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#2
23.06.2008, 16:18
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Цитата:
Уверен, Вы оговорились. Кластерная головная боль не может быть двусторонней. Она всегда строго односторонняя. Вопрос в другом, может ли меняться сторона боли? Сразу хотел бы высказать свое мнение по обзорам pubmed. Речь идет о субъективном мнении отдельных исследователей. Или о субъективном обзоре мнений совокупности авторов (конечно объективность здесь гораздо больше). Но мне кажется, ориентироваться нужно на критерии международной классификации головной боли. В ней авторы попытались учесть все достоверные исследования Мира. Насчет кластерного периода сказано довольно определенно. «Pain almost invariably (без исключений) recurs on the same side during an individual cluster period.» На счет смены стороны боли при длительном течении кластера, в классификации ничего нет. Постоянно фигурирует только термин «строго односторонняя». Почти согласен с Вашим анализом литературы, что сторона головной боли может меняться «не редко». Но я бы сказал не часто. Но в любом случае, это основание проанализировать, а тот ли диагноз? Кластерные головные боли относятся к тригеминальным цефалгиям. 3. Cluster headache and other trigeminal autonomic cephalalgias 3.1 Cluster headache 3.1.1 Episodic cluster headache 3.1.2 Chronic cluster headache 3.2 Paroxysmal hemicrania 3.2.1 Episodic paroxysmal hemicrania 3.2.2 Chronic paroxysmal hemicrania (CPH) 3.3 Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) 3.4 Probable trigeminal autonomic cephalalgia 3.4.1 Probable cluster headache 3.4.2 Probable paroxysmal hemicrania 3.4.3 Probable SUNCT А диагностическими критериями кластера являются: 3.1 Cluster headache Previously used terms: Ciliary neuralgia, erythro-melalgia of the head, erythroprosopalgia of Bing, hemicrania angioparalytica, hemicrania neuralgiformis chronica, histaminic cephalalgia, Horton’s headache, Harris- Horton’s disease, migrainous neuralgia (of Harris), petrosal neuralgia (of Gardner). Coded elsewhere: Symptomatic cluster headache is coded to the underlying causative disorder. Description: Attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites, lasting 15–180 minutes and occurring from once every other day to 8 times a day. The attacks are associated with one or more of the following, all of which are ipsilateral: conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis, eyelid oedema. Most patients are restless or agitated during an attack. Diagnostic criteria: A. At least 5 attacks fulfilling criteria B–D B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes if untreated1 C. Headache is accompanied by at least one of the following: 1. ipsilateral conjunctival injection and/or lacrimation 2. ipsilateral nasal congestion and/or rhinorrhoea 3. ipsilateral eyelid oedema 4. ipsilateral forehead and facial sweating 5. ipsilateral miosis and/or ptosis 6. a sense of restlessness or agitation D. Attacks have a frequency from one every other day to 8 per day2 E. Not attributed to another disorder3 А пациент ничего не сказал про симптомы группы «С», без которых диагноз кластера не может быть поставлен (правда эти симптомы его никто и не просил подтвердить, может они есть). При имеющейся информации пациент может вписываться например: 1. Cluster headache with coexistent trigeminal neuralgia (cluster-tic syndrome): Some patients have been described who have both Cluster headache and 13.1 Trigeminal neuralgia. They should receive both diagnoses. The importance of this observation is that both conditions must be treated for the patient to be headache free. 2. 3.2.1 Episodic paroxysmal hemicrania (правда против этого четкая провокация приступов алкоголем). Собственно из этих соображений я и предложил применение быстродействующих суматриптанов в плане как лечения, так и диф.диагностики. С уважением, Гусейнов Тимур Юсуфович. P.S. Эффект суматриптанов при кластере идентичен эффекту при мигрени. 
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#3
23.06.2008, 17:08
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Тимур Юсуфович, критерии есть критерии, никто не покушается. Но ради истины надо заметить, что все таки бывает и двухсторонняя кластерная боль и двухсторонняя мигрень.
Chronic cluster headache: a French clinical descriptive study. Donnet A, Lanteri-Minet M, Guegan-Massardier E, Mick G, Fabre N, Géraud G, Lucas C, Navez M, Valade D; Société Française d'Etude des Migraines et Céphalées (SFEMC). Department of Neurology, Clinical Neuroscience Federation, La Timone Hospital, Marseille, France. [Ссылки доступны только зарегистрированным пользователям ] BACKGROUND: Cluster headache (CH) is a relatively rare disease and episodic CH is more frequent than chronic CH. Few studies have described the characteristics of patients with chronic CH. METHODS: This was a descriptive study carried out by eight tertiary care specialist headache centres in France participating in the Observatory of Migraine and Headaches (OMH). From 2002 to 2005, OMH collected data from 2074 patients with CH, of whom 316 had chronic CH. From January to June 2005, 113 patients with chronic CH were interviewed using standardised questionnaires during a consultation. RESULTS: The male to female ratio was 4.65:1. Median age was 42 years. The majority of patients were smokers or former smokers (87%). 46% had primary chronic CH (chronic at onset) and 54% secondary chronic CH (evolving from episodic CH). Most patients had unilateral pain during attacks and 7% had sometimes bilateral pain during an attack. 48% reported a persisting painful state between attacks. Symptoms anteceding pain onset (mainly discomfort/diffuse pain, exhaustion, mood disorders) and auras were reported by 55% and 20% of patients, respectively. The functional impact of chronic CH was estimated as severe by 74% of patients, and 75.7% suffered from anxiety, as assessed by the Hospital Anxiety and Depression scale. There was no substantial difference in clinical presentation between primary and secondary CH. DISCUSSION: This study confirms the existence of auras and interictal signs and symptoms in patients with chronic CH, and male sex and smoking as CH risk factors. Primary and secondary chronic CH appear equally prevalent. Male sex does not appear to favour the shift from episodic to chronic CH.
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#4
23.06.2008, 17:09
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The Sinus, Allergy and Migraine Study (SAMS).
Eross E, Dodick D, Eross M. Scottsdale Headache Center at Arizona Neurological Institute, Scottsdale, AZ 85255, USA. OBJECTIVE: The objective of this study is to classify (according to the current International Headache Society's criteria [ICHD-II]) the headache types that those with self-diagnosed sinus headache experience and to determine barriers to correct diagnosis. BACKGROUND: The American Migraine Study II estimates that 28 million Americans suffer from migraine headache. The majority of these patients remain undiagnosed and many are erroneously diagnosed as having sinus headache. Despite this common diagnosis, the concept of sinus headache remains an enigma with a relative paucity of information in the literature. METHODS: Advertising in the greater Phoenix, U.S. metropolitan area was used to recruit 100 willing and consecutive subjects to participate in this descriptive clinical study (The Sinus, Allergy and Migraine Study [SAMS]). All patients who believed they suffered from sinus headache and were over 18 years of age were enrolled without exclusion. A detailed history and exam was performed in each patient, and patients were given headache diagnoses based on the current International Headache Society's (IHS) criteria. RESULTS: Of the 100 subjects with self-diagnosed headache, IHS diagnoses mistaken as sinus headache included migraine with or without aura (52%), chronic migraine associated with medication overuse versus probable medication overuse headache (11%), probable migraine (23%), cluster headache (1%), hemicrania continua (1%), headache secondary to rhinosinusitis (3%), and headaches nonclassifiable (9%). Weather changes (83%), seasonal variation (73%), exposure to allergens (62%), and changes in altitude (38%) were frequent migraine triggers. Seventy-six percent of migraine subjects reported pain in the distribution of the second division of the trigeminal nerve (either unilateral or bilateral), and 62% experienced bilateral forehead and maxillary pain with their headaches. The most common associated features included nasal congestion (56%), eyelid edema (37%), rhinorrhea (25%), conjunctival injection (22%), lacrimation (19%), and ptosis (3%). The headaches nonclassifiable were characterized by a bilateral maxillary pressure of mild to moderate intensity associated with at least one cranial autonomic symptom. Features suggestive of migraine were absent in all 9 of these nonclassifiable cases. CONCLUSIONS: The majority of those with self-diagnosed sinus headache have migraine or probable migraine. In those patients with migraine, the most common reasons for misdiagnosis include headache triggers, pain location, and associated features ("guilt by provocation, location, and association") commonly attributed to sinus headache. The clinician must be aware of these unique presentations of migraine so that a correct diagnosis can be made and effective treatment instituted. A portion of patients with self-diagnosed sinus headache suffer from a headache type, which is unclassifiable by the current IHS criteria. These headaches are characterized by bilateral maxillary pressure, mild to moderate pain intensity, cranial autonomic symptoms, and the complete absence of migraine features.
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#5
23.06.2008, 17:11
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Facial migraine in a rhinological setting.
Daudia AT, Jones NS. Department of Otorhinolaryngology, Head and Neck Surgery, University of Nottingham, Nottingham, UK. This study aims to investigate the incidence of migraine involving the face in a rhinology clinic and to describe its characteristics. It is a study of a cohort of 973 patients consecutively presenting to the outpatient clinic with symptoms of facial pain and/or rhinosinusitis. The study subgroup consisted of patients with facial pain and migraine excluding cluster headache and paroxysmal hemicrania. We studied the features of 51 patients who had facial pain with migraine. The diagnosis was based on the criteria used by the International Headache Society and was also supported by the outcome and response to treatment after a mean of 2 years and 2 months. Of the 973 consecutive patients, 409 (42%) had symptoms of facial pain and/or head pain or pressure. Fifty-one (12%) had migraine. Of these, 39 (76%) had unilateral pain and, in 12 (24%), it was bilateral. The distribution affected the forehead and/or eye or cheek in 32 (63%) patients. Twenty-four (47%) had migraine isolated to the second division of the trigeminal nerve. Twelve per cent of patients attending a rhinology clinic with facial pain had migraine. Of particular interest were the 6% of patients with facial pain who had migraine confined to the second division of the trigeminal nerve. This entity is not widely recognized and has rarely been described in the literature.
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#6
23.06.2008, 17:13
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По лечению:
Rev Neurol (Paris). 2005 Jul;161(6-7):696-9. Links [Treatment of cluster headache] [Article in French] Fabre N. Service de Neurologie, Hôpital Rangueil, Toulouse, France. Remarkable therapeutic improvements have come forward recently for trigemino-autonomic cephalalgias. Attack treatment in cluster headache is based on sumatriptan and oxygen. Non-vasoconstrictive treatments are opening a new post-triptan era but are not yet applicable. Prophylactic treatment of cluster headache is based on verapamil and lithium. The efficacy of anti-epileptic drugs in cluster headache remains to be demonstrated. Surgical treatment aimed at the parasympathetic pathways and at the trigeminal nerve demonstrates a high rate of recurrence and adverse events and questions about the relevance of a "peripheral" target in cluster headache. The efficacy of continuous hypothalamic stimulation in patients with intractable headache constitutes a breakthrough, but must be demonstrated at a larger scale and the benefice/risk ratio must be carefully evaluated. Indomethacin still remains the gold standard in paroxysmal hemicrania treatment. Until recently SUNCT was considered an intractable condition. However there are some reports of complete relief with lamotrigine, topiramate and gabapentin.
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#7
23.06.2008, 17:15
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Eur J Neurol. 2006 Oct;13(10):1066-77.
Links EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias. May A, Leone M, Afra J, Linde M, Sándor PS, Evers S, Goadsby PJ; EFNS Task Force. Department of Systems Neuroscience, University of Hamburg, Hamburg, Germany. [Ссылки доступны только зарегистрированным пользователям ] Cluster headache and the other trigeminal-autonomic cephalalgias [paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome] are rare but very disabling conditions with a major impact on the patient's quality of life. The objective of this study was to give evidence-based recommendations for the treatment of these headache disorders based on a literature search and consensus amongst a panel of experts. All available medical reference systems were screened for any kind of studies on cluster headache, paroxysmal hemicrania and SUNCT syndrome. The findings in these studies were evaluated according to the recommendations of the European Federation of Neurological Societies resulting in level A, B or C recommendations and good practice points. For the acute treatment of cluster headache attacks, oxygen (100%) with a flow of at least 7 l/min over 15 min and 6 mg subcutaneous sumatriptan are drugs of first choice. Prophylaxis of cluster headache should be performed with verapamil at a daily dose of at least 240 mg (maximum dose depends on efficacy or tolerability). Although no class I or II trials are available, steroids are clearly effective in cluster headache. Therefore, the use of at least 100 mg methylprednisone (or equivalent corticosteroid) given orally or at up to 500 mg i.v. per day over 5 days (then tapering down) is recommended. Methysergide, lithium and topiramate are recommended as alternative treatments. Surgical procedures, although in part promising, require further scientific evaluation. For paroxysmal hemicranias, indomethacin at a daily dose of up to 225 mg is the drug of choice. For treatment of SUNCT syndrome, large series suggest that lamotrigine is the most effective preventive agent, with topiramate and gabapentin also being useful. Intravenous lidocaine may also be helpful as an acute therapy when patients are extremely distressed and disabled by frequent attacks.
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#8
23.06.2008, 20:00
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Цитата:
С уважением, Гусейнов Т.Ю.
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#9
23.06.2008, 20:03
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Цитата:
Давно, делал доклад по головной боли на конференции, организованной институтом Бурденко. Сказал, что 95% головной боли являются первичными, т.е. без реального материального субстрата. А в 5%, причинной может быть, например опухоль головного мозга. После доклада встал видный профессор и сказал. Что голова при опухоли головного мозга болит в 100% это я вижу каждый день. А вот, чтобы без опухоли это скорее казуистика. Это было абсолютно серьезно.
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#10
23.06.2008, 20:06
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Цитата:
Biondi D, Mendes P. Treatment of primary headache: cluster headache. In: Standards of care for headache diagnosis and treatment. Chicago (IL): National Headache Foundation; 2004. p. 59-72. [38 references] MAJOR RECOMMENDATIONS Cluster Headache Acute Drug Treatment The goal of treatment for acute cluster is to decrease the pain, severity, and duration of each attack. Early intervention is critical, since a single cluster headache can be as short as 15 minutes. Because of the brief nature of cluster headaches, consider a non-oral route of administration when treating these headaches (see table 6.1 of the original guideline document). Oxygen Oxygen inhalation is the standard recommended therapy for cluster headaches. Treatment is initiated with 100% oxygen by non-rebreathing facial mask. Flow rate is set at 7 to 10 liters per minute and treatment should continue for 15 minutes. Although up to 70% of patients experience relief within 5 minutes, some patients report that oxygen suppresses rather than aborts the attack and that pain may return. Oxygen seems to be most successful when administered at the maximum pain intensity. There are no side effects with this treatment. Sumatriptan Sumatriptan, 6 mg administered subcutaneously (SQ), is an effective acute treatment for episodic and chronic cluster headaches, but it is most useful for patients who report 1 or 2 cluster attacks per day. Cluster attacks usually respond within 10 minutes. There is no evidence of tachyphylaxis, rebound syndromes, or drug dependency with the use of subcutaneous sumatriptan for cluster headaches. Cluster patients may find that their attacks can be aborted with sumatriptan SQ at smaller doses, such as 2 to 3 mg. Intranasal sumatriptan 20 mg is not as effective as the subcutaneous injection. In a trial comparing subcutaneous versus intranasal sumatriptan in cluster patients, injection resulted in 87% of patients experienced complete relief of pain within 15 minutes after injection compared with only 13.4% with sumatriptan nasal spray. Sumatriptan is contraindicated in patients with ischemic heart disease, uncontrolled hypertension, peripheral vascular disease, and concurrent use of another 5-HT1 agonist or ergot derivative medication. Zolmitriptan In a single open-label trial, oral zolmitriptan 10 mg demonstrated efficacy for cluster attacks; however, the adverse profile was significant. No data are available at this time with the nasal spray formulation. Dihydroergotamine (DHE) DHE administered by nasal spray or injection can decrease the intensity of individual attacks and may also completely abort the pain. Intravenous injection gives quicker relief, usually within 10 minutes, when compared with intramuscular or SQ injection. DHE dosage is 0.5 to 1 mg whether given intravenously, intramuscularly, or subcutaneously. Treatment can be repeated every 1 hour as needed up to a total of 3 mg per day. The total intranasal dose is 2 mg for a single treatment. Nasal Lidocaine Nasal lidocaine 4% topical solution can be applied in the form of nose drops or spray for acute treatment of a cluster attack. Patients should apply 15 drops in the nostril on the affected side at the onset of the headache, with the head turned to the ipsilateral side and tilted backwards. If necessary, this application can be repeated in 15 minutes. Lidocaine can be used up to 4 times per day but only twice per headache. The most common side effects of lidocaine include lightheadedness and a feeling of nervousness. Topical Intranasal Cocaine Topical intranasal cocaine has been used as a local anesthetic for treatment of cluster headaches, but because of its addictive potential, it is rarely used. Capsaicin Capsaicin acts by depleting substance P stores in neurons, and it can therefore desensitize sensory neurons. When a 0.025% capsaicin cream is applied intranasally twice a day via a cotton-tipped applicator in the nostril ipsilateral to the cluster headache, patients may experience less frequent and less intense attacks. Narcotic and Nonparenteral Analgesics Due to their slow onset of action, oral narcotics and other nonparenteral analgesics play little role in the treatment of cluster headaches. However, there may be a role for butorphanol, an opioid analgesic that can be administered by a nasal spray. Since butorphanol has no known cardiovascular risks, it is an alternative for patients who cannot use vasoconstrictive medications and for whom oxygen has failed. Given the high frequency of attacks in some cluster patients, opioid analgesics, if used, require close supervision. Olanzapine Olanzapine is an atypical neuroleptic that has been reported to be as effective in treating both chronic and episodic acute cluster attacks. In a report, the starting dose was 5 mg, with an increase up to 10 mg if no pain relief was found at the lower dose.
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#11
23.06.2008, 20:12
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Все же хочу напомнить. Все мои тезисы:
1. Нельзя на 100% сказать, что это кластер (хотя сейчас, уже можно на 98%) 2. Это можно проверить суматриптанами, что принесет пользу пациенту. И еще. Чем больше лечу, больше убеждаюсь, что в медицине возможно все. В том числе и двухсторонняя мигрень  . Но редко . Ну очень
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#12
23.06.2008, 20:35
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Тимур Юсуфович, лицевой мигрени в классификации нет, понятно. Но то, что мигрень может проявляться болями в области лица и вегетативными симптомами в области лица - это факт. И как раз важно разделять боли при синуситах и мигрень в области лица, приступы которой часто и больными и врачами ошибочно расцениваются, как боли при синусите. Посмотрите тему в разделе для врачей неврологов - неврологические заболевания все более излечимы, там я перевел клинический случай и разбор при лицевой мигренозной боли.
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#14
24.06.2008, 08:44
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Цитата:
Я оцениваю эффект отрицательно. Гусейнов Т.Ю.
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#15
24.06.2008, 10:04
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Цитата:
Но триптан все равно был лучше Кстати, пероральный.
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Линейный вид
