Diagnose und Therapie von Kopf- und Gesichtsschmerzen

The symptom headache is very frequent. Most frequently headache is the leading symptom of a primary headache syndrome such as migraine or tension-type headache. Sometimes it is caused by another disease. In everyday clinical practice it is important to diagnose and treat primary headaches properly. It is even more important not to miss a secondary headache, which is rare, but if misdiagnosed could conceal life-threatening conditions. This review provides an overview of the clinical picture, diagnostic procedures and treatment strategies of frequent headache syndromes such as migraine, tension-type headache, medication overuse headache, trigeminal autonomic cephalgias and trigeminal neuralgia. This is followed by a brief summary on symptomatic headache caused by non-neurological diseases as well as on diagnostic procedures and management of headache in the emergency situation.     

Headache

Headache, an almost universal human experience, is one of the most common complaints encountered in medicine and neurology. Described and categorized since antiquity, with the first classification by Aretaeus of Cappadocia, other classifications followed. The evaluation of this condition may be straightforward or challenging, and, though often benign, headache may prove to be an ominous symptom. This review discusses the current diagnosis and classification of headache disorders and principles of management, with a focus on migraine, tension-type headache, trigeminal autonomic cephalgias, and various types of daily headache.     

The diagnostic value of historical features in primary headache syndromes: a comprehensive review

BACKGROUND: Existing criteria for the diagnosis of headache do not indicate which clinical features are most important to establish or exclude primary headache diagnoses. OBJECTIVE: To determine the value of history taking in the evaluation of patients with primary headache syndromes. METHODS: A MEDLINE search of English-language studies published since 1966 and a hand search of bibliographies from retrieved articles. Included studies cited the sensitivity of clinical and historical features for the diagnosis of migraine, tension-type, and cluster headaches. Studies were classified according to their use of the International Headache Society criteria or other criteria as the reference standard for diagnosis. RESULTS: The features most predictive of migraine, when compared with tension-type headache, are nausea, photophobia, phonophobia, and exacerbation by physical activity. Positive likelihood ratios (95% confidence intervals) are 19.2 (15.0-24.5), 5.8 (5.1-6.6), 5.2 (4.5-5.9), and 3.7 (3.4-4.0), respectively. Headache precipitants are present equally in patients with migraine and tension-type headache, with the exception of food triggers, which confer a positive likelihood ratio of 3.6 (2.8-4.6) for the diagnosis of migraine. Visual aurae are present in 84% of patients with migraine with aura. Cluster headache is strictly unilateral, is periorbital in 80% of patients, and lasts less than 1 hour in 54% of patients. CONCLUSIONS: The features most predictive of the diagnosis of migraine, when compared with tension-type headache, are nausea, photophobia, phonophobia, exacerbation by physical activity, and an aura. Cluster headache is a distinct clinical syndrome.     

Epidemiological classification and social impact of chronic headache

The current prevalent opinion is that a diagnosis of chronic headache should be established in patients who have had a form of primary headache other than cluster headache on at least 15 days a month for at least 3 months. Chronic headache so defined includes four different subtypes: hemicrania continua and new daily persistent headache—two rare forms currently included in the group “Other primary headaches” of the 2004 International Classification of Headache Disorders, second edition (ICHD-II)—chronic tension-type headache, and chronic migraine. Regarding the latter, which has been better known lately as transformed migraine, the current revised diagnostic criteria establish that migraine must be present on at least 8 of the at least 15 days of headache per month and that there must not be any overuse of symptomatic medication. Chronic headache affects about 3–5% of the general population and results in a variety of negative repercussions both on individuals and on society at large.     

Somatic and psychological features of headache in systemic lupus erythematosus

OBJECTIVE: Headaches--especially of migrainous type--have been considered part of the disease spectrum of systemic lupus erythematosus (SLE). We wished to characterize prevalence and types of headaches in SLE and find out if headache is associated with disease, personality traits, or other psychological factors. METHODS: Fifty-eight consecutive Caucasian patients with SLE were given a clinical examination. We recorded SLE disease activity according to the SLE Disease Activity Index, types of headache according to International Headache Society criteria, and personality traits and emotional status according to Minnesota Multiphasic Personality Inventory-2 and Beck Depression Inventory (BDI). RESULTS: Thirty-eight SLE patients (66%) were headache sufferers; of these, 22 patients (38%) had migraine and 21 (36%) had tension-type headache. Headaches were not associated with disease activity or any other disease associated variable, including tests for antiphospholipid antibodies. Migraine was associated only with a tendency to social isolation and anxiety, while tension-type headache was associated with psychological distress, such as anxiety, somatic complaints, reduced energy, mental tension, social discomfort and withdrawal, and depressive mood according to the BDI. CONCLUSION; Migraine and tension-type headaches occur frequently in patients with SLE. Migraine shows the same clinical presentation as in a non-SLE population, and may not be part of a neuropsychiatric disease spectrum. This also applies to tension-type headache, which in contrast to migraine shows some associations with emotional and personality traits, and could represent components of a chronic pain syndrome.     

Primary Headache and Helicobacter Pylori

H. pylori infection has recently been associated with various vascular disorders. The aim of this study was to investigate its role in primary headache, a pathology strictly associated with vascular alterations. A total of 200 subjects affected by primary headache were evaluated. H. pylori infection was diagnosed by the 13C urea breath test. Headache was classified in tension-type headache, cluster headache, and migraine with or without aura. Prevalence of H. pylori infection and gastrointestinal (GI) symptoms were evaluated. H. pylori infection was found in 40% of the patients; prevalence of migraine without aura was found to be significantly greater in infected patients. The positive group showed no significant differences in the prevalence of the GI symptoms evaluated. In 30 infected patients, it was assessed whether the eradication of the bacterium was able to reduce frequency, intensity, and duration of clinical attacks of headache. After eradication, clinical attacks of headache completely disappeared in 17% of patients. Moreover, intensity, duration, and frequency of headache attacks were reduced in 69% of the remaining subjects. In conclusion, H. pylori infection is common in primary headache; bacterium eradication appears to be related to a significant reduction in clinical attacks of the disease.     

Identifying migraine in primary care settings

Migraine disorders are largely unrecognized and untreated, despite the heavy burden they impose on individuals and society. Studies have shown that the symptom severity and disability associated with undiagnosed migraine are as burdensome as those associated with diagnosed migraine. Of those persons with migraine identified in population-based surveys, many were previously unaware that they had migraine. Furthermore, coexisting headache types and comorbid conditions contribute to misdiagnosis among those who consult a physician for headache. Patients who do seek medical attention for headaches usually visit their primary care providers. The purpose of this review is to highlight the distinguishing characteristics of migraine compared with other headache disorders, based on the new International Classification of Headache Disorders. To aid in diagnosis, simple screening tools, such as ID Migraine (Pfizer Inc., New York, NY), are recommended. The clinical interview and headache diary aid in refining the diagnosis or suggesting the need for further evaluation. Improved recognition of migraine in primary care will increase the rate of successful treatment with effective migraine-specific therapies. This will result in improved functionality and decreased pain, and may help prevent disease progression.     

Intraoral topical nonsteroidal antiinflammatory drug application for headache prevention

Recent evidence suggests an association between migraine and tension-type headache and local inflammation occurring in a maxillary nerve segment. This study was designed to evaluate the efficacy of topical ketoprofen for the prevention of migraine, tension-type, and posttraumatic headache. Patients with a headache frequency of at least once a week recorded the frequency, severity, duration, and type of headache for 60 days. After 30 days, patients applied the medication daily for the next 30 days to the periapical area of the maxillary molars on the symptomatic side(s). Headache medications and analgesics were permitted, as needed. Headache burden was defined as the average intensity of each headache (0-10 scale) multiplied by its duration, in hours. The average monthly headache burden score for the 20 patients enrolled in this study decreased from 454.8 (30-day baseline) to 86.5 P < 0.001 during the 30-day treatment phase. Analgesic and headache medication intake were significantly reduced from baseline during the treatment phase, and side effects were minimal.     

Prevalence and classification of headache in patients with systemic lupus erythematosus

Studies on the prevalence of headache in systemic lupus erythematosus (SLE) have shown that it varies from 32 to 78%. The purpose of our study was to determine the prevalence and characteristics of headache in SLE compared with patients with different types of diffuse connective tissue diseases (DCTD) and its relationship with clinical and laboratory manifestations of SLE. We studied patients with SLE (SLE group) and patients with DCTD (control group). All patients were made to answer questionnaire to assess the presence of headache, characterized by at least five episodes of headache during the last year, which was classified according to the International Headache Society criteria. A total of 207 patients were studied, 115 in SLE group and 92 in the control group. The 1-year prevalence of headache was 75.7% in SLE group and 66% in the control group. When the groups were analyzed, 66.1% met the diagnostic criteria for migraine in the SLE group compared with 52.2% in the control group (p=0.04) and 13.9% for tension-type headache in SLE group compared with 16.3% in the control group. The former was the only variable that reached statistical significance comparing the two groups. Both headache and migraine were associated with Raynaud’s phenomenon in SLE patients (odds ratio of 2.80, 95% confidence interval: 1.11–7.05, p=0.02 and odds ratio of 2.34, 95% confidence interval: 1.04–5.23, p=0.03, respectively). These results suggest that headache is a common manifestation in SLE and in other DCTD and we cannot exclude the possibility that it may be related to the emotional stress induced by such clinical situations.     

A型肉毒毒素治疗头痛的现状分析

头痛是临床常见的症状之一,严重影响了患者的工作、生活和社会能力。当前,A型肉毒毒素用于治疗各种原发性头痛疾病的研究越来越多。许多资料表明A型肉毒毒素治疗偏头痛、慢性每日头痛及紧张型头痛有效且安全。然而,许多研究结果并不一致。本文就当前的研究资料进行综述分析。     

Plasma met-enkephalin levels: its relationship with age and type of headache

The aim of the present study was to assess the peripheral proenkephalin-A system in order to determine if it is related in any way to age and/or the type of headache. Our results show no significant change in plasma met-enkephalin (ME) and neutrophil met-enkephalin-containing peptide (NMECP) with aging in controls. Plasma ME levels and NMECP in patients suffering from migraine without aura and tension-type headaches were found to be similar in both groups, younger and older than 60 years old. When ME plasma levels were compared among the three groups of subjects in the two age-groups, only chronic tension-type headache patients differed ( [Formula: see text] ) from both controls and migraine without aura subjects.     

Chronic or recurrent headache in patients with systemic lupus erythematosus: a case control study

Controversy exists concerning the prevalence of headache in systemic lupus erythematosus (SLE) and its importance as a neuropsychiatric manifestation, especially when it occurs independently of disease activity and with the typical characteristics of primary chronic headache. Most reports to date have either studied both types of headache, whether or not related to systemic lupus erythematosus, or have not used adequate controls. This study determines the prevalence and types of chronic primary headache in patients with systemic lupus erythematosus in a case-control study which we performed in a tertiary care hospital. We studied 71 consecutive patients with systemic lupus erythematosus and 71 healthy unrelated subjects matched for age and sex from the same geographical area. Clinical evaluation using a specific standard protocol for the presence and characteristics of headache according to the operative classification criteria of the International Headache Society. The overall prevalence of headache, tension-type headache, and migraine was similar among patients and controls [33 (46.5%), 17 (23.9%) and 16 (22.5%) vs 31 (43.7%), 17 (23.9%) and 13 (18.3%), respectively]. The mean age of onset of headache was higher in the patients (28.7 +/- 14.3 vs 18.5 +/- 5.6 y; P = 0.001) and the subjective response to analgesics was lower than in the controls [19 (63%) vs 28 (93.3%); P = 0.004]. There were no differences in the presence of precipitating factors or family history of headache. There were no relevant clinical or immunological differences among the patients regarding the presence or absence of tension-type headache or migraine. Patients with systemic lupus erythematosus do not differ from healthy controls for the presence and type of chronic or recurrent headache.     

Review: Prophylactic botulinum toxin A reduces frequency of chronic migraine headaches in adults

QUESTION Does prophylactic botulinum toxin A reduce frequency of migraine or tension headaches, or chronic daily headaches in adults? REVIEW SCOPE Included studies compared botulinum toxin A, alone or combined with other prophylactic or analgesic treatments, with placebo or other treatments in adults who had headaches; were ≥?4 weeks in duration; and reported headache frequency or severity. Exclusion criteria were headaches associated with other disorders (e.g., cervical dystonia) or secondary headaches (e.g., postlumbar puncture headaches). Outcomes were patient-reported headache frequency or severity, indices that included patient-reported headache frequency and severity, and adverse events. REVIEW METHODS MEDLINE, EMBASE/Excerpta Medica, Cochrane Library, and reference lists were searched to March 2012 for randomized controlled trials (RCTs). 31 RCTs met inclusion criteria: 27 used placebo controls (n =?5423, mean age 42 y, 76% women) and 4 used active controls (n =?210, mean age range 30 to 42 y, 89% women), including topiramate, amitriptyline, methylprednisolone, and valproate. 10 placebo-controlled trials evaluated treatment for episodic migraine headaches (相似文献   

Overlapping conditions among patients with chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder

BACKGROUND: Patients with chronic fatigue syndrome (CFS), fibromyalgia (FM), and temporomandibular disorder (TMD) share many clinical illness features such as myalgia, fatigue, sleep disturbances, and impairment in ability to perform activities of daily living as a consequence of these symptoms. A growing literature suggests that a variety of comorbid illnesses also may commonly coexist in these patients, including irritable bowel syndrome, chronic tension-type headache, and interstitial cystitis. OBJECTIVE: To describe the frequency of 10 clinical conditions among patients with CFS, FM, and TMD compared with healthy controls with respect to past diagnoses, degree to which they manifested symptoms for each condition as determined by expert-based criteria, and published diagnostic criteria. METHODS: Patients diagnosed as having CFS, FM, and TMD by their physicians were recruited from hospital-based clinics. Healthy control subjects from a dermatology clinic were enrolled as a comparison group. All subjects completed a 138-item symptom checklist and underwent a brief physical examination performed by the project physicians. RESULTS: With little exception, patients reported few past diagnoses of the 10 clinical conditions beyond their referring diagnosis of CFS, FM, or TMD. In contrast, patients were more likely than controls to meet lifetime symptom and diagnostic criteria for many of the conditions, including CFS, FM, irritable bowel syndrome, multiple chemical sensitivities, and headache. Lifetime rates of irritable bowel syndrome were particularly striking in the patient groups (CFS, 92%; FM, 77%; TMD, 64%) compared with controls (18%) (P<.001). Individual symptom analysis revealed that patients with CFS, FM, and TMD share common symptoms, including generalized pain sensitivity, sleep and concentration difficulties, bowel complaints, and headache. However, several symptoms also distinguished the patient groups. CONCLUSIONS: This study provides preliminary evidence that patients with CFS, FM, and TMD share key symptoms. It also is apparent that other localized and systemic conditions may frequently co-occur with CFS, FM, and TMD. Future research that seeks to identify the temporal relationships and other pathophysiologic mechanism(s) linking CFS, FM, and TMD will likely advance our understanding and treatment of these chronic, recurrent conditions.     

Migraine is more frequent in individuals with optimal and normal blood pressure: a population-based study

BACKGROUND : The notion that hypertension causes headache is widely accepted despite the absence of confirmation by well-designed studies. OBJECTIVE : To investigate the association between headache, characterized as tension type and migraine like, with blood pressure and hypertension. METHODS : In a cross-sectional study we evaluate this association in a sample of 1174 individuals older than 17 years, representative of inhabitants of Porto Alegre, RS, Brazil. Headache and its subtypes were defined according to International Headache Society criteria. Hypertension was defined as the mean of two blood pressure readings >or=140/90 mmHg or use of antihypertensive drugs. RESULTS : Headache in lifetime, in the last year, and defined as episodic and chronic tension-type headache was not associated with hypertension. Individuals with optimal or normal blood pressure (Sixth Joint National Committee criteria) complained of migraine more frequently than the participants with high-normal blood pressure or hypertension. This association persisted after adjustment for several potential confounding factors (risk ratio, 0.56; confidence interval, 0.41-0.77). CONCLUSION : Our findings confirm that high blood pressure is not associated with the complaint of headache in the population. Individuals with migraine-like episodes of headache may have lower blood pressure than individuals without headache.     

APS and the brain

Antiphospholipid antibody syndrome (APS) may present with neurological syndromes. Cerebrovascular disease, chorea/ballismus, epileptic seizures, headache, cognitive impairment, transverse myelopathy, Devic's syndrome and multiple sclerosis-like presentations feature among others. Cerebrovascular disease is one of the most common presenting symptoms of APS, second only to deep vein thrombosis, and accounts for half of neurological manifestations in patients with APS; accelerated atherogenesis and cardioembolism are the most likely mechanisms implicated. Though infrequent, chorea is consistently associated with APS; the pathogenetic role of antiphospholipid antibodies (APLab) in this case might be routed through cerebrovascular disease in some cases and through purely immunological pathways in others. Both ischemic and immunological mechanisms have been demonstrated in the pathogenesis of epileptic seizures, which may account for 7% of neurological manifestations in APS. Although frequent in APS, a causative link between APLab and most common types of headache (migraine and tension-type headache) is more than dubious. Cognitive impairment may derive from a well-defined clinical tableau of multi-infarct dementia. Nevertheless, (highly frequent) less severe cognitive impairment has also been associated with the presence of APLab in the absence of magnetic resonance findings. A relationship between APS and transverse myelopathy seems likely but small numbers in the studies published to date preclude definite statements; routinely testing for APLab patients with neurological manifestations suggestive of multiple sclerosis seems to be unrecommended at the present time.     

Acute migraine in the Emergency Department: extending European principles of management

The World Health Organization (WHO) placed migraine 19th among all causes of disability (12th in women) measured in years of healthy life lost to disability (YLD). The importance of headache disorders, particularly of the primary forms, is established by their distribution worldwide, their duration (the majority being life-long conditions) and their imposition of both disability and life-style restrictions among large numbers of people. For these reasons, headache disorders should represent a public-health priority. In the Emergency Department (ED), as elsewhere, migraine is often under-diagnosed-and under-treated when it is diagnosed. The result is likely to be failure of treatment. Particular attention to diagnosis is needed in ED patients with acute headache, since there is a higher probability of secondary headache due to underlying pathologies. According to European principles of management, acute migraine treatment generally is stepwise. Of the two main steps, the first relies on symptomatic medication, preferably NSAIDs with or without antiemetics. The second step uses specific therapies, usually triptans. Modifications to routine practice are appropriate in the ED. Parenteral administration of symptomatic therapies is a preferred first choice, whilst immediate resort to triptans may be appropriate, and achieve better outcomes, in patients with severe headache and diagnostic confirmation of migraine.     

Clinical neuropsychiatric and neuromuscular manifestations in systemic lupus erythematosus

Thirty patients with SLE were studied retrospectively and subjected to clinical neurological examination. The accumulated neurological manifestations from the beginning of the disease until the time of examination were thus collected. Twenty-five patients (83%) had experienced neuropsychiatric manifestations while 11 patients (37%) had neuromuscular manifestations. The most frequent single symptom was migraine which had occurred in 40% of the patients. This was followed by severe protracted headache in 20%, vertigo in 20%, and psychiatric problems in 17%. Carpal tunnel syndrome and muscular weakness both occurring in 23% of the patients were the most prevalent neuromuscular manifestations, followed by myositis in 10%.     

Cardiac cephalgia: an underdiagnosed condition?

Cardiac cephalgia, or headache occurring as manifestation of myocardial ischemia, has only recently been recognized as a distinct entity. In patients with known ischemic cardiopathy, its diagnosis depends on the presence of severe headache that is accompanied by nausea, worsened by physical exercise, and only ceases with nitrate administration. We report on two patients who met diagnostic criteria for this entity. In both, headache was the only symptom of coronary ischemia, and delayed its diagnosis. Headache occurred both at rest and during exertion, and resolved only after the administration of nitrates. Cardiac cephalgia should be suspected in patients with a history of ischemic cardiopathy who present with de novo headache, even when thoracic pain is absent, especially if the headache improves with nitrates. Differential diagnosis with migraine is crucial to avoid the administration of vasoconstrictors.     

Prevalence of migraine in patients with a history of self-reported or physician-diagnosed "sinus" headache

BACKGROUND: Symptoms referable to the sinus area are frequently reported during migraine attacks, but are not recognized in diagnostic criteria. Underrecognition of migraine may be partly attributed to a variable clinical presentation, and migraines with "sinus" symptoms contribute to this problem. This study was conducted to determine the prevalence of migraine-type headache (International Headache Society [IHS]-defined migraine without aura [IHS 1.1], migraine with aura [IHS 1.2], or migrainous disorder [IHS 1.7]) in patients with a history of self-described or physician-diagnosed "sinus" headache. METHODS: During a clinic visit, patients with a history of "sinus" headache, no previous diagnosis of migraine, and no evidence of infection were assigned an IHS headache diagnosis on the basis of headache histories and reported symptoms. RESULTS: A total of 2991 patients were screened. The majority (88%) of these patients with a history of self-described or physician-diagnosed "sinus" headache were diagnosed at the screening visit as fulfilling IHS migraine criteria (80% of patients) or migrainous criteria (8% of patients). The most common symptoms referable to the sinus area reported by patients at screening were sinus pressure (84%), sinus pain (82%), and nasal congestion (63%). CONCLUSIONS: In this study, 88% of patients with a history of "sinus" headache were determined to have migraine-type headache. In patients with recurrent headaches without fever or purulent discharge, the presence of sinus-area symptoms may be part of the migraine process. Migraine should be included in the differential diagnosis of these patients.