. homonimuri vizualuri simptomebi da/an unilateraluri sensoruli simptomebi;

2. auris sul mcire erTi simptomi mainc, romelic TandaTanobiT viTardeba ≥ 5 wuTis manZilze da/an aurisgan gansxvavebuli simptomi, romelic vlindeba Tanmimdevrulad ≥ 5 wuTis Semdeg;

3. TiToeuli simptomi grZeldeba ≥ 5 da ≤ 60 wuTis ganmavlobaSi.

D. 1.1 Sakiki auris gareSe-s B-D kriteriumebis damakmayofilebeli Tavis tkivili viTardeba auris periodSi an moyveba mas 60 wuTis ganamvlobaSi.


1.5.1. qronikuli Sakiki

A. Tavis tkivili (daZabulobis tipis Tavis tkivili da/an Sakiki), romelic grZeldeba TveSi ≥ 15 dRis manZilze sul mcire 3 Tvis ganmavlobaSi;

B. uviTardeba pacientebs, romelTac aqvT sul mcire 5 Seteva, romelic akmayofilebs 1.1. Sakiki auris gareSe-s sadiagnostiko kriteriumebs;

C. sul mcire 3 Tvis manZilze ≥ 8 dRis ganmavlobaSi Tavis tkivili akmayofilebs qvemoT moyvanil C1 da/an C2 kriteriumebs, rac niSnavs imas, rom dakmayofilebulia tkivilisa da asocirebuli simptomebis kriteriumebi SakikisaTvis auris gareSe:

1. vlindeba sul mcire ori a-d niSnebidan:

(a) calmxrivi lokalizacia;

(b) mopulsire xasiaTi;

(c) tkivilis saSualo an mZime intesivoba;

(d) gauareseba dakavSirebulia Cveul fizikur aqtivobasTan an tkivilis gamo xdeba fizikuri aqtivobisTvis (magaliTad, fexiT siarulis, an safexurebze asvlis) Tavis arideba.

da sul mcire erTi niSani a an b kriteriumebidan:

(a) gulisreva da/an Rebineba;

(b) fotofobia da fonofobia.

69

2. tkivili gadis an msubuqdeba triptanebis an ergotaminis zemoqmedebiT zemoT moyvanili mosalodneli C1 simptomebis ganviTarebamde miRebis SemTxvevaSi.

D. adgili ara aqvs medikamentebis Warbad gamoyenebas da ar aris dakavSirebuli sxva mizezobriv paTologiasTan.

2. daZabulobis tipis Tavis tkivili

2.1. iSviaTi epizoduri daZabulobis tipis Tavis tkivili

aRweriloba: Tavis tkivilis iSviaTi epizodebi, romlebic grZeldeba ramdenime wuTidan ramdenime dRemde. tkivili tipiur SemTxvevebSi bilateraluria, damwoli an moWeriTi xasiaTis, msubuqi an saSualo intensivobis da misi gauareseba ar xdeba rutinuli fizikuri aqtivobis Sedegad. am dros adgili ara aqvs gulisrevas, magram SesaZlebelia gamovlindes foto - an fonofobia.


A. sul mcire 10 epizodi, romelic viTardeba saSualod TveSi < 1 dReze sixSiriT (< 12 dReze weliwadSi) da akmayofilebs B-D kriteriumebs;

B. Tavis tkivili grZeldeba 30 wuTidan 7 dRemde;

C. Tavis tkivili xasiaTdeba qvemoT CamoTvlilidan sul mcire, ori niSniT:

1. bilateraluri lokalizacia;

2. zewoliTi/moWeriTi (ara mfeTqavi) xasiaTi;

3. msubuqi an saSualo intensivobis;

4. ar uaresdeba iseTi Cveuli fizikuri aqtivobis fonze, rogoricaa magaliTad fexiT siaruli an kibeebze asvla.

D. qvemoT CamoTvlilidan orive:

1. ar aRiniSneba gulisreva an Rebineba (SesaZlebelia gamovlindes anoreqsia);

2. fotofobiidan an fonofobiidan vlindeba mxolod erT-erTi.


± manualuri palpaciiisas perikraniuli kunTebis momatebuli daWimuloba.

2.2. xSiri epizoduri daZabulobis tipis Tavis tkivili


igivea, rac 2.1. iSviaTi epoizoduri daZabulobis tipis Tavis tkivilis SemTxvevaSi, garda:

A. sul mcire 10 epizodi, romelic viTardeba TveSi ≥ 1, magram < 15 dRis ganmavlobaSi, sul mcire 3 Tvis manZilze (≥ 12 da < 180 dReze weliwadSi) da akmayofilebs B-D kriteriumebs (2.1).

2.3. qronikuli daZabulobis tipis Tavis tkivili


igivea, rac 2.1. iSviaTi epoizoduri daZabulobis tipis Tavis tkivilis SemTxvevaSi, garda:

A. Tavis tkivili, romelic viTardeba ≥ 15 dReze saSualod > 3 Tvis ganmavlobaSi (≥ 180 dReze wlis manZilze) da akmayofilebs B-D kriteriumebs (2.1).

70

3. klasteruli Tavis tkivili da sxva trigeminul-avtonomiuri cefalalgiebi

3.1. klasteruli Tavis tkivili

aRweriloba: mkveTrad unilateraluri Tavis Zlieri tkivilis Setevebi, romelic xasiaTdeba orbitaluri, supraorbitaluri, temporaluri, an am areebis raime saxis kombinirebuli lokalizaciiT, grZeldeba 15-180 wuTis ganmavlobaSi da viTardeba yoveldRiurad erTidan 8 Setevamde sixSiriT. Setevebi asocirebulia CamoTvlilidan erT an met niSanTan, romelTaganac TiToeuli ifsilateraluria: koniunqtivis hiperemia, cremldena, cxvirT sunTqvis gaZneleba, rinorea, Sublisa da saxis oflianoba, miozi, ftozi, quTuTos SeSupeba. pacientTa umravlesoba Setevis periodSi mousvenari an aJitirebulia.


A. sul mcire 5 Seteva, romelic akmayofilebs B-D kriteriumebs.

B. mZime an Zalian mZime unilateraluri, supraorbitaluri da/an temporaluri tkivili, romelic grZeldeba 15-180 wuTis ganmavlobaSi;

C. Tavis tkivils Tan sdevs qvemoT CamoTvlilidan erT-erTi:

1. koniunqtivis ifsilateraluri hiperemia da/an cremldena;

2. cxviris ifsilateraluri gaWediloba da/an rinorea;

3. quTuTos ifsilateraluri SeSupeba;

4. Sublisa da saxis ifsilateraluri oflianoba;

5. ifsilateraluri miozi da/an ftozi;

6. mousvenrobis an aJitirebis SegrZneba.

D. Setevebis sixSire meryeobs yoveldRiurad erTidan 8-mde dReSi;

E. ar aris dakavSirebuli sxva daavadebasTan.

3.1.1. epizoduri klasteruli Tavis tkivili

klasteruli tkivilis sul mcire ori periodi, romelic grZeldeba 7-365 dRis ganmavlobaSi da erTmaneTisagan gancalkevebulia 1 Tveze naklebi xangrZlivobis remisiis periodiT.

3.1.2. qronikuli klasteruli Tavis tkivili

Setevebi viTardeba 1 welze meti drois ganmavlobaSi remisiis periodebis gareSe an remisiis periodiT, romlis xangrZlivobac < 1 Tveze.

3.2. paroqsizmuli hemikrania

aRweriloba: Tavis tkivilis Setevebi, romelTa tkivilis maxasiaTeblebi da asocirebuli simptomebi da niSnebi msgavsia klasteruli Tavis tkivilisa, magram xasiaTdeba naklebi xangrZlivobiT. Setevebi ufro xSiria, metad gavrcelebulia qalebSi da absoluturad emorCileba indometaciniT mkurnalobas.


A. sul mcire 20 Seteva, romelic akmayofilebs B-D kriteriumebs;

B. mZime unilateraluri orbitaluri, supraorbitaluri an temporaluri lokalizaciis tkivilis Setevebi, romlebic grZeldeba 2-30 wuTis ganmavlobaSi;

C. Tavis tkivils Tan sdevs qvemoT CamoTvlilidan sul mcire erTi mainc:

1. koniunqtivis ifsilateraluri hiperemia da/an cremldena;

71

2. cxviris ifsilateraluri gaWediloba da/an rinorea;

3. quTuTos ifsilateraluri SeSupeba;

4. Sublisa da saxis ifsilateraluri oflianoba;

5. ifsilateraluri miozi da/an ftozi.

D. Setevebi SesaZlebelia ganviTardes 5-jer mTeli dRis manZilze, xolo sangrZlivoba naxevar dReze meti iyos; Tumca SesaZlebelia aRiniSnebodes naklebi sixSiris periodebic;

E. Setevebis Tavidan acileba srulad SesaZlebelia indometacinis Terapiuli dozebis saSualebiT;

F. ar aris dakavSirebuli sxva paTologiasTan.

3.2.1. epizoduri paroqsizmuli hemikrania

Setevebis sul mcire ori periodi, xangrZlivobiT 7-365 dRe, romlebic erTmaneTisagan gancalkevebulia remisiis ≥ 1 Tveze SualediT.

3.2.2. qronikuli paroqsizmuli hemikrania

Setevebi, romlebic viTardeba > 1 welze periodSi remisiis Sualedebis gareSe, an remisiis SualedebiT, romelTa xangrZlivobac naklebia 1 Tveze.

3.3. xanmokle calmxrivi nevralgiismagvari Tavis tkivilis Setevebi koniunqtivis SewiTlebiT da cremldeniT (SUNCT)

aRweriloba: es sindromi xasiaTdeba unilateraluri Tavis tkivilis xanmokle SetevebiT, romlebic ufro naklebi xangrZlivobisaa, vidre nebismieri sxva tipis trigeminuli nevralgiebis dros da Zalian xSirad Tan sdevs ifsilateraluri Tvalis gamoxatuli cremldena da siwiTle.



B. unilateraluri orbitaluri, supraorbitaluri an temporaluri lokalizaciis gamWoli an mfeTqvi tkivilis Setevebi, romlebic grZeldeba 5-240 wamis ganmavlobaSi;

C. tkivils Tan sdevs koniunqtivis ifsilateraluri hiperemia da cremldena;

D. Setevebi viTardeba dReSi 3-dan 200-mde sixSiriT;


xanmokle calmxrivi nevralgiismagvari Tavis tkivilis Setevebi kraniuli vegetatiuri simptomebiT (SUNA)

aRweriloba: es sindromi xasiaTdeba Tavis tkivilis xanmokle SetevebiT, romelTa xangrZlivobac bevrad naklebia, vidre nebismieri sxva tipis trigeminuli nevralgiebis dros da Zalian xSirad Tan sdevs gamoxatuli kraniuli avtonomiuri niSnebi.



B. unilateraluri orbitaluri, supraorbitaluri an temporaluri lokalizaciis gamWoli an mfeTqavi xasiaTis tkivilis Setevebi, romlebic grZeldeba 2 wamidan 10 wuTamde.

72

C. Tavis tkivils Tan axlavs qvemoT CamoTvlilidan erT-erTi:

1. koniunqtivis hiperemia da/an cremldena;

2. cxviris gaWediloba da/an rinorea;

3. quTuTos SeSupeba.

D. Setevebi viTardeba dReSi 1-ze meti sixSiriT dRis xangrZlivobis naxevarze meti drois ganmavlobaSi;

E. trigeruli areebis gaRizianebis Sedegad provocirebul tkivilis Setevebs ar mohyveba refraqteruli periodi;

F. ar aris dakavSirebuli sxva paTologiasTan.

4. sxva pirveladi Tavis tkivilebi

4.1. pirveladi mCxvletavi Tavis tkivili

aRweriloba: Tavis mCxvletavi tkivilis gardamavali da lokalizebuli Setevebi, romlebic viTardeba spontanurad struqturuli an kraniuli nervebis organuli daavadebis ararsebobis pirobebSi.


A. Tavis tkivili, romelic viTardeba erTaderTi gamWoli Setevis an misi seriebis saxiT da akmayofilebs B-D kriteriumebs;

B. eqskluziurad an ZiriTadad SeigrZnoba samwvera nervis pirveli totis sainervacio zonaSi (orbita, safeTqeli da Txemis are);

C. Setevebi grZeldeba ramdenime wamis manZilze da viTardeba araregularuli sixSiriT dReSi erTidan ramdenime Setevamde;

D. ar axasiaTebs Tanmxlebi simptomebis arseboba;


4.2. pirveladi xvelis Tavis tkivili

aRweriloba: Tavis tkivili, romelic viTardeba xvelis an daWimvis Sedegad raime intrakraniuli paTologiis ararsebobis pirobebSi.


A. Tavis tkivili, romelic akmayofilebs B da C kriteriumebs;

B. uecari dasawyisi da xangrZlivoba erTi wamidan 30 wuTamde;

C. misi provocireba da ganviTareba xdeba mxolod xvelis, gazmorebis da/an valsalvas sinjis Sedegad;

D. ar aris dakavSirebuli sxva paTologiasTan.

4.3. pirveladi Tavis tkivili fizikuri datvirTvisas

aRweriloba: Tavis tkivili, romlis provocirebac xdeba fizikuri datvirTvis raime formiT.


A. mfeTqavi xasiaTis Tavis tkivili, romelic akmayofilebs B da C

kriteriumebs;

B. grZeldeba 5 wuTidan 48 saaTamde;

C. misi provocireba da ganviTareba xdeba mxolod fizikuri datvirTvis Semdeg;


73

4.4. seqsualur aqtivobasTan dakavSirebuli pirveladi Tavis tkivili

aRweriloba: Tavis tkivili, romlis provocirebac xdeba sqesobrivi aqtivobiT, Cveulebriv iwyeba rogorc yru xasiaTis bilateraluri tkivili sqesobrivi agznebis matebasTan erTad da uecrad gardaiqmneba intensiur tkivilad orgazmis dros, raime intrakraniuli paTologiis ararsebobis pirobebSi.

4.4.1. preorgazmuli Tavis tkivili


A. yru xasiaTis tkivili Tavisa da kisris areSi, romelic asocirebulia kisris da/an qveda ybis kunTebis daWimulobasTan da akmayofilebs B

kriteriums.

B. viTardeba sqesobrivi aqvtivobis dros da Zlierdeba sqesobrivi agznebis matebasTan erTad;


4.4.2. orgazmuli Tavis tkivili


A. uecari Zlieri Tavis tkivili, romelic akmayofilebs B kriteriums;

B. viTardeba orgazmis dros;


4.5. Zilis Tavis tkivili

aRweriloba: Tavis yru xasiaTis tkivilis Setevebi, ris gamoc pacients yovelTvis uwevs gaRviZeba.


A. yru xasiaTis Tavis tkivili, romelic akmayofilebs B-D

kriteriumebs;

B. viTardeba mxolod Zilis periodSi da aRviZebs pacients;

C. damaxasiaTebelia qvemoT CamoTvlilidan sul mcire ori niSani:

1. viTardeba TveSi 15 Setevaze xSirad;

2. gaRviZebis Semdeg grZeldeba ≥ 15 wuTze xangrZlivad;

3. pirvelad viTardeba 50 wels zemoT asakSi.

D. ar aRiniSneba vegetatiuri simptomebi; agreTve, ar aRiniSneba erTze meti simptomi Semdegi simptomebidan: gulisreva, fotofobia an fonofobia;


4.6. pirveladi “mexis dacemismagvari” Tavis tkivili

aRweriloba: uecari dasawyisis mqone Zlieri intensivobis Tavis tkivili, romelic msgavsia Tavis tvinis anevrizmis gaskdomis Sedegad ganviTarebuli tkivilisa.


A. Tavis Zlieri tkivili, romelic akmayofilebs B da C kriteriumebs;

B. qvemoT CamoTvlilidan orive damaxasiaTebeli niSani:

74

1. uecari dasawyisi, romelic maqsimalur intensivobas aRwevs 1 wuTze naklebi drois ganmavlobaSi;

2. grZeldeba 1 saaTidan 10 dRemde.

C. kvirebis an Tveebis ganmavlobaSi regularuli recidivebi ar viTardeba;


4.7. uwyveti hemikrania

aRweriloba: mudmivi, mkacrad unilateraluri Tavis tkivili, romelic emorCileba indometaciniT Terapias.


A. Tavis tkivili > 3 Tveze periodSi, romelic akmayofilebs B-D kriteriumebs;

B. qvemoT CamoTvlilidan yvela damaxasiaTebeli niSani:

1. unilateraluri tkivili mxaris cvlilebis gareSe;

2. yoveldRiuri da uwyveti, tkivilisgan Tavisufali periodebis gareSe;

3. saSualo xarisxis intensivobis, Tumca gamwvavebebis dros SesaZlebelia Zlieri tkivili.

C. gamwvavebis dros vlindeba qvemoT CamoTvlilidan sul mcire erTi vegetatiuri simptomi, romelic tkivilis ifsilateralurad vlindeba:

1. koniunqtivis hiperemia da/an cremldena;

2. cxviriT sunTqvis gaZneleba da/an rinorea;

3. ftozi da/an miozi.

D. indometacinis Terapiuli dozebis sruli efeqti;


4.8. axali yoveldRiuri Tavis tkivili (NDPH)

aRweriloba: Tavis tkivili, romelic yoveldRiuria da dawyebis Semdeg Zalian male (uxSires SemTxvevaSi 3 dReSi) iqceva daumorCilebel tkivilad. igi tipiur SemTxvevebSi bilateraluria, zewoliTi an moWeriTi xasiaTis da saSualo an msubuqi intensivobis. SesaZloa, adgili hqondes fotofobias, fonofobias an msubuq gulisrevas.

8. nivTierebebis miRebasTan an maT moxsnasTan dakavSirebuli Tavis tkivili

8.2. medikamentebis Warbi moxmarebiT gamowveuli Tavis tkivili159


A. Tavis tkivili, romelic aRiniSneba TveSi ≥ 15 dRis ganmavlobaSi;

B. Semdegi mwvave/simptomuri medikamentebis regularuli Warbi gamoyeneba 3 Tveze meti drois ganmavlobaSi:

1. ergotaminis preparatebis, triptanebis, opioidebis an kombinirebuli analgetikebis regularuli gamoyeneba TveSi ≥ 10 dRis ganmavlobaSi 3 Tveze meti drois manZilze;

2. martivi analgetikebis an ergotaminis, triptanebis da tkivilgamayuCebeli opioidebis nebismieri kobinaciis regularuli xmareba TveSi ≥ 15 dRis ganmavlobaSi 3 Tveze meti drois manZilze,

75

medikamentebis calke aRebuli romelime jgufis gadaWarbebuli gamoyenebis gareSe.

C. Tavis tkivili ganviTarda an mniSvnelovnad gauaresda medikamentebis gadaWarbebuli gamoyenebis fonze.

11. Tavis an saxis tkivili, dakavSirebuli Tavis qalas, kisris, Tvalebis, yurebis, cxviris, sinusebis, kbilebis, piris, agreTve, saxis an Tavis qalas sxva struqturebis paTologiasTan

11.2.1. cervikogenuli Tavis tkivili


A. tkivili, romelic gadaecema kisridan, SeigrZnoba Tavis da/an saxis erT an met regionSi da akmayofilebs C da D kriteriumebs;

B. kisris malebis an kisris rbili qsovilebis klinikurad, laboratoriulad da/an gamosaxviTi kvleviT dadasturebuli paTologia an dazianeba, romelic CaiTvleba Tavis tkivilis gamomwvev Rirebul mizezad;

C. mtkicebuleba, romlis mixedviTac tkivili SeiZleba davukavSiroT kisris paTologias an dazianebas, qvemoT CamoTvlilidan sul mcire erT niSanze dayrdnobiT:

1. klinikuri niSnebis gamovlineba, rac miuTiTebs tkivilis wyaroze kisris areSi;

2. Tavis tkivilis gaqroba cervikaluri struqturebis an misi nervebis diagnostikuri blokadis Semdeg placebos an sxva adekvaturi kontrolis gamoyenebiT.

D. gamomwvevi paTologiis an dazianebis warmatebuli mkurnalobidan 3 TveSi tkivilis gaqroba.

11.7. Tavis an saxis tkivili, ganpirobebuli safeTqel-qveda ybis saxsris paTologiiT


A. morecidive tkivili Tavis da/an saxis erT an met regionSi, romelic akmayofilebs C da D kriteriumebs;

B. rentgenografiuli, magnitur-rezonansuli da/an Zvlis scintigrafiuli kvleviT vlindeba safeTqel-qveda ybis saxsris paTologia;

C. mtkicebuleba, rom tkivili SesaZlebelia ukavSirdebodes safeTqel-qveda ybis saxsris paTologias, romelic eyrdnoba qvemoT CamoTvlilidan sul mcire erT niSans:

1. tkivilis provocireba xdeba ybis moZraobisas da/an mkvrivi da uxeSi sakvebis ReWvis dros;

2. piris gaRebis sifarTe Semcirebulia;

3. ybis moZraobisas vlindeba xmauri erT-erTi an orive safeTqel-qveda ybis saxsris areSi.

4. erT-erTi an orive safeTqel-qveda ybis saxsris kafsulis mgrZnobeloba momatebulia.

D. tkivili gadis safeTqel-qveda ybis saxsris paTologiis warmatebuli mkurnalobidan 3 Tvis Semdeg da misi recidivebi aRar viTardeba.

76

danarTi 2 – avtonomiur-trigeminuli cefalalgiebis diferenciuli diagnostika

trigeminuli vegetatiuri cefalalgiebi erTmaneTisagan gansxvavdeba Semdegi niSnebiT160:

sqesi: klasteruli Tavis tkivili ufro gavrcelebulia mamakacebSi (mamr : mdedr – 3,5–7 : 1); paroqsizmul hemikrania metad gavrcelebulia qalebSi (mamr : mdedr – 1 : 2,13-2,36); SUNCT ufro xSiria mamakacebSi (mamr : mdedr – 2 : 1);

xangrZlivoba: klasteruli Tavis tkivili 15 wuTi – 3 saaTi; paroqsizmuli hemikrania 2 – 45 wuTi; SUNCT 2 -250 wuTi;

sixSire: klasteruli Tavis tkivili – yoveldRiuri – dReSi 8 Seteva; paroqsizmuli hemikrania dReSi 1-40 Seteva; SUNCT – dReSi 1 Setevidan, saaTSi 30 Setevamde;

mousvenroba Setevis periodSi: 100% klasteruli Tavis tkivilis dros, 50% paroqsizmuli hemikraniis dros da 50 % SUNCT-is SemTxvevaSi;

klasteruli Tavis tkivilis SemTxvevaSi dominanturia epizoduri forma, xolo paroqsizmuli hemikraniis dros ki – qronikuli;

indometacinze daqvemdebareba absoluturia paroqsizmuli hemikraniis dros, magram igi uefeqtoa klasteruli Tavis tkivilis, an SUNCT-is SemTxvevaSi;

alkoholi xSirad iwvevs klasteruli Tavis tkivilis provocirebas, iSviaTad paroqsizmul hemikranias da ar moqmedebs SUNCT-is provocirebaze.

diferenciuli diagnozi trigeminul nevralgiasTan

vegetatiur trigeminul cefalalgiebs trigeminuli nevralgiisagan ganasxvavebs Semdegi niSnebi:

trigeminuli nevralgia SesaZloa Tanaarsebobdes klasterul Tavis tkivilsa da paroqsizmul hemikraniasTan erTad (klasteruli da paroqsizmul hemikraniuli-tikuri sindromi);

lokalizacia: vegetatiuri cefalalgiebis dros orbitaluri, supraorbitaluri da temporaluri; trigeminuli nevralgiis SemTxvevaSi 90%-Si tkivili viTardeba samwvera nervis maqsilaruli da mandibularuli totebis sainervacio zonaSi, xolo rodesac igi vlindeba Tvalbudis totis sainervacio areSi, rogorc wesi, mas mravali wliT uswrebs win tkivilis arseboba danarCeni ori totis gavrcelebis zonaSi;

xangrZlivoba: trigeminuli nevralgiis dros tkivili xanmoklea (ramdenime wami), rac advilad ganasxvavebs mas klasteruli Tavis tkivilisa da paroqsizmuli hemikraniisagan;

trigeminuli nevralgiis dros vegetatiuri simptomebi ar aris TvalsaCinod warmodgenili, xolo Tuki isini saxezea, es paTologia, Cveulebriv, mravali wlis ganmavlobaSia dadgenili, rac mas ganasxvavebs SUNCT-isagan, romlis drosac vegetatiuri simptomebi Zalzed TvalsaCinoa.

77

danarTi 3 - Tavis tkivilis anamnezi

1. Tavis tkivilis ramden gansxvavebul tips aRwers pacienti?

aucilebelia TiToeuli tipisaTvis calk-calke anamnezis Sekreba. kargia, Tuki moxdeba koncentrireba pacientisaTvis yvelaze Semawuxebel tipze, magram danarCenebsac aucileblad sWirdebaT gamokvleva im SemTxvevaSi, Tuki isini klinikurad mniSvnelovania.

2. drosTan dakavSirebuli kiTxvebi:

a) ratom mogmarTaT konsultirebisTvis amJamad?

b) ramdeni xania, rac tkivili daiwyo?

g) ramdenad xSiria da drois mixedviT rogor viTardeba (gansakuTrebiT mniSvnelovania epizodur da yoveldRiur an qronikul Tavis tkivils Soris gansxvaveba)?

d) tkivilis xangrZlivoba.

3. xasiaTobrivi kiTxvebi:

a) tkivilis intensivoba;

b) tkivilis buneba da xarisxi;

g) tkivilis lokalizacia da gavceleba;

d) asocirebuli simptomebi.

4. mizezobrivi kiTxvebi:

a) winaswarganmwyobi da/an maprovocirebeli faqtorebi;

b) damamZimebeli da/an Semamsubuqebeli faqtorebi;

g) analogiuri Tavis tkivilis ojaxuri anamnezi.

5. mkurnalobasTan dakavSirebuli kiTxvebi:

a) ras mimarTavs pacienti Tavis tkivilis dros?

b) ramdenad limitirebulia aqtivoba (funqciuri unari) an ramdenad xdeba misTvis Tavis arideba?

g) ra medikamentebs iyenebda an iyenebs amJamad pacienti da ra saxiT?

6. janmrTelobis mdgomareoba Setevebs Soris periodSi:

a) absoluturad janmrTelia, Tu aRiniSneba narCeni an persistiuli simptomebi?

b) azrebi, SfoTva da SiSi ganmeorebiTi Setevebis da/an maTi mizezebis Taobaze.

78

danarTi 4 - Tavis tkivilis yovelkvireuli dRiuri

kvira I aRwereT Tqveni Tavis tkivili 10-quliani sistemiT da miuTiTeT, Tuki gaqvT CamoTvlilidan romelime simptomi

orS samS oTxS xuTS parask Sab kvira

Tavis tkivili (0=ar aris, 10=yvelaze uaresi)

avadmyofobis SegrZneba (diax/ara)

Rebineba (diax/ara)

sxva simptomebi (diax/ara)

Setevis xangrZlivoba (saaTi)

wamowolis aucilebloba (diax/ara)

dro. romlis ganmavlobaSic ver eweodiT normalur aqtivobas

miRebuli medikamentebis tabletebis raodenoba:

daniSnuli

sakuTari iniciativiT SeZenili

menstuacia (diax/ara)

79

15. gamoyenebuli literatura

1. International Headache Society. The international classification of headache disorders, 2nd edition. Cephalgia 2004; (24 Suppl 1): 8-160 2. Martin V, Elkind A. Diagnosis and classification of primary headache disorders. In: Standards of care for headache diagnosis and treatment. Chicago (IL): National Headache Foundation; 2004. p. 4-18. 3. http://www.who.int/mediacentre/factsheets/fs277/en/Fact sheet N°277. Headache disorders. March 2004. 4. http://www.who.int/mediacentre/factsheets/fs277/en/. 5. Tepper SJ, Dahlof CG, Dowson A, Newman L, Mansbach H, Jones M, et al. Prevalence and diagnosis of migraine in patients consulting thier physician with a complaint of headache: data from the Landmark Study. Headache 2004; 44(9):856-64. 6. Kelman L. Women's issues of migraine in tertiary care. Headache. Jan 2004;44(1): 2-7. [Medline]. 7. Kors EE, Haan J, Ferrari MD. Genetics of primary headaches. Curr Opin Neurol. Jun 1999;12(3):249-54. [Medline] 8. Edvinsson L, Uddman R. Neurobiology in primary headaches. Brain Res Brain Res Rev. Jun 2005;48(3):438-56. [Medline]. 9. Burstein R, Yarnitsky D, Goor-Aryeh I, Ransil BJ, Bajwa ZH. An association between migraine and cutaneous allodynia. Ann Neurol. May 2000;47(5):614-24. [Medline]. 10. Peroutka SJ. Dopamine and migraine. Neurology. Sep 1997;49(3):650-6. [Medline]. 11. Bendtsen L. Central sensitization in tension-type headache--possible pathophysiological mechanisms. Cephalalgia. Jun 2000;20(5):486-508. [Medline]. 12. May A, Bahra A, Büchel C, Frackowiak RS, Goadsby PJ. Hypothalamic activation in cluster headache attacks. Lancet. Jul 25 1998;352(9124):275-8. [Medline]. 13. Dodick DW. Diagnosing headache: clinical clues and clinical rules. ASdv Stud Med 2003; 3(2): 87-92. 14. Fisher CM,. Late-life migraine accompaniments—further experience. Stroke 1986; 17(5): 1033-42. 15. Lipton RB, Goadsby PJ, Sawyer JPC, Blakeborough P, Stewart WF. Migraine: diagnosis and assessment of disability. Rec Contemp Pharmacother 2000; 11(2):63-73. 16. Diamond Ml. The role of concomitant headache types and non-headache co-morbidities in the underdiagnosis of migraine. Neurology 2002; 58((9 Suppl 6)): S3-9. 17. Lipton RB, Dodick D, Sadovsky R, Kolodner K, Endicott J, Hettiarachchi J, et al. A self-administered screener for migraine in primary care: the ID Migraine-super (TM) Validation Study. Neorology 2003; 61(3):375-82. 18. Maizels M, Burchette R. Rapid and sensitive paradigm for screening patients with headache in primary care sttings. Headache 2003; 43(5):441-50. 19. Smetana GW. The diagnostric value of hystorical features in primary headache syndromes: a comprehensive review. Arch Intern Med 2000; 160(18): 2729-37. 20. Mulleners WM, Aurora SK, Chronicle EP, Stewart R, Gopal S, Koehler PJ. Self-reported photophbic symptoms in migraineurs and controls are reliable and predict diagnostic category accurately. Headache 2001; 41(1): 31-9. 21. Russel MB, Fenger K, Olesen J. The family history of migraine. Direct versus undirect information. Cephalgia, 1996; 16(3): 156-60. 22. Lipton RB, Cady RK, Stewart WF, Wilks K, Hall C. Diagnostic lessons from the spectrum study. Neurology 2002; 58(9 Suppl 6): S27-31. 23. Matharu MS, Boes CJ, Goadsby PJ. Management of trigeminal autonomic cephalgias and hemicrania continua. Drugs 2003; 63(16): 1637-77. 24. Cohen AS, Matharu MS, Goadsby PJ. Short-lasting unilateral neuralgiform headache attacks with conjunctival injenction and tearing (SUNCT) or cranial autonomic features (SUNA) – a prospective clinical study of SUNCT and SUNA. Brain 2006; 129(10):2746-60. 25. Goadsby Pj, Boes C. New daily persistent headache. J Neurol Neurosurg Psychiatry 2002; 72(Suppl II): ii6-ii9. 26. Landtblom AM, Fridriksson S, Boivie J, Hillman J, Johansson G, Johansson I. Sudden onset headache: a prospective study of features, incidense and causes. Cephalgia 2002; 22(5): 354-60. 27. American College for Emergency Physicians(ACEP). Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache. Ann Emerg Med 2002; 39:108-22. 28. Aygun D, Bildik F. Clinical warning criteria in evaluation by computer tomography the secondary neurological headaches in adults. Eur J Neurol 2003; 10: 437-42. 29. Agostoni E. Headache in cerebral veonous thrombosis. Neurol Sci 2004; 25 (Suppl Oct): S206-10. 30. Maggioni F, Dainese F, Mainardi F, Lisotto C, Zanchin G. Intermittent angle-closure glaucoma in the presence of white eye, posing as retinal migraine. Cephalgia 2005; 25(8): 622-6. 31. Joseph R, Cook GE, Steiner TJ, Clifford Rose F. Intracranial space-occupying lesions in patients attending a migraine clinic. Practitioner 1985; 229(1403): 477-81.

http://www.medscape.com/medline/abstract/14979877







80

32. Schievink WI. Misdiagnosis of spontaneous intracranial hypotension. Arch Neurol 2003. 60(120: 1713-8. 33. US Headache Consortium, Frishberg BM, Rosenberg JH, Matchar DB, McCrory DC, Pietrzak MP, et al. Evidence based guidelines in the primary care setting: neuroimaging in patients with non-acute headache. [cited 16 Oct 2006]. Available from url: http://www.aan.com/proffesionals/practice/pdfs/gl0088.pdf. 34. Skau M, Brennum J, Gjerris F, Jensen R. What is new about idiopathic intracranial hypertension? An updated review of mechanism and treatment. Cephalgia 2006; 16(4): 384-99. 35. Cumurciuc R, Crassard I, Sarov M, Valade D, Bousser MG. Headache as a only neurological sign of cerebral venous thrombosis: a series of 17 cases. J Neurol Neurosurg Psychiatry 2005; 76(8): 1064-7. 36. Smetana GW, Shmerling RH. Does this patient have temporal arteriitis? JAMA 2002; 287(1): 92-101. 37. van de Beek D, de Gars J, Spanjaard L, Weisfelt M, Reitsma JB, Vermeulen M. Clinical features and prognostic factors in adults with bacterial meningitis. New Engl J Med 2004; 351 (18):1849-59. 38. British Association for the Sudy of Headache. Guidelines for all healthcare professionals in the diagnosis and management of migraine, tension-type, cluster and medication-overuse headache, 3

rd edition. Hull; 2007.

39. Linn FH, Rinkel GJ, Algra A, van Gijn J. Headache characteristics in subarachnoid heamorrhage and benign thunderclap headache. J Neurol Neurosurg Psychiatry 1998; 65(5): 791-3. 40. Williams D, Cahil T, Dowson A, Fearon H, Lipscombe S, O’Sullivan E, et al. Usage of triptans among migraine patients: an audit in nine GP practices. Curr Med Res Opin 2002; 18(1): 160-4. 41. Atasoy HT, Atasoy N, Unal AE, Emre U, Sumer M. Phsyciatry comorbidity in medication overuse headache patients with pre-existin headache type of episodic tension-type headache. Eur J Pain 2005; 9(3): 285-91. 42. Zito G, Jull G, Story I. Clinical tests of musculosceletal dysfunction in the diagnosis of cervicogenic headache. Man Ther 2006; 11(2): 118-29. 43. Sjaastad O, Fredriksen TA, Pfafenrath V. Cervicogenic headache: diagnostic criteria. The Cervicogenic Headache International Study Group. Headache 1998; 38(6): 442-5. 44. Grant R. Overview: Brain tumour diagnosis and management/Royal College of Physicians Gudeoines. J Neurol Neurosurg Psychiatry 2004; 75(Suppl 2): ii 18-23. 45. Hamilton W, Kernick D. Clinical features of primaryu brain tumours: a case-control study using electronic primary care records. Br J Gen Pract 2007; 57(542): 695-9. 46. Coleman AL. Glaucoma. Lancet 1999; 354 (9192): 1803-10. 47. Holmes WF, McGregor EA, Sawyer JP, LIpton RB,. Information about migraine disability influences physicians’ perceptions of illness severity and treatment needs. Headache 2001. 41(4): 343-50. 48. Coeitayx RR, Kaufman JS, Chao R, Mann JD, Devellis RF. Four methods of estimating the minimal important difference score were compared to establish a clinically significant change in Headache Impact Test. J Clin Epidemiol 2006. 59(4):374-80. 49. Bayliss MS, Dewey JE, Dunlap I, Batenhorst AS, , Cady R, Diamond ML, et al. A study of the feasibility of internet administration of a computerized health survey: the Headache Impact test (HIT). Qual Life Res 2003; 12(8): 953-61. 50. Lipton RB, Stewart WF, Sawyer J, Edmeads JG. Clinical utility of an instrument assessing migraine disability: The Migraine Disability Assessment (MIDAS) questionnarie. Headache 2001; 41(9): 854-61. 51. Sempere AP, Porta-Etessam J, Medrano V, Garcia-Morales I, Concepcion L, Ramos A, et al. Neuroimaging in the evaluation iof patients with non-acute headache. Cephalgia 2005; 25(1):30-5. 52. Wang HZ, Simonson TM, Greco WR, Yuh WTC. Brain MR imaging in the evaluation of chronic headache in patients without other neurologic symptoms. Acad Radiol 2001; 8(5):405-8. 53. Tsushima Y, Endo K. MR imaging in the evaluation of chronic or recurrent headache. Radiology 2005; 235(2):575-9. 54. Vernooij MW, Ikram MA, Tanghe HL, Vincent AJ, Hofman A, Krestin GP, et al. Incidental findings on brain MRI in the general population. N Engl J Med 2007; 357 (18): 1821-8. 55. Weber F, Knopf H. Incidental findings in magnetic resonance imaging of the brains of healthy young men. J Neurol Sci 2006; 240(1-2):81-4. 56. Howard L, Wessely S, Leese M, Page L, McCrone P, Husain K, et al. Are investigations anxiolytic or anxiogenic? A randomised controlled trial of neuroimaging to provide reassurance in chronic daily headache. J Neurol Neurosurg Psychiatry 2005; 76(11): 1558-64. 57. Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A and Sandor PS. EFNS GUideline on the drug treatment of migraine-report of an EFNS Task Force. Eur J Neurol 2006; 13(6): 560-72. 58. Cutrer MF, Boes CJ. Cough, exertional and sex headaches. Neurol Clin N Am 2004; 22: 133-49. 59. Favier I, van Vliet JA, Roon KI. Trigeminal autonomic cephalgias due to structural lesions: a review of 31 cases. Arvh Neurol 2007; 64(1): 25-31.

81

60. Pascual J, Iglesias F, Oterino A, Vazquea-barquero A, Berciano J. Cough, exertional, and sexual headaches: an analysis of 72 benign and symptomatic cases. Neurology 1996; 46(6): 1520-24. 61. Yousry I, Forderrheuter S, Moriggl B, Hotmannspotter M, Naidich TP, Straube A et al. Cervical MR imaging postural headache: MR signs and pathophysiological implicators. ANJR Am J Neuroradiol 2001; 22(7):1239-50. 62. Moayeri NN, Henson JW, Schaefer PW, Zervas NT. Spinal dural enhancement on magnetic resonance imaging associated with sponataneous intracranial hypotension. Report of three cases and review of the literature. J Neurosurg 1998; 88(5): 912-8. 63. O’Neill J, McLaggan S, Gibson R. Acute headache and subarachnoidal heamorrhage: a retrospective revew of CT and lumbar puncture findings. Scott Med J 2005.; 50(4): 151-3. 64. Webb S, Bone I, Lindsay K. The investigation of acute severe headache suggestive of probable subarachnoid heamorrhage: a hospital-based study. Br J Neurosurg 2003; 17(6): 580-4. 65. Smetana GW, Shmerling RH. Does this patient have temporal arteritis? JAMA 2002; 287(1): 92-101. 66. Hayreh SS, Podhajsky PA, Raman R, Zimmerman B. Giant cell arteritis: validity and reliability of various diagnostic criteria. Am J Ophtalmol 1997; 123(3): 285-96. 67. British Association for the Study of Headache. Guidelines for all healthcare professionals in the diagnosis and management of migraine, tension-type, cluster and medication overuse headache, 3rd edition. Hull, 2007. 68. Ferrari MD. Current perspectives on effective migraine treatments: are small clinical differencies important for patients? Drugs Today 2003; 39:37-41. 69. Diener HC, Bussone G, De Liano H, Eikermann A, Englert R, Floeter T. et al. Placebo-controlled comparison of effectiveness if acetylsalicylic acid, sumatriptan and ibuprofen in the treatment of migraine attacks. Cephalgia 2004; 24(11): 947-54. 70. Lipton RG, Goldstein J, Baggish JS, Yataco AR, Sorrentino JV, Quiring JN. Aspirine is efficacious for the treatment of acute migraine. Headache 2005; 45(4): 283-92. 71. Mac Gregor EA, Dowson A, Davies PT. Mouse-dispersable aspirine in the treatment of migraine: a placiebo-controlled sudy. Headache 2002; 42(4): 249-55. 72. Goldstein J, Silberstein SD, Saper JR, Elkind AH, Smith TR, Gallagher RM, et al. Acetaminophen, aspirin and caffeine versus sumatriptan succinate in the early treatment of migraine: results from the ASSET trial. Headache 2005; 45(8): 973-82. 73. Codispoti JR, Prior MJ, Fu M, Harte CM, Nelson EB. Efficacy of non-prescription doses of ibuprofen treating migraine headache. A randomized controlled trial. Headache 2001; 41(7): 665-79. 74. Dib M, Maissiou H, Weber M, Henry P, Garcia-Acosta S, Bousser MG, et al. Efficacy of oral ketoprofen in acute migraine: a double-blind ranomized clinical trial. Neurology 2002; 58(11): 1660-5. 75. Lipton RB, Baggish JS, Stewart WF, Codispti JR, Fu M. Efficacy and safety of acetaminophen in the treatment of migraine: results of the double-blind, randomized, placebo-vontrolled, population-based study. Arch Intern Med 2000; 160(22): 2486-92. 76. Besly J. The clinical and financial impact of oral triptans in the management of migraine in the UK: A systematic review; J Med Economics 2000; 3 (35-47). 77. Diener HC, Jansen JP, Reches A, Pascual J, Pitei D, Steiner TJ, et al. Efficacy, tolerability and safety of orla eletriptan and ergptamie plus caffeine (Cafergot) in the acute treatment of migraine: a multi-centred, double-blind, placebo-controlled, randomized copmarision. Eur Nerol 2002; 47(2): 99-107. 78. Edmeads J. Defininig response in migraine: which endpoints are important? Eur Neurol 2005; 1: 22-8. 79. Ferrari MD, Roon KI, LIpton RB, Goadsby PJ. Oral triptans (serotonin 5-HT1B/1D agonists) in acute migraine treatment: a meta-analysis of 53 trials; Lancet, 2001; 358 (9294):1674. 80. British National Formulary. 56th ed. London; BMJ Publishing; 2008. 81. Diener HC. Efficacy of almotriptan 12,5 mg in achieving migraine-related composite end-points: a double-blind, randomized, placebo-controlled study in patients with various poor response to sumatriptan 50 mg. Curr Med Res Opin 2005; 21(10): 1603-10. 82. Brandes JL, Kudrow D, Stark SR, O’Caroll CP, Adelman JU, O’Donnell FJ, et al. Sumatriptan-naproxen for acute treatment of migraine: a randomized trial. JAMA 2007; 297(13):1443-54. 83. Chabriat H, Danchot J, Hugues FC, Joire JE. Combined aspirin and metoclopramide in the acute treatment of migraine attacks : a review. Headache Q 1997; 8(2): 118-21. 84. Dawsson A, Ball K, Haworth D. Comparison of a fixed combination of domperidone and paracetamol (Domperamol) with sumatriptan 50mg in moderate to sever migraine: a randomized UK primary care study. Curr Med Res Opin 2000; 16(3): 190-7. 85. Colman I, Brown MD, Innes GD, Grafstein E, Roberts TE, Rowe BH. Parenteral metoclopramide for acute migraine: meta-analyisis of randomized controlled trials, BMJ 2004; 329(7479): 1369-72.

82

86. Loder E. Fixed drug combinations for the acute treatment of migraine: place in therapy. CNS Drugs 2005; 19(9): 769-84. 87. Diener HC, Agosti R, Allais G, Bergmasn P, Bussone G, Davies B, et al. Cessatiosn versus continuation of 6-month migraine preventive therap[y with topiramate (PROMPT), a randomized, double-blind, placebo-controlled trial. Lancet Neurol 2007; 6(12):1054-62. 88. US Headache Consortium. Ramadan NM, Silbersten SD, Freitag F, Gilbert TT, Frishberg BM. Evidence based guidelines for migraine headache in the primary care setting: pharmacological management for prevention of migraine.[cited 16 Oct 2008]. Available from Url: http://www.aan.com/profesionals/practice/pdfs/gl0090.pdf. 89. Linde K, Rosnagel K. Propranolol for migraine prophylaxis (Cochrane review). In: The Cochrane Library, Issue 1. London: Wiley; 2006. 90. Chronicle E, Mulleners W. Anticonvulsant drugs for migrain prophylaxis (Cochrane Review) In: The Cochrane Library, Issue 3. London: Wiley; 2004. 91. Diener HC, Tfelt-Hansen P, Dahlof C, Lainez MJ, Sandrini G, Wang SJ, et al. Topiramate in migraine prophylaxis: results from a palcebo-controlled trial with propranolol as an active control. J Neurol 2004; 251(8): 943-50. 92. Tomkins GE, Jackson JL, O’Malley PG, Balden E, Santoro JE. Treatment of chronic headache with antidepressants: a meta-analysis. Am J Med 2001; 11(1): 54-63. 93. Bulut S, Berilgen MS, Baran A, Takatas A, Atmaca M, Mungen B. Venlafaxine versus amitryptiline in the prophylactic treatment of migraine: randomized, double-blind, cross-over study. Clin Neurol Neurosurg 2004; 107(1): 44-8. 94. Cleland PG, Barnes D, Elrington GM, Loizou LA, Rawes GD. Studies to assess if pizotifen prophylaxis improves migraine beyond the benefit offered by acute sumatriptan therapy alone. Eur Neurol 1997; 38(1): 31-8. 95. Diener HC, Matias-Guiu J, Hartung E, Pfaffenrath V, Ludin HP, Nappi G, et al. Efficacy and tolerability in migraine prophylactic treatment of flunarizine in reduced doses: a comparison with propranolol 160mg daily. Cephalgia 2002; 22(3): 209-21. 96 TronvikE, Storvner LJ, Helde G, Sand T, Bavim G. Prophylactic treatment of migraine with a angiotensin II receptor blocker : a randomized controlled trial. JAMA 2003; 289(1):65-9. 97. Bensenor IM, Cook NR, Lee IM, Chown MJ, Hennekers CH, Buring JE. Low-dose aspirin in migraine prophylaxis for women. Cephalgia 2001; 21(3): 175-83. 98. Vahedi K, Taupin P, Djomby R, El-Amrani M, Lutz G, Filipetti V, et al. Efficacy and tolerabilitu of acetazolamide in migraine prophylaxis: a randomized placebo-controlled trial. J Neurol 2002; 259(2): 206-11. 99. Eftedal OS, Lydresen S, Helde G, White L, Brubakk AO, Stovner LJ. A randomized, double-blind study of the prophylactic effect of hyperbaric oxygen therapy on migraine. Cephalgia 2004; 24(8): 639-44. 100 Lee ST, Park JH, Kim M. Efficacy of the 5-HT1 agonist buspirone hydrochloride, in migraneurs with anxiety: a randomized, prospective, parallel-group, double-blind, placebo-controlled study. Headache 2005; 45(8): 1004-11. 101. Steiner TJ, Lange R, Voelker M. Aspirin in episodic tension-type headache: placebo-controlled dose-ranging comparision with paracetamol. Cephalgia 2003; 23(1):59-66. 102. Moja PL, Cusi C, Sterzi RR, Canepari C. Selective serotonine reuptake inhibitors (SSRI) for preventong miograine and tension-type headaches (Cochrane Review). In: The Cochrane Library, Issue 3. London: Wiley; 2005. 103. Sycha T, KranZ G, Auff E, Schnider P. Botulinum toxin in the treatment of rare head and neck pain syndromes: a systematic review of the literature. J Neurol 2004; 251(Suppl1):119-30. 104. Law M, Morris JK, Jordan R, Wald N. Headaches and the treatment of blood pressure: results from a meta-analysis of 94 randomized placebo-controlled trials with 24 000 participants. Circulation 2005; 112(15):2301-6. 105. Spira PJ, Beran RG, Australian Gabapentin Chronic Daily Headache Group. Gabapentin in the prophylaxis of the chronic daily headache: a randomized, placebo-controlled study. Neurology 2003; 61(12): 1753-9. 106. Ekbom K, Krabbe A, Micieli G, Prisinski A, Cole JA, Pilgrim AJ, et al. Cluster headache attacks treated for up to three months with subcutaneous sumatriptan 6mg. Sumatriptan Cluster Headache Longterm Study Group. Cephalgia 1995; 15(3): 230-6. 107. van Vliet JA, Bahra A, Martin V, Ramdan N, Aurora SK, Mathew NT, et al. Intranasal sumatriptan in cluster headache: randomized, placebo-controlled, double-blind study. Neurology 2003; 60(4): 630-3. 108. Bahra A, Gawel MJ, Hrdebo JE, Millson D, Breen SA, Goadsby PJ. Oral zolmitriptan is effective in the acute treatment of cluster headache. Neurolgy 2000; 54(9): 1832-9. 109. Kudrow L. Response of cluster headache attacks to oxygen inhalation. Headache 1981; 21(1): 1-4. 110. Costa A, Pucci E, Antonaci F, Sances G, Granella F, Broich G, et al. The effect of intranasal cocaine and lidocaine on nitroglycerin-induced attacks of cluster hreadache. Cephalgia 2000; 20(2): 85-91. 111. Leone M, D’Amico D, Frediani F, Moschiano F, Grazzi L, Attanasio A, et al. Verapamil in the prophylaxis of tepisodic cluster headache: a double-blind study versus placebo. Neurology 2000; 54(6): 1382-5.

83

112. May A, Leone M, Alfa J, Linde M, Sandor PS, Evers S, et al. EFNS guidelines on the treatment of cluster headache and other trigeminal autonomic cephalgias. Eur J Neurol 2006; 13(10): 1066-77. 113. Steiner TJ, Hering R, Couturier EG, Davies PT, Whitmarsh TE. Double-blind placebo-controlled trial of lithium in episodic cluster headache. Cephalgia 1997; 17(6): 673-5. 114. Leone M, D’Amico D, Moschiano F, Fraschini F, Bussone G. Melatonin versus placebo in the prophylaxis of cluster headache: a double-blind pilot study with parallel groups. Cephalgia 1996; 16(7): 494-96. 115. El Amrani M, Massiou H, Bousser MG. A negative trial of sodium valproate in cluster headache: methodological issues. Cephalgia 2002; 22(3): 205-8. 116. Ambrosini A, Vanderheede M, Rossi P, Aloj F, Sauli E, Pierelli F, et al. Suboccipital injection with a mixture of rapid and long-acting steroids in cluster headache: a double-blind placebo-controlled study. Pain 2005; 118(1-2): 92-6. 117. Zeeberg P, Olesen J, Jensen R. Disconinuation of medication overuse in headache patients: recovery of therpeutic responsiveness. Cephalgia 2006; 26(10): 1192-8. 118. Katsarava Z, Limmroth V, Finke M, Diener HC, Fritsche G. Rates and predictors in relapse in medication overuse headache: a 1-year prospective study. Neurology 2003; 60(10): 1682-3. 119. Zeeberg P, Olesen J, Jensen R. Probable medication-overuse headache: the effect of 2-month drug-free period. Neurology 2006; 66(12): 1894-8. 120. Zed PJ, Loewen PS, Robinson G. Medication overuse headache: overview and systematic review of therapeutic approaches. Ann Pharmacother 1999; 33: 61-72. 121. Rissi P, Di Lorenzo C, Faroni J, Cesarino F, Nappi G. Advice alone vs structured detoxification programmes for medication overuse headache: a prossective, randomized, open-label trial in transformed migraine patients with low medical needs. Cephalgia 2006; 29(9): 1097-105. 122. Diener HC, Bussone G, Van Oene JC, Lahaye M, Schwalen S, Gopadsby PJ. Topiramate reduces heaache days in chronic migraine: a randomized, double-blind, palcebo-controlled study. Cephalgia 2007; 27(7): 814-23. 123. Descombes S, Brefel-Courbon C, Thalamas C, Albucher JF, Rascol O, Monbtastruc JL, et al. Amitriptyline treatment in chronic drug induced headache: a double-blind comparative pilot study. Headache 2001; 41(2): 178-82. 124. Briggs G, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation. 7th edition. Philadelphia: Lippincott Williams and Wilkins; 2005. 125. Lee A, Inch S, Finnigan D, editors. Therapeutics in pregnancy and lactation. Abingdon: Radcliffe Medical Press; 2000. 126. Curtis KM, Mohlajee AP, Peterson HB. Use of combined oral contraceptives among women with migraine and nonmigraneous headaches: a systematic review. Contraception 2006; 73(2): 189-94. 127. Etminan M, Takkouche B, Isorna FC, SamilA. Risk of ischaemic stroke in people with migraine: systematic reviw and meta-analysis of observational studies. BMJ 2005; 330(7482):63-5. 128. Brandes JL., The influence of estrogen on migraine: a systemetic review. JAMA 2006; 295(15): 1824-30. 129. Silberstein SD, Armelino JJ, Hoffman HD, Battikha JP, Hamelsky SW, Stewart WF, et al. Treatment of menstruation-associated migraine with the non-prescription combination of acetaminophen, aspirin, and caffeine: results from three randomized, placebo-controlled studies. Clin Ther 1999; 21(3): 475-91. 130. Loder E, Silberstein SD, Abu-Shakra S, Mueller L, Smith T. Efficacy and tolerability of oral zolmitriptan in menstrually associated migraine: a randomized, prospective, parallel-group, double-blind, placebo-controlled study. Headache 2004; 44(2): 120-30. 131. Mac Gregor EA, Frith A, Ellis J, Aspinall L, Hackshaw A. Prevention of menstrual atacks of migraine: a double-blind, placebo controlled cross-over study. Neurology 2006; 67(12); 2159-63. 132. Silberstein SD, Elkind AH, Schreiber C, Keywood C. A randomized trial of flovatriptan for the intermittent prevention of menstrual migraine. Neurology 2004; 63(2): 261-9. 133. Newman L, Mannix LK, Landy S, Silberstein S, Lipton RB, Putnam DG, et al. Natatriptan as short-term prophylaxis of menstrually associated migraine: a randomized, double-blind, placebo-controlled study. Cephalgia 2001; 41(3); 248-56. 134. Ashkenazi A, Silberstein SD. Hormone-related headache: pathophysiology and treatment. CNS Drugs 2006; 20(2): 125-41. 135. Wang SJ, Fuh JL, Lu SR, Juang KD, Wang PH. Migraine prevalence during menopausal transition. Headache 2003; 43(5): 470-8. 136. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ. Kooperberg C, Stefanick ML, et al. Risks and benefitsog estrogen plius progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. Jama 2002; 288(3): 321-33.

84

137. Nappi RE, Cagnacci A, Granella F, Piccinini F, Polatti F, Facchinetti F. Course of primary headaches during hormone replacement therapy. Mturitas 2001; 38(2): 157-63. 138. Crawford P, Simmons M. What dietary modifications are indicated for migraines? J Fam Pract 2006; 55(1): 62-6. 139. Wober C, Brannath W, Schmidt K, Kapitan M, Rudel E, Wessely P, et al. Prospective analysis of factorsrelated to migraine attacks: the PAMINA Study; Cephalgia 2007; 27(4): 304-14. 140. Boardman HF, Thomas E, Millson DS, Croft PR. The natural history of headache: predictors of onset and recovery. Cephalgia 2006; 26(9): 1080-8. 141. Jull G, Trott P, Potter H, Zito G, Niere K, Shierley D, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002; 27(17): 1835-43. 142. Lemstra M, Stewart B, Olszynski WP. EFfectiveness of multidisciplinary intervention in the treatment of migraine: a randomized clinical trial. Headache 2002; 42(9): 845-54. 143. Nobre ME, Leal AJ, Filho PM. Investigation into sleep disturbance of patients suffering from cluster headache. Cephalgia 2005; 25(7): 488-92. 144. Vos J, Passchier J. Reduced impact of migraine in everyday life: an observational study in the Dutch Society of Headache Patients. Headache 2003; 43(6): 645-50. 145. US Headache Consortium. Evidence based guidelines for migraine headache: behavioral and physical treatments.[cited 17 Oct 2008]. 146. Bronfort G, Nilsson N, Haas M, Evans R, Goldsmith CH, Assendelft WJ, et al. Non-invasive physical treatments for chronic/recurrent headache (Cochrane review). In: The Cochrane Library, Issue 3. London, Wiley; 2004. 147. Allais G, De Lorenzo C, Quirico PE, Lupi G, Airola G, Mana O, et al. Non-pharmacological approaches to chronic headaches: transcutaneous electrical nerve stimulation, lasertherapy and acupuncture in transformed migraine treatment. Meurol Sci 2003; 24 Suppl2: S138-42. 148. Vickers AJ, Rees RW, Zollman CE, McCarrey R, Smith CM, Ellis N et al. Acupuncture of chronic headache disorders in primary care: randomized controlled trial and economic analysis. Health Technol Assess 2004; 8(48):1-50. 149. Koh H, Robinson PG. Occlusal adjustment for treating and preventing temporomandibular joint disorders (Cochrane Review). In: The Cochrane Library, Issue 1. London: Wiley; 2003. 150. Prousky J, Seely D. The treatment of migraines and tension-type headaches with intravenous and oral niacin (nicotinic acid): systematic review of the literature. Nutrition J 2005; 4:3. 151. Pittler MH, Ernst E. Feverfew for preventing migraine (Cochrane Review). In: Cochrane Library, Issue 1. London: Wiley; 2004. 152. Cete Y, Dora B, Ertan C, Ozdemir C, Oktay C. A randomized prospective placebo-controlled study of intravenous magnesium sulphate vs metoclopramide in the management of acute migraine attacks in the emerghency department. Cephalgia 2005; 4:3. 153. Schoenen J, Jackuy J, Lenaerts M. Effectiveness of high dose riboflavin in migraine prophylaxis. A randomized controlled trial. Neurology 1998; 50(2): 466-70. 154. Maizels M, Blumenfeld A, Burchette R. A combination of riboflavin, magnesium and feverfew for migraine prophylaxis: a randomized trial. Headache 2004; 44(9): 885-90. 155. Diagnosis and management of headache in adults. A National Clinical Guideline – Scottish Intercollegiate Guidelines Network, November 2008. 156. Institutes for Clinical Systems Improvement. Healthvare Guideline: Diagnosis and Treatment of Headache, 7th edition, January 2006. 157. Tavis tkivilis saerTaSoriso klasifikacia, II gamocema. inglisuridan Targmani Sesrulebulia nanuli SublaZis, ana ZagniZis, maia kukavas, marine janeliZis mier. qarTul enaze gamocema organizebulia Tavis tkivilis saerTaSoriso sazogadoebis qvekomitetis mier, Tavmjdomare zaza qacarava. 158. Ollessen J, Bauser MG, Diener HC, Dodick D, First M, Goadsby PJ, et al. New appendix criteria open for a broader of chronic migraine. Cephalgia 2006; 26(6): 742-6. 159. Silberstein SD, Olesen J, Bousser MG, Diener HC, Dodick D, Firest M, et al. The International Classification of Headache Disorders, 2nd edition (ICHD-II) – revision of criteria for 8.2 – Medication overuse headache. Cephalgia 2005; 25(6): 460-5. 160. Zidverk-Trajkovic J, Pavlovic AM, Mijajlovic M, Jovanovic Z, Sternic N, Kostic VS. Cluster hadache and paroxysmal hemicrania: differential diagnosis. Cephalgia 2005; 25(4): 244-8.

85

17.avtorTa jgufi

klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier

avtorebi:

nato Sengelia (ojaxis eqimi)

qeTevan rusia (ojaxis eqimi)

marina janeliZe (nevrologi)

gia meliqiSvili (bavSvTa nevrologi)

givi javaSvili (redaqtori)

guram kiknaZe (redaqtori)

eqspertebi:

Tavis tkivilis saqarTvelos sazogadoeba;

saqarTvelos saojaxo medicinis profesionalTa kavSiri;

lela woworia _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti;

Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti;

Tamar ZagniZe _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti.

Documents

Tavis tkivilis marTva pirvelad jandacvaSi...2 Tavis tkivilis marTva pirvelad jandacvaSi 1. Tavis tkivilis definicia Tavis tkivili ewodeba tkivils Tavis areSi, romelic lokalizebulia