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1 Anesth Pain Med 2008; 3: 종설 근근막성두통 고려대학교의과대학구로병원마취통증의학과 최상식 Myofascial headache Sang-Sik Choi, M.D. Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University College of Medicine, Seoul, Korea Pericranial myofascial tenderness is a common phenomenon in primary headache. Nociception from pericranial muscles may play a role in provoking or aggravating headaches. Conversely, the central mechanisms of headache are also important in myofascial headaches. Myofascial headaches resulting from pericranial musculoskeletal dysfunction may stem from the referred pain caused by central convergence and facilitation. This review comprehensively evaluates myofascial headache in comparison with other primary headaches. (Anesth Pain Med 2008; 3: ) Key Words: myofascial headache, pericranial tenderness, primary headache. 서 두통은복부통증이나허리통증처럼동일한양상의통증에대해다양한원인이존재할수있고, 같은유형의두통이라도환자마다그리고동일환자에있어서도발병시간이나시간경과에따라다양한증상을보일수있다. 따라서정확한두통의진단을위해서는많은노력과주의가요구된다. 특히정확한치료를위해일차성두통 (primary headache) 과기질적요인에의한이차성두통 (secondary headache) 을반드시감별해야하며, 일차성두통의경우에도각각의두통에대해서아형 (subtype) 을감별해야만한다. 통증외래에서흔히경험하는두통으로는긴장형두통 (tension-type headache) 과편두통 (migraine), 그리고경추성두통 (cervicogenic headache) 이있다. 특히편두통과긴장형두 론 논문접수일 :2007 년 9 월 29 일책임저자 : 최상식, 서울시구로구구로 2 동 80 번지고려대학교구로병원마취통증의학과우편번호 : Tel: , Fax: clonidine@empal.com 233 통은임상에서볼수있는일차성두통의 90 % 이상을차지한다. 1) 두통과두개주위근육 (pericranial muscles) 과의관련성은잘알려져있는데머리와목, 얼굴, 어깨등많은근육들이연관된다 (Table 1). 특히긴장형두통과같은경우는두개주위의압통유무에따라여섯가지아형 ( 두개주변압통과관련된 / 관련되지않은고빈도삽화성긴장형두통 [frequent episodic tension-type headache associated with/without pericranial tenderness], 두개주변압통과관련된 / 관련되지않은저빈도삽화성긴장형두통 [infrequent episodic tension-type headache associated with/without pericranial tenderness], 두개주변압통과관련된 / 관련되지않은만성긴장형두통 [chronic tension-type headache associated with/without pericranial tenderness]) 으로분류된다. 2) 대부분의일차성두통에서대개 1 2 개이상의두개주변압통이나타나나아직까지는그기전에대해정확하게알지못한다. 현재까지두통과두개주변근근막조직의압통과의관련성을설명하는이론에는중추성기전 (central pain mechanism) 과 Travell과 Simons의근근막통증개념을근간으로한근원성 (myogenic) 모델, 그리고통합이론인 vascular-supraspinal-myogenic (VSM) 모델등이있다. 본종설에서는두통과두개주위근근막통증과의연관성 Table 1. Various Pericranial Muscle Tenderness is Connected with Many Headaches Pericranial muscles Head and face Neck Shoulder Temporalis Sternocleidomastoid Trapezius Occipitofrontalis Longus capitis Epicranial aponeurosis Rectus capitis posterior Superior oblique major and minor Masseter Rectus capitis anterior Semispinalis capitis & cervicis Splenius capitis & cervicis Longissimus capitis

2 234 Anesth Pain Med Vol. 3, No. 4, 2008 을살펴보고, 두통의진단과치료에있어서두개주위근근막통증의중요성을확인하고자한다. 두통의기전중추성기전두통의중추성기전이잘연구된것이편두통이다. 최초로 Wolff 등이 3,4) ergotamine과관련된실험실연구를근거로혈관성이론 (vascular theory) 을제창한후삼차신경-혈관계이론 (trigeminovascular theory), 신경인설 (neurogenic theory) 등다양한이론이제시되었다. 혈관성이론은두개내혈관의수축으로인해뇌혈류량의감소가발생하여전조증상이발생하고, 이어발생한과도한보상성혈관확장 (compensatory vasodilatation) 과혈관활성펩티드 (vasoactive polypeptides) 가매개된혈관주위의부종과염증에의해두통이발생한다는이론이다. 오랜동안두통의병태생리를설명하는정설로받아들여졌지만, 결정적으로혈관확장과편두통사이에는인과관계가확실하지않고, 혈관성이론으로전구증상 (prodromal symptom) 을설명하는데는한계가있었다. 5) 편두통에대한세로토닌작용제 (serotonin agonist) 의효과가실험실연구와임상에서확인되었는데 6) 이에대한연구결과를바탕으로혈관성이론의한계를보완한이론이삼차신경-혈관 (trigeminovascular theory) 이론이다. 두통은내장통증 (visceral pain) 과많은점에서유사하다. 비교적국소적이지못하고종종다른부위로연관통을일으키며, 서서히발생하였다가서서히소실되고, 자율신경계증상이나증후들을동반하며, 피로감을동반한다. 뇌막은체내다른구조물의섬유성피막과유사한구조를가지고있고, 동통에민감한수용체가뇌자체보다훨씬고밀도로분포되어있다. 이들동통에민감한신경섬유는동통신호를뇌내의침해수용성센터 (nociceptive center) 로보낼뿐만아니라, 신경인성염증 (neurogenic inflammation) 의발생을매개하기도한다. 7,8) 세로토닌작용제는뇌막혈관 (meningeal vesseles) 을수축시키고, 구심성삼차신경로 (trigeminal afferent) 의자극에의해야기된다양한통증관련물질 (CGRP, neurokinins, Substance P) 의분비를저해하고흥분역치를높여편두통에서효과를나타낸다. 삼차신경-혈관계이론은두통을중추신경계의감각처리과정 (central neuronal processing) 의변화와삼차신경혈관계 (trigeminovascular system) 의이상에의해발생한신경혈관통증증후군 (neurovascular pain syndrome) 의하나로본다. 뇌간핵들의활성 (activation of brain stem nuclei), 피질과흥분상태 (cortical hyperexcitability), 과분극의절정후탈분극이뒤따르는뇌피질의기전위변화 (cortical spreading depression) 등의중추신경계감각처리과정변화가발생하고, 삼차신경혈관계로부터온일차성구심침해수용정보 에의해활성화되어신경전달물질을분비하고, 이렇게분비된신경전달물질은두개강내혈관과경막에통증성염증을발생시켜두통을유발, 유지및악화시키게된다. 9-11) 그러나, 삼차신경-혈관계이론은생리에의해유발되는두통등특정편두통을설명할수없고, 편두통의전구증상이나경한비혈관성두통기 ( nonvascular headache phase), 그리고인지장애 (cognitive impairment) 같은신경학적증상을설명할수없었다. 이러한문제들을해결하기위해나온이론이신경인설이다. 12) 신경인설은편두통의원인을뇌자체로본다. 유전적으로편두통에민감한뇌가편두통을유발할만한상황에노출되면신경화학적변화가초래되고, 전구증상이발생하게된다. 이후신경화학적변화에의해삼차신경-혈관계가활성화되고, 혈관활성펩티드의분비와신경성염증이발생한다. 이러한결과로뇌간의삼차신경척수핵꼬리부분 (nucleus claudalis of the trigeminal nerve) 으로가는삼차신경유입 (trigeminal input) 의감각역치가감소하게되고, C1, C2 피부분절로부터오는감각성유입 (sensory input) 이삼차신경유입과통합되어궁극적으로체성감각 (somatosensory) 과변연피질 (limbic cortex) 에서시냅스되어두통으로해석되게된다. 13,14) Hargreaves와 15) Burstein은 16) 뇌간에서말초감각유입 (peripheral sensory input) 의감각증폭 (sensory windup) 과중추성감작, 그리고결과적으로피부에이질통이발생하는것을보여주었다. 근근막성이론근근막통증증후군 (myofascial pain syndrome, MPS) 은근육과주위의연조직 ( 건, 인대, 골막같은 ) 에발생한압통점 (tender point), 통증유발점 (trigger point), 단단한띠 (taut band), 연관통 (referred pain), 국소적인근육연축반응 (local twitch response), 운동제한등을동반한국소적인통증을특징으로하는근골격계질환으로때로는자율신경계의기능장애를동반한다. 17,18) MPS는신체의어느근육에서도발생할수있고, 진단은환자의병력과이학적검사에의해이루어지며, 염증성질환이나신경학적이상등다른질환에의한통증을배제하여야한다. Hubbard와 Berkoff가 19) 통증유발점에서 spontaneous electrical activity (SEA) 의존재를보고한후, 이러한비정상적인전기적활동이운동신경종판 (motor endplate) 에서기인한다는것이밝혀졌는데이는운동신경종판에서의비정상적인아세틸콜린의분비에의해초래된다. 운동신경종판의비정상적인아세틸콜린의분비로인해지속적이고비정상적인근육의단축 (shortening) 과구축 (contracture) 이발생하고, 이로인한국소적인허혈과대사의증가로인해에너지고갈 (energy crisis) 이초래된다. 이러한변화에더불어다양한신경혈관활성 (neurovasoactive) 물질들 (prostaglandin, bradykinin,

3 최상식 : 근근막성두통 235 substance P, CGRP, K +, serotonin, histamine 등 ) 이분비되고, 이들은근육의유입신경 (afferent fiber) 을감작시키고, 국소적인통증을유발한다. 비정상적인근육의단축과구축은전체근섬유에발생하는것은아니고, 조직학적으로일부근절 (sarcomere) 에나타나게되는데, 이들근절의지속적인단축과구축에의해 contraction knot 이라고불리는단단한결절이형성된다. 최근에는근근막조직의말초감작과중추감작의상호작용을중요하게생각한다. 말초감작에의해척수후각으로의자극빈도와강도가증가하게되면, 척수후각을소통 (facilitation), 강화 (potentiation) 시켜중추감작이발생하게된다. 이때자율신경계에도영향을미쳐 painful skin rolling, hypersensitivity to touch, 온도나혈류변화, 비정상적발한, 기모반사의변화 (altered pilomotor) 등의결과를초래하기도한다. 17,18) 근근막통증이두통을유발하는기전은두개주위에발생한통증유발점에의해유발된자극이중심성폭주 (convergence) 와소통에의해머리나얼굴로삼차신경-경추연관통 (trigeminocervical referral) 이발생하여두통이발생하는것으로생각된다. 20) 두통특히만성두통의경우근골격계증상과깊은관계가있는데 21-23) 경부에제한된통증을가진환자의경우다른부위에국한된통증을가진경우보다두통의발생빈도가높다. 삼차신경-경추신경핵 (trigeminocervical nucleus) 은상부경추신경 (C1-C3) 과삼차신경의하행로 (descending tract) 가폭주하는곳이다 (Fig. 1). 이러한신경해부학적구조때문에경부의침해성자극이경부나후두뿐아니라, 삼차신경지배영역인안면과두부에통증을유발할수있다. 이러한폭주와소통현상이지속되면척수후각뉴우런을감작시키고, 신경가소성변화를일으켜구조적 인변화를초래할수있다 ) 통합이론 (vascular-supraspinal-myogenic theory, VSM) Olesen은 27) 위에설명한가설들을종합하여두통의유발기전에대한통합가설을제시하였다. 이모델에의하면뇌혈관과두개주위근육에대한침해수용성자극과이들감각정보에대한척수상부에서의변조 (modulation) 에의해통증의강도가결정된다. 이과정에서상위척수증폭 (supraspinal facilitation) 이가장중요한역할을할것으로생각된다. 즉, 뇌혈관과두개주위근육에대한침해수용성자극이같은뉴우런에폭주하고이것이최종적으로척수상부에서통합되어척수상부에서의효과 (supraspinal effects) 를더하게되면서통증의강도가결정된다. 이모델은최근의미측신경핵뉴우런 (nucleus caudalis neurons) 에대한체성내장신경유입로 (somatovisceral afferents) 의폭주에대한실험연구의결과와도일치한다. 이들세가지효과들에의한합은다양하게나타날수있으므로환자마다그리고, 동일환자에있어서도발병시간이나시간경과에따라다양한증상을보이게된다. 또, 이들각각의신경원들에의한정보는통합되어두통의형태를결정하게되는데, 침해수용이근근막통증유발점에서주로오는경우에는긴장성두통양상이나타나고, 혈관계에서주로오는경우에는편두통양상이나타나게된다고보았다. 결국이가설에의해두통을일으키는원인기전으로통증유발점이왜중요한역할을하는지, 왜일부환자들에서편두통과긴장형두통의특징을다나타내는지, 또만성긴장형두통을가지고있는일부환자들에서때때로편두통양상의두통을보이는지를통합적으로설명할수있게되었다. 또한편두통과긴장성두통에대해현재임상경험을통해일반적으로받아들여지는다양한양식의치료 (multimodal treatment) 에대한합리적인설명을가능하게한다. 근근막성두통과다른두통과의관계 근근막성두통과긴장형두통 Fig. 1. Convergence between upper cervical nerve and trigeminal nerve accounts for the cervical-trigeminal pain referral. From Samer Narouze: Cervicogenic Headache: Diagnosis and Treatment. ASA Refresher Course 2007; 35: International Headache Society (IHS) 의정의에도불구하고일차성두통으로서의긴장형두통은분명치못한부분이많다. 두개주위근육의과도한불수의적수축에의하여긴장형두통이발생한다는것이전통적인관점이었다. 그러나일부에서중추통증프로세스 (central pain processing) 의변화로인해두개주위근근막조직이나두개강내조직의유입자극이과민하게반응하여두개주위압통과통증유발점이발생한다는순수한중추성기전을주장하였고, 지난수십년간긴장형두통이근근막조직에서기인하는가아니면직접적으로중추성기전에의해뇌에서기인하는가하는것이논쟁의중심이었다. 27,28-31) 그러나아직까지각각의주장

4 236 Anesth Pain Med Vol. 3, No. 4, 2008 을뒷받침할근거가임상적으로나실험적으로없다. 최초로 Langemark와 Olesen에의해 28,32) 두개강주위근육의압통과두통의관련성이언급된이래두통환자에서두개주위근육의압통은대표적인임상소견중하나로밝혀졌고, 이는긴장형두통환자에서두개주위의말초침해수용체의활성이병태생리학적으로중요한역할을한다는것을의미한다. 30,31,33,34) 만성긴장형두통환자에서두통의빈도와강도는근육의압통정도와밀접한관련이있다. 또, 긴장형두통에서근육의단단함 (muscle hardness) 이증가되어있고, 근육의단단함이클수록근육의압통도증가한다. 그러나압통부위의물리적, 온도, 그리고전기자극에의한통증역치가감소하는소견을볼때말초성기전뿐아니라일부중추성기전도함께관여하리라생각된다 ) 또한, 증가된압통과긴장형두통과의연관성은명확하지만, 이러한압통의기전과침해수용체로서의역할에대해서는정확하게밝혀진것이없는상태이다. 27,28) 몇몇연구에서는두통이근근막압통과무관하다는부정적인결과가보고되기도하였다. 긴장형두통환자에서두개주위근육의근전도소견은크게도움이되지않는다. 대부분의보고에서두개주위근전도활성도 (pericranial EMG activity) 와두통의강도, 압통과는관계가없었고, 믿을만한인과관계도찾을수없었다 ) 그러나두통과두개주위압통사이에밀접한관련이있는것은확실해보인다. 두개주위근육들의압력통증역치 (pressure pain threshold, PPT) 와다른일반적인자극에의한통증역치가여러연구에서상충된결과들이보고되었지만, 최근발달된실험기법을이용한연구에서긴장형두통에서통증역치가정상보다낮음이많이보고되고있다. 34) 또한, 근전도검사는근섬유전체에대한활성도를보는것이기때문에일부근절에발생한비정상적인근육의단축과구축은측정되지않을가능성이크다. 42,43) 이러한여러이유로근전도의진단적가치가떨어지므로 IHS 개정판에서는검사항목에서누락되었다. 긴장형두통에서나타나는두개주위의압통은대개양측성이고, 상부승모근 (upper trapezius), 후경부 (posterior cervical, suboccipital) 그리고흉쇄유돌근 (sternocleidomastoid) 같은근육들이관여한다. 많은경우두개주위의압통점을촉진하는경우머리로연관통이발생하고, 두통이재현될수있다. 또한, 긴장형두통환자에서는많은경우경부의통증, 경직, 운동제한, 그리고통증유발점을포함한근근막통증증후군의특징적인증상을동반한다. 따라서, 두개주위압통과연관된긴장형두통의많은경우두통이근근막성원인에의하여발생할가능성이크다. 이에대한확실한증거를얻기위해서는대규모의잘고안된연구가절실하게필요한상황이다. 근근막성두통과편두통편두통환자에서근육압통에대한증거는긴장형두통에비해제한되지만여러연구에서편두통과근육압통에대한연관성이보고되었다 ) 편두통발작시두통이있는부위와같은부위에대한근육의압통이반대편부위에비해유의하게크게관찰되었다. 45) 그리고편두통환자에서상부경부의통증과압통점이높게나타났으며 46) 근골격계 기능이상이크게나타났다. 47) 최근에는편두통을가진어린이에게서긴장형두통을가진어린이나두통이없는어린이에비해일부경부근육에대한촉진시압통이높게나타났고, 목-어깨부위의일상생활과연관된압통 (selfeported tenderness) 도높게보고되었다. 48) 편두통환자들중, 특히전조증상이없는많은환자에서두개및경부, 그리고저작근에서현재앓고있는두통양상과같은연관통을유발하는압통점을갖는것으로알려져있고, 많은편두통환자들이통증발작중이나발작사이에경부통증과경직, 그리고운동제한을호소한다. 17,52-54) 또, 편두통발작이없는경우에도정상인에비해쉽게압통이유발되었고, 두통의강도가심해질수록압통점이존재하는근육들의압통도증가하였다. 28,45,53,55) 통증유발점의과도한자극이기존의편두통을유발하고, 두통발작시통증을증가시키기도한다. 또한이근육들의압통점부위에식염수나, 리도카인을주사하였을경우환자들의 60% 에서두통이완전히없어졌다는보고도있다. 54) 이러한결과로미루어볼때전조가없는편두통의많은경우는통증유발점과연관된통증일가능성도생각할수있다. 최근여러학자들이전조가없는편두통의일부가근근막통증증후군에의한것으로생각하지만, 근육이통증의일차적인원인인지아니면중추기전에의해통증유발점이활성화되어통증이발생되는것인지에대해서는아직논란이있다. 근근막성두통과경추성두통경추성두통은경부의다양한원인에의해발생하는두통으로환자에따라경도에서생활을하기힘들정도의심한통증에이르기까지다양한통증스펙트럼을지니는증후군이다. 일반적으로경추성두통은편측의지속적인두통을주증상으로하고, 두통이악화될경우통증발작이수시간에서수일, 또는수주동안지속되며, 경부에서통증이시작되어눈주위-전두부-측두부 (oculo-fronto-temporal region) 로통증이방사되는특징을갖는다. 환측에눈물, 결막충혈, 그리고콧물같은교감신경계증상이나타나기도하며, 심한경우는구역, 구토, 광선공포증 (photophobia) 그리고소리공포증 (phonophobia) 을유발하기도한다. 2,56) 이학적검사에서는경부의운동제한과압통이나타난다. 두통은안면통을

5 최상식 : 근근막성두통 237 동반하기도한다. 이러한현상들때문에경추성두통이경추, 안면, 머리그리고경막의유입성감각정보가삼차신경핵 (trigeminal nucleus) 에폭주되어발생한다는이론이나오게되었다. 1988년 IHS에서는경추성두통과관련된전문가그룹의합의된내용을바탕으로경추성두통을분류하였으나, 긴장형두통과경추성두통이다른질환인지에대해많은논쟁이있었고지금도지속되고있다. 56,58) 일부에서는명백하게근골격계요소를가지고있는경우는긴장형두통으로분류해야한다고주장하고, 일부에서는오히려근골격계에서기인한두통의경우경추성두통으로반드시진단해야한다고주장한다. 59) 그러나또다른일부에서는서로다른여러형태의두통들중에서결정적으로근골격계의기능이상에의해두통이발생한경우는단순히근골격계두통 (musculoskeletal headache) 으로분류해야한다고주장하기도한다. 46) 이렇듯여러주장과반박이이루어지는가장큰이유는경추성두통의정의와진단기준이모호하기때문이다. 경추성두통의정의는경부에서기인한두통이라는점이핵심인데이에대한범주는너무광범위하여구체화된질환으로사용하기에는문제가있다. 실제로경추에존재하는관절, 근육, 인대, 경막, 추간판등모든경추구조물이경추성두통의원인이될수있는데 49,51) 이들구조물의이상에의한두통을경추성두통이라고진단을내리는경우기존의진단들과많은경우충돌하게된다. 예를들면상부경추의추간판탈출에의해두통이동반하는경우이를추간판탈출증으로진단하고두통을부수적인증상의하나로 보는것이합리적이지진단을경추성두통으로내릴수는없는것이다. 경추성두통의진단기준은하나의특정질환에관련한자연경과나병변에대한해부병리적구조적이상소견등을바탕으로하지않은특정증상의모임에가깝다. 따라서, 유사한증상을보이지만병인이다른여러요인에의한두통을한가지로진단함으로써병인에맞추어치료가되기보다는경추성두통이라는진단하에부적절한치료가우선될가능성이있다. 그리고하나의원인에의해다양한증상이나타날수있는가능성을막게되어동일질환임에도불구하고다른진단이내려질가능성도존재한다. 실제로저자의경험과다른많은저자들의보고를고려해볼때경추성두통의진단기준에는일부맞지않지만눈주위와안후부로통증이방사되는근근막성두통이드물지않았다. 경추성두통의원인으로두개-경추이행부 (cranial-cervical junction) 에서의경막과후두하근육들 (suboccipital muscles) 의취약한해부학적연관성 50) 을들기도하는데이는경추성두통의많은부분에서근근막성통증이중요한역할을하는것을의미한다. 결론적으로근근막통증에서기인하는경추성두통의비중은클것으로생각되며, 이러한경우근근막성두통으로진단을내리는것이보다합리적일것으로생각된다. 근근막성두통근근막성두통을유발하는근육으로는흉쇄유돌근 (sternocleidomastoid, sensory suppy by C2, C3), 승모근 (trapezius, Fig. 2. Myofacial pain patterns of the head and neck show the TrP and its pain referral pattern. From: Simons DG, Travell JG, Simons LS. Myofascial Pain and Dysfunction: The Trigger Point Manual, vol 1. Upper Half of Body (ed 2). Baltimore, MD, Lippincott Williams & Wilkins, 1999.

6 238 Anesth Pain Med Vol. 3, No. 4, 2008 sensory suppy by C3, C4), 머리와목널판근 (splenius capitis, splenius cervicis, sensory suppy by dorsal rami of cervical spinal nerves), 머리와목의반극근 (semispinalis capitis, semispinalis cervicis, sensory suppy by dorsal rami of cervical spinal nerves), 후두하근 (suboccipitalis, sensory suppy by C1, C2), 전두근 (frontalis, sensory suppy by V1), 후두근 (occpitalis, sensory suppy by C2, 3), 측두근 (temporalis, sensory suppy by V2), 교근 (masseter muscle, sensory suppy by auriculotemporal nerve) 등이있다 (Fig. 2). 이들근육의이상에의해통증신호가중추로전달되는과정에서, 즉 C1-C3 경추신경과삼차신경유입 (trigeminal afferents) 이삼차경추신경핵 (trigeminocervical nucleus) 에서상호작용을하여 trigeminocervical referral 기전에의해두통이발생하는것으로생각된다. 17,27,60,61) 각근육에따라특정부위로의두통을동반하게된다. 승모근의경우두통이측두부, 그리고안와와안와후부위로방사된다. 17,62) 흉쇄유돌근의경우는전두-측두부위, 후두부, 두정부, 이마그리고안와부로두통이발생한다. 63) 머리널판근과목널판근은대개환측두정부, 안와후부, 그리고후두로방사된다. 64) 그외대부분의경부-후두부근육들 (cervicooccipital muscles) 도일반적으로후두부, 눈주위, 그리고이마로방사된다. 17) 실험적으로 C1-C3 지배근육들을자극하였을때두통이유발되었으나, 그아래경추신경의지배를받는근육들의자극은두통을유발하지못하였다. 경부골부착부병변 (enthesopathy) 의이상도머리와상부경추축 (proximal axial cervical spine) 으로연관통을유발시켜근근막성두통을유발할수있다. 경부의골부착부병변에의 한두통도위에설명한기전과동일한기전으로발생하게된다. Hackett 등은 65) suboccipital, interspinous, supraspinous, 그리고 intertransverse ligaments에서머리로방사하는통증에대해이미자세하게기술하였다 (Fig. 3). 이외에도후두근육에의한후두신경포획등도두통의원인이될수있는데, 이는앞에설명한기전과더불어신경포획에의한직접적인신경증상에의한것일수있다. 일례로대후두신경이나삼차후두신경이반극근이나승모근을경로할때포획되어두통을유발할수도있는데 66) 후두하부위에서시작되어후두나외측두피로통증이전이된다. 경우에따라서는병측의눈뒤, 경부, 관자놀이, 앞이마에도통증을유발시킨다. 이때신경이주행하는부위를눌러통증을유발시키거나악화시킬수있는데경우에따라서는 Tinnel sign 양성소견을보이기도한다. 두통의발생에는자세도중요한역할을한다. 67) 귀가어깨의중심과지면에수직으로일치될때가정상적인머리의위치인데, 이위치에서머리가앞으로치우칠때이를 forward head posture (FHP) 라고한다. 머리가앞으로 1인치정도치우치면약 5 kg 정도의압축력이경추에더걸리게된다. FHP 상태에서는후경추펴짐근 (posterior cervical extensor muscles: suboccipital, semispinalis, splenii, upper trapezius muscles) 과흉쇄유돌근의단축이발생하고, 경부의통증과두통을유발할수있다. 실제적으로삽화성긴장형두통 68) 과만성긴장형두통, 69) 편두통 44) 같은일차성두통환자에서 FHP의증가는잘알려져있다. 따라서, 반드시근근막성두통의치료에있어서자세의교정도고려해야한다. 근근막성두통의치료는근육의지속적이고비정상적인단축에의해발생한통증유발점을해제시키는것이목표가된다. 이를위하여통증유발점주사, 근육내자극술, 스프레이분사후신장치료 (spray and stretch), 보톡스통증유발점주사 70-74) 등을이용한중재적치료가이루어지고있다. 결론적으로두통과근근막통증과는밀접한관련이있다. 두통의치료에있어서근근막통증은두통을유발하는원인으로서뿐아니라악화요인으로서도반드시적절하게치료되어야한다. 참고문헌 Fig. 3. Referred pain from head and neck ligaments extends to the head and upper extremity. From: Hackett GS, Hemwall GA, Montgomerry GA. Ligament and tendon relaxation treated by prolotherapy. 5th ed. p Rasmussen BK, Jensen R, Schroll M, Olesen J: Epidemiology of headache in a general population - a prevalence study. J Clin Epidemiol 1991; 44: Headache Classification Subcommittee of the International Headache Society: The International Classification of Headache Disorders. 2nd ed. Cephalalgia 2004; 24 (Supp1): Graham JR, Wolff HG: Mechanisms of headache and action of ergotamine tartrate. Arch Neuro Psychiatry 1938; 39: Ray BS, Wolff HG: Experimental studies on headache: Painsensitive structures of the head and their significance in headache.

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