頭痛醫學

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1 門急診常見頭痛的治療及陷阱 Pitfalls of Headache and Treatment in Practice 奇美醫學中心全人醫療科林高章主任 ER----Emergency Room

2 Functional headache ( 功能性頭痛 ) Migraine Tension type headache Cluster and other trigeminal autonomic cephalalgia Other primary headache (stabbing, cough, intercourse..) Episodic <15d/m Chronic >15d/m, >3m

3 2 Migraine Diagnosis (IHS criteria) Migraine Without Aura (ICHD, 2004) At least two of the following features: Unilateral location Throbbing character Worsening pain with routine activity Moderate to severe intensity At least one of the following features: 1 Nausea Adolescents and/or vomiting migraine: 1-48 hours, Photophobia bilateral, and autonomic phonophobia disturbance Obvious postdrome symptoms Medical History, Headache diary, Migraine triggers 1 Investigations (only to exclude secondary causes) ex: EEG / CT Brain / MRI Adults: 頻率 5 times, 時間持續 4-72 hours

4 台灣經驗 (755 headache patients, 102 neurologists) 中重度頭痛噁心畏光敏感性 82%, 特異性 73% 陽性預測率 =91%( 神經科門診 ) J Formos Med Assoc 2008;107: In past 3m, does your HA have nausea? 2. Do you have more light sensitive during HA? 3. Do you have more disability during HA? 2/3==91% 3/3==98% (Lipton et al, Neurology, 2004)

5 Migraine headache ( 偏頭痛 ) Trigeminal nerve was stimuli extending from occipital to anterior, and substance-p (glutamate, CGRP) extra-vasation with evolving to central sensitization to hypothalamus resulting in nausea/vomiting, visual blurring, or fatigue symptoms.

6 Cortical spreading depression 皮質擴散抑制藥物介入時機

7 EBM for acute migraine (US) 1. Sumatriptan (po, iv, sc) 2. Rizatriptan (po) 3. Naprosin solium (po) 4. Ibuprofen (po) 5. Prochlorperazine (iv) 1. Diclofenac K (po) Group 1 recommend 2. Chlorpromazine (im, iv) 3. Metochlopromide (iv) 4. Ketorolac (im) Group 2 recommend 1. Cafergot (po) 2. Metochlopromide (im) Group 3 recommend (C) (AAN guideline-2000)

8 Taiwan guideline for Acute Rx (2007) (A) Imigran- 英明格 (po, nasl),(rizatan- 羅沙疼 ) (B) Ergots (cafergot),dhe,panadol,nsaids (A) Aspirin,Ibuprofen (PO)- 輕度偏頭痛

9 (B) Primperan, Novamin, Droperidol (im/iv) (C) Magnesium, Valproate, Lidocaine, Opioids

10 Tension type headache ( 緊縮性頭痛 ) Headaches lasting from 30 minutes to 7 days At least two of the following pain characteristics: Pressing or tightening (nonpulsating) quality Mild to moderate intensity Bilateral location No aggravation from walking stairs or similar routine activities Both of the following: No nausea or vomiting Photophobia and phonophobia absent, or only one is present

11 Tension-type Headache or Migraine Mild Moderate Severe Unilateral Bilateral Photophobia Nausea Throbbing Pressure Aura Vomiting Aggravated by Activity Tension-Type ( 輕 / 中 ) 疼痛嚴重度 ( 中 / 重 ) Migraine 2002 Primary Care Network

12 Cluster headache ( 叢發性頭痛 ) Unilateral 100% Restlessness 93% Retroorbital 92%, (temporal 70%) Lacrimation 91% Conjuctival injections 77% Nasal congestion/rhinorrhea 75% Ptosis/eyelid swelling 74% Phonophobia/phophobia 50% 季節性因素, 男 > 女, 頭痛嚴重度 - 中, 頭痛合併流淚 / 紅眼 / 眼窩痛 / 眼皮墜..

13 Treatment Acute tryptans (Imigran/ Rizatan) 74% effective within 15 min Nasal spray may be more effective Oxygen (100% O2, high flow volume, 7-12L)

14 References 陳韋達陳錫銘陳威宏陳彥宇傅中玲謝蒼松許立奇莊凱迪林高章林日暉劉崇祥盧相如蔡景仁王博仁王署君吳進安 ( 台灣頭痛學會治療準則小組 ). 偏頭痛急性發作藥物治療準則.Acta Neurol Taiwan 2007;16: 林高章陳錫銘陳威宏陳韋達陳彥宇傅中玲謝蒼松許立奇莊凱迪林日暉劉崇祥盧相如蔡景仁王博仁王署君吳進安 ( 台灣頭痛學會治療準則小組 ) 偏頭痛預防性藥物治療準則 Acta Neurol Taiwan 2008;17: 陳炳錕陳錫銘陳威宏陳彥宇傅中玲李連輝廖羽筑林高章曾弘斌蔡景仁王博仁王署君楊鈞百姚俊興吳進安 ( 台灣頭痛學會治療準則小組 ) 叢發性頭痛治療準則 Acta Neurol Taiwan 2011; 20:

16 Organic headache (pearl symptoms) Midnight or early morning headache Associated with Sz, neck stiffness, focal neurological signs, lapse.. Headache with LOC Headache pattern change Thunderclap headache (Shower HA) Other (RCVS-Reversible cerebral vasoconstriction syndrome )

17 Increased intracranial hypertension CPP= MAP-ICP = D+1/3(S-D)- ICP (2006, BJA)

18 Symptoms and signs of IICP Headache/vomiting/papilloedema Cushing triad VI palsy Thumb signs Sella erosion Sulci effacement

19 IICP DVT pseudo-tumor cerebri Empty sella Midline shift VI palsy Thumb sign

20 Idiopathic IICP (pseudotumor cerebri) 1. Most frequently occurs in obese women of childbearing age. 2. F:M=3~8:1 3. May associate with endocrine (adrenal insuff, Cushing synd, hyper-, hypo-thyroidism..), drugs (cimetidine, steroids, minocycline, nalidixic acid, tamoxifen..), IDA, CKD, SLE, Lyme disease Headache, N/V, gradual visual loss,papilloedema.. 5. Ddx by screening of CT/MRI/CSF/biochemistry/serology tests.. 6. Rx: medical (prednisolone) and surgery (CSF diversion). 7. Underlying control (weight loss, stop causative meds..).

21 Red flags in IICP

22 Cases scenario CC: 35-year-old had severe headache with vomiting for 2 days. PI: Persistent headache for 4 weeks, from occipital extended to frontal area. Non-pulsation character, position-related (upright worsen, lying down better), whole days long.severe pounding pain when head down (pain score 7-8) Neurological exam.- NP

23 Brain CT (without contrast) 1.IICP 2.Sinus thrombosis

24 R/o SAH, aneurysm or AVM rupture

25 C- C+

26 MRI (T2WI) SDH? Subdural effusion?

27 MRI

28 CSF study IP/TP= 60/30 mm H20 India ink- negative. Gram stain- negative TB-PCR-negative. WBC=1 RBC=140 L:N=1:0 Protein= 54.3 (15-45mg) Sugar 77 (40-70) Diagnosis?

29 Intracranial hypotension syndrome: a comprehensive review (Neurosurg Focus, 2003) 1. It is characterized by orthostatic headache, usually occur or worsen with upright posture. 2. May associate with chronic headache or even no suffers. 3. Pain exacerbated by laughing, coughing, or Valsalva maneuver. 4. Resistant to treatment of analgesic agents.

30 5. Nausea, vomiting, anorexia, neck pain, dizziness, horizontal diplopia, change in hearing, galactorrhea, facial numb and weakness can occur, related to orthostatic nature. 6. Usually benign course and resolve symptoms with conservative treatment. 7. Dx can be confirmed by CSF opening pressure (<60 mmh20), CSF usually be normal or mild increase protein, WBC, or RBC. 8. Occur from a persistent CSF leakage, dural puncture, myelography or spinal anesthesia; may be violated as craniotomy, spinal surgery, craniospinal trauma, or VP shunting.

31 CT and MRI diagnosis CT demonstrate obliteration of basal cisterns due to sagging of brain (misdiagnosed of SAH). MRI (Gd+) with diffused thickening of pachymeninges, engorge venous sinus, subdural fluid collection, enlargement of pituitary gland, and downward displacement of the brain. MR images resolution parallels to clinical improvement. Compensatory hypothetical mechanism to CSF loss with above findings.

32 Treatment 1. Conservative treatment and bed rest. 2. Increase fluid restoration, eliminating CSF leakage. 3. Increase salty intake. 4. Epidural blood patch to be a safe and effective treatment (85~98%). 5. Epidural fibrin glue shows a promising result. 6. Surgical correction when all procedures are failed. Pearl symptom: Orthostatic headache

33 What kind of headache appearance is pathogenic? All might be.

34 Sinus thrombosis with ICH yrs, young F, had pulsatile tinnitus and bilateral throbbing headache for 1 month. 2. S/s off and on after medications but frequent recurrence. 3. Neck rigid followed persistent headache and MFP told by physician. 4. Lapse with seizure once, and was sent to ER. 5. PE/NE with Lt side weakness. 無緣無故怎麼會出血? 如果高血壓, 也不是常見位置! 怎麼會頭痛????

35 高血壓常見出血位置 Putamen (40%) Thalamus (30%) Brain stem-pons(10%) Cerebellum (10%) Subcortical area (10%)

36 Management of sinus thrombosis 1. ICU care with IICP control 2. Heparinization CPP= MAP- ICP Pearl symptom: Headache with lapse, neck rigid or focal NE signs P V

37 對於奇怪的頭痛, 不論有否合併神經學異常其他例子,DVT 一定要考慮! yrs teenager had fever and headache for 2 wks yr-old F had poorly controlled Sz and severe headache for 1 week.

38 Cervicogenic headache 1. Occipital headache and nuchal numb for a long time. 2. Sudden onset of left limbs weakness and numb for 2 days. 3. Left dystonic limb and unsteady gait. 4. Neck supple and no cranial nerve lesion 5. Brain CT= Negative

39 頸因性頭痛 (ICHD-II, 2004) A. 源自頸而表現在頭及 / 或臉一處或多處的疼痛, 符合基準 C 及 D B. B. 經臨床實驗室及 / 或影像證明, 有一已知是或普遍認定為頭痛確切致因的頸椎或頸部軟組織疾患或病變 C. C. 依據至少下列一項, 證實該疼痛可歸因於頸疾患或病變 : 1. 臨床徵候顯示, 疼痛來自頸部 2. 在安慰劑或其他合適的控制型試驗下, 對頸部結構或其支配神經施行診斷性神經阻斷後, 可解除頭痛 D. D. 疼痛在致病疾患或病變有效治療後三個月內緩解

40 Cervical artery dissection yrs male patient suffered from headache and right neck pain after message. 2. Throbbing HA pattern without Nausea/Vomiting. 3. Transient fall and dizzy after morning awakened on the next day. 4. NE-NP, PE-Neck bruits? 5. HA subsided with NSAID, but dizzy persistent.. Diagnosis?

41 自發性或外傷性 Pearl symptom: Headache and neck bruit (post-massage) 頸動脈撕裂傷 1. 頭痛及頸部疼痛為主要主訴 2. 神經學檢查 ( 必須聽一聽頸部有否雜音 ) 3. CT/MRI 不一定會有發現, 必須靠血管檢查 (CTA,MRA) 4. 頸動脈超音波可以協助了解是否狹窄或撕裂 5. 治療可以置放頸部支架或血管修補術

42 Space-occupied Pearl symptom: lesion (primary Headache brain and tumor VF defect or meta?) yrs old, F, had sudden headache with pounding character over vertex (VAS-10). 2. Previous migraine Hx(+), and breast ca 5 yrs ago, with CT/RT therapy. 3. PE/NE showed no focal limbs weakness, visual filed (VF) defect was defined by confrontation test. Diagnosis?

43 SAH, aneurysm rupture yrs old male pt, HTN+, DM+, Sudden severe headache and LOC. 2. Vomiting during HA, and four limbs weakness defined. 3. Neck stiffness was noted (4fb band width) and OCHA on arriving at ER. 4. pupil dilated on both eyes

44 Pearl symptom: Unusual headache and neck stiffness SAH 1. 自發性必需深究原因 ( 年輕人 -AVM; 中老年 -Aneurysm) 2. 外傷性可以症狀治療處理 3. 血壓高必須區別是否腦壓升高. 4. 注意有否 IICP( 如前 -Cushing, severe vomiting, VI palsy..) 5. 外傷性但輕微神經學症狀, 不一定要住 ICU. 6. 使用 Nimotop (CCB) 避免血管收縮造成腦缺血 7. TCD 可以了解腦血流狀況 ( 流量高低, 阻力高低 ) Thunderclap headache ( 雷擊性頭痛 )

45 Summary of findings Increased Intracranial Pressure (ICP) and Cerebral Circulatory Arrest INDICATION SENSITIVITY (%) SPECIFICITY (%) REFERENCE STANDARD Cerebral Circulatory Arrest and Brain Death Conventional angiography, EEG, clinical outcome Recommendation: TCD is a useful adjunct test for the evaluation of cerebral circulatory arrest associated with brain death (Type A, Class II evidence). (Copyright 2004 American Academy of Neurology)

46 E1VEM1 FLACCID RESPONSE ALL REFLEX(-) Small systolic sharp Reverse flow pattern MCA + BA ( 較準確 )

47 SDH with IICP High Peak, Low diastolic

48 Meningoencephalitis yrs, F, URI for 1 wk. 2. Fever and non-specific headache off and on, but persistent for 10 more days. 3. Seizure once and was sent to ER. 4. PE/NE; neck stiff (2fb), and post-ictal confusion. Diagnosis?

49 Pearl symptom: Headache, fever and conscious change 腦膜腦炎 1. 可以單獨影響腦膜或腦炎 ( 意識較易影響 ) 2. 區別病因 ( 病毒, 細菌, 其他 ) 3. CSF+MRI 檢查 4. 確定病毒性, 急診就需使用 acyclovir ( 愈早使用愈好 ) 5. 預後依其影響範圍而定 6. 抽搐必須藥物控制避免缺氧或重積癲癇 7. 使用 EEG 評估功能影響 ( 不必一直 MRI 追蹤 )

50 Pearl symptom: Headache, eyeball pain Acute glaucoma yrs, F, Rt frontal headache for 5 days, with hallow vision ( 中空, 光蘊, 散射光..) 2. PE- right reddish eye, tender over eyeball (+) 3. IOP 30(od), 18(os) 4. NE- NP Diagnosis?

51 Pearl symptom: Headache, exo-oph, eye bruits CCF (Carotid cavernous fistula) yrs, M, had MCA, on right frontal and eye injury. 2. Chemosis, exopthalmosis, and throbbing headache. 3. Carotid and right eye bruit. 4. Confirmed by angiography or imaging study. Diagnosis? 5. Rx with balloon tamponade or surgical repair.

52 Take home message 1. 區別 Functional 或 Organic HA 2. Organic HA 必須影像區別 (SAH, SIH, tumor, dissection, meningitis, meningo-encephalitis, CCF, glaucoma, sinusitis, sinus thrombosis, etc) 3. Babinski s sign should be performed if possible ( 可以區別 pyramidal tract 是否 involved) 4. NSAIDs/ acetaminophen/aspirin are preferred firstly, and opioids followed if pain not subsided or pain score> Education is useful to prevent the re-visiting ED.

53 Thank you for your attention

<4D6963726F736F667420506F776572506F696E74202D2032303134C4EA20CDB7CDB420C2EDB4BAC0B4A3A8C9BEBCF5B0E6A3A92E707074205BBCE6C8DDC4A3CABD5D>

<4D6963726F736F667420506F776572506F696E74202D2032303134C4EA20CDB7CDB420C2EDB4BAC0B4A3A8C9BEBCF5B0E6A3A92E707074205BBCE6C8DDC4A3CABD5D> 头痛马春来复旦大学附属华山医院药剂科 Nov 2014 学习目标头痛的流行病学定义了偏头痛的病理生理学基础治疗药物的药理作用急性和预防偏头痛治疗的一般原则为偏头痛患者制定个性化的治疗计划治疗药物的禁忌症和不良反应