두통의 임상적 평가-일이차 두통의 감별진단

도진국(Jin Kuk Do) 대한생물치료정신의학회 2004 생물치료정신의학 Vol.10 No.2

두통환자의 임상적 평가는 이상에서 간단히 살펴본 것처럼 여러 가지 면에서 접근 할 수 있다. 임상에서는 일차두통이 이차두통보다는 흔한 것이 사실이다. 하지만 법의학적인 문제에서나 환자를 위해서나 이차두통을 배제하기 위한 노력을 게을리 하지 말아야 한다. 두통환자를 대하면서 섬세한 문진과 검사를 통한 접근이야말로 해결의 열쇠라는 것을 잊지 말아야 할 것이다. Headache is one of the most common reasons for neurologic consultation. We should always distinguish primary from secondary headaches. In the absence of secondary headache, the clinician proceeds to diagnosing a primary headache disorder. The clinician must remain vigilant concerning secondary and alert to the "red flags". Headache management starts with diagnosis and this begins with a good history and physical examination. This clinical process provides clear information for the clinician and sets patients at ease in the knowledge that the doctor is interested in their problem. With the publication of the second edition of The International Classification of Headache Disorders(ICHD-2) in January 2004, clinicians who treat headache should become familiar with the revised criteria, which will become the standard for treatment and research. I offer orderly approach to primary headache diagnosis based on attack frequency and duration, using the ICHD-2. In this article, clinical evaluation of headache and differential diagnosis between primary and secondary headache will be reviewed.

국제두통학회 신분류법에 근거한 제 4군 기타 원발성 두통의 최신 지견

하정호 東國大學校醫學硏究所 2004 東國醫學 Vol.11 No.1

최근 국제두통학회에서 개정한 두통 분류법 중 제 4군 기타 원발성 두통은 임상적으로 이질적인 두통군이며, 그 병인에 대해서도 잘 밝혀져 있지 않다. 또한 일부의 두통 즉, hypnic headache, primary thunderclap headache, hemicrania continua, newly developed persistent headache이 새로이 포함되었다. 이에, 제 4군에 포함된 두통에 대해서, 임상 양상, 분류의 근거, 치료 및 병안에 대해서 논하고자 한다. Group 4 of International Classification of Headache Disorder, 2^{nd} editon (ICHD-2) includes the clically heterogenous headaches, of which pathogenesis is poorly understood. Some headaches-hypnic headache, primary thunderclap headache, hemicrania continua, and newly developed persistent headache- are newly brought under ICHD-2. I intend to review and discuss the presentation, the basis of the categorizing, the treatment and the pathogenesis of the other primary headaches of ICHD-2, group 4

노인두통의 임상적 접근

이동국(Dong-Kuck Lee) 대한임상노인학회 2011 대한임상노인의학회지 Vol.12 No.2

Headaches in the elderly, although less prevalent than in younger adults, is a common complaint that presents a special challenge to the physician. Headaches in the elderly can conveniently be divided into primary and secondary headaches. Primary headache disorders, such as migraine, cluster headache, and tension-type headache, are diseases unto themselves. Secondary headache represents a symptom of an underlying disease such as an intracranial mass lesion or a metabolic disorder. The clinician faces not only a broad differential diagnosis, but must contend with the difficulty of managing headache when comorbid illnesses can contraindicate or complicate effective treatments. Although the overall incidence of headache declines with advancing age, the relative proportion of secondary headaches increase, thus highlighting the importance of a careful evaluation and a high level of suspicion when evaluating an elderly patient with a complaint of headache.

소아청소년에서 연령에 따른 일차두통의 임상적 특징

홍연주(Yeon Ju Hong),김민성(Min Sung Kim),이경연(Kyung Yeon Lee),심창선(Chang Sun Sim) 대한소아신경학회 2010 대한소아신경학회지 Vol.18 No.2

Purpose : Childhood headache is different from adulthood headache and according to their age in clinical aspects. This study investigated the clinical differences of pri- mary headache according to ages of children and adolescents. Methods : A 300 children who did not show abnormalities on neurologic exami- nation or brain CT or MRI were classified into two groups according to their ages. Results : The percentage of those in the migraine group (24.2% vs. 35.9% in Groups 1 and 2 respectively) was higher in Group 2, but it was not statistically signi- ficant. In relation to the duration of headache, pain lasting for less than one hour accounted for 59.8% and 40% in Groups 1 and 2, respectively (P =0.001). In relation to the location headaches developed, the frontal region (40.2%) and temporal region (48.1%) were the most common in Groups 1 and 2, respectively (P<0.001). In rela- tion to the nature of the headaches, tightening sensation accounted for the highest percentage in both groups; however, pulsating sensation were more common in Group 2 than in Group 1 (16.2% vs. 8.3%, P =0.038). In relation to the severity of head- aches, severe to profound headaches accounted for 35.5% and 61.1% in Groups 1 and 2, respectively (P <0.001). In relation to laterality, unilateral headaches accounted for 12.4% and 26.7% in Groups 1 and 2, respectively (P =0.002). In relation to accom- panying symptoms, the incidence of photophobia was higher in Group 2 than in Group 1 (P =0.047). Conclusion : Age factors should be considered in the diagnosis of childhood head- aches. Also, we consider that there may be a need to establish diagnostic criteria specifically for childhood headaches separately from those for adulthood headaches.

일차 두통의 병태생리

노영일(Young Il Rho) 대한소아신경학회 2006 대한소아신경학회지 Vol.14 No.2

The primary headaches include migraine, tension-type headache(TTH), cluster headache, and other primary headaches. An understanding of the basic pathophysiology facilitates the assessment and management of patients with headache. There have been remarkable advances in the last decade in unraveling the mystery of primary headaches. The vascular theory has been superseded by the neurovascular phenomenon, which seems to be the permissive triggering factor in migraine and cluster headache. Calcitonin gene-related peptide(CGRP) is one of the main neuropetides involved in the neurogenic inflammation, which is important in the generation of migraine. The serotonin also appears to have a pivotal role in some aspects of migraine pathogenesis. Cortical spreading depression(CSD) seems to be an important phenomenon explaining migraine with aura. The brain stem nuclei(raphe and locus coeruleus) and cortical hyperexcitability may well have a important role in generating CSD. These have been achieved through new imaging modalities such as positron emission tomography(PET) and functional magnetic resonance imaging(fMRI). In migraine, the throbbing pain is mediated by the sensitization of the meningeal nociceptor of trigeminovascular neurons. The sustained sensitization of peripheral trigeminal neurons eventually leads to subsequent sensitization of central trigeminovascular neurons, which can be manifested as cutaneous allodynia. TTH and migraine belong to the same physiological spectrum. However, they are genetically most likely multifactorial.

두통 초진 환자에서 신경영상검사 소견

김병수,김수경,김재문,문희수,박광열,박정욱,손종희,송태진,주민경,차명진,김병건,조수진 대한신경과학회 2018 대한신경과학회지 Vol.36 No.4

Background: Neuroimaging can play a crucial role in discovering potential abnormalities to cause secondary headache. There has been a progress in the fields of headache diagnosis and neuroimaging in the past two decades. We sought to investigate neuroimaging findings according to headache disorders, age, sex, and imaging modalities in first-visit headache patients. Methods: We used data of consecutive first-visit headache patients from 9 university and 2 general referral hospitals. The International Classification of Headache Disorders, third edition, beta version was used in headache diagnosis. We finally enrolled 1,080 patients undertook neuroimaging in this study. Results: Among 1,080 patients (mean age: 47.7±14.3, female: 60.8%), proportions of headache diagnosis were as follows: primary headaches, n=926 (85.7%); secondary headaches, n=110 (10.2%); and cranial neuropathies and other headaches, n=43 (4.1%). Of them, 591 patients (54.7%) received magnetic resonance imaging (MRI). Neuroimaging abnormalities were found in 232 patients (21.5%), and their proportions were higher in older age groups and male sex. Chronic cerebral ischemia was the most common finding (n=88, 8.1%), whereas 76 patients (7.0%) were found to have clinically significant abnormalities such as primary brain tumor, cancer metastasis, and headache-relevant cerebrovascular disease. Patients underwent MRI were four times more likely to have neuroimaging abnormalities than those underwent computed tomography (33.3% vs. 7.2%, p<0.001). Conclusions: In this study, the findings of neuroimaging differed according to headache disorders, age, sex, and imaging modalities. MRI can be a preferable neuroimaging modality to identify potential causes of headache.

Efficacy of ketamine in the treatment of migraines and other unspecified primary headache disorders compared to placebo and other interventions: a systematic review

Chah, Neysan,Jones, Mike,Milord, Steve,Al-Eryani, Kamal,Enciso, Reyes The Korean Dental Society of Anesthsiology 2021 Journal of Dental Anesthesia and Pain Medicine Vol.21 No.5

Background: Migraine headaches are the second leading cause of disability worldwide and are responsible for significant morbidity, reduction in the quality of life, and loss of productivity on a global scale. The purpose of this systematic review and meta-analysis was to evaluate the efficacy of ketamine on migraines and other primary headache disorders compared to placebo and other active interventions, such as midazolam, metoclopramide/diphenhydramine, and prochlorperazine/diphenhydramine. Methods: An electronic search of databases published up to February 2021, including Medline via PubMed, EMBASE, Web of Science, and Cochrane Library, a hand search of the bibliographies of the included studies, as well as literature and systematic reviews found through the search was conducted to identify randomized controlled trials (RCTs) investigating ketamine in the treatment of migraine/headache disorders compared to the placebo. The authors assessed the risk of bias according to the Cochrane Handbook guidelines. Results: The initial search strategy yielded 398 unduplicated references, which were independently assessed by three review authors. After evaluation, this number was reduced to five RCTs (two unclear risk of bias and three high risk of bias). The total number of patients in all the studies was 193. Due to the high risk of bias, small sample size, heterogeneity of the outcomes reported, and heterogeneity of the comparison groups, the quality of the evidence was very low. One RCT reported that intranasal ketamine was superior to intranasal midazolam in improving the aura attack severity, but not duration, while another reported that intranasal ketamine was not superior to metoclopramide and diphenhydramine in reducing the headache severity. In one trial, subcutaneous ketamine was superior to saline in migraine severity reduction; however, intravenous (I.V.) ketamine was inferior to I.V. prochlorperazine and diphenhydramine in another study. Conclusion: Further double-blind controlled studies are needed to assess the efficacy of ketamine in treating acute and chronic refractory migraines and other primary headaches using intranasal and subcutaneous routes. These studies should include a long-term follow-up and different ketamine dosages in diagnosed patients following international standards for diagnosing headache/migraine.

원발성 두통에 대한 별갑약침의 임상적 효과 3례 보고

황윤경,김원일,김광록,Hwang, Yun-kyeong,Kim, Won-ill,Kim, Koang-lok 대한한방내과학회 2017 대한한방내과학회지 Vol.38 No.5

Objectives: To report the clinical application and effects of ByeolGab (Trionycis Carapax) pharmacopuncture in patients with primary headache. Method: Three patients who suffered from primary headache were treated with ByeolGab pharmacopuncture and acupuncture for 2 weeks. We used the Henry Ford Headache Disability Inventory (HDI), a six point scale, and a visual analogue scale (VAS) three times and analyzed the results. Result: After treatment with ByeolGab pharmacopuncture, the VAS, HDI, and six point scale scores were improved in all three patients. The symptoms of headache and other symptoms were also improved. Conclusion: ByeolGab pharmacopuncture is an effective treatment for patients complaining of primary headache.

The evolving classifications and epidemiological challenges surrounding chronic migraine and medication overuse headache: a review

Emanuel Schembri,Michelle Barrow,Christopher McKenzie,Andrew Dawson 대한통증학회 2022 The Korean Journal of Pain Vol.35 No.1

Changes in diagnostic criteria, for example, the various International Classification of Headache Disorders criteria, would lead to changes in the outcomes of epidemiological studies. International Classification of Headache Disorders-1 was based mainly on expert opinion, yet most of the diagnostic criteria were reliable and valid, but it did not include chronic migraine. In its second version, the classification introduced chronic migraine, but this diagnosis resembled more a high-frequency migraine rather than the actual migraine transformation process. It also introduced medication overuse headache, but it necessitated analgesic withdrawal and subsequent headache improvement to be diagnosed as such. Hence patients having medication overuse headache could only be diagnosed in retrospect, which was an awkward situation. Such restrictive criteria for chronic migraine and medication overuse headache omitted a high proportion of patients. International Classification of Headache Disorders-3 allows a diagnosis of medication overuse headache due to combination analgesics if taken for at least 10 days per month for more than three months. Hence the prevalence rate of medication overuse headache and chronic migraine can increase compared to the previous version of the headache classification. Different criteria have been used across studies to identify chronic migraine and medication overuse headache, and therefore the information acquired from previous studies using earlier criteria becomes uncertain. Hence much epidemiological research would need to be interpreted cautiously or repeated with the most updated criteria, since the subjects in studies that apply the latest criteria may be phenotypically different from those in older studies.

Clinical Analysis and Red Flag Signs in Pediatric Headache According to Age

Yoon Hee Jo,Yoo Jung Lee,Donghyun Shin,Soo Young Lyu,Ju Hyun Kong,Yun-Jin Lee,Sang Ook Nam,Young Mi Kim 대한소아신경학회 2024 대한소아신경학회지 Vol.32 No.2

Purpose: The clinical characteristics of headaches vary by age among pediatric patients. Red flag signs are key factors in differentiating secondary headaches and should be considered in the context of the patient’s age. Methods: This study involved a retrospective chart review of pediatric patients presenting with headaches. Patients were categorized by age into three groups: pre-school age (under 6 years), school-age (6 to 12 years), and adolescence (over 12 years). Demographic data, headache characteristics, laboratory findings, and neuroimaging results were evaluated. Overall, 17 potential red flags were assessed. Results: A total of 687 patients were included, of whom 102 were of pre-school age, 314 were school-aged, and 271 were adolescents. The frequency of overweight/obesity was found to increase with age. The pre-school age group experienced a shorter period from symptom onset to presentation and a briefer duration of pain. In contrast, adolescents displayed a longer period from symptom onset, a greater frequency of headaches occurring at least three times per week, and a higher rate of headache episodes lasting over 3 days. Children under 6 years old were more commonly diagnosed with secondary headaches than older children. Across age groups, secondary headaches were suspected when systemic symptoms such as fever were present, when the headache had a sudden onset, when the patient responded poorly to medication, or when abnormal neurological signs and symptoms were observed. Conclusion: The clinical features of pediatric patients vary by age group. Clinicians should consider red flag signs in the context of patient age and individual characteristics.