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AU U

MC TIU 1. Trnh by cch tip cn mt trng hp au u. 2. Hiu c phn loi au u theo ICHD - II. 3. Nu c im lm sng v phng php iu tr au u migraine. 4. Nu c im lm sng v phng php iu tr au u cng c. 5. Nu c im lm sng v phng php iu tr au u cm. 6. Nu c im lm sng v phng php iu tr au dy thn kinh V. NI DUNG 1. NH NGHA au u l cm gic kh chu vng gii hn bi chm v hc mt do s kch thch cc cm th au. au u l mt triu chng rt thng gp trong thc hnh y khoa, l triu chng ca rt nhiu loi bnh khc nhau. 2. S PHN B THN KINH CM GIC CA VNG U MT - Vng mt v cc xoang, hc mt: thn kinh tam thoa. - Da u: thn kinh chm ln v chm nh. - Vng sau tai: thn kinh tai ln. - Vng c: cc r C2, C3, C4. - Trong s: vng mng no trn lu do thn kinh tam thoa, vng di lu do thn kinh thit hu chi phi. Nhu m no khng c c quan cm th au, tuy nhin, cc mch mu, nht l cc xoang tnh mch trong no, rt nhy cm vi cm gic cng hay co ko. 3. TIP CN MT TRNG HP AU U 3.1. Hi bnh s: trc mt trng hp au u, cn phi hi bnh s y v chnh xc gip chn on. - au u t lc no? Mi xy ra hay nhiu ln tng t? au u xy ra t ngt khi bnh nhn ang gng sc gp trong xut huyt mng no, xut huyt no. au u nhiu ln c th l migraine hay au u cng c. - Thi gian xut hin au u? au u migraine thng xy ra vo bui sng. au u cng c xy ra khi lm vic cng thng. au u tng nhiu v m hay khi nm do tng p lc ni s. - c tnh cn au, au c theo nhp mch hay khng? au u theo nhp mch thng l migraine, nhim trng. au u m gp trong au u cng c. - au u tng cn hay au lin tc? au u tng cn trong au u migraine.

au lin tc trong au u do cng c. - Cng cn au u? (nh, trung bnh, nng d di) au u d di gp trong xut huyt mng no, xut huyt no. au u m gp trong au u cng c. au u ngy cng tng do tn thng chon ch ni s. - V tr au u? au na u gp trong au u migraine, u no. au u sau gy trong tn thng ct sng c, tn thng h sau. au vng trn, mt c th do vim xoang. au hc mt do tng nhn p. - Cc yu t lm tng v gim cn au? au u migraine v tng p lc ni s tng khi gng sc. au u cng c gim khi ngh ngi. - Cc triu chng km theo: Nn i, s nh sng gp trong migraine hay hi chng mng no. Nght mi v sung huyt nim mc mt gp trong au u tng cm. Co git trong u no. - Bnh nhn c tin cn chn thng s no gn y khng? - Cc bnh ton thn nh AIDS, lao c th gy bin chng thn kinh. 3.2. Thm khm lm sng Trc mt trng hp au u cn phi khm lm sng ton din v khm thn kinh, mc ch tm cc du hiu thn kinh nh v, du hiu mng no, soi y mt tm cc triu chng ca tng p lc ni s.... Thm khm lm sng tr li cc vn t ra khi hi bnh, gip chn on. 3.3. Cc xt nghim cn thc hin 3.3.1. Cc xt nghim hnh nh hc: - Cc xt nghim hnh nh hc cn thc hin trong cc trng hp sau: . au u mi khi pht vi cng d di. . au u mi khi pht sau 50 tui. . Triu chng khng ging cc loi au du tng xy ra. . C cc triu chng thn kinh nh v. . Xy ra sau chn thng. . p ng iu tr km. . Trn bnh nhn suy gim min dch. - ngi trng thnh c triu chng au u migraine t lu, khng c thay i v c tnh cn au, khng c du thn kinh nh v, vic ch nh xt nghim hnh nh hc l khng cn thit. - Cc k thut hnh nh hc: CTscanner u: pht hin tn thng chon ch, bnh mch mu no. MRI, MRA no: tn thng chon ch, d dng mch mu no. Mch no : d dng mch mu no, phnh mch, thuyn tc tnh mch. 2

3.3.2. Dch no ty: ch nh trong vim mng no, xut huyt mng no. 3.3.3. Cc xt nghim sinh ha - Tc lng mu: vim ng mch. - Nng ru, nng thuc. - Bun, creatinin. - Ion . - ng huyt. 4. PHN LOI AU U Vic phn loi au u theo thi gian c nhiu thay i. Bng phn loi au u Quc t ln II 2004 (ICHD II: The International Classification of Headache Disorders, 2nd edition 2004) c nh gi l phn loi tt nht hin nay, tuy nhin cng cn nhiu gii hn trong chn on v iu tr. BNG PHN LOI AU U QUC T LN II 2004 The International Classification of Headache Disorders, 2nd edition 2004 (ICHD - II) Phn 1: au u nguyn pht 1. Migraine: Migraine khng tin triu Migraine c tin triu Migraine mn tnh 2. au u cng c: au u cng c cn khng thng xuyn au u cng c cn thng xuyn au u cng c mn tnh 3. au u cm v au u dy V t ch: au u cm au na u kch pht 4. Cc au u nguyn pht khc: au u khi ng, au u st nh nguyn pht, au na u lin tc. Phn 2: au u th pht 5. au u sau chn thng u v c. 6. au u do bnh mch mu trong s v ct sng. 7. au u lin quan bnh ni s khc khng do nguyn nhn mch mu: tng p lc ni s t pht, au u sau chc d mng cng, u ni s, au u sau co git ng kinh. 8. au u do thuc. 9. au u do nhim trng h thn kinh trung ng. 10. au u do ri lon cn bng ni mi: thiu oxy m, tng huyt p. 11. au u do bnh c, mt, tai mi hng, rng hm mt. 12. au u trong ri lon tm thn. 13. au thn kinh s v au mt do nguyn nhn trung ng: au dy thn kinh V. 14. Cc au u khc, au thn kinh s v au mt nguyn pht hoc do nguyn nhn trung ng (cha phn loi).

4.1. au u migraine 4.1.1. i cng: - L bnh au na u tng cn theo nhp mch, cng thay i, c tnh chu k. - T l bnh l 18% n, 6% nam. - Khi pht tui thiu nin v tui trng thnh. 4.1.2. C ch bnh sinh: S kch hot cc neurone phn tit cht dn truyn TK (dopamine v serotonin) thn no lm nhy cm ha v no, dn n pht sinh sng kch thch v no lan t vng chm ra pha trc, lm gim chuyn ha v ti mu gy ra s kch hot h mch mu - thn kinh sinh ba lm phng thch cc cht CGRP, neurokinin A, cht P gy hin tng vim v trng ca thnh mch v gy au. 4.1.3. c im lm sng au u migraine: Yu t khi pht: - Yu t tm l: stress, ng qu nhiu, mt ng. - Yu t mi trng: thay i thi tit, mi khi, thuc l, nc hoa. - Hormon: chu k kinh nguyt, thai k, mn kinh, thuc nga thai. - Ch n: ru, caffeine, ch n khng iu . Du hiu bo trc: Trong vi gi hoc mt ngy trc khi c cn au u, bnh nhn c cc triu chng v tm thn hoc thn kinh thc vt nh trm cm hoc kch thch, ung nhiu, tiu nhiu, ph, bun nn, tiu chy hoc to bn, m hi, mt mi. Tin triu: - m im di chuyn c cu trc, v d nh dng sng hoc mt hnh lim rng ca. - Mt hoc gim th lc n thun. - Cm gic t b, chm chch mt chi trn v mt cng bn. - Tin triu t gp hn l t tay v mt mt bn hay mt ngn ng thong qua. au u: - Khi pht au thng mt bn u, sau c th lan sang hai bn. - au theo nhp mch. - Cng tng dn v d di. - Thi gian cn au t vi gi n vi ngy nu khng iu tr. Trng hp cn ko di gi l trng thi migraine. Triu chng i km: bun nn, nn, s ting ng, s nh sng, s mi, chng mt t th, mt kh nng tp trung. Trng thi sau cn: Mt mi, u oi, cm gic yu ton thn v bun ng, ko di vi gi n vi ngy 4

Cn au u migraine 4.1.4. iu tr au u migraine Gm cc bc: . iu tr ct cn au. . iu tr nga cn: khi s cn nhiu > 3 cn mi thng hay khi iu tr ct cn khng hiu qu, phi dng thuc lu di 3-6 thng. . Trnh cc yu t khi pht cn. . Tm l liu php. iu tr ct cn: - Thuc gim au: Acetaminophen Aspirin Ibuprofen Naproxen Ketoprofen Acetaminophen + codein Cc thuc gim au trung ng ch dng cho cn nng. - Thuc chng nn: Metoclopramide Domperidone - Thuc c hiu migraine: Ergotamine tartrate 2 5 mg, mi tun dng ti a 2 ln (< 12mg/tun) trnh ng c v l thuc thuc. Chng ch nh: cao huyt p, suy vnh, vim ng mch, thai k, khng phi hp vi khng sinh macrolides Dihydroergotamine dng kh dung hay tnh mch. Sulmatriptan. Zolmitriptan. - Thuc an thn: benzodiazepones. iu tr nga cn: - Thuc c ch bta: Propranolol 20 60 mg/ngy, Timolol, Atenolol. 5

- Thuc chng trm cm ba vng: Amitriptyline 10 25 mg/ngy. - Thuc c ch calci: Diltiazem, Verapamil, Flunarizine 10 mg/ngy - Thuc khng serotonin v histamin: Pizotifen, Cyproheptadine 4 mg/ngy. - Thuc chng ng kinh: Valproate 400 600 mg/ngy, Phenytoin. Trnh cc yu t khi pht cn: - Trnh cc thuc dn mch, thuc nga thai. - Sinh hot, n ung, ngh ngi iu . - Trnh cc cng thng tm l. - Trnh cc thc n cha ru, bia, tyramine. - Gii hn s dng caffeine. Tm l liu php: Gii thch cho bnh nhn v kh nng iu tr bnh nhn bt lo lng, cn kin nhn tun th iu tr. 4.2.au u cng c 4.2.1. C ch bnh sinh: - Cc c vng mt, c, da u b co tht lm tng p lc trong cc c, gy ra gim lng mu nui c lm tng sinh acid lactique kch thch phng thch cc cht gy au. - Yu t khi pht: mt ng, ng qu nhiu, n qu no, ung nhiu ru, lm vic trong mi trng n o, cng thng, bnh ton thn. 4.2.2. c im lm sng au u cng c: Cn au u ko di vi pht n nhiu ngy. Cm gic au nh sit cht, nng u c hai bn u, au khng theo nhp mch, cng au trung bnh, khng tng khi hot ng, khng c nn i nhng c th c triu chng s nh sng hay ting n. 4.2.3. iu tr au u cng c : - Thuc gim au: p ng tt vi cc thuc gim au thng thng. - Thuc gin c. - Thuc chng trm cm. - Tm l liu php. - Trnh ru, thuc l, n ung iu , trnh cng thng, trnh c gng qu mc. - Xoa bp cc c vng gy v da u, p m. 4.3. au u cm 4.3.1. i cng: - Do s gin cc ng mch trong hc mt. - Yu t khi pht: ung ru, nh sng chi, hot ng mnh, thc n c cha nitrite ( hp, tht ngui), thuc gin mch. 4.3.2. c im lm sng: - Cn au ca au u cm c cng rt d di, cn thng xy ra ng gi, thng xy ra vo ban m sau khi bnh nhn ng c vi gi.

- Cn au tp trung sau hc mt hoc trn trn gn pha thi dng mt bn u, au c cng d di km theo cc triu chng co nh ng t, hp khe mi, ph mi mt, sung huyt kt mc mt, nght mi mt bn, v m hi mt bn mt. au c th lan xung vai, c mt bn. Bnh nhn c triu chng s nh sng nhng thng t khi nn i. - Mi t au thng ko di khong ba thng, cc t cch nhau khong 12 thng hay hn. - Tn s cn au trong mi t: mi ngy u au hay cch ngy. 4.3.3. iu tr au u cm iu tr ct cn: - Th oxy qua mt n 8 lt/pht trong ti a 15 pht, oxy lm tng p sut phn trong mu v gy co mch lm gim cn au. - Dihydroergotamine tnh mch hay nhm Triptans. - Lidocaine, capsaicin nh mi gy t ti ch: hiu qu cha r rng. iu tr nga cn: - Corticoides: Prednisone liu 0,5 mg/kg, dng ti a khng qu 3 tun. - Lithium. - Thuc c ch calci: Verapamil, Nimodipine, Flunarizine. - Thuc chng ng kinh: Valproate, Topiramate. - Khng vim non-steroid. - Trnh ru, thuc l, thc n c nitrite. 4.4. au thn kinh V 4.4.1. i cmg: - Thn kinh V l thn kinh s ln nht, c chc nng tip nhn cm gic vng mt, cc xoang, hc mt, ming; vn ng cc c nhai; chc nng giao cm. - Thn kinh V gm 3 nhnh: . Thn kinh mt. . Thn kinh hm trn. . Thn kinh hm di. - Nguyn nhn au thn kinh V l do thn kinh V b chn p vi th trong s, d dng mch mu, u, do cc ng mch b x m, do cc chi xng mt trn xng , mt s trng hp do s mt myelin ca thn kinh V. 4.4.2.c im lm sng: - Bnh thng gp ph n tui trung nin 50-70tui. - C cc cn au nh in git ti vng chi phi thn kinh V1, V2, V3. Cn au kch pht ko di vi giy v di 2 pht. - Bnh nhn c vng c sng, y l ni kch thch nh s gy cn au. - Cc tc nhn c th gy au: nhai, nh rng, ni chuyn, ci - Sau cn au c thi gian tr khong vi pht. - Khm thn kinh khng c triu chng tn thng thn kinh V.

V tr cc vng c sng

4.4.3. iu tr: iu tr ni khoa: - Thuc chng ng kinh: Carbamazepine: liu khi u 100-200mg/ngy, tng dn mi 200mg cho n khi c tc dng, liu trung bnh hiu qu l 6001200mg/ngy, c ch l c ch cc neuron b kch thch bng cch ngn cn knh Na+ mng t bo, do lm gim s phng in lc ch. Phenytoin 300-400mg/ngy. Valproate. Clonazepam. - Baclofen: khi u 5-10mg 3 ln/ngy, sau tng liu 10mg mi 2 ngy cho n khi c tc dng, liu hiu qu thng thng 50-60 mg/ngy. iu tr ngoi khoa: phu thut gii p vi mch mu. TI LIU THAM KHO 1. J Olesen, T J Steiner (2004), The International Classification of Headache Disorders, 2nd edition, J. Neurol. Neurosurg. Psychiatry;75; p. 808-811. 2. Victor M (2005), Principle of Neurology, 7th edition, McGraw - Hill companies, p.144-167. 3. L Vn Nam, L Th Cm Dung (2006), Thn Kinh Hc, NXB i Hc Quc Gia, p.303-318. 4. V Anh Nh v cng s (2007), Chn on v iu tr au u, NXB Y Hc.

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