Formisano Rita, Bivona Umberto, Catani Sheila, D'Ippolito Mariagrazia, Buzzi M Gabriella
Post-Coma Unit and Headache Center, IRCCS Fondazione Santa Lucia, Rome, Italy.
J Headache Pain. 2009 Jun;10(3):145-52. doi: 10.1007/s10194-009-0108-4. Epub 2009 Mar 18.
The International Classification of Headache Disorders does not separate the moderate from severe/very severe traumatic brain injury (TBI), since they are all defined by Glasgow coma scale (GCS) < 13. The distinction between the severe and very severe TBI (GCS < 8) should be made upon coma duration that in the latter may be longer than 15 days up to months in the case of vegetative state. Post-traumatic amnesia duration may double the coma duration itself. Therefore, the 3-month parameter proposed to define the occurrence or resolution of post-traumatic headache (PTH) appears inadequate. Following TBI, neuropathic pain, central pain, thalamic pain, combined pain are all possible and they call for proper pharmacological approaches. One more reason for having difficulties in obtaining information about headache in the early phase after regaining consciousness is the presence of concomitant medications that may affect pain perception. Post-traumatic stress disorder (PTSD) develops days or weeks after stress and tends to improve or disappear within 3 months after exposure; interestingly, this spontaneous timing resembles that of PTH. In our experience the number of TBI patients with PTH at 1-year follow-up is lower in those with longer coma duration and more severe TBI. Cognitive functioning evaluated after at least 12 months from TBI, showed mild or no impairment in these patients with severe TBI and PTH, whereas they have psychopathological changes, namely anxiety and depression. The majority of patients with PTH after severe/very severe TBI had skull fractures or dural lacerations and paroxystic EEG abnormalities. The combination of psychological changes (depression and anxiety) and organic features (skull fractures, dural lacerations, epileptic EEG abnormalities) in PTH may be inversely correlated with the severity of TBI, with prevalence of psychological disturbances in mild TBI and of organic lesions in severe TBI. On the other hand, only in severe TBI patients with good cognitive recovery the influence of the psychopathological disorders may play a role. In fact, the affective pain perception is probably related to the integrity of cognitive functions as in mild TBI and in severe TBI with good cognitive outcome.
《国际头痛疾病分类》并未将中度创伤性脑损伤与重度/极重度创伤性脑损伤（TBI）区分开来，因为它们均由格拉斯哥昏迷量表（GCS）<13定义。重度与极重度TBI（GCS<8）的区分应依据昏迷持续时间，对于后者，在植物人状态下昏迷持续时间可能长达15天甚至数月。创伤后遗忘持续时间可能是昏迷持续时间的两倍。因此，提议用于定义创伤后头痛（PTH）发生或缓解的3个月参数似乎并不充分。TBI后，神经性疼痛、中枢性疼痛、丘脑性疼痛、混合性疼痛均有可能发生，需要采取适当的药物治疗方法。在意识恢复后的早期阶段难以获取头痛信息的另一个原因是存在可能影响疼痛感知的伴随用药。创伤后应激障碍（PTSD）在应激数天或数周后出现，且在暴露后3个月内往往会改善或消失；有趣的是，这个自然的时间与PTH相似。根据我们的经验，在1年随访时，昏迷持续时间较长且TBI较严重的患者中，患有PTH的TBI患者数量较少。在TBI至少12个月后评估认知功能发现，这些患有重度TBI和PTH的患者存在轻度或无损伤，然而他们有心理病理变化，即焦虑和抑郁。重度/极重度TBI后患有PTH的大多数患者有颅骨骨折或硬脑膜撕裂以及阵发性脑电图异常。PTH中心理变化（抑郁和焦虑）与器质性特征（颅骨骨折、硬脑膜撕裂、癫痫性脑电图异常）的组合可能与TBI的严重程度呈负相关，轻度TBI中以心理障碍为主，重度TBI中以器质性病变为主。另一方面，只有在认知恢复良好的重度TBI患者中，心理病理障碍的影响才可能起作用。事实上，情感性疼痛感知可能与认知功能的完整性有关，如在轻度TBI和认知结局良好的重度TBI中那样。
