神经病学 — 头痛 (Headache) 哈尔滨医科大学附属第二医院 神经病学教研室

第一节 概 述 Headache is one of the most common clinical symptoms 第一节 概 述 Headache is one of the most common clinical symptoms. Its pathogenesis is more complicated.

Pathogenesis Pain-Sensitive structures of the brain 1) Brain skin, subcutaneous tissu,etc. 2) Arteries and muscles; 3) Venous sinuses and meningeal arteries; 4) The trigeminal(V), glossopharyngeal(IX); vagus(X), etc.

Classification of the headache 1. Acute(2w) ,subacute(3m) or chronic(>3m); 2. Mild, morderate or severity; 3. Original(migraine, cluster, tension); secondary(trauma,infection,tumor);

Diagnosis 1. Family history, state of mind and sleeping; 2. Speed of onset, attack time,quality, position, relapsing and the factors of becoming severity. 3. Omen and accompany symptoms; 4. Performing a careful physical examination, select some suitable assistant tests.

Treatment 1. Family history, state of mind and sleeping; 2. Speed of onset, attack time,quality, position, relapsing and the factors of becoming severity. 3. Omen and accompany symptoms; 4. Performing a careful physical examination, select some suitable assistant tests.

第二节 偏头痛 (migraine) 1. Etiology : ① Heredity; ② Endocrine and metabolism; ③ Other factors.

2. Pathogenesis 1) Blood vessel theory; 2) Nerve- vessel theory; 3) Nerve-transmitter theory.

Clinical Manifestations 1. Migraine with Aura (Classic Migraine) ① Proemial stage ② Aura stage ③ Headache stage ④ Later stage of headache 2. Migraine without Aura (common Migraine)

2. Special-type of Migraine 1) Ophthalmoplegia 2) Hemiplegia 3) Basilar-type 4) Later-onset 5) 等位发作

Diagnosis 1. Common type (1988 diagnostic criteria) 1) 符合下述2～4项，至少发作5次以上。 2）如不治疗 ，每次发作持续24小时。 3）具有以下特点至少两项：单侧性；博动性；不敢 活动；活动后头痛加重。 4）发作期间有下列之一：恶心及呕吐；畏光和畏声。 5）无其它已知类似疾病；病史躯体正常。

2. typical Migraine 1）符合下述两项，至少发作2次。 2）具有以下特征至少3项：局限性脑皮质或脑干功能 障碍1或1个以上先兆症状;至少有一个先兆症状， 逐渐发展持续4分以上；或相继发生2个或2个以上 症状；先兆症状持续<6分钟；先兆与头痛无间歇期。 3）具有以下特征一项以上：无器质疾病证据；有器质 疾病可能，但辅助检查以排除；虽有器质病，但与 偏头痛无相关。

Differential Diagnosis 1. Arterial headache 2. Cluster headache 3. Painful ophthalmoplegia 4. Carotidynia

Treatment 1. Onset stage 1) Mild-moderation: Rest; Acetaminophen; Asprin, Ibuprophen. 2) Moderate-severity:Dihydrogotamine mesylate, Ergotamine, Sumatriptan. 3) severity: Dihydrogotamine mesylate, Pethidine, Codeine, Chlorpromazine. 4) Treat the symptoms

2. Preventive treatment 1）-受体阻滞剂 2）钙拮抗剂 3）抗组胺药物 4）麦角衍生物 5）其他药物如去普坦类

第三节 紧 张 性 头 痛 (Tension Headache)

Etiology And Pathogenesis 多因素:  肌肉或筋膜结构收缩或缺血  细胞内外钾离子运转障碍  CNS内单胺能系统慢性或间断性功能障碍  情绪障碍,应激,心理紧张,抑郁所致持久性 颈肩肌肉痉挛及血管收缩引起的牵涉痛有 关。

Clinical Manifestations Onset: 20yrs, M>F. Quality: diffuse, band-like, dull headache. Position: bilateral occipital, frontal. Course: days or years. Accompany symptoms: vertigo,insomnia, anxious and depression. Part of the patients have daily chronic headache.

Tension Headache-Diagnosis TH classification of IHA (1988): 1. TH attack: >10times, time<180days/yr, <15d/m; 2. TH attack with disease around skull muscles: Attach pain of the bone and muscles around the skull. EMG activation increase. 3. TH attack without disease around skull muscles: Without attach pain of the bone and muscles around the skull. EMG is normal. 4. Chronic headache:Time of headache≥180d/yr,≥ 15/m.

Treatment Drugs used in tension headache should be personalize :  Insomnia should give benzodiazepines such as diazepam;  Depression and anxious should give amitriptyline, imipramine and fluoxetine.  Acute attacks may response to aspirin, nonsteroid anti-inflammatory drugs (acetaminophen, ergotamine)

第四节 低颅压头痛 （Intracranial hypotension headache） Intracranial pressure <90mmH2O Etiology And Pathogenesis： Original: CSF secret disorder. Secondary: CSF leaking (lumbar puncture, trauma, operation, meningitis, severe infection, etc. )

Clinical Manifestations  Position: Occipital and frontal.  Quality: mild or sever dull and beating pain.  Position of the body: severity when standing, lighten when lying.  Accompany symptoms: nausea, vomiting, vertigo, tinnitus, rigidity, etc.

Diagnosis and Differential Diagnosis  典型临床表现  CT/MRI  腰穿  与脑、脊髓肿瘤、脑室梗阻、寄生虫感 染、脑静脉血栓形成、亚急性硬膜下血 肿、颈椎病鉴别。

Treatment 1. Etiologic treatment 2. Symptomatic treatment 3. Special treatment: 1) Epidural blood patching 2) Caffeine therapy

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