從臨床流行病學與神經耳科學來探討與偏頭痛相關之眩暈及頭暈

Abstract

目的 本研究之主要目的為分析與偏頭痛相關之眩暈及頭暈患者之臨床表現，並尋找與治療效果相關之因子。此外，一併探討不同診斷疾病群間之關係。 方法 病患來源為自2007年7月至2008年1月於耳鼻喉科眩暈特別門診就診之病患，所有病患均接受一系列之檢查並排除其他可能之診斷。研究之收案條件為5次以上之偏頭痛與2次以上之前庭症狀，計110名病患納入本研究。每位患者都接受制式化的當面訪談，並收集相關之臨床症狀與檢查結果，再依據基底型偏頭痛 ( BtM)、確定偏頭痛型眩暈 (dMV)、與疑似偏頭痛型眩暈(pMV) 之診斷基準進行分類比較。除了7名患者未完成治療與追蹤外，其他病人均接受藥物治療為期三個月，結束後依病歷記載分析其治療結果。 結果 病患之平均年齡為40歲，多數為女性（85％）且有偏頭痛之家族史（72％），症狀發作之年齡大多介於20至 29歲之間，且61％之患者以頭痛為初始表現。106位（96％）患者均表示有一種以上之偏頭痛誘發因子。與治療結果相關之因子為年齡 (年齡每小10歲之危險性為2.38倍，95%信賴區間： 1.39 ~ 4.07)，前庭症狀之發作頻率 (危險性=7.73, 95%信賴區間：2.05 ~ 19.1)，以及異常的視運動眼振測驗 (危險性=5.40, 95%信賴區間： 1.60 ~ 18.2)。此外，BtM 與 dMV兩組之臨床表現相似，包括偏頭痛之相關症狀、動暈症、以及頭痛與頭暈間之時序性，但BtM 組有較多神經學症狀與較頻繁之發作頻率，且眼振電圖檢查出現較多中樞性徵象。反之，pMV組則屬病症最輕微。 結論 本研究收集了與偏頭痛相關之眩暈及頭暈在台灣地區之代表性族群，且臨床表現與文獻之記載相符。與治療結果相關之重要因子包括年齡、前庭症狀之發作頻率與異常之視運動眼振測驗。三組不同診斷疾病群之間的關係可能意味此一症候群在臨床嚴重度的不同，其中基底型偏頭痛之症狀最為嚴重且治療成果最不理想。

Objective This study was designed to analyze the clinical manifestation of patients with migraine-related vertigo and dizziness, and explore the association between clinical characteristics and treatment effectiveness. The relationships between different diagnostic groups were investigated as well. Method The source population was comprised of patients visiting a vertigo special clinic from July 2007 to January 2008. Subjects with other potential diagnoses were excluded. Inclusion criteria consisted of > 5times of migrainous headache and > 2 times of vertigo/dizziness episodes. One-hundred and ten subjects were enrolled and eligible for this study. All the patients received structured interview of clinical presentations, and the results of audiovestibular function tests were recorded. Further classification of study subjects were based on the diagnostic criteria of basilar type migraine (BtM), definite migrainous vertigo (dMV) and probable migrainous vertigo (pMV). Excluding 7 subjects lost from clinic, treatment effectiveness was evaluated in 103 subjects after a consecutive 3-month medication. Result The demographic characteristics constitute a mean age of 40 years old, female predominance (85%), strong family preponderance (72%), plateau of onset of symptoms around 20-29 years old, and headache as the first presenting symptom in 61% of subjects. Migraine precipitants were identified in 106 subjects (96%). Significant factors associated with poor response are: younger age at presentation (adjusted odds ratio (aOR) =2.38 for each 10-year decline, 95% confidence interval (CI): 1.39 ~ 4.07), frequent vestibular episodes (aOR=7.73, 95% CI: 2.05 ~ 19.1), and abnormal optokinetic nystagmus (OKN) tests (aOR=5.40, 95% CI: 1.60 ~ 18.2). Food precipitation showed borderline correlation with treatment response (aOR=0.31, 95% CI: 0.09 ~ 1.04). Furthermore, BtM and dMV group are similar in clinical presentation, e.g. migrainous symptoms, motion sickness and sequential relationship between migraine and vertigo, but differs in that BtM had more extensive neurological symptoms, more frequent vestibular symptoms, more central signs on electronystagmography tests, and also, the worst treatment effectiveness. In contrast, pMV group represents the least severe clinical manifestation. Conclusion This study enrolled a representative sample of migraine-related vertigo and dizziness in Taiwan. The significant factors in relation to treatment effectiveness are identified, i.e. frequency of vestibular episodes, age at presentation, and OKN abnormalities. The relationship between these three diagnostic groups is most likely a distribution of severity across the disease spectrum, with BtM presenting the most extensive involvement of the brainstem and the worst treatment response.