頭痛診斷的思路

Headache第七章頭痛1.頭痛診斷的思路2.原發(fā)性與繼發(fā)性頭痛的鑒別3.偏頭痛的臨床表現(xiàn)&治療

4.緊張型頭痛的臨床表現(xiàn)&治療5.偏頭痛、叢集性頭痛、緊張型頭痛的鑒別6.低顱壓頭痛的臨床表現(xiàn)&治療本章重點(diǎn)第一節(jié)概述頭痛(headache)是臨床常見的癥狀局限于頭顱上半部疼痛(眉弓\耳輪上緣和枕外隆突連線以上)概念繼發(fā)性頭痛外傷\感染\腫瘤等所致①根據(jù)病因分為:頭痛的分類特發(fā)性頭痛偏頭痛叢集性頭痛緊張型頭痛②國(guó)際頭痛協(xié)會(huì)(2004)分類P158表7-1頭痛病因頗多?鑒別各種特發(fā)性頭痛：偏頭痛\緊張型頭痛\叢集性頭痛?排除顱內(nèi)器質(zhì)性病變：腦腫瘤\腦出血\腦膜炎等頭痛診斷思路?排除全身性疾?。喊l(fā)熱\內(nèi)環(huán)境紊亂\高血壓癲癇大發(fā)作后?排除五官疾?。罕歉]炎\牙痛\青光眼頭痛診斷思路如患者的頭痛已發(fā)生數(shù)年,通常為良性病因(如偏頭痛或緊張性頭痛),盡管急性發(fā)作時(shí)可伴明顯的功能障礙最重要的是,確定目前的頭痛與以往相似,還是代表新的疾病問診體檢輔助檢查CT&MRICSFEEG問診重點(diǎn)：①情緒\睡眠\(yùn)職業(yè)狀況,服藥史\中毒史\家族史②發(fā)病急緩,發(fā)作時(shí)間\性質(zhì)\部位\頻度\嚴(yán)重程度\持續(xù)時(shí)間\緩解&加重原因③先兆癥狀\伴隨癥狀&共存的疾病④對(duì)日常生活\工作&社交的影響頭痛的診斷頭痛發(fā)作時(shí)減輕&終止癥狀病因治療對(duì)癥治療預(yù)防性治療(慢性頭痛反復(fù)發(fā)作)去除病因

頭痛的治療第二節(jié)偏頭痛Migraine反復(fù)發(fā)作、多為偏側(cè)、中重度、搏動(dòng)性頭痛一次歷時(shí)約4-72小時(shí)可伴有視覺、感覺、運(yùn)動(dòng)、情緒紊亂及胃腸道等植物神經(jīng)癥狀安靜環(huán)境、休息，頭痛可緩解常有家族史臨床常見的特發(fā)性頭痛概念第一節(jié)偏頭痛(Migraine)(1)遺傳:約60%病人有家族史親屬偏頭痛風(fēng)險(xiǎn)是一般人群的3~6倍家族性偏頭痛患者未發(fā)現(xiàn)一致的遺傳模式病因&發(fā)病機(jī)制病因家族性偏癱型偏頭痛--高度遺傳外顯率常染色體顯性遺傳定位3個(gè)疾病基因位點(diǎn):19p13,1q21,1q31(2)內(nèi)分泌與代謝因素:

?女性易患,常始于青春期

?月經(jīng)期發(fā)作加頻,妊娠期&絕經(jīng)后發(fā)作減少\停止

?5-羥色胺(5-HT)\去甲腎上腺素\P物質(zhì)\花生四烯酸等代謝異常影響偏頭痛發(fā)生病因病因&發(fā)病機(jī)制(3)某些食物可誘發(fā)?奶酪(含酪胺)?熱狗&熏肉(含亞硝酸鹽防腐劑)?巧克力(含苯乙胺)?谷氨酸鈉(味精)?紅酒&葡萄酒禁食\緊張\情緒\月經(jīng)\強(qiáng)光&藥物可誘發(fā)(如口服避孕藥,血管擴(kuò)張劑如硝酸甘油)病因病因&發(fā)病機(jī)制(1)傳統(tǒng)血管學(xué)說(shuō)

?偏頭痛先兆癥狀--顱內(nèi)血管收縮

?頭痛--顱內(nèi)\外血管擴(kuò)張發(fā)病機(jī)制病因&發(fā)病機(jī)制(2)神經(jīng)血管假說(shuō)：

?偏頭痛可能繼發(fā)于原發(fā)性腦干神經(jīng)元功能紊亂

?刺激導(dǎo)水管周圍灰質(zhì)&中縫背核可產(chǎn)生偏頭痛

?中縫背核是5-HT受體高聚集區(qū),可能是偏頭痛發(fā)生器(3)5-HT能神經(jīng)元異常學(xué)說(shuō):(是神經(jīng)血管假說(shuō)的補(bǔ)充)

?許多抗偏頭痛藥是中樞性5-HT受體拮抗劑&激動(dòng)劑

?急性發(fā)作期血小板中5-HT↓,尿中5-HT↑

?利血平耗竭5-HT可誘發(fā)偏頭痛

?睡眠可減少5-HT神經(jīng)元點(diǎn)燃,終止發(fā)作

?頭痛時(shí)降鈣素基因相關(guān)肽(CGRP)濃度↑,服用5-HT受體激動(dòng)劑水平降低病因&發(fā)病機(jī)制發(fā)病機(jī)制臨床表現(xiàn)1.女性占2/3以上,10歲前\20歲前\40歲前發(fā)病分別25%,55%,90%2.大多數(shù)患者有偏頭痛家族史3.發(fā)作前數(shù)h至數(shù)d伴前驅(qū)癥狀(嘔吐\畏光\畏聲\抑郁\倦怠),10%的患者有視覺&其他先兆4.發(fā)作頻度不等,偶有持續(xù)性發(fā)作病例臨床表現(xiàn)國(guó)際頭痛協(xié)會(huì)(2004)偏頭痛分型P160表7-2?臨床最常見類型,約占偏頭痛的80%?無(wú)典型先兆,常見雙顳部&眶周疼痛,可為搏動(dòng)性?發(fā)作時(shí)常有頭皮觸痛,嘔吐偶可終止頭痛臨床表現(xiàn)臨床試驗(yàn):壓迫同側(cè)頸動(dòng)脈或顳淺動(dòng)脈頭痛可減輕1.無(wú)先兆的偏頭痛(migrainewithoutaura)

--普通偏頭痛(commonmigraine)臨床表現(xiàn)2.有先兆的偏頭痛(migrainewithaura)1.有先兆的偏頭痛臨床表現(xiàn)臨床表現(xiàn)2.有先兆的偏頭痛(migrainewithaura)(1).伴典型先兆的偏頭痛性頭痛：與先兆同時(shí)或先兆后60分鐘內(nèi)出現(xiàn)符合偏頭痛特征的頭痛，與先兆同時(shí)或先兆后60分鐘內(nèi)出現(xiàn)不符合偏頭痛特征的頭痛，稱為伴典型先兆的非偏頭痛性頭痛先兆后60分鐘內(nèi)不出現(xiàn)頭痛，稱為典型先兆不伴頭痛臨床表現(xiàn)2.有先兆的偏頭痛(migrainewithaura)(2).偏癱型偏頭痛(hemiplegicmigraine):?臨床少見,多在兒童期發(fā)病?先兆除偏癱外，還應(yīng)包括視覺、感覺和言語(yǔ)三種先兆之一，先兆持續(xù)5min-24h，與先兆同時(shí)或先兆后60分鐘內(nèi)出現(xiàn)符合偏頭痛特征的頭痛?偏頭痛消退后偏癱持續(xù)10min~數(shù)周不等?分兩型:家族型\散發(fā)型臨床表現(xiàn)2.有先兆的偏頭痛(migrainewithaura)（3）.基底型偏頭痛(basilarmigraine)或稱基底動(dòng)脈偏頭痛(basilararterymigraine)?兒童&青春期女性較多見?頭重腳輕\眩暈\復(fù)視\眼震\耳鳴\構(gòu)音障礙\雙側(cè)肢體麻木&無(wú)力\共濟(jì)失調(diào)\意識(shí)改變\跌倒發(fā)作&黑矇等腦干&枕葉癥狀,提示椎-基底動(dòng)脈缺血?多見閃光\暗點(diǎn)\視物模糊\黑矇\視野缺損等視覺先兆,持續(xù)20~30min,先兆同時(shí)或先兆后60分鐘內(nèi)出現(xiàn)符合偏頭痛特征的頭痛,常伴惡心\嘔吐1.診斷

?根據(jù)偏頭痛發(fā)作臨床表現(xiàn)\家族史&神經(jīng)系統(tǒng)檢查?不典型者可用麥角胺&曲普坦類試驗(yàn)治療?腦部CT\MRI\MRA檢查正常?排除顱內(nèi)動(dòng)脈瘤\占位性病變&痛性眼肌麻痹等可確診診斷&鑒別診斷國(guó)際頭痛協(xié)會(huì)(2004)偏頭痛診斷標(biāo)準(zhǔn)P162診斷&鑒別診斷偏頭痛\叢集性頭痛\緊張性頭痛的分布&特點(diǎn)少見,一側(cè)眶周發(fā)作性劇烈頭痛,特點(diǎn):反復(fù)密集發(fā)作?家族史罕見,發(fā)病較偏頭痛晚,平均25歲,男:女性4~5:1?在叢集發(fā)作(數(shù)周至數(shù)月)期內(nèi)一次接一次成串發(fā)作?極劇烈單側(cè)持續(xù)非搏動(dòng)性頭痛,持續(xù)數(shù)min~2h?開始鼻旁燒灼感&眼球后壓迫感,伴同側(cè)結(jié)膜充血\流淚\流涕&Horner征等,可伴頭痛側(cè)眼瞼下垂?飲酒&血管擴(kuò)張藥可誘發(fā)?幾乎每日同一時(shí)間(常在晚上)發(fā)作,從睡眠中痛醒?每年春\秋季發(fā)作一兩次,發(fā)作間期數(shù)月或數(shù)年無(wú)頭痛診斷&鑒別診斷2.鑒別診斷

(1)叢集性頭痛(clusterheadache)?吸氧(100%氧氣8~10L/mim,10~15min)?舒馬普坦(sumatriptan)\二氫麥角胺(dihydroergotamine)可迅速緩解頭痛?潑尼松40~60mg/d,p.o,1w,多可在2d內(nèi)消退,第2w逐漸減量停藥診斷&鑒別診斷發(fā)作期預(yù)防復(fù)發(fā)?美西麥角(methysergide)2~8mg口服,1次/d?鈣離子拮抗劑(異博定緩釋型)預(yù)防夜間發(fā)作?睡前用麥角胺直腸栓劑&二氫麥角胺皮下注射

(1)叢集性頭痛治療臨床最常見的慢性頭痛,約占頭痛病人的40%幾乎每日雙枕部非搏動(dòng)性頭痛,持續(xù)性鈍痛如帶子緊束頭部&頭周縮箍感\(zhòng)壓迫感\(zhòng)沉重感不伴前驅(qū)癥狀---慢性每日頭痛(dailychronicheadache)可伴頭昏\失眠\(yùn)焦慮&抑郁頭痛部位壓痛點(diǎn)頸肩背部肌肉僵硬感診斷&鑒別診斷(2).緊張型頭痛(Tension-typeheadache)：本病許多治療藥物與偏頭痛相同?急性發(fā)作期--對(duì)乙酰氨基酚\阿司匹林\非甾體抗炎藥麥角胺&二氫麥角胺等?預(yù)防性治療--阿米替林\丙咪嗪&選擇性5-羥色胺再攝取抑制劑(如舍曲林\氟西汀)有效?心得安對(duì)某些病例有用?失眠者可用苯二氮卓類如地西泮10~20mg/d口服診斷&鑒別診斷(2).緊張型頭痛的治療診斷&鑒別診斷(3)痛性眼肌麻痹(painfulophthalmoplegia)Tolosa-Hunt綜合征海綿竇特發(fā)性炎癥伴頭痛&眼肌麻痹?發(fā)生于任何年齡,壯年多見?頭痛發(fā)作常表現(xiàn)球后&眶周頑固性脹痛\刺痛&撕裂痛,伴惡心\嘔吐,數(shù)d后出現(xiàn)痛側(cè)動(dòng)眼\滑車&外展神經(jīng)麻痹,表現(xiàn)上瞼下垂\眼球運(yùn)動(dòng)障礙&光反射消失等?持續(xù)數(shù)d至數(shù)w緩解,數(shù)月至數(shù)年后又可復(fù)發(fā)?皮質(zhì)類固醇口服有效如高血壓&低血壓\未破裂顱內(nèi)動(dòng)脈瘤&動(dòng)靜脈畸形\慢性硬膜下血腫等均可有偏頭痛樣頭痛,部分病例有局限性神經(jīng)體征\癲癇發(fā)作&認(rèn)知功能障礙腦CT\MRI\DSA可顯示病變

診斷&鑒別診斷(4)血管性頭痛治療目的減輕&終止發(fā)作緩解伴發(fā)癥狀預(yù)防頭痛復(fù)發(fā)包括發(fā)作期治療&預(yù)防性治療

治療1.發(fā)作期治療

急性偏頭痛發(fā)作單用止痛劑

對(duì)乙酰氨基酚(acetaminophen)

萘普生(naproxen)

布洛芬(ibuprophen)

無(wú)效時(shí)麥角制劑&5-HT激動(dòng)劑舒馬普坦通常有效

治療?適用于頻繁發(fā)作,尤其1次/week以上嚴(yán)重影響正常生活&工作?急性期麥角生物堿治療不能耐受&禁忌的患者治療心得安\阿米替林\丙戊酸是治療的支柱2.預(yù)防性治療

鈣通道拮抗劑，普通型&典型偏頭痛均有效非藥物治療：停服某些藥物：調(diào)整飲食：鍛煉耐力：第二節(jié)低顱壓性頭痛IntracranialHypotensionHeadache低顱壓性頭痛(intracranialhypotensionheadache)CSF壓力降低(<70mmH2O)導(dǎo)致的頭痛概念

多為體位性常在直立后15min內(nèi)出現(xiàn)頭痛\明顯加劇臥位頭痛緩解&消失包括特發(fā)性&繼發(fā)性?特發(fā)性病因不明可能與血管舒縮障礙致CSF分泌減少&吸收增加有關(guān)?繼發(fā)性可因多種原因腰穿\頭頸部外傷\腦室分流術(shù)使CSF漏出增多脫水\糖尿病酮癥酸中毒\尿毒癥\全身嚴(yán)重感染\腦膜腦炎\過度換氣&低血壓等使CSF生成減少病因&發(fā)病機(jī)制CSF量減少\壓力降低\腦組織移位下沉等使顱內(nèi)痛敏結(jié)構(gòu)如腦膜\血管&三叉\舌咽\迷走等受牽張引起頭痛

見于各種年齡

特發(fā)性多見于體弱女性,繼發(fā)性無(wú)明顯性別差異

頭痛以枕部&額部多見,呈輕-中度鈍痛&搏動(dòng)樣疼痛,緩慢加重,常伴惡心\嘔吐\眩暈\耳鳴\頸僵&視物模糊

頭痛與體位有明顯關(guān)系,立位出現(xiàn)&加重,臥位減輕&消失,頭痛多在變換體位后15min內(nèi)出現(xiàn)

臨床表現(xiàn)根據(jù)體位性頭痛典型臨床特點(diǎn)腰穿測(cè)腦脊液壓力(<60mmH2O)可確診部份病例放不出CSF(“干性穿刺”)少數(shù)病例CSF細(xì)胞數(shù)輕度增加,蛋白質(zhì)\糖\氯化物正常

注意與產(chǎn)生體位性頭痛的疾病鑒別?腦&脊髓腫瘤?腦室梗阻綜合征?寄生蟲感染?腦靜脈血栓形成?亞急性硬膜下血腫&頸椎病

診斷&鑒別診斷治療1.病因治療如控制感染\糾正脫水&糖尿病酮癥酸中毒等2.對(duì)癥治療臥床休息\補(bǔ)液(2000~3000ml/d)穿緊身褲&束腹帶適量用鎮(zhèn)痛劑腰穿后頭痛可鞘內(nèi)注射無(wú)菌生理鹽水治療3.

藥物治療苯鉀酸鈉咖啡因500mg,皮下&肌肉注射或加入500~1000ml乳化林格液緩慢靜脈滴注治療4.硬膜外血貼療法(epiduralbloodpatching)

壓迫硬膜囊&阻塞腦脊液漏出口,迅速緩解頭痛,適于腰穿后頭痛&自發(fā)性低顱壓性頭痛有效率達(dá)97%1.臨床診斷頭痛時(shí)應(yīng)注意什么2.偏頭痛的概念3.有先兆偏頭痛的臨床表現(xiàn)&治療

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