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
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
Migraine
Diagnosis
(IHS criteria)
Migraine Without
Aura (ICHD,
2004)
 At least two of the following features:
2
Unilateral location
Throbbing character
Worsening pain with routine activity
Moderate to severe intensity
 At least one of the following features:
Adolescents
migraine:
Nausea
and/or vomiting
1-48 hours,
bilateral,
autonomic
disturbance
Photophobia
and
phonophobia
1
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
台灣經驗
(755 headache patients, 102 neurologists)
中重度頭痛、噁心、畏光
1. In past 3m, does your HA have nausea?
敏感性 82%，特異性 73%
2. Do you have more light sensitive during HA?
陽性預測率=91%(神經科門診) 3. Do you have more disability during HA?
J Formos Med Assoc 2008;107:485–94
2/3==91%
3/3==98% (Lipton et al, Neurology, 2004)
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.
藥物介入時機
Cortical spreading depression
皮質擴散抑制
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)
2. Chlorpromazine (im, iv)
Group 1 recommend
3. Metochlopromide (iv)
4. Ketorolac (im)
1. Cafergot (po)
Group 2 recommend
(C)
2. Metochlopromide (im)
Group 3 recommend
(AAN guideline-2000)
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
(B) Primperan, Novamin, Droperidol (im/iv)
(C) Magnesium, Valproate, Lidocaine, Opioids
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
Tension-type Headache or Migraine
Mild
Moderate
Severe
Unilateral
Bilateral
Photophobia
Nausea
Aura
Vomiting
Aggravated
by Activity
Throbbing
Pressure
Tension-Type
(輕/中)疼痛嚴重度(中/重)
Migraine
© 2002 Primary Care Network
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..
Treatment
• Acute
– tryptans (Imigran/ Rizatan)
• 74% effective within 15 min
• Nasal spray may be more effective
– Oxygen (100% O2, high flow volume,
7-12L)
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;16:252-268.
•
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;17:132-148.
•
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: 213-217.
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…)
Increased intracranial hypertension
CPP= MAP-ICP = D+1/3(S-D)- ICP
(2006, BJA)
Symptoms and signs of IICP






Headache/vomiting/papilloedema
Cushing triad
VI palsy
Thumb signs
Sella erosion
Sulci effacement
IICP
pseudo-tumor cerebri
DVT
Empty sella
Midline shift
VI palsy
Thumb sign
Idiopathic IICP
(pseudotumor cerebri)
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...
4. 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..).
1.
Red flags in IICP
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
Brain CT (without contrast)
1.IICP
2.Sinus thrombosis
R/o SAH, aneurysm or AVM
rupture
C-
C+
MRI (T2WI)
SDH? Subdural effusion?
MRI
CSF study

IP/TP= 60/30 mm H20

WBC=1

India ink- negative.

RBC=140

Gram stain- negative

L:N=1:0

TB-PCR-negative.

Protein= 54.3 (15-45mg)

Sugar 77 (40-70)
Diagnosis?
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.
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.
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.
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
What kind of headache
appearance is pathogenic?
All might be.
Sinus thrombosis with ICH
1.
37 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????
高血壓常見出血位置
•
•
•
•
•
Putamen (40%)
Thalamus (30%)
Brain stem-Pons(10%)
Cerebellum (10%)
Subcortical area (10%)
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
對於奇怪的頭痛,不論有
否合併神經學異常,DVT
其他例子
一定要考慮!
1. 18 yrs teenager had
fever and headache
for 2 wks.
2. 45 yr-old F had
poorly controlled Sz
and severe headache
for 1 week.
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
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
Cervical artery dissection
1.
29 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?
Pearl symptom:
自發性或外傷性
Headache and neck bruit
頸動脈撕裂傷
(post-massage)
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
Space-occupied
lesion
Pearl symptom:
Headache
VF defect
(primary
brainand
tumor
or meta?)
1.
56 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?
SAH, aneurysm
rupture
1.
68 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
Pearl symptom:
Unusual headache and neck stiffness
SAH
1.
2.
3.
4.
自發性必需深究原因(年輕人-AVM; 中老年-Aneurysm)
外傷性可以症狀治療處理
血壓高必須區別是否腦壓升高.
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)
Summary of findings Increased Intracranial
Pressure (ICP) and Cerebral Circulatory
Arrest
INDICATION
Cerebral
Circulatory Arrest
and Brain Death
SENSITIVITY
(%)
91-100
SPECIFICITY
(%)
REFERENCE
STANDARD
97-100
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)
Small systolic sharp
Reverse flow pattern
MCA + BA (較準確)
E1VEM1
FLACCID RESPONSE
ALL REFLEX(-)
SDH
with
IICP
High
Peak,
Low
diastolic
Meningoencephalitis
1. 28 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?
Pearl symptom:
Headache, fever and conscious change
腦膜腦炎
1.
2.
3.
4.
可以單獨影響腦膜或腦炎(意識較易影響)
區別病因(病毒,細菌,其他)
CSF+MRI檢查
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)
Pearl symptom:
Acute
glaucoma
Headache, eyeball pain
1. 46 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?
CCF
Pearl symptom:
(Carotid
cavernous
fistula)
Headache, exo-OPH, eye bruits
1.
70 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.
5.
Rx with balloon tamponade
or surgical repair.
Diagnosis?
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> 7-8
5.
Education is useful to prevent the re-visiting ED.
Thank you for your attention