头痛Headache.ppt

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1、头痛Headache Still waters run deep.流静水深流静水深,人静心深人静心深 Where there is life,there is hope。有生命必有希望。有生命必有希望eararmhandlegfootheadeyenosemouthtoothfacestomachbackWheres his neck?(feet)(teeth)Whats the matter Whats the matter with with herher?I have a headacheheadacheWhat should she do?She should lie down and

2、 rest.A Cure for a HeadacheA Cure for a HeadacheOne day a man went into a chemists shop and said,Have you anything to cure a headache?The chemist took a bottle from a shelf,held it under the gentlemans nose and took out the cork.The smell was so strong that tears came into the mans eyes and ran down

3、 him cheeks.What did you do that for?he said angrily,as soon as he could get back his breath.but that medicine has cured your headache,hasnt it?You fool.said the man,Its my wife that has the headache,not me.Definition of a HeadacheDefinition of a HeadacheUnpleasant sensations in the regions of crani

4、al vault.Headache is one of the most common clinical symptoms.Its pathogenesis is more complicated.90%of individuals have at least one headache per year头痛是指颅外或颅内疾病刺激对疼痛的敏感结构,造成头颅上半部(眉毛、耳轮上部、枕外隆突联线以上）的疼痛。也可以是面部或颈部所引起的牵涉痛。头痛在西医来说仅仅是个临床症状，而不是一个独立的疾病。EtiologyHeadache occurs in all age groups and is the

5、seventh leading reason for medical office visits;Although most often a benign condition,headache of new onset may be the earliest or the principal manifestation of serious systemic or intracranial disease.An etiologic diagnosis of headache on based on understanding the pathophysiology of head pain;o

6、btaining a history,with characterization of the pain as acute,subacute,or chronic;perorming a careful physical examination;and formulating a differential diagnosis.EtiologyIntracranial diseaseExtracranial diseaseSystemic diseaseNeurosisIntracranial diseaseIntracranial diseaseInfection:encephalitis(脑

7、膜炎)Vascular disease:cerebral accidentTumorCranial injury:concussion of brain（脑震荡）varying combination of headache,dizziness,vertigo,impaired memory,irritability and difficulty with concentrationOthers:migraine（偏头痛）cluster headache （丛集性头痛）颅内病变引起的头痛（一）脑膜脑炎：属脑膜刺激性头痛，颈项部也多疼痛，有脑膜刺激征。起病多较急骤，并有发热和脑脊液的阳性所见。（

8、二）脑血管病：1出血性脑血管病：脑出血多有剧烈头痛，但不以头痛就诊。以头痛为主诉者为蛛网膜下腔出血，常因无偏瘫等神经系统局限体征，而被漏诊。本病多在用力或情绪激动后突发剧烈头痛、呕吐、也具有脑膜刺激性头痛特点。病因多为先天性动脉瘤、动静脉畸形和脑动脉硬化。血性陈旧出血性脑脊液可以确诊。2缺血性脑血管病：脑血栓一般甚少头痛，但椎一基底动脉短暂缺血发作性头痛并不少见，以下诸占可作为诊断依据：头痛可因头位转动或直立位时诱发。头痛前后或同时多伴有其他脑干短暂性缺血症状，以眩晕最多见，其他可有闪辉暗点、黑朦、复视、口面麻木、耳内疼痛、视物变形等。可有轻微的脑干损害体征，如眼球震颤（患者头后仰转颈，使一侧

9、椎动脉受压后更易出现）、一侧角膜反射或（和）咽反射的迟钝或消失、平衡障碍或阳性病理反射等。有明确病因，如脑动脉硬化、糖尿病、冠心病以及颈椎的增生、外伤或畸形等。脑血流图（头后仰转颈后波幅下降达30%以上）、颅外段椎动脉多普勒超声检查（管径狭窄或/和血流量降低）、眼震电图（转颈后出现眼震）等实验室检查阳性。缺血性脑血管病产生头痛的机制，可能因颅内供血不足，颅外血管代偿性扩张所致，因此，也具有血管性头痛特点。3脑动脉硬化：系因脑部缺氧引起。头痛多伴神经衰弱表现，有高血压者则有高血压头痛特点，并有轻微神经系统损害体征，眼底和心脏等有动脉硬化征象和血脂增高等。4高血压脑病：高血压患者如血压骤升而致脑部

10、小动脉痉挛发生急性脑水肿时，可因急性颅内压增高而产生剧烈头痛，眼底可见视网膜动脉痉挛、出血、渗出等。多见于尿毒症和子痫等。（三）颅内肿物及颅内压增高：包括脑瘤、脑脓肿、颅内血肿、囊肿（蛛网膜炎）、脑寄生虫等。一方面，肿物本身对颅内疼痛敏感组织的压迫、推移、可引起局部及邻近部位的头痛（牵引性头痛），如垂体瘤可产生双颞或眼球后胀痛，头痛呈进行性加重，并有神经系统局限体征；另一方面，80%的肿物患者有颅内压增高，全头部呈现胀痛、炸裂痛，缓慢发生者早期仅在晨起后发生（因平卧一夜后脑静脉郁血，颅内压更加增高），以后逐渐为持续性痛，在咳嗽、用力后因颅压突增，头痛加重，并有呕吐、视乳头水肿、视网膜出血、精神

11、症状、癫痫等。详见第五节。（四）低颅压综合征：多发生于腰椎穿刺、颅脑损伤、手术或脑膜脑炎等之后以及严重脱水等情况下，侧卧位腰穿脑脊液压力在0.59-0.78kPa（70-80mm水柱）以下，或完全不能流出。起坐后突发剧烈头痛，常伴恶心、呕吐、系因此时颅内压进一步下降，颅内疼痛敏感组织失去了脑脊液的托持而受到牵拉所致，故也属于牵引性头痛。平卧后头痛即迅速缓解。偶或有徐脉和血压升高。（五）癫痫性头痛：多见于青少年及儿童、头痛呈剧烈搏动性痛或炸裂痛，发作和终止均较突然，为时数秒至数十分钟，偶可长达一天，发作频率不等。可伴有恶心、呕吐、眩晕、流涕、流泪、腹痛、意识障碍或恐怖不安等。脑电图检查特别在发作

12、进常有癫痫波形，也可有其他类型的癫痫发作史、癫痫家族史和有关的病因史，服用抗癫痫药物可控制发作。可能系各种疾病导致间脑部位异常放电所致。（六）颅脑损伤后头痛：颅脑损伤早期头痛与软组织损伤、脑水肿、颅内出血、血肿、感染等有关。后期的头痛相当多见，大多为衰弱表现，称为“外伤性神经症”或“脑外伤后综合症”。但很大一部分患者或并发或单独尚有其他头痛表现，机制也十分复杂。常见的有血管性头痛（包括各种类型的偏头痛类血管性头痛）、肌收缩头痛、颅表神经痛以及头皮疤痕引起的头痛等。系与局部血管、血管运动中枢、头皮、颈肌、颈神经根或头颈部各个神经分枝受损有关，有的则和并发的颈椎损伤所致的椎动脉短暂缺血等因素有关。

13、少数头痛为外伤晚期并发症引起，如颅内血肿、外伤性脑蛛网膜炎、低颅压综合征、自发性气脑、癫痫性头痛以及晚发性脑脓肿、脑膜炎等。故应详细询问病史并作有关检查，明确头痛的性质和类型，不宜不加分析笼统地诊断为脑外伤后遗症。(七)血管性头痛（1）偏头痛：常在青春期发病，部分患者有家族史，多因劳累、情绪因素、经期等诱发。典型者（眼型偏头痛）头痛发作前先有眼部先兆，如闪辉、黑朦、雾视、偏盲等，也可有面、舌、肢体麻木等，与颅内血管痉挛有关。约10-20分钟后，继以颅外血管扩张，出现一侧或双侧剧烈搏动性痛或胀痛，多伴有面色苍白、肢冷、嗜睡等，并可有情绪和行为等改变；头痛至高峰后恶心、呕吐、持续数小时至一天恢复。

14、发作频率不等。无上述先兆者称“普通型偏头痛”。较为常见，发作长者可达数日。少数头痛反复发作后出现一过性动眼神经麻痹者称“眼肌麻痹型偏头痛”，但发病久后眼肌麻痹不再恢复。本病发病机制复杂，近年倾向于认为，诱发因素作用于中枢神经后，经单胺能通路产生神经递质变化，继之激活血小板引起5-HT和血栓素A2（TX A2）的释放和耗竭，相继产生颅内外血管的收缩及扩张，扩张管壁由于吸附5-HT产生血管过敏，加之组织胺、缓激肽等参与，发生头痛及其神经性血管性反应。（2）丛集性头痛：成年男性多见，发作时颅内外血管均有扩张，搏动性剧痛以一侧眶上眶周为主，伴有头痛侧流涕、鼻阻、颜面充血等，持续约半小时至2小时缓解，常

15、在每天同一时间以同一形式多次发作，夜间也可发生。发作持续数周至2-3个月后，逐渐减少，减轻而停止。但间隔数周或数年后再次出现类似的丛集样发作。病因也未完全明了，有的可能和过敏反应、外伤、蝶腭神经节或岩大浅神经病变有关。Extracranial diseaseExtracranial diseaseBone disease:osteoarthritis(骨关节炎)of cervical spineNeuralgia:trigeminal neuralgia （三叉神经痛）Disease of head organs:eye nose ear teeth头颈部神经炎性头痛：枕大神经、眶上神经和耳颞

16、神经等，均可因受寒、感染或外伤引起头部神经的神经痛。三叉神经第一支也可因感染、受寒等，引起前头部持续性或伴发短暂加剧的发作痛，称三叉神经炎或症状性三叉神经痛。头颈部皮肤、肌肉、颅骨病变引起的头痛：头皮的急性感染、疖肿、颅骨肿瘤均可引起局部头痛。原发病灶明显，诊断不难。紧张性头痛（肌收缩性头痛）：相当多见。系因头颈部肌肉持续收缩所致，多为前头部、枕颈部或全头部持续性钝痛。病因大多为精神紧张或焦虑所致，也可继发于血管性头痛或五官病变的头痛，有时为头颈部肌炎、颈肌劳损或颈椎病所致。五官及口腔病变引起的头痛 1鼻部病变：（1）副鼻窦炎：头痛恒伴有鼻阻、流涕和局部压痛。除蝶窦炎头痛可在头内深部或球后外，

17、其他多以病窦部位为主。头痛程度常和副鼻窦引流情况有关，故前额窦炎头痛多以晨起为重，久立后逐渐减轻，而上凳窦炎则反之。鼻中隔偏曲可因损及鼻甲，产生类似上颌窦为的头痛。（2）鼻咽腔癌肿：典型者除头痛外，有鼻衄、脓涕、多发性颅神经麻痹（因填塞耳咽管，耳聋系传导性！）和颈部淋巴结转移。鼻咽腔活检可确诊。少数症状可不典型，应多次作鼻咽腔活检以求早期确诊。2眼部病变：（1）屈光不正（远视、散光、老视）及眼肌平衡失调：头痛多为钝痛，可伴眼痛眼胀，阅读后加重，并可有阅读错行或成双行现象，久后可有神经衰弱表现。（2）青光眼：疼痛以患眼为主扩及病侧前额，急性者常伴有呕吐、视力减退、角膜水肿、混浊等；慢性者有视乳头

18、生理凹陷扩大等。测量眼压可明确诊断。（3）眼部急性感染：也常引起剧烈头痛，但局部征象明显，不易漏诊。3耳部病变：急性中耳炎、乳突炎可有严重耳痛并扩及一侧头痛，多呈搏动性。4口腔病变：牙痛有时可扩及病侧面部疼痛。颞颌关节痛常自局部扩及一侧头痛，咬合时关节疼痛，并有局部压痛。Systemic diseaseSystemic infectionCardiovascular disease:hypertensionIntoxication:carbon monoxideHeatstrokeOthers:pre menstrual tensionchronic diseaseNeurosis神经官能症及

19、精神病引起的头痛 临床上最常见的头痛原因是神经衰弱，但必须在排除上述各种器质性疾病并有明确的神经衰弱表现时，方能诊断。头痛可能与对疼痛的耐受阈降低有关，但有患者因血管功能失调或精神紧张，头痛具有血管性头痛或肌收缩性头痛的特点。焦虑症头痛多伴有明显的焦虑不安表现。抑郁患者也常有头痛，抑郁症状反被忽略，应高度警惕。癔症的头痛多部位不定，性质多变，且有其他癔病表现，如发病的情绪因素以及躯体的其他种种不适等。有时也可出现急性头痛发作，症状夸张，常号哭、翻滚、呼叫，除有零乱的感觉障碍和双侧腱反射亢进外，体检及神经系统无其他异常。当询问病史及查体以吸引其注意力后，头痛可明显减轻，暗示治疗可迅速痊愈。重性精

20、神病中也可有头痛，但很少以头痛为主诉就诊。Pathogenesisathogenesis Pain-Sensitive structures of the brain 1)Brain skin,subcutaneous tisue,etc.2)Arteries and muscles;3)Venous sinuses and meningeal arteries;4)The trigeminal(V),glossopharyngeal(IX);vagus(X),C23 etc.发病机理头痛是因头颈部痛觉末稍感受器受到刺激产生异常的神经冲动传达到脑部所致。颅外组织除颅骨本身外，自骨膜直至五官、口

21、腔均对疼痛敏感；颅内组织只有静脉窦及其回流静脉、颅底硬脑以及脑底动脉对疼痛敏感，脑部其余组织均对痛觉不敏感。颅内痛觉经第、对脑神经和第23对颈神经传导，颅外痛觉除上述神经外，尚可经交感神经传导。主要机理有：颅内外动脉的扩张（血管性头痛）；颅内痛觉敏感组织被牵引或移位（牵引性头痛）；颅内外感觉敏感组织发生炎症（例如脑膜刺激性头痛）；颅外肌肉的收缩（紧张性或肌收缩性头痛）；传导痛觉的颅神经和颈神经直接受损或发生炎症（神经炎性头痛）；五官病变疼痛的扩散（牵涉性头痛）等。在发生上述头痛过程中有致痛的神经介质参与，如P物质、神经激肽A、5羟色胺（5-HT）、降钙素基因相关肽（CGRP）、血管活性肠肽（V

22、IP）和前列腺素（PGE）等。此外，精神因素也可引起头痛，可能与疼痛耐受阈值的降低有关。与任何疼痛一样，疼痛的严重程度也因人而异，同一病人的头痛也可因当时的身体和精神状况不同而有所不同。Classification of the headache 1Acute(2w),subacute(3m)or chronic(3m);2 Original(migraine,cluster,tension);secondary(trauma,infection,tumor);Acute onset:1、Subarachnoid hemorrhageCerebrovascular disease 2、Meni

23、ngitis or encephalitis3、Ocular disorders(glaucoma,acute iritis 4、Seizures 5、Lumbar puncture 6、Hypertensive encephalopathy 7、CoitusSubacute onsetGiant cell(temporal)artertisIntracraninl mass(tumor,abscess)Benign intracranial hypertension)Trigeminal neuralgia(tic douloureux)Glossopharyngeal neuralgia(

24、与心绞痛鉴别)Postherpetic neuralgia(如头部的带状庖疹)HypertensionAtypical facial painChronicMigraine Cluster headacheTensionCervical spine diseaseSinusitis(如海绵窦炎)Dental disease国足让人头痛Clinical manifestationClinical manifestation1、Onsetacute infection:acute onset with fever and severe headachecerebral or subarachnoi

25、d hemorrhage:acute onset without feverbrain tumor:chronic persistentmigraine:recurrent(周期性的)Clinical manifestationClinical manifestation“Sudden”=occurrs abruptly and worst at the beginningSudden headache in a patient who does not normally have headaches may indicate serious intracranial pathology.“I

26、CH”intracranial hemorrhage,includes intracerebral hemorrhageintraventricular hemorrhagetumor bleeding cerebellar hemorrhageHeadacheOnsetProgressiveSuddenexplosiveRecurrentConsider:CNS infectionSpace-occupy lesionSevere hypertensionHypoxiaCO intoxiciationTemporal arteritis*EENTD problemsConsider:Migr

27、aineTension headacheCluster headacheCervical spondylosisTemporal arteritis*EENTD problemsConsider:SAH*EENTD:Eye,ear,nose,throat,dental Progressive1.Fever without obvious focus or 2.Rigid neck1.No fever and 2.Supple neck*Neurological exam.AbnormalTemporalarteritisSevere HTNHypoxiaCO intoxicationESRAc

28、ute glaucoma SinusitisOtitisTMJ problemPeriapical abscessBrain CTSpace-occupy lesionSlow bleedingToxic signs+deliriumAntibioticsBrain CTLumbar punctureOther CNS infectionBact.meningitisAq PCN 3 MU stand q 4 hrCeftriaxone 2gm stand q 12 hrConsult NeuroConsult NeuroNormal*Basic NE package:MOC(Memory,O

29、rientation and Calculation),VF,EOM,F-N test,Motor and Sensory function,Fundi Clinical manifestation Clinical manifestation2、Localization diseased part usually referred to ipsilateral side Most tension-type headaches are described as tight“bandlike”pain or as dull deeply located,and aching painClinic

30、al manifestationClinical manifestation-Unilateral frontal headacheAcute glaucoma(cloudy cornea,dilated pupil)Iritis(irregular and constricted pupil)Cluster headache Temporal arteritis Trigeminal neuralgia Unilateral painTemporal nonthrobbingTemporal arteritisTMJ problemPrednisoloneNarcoticsCafergot1

31、00%O2Severe periorbitalCluster haeadacheAcute glaucomaPilocarpineTimololDiamoxManritolAura+unilateral throbbingClassic migraineFrequent(daily to weekly)Infrequent 1/monthProphylactic:Inderal SibeliumTCAProzacAbortive:Prochlorperazine IVChlorpromazine IVCafergot2#st,1#q 30 prn.6/D,10/wkSumatriptanIbu

32、profenTemporal arteritis 55 years old,M:F=1:4localized tenderness over the superficial temporal A.Fever,malaise,ESR,low-grade anemia,leukocytosisserious complication-involvement of ophthalmic a.Tx:prednisolone 60 mg/d,NSAIDs.RecurrentAssess symptomatologyBilateral painUnilateral painNeck and occiput

33、Whold or FrontotemporalThrobbingTight pressureCerrical SpondylosisorTensionCommon migraineTemporal nonthrobbingTo be continuedSevere periorbitalAura+unilateral throbbingTo be continuedTo be continuedTension headache Clinical manifestation Clinical manifestation3、Severity:Mild,morderate or severity M

34、ost severe forms:migraine（偏头痛）trigeminal neuralgia(三叉神经痛)meningeal irritation （脑膜刺激）The head pain in brain tumor is of moderate intensity,headache in vascular disease or infectious disease is usually striking（显著的）.Occurrence brain tumor:persistenceSAHmeningeal irritation 75%,but may take several hou

35、rs to develop.1/2 patients experience a LOC at onset.Fever:unusual at presentation but common after the 4th day.blood at area of Circle of Willis90%first 24 hours80%at 3 days50%at 1 weekA falsely negative CT can result from severe anemia or small volume SAH.SuddenExplosiveBrain CTPositiveSAHICHNegat

36、iveLumbar puncture1.Consult NS or Neuro2.Pain Control3.Quiet Dark Room4.Control BPNegativeBenign causesPain controlFM/Neuro OPDSAH1.RBC5 OldFresh2.XanthochromiaMeningitisWhile the majority of cases of meningitis can be diagnosed and treated without the use of CT,it may be needed in certain cases suc

37、h as Lumbar puncture.Severe hypertensionDiffuse and throbbing(搏动的)headacheWorse in the morningMay awaken the patient from sleepDiastolic BP usually above 130 mmHgCO intoxicationTwo or three family members presenting with headache should raise the suspicion of CO intoxication.(车内、机房）Cluster headacheA

38、lways on one side Usually in males Triggered by alcohol Frequently starts at night Intense,The patient must pace the floor,eye tearing and nose stuffy.Headache last for 1-2 hrs Occurs in clusters(e.g.nightly for several months)Clinical manifestationClinical manifestation4、Time of headacheTumorMenstr

39、ual Acute(2w),subacute(3m)or chronic(3m);Clinical manifestationClinical manifestation5、Provocation and relievingbrain tumor:increased during cough associated with nausea and vomittingmigraine:relieved after ergot（麦角）derivative or by sleepAssociated symptoms1、Headache with vomiting:increased intracra

40、nial pressure2、headache with fever3、headache with disturbance of disturbance of consciousnessconsciousness 4、headache with ep5、headache with Infection 6、headache with vertigo7、headache with hallucinations and illusions hallucinations and illusions 8、headache with the meninges incitement sign9、headac

41、he with sight obstacle InquiryInquiry points points（Detailed history and physical examination are always important）1、The quality,location,during,and time course of the headache and the conditions that produce,exacerbate,or relieve it should be carefully reviewed（Spinal fluid tests sometimes are neededCT scanning is indicated in some cases）2、Associated symptoms3、with disease 4、Occupation 5、treatment问诊要点