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1 Review online ML Comm Korean J Otorhinolaryngol-Head Neck Surg 2009;52: / DOI /kjorl-hns pissn / eissn Diagnosis and Management of Migrainous Vertigo Seong-Ki Ahn Department of Otolaryngology, School of Medicine, Gyeongsang National University, Jinju, Korea 편두통성현훈의진단및치료 안성기 경상대학교의학전문대학원이비인후과학교실 Address for correspondence Seong-Ki Ahn, MD, PhD Department of Otolaryngology, School of Medicine, Gyeongsang National University, 90 Chilam-dong, Jinju , Korea Tel Fax skahn@gnu.ac.kr Interplay between migraine and balance disorder morbidities has been a topic of interest for many years. Migrainous vertigo (MV) is acknowledged as a common cause of episodic vertigo. Like migraine itself, MV is diagnosed on the basis of clinical information as there are no specific biological makers. A preliminary classification proposed two separate diagnostic categories: definite and probable MV. For treatment of MV, it is suggested that drugs used for migraine may be effective. However, current treatment recommendations are generally based on expert opinion rather than ran-domized or controlled trials. Therefore, large prospective, multi-center studies are necessary to better define criteria and optimal treatment. Korean J Otorhinolaryngol-Head Neck Surg 2009;52: Key WordsZZMigraine Vertigo Diagnosis Therapy. 서론 편두통성현훈 (migrainous vertigo) 은재발성현훈환자의원인질환에서양성돌발성두위현훈과함께어지럼클리닉에서흔히볼수있는질환이다. 1) 최근이비인후과의사들도이질환에대한인식및관심도가점점높아져가고있기때문에이질환에대한전반적인이해가필요하다. 편두통환자들에서현훈또는어지럼의증상을호소하는빈도는약 52% 로많다. 2,3) 또한편두통환자에서현훈의발생률이일반인보다세배정도더높게발생하는데이는단순히우연히편두통과현훈이함께생긴것보다는편두통과현훈사이의인과관계 (causal relationship) 에발생할것이라는견해가옳을것이다. 4,5) 국제두통학회 (The International Headache Society, IHS) 의편두통분류에현훈은단지뇌기저동맥편두통 (basilar artery migraine) 의전조증상의하나로서만기술이되어있다. 6) 그러나현훈증상만으로는뇌기저동맥편두통 (basilar artery migraine) 의진단기준에부합되지않기때문에편두통성현훈을다른하나의진단명 (disease entity) 으로보는견해 가지배적이다. 하지만아직까지는편두통성현훈에대한체계화되고전세계적으로통일된진단기준및정확한병리기전은없다. 저자는최근발표된보고들을바탕으로편두통성현훈의진단기준, 임상양상, 감별진단및치료에대하여알아보고자한다. 용어 (Nomenclature) 편두통과현훈사이의연관성이높음에도불구하고현재까지이에대한하나의통일된용어가없는실정이다. 편두통과관련하여발생한현훈인경우에, 대부분의논문에서편두통성현훈 (migrainous vertigo), 7,8) 편두통과연관된전정병증 (migraine-related vestibulopathy), 9) 전정성현훈 (vestibular migraine), 10) 또는편두통과연관된현훈또는어지럼 [migraine-related(or associated) vertigo or dizziness] 11) 등으로기술되어있다. 편두통과연관된전정병증과전정성현훈은편두통과전정신경계와원인병리론 (etiopathogenesis) 에따른것이고나머지는단순히서술 Copyright c 2009 Korean Society of Otorhinolaryngology-Head and Neck Surgery 793

2 Korean J Otorhinolaryngol-Head Neck Surg 2009;52: 적으로기술한것이다. 저자는여기에서는편의상편두통성현훈이라고모두기술하였다. 임상증상 현훈의양상은대부분자발적또는체위성현훈이다. 일부환자에서는처음에는자발적현훈을보이다가나중에체위성현훈으로바뀌기도한다. 12) 또한머리움직임에의해현훈이더심해지거나자세의불균형을느끼기도하며 (head motion intolerance), 물체가움직이는착각을하기도한다. 지속시간은수초에서수일로매우다양하다. 심지어일부환자에서는현훈이완전회복되는데걸리는시간이수주까지걸리기도한다. 빈도역시매우불규칙한양상으로나타난다. 그리고전체환자의약 10~30% 만이편두통의전조증상들과함께현훈이발생하며, 이때지속시간은약 5~60 분정도이다. 하지만현훈이편두통의두통과함께시작될수도있으며, 편두통발작동안에생길수도있다. 일부환자에서는, 편두통과현훈이전혀관계가없는경우도있다. 7,11,13) 흥미로운점은상당수의환자에서현훈없이편두통의발작시나타나는두통의강도에비해, 현훈과함께나타나는경우는두통의강도가약하다는것이다. 또한편두통발작동안에온도안진검사로전정계를자극하면두통이없어지거나두통의세기가감소된다는보고 Table 1. Clinical features of definite migrainous vertigo in 33 patients (Cited from Cephalalgia, 2004, Neuhauser H, Lempert T) 현훈의특징 * 임상증상 % 회전성현훈 70 자기자신또는주위물체가움직이는듯한느낌 18 체위성현훈 42 머리움직임에의해현훈이더심해지거나자세의불균형을느낌 (head motion intolerance**) 48 현훈의지속시간 수초-5분 분 33 1시간-1일 21 1일이상 27 현훈동안에편두통증상 편두통성두통 94 항상 45 가끔 48 두통이없음 6 광과민증 70 고성공포증 64 시각또는다른전조증상들 36 * 일부환자들은한가지이상의현훈증상을보였다, **head motion intolerance 증상만가진환자는없었다 도있다. 14) 그리고현훈과함께광과민증 (photophobia), 고성공포증 (phonophobia) 그리고시각전조증상등을경험할수있으며, 이와같은증상들은편두통과현훈의인과관계를알수있기때문에매우중요하다. 청력감소와이명은편두통성현훈의주된증상은아니지만종종보고되고있다. 9,11,15) 결론적으로, 편두통성현훈의임상증상은앞서기술한대로매우다양하다 (Table 1). 따라서반복적인현훈을가진환자에서편두통성두통, 광과민증, 고성공포증, 시각전조등의편두통의주된증상들이동반되는지병력청취시에항상물어보는것이중요하다. Table 2. Diagnostic criteria of migrainous vertigo (Cited from Neurology, 2001, Neuhauser H, Leopold M, von Brervern M, Arnold G, Lempert T) 확실한편두통성현훈 (Definite migrainous vertigo) 1. 중등도이상강도의재발성, 주기적현훈 * 2. IHS의편두통기준에따른편두통의과거력또는현병력 3. 최소 2번이상의현훈발작동안에다음의편두통증상이하나이상동반됨 : 편두통성두통 **, 광과민증, 고성공포증, 시각또는다른전조증상들 4. 적절한검사를통하여다른원인이배제되어야함 * 현훈증상은회전성현훈또는자기자신또는주위물체가움직이는듯한느낌이다. 현훈은자발적또는체위변화에의한것일수도있으며, 머리움직임에의해현훈이더심해지거나자세의불균형을느낄수있다. 중등도강도란일상생활을방해할정도이지만일상생활은가능하다. 하지만심한강도는일상생활을할수없는경우이다. ** 전조증상이없는편두통성두통 (Migraine without aura) 의특징 1. 다음과같은기준을만족하는발작이최소 5번이상되어야한다. 2. 치료하지않거나치료가불완전할경우두통발작이 4-72시간지속된다. 3. 두통은다음중최소한두가지이상을가진다. - 일측성 - 박동성 - 중등도또는심도의통증강도 - 일상적인육체활동 ( 걷거나계단을오르는일 ) 에의해악화되 - 거나이를회피하게됨 4. 두통이있는동안다음중최소한한가지이상을가진다. - 오심또는구토 - 광과민증과소리공포증 5. 다른질환에기인하지않음 가능성이높은편두통성현훈 (Probable migrainous vertigo) 1. 중등도이상강도의재발성, 주기적현훈 2. 아래의항목중하나를만족함 : - IHS의편두통기준에따른편두통의과거력또는현병력 - 최소 2번이상의현훈발작동안에다음의편두통증상이동반됨 - 현훈발작의 50% 이상이유발요인들 ( 음식, 수면장애, 호르몬변화등 ) 에의함 - 항편두통약물의복용후증상이 50% 이상호전됨 3. 다른질환에기인하지않음. 794

3 Diagnosis and Management of Migrainous Vertigo Ahn SK 진단기준 편두통과마찬가지로편두통성현훈은생물학적표지 (biological marker) 에의해서가아니라병력청취를통해서진단을내린다. 지금까지편두통성현훈의진단기준은국제적으로통일된것이없지만 2001년독일의 Neuhauser 등 7) (Table 2) 과 2003년미국피츠버그대학교의 Furman 등 8) (Fig. 1) 이제시한진단기준이많이인용되고있다. 실제로이두그룹이제시한진단기준은약간의차이가있을뿐거의비슷하다. 임상에서는두그룹에서제시한진단기준을이용하여편두통성현훈을진단하면크게문제는없을것으로생각된다. Lifetime diagnosis of migraine by IHS criteria (A) Episodic or fluctuating vestibular symptoms, i.e. vertigo or illusory motion or head motion intolerance (B) NOT only dizziness (C) No identified pathology (Méniére s, etc.) (D) Symptoms NOT constant Vestibular symptoms are: (A) Moderate or severe 1 migrainous symptom(s) have occurred during 2 attacks of episodic vestibular symptoms, within the last 2 years, e.g.: (A) Migrainous headache (B) Photophobia (C) Phonophobia (D) Aura (other than dizziness), e.g. visual changes Diagnosis of definite migrainous vertigo (A) Episodic or fluctuating vestibular symptoms, i.e. vertigo or illusory motion or head motion intolerance (B) NOT only dizziness (C) No identified pathology (e.g. Méniére s, etc.) (D) Symptoms NOT constant Vestibular symptoms are: (A) Moderate or severe ONE of the following migraine symptoms: (A) A lifetime diagnosis of migraine by IHS criteria (B) Migrainous symptoms during 2 attacks of vertigo (C) Migraine-precipitants before vertigo (for 50% attacks) (a) Food triggers (b) Sleep irregularities (c) Hormonal change (D) Response to migraine medications (for 50% attacks) (a) Specific drug(s): Diagnosis of probable migrainous vertigo Fig. 1. Diagnostic criteria for migrainous vertigo (Cited from Curr Opin Neurol, 2003, Furman JM, Marcus DA, Balaban CD). Moderate vestibular symptoms interfere with daily activities, and severe vestibular symptoms prohibit daily activities. Head motion intolerance is the sensation of imbalance or illusory self or object motion provoked by head motion. Adapted with permission (10). IHS: international headache society. Table 3. Differential diagnosis for migrainous vertigo (Cited from Cephalalgia, 2004, Neuhauser H, Lempert T) Disorder Key features Benign paroxysmal positional vertigo (BPPV) Vertigo lasting seconds to 1 min provoked by changes in head position. Positive positional test with typical torsional nystagmus. Ménière s disease Vertigo lasting 20 min to 3 h with concurrent hearing loss, tinnitus and aural fullness. Progressive hearing loss over years is a diagnostic criterion (46). Central positional vertigo History similar to BPPV but latency, duration and direction of positional nystagmus not typical for BPPV. Frequency additional neurological or neurotological signs. Vertebrobasilar TIA Attacks lasting mostly minutes, with brainstem symptoms including vertigo, ataxia, dysarthria, diplopia or visual field defects (not longstanding recurrent vertigo alone). Usually elderly patients with vascular risk factors. Vascular compression of the 8th nerve Brief attacks of vertigo (seconds) several times per day wity or without cochlear symptoms, response to carbamazepine. Perilymph fistula Vertigo after head trauma, barotrauma, stapedectomy of provoked by coughing sneezing, straining or loud sounds. Autoimmune inner ear disease Frequent attacks of variable duration, often bilateral with rapidly progressing hearing loss. Insufficient compensation of unilateral vestibular loss Brief and mild spells of vertigo during rapid head movements, oscillopsia with head turns to affected ear. Positive head thrust test to affected side. Schwannoma of the 8th nerve Rarely presents with attacks of vertigo. Key symptoms are slowly progressive unilateral hearing loss and tinnitus. Abnormal BAER. TIA: transient ischemic attack, BAER: brainstem auditory evoked response 795

4 Korean J Otorhinolaryngol-Head Neck Surg 2009;52: 감별진단 급성기약물요법 반복적인현훈을주소로오는환자들에서편두통성현훈과함께여러가지질환들을반드시고려해야한다. 대표적인감별진단질환들로서는양성돌발성두위현훈, 메니에르병, 중추성체위성현훈, 추골뇌기저동맥순환부전, 자가면역내이질환, 외림프누공등이다. 이와같은질환들의주요임상양상들을 Table 3에요약하였다. 특히초기의메니에르병은와우증상들이없기때문에편두통성현훈과거의감별이되지않는다. 12) 치료 편두통성현훈의체계적인치료법은아직까지없는실정이다. 따라서대부분의경우편두통의일반적인치료방법에준해서치료를하고있다. 즉, 편두통을촉진시키는유발인자들의제거또는회피, 수면조절, 그리고전정재활치료와같은비약물요법, 급성기약물요법, 예방적약물요법그리고우울증, 불안장애, 공황장애등동반이환된질환들의치료등이대표적인치료방법들이다. 11,12,16) 비약물요법 비약물요법은유발인자의회피또는제거와함께수면조절및전정재활치료등이다. 대표적인유발인자들로서는스트레스, 수면변화, 특정음식, 빛이나시끄러운소리, 날씨변화, 식사를하지않은경우, 여자의경우생리, 폐경기등과같은호르몬변화등여러가지요인들이다. 따라서각개인의유발인자를파악하고환자에게인지하여유발요인을제거또는회피하는것이중요하다. 편두통을유발시키는것으로잘알려진음식들은초콜릿, 햄, 소시지, 타이라민 (tyramine) 성분이포함된숙성된치즈, 커피, 붉은포도주, 카페인성분의음표, 글루타민산나트륨 (monosodium L-glutamate, MSG) 이첨가된음식물, 아스파탐 (aspartame) 이들어있는인공감미료, 땅콩과호두같은견과류또는이를재료를한버터등이다. 17) Reploeg와 Goebel 18) 의보고에의하면편두통성현훈의치료환자 81명중 13 명이약물치료없이이와같은식이조절만을통해증상의호전을보았다고한다. 그리고편두통성현훈또는편두통과거력이있는환자에서전정기능의장애가있는환자들을대상으로전정재활치료를한결과주관적및객관적현훈의증상들이호전됨을보여전정재활치료역시일부환자에게는도움을줄수있다. 19) 급성기약물은주로항히스타민제, 신경안정제와같은대증요법과편두통성현훈발작을중지 (abortion) 시키는약물로나눌수있다. 편두통성현훈이발생하면환자들은심한현훈과함께오심또는구토등이동반되기때문에이에대한대증요법이필요하다. 자주사용되는약물로서는항히스타민제로서항어지럼및항구토제인 promethazine HCL(himazine ) 을사용할수있으며, 진정작용이덜한 dimenhydrinate(dramamine ) 또는 meclizine HCL( 염산메클리진 ) 등을사용할수도있다. 그리고편두통발작시처럼편두통성현훈의경우에도위정체 (gastric stasis) 가될수있으므로 metoclopramide HCL(macperan ) 을사용하면위장관운동을촉진시켜경구약물의흡수를도와줄수있다. 또한 diazepam(valium ) 과같은신경안정제를사용하기도한다. 그러나이러한약물이혈액으로들어가서효과를나타내기까지의시간이약 20~30 분정도걸리기때문에만약환자의현훈지속시간이 20분미만인경우는이와같은약물이크게도움이되지않을수있다. 15,20) 그리고이런대증요법외에편두통성현훈발작을중지시키기위하여사용할수있는대표적인약물이 triptans( 세로토닌수용체 1B/1D 작용약제 ) 이다. 이러한 triptans 계열약물들은편두통의두통발작시에투여하면투여후 1시간이내에효과가나타나며, 투여후 2시간이지나면환자의약 80% 에서증상의호전을볼수있다. 또한오심, 구토, 광과민증, 고성공포증의증상들도함께호전시킨다고알려져있기때문에편두통의급성기치료약물로서많이사용되고있다. 21,22) 비록확실한약물효과에대하여결론을내리지는못했지만 19명의편두통성현훈환자에게 zolmitriptan 과위약을사용한무작위대조시험에서 zolmitriptan 을사용하여약 38% 에서증상의호전이있었다. 23) 또한현훈이있는편두통환자의일부그룹에게 sumatriptan 을투여한후편두통과함께현훈의증상이호전되었다는보고가있다. 24) 그리고세로토닌을생쥐의꼬리정맥 (tail vein) 을통해주입한후와우첨부에위치한나선신경절과와우축, 그리고상 하전정신경등에서혈장단백유출을관찰한결과와, 흰쥐전정핵에서세로토닌수용체 1F와 glutamate 의공동국재화 (colocalization) 를이중면역형광법을이용하여관찰한실험들은, 이와같은세로토닌수용체일부약물들이편두통뿐만아니라편두통성현훈의치료에도움이될것이라는것을뒷받침한다. 25,26) 그러나편두통성현훈환자에서이러한 triptans 계열약물사용의적응증에대해서는확립된것은없다. 대부분편두통의치료 796

5 Diagnosis and Management of Migrainous Vertigo Ahn SK 방침과같이한달에 1회정도의심한편두통성현훈이있고지속시간이최소 2시간이상인경우는 triptans 계열의약물을사용해볼만하다. 22) 사용시주의점은혈관수축을일으키기때문에허혈성심장질환환자들에게는투여해서는안된다. 그리고혈관수축제인 ergotamine 도편두통성두통을중지하기위하여시도해볼수있다. 11) 예방적약물요법 적응증편두통성현훈에서예방적약물요법의적응증은현재까지확립이되어있지않다. 따라서임상에서는대부분편두통의예방적치료기준에준해서치료를하고있는실정이다. 따라서미국 Headache Consortium Guidelines 에서제시한적응증들을근거로대부분사용하고있다. 임상에서예방적약물요법을시행하는적응증들은다음과같다. 17,27,28) 첫째, 급성기약물요법에도불구하고일상생활에현저한장애가있으면서자주재발하는경우 ( 예를들면, 한달에 2회이상의발작으로인해 3일이상의일상생활에지장을초래할때, 또는발작의빈도는드물지만발작의정도가너무심해서일상생활에지장이있는경우 ) 이다. 둘째, 급성기약물을사용할수없거나반응하지않거나부작용이문제가되거나사용상곤란이있는경우이다. 셋째, 급성기약물을너무많이사용한경우사용할수있다. 넷째, 1주에 2회이상으로빈도가매우높은경우, 시간이경과하면서더자주발생하거나급성기약물의과다사용으로인한위험요소가클때이다. 마지막으로환자가원하는경우즉, 발작의빈도를가능한한줄이고자할때예방적요법을사용할수있다. 예방적약물사용시일반적인원칙예방적약물의사용시다음과같은일반적인원칙에준해서약물치료를하는것이도움이될수있다. 17,28) 첫째, 처음에는가능한저용량으로시작하여수주또는수개월에걸쳐서용량을점진적으로올리는것이좋다. 약물의효과가충분히입증된약물을사용한다. 둘째, 처음 2~6 주동안에는증상의호전을보이지않을수있기때문에환자들에게충분한설명과교육이필요하며, 최소 4~6 주정도사용한후에약물의효과를판정하는것이좋다. 셋째, 환자들에게질환을완전히치유한다는개념보다는빈도와세기를줄이는것이목적이라는설명도필요하다. 넷째, 약물선택시약물의부작용을설명하며약물의선택에있어서환자가적극적으로참여하도록하는것이좋다. 다섯째, 성공적인약물요법의기준은약물투여후 50% 이상의빈도가줄어든경우를말하여, 약물의사용기간은정해진것은없지만편두통의치료를참고하면대부분약 3~12 개월정도에걸쳐서서히감량시키면서약물을끊는다. 하지만최소 3개월이내에는약물치료에대한완전한증상소실을기대하기는어렵다. 편두통의예방적약물치료순서를간략하게요약하면 Fig. 2와같다. 29) 대표적인예방약제들현재까지는편두통성현훈에서예방적약물에대한대규모의전향적무작위임상실험이없기때문에대부분편두통의두통을예방하는약물들이편두통성현훈의치료에그대로사용되고있다. 이러한대표적인약물들로서는베타수용체차단제 (beta-blockers), 칼슘통로차단제 (calcium channel blockers), 삼환계항우울제 (tricyclic antidepressants, TCA), 세로토닌재흡수억제제 (selective serotonin reuptake inhibitor, SSRI), 항경련제, carbonic acid anhydrase 억제제인 acetazolamide, clonazepam 등이있다. 11,17,30,31) 널리사용되는예방약물들에대한적정용량을 Pharmacologic Migraine Prophylaxis Patient selected for pharmacologic migraine prophylaxis Consider a first-line agent, if no contraindication: Amitriptyline Divalproex (Depakote) or valproic acid(depakene) Propranolol (Inderal) or timolol (Blocadren) Topiramate (Topamax) If not effective after two to three months, adjust dose successively until effective. If initial agent not effective at maximum dose, or adverse effects make agent prohibitive, try a different first-line agent. If no single first-line agent is effective and tolerable, consider a combination of two first-line agents. Prohibitive adverse effects? If no first-line agent or combination is effective and tolerable, consider an alternative agent, if no contraindications: Atenolol (Tenormin), metoprolol Hormone therapy (Toprol XL), or nadolol (Corgard). Lisinopril (Zestril) Candesartan (Atacand). Magnesium Dihydroergotamine mesylate Naproxen sodium (Anaprox) timed-release (DHE-45) or naproxen (Naprosyn) Feverfew Verapamil (Calan) Fluoxetine (Prozac) Vitamin B2 (riboflavin) or Gabapentin (Neurontin) coenzyme Q10 Fig. 2. Algorithm for pharmacologic migraine prophylaxis (Cited from Am Fam Physician, 2006, Modi S, Lowder DM)

6 Korean J Otorhinolaryngol-Head Neck Surg 2009;52: Table 4. Beta-blocker, antidepressants, calcium-channel blockers, and anticonvulsants in the preventive treatment (Cited from Neurologist, 2006, Bigal ME, Lipton RB) ß-blockers Agent Daily dose Comment. Atenolol mg Use it QD Less side effects than propranolol Metroprolol mg Use the short-acting form QID Use the long-acting form BID Propranolol mg Use the short-acting form BID or TID Use the long-acting form QD or BID Antidepressants Amitriptyline mg Start at 10 mg at bedtime Doxepin mg Start at 10 mg at bedtime Nortriptyline mg Start at mg at bedtime If insomnia, give early in the morning Selective serotonin reuptake inhibitor Fluoxetine mg Evidence for efficacy in migraine is controversial Sertraline mg Some may worsen the migraine pattern Paroxetine mg May be used as an adjuvant in the treatment of migraine and depression Calcium-channel blockers Verapamil mg Start 80 mg BID or TID Flunarizine 5-10 mg QD at bedtime Weight gain is the most common side effect Anticonvulsants Topiramate 100 mg Start mg bedtime Increase mg per week Attempt to reach mg Valproate mg Start mg QD: once a day, QID: four times a day, BID: twice a day, TID: three time a day Table 4에요약하였다. 30) 베타수용체차단제 (Beta blocker) 현재편두통성현훈의예방적치료제로서베타수용체차단제가가장많이사용되고있다. 11) 베타수용체차단제의예방효과에대한기전은명확하지않으나중추성베타수용체를억제하여교감신경계의활성을억제하고세로토닌수용체에관여하여작용한다고알려져있다. 이에관련된약제들로서는 propranolol, atenolol, 그리고 metoprolol 등이다. 부작용으로서는무기력, 피로감, 졸림, 기립성저혈압, 우울증, 당뇨및천식의악화, 서맥등이있을수있다. 울혈성심부전증, 천식, Raynaud 병, 인슐린의존당뇨병환자등에게는사용을금한다. 그리고갑자기베타수용체차단제를중단하면두통, 떨림이있으므로서서히감량해야한다. 17) 칼슘통로차단제 (Calcium channel blockers) 편두통의예방약제로서그효능성을입증한대표적인 칼슘통로차단제들인 verapamil, flunarizine(sibelium, nariven, sarium ) 등도편두통성현훈의약물로사용되고있다. 10,16) Nifedipine 과 diltiazem 은효과의우수성이입증되지못했다. Verapamil 의가장흔한부작용은변비이며, 오심, 저혈압, 두통등이생길수있다. Flunarizine 의경우는장기투여시약물유발파킨슨증후군과같은피라미드외징후를유발할수있음을주의해야하고, 체중증가, 졸림, 구내건조감, 저혈압등이생길수있다. 항우울제 (Antidepressants) 대표적인약물들로서는삼환계항우울제인 amitriptyline, nortriptyline, dothiepine, doxepin, 그리고 protriptyline 등이다. 특히 amitriptyline 는대표적인편두통의예방약물중의하나로편두통성현훈에서도사용되고있다. 16) 일부두통전문가들은진정 (sedation) 작용의부작용이적은 nortriptyline 을선호하기도한다. 28) 특히수면장애및우울증이동반되어있는경우에사용하면좋다. 이러한항우울제의부작용들로서는구내건조감, 진정, 기립성저혈압, 서 798

7 Diagnosis and Management of Migrainous Vertigo Ahn SK 맥, 녹내장, 요잔류등이있다. 진정작용이있으므로주로취침전에투여하는것이좋다. 또한 fluoxetine, paroxetine, 그리고 sertraline 등과같은선택적세로토닌재흡수억제제도우울증이동반되어있는경우사용할수있다. 항경련제 (Anticonvulsants) 항경련제또한편두통예방약제로입증되었기때문에임상에서많이사용하고있다. 대표적인약물들로서는 valproate, topiramate, 그리고 gabapentin 등이다. 편두통성현훈환자에있어서는비록소규모연구이기는하지만 topiramate 와 lamotrigine 와같은항경련제를사용하여치료효과를보았다고한다. 32,33) 부작용으로서는 valproate 의경우는오심, 구토, 소화불량, 간독성등이있다. 투여전반드시간기능검사가필요하다. Topiramate 의경우는체중감소, 손발저림, 인지기능장애, 신장결석등이있다. 신장결석과거력이있는경우는주의해서사용하여야한다. 기타약물그밖의약물들로서는 acetazolamide 는가족성편두통, 진전, 그리고이온통로질환이있는환자에서현훈을조절할때권장된다. 30) 또한편두통성현훈환자에서불안장애, 공황장애와같은동반이환된질환이있는경우에는 clonazepam을사용할수있다. 11) 혼합요법편두통의예방요법에서단독요법이원칙이지만보다효과를높이거나부작용을줄이기위해약물을혼합해사용할수있다. 흔히사용되는혼합약물은베타수용체차단제와항우울제, 항경련제와항우울제이다. 특히베타수용체차단제와항우울제는약물의상호작용이적어널리사용된다. 항우울제와선택적세로토닌재흡수억제제의혼합은경련의위험을높일수있고고혈압을유발할수있으며, 선택적세로토닌재흡수억제제와베타수용체차단제의혼합은저협압의위험이있다. 하지만편두통성현훈의환자의치료에있어서이러한혼합요법에관한보고는매우드문실정이므로추가적인연구가필요하다. 11,18) 결론 편두통과현훈사이의관련성에대해서현재많은연구들이계속발표되고있다. 하지만임상증상의다양한점, 정확한기전이확립되지않은점그리고진단기준의통일 성이없는점등은편두통성현훈에대한임상연구및치료에제한을주고있다. 따라서앞으로편두통성현훈의병리기전을밝히기위한실험모델개발과함께, 진단기준의통일및과치료에대한더많은연구들이필요하리라생각된다. REFERENCES 1) Neuhauser HK. Epidemiology of vertigo. Curr Opin Neurol 2007; 20(1): ) Neuhauser HK, Radtke A, von Brevern M, Feldmann M, Lezius F, Ziese T, et al. Migrainous vertigo: prevalence and impact on quality of life. Neurology 2006;67(6): ) Vuković V, Plavec D, Galinović I, Lovrencić-Huzjan A, Budisić M, Demarin V. Prevalence of vertigo, dizziness, and migrainous vertigo in patients with migraine. Headache 2007;47(10): ) Kuritzky A, Ziegler DK, Hassanein R. Vertigo, motion sickness and migraine. Headache 1981;21(5): ) Kayan A, Hood JD. Neuro-otological manifestation of migraine. Brain 1984;107(Pt 4): ) Olesen J. Classification and diagnostic of headache disorders. Neurol Clin 1990;8(4): ) Neuhauser H, Leopold M, von Brervern M, Arnold G, Lempert T. The interrelations of migraine, vertigo, and migrainous vertigo. Neurology 2001;56(4): ) Furman JM, Marcus DA, Balaban CD. Migrainous vertigo: development of a pathogenetic model and structured diagnostic interview. Curr Opin Neurol 2003;16(1): ) Cass SP, Furman JM, Ankerstjerne K, Balaban C, Yetiser S, Aydogan B. Migraine-related vestibulopathy. Ann Otol Rhinol Laryngol 1997;106(3): ) Dieterich M, Brandt T. Episodic vertigo related to migraine (90 cases): vestibular migraine? J Neurol 1999;246(10): ) Johnson GD. Medical management of migraine-related dizziness and vertigo. Laryngoscope 1998;108(1 Pt 2): ) Neuhauser H, Lempert T. Vertigo and dizziness related to migraine: a diagnostic challenge. Cephalalgia 2004;24(2): ) Cutrer FM, Baloh RW. Migraine-associated dizziness. Headache 1992;32(6): ) Kolev O. How caloric vestibular irritation influences migraine attacks. Cephalalgia 1990;10(4): ) Parker W. Migraine and the vestibular system in adults. Am J Otol 1991;12(1): ) Eggers SD. Migraine-related vertigo: diagnosis and treatment. Curr Pain Headache Rep. 2007;11(3): ) Jeong JS. Neurology. 1st ed. Seoul, Korea: Koonja press;2007. p ) Reploeg MD, Goebel JA. Migraine-associated dizziness: patient characteristics and management options. Otol Neurotol 2002;23(3): ) Whitney SL, Wrisley DM, Brown KE, Furman JM. Physical therapy for migraine-related vestibulopathy and vestibular dysfunction with history of migraine. Laryngoscope 2000;110(9): ) Baloh RW. Neurotology of migraine. Headache 1997;37(10): ) Goadsby PJ, Lipton RB, Ferrari MD. Migraine-current understanding and treatment. N Eng J Med 2002;346(4): ) Harker LA. Migraine-associated vertigo. In: Baloh RW, Halmagyi GM, editors. Disorders of the vestibular system. 1st ed. New York: Oxford University Press;1996. p ) Neuhauser H, Radtke A, von Brevern M, Lempert T. Zolmitriptan for treatment of migrainous vertigo: a pilot randomized placebo

8 Korean J Otorhinolaryngol-Head Neck Surg 2009;52: controlled trial. Neurology 2003;60(5): ) Bikhazi P, Jackson C, Ruckenstein MJ. Efficacy of antimigrainous therapy in the treatment of migraine-associated dizziness. Am J Otol 1997;18(3): ) Koo JW, Balaban CD. Serotonin-induced plasma extravasation in the murine inner ear: possible mechanism of migraine-associated inner ear dysfunction. Cephalalgia 2006;26(11): ) Ahn SK, Khalmuratova R, Jeon SY, Kim JP, Park JJ, Hur DG, et al. Colocalization of 5-HT1F receptor and glutamate in neurons of the vestibular nuclei in rats. NeuroReport 2009;20(2): ) Silberstein SD, Rosenberg J. Multispecialty consensus on diagnosis and treatment of headache. Neurology 2000;54(8): ) Bigal ME, Lipton RB. The preventive treatment of migraine. Neurologist 2006;12(4): ) Modi S, Lowder DM. Medications for migraine prophylaxis. Am Fam Physician 2006;73(1): ) Baloh RW, Foster CA, Yue Q, Nelson SF. Familial migraine with vertigo and essential tremor. Neurology 1996;46(2): ) Dichgans M, Freilinger T, Eckstein G, Babini E, Lorenz-Depiereux B, Biskup S, et al. Mutation in the neuronal voltage-gated sodium channel SCN1A in familial hemiplegic migraine. Lancet 2005;366 (9483): ) Carmona S, Settecase N. Use of topiramate (topamax) in a subgroup of migraine-vertigo patients with auditory symptoms. Ann N Y Acad Sci 2005;1039: ) Bisdorff AR. Treatment of migraine related vertigo with lamotrigine an observational study. Bull Soc Sci Med Grand Duche Luxemb 2004;(2):

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<303120C1BEBCB D20C1A4BCBAC7D D35302E687770> Research in Vestibular Science Vol. 11, No. 2, June 2012 Review pissn 2092-8882, eissn 2093-5501 편두통성현훈의진단과감별진단 충남대학교의과대학신경과학교실 정성해 Diagnosis and Differential Diagnosis of Migrainous Vertigo Seong-Hae