偏头痛与丛集性头痛的脑自主神经症状的特征和比较

背景：脑自主神经症状是三叉神经性头痛的主要特点，丛集性头痛是其中最常见的，但它们也可能发生在偏头痛患者。偏头痛，即严格意义上的单侧头痛，脑自主神经症状的出现会造成与丛集性头痛诊断的混乱。目前很少有人报告丛集性偏头痛与偏头痛的脑自主神经症状的区别。方法：本研究前瞻性连续观察头痛门诊的偏头痛患者和丛集性头痛患者。我们调查的6个脑自主神经症状项目包括：结膜充血，流泪，鼻塞，流鼻涕，眼睑水肿和前额/面部出汗。脑自主神经症状特点包括头痛的偏侧，强度，时间性和持续性。结果：我们观察的786偏头痛患者（625F/161M，平均年龄40±13岁）和98（11F/87M，平均年龄36±11岁）的丛集性头痛患者患者。在偏头痛患者中有脑自主神经症状为56％，在偏头痛的不同亚型没有差异。除了额头/面部出汗，偏头痛患者和丛集性头痛患者的其他脑自主神经症状的特点是不同的。偏头痛的脑自主症状往往是双侧的（OR：5.8-23.8），不限于头痛侧的（OR：5.0-20.4），出现轻到中等程度紧张的（OR：1.7-7.7）和头痛发作一致的（OR：2.8-6.7）。结论：目前有一半的偏头痛患者的有脑自主神经症状，这一临床特征可能有助于区分偏头痛和丛集性偏头痛。

专家评价：DavidDodickwithToddJSchwedtMayoClinicScottsdale,UnitedStatesofAmericaNeurologicalDisordersThislargestudyconfirmsthat,althoughcranialautonomicfeaturesdistinguishthetrigeminalautonomiccephalalgias（TACs）andhemicraniacontinuafromotherheadachetypes,theyarealsocommonlypresentduringmigraine.However,autonomicsymptomsduringmigrainetendtobelesssevere,bilateral,andinconsistentlypresentfromoneattacktoanother.PresenceofcranialautonomicsymptomsisessentialforthediagnosisoftheTACsandhemicraniacontinua.TheTACsincludeclusterheadache,paroxysmalhemicrania,andshort-lastingunilateralneuralgiformheadacheattackswithconjunctivalinjectionandtearing（SUNCT）.Commonautonomicsymptomsincludeconjunctivalinjection,eyelidedema,miosis,ptosis,lacrimation,nasalcongestionorrhinorrhea,andfacialsweating.AutonomicsymptomsmustoccuripsilateraltotheheadachefortheformaldiagnosisoftheTACsandhemicraniacontinua.AlthoughcranialautonomicsymptomsarehallmarkfeaturesoftheTACsandhemicraniacontinua,ithasbeenrecognizedthattheymayalsooccurduringmigraineheadaches.Thisinvestigationanalyzedthefrequencyandcharacteristicsofautonomicsymptomsduringmigraineandclusterheadaches.Theinvestigatorsprospectivelyenrolled786migraineursand98clusterheadachesubjects.Fifty-sixpercentofmigraineursand97%ofclusterheadachesubjectsreportedatleastoneautonomicsymptomassociatedwiththeirheadaches.Amongmigraineurswithautonomicsymptoms,forehead/facialsweatingwasthemostcommon（51.7%）followedbylacrimation（44.2%）,nasalcongestion（25.2%）,conjunctivalinjection（23.8%）,rhinorrhea（21.5%）,andeyelidedema（15.6%）.Themeannumberofautonomicsymptomswaslowerinmigrainecomparedtocluster（1.8±1.1vs.3.5±1.4,p<0.001）.Migrainesubjectshadahigherfrequencyofbilateralautonomicsymptoms（rangingfrom67%-95%dependingonthesymptom,oddsratio（OR）migrainetoclusterrangingfrom5.8to23.8）.Autonomicsymptomswerelesssevereduringmigrainethancluster（OR1.7to7.7）andlessfrequentlyoccurredduringallmigraineattacks（OR2.8to6.7）.Thecombinationofautonomicfeaturesthatwasmostpredictiveformigrainewassymptomsoccurringbilaterallywitheithermild-to-moderateintensityofautonomicsymptomsoroccurrenceofsymptomsintheabsenceofheadache.Strengthsofthisstudyincludethelargesamplesizeanddetailedquestionnaireregardingautonomicsymptoms.Limitationsincluderecallbias（subjectswereaskedtorecallwhetherornottheyhaveautonomicsymptomsduringheadachesasopposedtoprospectivelydocumentingtheirpresence）,inabilitytodetectptosisandmiosisduetopoorreliabilityofself-report,andlackofconfirmationanddetectionofautonomicsymptomsbywitnesses.However,theselimitationswouldlikelyresultinanunderestimationofsymptoms.Thisstudyconfirmsthepriorsuggestionthatcranialautonomicsymptomsarecommonduringmigraineheadaches.Comparedtoclusterheadache,autonomicsymptomsinmigrainetendtobelesssevere,bilateral,andoccurlessconsistentlywitheachheadache.