Diagnosis of headaches in dental clinic 반적으로원발두통에비해이차두통의유병률은매우낮다. 여기서명심해야할것은두통환자에서다음과같은소견이나타나면환자를즉시응급실로내원시켜야한다는점이다 (Table 1) 국제두통질환분류국제적으로통일된두통질

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1 ISSN eissn Review Article Diagnosis of headaches in dental clinic Hye-Jin Lee, Young-Gun Kim, Seong-Taek Kim* Department of Orofacial Pain and Oral Medicine, Yonsei University College of Dentistry, Seoul, Republic of Korea Headache disorders, one of most common disease in general population, have been developed according to many versions of international classifications. The primary headaches are those in which no consistently identified organic cause can be determined. It is divided into the following categories: (1) migraine, (2) tension-type headache, (3) cluster headache and other trigeminal autonomic cephalalgias, (4) other primary headaches. This review described a diagnosis of primary headache disorders based on International Classification of Headache Disorders (ICHD)-3 beta criteria. (J Dent Rehabil Appl Sci 2016;32(2):102-8) Key words: headache; headache disorders, primary; migraine disorders; tension-type headache; temporomandibular joint disorders 서론 두통은전체인구중 90% 이상이일생에한번이상겪게되는질환으로문명화와더불어점점증가하는추세이며치과의사도임상에서종종두통환자를접할수있다. 1 그러나이런환자에게치과의사로서어떠한정보를주기가쉽지않은것이사실이며, 대부분의경우단순진통제를처방해주거나신경과로환자들을의뢰하는것이현실이다. 하지만환자의병력 (history) 을세심히청취하고기본적인두통의증상을제대로파악하면 organic disease에의한이차두통이아닌원발두통의경우에는진단및치료가가능하다. 발두통이라고하며, 뇌종양, 뇌혈관질환, 외상, 감염, 약물과용등의다른원인에의해발생하는두통을이차두통이라고한다 (Fig. 1). 편두통 (migraine), 긴장형두통 (tension-type headache), 삼차자율신경두통 (trigeminal autonomic cephalalgias) 등이원발두통에해당한다. 2 일 문헌고찰 1. 원발두통 (primary headache) 과이차두통 (secondary headache) 특별한원인질환없이두통자체가질환인경우를원 Fig. 1. Secondary headache due to cerebral hemorrhage. *Correspondence to: Seong-Taek Kim Professor, Department of Orofacial Pain and Oral Medicine, Yonsei University College of Dentistry, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea Tel: , Fax: , k @yuhs,ac Received: June 14, 2016/Last Revision: June 20, 2016/Accepted: June 21, 2016 Copyright 2016 The Korean Academy of Stomatognathic Function and Occlusion. cc This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 102

2 Diagnosis of headaches in dental clinic 반적으로원발두통에비해이차두통의유병률은매우낮다. 여기서명심해야할것은두통환자에서다음과같은소견이나타나면환자를즉시응급실로내원시켜야한다는점이다 (Table 1) 국제두통질환분류국제적으로통일된두통질환분류와진단기준은 1988년처음확립되었다. 국제두통학회는 1988년모든두통질환을체계적으로분류하고그진단기준을발표하였으며, 이를바탕으로 2004년국제두통질환분류 (International Classification of Headache Disorders) 에대한개정판 (ICHD-2) 이나왔다. 국제두통질환분류제 3판 (ICHD-3) 은 2판에서논쟁이되었던부분들에대한보완과함께 ICHD-3과같은분류를사용할세계보건기구의국제질병분류개정판과공조하기위하여정식개정판이전에베타판을먼저발표하였다 (Table 2). 4 이분류는계층적구조를가지고있기때문에우선환자가호소하는증상이 14가지의두통질환분류중 1. 편두통혹은 2. 긴장형두통같이크게어떤군에속할지결정한후각각의소분류에대해좀더세밀한진단을하게된다. 예를들어 1. 편두통은 14가지두통질환분류중한가지인데 1.2 조짐편두통과같은소분류를포함하고, 조짐편두통은다시 전형조짐편두통과같은하위분류로나눠진다. Table 1. Red flags of worrisome headache Worrisome Headache Red Flags: SNOOP Systemic symptons (fever, weight loss) or Secondary headache risk factors (HIV, systemic cancer) Neurologic symptoms of abnormal signs (confusion, impaired alertness, or consciousness) Onset: sudden, abrupt, or splint-second Older: new onset and progressive headache, especially in middle-age > 50 (giant cell arteritis) Privous headache history or headache progression: first headache or different (change in attack frequency, severity, or clinical features) Table 2. International headache classification (ICHD-3 beta) 4 The International Classification of Headache Disorders, 3rd edition (beta version) Part one: the primary headaches 1. Migraine 2. Tension-type headache 3. Trigeminal autonomic cephalalgias 4. Other primary headache disorders Part two: the secondary headaches 5. Headache attributed to trauma or injury to the head and/or neck 6. Headache attributed to cranial or cervical vascular disorder 7. Headache attributed to non-vascular intracranial disorder 8. Headache attributed to a substance or its withdrawal 9. Headache attributed to infection 10. Headache attributed to disorder of homoeostasis 11. Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structure 12. Headache attributed to psychiatric disorder Part three: painful cranial neuropathies, other facial pains and other headaches 13. Painful cranial neuropathies and other facial pains 14. Other headache disorders J Dent Rehabil Appl Sci 2016;32(2):

Lee HJ, Kim YG, Kim ST 1) 편두통 (1) 진단임상적으로편두통은흔한중증원발두통질환이다. 세계질병부담연구에따르면전세계적으로편두통은 3 번째로유병률이높고, 장애를유발하는모든질환중 7 위를차지했다. 편두통은편두통진단기준을만족하는두통발작이최소한 5번이상일어난경우진단할수있다 (Table 3).

3 Lee HJ, Kim YG, Kim ST 1) 편두통 (1) 진단임상적으로편두통은흔한중증원발두통질환이다. 세계질병부담연구에따르면전세계적으로편두통은 3 번째로유병률이높고, 장애를유발하는모든질환중 7 위를차지했다. 편두통은편두통진단기준을만족하는두통발작이최소한 5번이상일어난경우진단할수있다 (Table 3) 시간지속되는두통이주로 2 편측, 3 중등도에서심도강도, 4 박동성양상으로나타나고 5 걷거나계단을오르는등의일상의신체활동에의해통증이악화되며, 6 두통이있는동안구역또는구토, 빛공포증과소리공포증중한가지이상을동반되는것이전형적인특징이다. (2) 기전편두통의발병기전으로삼차신경혈관계이론 (trigeminovascular theory) 이비교적많은부분에서받아들여지고있다. 편두통환자들은유전적또는환경적인자에의해편두통발작에대한뇌의역치가낮아져있고, 일반인과는달리대뇌피질신경세포의과흥분성 (cortical neuronal hyperexcitability) 을가지고있다. 자극이가해진대뇌피질에서일시적으로전기적활동성감소가발생된후억제된전기적활동성이자극부위로부터파형의형태를지니며주변으로번져나가는겉질확산억제 (cortical spreading depression) 가일어나며, 겉질확산억제로인해전기적활동성이감소된부위에서는국소적으로혈류감소가동반된다 (Fig. 2). Table 3. Diagnostic criteria for migraine without aura 4 Diagnostic criteria for migraine without aura (1-1) A. At least five attacks fulfilling criteria B - D B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) C. Headache has at least two of the following four characteristics: 1. unilateral location 2. pulsating quality 3. moderate or severe pain intensity 4. aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs) D. During headache at least one of the following: 1. nausea and/or vomiting 2. photophobia and phonophobia E. Not better accounted for by another ICHD-3 diagnosis. ICHD, international classification of headache disorders. A B C D Hypoperfusion Hyperperfusion Normal CBF Aura Headache Hours after angiography Fig. 2. Cerebral blood flow (CBF) during aura. 104 J Dent Rehabil Appl Sci 2016;32(2):102-8

Diagnosis of headaches in dental clinic 국소적혈류의감소는겉질확산억제가이미경과하여전기적활동성이정상화된후에도일정시간이상유지되는데, 이것은편두통환자에서나타나는편두통조짐 (Aura, Fig. 3) 과시간적연관성이있는것으로밝혀졌다.

4 Diagnosis of headaches in dental clinic 국소적혈류의감소는겉질확산억제가이미경과하여전기적활동성이정상화된후에도일정시간이상유지되는데, 이것은편두통환자에서나타나는편두통조짐 (Aura, Fig. 3) 과시간적연관성이있는것으로밝혀졌다. 5 조짐편두통은전체편두통의약 20% 정도만을차지하고있는데무조짐편두통에서는겉질확산억제가소뇌나임상표현형이약한대뇌부위에서시작되어비특이적인어지럼증으로간과되거나증상으로인식되지못하는것으로설명할수있다. 임상적으로확인된무조짐편두통의예방약제들을투여함으로써겉질확산억제가억제되는실험결과들을통해서그러한가능성을고려해볼수있다. 두개강내에존재하는통증에예민한혈관들은주로삼차신경절로연결되어있는데, 겉질확산억제로인해두피및두개부위혈관에분포하는삼차신경의말단이자극되면, 특정신경전달물질들이방출되고이물질들이혈관확장, 혈장의혈관밖수축및염증반응을유도하여신경인성염증반응 (neurogenic inflammation) 을일으켜두통이일어난다는것으로편두통의발생기전을설명하고있다. 6 편두통환자들에서어떤원인이대뇌피질의과흥분성을만들어내는지는아직까지명확하지않은데, 이에대하여유전적인소인이있을것이라는가능성이제시되고있다. 매우드물게발생하는편두통의한유형인가족편마비편두통 (familial hemiplegic migraine) 에관계되는유전자가알려져있다. 7 2) 긴장형두통일반인구의평생유병률이 30-78% 에달하는매우흔한두통으로정확한기전은아직밝혀지지않았다. 두통의양상은주로 무겁다, 짓누르는것같다, 조인다, 어깨에무엇을올려놓은것같다 등으로표현되기때문에이전에는신경성두통, 스트레스두통, 긴장성두통등으로불렸다. 하지만최근연구들에서일회성으로나타나는삽화성긴장형두통 (episodic tensiontype headache) 은주로스트레스와연관되어있으나, 만성긴장형두통은중추성요인과관련되어있는것으로추정하고있다. 두개주변근육근막조직에서오는유해한자극으로인하여척수후근신경세포 (dorsal horn neuron) 들이감작되어정상적인상태에서는느끼지않아야될정도의자극에통증을느끼게되는것으로발생기전을설명하고있다. A B C D Fig. 3. Visual aura in migraine patient. J Dent Rehabil Appl Sci 2016;32(2):

5 Lee HJ, Kim YG, Kim ST 긴장형두통은 1 전형적으로양측위치, 2 경도에서중등도강도, 3 압박하고조이는느낌 ( 비박동성 ) 의통증이 4 수분에서수일간지속되며, 5 통증은걷기나계단오르기같은일상신체활동에의해악화되지않고, 6 구역이나구토를동반하지않는다. 7 빛공포증이나소리공포증중한가지는있을수있다. 고빈도삽화긴장형두통 (frequent episodic tension-type headache) 는종종무조짐편두통 (migraine without aura) 과공존한다. 편두통치료는긴장형두통치료와치료방법이다르므로이두가지두통을구별하고, 각두통에맞춘올바른치료를선택할수있도록환자를교육하여약물과용두통의발생을예방하여야한다. 3) 삼차자율신경두통편측의안와, 안와위, 측두부에발생하는심한통증발작과종종동측으로동반되는두개부부교감자율신경소견 ( 결막충혈, 눈물, 코막힘, 콧물, 이마와얼굴의땀, 동공수축, 눈꺼풀처짐, 눈꺼풀부종 ) 을공통적으로보인다. 군발두통 (cluster headache), 돌발반두통 (Paroxysmal hemicrania) 등이이에속한다. 4) 턱관절질환에기인한두통국제두통질환분류 11. 두개골, 목, 눈, 귀, 코, 부비동, 치아, 입또는기타얼굴및경부구조물의질환에기인한두통또는얼굴통증은두통이두개골, 경부, 얼굴, 목, 눈, 귀, 코, 부비동, 치아또는구강질환과밀접한시간연관성을가지고처음으로발생하거나만성화되었거나또는악화 ( 보통빈도와 / 또는강도가 2배이상증가된경우 ) 되었을때그질환에기인한이차두통으로분류한다. 턱관절및저작근부위통증을주소로치과에내원하는환자들이증가하는추세로치과의사가이러한질환을가진환자를직접적으로진찰할가능성이증가되었다 (Table 4). 5) 만성두통과약물과용두통앞에서살펴본바와같이편두통 / 긴장성두통 / 군발두통의특징적인양상을보이는두통이 3개월을초과하는기간동안한달에 15일이상발생한경우이러한두통을만성편두통 (1.3)/ 만성긴장형두통 (2.3)/ 만성군발두통 (3.1.2) 이라고진단할수있다 ( 각진단명뒤의번호는 ICHD-3의 code를의미함 ). 두통의급성또는대증치료약물을규칙적으로과용한 ( 약물의종류에따라한달에 10일이상또는 15일이상 ) 결과로 3개월이상의기간동안한달에 15일이상발생한두통은약물과용두통 (8.2) 으로진단내릴수있다. 3 Table 4. Headache attributed to temporomandibular disorder (TMD) Headache attributed to temporomandibular disorder (TMD) Description: Headache caused by a disorder involving structures in the temporomandibular region. Diagnostic criteria: A. Any headache fulfilling criterion C B. Clinical and/or imaging evidence of a pathological process affecting the temporomandibular joint (TMJ), muscles of mastication and/or or associated structures C. Evidence of causation demonstrated by at least two of the following: 1. headache has developed in temporal relation to the onset of the temporomandibular disorder 2. either or both of the following: a) headache has significantly worsened in parallel with progression of the temporomandibular disorder b) headache has significantly improved or resolved in parallel with improvement in or resolution of the temporomandibular disorder 3. the headache is produced or exacerbated by active jaw movements, passive movements through the range of motion of the jaw and/ or provocative manoeuvres applied to temporomandibular structures such as pressure on the TMJ and surrounding muscles of mastication 4. headache, when unilateral, is ipsilateral to the side of the temporomandibular disorder D. Not better accounted for by another ICHD-3 diagnosis. ICHD, international classification of headache disorders. 106 J Dent Rehabil Appl Sci 2016;32(2):102-8

6 Diagnosis of headaches in dental clinic 약물과용두통의진단은임상적으로중요한의미를갖는다. 3개월이상의기간동안한달에 15일이상두통이발생하는환자의약절반정도가약물과용두통에해당한다. 만성편두통환자의 50% 정도가관련약물을중단하면삽화편두통으로변한다. 약물과용두통진단기준과다른만성두통 ( 대부분만성편두통또는만성긴장형두통 ) 의진단기준을모두충족한다면, 약물과용두통과만성편두통또는약물과용두통과만성긴장형두통으로진단할수있다. 약물과용두통의원인과결과에대한간단한조언이치료의필수적인부분이되기때문에두통이빈번한환자들의경우복용약물에대한병력청취가두통을치료하는데있어매우중요하다. 결론 치과에내원하는환자들중종종두통을동반증상으로호소하는경우가있다. 본종설은최근개정된국제두통학회 ICHD-3 beta 분류법으로두통을분류하였고이중응급하거나생명에위협적인이차성두통의감별법및일반적인일차성두통의진단에관하여기술하였다. 무엇보다도치료에앞서정확한진단이반드시선행되어야한다. References 1. Lee TG, Chung KC, Choi JW. Prevalence of migraine in Korean adults: a nationwide survey. Korean J Headache 2000;1: The Korean Headache Society. Korean version of international classification of headache disorders. 2nd ed. Seoul; Medical publishing; p Silberstein SD, Lipton RB, Dalessio DJ. Overview, diagnosis, and classification. In: Silberstein SD, Lipton RB, Dalessio DJ, editors. Wolff s headache and other head pain. 7th ed. Oxford; Oxford University Press; p Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition (beta version). Cephalalgia 2013;33: Goadsby PJ. Migraine pathophysiology. Headache 2005;45:S Silberstein SD. Migraine pathophysiology and its clinical implications. Cephalalgia 2004;24 Suppl 2: Dichgans M, Freilinger T, Eckstein G, Babini E, Lorenz-Depiereux B, Biskup S, Ferrari MD, Herzog J, van den Maagdenberg AM, Pusch M, Strom TM. Mutation in the neuronal voltage-gated sodium channel SCN1A in familial hemiplegic migraine. Lancet 2005;366: J Dent Rehabil Appl Sci 2016;32(2):

7 Review Article 치과임상에서의두통의진단 이혜진, 김영건, 김성택 * 연세대학교치과대학구강내과학교실 두통은전체인구중상당수가일생에한번이상겪게되는질환으로, 계속하여논의되고개정되어현재까지국제적인분류법이마련되어왔다. 원발두통은, 다른원인질환에의하지않은통증을의미하며, 다음과같이분류할수있다 : 1) 편두통 2) 긴장형두통 3) 군발두통과기타삼차자율신경두통 4) 기타원발두통. 한편턱관절장애에기인한두통및약물과용두통은두통의원인이기질적인경우로이차성두통에분류된다. 본종설에서는국제두통질환분류제3판의베타판 (ICHD-3 beta) 에근거한두통의진단에대하여고찰해보고자한다. ( 구강회복응용과학지 2016;32(2):102-8) 주요어 : 두통 ; 원발두통 ; 편두통 ; 긴장형두통 ; 측두하악관절장애 * 교신저자 : 김성택 (03722) 서울특별시서대문구연세로 50-1 연세의료원치과대학병원구강내과 Tel: Fax: k @yuhs,ac 접수일 : 2016 년 6 월 14 일 수정일 : 2016 년 6 월 20 일 채택일 : 2016 년 6 월 21 일 108

한국성인에서초기황반변성질환과 연관된위험요인연구

한국성인에서초기황반변성질환과 연관된위험요인연구 한국성인에서초기황반변성질환과 연관된위험요인연구 - - i - - i - - ii - - iii - - iv - χ - v - - vi - - 1 - - 2 - - 3 - - 4 - 그림 1. 연구대상자선정도표 - 5 - - 6 - - 7 - - 8 - 그림 2. 연구의틀 χ - 9 - - 10 - - 11 -