【原】枕神经痛与颈源性头痛的诊断与治疗（五）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

本次文献选自Barmherzig R, Kingston W. Occipital Neuralgia and Cervicogenic Headache: Diagnosis and Management. Curr Neurol Neurosci Rep. 2019 Mar 19;19(5):20.本次学习由阎芳副主任医师主讲。

 

Diagnostic Considerations

The diagnostic criteria for ON are outlined in the ICHD-3 and summarized in Table 1. Diagnostic criteria for CGHwere previously put forward by the Cervicogenic Headache International Study Group (CHISG) in 1998 with a broader definition, allowing for the presence of photophobia, phonophobia, and nausea. This broader definition was felt to lead to over classification of CGH, or conversely, the missed diagnosis of migraine. The ICHD-3 has promulgated a more limited definition for CGH, requiring the anatomic dependency on a cervical pathology, although neck pain is not required for diagnosis; see Table 2.

Table 1 ICHD-3 diagnostic criteria for occipital neuralgia

A. Unilateral or bilateral pain in the distribution(s) of the greater, lesser and/or third occipital nerves and fulfilling criteria B-D

B. Pain has at least two of the following three characteristics:

1. recurring in paroxysmal attacks lasting from a few seconds to minutes

2. severe in intensity

3. shooting, stabbing, or sharp in quality

C. Pain is associated with both of the following:

1. dysesthesia and/or allodynia apparent during innocuous stimulation of the scalp and/or hair

2. either or both of the following:

· (a) tenderness over the affected nerve branches

· (b) trigger points at the emergence of the greater occipital nerve or in the distribution of C2

D. Pain is eased temporarily by local anesthetic block of the affected nerve(s)

E. Not better accounted for by another ICHD-3 diagnosis

Table 2 ICHD-3 diagnostic criteria for cervicogenic headache

A. Any headache fulfilling criterion C

B. Clinical and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck, known to be able to cause headache

C. Evidence of causation demonstrated by at least two of the following:

1. headache has developed in temporal relation to the onset of the cervical disorder or appearance of the lesion

2. headache has significantly improved or resolved in parallel with

improvement in or resolution of the cervical disorder or lesion

3. cervical range of motion is reduced and headache is made significantly worse by provocative maneuvers

4. headache is abolished following diagnostic blockade of a cervical structure or its nerve supply

D. Not better accounted for by another ICHD-3 diagnosis 

诊断注意事项

    ICHD-3概述了ON的诊断标准，总结在表1中。颈源性头痛国际研究小组（CHISG）于1998年提出了CGH的诊断标准，其定义更广泛，包含了畏光、畏声和恶心。这种更广泛的定义被认为会导致更多的头痛被纳入CGH的范畴，或者相反，导致偏头痛的漏诊。ICHD-3发布了一个限制更为严格的CGH定义，尽管诊断上不需要有颈部疼痛，但要求有颈部病变的解剖学依据；见表2。

表1 ICHD-3枕神经痛诊断标准

A.枕大神经、枕小神经和/或第三枕神经分布区的单或双侧疼痛，符合标准B-D

B.疼痛至少具有以下三种特征中的两种：

1.反复发作，持续几秒到几分钟

2.强度严重

3.性质为枪击样、针刺样或锐痛

C.疼痛存在以下两种情况：

1.头皮和/或头发的非伤害性刺激导致明显的感觉异常和/或触诱发痛

2.下列其中一项或两项：

·（a）受影响神经分支压痛

·（b）枕大神经投影处或C2神经分布区的扳机点

D.局麻药阻滞受累神经可暂时缓解疼痛

E.其它ICHD-3诊断不能更好地解释

表2 ICHD-3颈源性头痛诊断标准

A.任何符合标准C的头痛

B.已知会导致头痛的颈椎或颈部软组织内疾病或病变的临床和/或影像学证据

C.下列至少两项证明因果关系的证据：

1.头痛的发生与颈部疾病的发作或病变的出现有时间先后关系

2.头痛与颈部疾病或病变的改善或消退同时显著改善或消退

3. 颈部活动范围缩小，颈部大范围动作会使头痛明显加重

4.诊断性阻滞颈部结构或其神经支配后，头痛消失

D. 其它ICHD-3诊断不能更好地解释

 

Investigations

A detailed history and examination should be starting point for the cervical spine, such as passive flexionexamination should include movement tests of the cervical spine, such as passive flexion, such as passive flexion, extension, and rotation; segmental palpation of the cervical facet joints; and assessment for palpation tenderness over the GON, LON, and upper cervical muscle groups.

检查

     临床医生应从详细的病史询问和体格检查开始。除一般的体格检查，还应包括颈椎的运动测试，如被动屈、伸和旋转；颈部小关节分段触诊；以及对GON、LON和上颈肌群触诊压痛的评估