头痛、忧郁与轻微TBI:错综复杂的关系


  【24drs.com】头痛和忧郁之间的关系相当复杂,特别是发生轻微的创伤性脑部伤害(mild traumatic brain injury,mTBI)之后。
  
  一篇发表于美国疼痛协会(AHS)第56届年度科学会议中的新研究,强调这些关联是如何相互影响。
  
  研究显示,发生mTBI之后一年,患有头痛的病患发生忧郁的机会是有mTBI但无头痛者的近5倍,而患有忧郁者则是更可能发生头痛。
  
  第一作者、西雅图华盛顿大学医学中心神经科与神经外科临床教授Sylvia Lucas博士表示,早期发现并治疗这两种状况,可减少他们的影响期间;希望有更多研究探讨这个议题,看我们是否能随著时间将之改变。
  
  Lucas博士表示,虽然有许多研究探讨原发性头痛者发生忧郁时的头痛,但少有研究直接探讨发生mTBI之后的这些合并症;大约75%的TBIs是轻微的。
  
  为了此次研究,研究者检视了华盛顿大学医学中心、第一级创伤中心,212名mTBI病患一年期间的头痛情况。
  
  这些研究对象平均年龄44岁,多数是男性(76%)、白人(75%)、教育程度至少为高中(83%),创伤原因主要包括车祸(58%)、跌倒(24%)、斗殴(5%)以及运动伤害(3%)。
  
  研究者在研究对象受伤后7天内对其进行访视与初次评估,在创伤之后3、6、12个月,以电访方式、使用结构式问卷进行追踪评估。
  
  头痛评估包括头痛发生率与盛行率之信息、研究开始时与后续三次调查时的头痛特征。Lucas博士指出,这次的研究与要求记录创伤后一周内发生头痛的「International Headache Classification, 2nd Edition (ICHD-2)」研究不一样。
  
  她表示,我们问这些病患在这一年期间是否有任何时间发生头痛,并请他们加以描述。
  
  Lucas博士表示,大部份头痛是在创伤后3个月内发生;不过,不少研究对象在那之后指出有新发生的头痛或者是变严重。
  
  一年间,新发生或者是变严重之头痛的发生率与累积发生率为91%,Lucas博士表示,这比率高于中度到严重TBI者的71%。
  
  研究者根据ICHD-2准则对头痛进行分类,偏头痛和可能偏头痛(开始时59%、一年时53%)是最常见的类型,其次依序是紧张型头痛(开始时37%、一年时32%)以及颈源性头痛(开始时4%、一年时4%)。
  
  同时探讨头痛和忧郁时,研究者发现52%的病患在开始时只有头痛,43%在一年时只有头痛。有忧郁但无头痛者相当少见,约4%的mTBI病患在开始时有忧郁但无头痛,一年时则剩下2%。
  
  不过,伴随头痛发生忧郁并不少见,合并发生比率从开始时的11%增加到一年时的25%。
  
  虽然创伤性头痛后初期与忧郁无关,在一年后,有头痛者比没有头痛者更可能发生忧郁(相对风险[RR],5.43;P<.001);同样的,忧郁患者在一年时比没有忧郁者更可能会发生头痛(RR,1.56;P<.001)。
  
  Lucas博士认为,在开始时有头痛和忧郁者,在一年时依旧有这两种情况。
  
  她强调持续监测mTBI病患的重要性,即使一开始在诊所或急诊室看到这些病患时无症状,在追踪时仍然必须多加留意。
  
  美国每年约发生230万例脑部创伤事件,Lucas博士表示,这个数据并不包括服役相关事件或未寻求照护之病患,所以极可能是被低估了。
  
  Lucas博士被问到研究者是否曾探讨这类mTBI病患的创伤后压力事件时,她表示没有,但是曾探讨认知结果,且「慢慢搜集资料中」。
  
  另一名听众问Lucas博士是否了解创伤后头痛的病理生理学,因为mTBI之后,头痛似乎是比疲劳、头晕、视力减退问题持续更久。
  
  Lucas博士表示,她只能推测生理相关因素,但是也可能有一些持续的微血管或钙离子通道疾病,有趣的是,这些症状没有一起发生,它们有个别的原因。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=7095&x_classno=0&x_chkdelpoint=Y
  

Headache, Depression, and Mild TBI: A Complex Relationship

By Pauline Anderson
Medscape Medical News

LOS ANGELES — Headache and depression have a complicated relationship, especially after mild traumatic brain injury (mTBI).

Just how intertwined these conditions are was highlighted in a new study presented here at the American Headache Society (AHS) 56th Annual Scientific Meeting.

A year after suffering an mTBI, patients with headache were about 5 times more likely to be depressed than patients with mTBI without headache, and those who were depressed were more likely to suffer headaches, the study showed.

"Early identification and treatment of both these conditions may reduce their impact over time," said lead researcher Sylvia Lucas MD, PhD, clinical professor of neurology and neurological surgery, University of Washington Medical Center, Seattle.

"Hopefully, more research will be directed at this to see if we can change the trajectories over time as well."

Although there has been a lot of research on headache occurring with depression in primary headache, there is little in the literature directed at this comorbidity after mTBI, said Dr. Lucas.

About 75% of TBIs are mild.

For the study, researchers examined headache over the course of 1 year in 212 patients with mTBI at a single center, the University of Washington, which has a level 1 trauma center.

Participants had a mean age of 44 years and were mostly male (76%), white (75%), and had at least a high school education (83%). Their injuries primarily involved vehicle accidents (58%), followed by falls (24%), assaults (5%), and sports mishaps (3%).

Researchers carried out baseline assessments during face-to-face interviews within 7 days of the injury. Follow-up interviews using a structured questionnaire were completed over the telephone at 3, 6, and 12 months postinjury.

Headache Evaluation

The headache evaluation included information about incidence and prevalence of headache and headache characteristics at baseline and at 3 subsequent points. Dr. Lucas noted that the study deviated from the International Headache Classification, 2nd Edition (ICHD-2), requirement for posttraumatic headache that the headache be reported within 1 week of an injury.

"We asked people if they had a headache at any time point over 1 year, and we asked them to describe it," she said.

Most of the headaches were reported within 3 months of the injury; however, a significant number of participants reported new or worsened headache after that, said Dr. Lucas.

The incidence and cumulative incidence of new or worsened headache over the course of 1 year was 91%. This, said Dr. Lucas, is higher than for moderate to severe TBI, which is on the order of 71%.

Using ICHD-2 criteria, researchers categorized the headaches. Migraine and probable migraine (59% at baseline and 53% at 1 year) was the most common phenotype, followed by tension-type headache (37% at baseline and 32% at 1 year) and cervicogenic headache (4% at baseline and 4% at 1 year).

Looking at headache and depression together, the researchers found that 52% of patients had headache alone at baseline, and 43% had headache alone at 1 year. Depression without headache was rather rare: About 4% of the mTBI patients had depression without headache at baseline, and 2% had it at 1 year.

However, depression occurring along with headache was not rare: This comorbidity increased from 11% at baseline to 25% at 1 year.

Although early after the injury headache and depression were unrelated, after 1 year, participants who had headache were much more likely to be depressed than those without headache (relative risk [RR], 5.43; P ? .001).

Likewise, depressed patients were significantly more likely to have headache than their nondepressed counterparts at 1 year (RR, 1.56; P ? .001).

"The majority of subjects who had headache and depression at baseline continued to have both at 1 year," commented Dr. Lucas.

Ongoing Monitoring

She stressed the importance of ongoing monitoring of mTBI patients. "Even if we see these people early on in our clinic or in the emergency room and they have no symptoms, it's certainly worth seeing them in follow-up."

Some 2.3 million traumatic brain injuries occur every year in the United States. This figure does not capture military-related injuries or those for which patients do not seek care. "So this figure is very much an underestimate," said Dr. Lucas.

Asked whether the researchers had investigated posttraumatic stress disorder in this group of mTBI patients, Dr. Lucas said they had not but that they had looked at cognitive outcomes and are "slowly getting to that data."

Another audience member wondered whether Dr. Lucas had a sense of the pathophysiology of posttraumatic headache, given that headache seems to persist long after fatigue, dizziness, and visual problems subside after an mTBI.

Dr. Lucas said she could only speculate about the physical correlates, but that it could have something to do with a persistent microvascular disease or with calcium channels. "It's an interesting observation that these symptoms do not go together. They may have individual etiologies."

Dr. Lucas reports receiving research funding from the National Institute on Disability and Rehabilitation Research, the Department of Defense, Allergan, Amgen, and the Wadsworth Foundation; being on advisory boards of Kineta, Allozyne, and MAP/Allergan; and receiving honoraria from BiogenIdec, Genzyme, and Zogenix.

American Headache Society (AHS) 56th Annual Scientific Meeting. Scientific Paper Presentation OR15. Presented June 28, 2014.

    
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