头痛专题知识培训.pptx

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,#,头痛专题知识培训,头痛专题知识培训,第1页,ear,arm,hand,leg,foot,head,eye,nose,mouth,tooth,face,stomach,back,Wheres his,neck,?,(,feet),(,teeth),头痛专题知识培训,第2页,Whats the matter,with her,?,I have a,headache,What should she do?,She should lie down and rest.,头痛专题知识培训,第3页,A Cure for a Headache,One 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 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.,头痛专题知识培训,第4页,Definition of a Headache,Unpleasant sensations in the regions of cranial vault.,头痛专题知识培训,第5页,Headache is one of the most common clinical symptoms.Its p,athogenesis is more complicated.,90%of individuals have at least one headache per year,头痛专题知识培训,第6页,头痛是指颅外或颅内疾病刺激对疼痛敏感结构,造成头颅上半部,(,眉毛、耳轮上部、枕外隆突联线以上）疼痛。也能够是面部或颈部所引发牵涉痛。头痛在西医来说仅仅是个临床症状，而不是一个独立疾病。,头痛专题知识培训,第7页,Etiology,Headache occurs in all age groups and is the 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.,头痛专题知识培训,第8页,An etiologic diagnosis of headache on based on understanding the pathophysiology of head pain;obtaining a history,with characterization of the pain as acute,subacute,or chronic;perorming a careful physical examination;and formulating a differential diagnosis.,头痛专题知识培训,第9页,Etiology,Intracranial disease,Extracranial disease,Systemic disease,Neurosis,头痛专题知识培训,第10页,Intracranial disease,Infection:encephalitis(,脑膜炎,),Vascular disease:cerebral accident,Tumor,Cranial injury:concussion of brain,（脑震荡）,varying combination of headache,dizziness,vertigo,impaired memory,irritability and difficulty with concentration,Others:migraine,（偏头痛）,cluster headache,（丛集性头痛,）,头痛专题知识培训,第11页,颅内病变引发头痛,（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，并有发烧和脑脊液阳性所见。,头痛专题知识培训,第12页,（二）脑血管病：,1,出血性脑血管病：脑出血多有猛烈头痛，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猛烈头痛、呕吐、也含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能够确诊。,2,缺血性脑血管病：脑血栓普通甚少头痛，但椎一基底动脉短暂缺血发作性头痛并不少见，以下诸占可作为诊疗依据：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它脑干短暂性缺血症状，以眩晕最多见，其它可有闪辉暗点、黑朦、复视、口面麻木、耳内疼痛、视物变形等。可有轻微脑干损害体征，如眼球震颤（患者头后仰转颈，使一侧椎动脉受压后更易出现）、一侧角膜反射或（和）咽反射迟钝或消失、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验（管径狭窄或,/,和血流量降低）、眼震电图（转颈后出现眼震）等试验室检验阳性。,缺血性脑血管病产生头痛机制，可能因颅内供血不足，颅外血管代偿性扩张所致，所以，也含有血管性头痛特点。,头痛专题知识培训,第13页,3,脑动脉硬化：系因脑部缺氧引发。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猛烈头痛，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。,头痛专题知识培训,第14页,（三）颅内肿物及颅内压增高：包含脑瘤、脑脓肿、颅内血肿、囊肿（蛛网膜炎）、脑寄生虫等。首先，肿物本身对颅内疼痛敏感组织压迫、推移、可引发局部及邻近部位头痛（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；另首先，,80%,肿物患者有颅内压增高，全头部展现胀痛、炸裂痛，迟缓发生者早期仅在晨起后发生（因平卧一夜后脑静脉郁血，颅内压愈加增高），以后逐步为连续性痛，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。起坐后突发猛烈头痛，常伴恶心、呕吐、系所以时颅内压深入下降，颅内疼痛敏感组织失去了脑脊液托持而受到牵拉所致，故也属于牵引性头痛。平卧后头痛即快速缓解。偶或有徐脉和血压升高。,头痛专题知识培训,第15页,（五）癫痫性头痛：多见于青少年及儿童、头痛呈猛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。脑电图检验尤其在发作进常有癫痫波形，也可有其它类型癫痫发作史、癫痫家族史和相关病因史，服用抗癫痫药品可控制发作。可能系各种疾病造成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、感染等相关。后期头痛相当多见，大多为衰弱表现，称为“外伤性神经症”或“脑外伤后综合症”。但很大一个别患者或并发或单独还有其它头痛表现，机制也十分复杂。常见有血管性头痛（包含各种类型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发头痛等。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相关，有则和并发颈椎损伤所致椎动脉短暂缺血等原因相关。少数头痛为外伤晚期并发症引发，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。故应详细问询病史并作相关检验，明确头痛性质和类型，不宜不加分析笼统地诊疗为脑外伤后遗症。,头痛专题知识培训,第16页,(,七,),血管性头痛,（,1,）偏头痛：常在青春期发病，个别患者有家族史，多因劳累、情绪原因、经期等诱发。经典者（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，与颅内血管痉挛相关。约,10-20,分钟后，继以颅外血管扩张，出现一侧或双侧猛烈搏动性痛或胀痛，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、连续数小时至一天恢复。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。少数头痛重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，多年倾向于认为，诱发原因作用于中枢神经后，经单胺能通路产生神经递质改变，继之激活血小板引发,5-HT,和血栓素,A2,（,TX A2,）释放和耗竭，相继产生颅内外血管收缩及扩张，扩张管壁因为吸附,5-HT,产生血管过敏，加之组织胺、缓激肽等参加，发生头痛及其神经性血管性反应。,头痛专题知识培训,第17页,（,2,）丛集性头痛：成年男性多见，发作时颅内外血管都有扩张，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，连续约半小时至,2,小时缓解，常在天天同一时间以同一形式屡次发作，夜间也可发生。发作连续数周至,2-3,个月后，逐步降低，减轻而停顿。但间隔数周或数年后再次出现类似丛集样发作。病因也未完全明了，有可能和过敏反应、外伤、蝶腭神经节或岩大浅神经病变相关。,头痛专题知识培训,第18页,Extracranial disease,Bone disease:osteoarthritis,(,骨关节炎,),of cervical spine,Neuralgia:trigeminal neuralgia,（三叉神经痛）,Disease of head organs:,eye nose ear teeth,头痛专题知识培训,第19页,头颈部神经炎性头痛：枕大神经、眶上神经和耳颞神经等，均可因受寒、感染或外伤引发头部神经神经痛。三叉神经第一支也可因感染、受寒等，引发前头部连续性或伴发短暂加剧发作痛，称三叉神经炎或症状性三叉神经痛。,头颈部皮肤、肌肉、颅骨病变引发头痛：,头皮急性感染、疖肿、颅骨肿瘤均可引发局部头痛。原发病灶显著，诊疗不难。,担心性头痛（肌收缩性头痛）：相当多见。系因头颈部肌肉连续收缩所致，多为前头部、枕颈部或全头部连续性钝痛。病因大多为精神担心或焦虑所致，也可继发于血管性头痛或五官病变头痛，有时为头颈部肌炎、颈肌劳损或颈椎病所致。,头痛专题知识培训,第20页,五官及口腔病变引发头痛,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，其它多以病窦部位为主。头痛程度常和副鼻窦引流情况相关，故前额窦炎头痛多以晨起为重，久立后逐步减轻，而上凳窦炎则反之。鼻中隔偏曲可因损及鼻甲，产生类似上颌窦为头痛。,（,2,）鼻咽腔癌肿：经典者除头痛外，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。少数症状可不经典，应屡次作鼻咽腔活检以求早期确诊。,头痛专题知识培训,第21页,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；慢性者有视乳头生理凹陷扩充等。测量眼压可明确诊疗。,（,3,）眼部急性感染：也常引发猛烈头痛，但局部征象显著，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。,头痛专题知识培训,第22页,Systemic disease,Systemic infection,Cardiovascular disease:hypertension,Intoxication:carbon monoxide,Heatstroke,Others:pre menstrual tension,chronic disease,头痛专题知识培训,第23页,Neurosis,头痛专题知识培训,第24页,神经官能症及精神病引发头痛,临床上最常见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神经衰弱表现时，方能诊疗。头痛可能与对疼痛耐受阈降低相关，但有患者因血管功效失调或精神担心，头痛含有血管性头痛或肌收缩性头痛特点。焦虑症头痛多伴有显著焦虑不安表现。抑郁患者也常有头痛，抑郁症状反被忽略，应高度警觉。癔症头痛多部位不定，性质多变，且有其它癔病表现，如发病情绪原因以及躯体其它种种不适等。有时也可出现急性头痛发作，症状夸大，常号哭、翻滚、呼叫，除有零乱感觉障碍和双侧腱反射亢进外，体检及神经系统无其它异常。当问询病史及查体以吸引其注意力后，头痛可显著减轻，暗示治疗可快速痊愈。重性精神病中也可有头痛，但极少以头痛为主诉就诊。,头痛专题知识培训,第25页,P,athogenesis,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.,头痛专题知识培训,第26页,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神经冲动传到达脑部所致。颅外组织除颅骨本身外，自骨膜直至五官、口腔均对疼痛敏感；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,2,3,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。,头痛专题知识培训,第27页,主要机理有：颅内外动脉扩张（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（比如脑膜刺激性头痛）；颅外肌肉收缩（担心性或肌收缩性头痛）；传导痛觉颅神经和颈神经直接收损或发生炎症（神经炎性头痛）；五官病变疼痛扩散（牵涉性头痛）等。在发生上述头痛过程中有致痛神经介质参加，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（,VIP,）和前列腺素（,PGE,）等。另外，精神原因也可引发头痛，可能与疼痛耐受阈值降低相关。与任何疼痛一样，疼痛严重程度也因人而异，同一病人头痛也可因当初身体和精神情况不一样而有所不一样。,头痛专题知识培训,第28页,Classification of the headache,1Acute(2w),subacute(3m)or,chronic(3m);,2 Original(migraine,cluster,tension);,secondary(trauma,infection,tumor);,头痛专题知识培训,第29页,Acute onset:,1,、,Subarachnoid hemorrhage,Cerebrovascular disease,2,、,Meningitis or encephalitis,3,、,Ocular disorders(glaucoma,acute iritis,4,、,Seizures,5,、,Lumbar puncture 6,、,Hypertensive encephalopathy,7,、,Coitus,头痛专题知识培训,第30页,Subacute onset,Giant cell(temporal)artertis,Intracraninl mass(tumor,abscess),Benign intracranial hypertension),Trigeminal neuralgia(tic douloureux),Glossopharyngeal neuralgia(,与心绞痛判别,),Postherpetic neuralgia(,如头部带状庖疹,),Hypertension,Atypical facial pain,头痛专题知识培训,第31页,Chronic,Migraine,Cluster headache,Tension,Cervical spine disease,Sinusitis,(,如海绵窦炎,),Dental disease,国足让人头痛,头痛专题知识培训,第32页,Clinical manifestation,1,、,Onset,acute infection:acute onset with fever and severe headache,cerebral or subarachnoid hemorrhage:acute onset without fever,brain tumor:chronic persistent,migraine:recurrent,(,周期性,),头痛专题知识培训,第33页,Clinical manifestation,“Sudden”=,occurrs abruptly,and,worst at the beginning,Sudden headache in a patient who does not normally have headaches may indicate serious intracranial pathology.,“,ICH”intracranial hemorrhage,includes,intracerebral hemorrhage,intraventricular hemorrhage,tumor bleeding,cerebellar hemorrhage,头痛专题知识培训,第34页,Headache,Onset,Progressive,Sudden,explosive,Recurrent,Consider:,CNS infection,Space-occupy lesion,Severe hypertension,Hypoxia,CO intoxiciation,Temporal arteritis,*EENTD problems,Consider:,Migraine,Tension headache,Cluster headache,Cervical spondylosis,Temporal arteritis,*EENTD problems,Consider:,SAH,*,EENTD:Eye,ear,nose,throat,dental,头痛专题知识培训,第35页,Progressive,.Fever without obvious focus or,2.Rigid neck,.No fever and,.Supple neck,*,Neurological exam.,Abnormal,Temporal,arteritis,Severe HTN,Hypoxia,CO intoxication,ESR,Acute glaucoma,Sinusitis,Otitis,TMJ problem,Periapical abscess,Brain CT,Space-occupy lesion,Slow bleeding,T,oxic signs,+delirium,Antibiotics,Brain CT,Lumbar puncture,Other CNS infection,Bact.meningitis,Aq PCN 3 MU st,and q 4 hr,Ceftriaxone 2gm st,and q 12 hr,Consult Neuro,Consult Neuro,Normal,*,Basic NE package:MOC(Memory,Orientation and Calculation),VF,EOM,F-N test,Motor and Sensory function,Fundi,头痛专题知识培训,第36页,Clinical manifestation,2,、,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 pain,头痛专题知识培训,第37页,Clinical manifestation,-,Unilateral frontal headache,Acute glaucoma(cloudy cornea,dilated pupil),Iritis(irregular and constricted pupil),Cluster headache,Temporal arteritis,Trigeminal neuralgia,头痛专题知识培训,第38页,Unilateral pain,Temporal,nonthrobbing,Temporal arteritis,TMJ problem,Prednisolone,Narcotics,Cafergot,100%O,2,Severe periorbital,Cluster haeadache,Acute glaucoma,Pilocarpine,Timolol,Diamox,Manritol,Aura+unilateral throbbing,Classic migraine,Frequent,(daily to weekly),Infrequent,1/month,Prophylactic:,Inderal,Sibelium,TCA,Prozac,Abortive:,Prochlorperazine IV,Chlorpromazine IV,Cafergot,2#st,1#q 30 prn.,6/D,10/wk,Sumatriptan,Ibuprofen,头痛专题知识培训,第39页,Temporal arteritis,55,years old,M:F=1:4,localized tenderness over the superficial temporal,A,.,Fever,malaise,ESR,low-grade anemia,leukocytosis,serious complication-involvement of ophthalmic a.,Tx:prednisolone 60 mg/d,NSAIDs,.,头痛专题知识培训,第40页,Recurrent,Assess symptomatology,Bilateral pain,Unilateral pain,Neck and occiput,Whold or,Frontotemporal,Throbbing,Tight,pressure,Cerrical,Spondylosis,or,Tension,Common migraine,Temporal,nonthrobbing,To be continued,Severe periorbital,Aura,+unilateral throbbing,To be continued,To be continued,Tension headache,头痛专题知识培训,第41页,Clinical manifestation,3,、,Severity,:,Mild,morderate or severity,Most 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）,.,Occurrence brain tumor:persistence,头痛专题知识培训,第42页,SAH,meningeal irritation 75%,but may take several hours to develop.,1/2 patients experience a LOC at onset.,Fever:unusual at presentation but common after the 4th day.,头痛专题知识培训,第43页,blood at area of Circle of Willis,90%first 24 hours,80%at 3 days,50%at 1 week,A falsely negative CT can result from severe anemia or small volume SAH.,头痛专题知识培训,第44页,Sudden,Explosive,Brain CT,Positive,SAH,ICH,Negative,Lumbar puncture,1.,Consult NS or Neuro,2.Pain Control,3.Quiet Dark Room,4.Control BP,Negative,Benign causes,Pain control,FM/Neuro OPD,SAH,.RBC5,OldFresh,2.Xanthochromia,头痛专题知识培训,第45页,Meningitis,While the majority of cases of meningitis can be diagnosed and treated without the use of CT,it may be needed in certain cases such as,Lumbar puncture,.,头痛专题知识培训,第46页,Severe hypertension,Diffuse and throbbing,(,搏动,),headache,Worse in the morning,May awaken the patient from sleep,Diastolic BP usually above 130 mmHg,头痛专题知识培训,第47页,CO intoxication,Two or three family members presenting with headache should raise the suspicion of CO intoxication.,(,车内、机房）,头痛专题知识培训,第48页,Cluster headache,Always 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),头痛专题知识培训,第49页,Clinical manifestation,4,、,Time of headache,Tumor,Menstrual,Acute(2w),subacute(3m)or,chronic(3m);,头痛专题知识培训,第50页,Clinical manifestation,5,、,Provocation and relieving,brain tumor:increased during cough,associated with nausea and vomitting,migraine:relieved after ergot,（,麦角,）,derivative or by sleep,头痛专题知识培训,第51页,头痛专题知识培训,第52页,头痛专题知识培训,第53页,Associated symptoms,1,、,Headache with vomiting:,increased intracranial pressure,2,、,headache with fever,3,、,headache with,disturbance of consciousness,4,、,headache with ep,5,、,headache with Infection,6,、,headache with vertigo,7,、,headache with,hallucinations and illusions,头痛专题知识培训,第54页,8,、,headache with the meninges incitement sign,9,、,headache with sight obstacle,头痛专题知识培训,第55页,头痛专题知识培训,第56页,Inquiry,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 needed,CT scanning is indicated in some cases,）,头痛专题知识培训,第57页,2,、,Associated symptoms,3,、,with disease,4,、,Occupation,5,、,treatment,头痛专题知识培训,第58页,