頭痛疾病的國際分類課件

頭痛疾病的國際分類InternationalClassificationofHeadacheDisorders-secondeditionICHD-II背景偏頭痛的患病率在歐美國家為1500－2000/10萬人，發(fā)病率為10－15％；在中國，患病率為732.1/10萬人，發(fā)病率為0.06％但實際是由于中國的診斷標準在許多下級醫(yī)院不是很明確，許多醫(yī)師對頭痛分類仍然沿用不規(guī)范的用語，致使許多病例無法納入統(tǒng)計。按照神經(jīng)科醫(yī)師在臨床上接診的情況，我國的頭痛患病人數(shù)絕不會與歐美有如此大的差距。頭痛疾病分類的歷史最早的是60年代兩個相似的頭痛分類，列出了當時被認可的一些頭痛疾患，只能算是描述，而不是診斷標準。1988年國際頭痛協(xié)會IHS頭痛分類委員會首次出版了“頭痛疾患國際的分類（ICHD）”，立即被全世界廣泛接受并應用于臨床。雖然當時的診斷標準基于專家的意見，但隨后的研究證明完全可靠有效。而且?guī)缀醪恍枰M一步改進。ICHD-I使得研究的進展，并導致了更完善的ICHD-II的提出。頭痛疾病的國際分類4類原發(fā)性頭痛、8類繼發(fā)性頭痛和另外的2類原發(fā)性頭痛偏頭痛緊張性頭痛叢集性頭痛及其它三叉自主神經(jīng)性頭痛其它原發(fā)性頭痛繼發(fā)性頭痛歸因于頭和（或）頸部外傷的頭痛歸因于顱或頸部血管疾病的頭痛歸因于非血管性的顱疾病的頭痛歸因于某些物質(zhì)或它的戒斷的頭痛歸因于感染的頭痛歸因于代謝疾病的頭痛歸因于顱骨、頸、眼、耳、鼻、鼻竇、牙、口、或其它頭面部結(jié)構(gòu)疾病的面部痛歸因于精神疾患的頭痛顱神經(jīng)痛，中樞性或原發(fā)性面部痛及其它頭痛顱神經(jīng)痛和中樞性疾病有關(guān)的面部痛顱神經(jīng)痛，中樞性或原發(fā)性面部痛及其它頭痛采用逐級分類法，共有四級8歸因于物質(zhì)或它的戒斷的頭痛8.1歸因于急性物質(zhì)使用或暴露的頭痛

8.1.1一氧化氮前體誘導的頭痛

8.1.1.1一氧化氮前體誘導的即刻頭痛

8.1.1.2一氧化氮前體的遲發(fā)性頭痛一、原發(fā)性頭痛

Part1:TheprimaryheadachesMigrainePrevalenceLipton,2007One-yearperiodprevalenceofmigrainebyageandgenderAmericanMigrainePrevalenceandPreventionStudy1、偏頭痛1.1無先兆的偏頭痛1.2有先兆的偏頭痛1.3兒童周期綜合癥為前驅(qū)的偏頭痛1.4視網(wǎng)膜性偏頭痛1.5偏頭痛合并癥1.6很可能的偏頭痛1.1無先兆偏頭痛的IHS診斷標準至少有滿足標準B-D的5次發(fā)作每次持續(xù)4－72小時（未治療或治療無效）頭痛至少有下列特征中的兩項單側(cè)痛搏動性痛中或重度疼痛因日常體力活動加重或避免此類活動（如走路或爬樓梯）頭痛過程中至少伴隨下列一項惡心和/或嘔吐畏光和畏聲不能歸因于其它疾患1.1無先兆的偏頭痛對小兒，持續(xù)1－72小時嬰幼兒的畏光畏聲可從其行為判斷發(fā)作頻率≥15天/月則診斷為慢性頭痛1.2有先兆的偏頭痛及其亞型先兆是局灶神經(jīng)系統(tǒng)體征典型地發(fā)生在頭痛之前或伴隨頭痛一起發(fā)生，或也可只有先兆而無頭痛。先兆通常經(jīng)5－20分鐘發(fā)展起來，持續(xù)20－60分鐘。視覺先兆最為普遍,其次是無力和失語。1.2有先兆的偏頭痛1.2.1有偏頭痛的典型先兆的頭痛

頭痛滿足無先兆偏頭痛的診斷標準1.2.2無偏頭痛的典型先兆的頭痛

伴隨先兆的是輕至重度的緊張性頭痛樣偏頭痛1.2.3無頭痛的典型先兆1.2.4家族性偏癱性偏頭痛FHM

先兆必須包括某種程度的偏癱，且至少有一個親屬有相同的發(fā)作1.2.5散發(fā)性偏癱性偏頭痛

無家族史1.2.6基底型偏頭痛

表明后顱窩受累及，而不是基地動脈1.2有先兆的偏頭痛的IHS診斷標準至少2次頭痛發(fā)作符合B-E能完全逆轉(zhuǎn)的視覺、感覺、或言語癥狀，但無運動障礙至少滿足下列兩項同向視覺癥狀包括陽性體征（如點狀色斑或線形閃光幻覺），和/或陰性癥狀（視野缺損），和/或單側(cè)感覺癥狀包括陽性體征（針刺感）和/或陰性體征（麻木感）至少一個癥狀漸漸發(fā)展≥5分鐘和/或不同癥狀接連發(fā)生。每個癥狀持續(xù)5－60分鐘滿足無先兆偏頭痛診斷標準B-D的頭痛在有先兆時發(fā)生或在先兆發(fā)生后60分鐘內(nèi)發(fā)生不能歸因于其它疾患1.3兒童周期綜合癥為前驅(qū)的偏頭痛1.3.1周期性嘔吐綜合征1.3.2腹型偏頭痛1.3.3良性發(fā)作性眩暈1.3.1周期性嘔吐

至少５次發(fā)作符合標準Ｂ和Ｃ。周期性發(fā)作，個別患兒呈刻板性，強烈惡心和嘔吐持續(xù)１小時至５天。發(fā)作期間嘔吐至少４次／小時，或至少１小時。２次發(fā)作間期癥狀完全緩解。不能歸因于其它疾病。

1.3.2腹型偏頭痛

至少５次發(fā)作符合標準Ｂ～Ｄ腹部疼痛發(fā)作持續(xù)１～７２小時（未治療或治療不成功）。腹部疼痛具備以下所有特點①位于中線、臍周或難以定位②性質(zhì)為鈍痛或“微痛”③程度為中度或重度腹痛期間至少有以下２項①食欲減退②惡心③嘔吐④蒼白。不能歸因于另一種疾病。

1.3.3兒童良性發(fā)作性眩暈

“無先兆多次嚴重眩暈發(fā)作，數(shù)分鐘到數(shù)小時后自行緩解”至少應在５次以上。發(fā)作間期神經(jīng)系統(tǒng)檢查和聽力、前庭功能正常，腦電圖正常。

1.5偏頭痛合并癥1.5.1慢性偏頭痛1.5.2偏頭痛持續(xù)狀態(tài)1.5.3無梗塞的持續(xù)先兆1.5.4偏頭痛性梗塞1.5.5偏頭痛誘發(fā)的癲癇1.5.1慢性偏頭痛偏頭痛≥15天/月，持續(xù)3個月以上，無藥物濫用。如有藥物濫用（急性抗偏頭痛藥物和/或混合止痛藥≥10天/月）或普通止痛藥服用15天/月，則診斷為藥物濫用性頭痛8.2，如停藥后癥狀改善，則更支持該診斷。否則診斷為伴可能藥物濫用的可能偏頭痛。1.5.2偏頭痛持續(xù)狀態(tài)盡管經(jīng)過治療，頭痛仍持續(xù)72小時以上。伴虛弱。如不伴虛弱，則診斷無先兆的可能偏頭痛。1.5.3無梗塞的持續(xù)先兆先兆持續(xù)2周以上無梗塞的影像學證據(jù)1.5.4偏頭痛性梗塞7天內(nèi)1個或更多個偏頭痛先兆不能完全恢復，和/或相關(guān)的缺血性梗死的神經(jīng)影像學定位依據(jù)。與其它原因引起的中風的鑒別診斷：神經(jīng)系統(tǒng)缺損癥狀必須與先前發(fā)作的偏頭痛先兆極其相似中風發(fā)生在典型的偏頭痛發(fā)作過程中必須排除其它中風的原因1.5.5偏頭痛激發(fā)的癲癇癲癇在偏頭痛先兆發(fā)生的一小時內(nèi)發(fā)生眼肌麻痹型偏頭痛

放入13顱神經(jīng)痛和與中樞疾病有關(guān)的面痛中。診斷標準為至少２次發(fā)作滿足Ｂ偏頭痛樣頭痛發(fā)作的同時或４日內(nèi)發(fā)生第3、４和（或）６對腦神經(jīng)中一條或多條輕癱適當?shù)臋z查排除眼窩和后顱窩組織損傷。

THETREATMENT

APPROACHTO

MIGRAINEMigraine,DepressionandAnxietyPatientswithmigraine3timesmorelikelytodevelopdepressionPatientswithdepression3timesmorelikelytodevelopmigraine(Breslau,1991;Breslau,Davis,1993,Patel,2007)MalepatientswithPanicDisorder7timesmorelikelytohavemigraine(Stewart,1989,Sheftell,2007)40%patientswithanxietyreportedapaindisorderand7%patientswithpanicdisorderreportedtakingpainmedicationsdaily(Kuch1991)50%ofMigraineursexperienceanxiety(Devlen1994)PathophysiologyofMigraineAsdescribedbyGoadsby,migraineinvolvesa"dysfunctionofbrainstempathwaysthatnormallymodulatesensoryinput".Moreprecisely,migraineinvolvesabnormalsensorymodulation.

Boyd,2005TrigeminalNerveEndingNeurogenicinflammation:Followingstimulationofthetrigeminalnerve,neuroinflammatorypeptides,suchassubstanceP,CGRP,andneurokininA,arereleasedfromperivascularnervefibers,triggeringneurogenicinflammation,whicheventuallyleadstothepainofmigraine.Silberstein,1998RatesofMigraineSymptomsYoungandSilberstein,2006AuraVisual

Scotoma:scintillating;flashes,mosaicvision Illusion:fortification,shimmering,rotation, oscillation,metamorphopsia,macropsiaSensory

Paresthesias:oftenmigrating,lastingfor minutes,canbecomebilateralLanguage DysarthriaordysphasiaMotor

WeaknessDisturbedsensorium

Déjàvu,jamais-vuScintillatingScotomaClinicalPhasesofaMigraineAttackGraphcourtesyoftheMigraineAssociationofIrelandAcuteTreatmentofMigraineGoalsofAcuteTreatmentRapidtreatmentMinimizerecurrenceRestoreabilitytofunctionMinimizetheuseofbackupandrescuemedicationsOptimizeself-careReduceuseofresourcesCosteffectivenessMinimalornoadverseeventsTriptansSelectiveagonistof5-HT1Dand5-HT1BreceptorsBlocksplasmaextravasationfromcranialvesselsBlockseffectsofCalcitoninGene-RelatedPeptide(CGRP)NonspecificTreatmentsAcuteTreatmentinClinicorEmergencyDepartmentPreventiveTreatmentDecreaseOfficevisits51%DecreaseERvisits82%DecreaseCTandMRIscanwithmigrainediagnosis(75%and88%)AMSIIshowedonly5%ofmigraineursusepreventivetherapy25%ofMigraineurshave>3attacks/monthPhysiciansshouldoffertherapywhen>2attacks/month-AdrenergicBlockersMostwidelyusedpreventivemedicationclass50%effectiveinproducing>50%reductioninattackfrequencyAnalysisof74controlledtrialsconfirmeffectivenessofpropranolol(atenolol,metoprolol,timolol,nadololalsoeffective)Blockcentral-receptorsthatinterferewithvigilance-enhancingadrenergicpathwayInhibitnitricoxideproduction(propranolol)NotEffective--blockerswithintrinsicsympathomimeticactivity(acebutolol,alprenolol,oxprenolol,pindolol)CalciumChannelAntagonistsMechanismofActionBlock5-HTreleaseBlockcalciumdependentenzymesinvolvedinprostaglandinformationInterferewithpropagationofspreadingdepression45controlledtrials-highdropoutratesduetoSideEffectsVerapamilmostusefulNicardipineandnifedipinenotrecommendedAnticonvulsantsValproicAcidIncreasesbrainlevelsof-aminobutyricacid5studieswithstrongevidenceforefficacyweightgain,GIsymptoms,thrombocytopenia,hepatitis/pancreatitisTopiramateNointerferencewithbirthcontrolpillsat<200mg/dWeightloss(3.8%ofbaselinebodyweight)paresthesias(50%)treatedwithpotassiumGabapentinmixedresultsforeffectiveness,drowsinesssideeffectLamotrigineandPhenytoin:ineffectiveDrugDoseRouteAspirin500-650mgOralParacetamol500mg-4gOralMIGRAINE:ABORTIVETHERAPYNon-specifictreatmentIbuprofen200-300mgOralDiclofenac50-100mgOral/IMNaproxen500-750mgOralABORTIVETHERAPYFORMIGRAINEDrugDoseRouteErgotalkaloidsErgotamine1-2mg/d;max-6g/dOralDihydroergotamine0.75-1mgSC5-HTreceptor

agonistsSumatriptan25-300mg6mgOrallySCRizatriptan10mgOrallySpecifictreatmentDrugDose(mg)/dRouteDomperidone10-80mgOralMetoclopramide5-10mgOral/IVPromethazine50-125mgOral/IMChlorpromazine10-25mgOral/IVANTI-NAUSEANTDRUGSFORMIGRAINETREATMENTWHYTHENEEDFORPROPHYLAXIS?Abortivedrugsshouldnotbeusedmorethan2-3timesaweekLong-termprophylaxisimprovesqualityoflifebyreducingfrequencyandseverityofattacks80%ofmigraineursmayrequireprophylaxisWHENISPROPHYLAXISINDICATED?AccordingtotheUSHeadacheConsortiumGuidelines,indicationsforpreventivetreatmentinclude:Patientswhohaveveryfrequentheadaches(morethan2perweek)Attackdurationis>48hoursHeadacheseverityisextremeMigraineattacksareaccompaniedbyprolongedauraUnacceptableadverseeffectsoccurwithacutemigrainetreatmentContraindicationtoacutetreatmentMigrainesubstantiallyinterfereswiththepatient’sdailyroutine,despiteacutetreatmentSpecialcircumstancessuchashemiplegicmigraineorattackswithariskofpermanentneurologicinjuryPatientpreferenceDrugsDose(mg/d)BetablockersPropranolol40-320CalciumChannelBlockersFlunarizineVerapamil10-20120-480TCAsAmitriptyline10-20SSRIsFluoxetine20-60PREVENTIVETHERAPYFORMIGRAINEDrugsDose(mg/d)Anti-convulsantSodiumvalproate600-1200Anti-histaminicCyproheptadine4-8PREVENTIVETHERAPYFORMIGRAINE

(CONTD.)ROLEOFBETABLOCKERSINMIGRAINEPROPHYLAXIS‘Goldstandard’inmigraineprophylaxisEstablishedefficacyandsafetyinmigraineprophylaxisEspeciallypreferredifhypertensionoranxietyco-existROLEOFPROPRANOLOLINMIGRAINEPROPHYLAXISLIMITATIONSOFIMMEDIATE-RELEASEPROPRANOLOLShortt?of3-5hrsMultipledailydosingrequiredtomaintainadequatedegreeofbeta-receptorblockadethroughout24hrPoorpatientcompliancemaycompromiseefficacyADVANTAGESOFEXTENDED-RELEASEPREPARATIONOFPROPRANOLOLMigrainepatientsareasymptomaticbetweenattacksImportanttominimizenumberofdailydosesduringprophylactictreatmentOnce-dailyadministrationimprovescomplianceStabledrugconcentrationfor24hrsDOSAGEOFPROPRANOLOLStartingdose:40-80mgoncedailyMax.dose/day:240mgIfsatisfactoryresponseisnotobtainedwithin4-6weeks,afterreachingthemaximaldose,therapyshouldbediscontinuedTaperslowlytoavoidreboundheadacheandadrenergicsideeffectsMax.duration:9to12months2.Tension-typeheadacheDiagnosticcriteriaAtleast10episodesfulfillingfollowingcriteriaHeadachelasting30minsto7daysHas2atleast2ofthefollowingBilaterallocationPressing/tightening(non-pulsating)qualityMildormoderateintensityNotaggravatedbyphysicalactivitysuchaswalkingorclimbingstairsNonauseaorvomiting<2episodesofphotophobiaorphonophobiaNotattributabletoanotherdisorderCategoriesInfrequentepisodictensiontypeheadacheOccurs<1daypermonth(<12days/year)FrequentepisodictensiontypeheadacheOccurs>1and<15days/month(>12and<180days/year)ChronictensiontypeheadacheOccurs>15days/month(180ormoredays/year)CausesUncertain?ActivationofhyperexcitableperipheralafferentneuronsfromheadandneckmusclesAssociatedwithandaggravatedbymuscletendernessandpsychologicaltensionbutdonotcauseitAbnormalitiesincentralpainprocessingandgeneralisedincreasedpainsensitivityarefoundinsomeindividualsGeneticfactorsPeopleatriskPrevalencepeaksatage40-49inbothsexesMeanlifetimeprevalenceis46%Chronictensiontypeheadacheaffects3%ofgeneralpopulationFemaletomaleratiois4:5PrevalenceincreaseswitheducationallevelCanoccurinchildrenPresentationMildtomoderatebilateralpainSensationofmuscletightnessorpressureLastshourstodaysNotassociatedwithconstitutionalorneurologicalsymptomsPeoplewithchronictensionheadachemorelikelytoseekhelpoftenhaveahistoryofepisodicheadachebutdelayeduntilfrequencyanddisabilityarehighDifferentialdiagnosisMigraine–inchronicformcharacteristicfeaturesdisappearandpainislesssevereNeckproblems–muscletendernessoftensiontypeheadachemayinvolvetheneckMedicationoveruseheadache–considerinpatientstakingopioidorcombinationanalgesicsforanaverageof10days/monthExaminationandinvestigationExaminationNeurologicalexaminationManualpalpationofpericranialmuscles(frontal,temporal,masseter,pterygoid,sternomastoid,spleniusandtrapezius.FundoscopyforpapilloedemaInvestigationsIfneuroexaminationnormalnoneneededInvestigationNeuroimagingshouldbearrangedifAtypicalpatternofheadacheHistoryofseizuresNeurologicalsignsorsymptomsSymptomaticillness–acquiredimmunodeficiencysyndrome,tumoursorneurofibromatosisTreatmentInfrequentheadacheGoodresultsfromnonprescriptionmedicationMayneedreassuranceIfrequiredrugsonmorethan2-3days/weekthenmedicaltreatmentisindicatedtopreventmedicationmisuseheadacheTreatmentAcutetherapyforindividualattacksSimpleanalgesiaAspirin500–1000mgNSAIDSParacetamolmoreeffectivethanplacebolesseffectivethanNSAIDSCombinationdrugscontainingsimpleanalgesicsandcaffeinearehelpfulOpioidsorsedativesshouldnotbeusedasimpairalertnessandcancauseoveruseanddependenceTreatmentPreventivetreatmentConsiderwhenheadachesarefrequentoracuteattacksdon’trespondtoabortivetreatmentBestevidenceisforAmitriptyline75-150mg/day.Ithelpsbothpainandmuscletenderness.WorksbestwhenstartedatlowdoseandincreasedweeklyMirtazipine15-30mg/dayUnhelpfulSSRI’sBotuliniumtoxinTreatmentPreventivetreatmentShouldbeconsideredwhenatleast2headaches/monthasriskofchronicheadachegoesupexponentiallywhenfrequencyreaches1/weekasdoesseverityofpainBenefitorpreventivetreatmentisdiminishedwhenpatientsaresimultaneouslyoverusingabortivetreatments.WithdrawalofmedicationisadvisedbeforestartingpreventativetherapyTreatmentEducation,lifestyleandnon-pharmacologicaltreatmentLittleevidenceexiststosupportorrefutemostdietaryorlifestylerecommendationsfortensiontypeheadache.TreatmentReferralDiagnosisisunclearDoesnotrespondtotreatmentComplicatedbymedicationoveruseRequireneuroimagingPrognosis45%ofadultswithfrequentorchronictensiontypeheadachewillgointoremission39%willcarryonwithfrequentheadaches16%willcarryonwithchronicheadachePoorprognosisAssociatedwithPresenceofchronicheadacheatbaselineCo-existingmigraineNotbeingmarriedSleepproblemsGoodprognosisAssociatedwithOld