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作者：Emma Hitt, PhD  
出處：WebMD醫學新聞

　　February 16, 2010 — 新的研究顯示，對於偏頭痛患者來說，與偏頭痛有關的頸部疼痛比噁心更常見。
　　
　　主要作者、北卡羅萊納州教堂山卡羅萊納頭痛機構的Anne H. Calhoun醫師指出，發現與偏頭痛有關的頸部疼痛比噁心常見是一個很大的意外，因為教科書，以及國際頭痛分類第二版（ICHD-2）標準中並未提到這個問題。
　　
　　她向Medscape神經學表示，然而，當我們在美國神經醫學會上發表這些發現時，來自頭痛專家們的反應幾乎是一致的：頻頻點頭且同意。這是許多有經驗的頭痛專家已經注意到的、但從未被報告出來。
　　
　　他們的報告於1月20日線上發表於頭痛（Headache）期刊。
　　
　　【釐清偏頭痛診斷】
　　這項前瞻性研究收納了113位罹患偏頭痛病患，這些病患偏頭痛發作頻率從陣發性到慢性偏頭痛，接受後續追蹤至少1個月，直到6次偏頭痛發作接受治療。
　　
　　這些病患也接受偏頭痛密集度評估、是否有噁心以及頸部疼痛。他們收集了2411偏頭痛－天的數據，包括這些病患偏頭痛發作的786天。
　　
　　研究作者們表示，不論治療時偏頭痛密集度如何，伴隨著偏頭痛較為常見的是頸部疼痛，勝過於噁心（P<0.0001）。偏頭痛盛行率與頭痛的「慢性化」有關，從陣發性轉變為慢性每日頭痛。
　　
　　根據Calhoun醫師表示，許多臨床醫師將有頸部疼痛與壓力性頭痛相連結，使得這些病患錯誤地接受肌肉鬆弛藥物、安神劑、或是不同的OTC（非處方用藥）止痛藥物治療。
　　
　　她附帶表示，我們希望這篇文獻讓那些被指控仍然使用目前各式各樣醫療疾病分數、以及疾病診斷標準的初級照護醫師們，能夠釐清偏頭痛的診斷。理想地，這些發現最終將被確認且納入ICHD診斷條件中。
　　
　　Calhoun醫師指出，還有一個未被回答的問題，是造成這個問題的病理生理學。頸部疼痛可能是中央致敏作用的一個病徵，以及/或是偏頭痛慢性化的一個指標（當頭痛從陣發性轉變成慢性每日頭痛），但是這仍然需要進一步證實。
　　
　　【這項發現是有用的】
　　德州休士頓貝勒醫學院的Randolph W. Evans醫師表示，這些發現可能重申過去的發現，在協助區分偏頭痛與其他種類的頭痛上可能是有用的。
　　
　　Evans醫師向Medscape神經學表示，大約半數罹患偏頭痛的人不知道他們有偏頭痛的問題，因此這些發現在協助區分偏頭痛、與一單純壓力性頭痛上，還有了解頸部頭痛在偏頭痛發作時出現的頻率是有幫助的。
　　
　　舊金山加州大學的Till Sprenger醫師指出，在三叉頸部複合體的三叉神經次級神經元接受到三叉神經與C1及C2神經區域神經輸入匯聚，這可能導致牽涉痛，除此之外，這些神經元會在偏頭痛發作時被敏感化。
　　
　　因為這樣，Sprenger醫師同意Calhoun醫師與Evans醫師的看法，認為這些發現對於頭痛領域相當有經驗的臨床醫師來說並非意外，但是他們表示，如果有執行嚴謹的臨床研究確認頸部疼痛是偏頭痛的一個整體症狀，將會是有用的。
　　
　　Sprenger醫師表示，許多頭痛病患在接受頭痛專家診治前，進行頸部影像學檢查，特別是MRI（核磁共振造影），但是對大部分病患而言，這些影像學檢查是不需要的。
　　
　　這項研究是由格蘭素史克藥廠贊助。Calhoun醫師接受Teva藥廠的研究贊助以及顧問費用。Evans醫師表示接受默克、Ortho-McNeil、輝瑞以及格蘭素史克藥廠邀請作為顧問或是諮詢對象。


Neck Pain More Common Than Nausea in Migraine

By Emma Hitt, PhD
Medscape Medical News

February 16, 2010 — In patients with migraine, neck pain was more commonly associated with migraine than was nausea, which is considered a defining characteristic of the disorder, a new study shows.

“The finding that neck pain was more commonly associated with migraine than was nausea would seem to be a big surprise, given the absence of its mention in textbooks and in The International Headache Classification II (ICHD-2) criteria,” said lead author Anne H. Calhoun, MD, with the Carolina Headache Institute in Chapel Hill, North Carolina.

“However, when we first presented these findings at the American Academy of Neurology meeting, the response from headache specialists was almost universal: vigorous nodding and assent,” she told Medscape Neurology. “This is something that many experienced headache specialists have noticed but have never reported.”

Their report was published online January 20 in the journal Headache.

Clarify Migraine Diagnosis

The prospective study included 113 patients with migraines, who had a frequency of attacks from episodic to chronic migraine and who were followed up for at least 1 month and until 6 migraine episodes had been treated.

Patients were also assessed for headache intensity, the presence of nausea, and neck pain. Data on 2411 headache-days were collected, including 786 days on which patients had migraines.

“Regardless of the intensity of headache pain at time of treatment, neck pain was a more frequent accompaniment of migraine than was nausea (P < .0001),” note the study authors. “Prevalence of neck pain correlated with chronicity of headache as attacks moved from episodic to chronic daily headache.”

According to Dr. Calhoun, many clinicians associate the presence of neck pain with a tension-type headache, “relegating many patients incorrectly to treatment with muscle relaxers, tranquilizers, or various OTC [over-the-counter] analgesics.”?

“We hope that this paper will clarify migraine diagnosis for primary care physicians who are charged with staying current with scores of diverse medical conditions and their diagnostic criteria,” she added. “Ideally, these findings will ultimately be confirmed and incorporated into ICHD criteria.”

An unanswered question, said Dr. Calhoun, is the issue of underlying pathophysiology. “The neck pain may be a sign of central sensitization and/or a marker for chronification in migraine (as the headache disorder moves from episodic to chronic daily headache), but this remains to be proved.”

Findings Useful

Randolph W. Evans, MD, with the Baylor College of Medicine in Houston, Texas, noted that these findings probably reiterate previous findings but may be useful in helping to distinguish migraine from other types of headaches.

"About half the people who have migraine don’t realize that they have migraine," Dr. Evans told Medscape Neurology, "so the findings are useful in helping to differentiate migraine from a simple tension-type headache and to understand how commonly migraines can cause neck pain as part of the migraine attack."

Till Sprenger, MD, from the University of California, San Francisco, pointed out that the trigeminal second-order neurons in the trigeminocervical complex receive convergent input from trigeminal and C1 and C2 innervated areas that can lead to referred pain and, moreover, that these neurons can be sensitized during migrainous pain.

Because of this, Dr. Sprenger agreed with Dr. Calhoun and Dr. Evans that these findings are not a real surprise for clinicians experienced in the headache field, but noted that it is useful to have a properly conducted trial confirming that neck pain is an integral symptom of migraine.

"Many headache patients have imaging studies of their neck, typically MRI [magnetic resonance imaging], before they are seen by a headache specialist, and most, almost all, of these imaging studies are unnecessary," Dr. Sprenger said.

This investigator-initiated study was funded by GlaxoSmithKline. Dr. Calhoun receives research support and is a consultant for Teva Pharmaceuticals. Dr. Evans has disclosed that he has served as an adviser or consultant to Merck, Ortho-McNeil, Pfizer, and GlaxoSmithKline.

Headache. 2010;67:154-160.