1、98年專科護理師訓練年專科護理師訓練神經系統常見問題之評估神經系統常見問題之評估(一一)頭痛頭痛 Headache頭暈頭暈 Dizziness成大醫院神經科 黃涵薇醫師Pain-sensitive cranial structuresl顱外lSkin,subcutaneous tissues,muscles extracranial arteries,periosteum of skulllEye,ear nasal cavities perinasal sinusesl顱內l血管lIntracranial venous sinuses and their large tributaries,
2、esp.pericavernous structureslArteries within the dura and pia-subarachnoid,particulary the proximal parts of the ACA,MCA and the intracranial segment of ICAlThe middle meningeal and superficial temporal arteriesl腦膜lParts of the dura at the base of the brainl顱神經lThe optic,oculomotor,trigeminal,glosso
3、pharyngeal,vagus,(and the first three cervical nerves)lFrom supratentorial structureslAnterior 2/3 of head(V1,V2 dermatones)lFrom infratenotrial structureslVertex,posterior head and neck lFrom VII,IX,X cranial nerveslNaso-orbital region,ear,throatPain from extracrainal part of body NOT refer to head
4、,EXCEPTlCervical portion of ICAlEyebrow,supraorbital regionlUpper cervical spinelocciputlAngina pectoris(rare)lJaw,vertexAreas of refer pain from intracranial structures 國際頭痛疾病分類國際頭痛疾病分類 ICHD(International Classification of Headache Disorders)l第一版在1988年公布，第二版於2004年刊登於Cephalalgia雜誌。l不論是中文版或英文版的國際頭痛疾病
5、分類都長達一百五十頁以上!l在英文版第二版中，作者建議這份內容龐大的分類文件不是用來背的，這是一份須要一次又一次不斷查看的文件。l原發性(Primary)l次發性(Secondary)l以決定頭痛的原因及訂定適切的治療計畫頭痛頭痛 Headache原發性頭痛原發性頭痛(primary headache)l意謂頭痛本身即為痛的成因。l超過百分之九十的頭痛患者屬於此類。l重點就是排除次發性的可能。無預兆偏頭痛無預兆偏頭痛 Migraine without aura A.至少有5次能符合基準B-D的發作B.頭痛發作持續頭痛發作持續4-72小時小時(未經治療或治療無效未經治療或治療無效)C.頭痛至少具
6、下列二項特徵：頭痛至少具下列二項特徵：1.單側單側2.搏動性搏動性 3.疼痛程度中或重度疼痛程度中或重度4.日常活動會使頭痛加劇或避免此類活動（如走路或爬樓日常活動會使頭痛加劇或避免此類活動（如走路或爬樓梯）梯）D.當頭痛發作時至少有下列一項：當頭痛發作時至少有下列一項：1.噁心及噁心及/或嘔吐或嘔吐2.畏光及怕吵畏光及怕吵E.非歸因於其他疾患 典型預兆偏頭痛性頭痛典型預兆偏頭痛性頭痛 Typical aura with migraine headache A.至少有2次符合基準B-D的發作B.預兆至少包括下列一項，但無肢體無力：預兆至少包括下列一項，但無肢體無力：1.完全可逆視覺症狀，包括正
7、向特徵完全可逆視覺症狀，包括正向特徵(如：閃爍的光、點或線如：閃爍的光、點或線)及及/或負向特或負向特徵徵(即視力喪失即視力喪失)2.完全可逆感覺症狀，包括正向特徵完全可逆感覺症狀，包括正向特徵(即針刺感即針刺感)及及/或負向特徵或負向特徵(即麻木感即麻木感)3.完全可逆失語性語言障礙完全可逆失語性語言障礙C.至少具下列至少具下列2項：項：1.單單側的視覺症狀及側的視覺症狀及/或單側感覺症狀或單側感覺症狀2.至少一種預兆症狀在至少一種預兆症狀在5分鐘逐漸產生，及分鐘逐漸產生，及/或不同預兆症狀，在或不同預兆症狀，在5分鐘分鐘相繼發生相繼發生3.每一種症狀持續每一種症狀持續5及及60分鐘分鐘D.
8、符合無預兆偏頭痛 基準B-D的頭痛，在預兆同時或預兆之後的60分鐘內發生E.非歸因於其他疾患 緊縮型頭痛緊縮型頭痛 Tension-type headache A.Frequent:至少有十次能符合基準B-D之發作，且發作平均每月1日但15日，已至少三個月（每年12日且180日,頭痛持續30分鐘至7日 Chronic:頭痛平均發作每月15日，已3個月（每年180日）且符合基準B-D,頭痛持續數小時或可能持續不斷B.頭痛至少具下列二項特徵：頭痛至少具下列二項特徵：1.雙側雙側2.壓迫壓迫/緊縮性（非搏動性）緊縮性（非搏動性）3.程度輕或中度程度輕或中度4.不因日常活動如走路或爬樓梯而加劇不因日常
9、活動如走路或爬樓梯而加劇C.下列兩項皆符合：下列兩項皆符合：1.無噁心或嘔吐（可能有食慾不振）無噁心或嘔吐（可能有食慾不振）2.最多只有畏光或怕吵其中一項症狀最多只有畏光或怕吵其中一項症狀D.非歸因於其他疾患 叢發性頭痛叢發性頭痛 Cluster headache A.至少有5次符合基準B-D之發作B.位於單側眼眶、上眼眶及/或顳部重度或極重度疼痛，如不治療可持續15至180分鐘 C.頭痛時至少伴隨下列一項：頭痛時至少伴隨下列一項：1.同側結膜充血及同側結膜充血及/或流淚或流淚2.同側鼻腔充血及同側鼻腔充血及/或流鼻水或流鼻水3.同側眼皮水腫同側眼皮水腫4.同側前額及臉部出汗同側前額及臉部出汗
10、5.同側瞳孔縮小及同側瞳孔縮小及/或眼皮下垂或眼皮下垂6.不安的感覺或躁動不安的感覺或躁動D.發作頻率為每二日一次至每日八次 E.非歸因於其他疾患 典型三叉神經痛典型三叉神經痛 Classical trigeminal neuralgia A.發作性(paroxysmal)疼痛發作，持續由不到一秒到兩分鐘，影響三叉神經一支或一支以上分支的支配區，且符合基準B及CB.疼痛至少具下列一項特徵：1.劇烈、尖銳、表淺或刺戳痛2.於誘發區引發或由誘因引發C.就個別病人而言，疼痛的發作型態是固定(stereotyped)的D.沒有神經功能缺損的臨床證據E.非歸因於其他疾患 次發性頭痛次發性頭痛(Secon
11、dary headache)l意謂頭痛由其他原因所引起l頭部與頸部外傷頭部與頸部外傷l顱部或頸部血管疾患顱部或頸部血管疾患l非血管性顱內疾患非血管性顱內疾患l物質或物質戒斷物質或物質戒斷l感染感染l體內恆定疾患體內恆定疾患l頭顱頭顱,頸頸,眼眼,鼻鼻,耳耳,口口,鼻竇鼻竇,牙或其他面部或顱部結構疾患牙或其他面部或顱部結構疾患l精神疾患精神疾患 國際頭痛疾病分類國際頭痛疾病分類 ICHD IIl需治療引起頭痛之原因。與腦瘤腦瘤相關的頭痛lThe pain has no specific featuresltend to be deep-seated,usually non-throbbinglL
12、asts a few minutes to an hour or morelOccur once or many times during a daylPhysical activity and changes in position of the head may provoke pain,whereas rest diminishes its frequency lIf unilateral,the pain is nearly always on the same side of tumorlSupratentorial/infratentorial tumor 的頭痛以interaur
13、icular circumference為分界lLate stage,IICP leads to lUnilateral to bioccipital or bifrontal headache,nocturnal awakening,projectile vomiting與中風中風相關的頭痛l25%stroke with headache around the onset l50%headache onset prior to the neurological deficitslpressing or throbbinglIf unilateral,pain is usually ipsil
14、ateral to the side of stroke lMore in llarge strokelposterior circulationlwith a history of primary headache老年人老年人的特殊頭痛lTemporal arteritis(Giant cell arteritis)l肇因於頭部動脈的發炎,多是外頸動脈的分支l頭皮動脈腫脹壓痛併ESR或CRP上升l可能伴隨polymyalgia rheumatica及jaw claudicationl變異性大,故凡是60歲以上新發的持續性頭痛均需懷疑此診斷,進行適當的診察l易併發前側缺血性視神經病變(ante
15、rior ischemic optic neuropathy)導致失明,由一側失明進展至另一側的時間小於一週l需積極用高劑量類固醇預防治療,治療三天內顯著緩解頭痛l通常也有腦部缺血及失智的危險lHypnic headachel鈍痛,只在睡眠中發生,使病人醒來l三項中具其二l首次發作在50歲以後,醒來後頭痛持續15分鐘以上,一個月發生15次以上l無自主神經系統症狀,且噁心,畏光,怕吵不超過一項”雷擊般頭痛雷擊般頭痛”Thunderclap headachelSubarachnoid hemorrhagelSentinel leaklAcute hypertensive crisislCervic
16、al artery dissectionlPituitary hypoplexylCerebral spasmlPrimary thunderclap headachelPrimary cough headachelPrimary headache associated with sexual activitylCerebral venous thrombosis需懷疑顱內高壓顱內高壓之頭痛 IICP HeadachelSymptomsl廣泛性脹痛,平躺更易頭痛lValsalva maneuver會更痛 l半夜痛醒(nocturnal awakening)l噴射性嘔吐(projectile v
17、omiting)lIICP Signsl視乳頭水腫(papilloedema)l盲點擴大l視野缺損 l第六對腦神經痲痺 l臥姿經腰椎穿刺測量出腦脊髓液壓力增加(在非肥胖者200mm H2O；在肥胖者250mm H2O)lCushing responselHypertension,bradycardia,slow and irregular breathing 腦脊髓液低壓腦脊髓液低壓之頭痛 Intracranial hypotensionA.整個頭整個頭(diffuse)及及/或鈍痛，在坐起或站立後或鈍痛，在坐起或站立後15分鐘內惡化，至少分鐘內惡化，至少具下列一項，且符合基準具下列一項，且符
18、合基準D：1.頸部僵硬頸部僵硬2.耳鳴耳鳴3.聽力障礙聽力障礙4.畏光畏光5.噁心噁心B.至少具下列一項：1.MRI有腦脊髓液低壓的證據（如：硬腦膜對比增強）2.傳統脊髓攝影、CT脊髓攝影、或腦池攝影術證實有腦脊髓液滲漏3.在坐姿，腦脊髓液起始壓力60mm H2OC.有/無硬腦膜穿刺或導致腦脊髓液瘻管病因等病史D.頭痛在硬腦膜外血液貼片後72小時內緩解 原發性頭痛和次發性頭痛可以並存原發性頭痛和次發性頭痛可以並存!Approach patients with headachelLocation lQualitylTightness,pressure,throbbing,stabbinglInt
19、ensitylMode of onset,time-intensity curve,and durationlPrecipitating,aggravating and relieving factorslAssociative symptomsHead Ache 有關頭痛需要獲得的病史有關頭痛需要獲得的病史評估頭痛的嚴重程度評估頭痛的嚴重程度l目測類比量表(Visual analogue scale,VAS)l區分頭痛為十級，即1至10分。l0代表沒有頭痛、10代表這一輩子最嚴重的疼痛。l概括而言1到3分表示輕度，4到6分表中度，7到9分表重度，而10分表示極重度。SNOOP Maria-C
20、arman B.Wilson,MD.lSymptoms（症狀）如發燒，倦怠，體重減輕lNeurological（神經學）症狀或徵象lOnset（發生）突然，快速惡化lOlder（年紀大的病患）出現新發生或逐漸惡化之頭痛lPrevious（原先）頭痛的頻率、強度、時程、特色改變焦點病史焦點病史l病人這種頭痛有多久了？l長時間持續多年且未曾改變的頭痛常為原發性頭痛，如偏頭痛。l新頭痛的發生，特別是超過50歲，則是個警訊。l若病人已有多年頭痛，它改變了嗎？l了解原本頭痛的改變，包括頻率、強度、時程等不同的特徵。l何時頭痛發生？l夜間頭痛可能是次發性，導因於某些引起顱內壓上昇的情形。有些時候，剛睡醒時
21、也會有次發性頭痛。因為這些相似性，頭痛發生的時間需進一步探討來決定原發或次發。l睡眠時發生的頭痛可以是原發的。叢發性頭痛及偏頭痛都可在睡眠時發生或將人痛醒。l頭痛是突發或慢慢發生？l對於數秒或數分鐘即痛到最痛者，可能會評估是否有潛在疾患如腦出血、栓塞、顱內壓上昇等情形。l原發性頭痛，包括不明原因（idiopathic）、刺戳性(stabbing)頭痛、咳嗽或用力(exertion)引起的、和性交有關的、叢發性及叢發類(variant)，都可以快速發生。l是否曾注意到下列神經學症狀：意識混亂、意識不清、麻木、無力、言語視力或平衡因難、或其他神經學不正常的症狀及徵象？l若在偏頭痛發生前產生這些症狀
22、，病人可能符合預兆偏頭痛。然而，必須區分不符合典型預兆偏頭痛的症狀及徵象，因此會仔細的詢問相關病史看看是否這些症狀指向其他問題。l若病人曾經歷過預兆，它是如何發生又持續多久？l偏頭痛預兆通常在數分鐘內逐漸產生，約在15至20分鐘達到頂峰後，約25分鐘消失。l依定義，偏頭痛預兆小於一小時。若預兆超過一小時，需小心是否為migraineous infarct。l是否曾經歷發燒、倦怠、體重減輕或全身不適？l這些症狀可能和潛在的感染、發炎或惡性腫瘤有關，可能有進一步檢查的必要焦點身體檢查焦點身體檢查lPhysical examinationlT/P/R and BPlHead and necklLoc
23、al heat/swelling/erythemalLocal tenderness/knocking painlEyes injection/bruitlNeck bruitlNeck stiffnesslNeurological examinationlConsciousness level/contentlCranial nerveslPupil size,light reflex,(eye fundus)lEOM limitationlFacial palsy,gag reflex,tongue deviationlMotor systemlMuscle powerlDTRlSenso
24、ry systemlPinprick,light touchlCoordination systemlF-N-F/H-K-S testlGaitlIII,IV,VI 眼動神經眼動神經l眼皮下垂 ptosislpartial/completel眼動是否對稱,有無雙影X000000X0000000正常-4不動l肌力 Muscle Powerl5分:正常l4分:抗阻力l3分:抗重力l2分:平移l1分:肌肉收縮l0分:不動555555555555l肌腱反射 DTR(deep tendon reflex)lHypol01lLow motor neuron lesionlNormall2lHyperl3c
25、lonuslUpper motor neuron lesion+實驗室與診斷檢查實驗室與診斷檢查l血液檢查l影像學檢查lCT or MRI?lCTA/MRA or conventional angiography?l腦脊髓液檢查lOpen/close pressurelCSF appearancelWBC,RBC,total protein,lactic acid,glucoselCulture/antigen identification/PCRHeadache Hygiene Tips(1)lGet Regular SleeplGo to bed and wake up at regula
26、r times each day lDo not sleep excessively on the weekends and too little on the weekdays lMost adults need approximately 6-8 hours of sleep per night lEat Regular MealslLow blood sugar can trigger a headache lEat regular meals three times each day including protein,fruits,vegetables and carbohydrat
27、es lToo much sugar may lead to a rapid increase in blood sugar followed by a rapid decline in blood sugar,which can trigger a headache lGet Moderate Amounts of Routine ExerciselModerate exercise three to five times each week will help reduce stress and keep you physically fit lToo much exercise or i
28、nconsistent patterns of exercise may trigger headache Headache Hygiene Tips(2)lDrink Plenty of WaterlA normal adult should drink plenty of water throughout the day lDehydration may cause headaches lLimit Caffeine,Alcohol and other DrugslCaffeine is a stimulant and caffeine withdrawal may cause heada
29、ches when blood levels of caffeine taper lAlcohol may be a trigger for headaches and alcohol in moderation may reduce the number of headaches lReduce StresslStress may lead to an increase in headache lRelaxation and stress management may help reduce headaches Headache-Cases discussionCASE 1l28歲女性l主訴
30、主訴:頭痛三個月l現在病史：現在病史：l似乎三個月前就開始會頭痛，然後發現次數愈來愈頻繁，也愈痛，尤其最近這兩週較嚴重，甚至胃口不好，吃不下飯。l頭痛的部位是整個頭，緊緊脹脹的痛、好像是整圈緊紮的痛，早上睡醒或者好好去睡一覺後，會覺得好一點，經常是越到下午越容易頭痛。但是不曾有半夜痛醒來的經驗。l頭痛起來時，並沒有眼前出現閃光，眼睛周圍沒有痛，不會怕光，沒有伴隨嘔吐或噁心，最近視力正常，記憶力也還好。l最近沒有感冒、發燒、鼻塞、濃鼻涕，也沒有過敏性鼻炎、鼻竇炎。耳朵也不會痛。手腳活動正常，不會常跌倒l最近半年換新工作，因工作還未完全熟悉，且業務量大，常常加班，自覺很辛苦。l身體檢查：身體檢查：
31、l血壓 136/88 mmHg 心跳 96/minl意識清醒、記憶正常，神經學檢查一切正常CASE 225 year-old female,no underlying diseaselSubacute progressive headache for 2 monthslDiffuse,swelling sensation lCough and defecation worse the headachelMidnight headache,awaking her from sleeplnausea/vomiting while headachelBlurred vision(+)lBody we
32、ight loss(+)lFever(-)Summary of N.E.&lablConscious clearlNeck supplelNE all normal,except papilloedema(OU)lCSF open pressure 310 mmH2O,no cellLupus leukoencephalopathy with IICP病人主訴Dizziness”頭暈”的意思是.?lVertigo 眩暈lan illusion of motionl“spinning sensation”,”whirling”,”tilting”llikely to indicate an ab
33、normality of the semicircular canals or the central nervous system structures that process signals from the semicircular canals lNonspecific“dizziness”l“giddy”or“lightheaded”lDisequilibriumlPresyncopel40%have peripheral vestibular dysfunctionl25%have other problems,such as presyncope and disequilibr
34、ium l15%have a psychiatric disorder l10%have a central brainstem vestibular lesionl10%remains uncertain in approximately當病人主訴當病人主訴”頭暈頭暈”.區分區分vertigo和和dizziness(1)lTime course lVertigo is never continuouslEven when the vestibular lesion is permanent,the central nervous system adapts to the defect so
35、that vertigo subsides over several weekslProvoking factors lSome are precipitated by maneuvers that change head position or middle ear pressure lmaneuvers that change head position without lowering blood pressure or decreasing cerebral blood flow is diagnosticl Aggravating factors lAll vertigo is ma
36、de worse by moving the head.lIf head motion does not worsen the feeling,it is probably another type of dizziness.lAssociated signs and symptoms lNystagmus lis not always readily visible,although it often can be elicited by provocative maneuvers or with electronystagmography.lPostural instability lit
37、 is common for patients with vertigo to have difficulty maintaining steady upright posture when walking,standing,and even sitting unsupported,particularly when the symptoms are acute.lHearing loss lvery suggestive of a peripheral cause of vertigo,although their absence does not exclude the diagnosis
38、lBrainstem signs lThe presence of additional neurologic signs strongly suggests the presence of a central vestibular lesion.區分區分vertigo和和dizziness(2)Peripheral vertigoBenign paroxysmal positional vertigo lThe most common form of positional vertigo,accounting for nearly 1/2 of patients with periphera
39、l vestibular dysfunction lMost commonly attributed to calcium debris within the posterior semicircular canal,known as canalithiasis lposterior canal BPPV more often than the anterior(superior)and horizontal semicircular canalslSymptomslrecurrent episodes of vertigo lasting one minute or less lprovok
40、ed by specific types of head movementsltypically recur periodically for weeks to months without therapy lmay be associated with nausea and vomitinglhave no other neurologic complaintsDix-Hallpike maneuver lWith the patient sitting,the neck is extended and turned to one side.The pt is then placed sup
41、ine rapidly,so that the head hangs over the edge of the bed.The patient is kept in this position and observed for nystagmus for 30 seconds.Nystagmus usually appears with a latency of a few seconds and lasts less than 30 seconds.It has a typical trajectory,beating upward and torsionally,with the uppe
42、r poles of the eyes beating toward the ground.After it stops and the patient sits up,the nystagmus will recur but in the opposite direction.Therefore,the patient is returned to upright and again observed for nystagmus for 30 seconds.If nystagmus is not provoked,the maneuver is repeated with the head
43、 turned to the other side.If nystagmus is provoked,the patient should have the maneuver repeated to the same(provoked)side;with each repetition,the intensity and duration of nystagmus will diminish.Vestibular neuritis lViral or postviral inflammatory disorder affecting the vestibular portion of the
44、eighth cranial nervelSymptomslSapid onset of severe vertigo lnausea,vomitinglgait instability.lpreserved ability to ambulate.toward the affected sidelhave no other neurologic complaintslSignslSpontaneous vestibular nystagmus lunilateral,horizontal,or horizontal-torsionallsuppressed with visual fixat
45、ionldoes not change direction with gazelfast phase of nystagmus beats away from the affected side.Menieres disease lArise from abnormal fluid and ion homeostasis in the inner ear lendolymphatic hydrops with distortion and distention of the membranous,endolymph-containing portions of the labyrinthine
46、 system lSyndrome lepisodic vertigo lassociated with nausea and vomiting,and persists from 20 minutes to 24 hours duration lSensorineural hearing loss loften initially affects the lower frequencies.lprogresses over time,and often results in permanent hearing loss at all frequencies in the affected e
47、ar over an 8 to 10 year period ltypically associated with intense aural fullness or pressure in the ear or the side of the head lTinnitus lcharacteristically low pitch lmay be associated with auditory distortionCentral vertigoLateral medullary infarction lWallenberg syndromelIpsilateral Horners synd
48、rome lDissociated sensory loss(loss of pain and temperature sensation on the ipsilateral face and contralateral limbs and trunk)lAbnormal eye movements lIpsilateral loss of corneal reflex lHoarseness and dysphagia lIpsilateral limb ataxia Cerebellar stroke lVertigo,may with nausea/vomitinglLimb dysm
49、etria,dysarthria,or headachelUsually unable to stand or walk unsupported lThe direction of falling is not necessarily opposite to the direction of the nystagmuslNystagmus lother than horizontal or horizontal-torsional,lmay change direction with gazelnot suppressed with visual fixation lPatients with
50、 a vascular event are typically older and/or have atherosclerosis risk factors(hypertension,diabetes,smoking).Vestibular schwannoma(acoustic neuroma)lSymptoms can be due to cranial nerve involvement,cerebellar compression,or tumor progression.lCochlear nerve(95%)lThe two major symptoms were hearing
