University Centre for Adaptive Disorders and Headache (UCADH), IRCCS C. Mondino Foundation, Pavia, Italy.
Eur J Neurol. 2011 Mar;18(3):373-81. doi: 10.1111/j.1468-1331.2010.03212.x. Epub 2010 Sep 27.
A large number of instrumental investigations are used in patients with non-acute headache in both research and clinical fields. Although the literature has shown that most of these tools contributed greatly to increasing understanding of the pathogenesis of primary headache, they are of little or no value in the clinical setting.
This paper provides an update of the 2004 EFNS guidelines and recommendations for the use of neurophysiological tools and neuroimaging procedures in non-acute headache (first edition). Even though the period since the publication of the first edition has seen an increase in the number of published papers dealing with this topic, the updated guidelines contain only minimal changes in the levels of evidence and grades of recommendation.
(i) Interictal EEG is not routinely indicated in the diagnostic evaluation of patients with headache. Interictal EEG is, however, indicated if the clinical history suggests a possible diagnosis of epilepsy (differential diagnosis). Ictal EEG could be useful in certain patients suffering from hemiplegic or basilar migraine. (ii) Recording evoked potentials is not recommended for the diagnosis of headache disorders. (iii) There is no evidence warranting recommendation of reflex responses or autonomic tests for the routine clinical examination of patients with headache. (iv) Manual palpation of pericranial muscles, with standardized palpation pressure, can be recommended for subdividing patient groups but not for diagnosis. Pain threshold measurements and EMG are not recommended as clinical diagnostic tests. (v) In adult and pediatric patients with migraine, with no recent change in attack pattern, no history of seizures, and no other focal neurological symptoms or signs, the routine use of neuroimaging is not warranted. In patients with trigeminal autonomic cephalalgia, neuroimaging should be carefully considered and may necessitate additional scanning of intracranial/cervical vasculature and/or the sellar/orbital/(para)nasal region. In patients with atypical headache patterns, a history of seizures and/or focal neurological symptoms or signs, MRI may be indicated. (vi) If attacks can be fully accounted for by the standard headache classification (IHS), a PET or SPECT scan will normally be of no further diagnostic value. Nuclear medical examinations of the cerebral circulation and metabolism can be carried out in subgroups of patients with headache for the diagnosis and evaluation of complications, when patients experience unusually severe attacks or when the quality or severity of attacks has changed. (vii) Transcranial Doppler examination is not helpful in headache diagnosis.
Although many of the examinations described in the present guidelines are of little or no value in the clinical setting, most of the tools, including thermal pain thresholds and transcranial magnetic stimulation, have considerable potential for differential diagnostic evaluation as well as for the further exploration of headache pathophysiology and the effects of pharmacological treatment.
在研究和临床领域中，大量的仪器检查被用于非急性头痛患者。尽管文献表明，这些工具中的大多数极大地促进了对原发性头痛发病机制的理解，但它们在临床环境中几乎没有或没有价值。
本文提供了对 2004 年 EFNS 关于神经生理工具和神经影像学程序在非急性头痛中使用的指南（第一版）的更新。尽管自第一版发表以来，涉及该主题的已发表论文数量有所增加，但更新后的指南在证据水平和推荐等级方面仅略有变化。
（i）在头痛患者的诊断评估中，常规脑电图检查不是必需的。然而，如果临床病史提示可能存在癫痫诊断（鉴别诊断），则需要进行脑电图检查。对于患有偏瘫性或基底偏头痛的某些患者，发作期脑电图可能有用。（ii）不建议将诱发电位记录用于头痛障碍的诊断。（iii）对于头痛患者的常规临床检查，没有证据支持推荐反射反应或自主测试。（iv）使用标准化的触诊压力对颅周肌肉进行手动触诊，可以用于患者分组，但不能用于诊断。不建议将疼痛阈值测量和肌电图用作临床诊断测试。（v）对于无近期发作模式改变、无癫痫发作史且无其他局灶性神经症状或体征的成人和儿童偏头痛患者，常规进行神经影像学检查是不必要的。对于三叉神经自主头痛，应仔细考虑神经影像学检查，并且可能需要额外扫描颅内/颈部血管和/或蝶鞍/眼眶/（副）鼻旁区域。对于具有非典型发作模式、癫痫发作史和/或局灶性神经症状或体征的患者，可能需要进行 MRI 检查。（vi）如果发作可以完全用标准头痛分类（IHS）解释，那么 PET 或 SPECT 扫描通常不会有进一步的诊断价值。当患者经历异常严重的发作或发作的质量或严重程度发生变化时，核医学脑循环和代谢检查可用于头痛患者的亚组诊断和并发症评估。（vii）经颅多普勒检查对头痛诊断没有帮助。
尽管本指南中描述的许多检查在临床环境中几乎没有或没有价值，但大多数工具，包括热痛阈值和经颅磁刺激，具有相当大的鉴别诊断评估潜力，以及进一步探索头痛发病机制和药物治疗效果的潜力。
