RECENT ADVANCE

ORIGINAL ARTICLE

QUALITY OF LIFE AND SLEEP QUALITY AMONG PATIENTS WITH LOW BACK PAIN

GREATER OCCIPITAL

18

TOPIC REVIEW

29

INTERESTING CASE

NEUROLEPTIC MALIGNANT SYNDROME PALIPERIDONE LONG ACTING INJECTION

ORAL RISPERIDONE INTRAMUSCULAR HALOPERIDOL

41

VACCINATION AND NEUROLOGICAL COMPLICATION?

53

56

www.neurothai.org

31 2 - 2558

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Thai
Journal
of
Neurology

ISSN
2228-9801

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Multiple Sclerosis

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10320 E-mail : nstt2004@gmail.com
www.neurothai.org


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31




Thai Citation Index:
TCI

(Thai Journal of Neurology)

Thai
Journal of Neurology

1.

1.1 (Editorial)

1.2 (General article)

1.3 (Review article)

1.4 (Original article)




1.5 (Journal reading)

1.6 (Recent advance)

1.7 (Letter to the
editor)



1.8 (Interesting case)

1.9

2.
2.1 A 4
(8.5 x 11 )
2 (double space)
1
2.2

(corresponding

author)

2.3

2.4
1
-
3 x 5
digital file

2.5

(Keyword) 5 (Introduction)
(Material and Methods)
(Results) (Conclusion
and Discussion) (Acknowledgement) (References)
2.6 Vancouvers
International Committee of Medical Journal
(Superscript)
3
3 3
et al

Leelayuwat C, Hollinsworth P, Pummer S, et al.

Antibody reactivity profiles following immunisation
with diverse peptides of the PERB11 (MIC) family.
Clin Exp Immunol 1996;106:568-76.

Solberg He. Establishment and use of reference

values with an introduction to statistical technique.
In: Tietz NW, ed. Fundamentals of Clinical Chemistry.
3rd. ed. Philadelphia: WB Saunders, 1987:202-12.

3.
1
..
somtia@kku.ac.th

4.
4.1

(foot note)

4.2

4.3 5


RECENT ADVANCE

ORIGINAL ARTICLE
QUALITY OF LIFE AND SLEEP QUALITY AMONG PATIENTS WITH LOW BACK PAIN

GREATER OCCIPITAL

18
TOPIC REVIEW

29

INTERESTING CASE
NEUROLEPTIC MALIGNANT SYNDROME PALIPERIDONE LONG ACTING INJECTION
ORAL RISPERIDONE INTRAMUSCULAR HALOPERIDOL

41

JOURNAL READING
VACCINATION AND NEUROLOGICAL COMPLICATION?

53

56

Vol.31 NO.2 2015

(ODS, osmotic demyelination

syndrome) central pontine
myelinolysis extrapontine myelinolysis
ODS central pontine
myelinolysis extrapontine myelinolysis


120
mEq/L 48




6-8

1

52 25

Thai Journal of Neurology

behavioral
disturbance, slurred speech, dysarthria, dysphagia,
paraparesis quadriparesis, lethargy, confusion,
disorientation, obtundation coma

locked in syndrome



2- 6

magnetic resonance imaging (MRI) MRI

Vol.31 NO.2 2015

1 MRI
4
MRI

diffusion-weighted
imaging

1 . MRI of Brain. T2-weighted MRI of the brain demonstrating pontine demyelination (arrows)
. T2-weighted MRI of the brain demonstrating basal ganglia demyelination. ( 2)

48

blood brain barrier

glia cell complement
cytokine apoptosis
2 2

Thai Journal of Neurology

Vol.31 NO.2 2015

2 ( 3)

1.
2.
3.

4.
5.
(over correction)

1.
105 mEq/L 120
mEq/L 4

2.
8-10 mEq/L
24 18 mEq/L 48
Stern 5
12 mEq/L 24
18 mEq/L 48
Oh Androgue6
8 24

(auto-correction)
antidiuretic hormone


(prompt diuresis)

3. 2 hypokalemia,
alcoholism, malnutrition, advance liver disease,
post liver transplantation
thiazide
pituitary
glycine infusion

8-10 mEq/L 1012 mEq/L 18 mEq/L 48

6-8 mEq/L

4-6 mEq/L 7
( 135-145
mEq/L)

Vol.31 NO.2 2015

120-125
mEq/L 120
mEq/L

1


Sodium requirement (mEq) = (desired sodium
- serum sodium) x total body water
2

1
1

Vol.31 NO.2 2015

Thai Journal of Neurology

1 (
3)

0.9% NaCl

3 % NaCl 1

1 mEq/L

acute symptomatic water intoxication

3% NaCl
100-150 10-15

Vol.31 NO.2 2015

8 . 24 .

2-3

(Over correction)

(re-lowering) 3

3 ( 7)

1
1
4- 5
mEq/L 5% dextrose water 6 mL/kg
lean body weight 2
2 mEq/L

antidiuretic hormone

desmopressin
120 mEq/L 7
1. 5%
dextrose water 3 ml/kg/
hour
2. Desmopressin 2-4 micrograms parenterally
8
3.

8-10 mEq/L 24
18 mEq/L 48

Thai Journal of Neurology

Vol.31 NO.2 2015

1. Re-lowering
4 8-10

9
4 106 mEq/L

129 mEq/L 48 2


120 mEq/L
8

2.

6-8
(irreversible)
3. Plasmapheresis10

4 ( 9)

8 . 24 .

1.

Singh JD, Fugate JE, Rabinstein AA. Central pontine and

extrapontine myelinolysis: a systematic review. European
Journal of Neurology 2014, 1443 50.

2.
3.
4.

5.

6.

7.

8.

9.

10.

King JD, Rosner MH, Osmotic demyelination syndrome.

Am J Med Sci 2010;339:5617.
Adrogue HJ , Madia NE. Hyponatremia. N Eng J Med
2000;342,1581-9.
Sterns RH, Cappuccio JD, Silver SM, Cohen EP.
Neurologic sequelae after treatment of severe
hyponatremia: amulticenter perspective. J Am Soc
Nephrol 1994; 4:1522 30.
Sterns RH. Severe symptomatic hyponatremia: treatment
and outcome. A study of 64 cases. Ann Intern Med 1987;
107:656 64.
Oh MS, Uribarri J, Barrido D, et al. Danger of central pontine
myelinolysis in hypotonic dehydration and recommen
dation for treatment. Am J Med Sci 1989; 298:41-3.
Verbalis JG, Goldsmith SR, Thompson CJ. Diagnosis,
evaluation, and treatment of hyponatremia: expert panel
recommendations. The American Journal of Medicine
2013 ;126, S1-S42.
Soupart A, Penninckx R, Stenuit A, et al. Reinduction of
hyponatremia improves survival in rats with myelinoly
sis-related neurologic symptoms. J Neuropathol
Exp Neurol 1996; 55:594- 601.
Oya S, Tsutsumi K, Ueki K, Kirino T. Reinduction of
hyponatremia to treat central pontine myelinolysis.
Neurology 2001; 57:1931-2.
Bibl D, Lampl C, Gabriel C, et al. Treatment of central
pontine myelinolysis with therapeutic plasmapheresis.
Lancet 1999; 353:1155.

Vol.31 NO.2 2015

Vol.31 NO.2 2015

Abstract
Objective: To evaluate the potential factors
affect quality of life and sleep quality in patients
presented with low back pain in Phramongkutklao
hospital.
Methods: A cross-sectional study enrolled
patients who were diagnosed with low back pain.
Demographic characteristics, history and character
of pain, medications were reviewed. Excessive
daytime sleepiness (using Epworth Sleeping Scale
[ESS]), and health-related quality of life (36-item
Short Form Health Survey [SF-36]) questionnaires
were completed.
Results: Among 103 patients, 36 (35%) were
men and 67 (65%) were women. Mean age was
61.7 14.5 years (range 19-87). The most common
co-morbid health condition was hypertension in 48
patients (46.6%). The mean duration of back pain
was 39.5 months, ranged 0.25-600 months. Most
patients had back pain with radiating to below
knee 49 patients (47.6%). The common etiologies
of low back pain were lumbar spondylosis 37.9%
and spinal stenosis 27.2%. History of back surgery
was 28.2%. Antiepileptic drugs (84.5%) were the
commonest prescribed medication.
The long duration of low back pain showed
significantly increased Epworth sleepiness scale,
indicating poor sleep quality (p=0.043). Low back
pain with neuropathic pain showed worse disability
compared to back pain without this condition by
SF-36, Physical Health domain (Physical functioning
p-value = 0.047, Role limitation due to physical
health p-value = 0.003).
Conclusions: The long duration of back pain
was a strongly negative factor to sleep quality and
neuropathic pain affected quality of life.
Keywords: quality of life, excessive daytime
sleepiness, low back pain

Thai Journal of Neurology

Quality of Life and Sleep

Quality among Patients with
Low Back Pain

Karn Saksornchai,
Pasiri Sithinamsuwan,
Chesda Udommongkol
Division of Neurology Unit,
Phramongkutklao Hospital

Karn Saksornchai, Pasiri Sithinamsuwan,

Chesda Udommongkol
Division of Neurology Unit, Phramongkutklao Hospital
Correspondence:
Dr. Karn Saksornchai,
Division of Neurology Unit, Phramongkutklao Hospital
Bangkok, Thailand. Email: whizkss@me.com

10

Introduction
Back pain is a growing public health problem.
According to World Health Organization, as many as
80% of adults experience back pain in their lifetime.1
Evidences suggest that the prevalence of back
pain is high even in children and adolescents.2,3
Consequences of this condition include economic
burden4-6, disability7, occupational absenteeism9,10,
and diminished work capacity.6,11 Moreover, in
studies examining pain in various regions of the
spine, the overall prevalence rates are highest for
low back pain, followed by neck pain and mid back
pain.8,12,13 It has also been observed that women are
more likely to experience back pain than men.2,12-16
Several studies have described the relationship of
either back or neck pain with health-related quality
of life. Most of them were conducted on different
general adult populations12-16 or patients with chronic
back pain17-21 and fewer on other populations such
as school children22 and elderly23. Back pain affects
quality of life and sleep quality, however, little is
known about these conditions in Thailand. Insight
into these data might raise awareness of local and
regional government health authorities and lead to
improvements in health care service for people with
back pain. Therefore, the purpose of this study was
to determine character and burdens of low back
pain in the aspects of excessive daytime sleepiness,
indicating sleep quality, and quality of life.

Methods
Population: We included consecutive patients
with low back pain presented to outpatient Spine
clinic, Phramongkutklao Hospital, between June
2014 and November 2014.

Vol.31 NO.2 2015

Measures: Patients had been directly interviewed and asked to complete questionnaires.
Demographic characteristics, history and character
of pain and medications were assessed. The questionnaires comprised questions about quality of
life, using the Short Form 36 Health Survey (SF-36)
and excessive daytime sleepiness, using Epworth
Sleeping Scale (ESS). Patients with back pain were
also assessed for neuropathic component using
DN4 questionnaire 41 (Douleur Neuropathique en
4), indicating a present of neuropathic pain if the
score 4.
The ESS composes of 8 questions asking the
subjects to rate their probability of falling asleep
(doze) on a scale of increasing probability from 0
to 3 for eight different situations that most people
engage in during their daily lives. A number in the
range of 0-10 indicates normal while the 11-24
indicates excessive daytime sleepiness.
The SF-36 is a measure of health status. This
questionnaire consists of eight scaled scores,
which are the weighted sums of questions in their
sections.Each scale is directly transformed into a
0-100 scale on the assumption that each question
carries equal weight. The lower the score indicates
the more disability whereas the higher the score the
less disability.
Statistical analysis: The continuous data were
determined in mean and standard deviation. The
discrete data were determined in number and percent.
Comparisons between groups were evaluated by
unpaired students t test for continuous data and
chi-square test for categorical data. All p values
were two-sided with a level of significance was
0.05. Statistical analysis was performed using SPSS
version 16 software package.

Thai Journal of Neurology

Vol.31 NO.2 2015

Results
A total of 103 patients with low back pain were
recruited into the study. There were 36 men (35%)
and 67 women (65%), with the mean age of 61.7
14.5 years (range 19-87). Eighteen patients (17.5%)
had a history of alcohol consumption or drug abuse.
The three most common chronic co-morbid health
conditions were hypertension 48 patients (46.6%),
dyslipidemia 27 patients (26.2%) and diabetes
mellitus 26 patients (25.2%). The demographic and
clinical characteristics of the studied patient were
given in Table1.
The average duration of back pain was 39.5
months, range 0.25-600 months. The majority
of patients had taken various medications, most
common was antiepileptic drugs (84.5%); followed
by non-steroidal anti-inflammatory drugs (NSAIDs)
(62.1%) and analgesics/opiate (52.4%). History
of back surgery was 28.2%. The two commonest
etiologies of low back pain were lumbar spondylosis
(37.9%) and spinal stenosis (27.2%). Most patients
had back pain with radiating pain to below knee
level 49 patients (47.6%), followed by back only 21
(20.4%). The characteristics of low back pain and
previous treatments amongst the studied population
were summarized in Table1.
Correlation of back pain with quality of sleep
evaluated by Epworth sleepiness scale (ESS)
The average ESS in this study was 3.6 (range
0-15). The majority of patients (21.4%) had score
0. There were 91 patients (89.2%) with ESS score
10 (normal), while 11 patients (10.8%) with score
11 (presence of excessive daytime sleepiness,
EDS). The long duration of low back pain showed
statistically significantly increased ESS, indicating

more daily time sleepiness (p=0.043). The associated factors of EDS was diabetes mellitus (DM),
which 54.5% of low back pain patients with EDS
sleepiness had DM while 22.0% of low back pain
patient without EDS had DM, p value =0.019. Age,
gender, etiologies and characters of low back pain
and medication use were not associated with excessive daytime sleepiness. The details of each group
were shown in Table 2.
Correlation of back pain with quality of life evaluated by the Short Form 36 Health Survey<SF-36>
SF-36 was determined to 8 important domains,
Physical functioning, Role limitation due to Physical
health, Role limitation due to emotional problem,
Energy/fatigue, Emotional well-being, Social functioning, Pain, General health. The average of total
SF-score was 49.5 (range 6-99). The low back
pain patients with neuropathic pain showed lower
SF-36, representing more disability, than without
this condition, which this finding showed statistically
significant especially in Physical Health domain. The
details of SF-36 score both total and 8-domains and
subgroup for neuropathic pain assessment were
shown in Table 3.
Table 1. Demographic and clinical characteristics
(n = 103)
Variables
Age, years
Mean SD
Range
Sex
Male
Female
Alcohol/drug abuse

Number (%)
61.7 14.5
19-87
36 (35)
67 (65)
18 (17.5)

11

12

Variables
Number (%)
Comorbid medical illness
Diabetes mellitus
26 (25.2)
Hypertension
48 (46.6)
Dyslipidemia
27 (26.3)
Gout
5 (4.9)
Ischemic heart disease
6 (5.8)
Cancer
4 (3.9)
Duration of back pain
Mean SD
39.5 82.8
Range
0.25-600
History of previous back surgery 29 (28.2)
Previous medication
27 (26.2)
Paracetamol
64 (62.1)
Non-sterioidal
anti-inflammatory drugs
48 (46.6)
Muscle relaxants
54 (52.4)
Analgesics,opiate
16 (15.5)
Antidepressant
87 (84.5)
Antiepileptic
55 (53.4)
Pregabalin
28 (27.2)
Gabapentin
5 (4.9)
Pregabalin+ gabapentin
Causes of back pain
Spondylosis
39 (37.9)
Disc herniation
13 (12.6)
Spinal stenosis
28 (27.2)
Myofascial pain
5 (4.9)
Other (trauma, cancer)
16 (5.5)
Location of pain
Back only
21 (20.4)
Radiating pain to thigh
15 (14.6)
Radiating pain to below knee 49 (47.6)
Neurological deficits
17 (16.5)

Vol.31 NO.2 2015

Vol.31 NO.2 2015

Thai Journal of Neurology

Table 2. Excessive daytime sleepiness evaluated by Epworth sleepiness scale

Variables

Normal (ESS0-10),
n=91 N (%)
Age, years, mean SD
61.7 14.1
Male
31 (34)
Alcohol/drug abuse
16 (17.6)
Hypertension
44 (48)
Diabetes mellitus
20 (22.0)
Dyslipidemia
23 (25.3)
Duration of back pain, months, mean SD
33.9 60.9
History of previous back surgery
27(29.7)
Etiologies of low back pain
Spondylosis
33 (36)
Disc herniation
13 (14.28)
Spinal stenosis
25 (27)
Myofascial pain syndrome
4 (4.4)
Others (trauma, cancer)
15 (16.5)
Location of pain
Pain at back only (no radiating pain)
20 (22)
Pain radiate to thigh
11 (12)
Pain radiate to below knee
45 (49)
With neurological deficit
15 (16.5)
Treatment
NSAIDs
60 (65.9)
Muscle relaxants
42 (46.2)
Analgesics, opiate
49 (53.8)
Antidepressant
14 (15.4)
Antiepileptic
79 (86.8)
Pregabalin
51 (56)
Gabapentin
24 (26.4)
Pregabalin+ gabapentin
5 (5.5)

EDS (ESS 11-24),

n=11 N (%)
62.6 18.1
4 (36.4)
1 (9.1)
4 (36.4)
6 (54.5)
4 (36.4)
87.5 183.5
2 (18.2)
6 (54.5)
0
3 (27)
1 (9.1)
1 (9.1)

p-value
0.841
0.879
0.475
0.452
0.019*
0.431
0.043*
0.342
0.528
-

1 (9.1)
4 (36.4)
4 (36.4)
2 (18.2)

0.165
-

5 (45.5)
6 (54.5)
5 (45.5)
2 (18.2)
8 (72)
4 (36.4)
4(36.4)
0

0.182
0.598
0.417
0.545
0.213
0.346
-

13

14

Vol.31 NO.2 2015

Table 3. Quality of life (SF-36) in low back pain with/without neuropathic component
Variables

Overall (n = 102) With neuropathic

pain (n=49)
Physical functioning
46.1 27.6
40.2 25.6
Role limitation due to physical
14.3 33.0
4.6 11.4
health
Role limitation due to emotional
44.3 53.5
36.7 52.8
problem
Energy/fatigue
61.626.4
60.3 27.1
Emotional well-being
68.2724.6
65.826
Social functioning
65.534.6
64.532.4
Pain
52.3 22.9
4820
General health
43.624.9
41.324.6
Total SF-36
49.5 21.8
45.2418

Discussion
Low back pain is a very common condition in
clinical practice, causing disability affecting quality of life and sleep quality. Our study showed that
this condition seems more common in women than
men, similar to some previous studies 12, 24-27, while in
other studies from USA and Europe, gender specific
was inconsistent28-31. More formal epidemiological
researches are needed to determine this aspect as
regional differences. The most popular medication
for back pain treatment in our spine clinic was antiepileptic drug especially pregabalin, similar to one
study showing that chronic low back pain was more
common to develop neuropathic pain 32 , though
reliable prevalence rated are not currently available.
Rates of back pain were highest in patients with a
diagnosis of spondylosis or spinal canal stenosis,
37.9% and 28% respectively.
Most of patients with low back pain in our study
had no trouble with sleep quality. However it was

No neuropathic
pain (n=53)
51.0 28.6
23.6 40.8

p-value

50.3 53.8

0.201

63.0 26.1
7023.4
65.736.8
56.425.3
45.7925.4
53.2824.5

0.608
0.340
0.859
0.067
0.368
0.063

0.047*
0.003*

found that the long duration of back pain was significantly associated with more excessive daytime
sleepiness. This corresponded with many studies
that chronic low back pain was associated with
many negative dimensions of quality of life including
sleep. Significant self-reported sleep disturbance
affected up to 55% of people with low back pain.3337
Moreover, in our study DM seems to affect sleep
quality.
We found a significant relationship between
back pain and some SF-36 dimensions. The
statistics significant differences of neuropathic
components were seen in physical health domain
(physical functioning, role limitation due to physical
health). This was also recognized concordance with
the results of previous studies 38, 39, 40. It might be
assumed that the participants experiencing back
pain were more likely to have worse scores on the
physical function scale and physical health scale.
Non-surprisingly, it was found that neuropathic pain
was associated with poorer physical health.

Thai Journal of Neurology

Vol.31 NO.2 2015

The strength of this study was that we used two

standardized functional assessment questionnaires,
SF-36 and Epworth sleepiness scale to assess
quality of life and sleep. We could find a burden of
neuropathic pain in low back pain that significantly
affected quality of life which requires proper treatment. To our knowledge this was the first report in
Thailand and would alert physicians in the future.
The interpretation of this study is subjected to some
limitations. First, the cross-sectional observational
design as opposed to a longitudinal design does
not allow for the examination of the causal relationship of back pain and quality of life or sleepiness.
Second, we assessed only duration of pain and
not its severity. Previous studies indicated that the
crude relationship between pain severity (grade of
pain intensity and associated disability) and healthrelated quality of life is negative 14, 16. However, the
same was not true after adjustment for different
confounding variables 13, 14. Finally, because of data
unavailability, we did not control for other potential
confounders, such as depression. It is possible
that the inclusion of more covariates in our analyses would reduce effect sizes, but this should be
confirmed in future research.

Conclusions

References
1.

2.

3.

4.

5.

6.

7.
8.

9.

10.

The long duration of back pain was a strongly

negative factor to sleep quality and neuropathic
pain affected quality of life.

11.

Acknowledgement

12.

I would like to share my deep gratitude to

1. Neurology staff : Dr.Pasiri Sitinamsuwan,
Dr.Chesda Udommongkol
2. My colleague : Dr.Patima Weenasonti

13.

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in the change in health-related quality of life associated
with low back pain. Qual Life Res 2012;21:1705-11.
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neck pain and its related disability in the Saskatchewan
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Unsal A, Tozun M, Ayranci U. Prevalence of low back
pain among a group of Turkish men and its effect on
quality of life. Pak J Med Sci 2010;26:930-4.
Hasanefendioglu EZ, Sezgin M, Sungur MA, Cimen OB,
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Klemenc-Ketis Z. Predictors of health-related quality of
life and disability in patients with chronic non-specific
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F,Cedraschi C. Assessing the association between low
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Hasanefendioglu EZ, Sezgin M, Sungur MA, et al. Healthrelated quality of life in patients with chronic low back
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life in women with different intensity of low back pain.
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Thai Journal of Neurology

17

18

Greater occipital
: Prospective Cohort
study

.. 2555 .. 2556

(visual analog scale VAS),

(duration),
(Headache Impact Test , HIT-6
score), (allodynia),
Greater occipital,

5 , 1 4

:
6 ( 4 ) 42.335.81
8.336.15 4
3
(6.0014.70 2.334.08 ./4 ,p=0.05)
Tramadol ( 375 .//4
,p=0.04)
5 1
1 allodynia
3 Greater
occipital

: Greater
occipital

Vol.31 NO.2 2015

Greater Occipital

,
,

, ,


Correspondence:

50200
Email: surat.md@gmail.com

Vol.31 NO.2 2015

Ophthalmic branch
Trigeminal nerve

(large cranial vessel, proximal
intracranial vessel or dura mater)
Ophthalmic division Trigeminal nerve
posterior fossa
C2 nerve root

Trigeminal nucleus
complex brainstem dorsal horn C1-2

Trigeminal nuclear complex refer pain
1

Trigeminal nerve
Trigeminal nuclear complex
C1-2

Trigeminal nucleus
brainstem Greater
occipital nerve (greater occipital nerve block,
GONB) C2

GONB cervicogenic headache,
cluster headache, migraine2
Greater occipital nerve block
Occipital nerve
thinly myelinated A delta fibers
unmyelinated C fibers (sensory fiber)
motor fiber sensory

Thai Journal of Neurology

fiber Trigeminal nucleus caudalis

dorsal horn2 cervical and trigeminal
convergence
3
3 4 6
54-85 2
allodynia4,6
Greater occipital5

Greater occipital
Amide3 lidocaine bupivacaine
lidocaine bupivacaine

lidocaine bupivacaine
1:1 lidocaine

7,

3
5
suboccipital
9

GONB


GONB

GONB

Greater occipital

19

20

Greater occipital

Greater occipital
,

GONB
(active migraine)
4

: prospective cohort study

. 2555 . 2556
: 4


3
1 (1st visit):
1
5
2 (2nd visit):
1 1
3 (3rd visit):
1 4

Vol.31 NO.2 2015

1. 18
2. ICHD-II10

3.

2 HIT-6 score

4.
(preventive medication)
4

1. 18
2.
3.

4.
5.
6.
(medication overused headache,
MOH) ICHD-II10
7.

:
1.

2.

3. ,
, , ,
allodynia
4.
5.

Thai Journal of Neurology

Vol.31 NO.2 2015

6.

-
(headache duration)

( 1 =, 2=,
3=)
- (VAS) VAS
(
)
4

- (allodynia)
7. Greater occipital
8.
Headache Impact
Test-6 (HIT-6 score)
9.

Greater occipital 4
10.
Greater occipital, 5 , 1
4

Greater Occipital
Occipital protuberance 2
2
Greater occipital 2%
lidocaine 1.5 cc. Greater occipital
10

1. (descriptive statistic)

(continuous variables) ,
,

HIT-6 score

(categorical variables) ,,
,

2.
Greater occipital
Students t-test chi
square Fisher exact test

.. 2555 .. 2556
7
1
6 4 (
66.7) 42.335.81
8.336.15
( 83.3),
( 66.7)
/ ( 83.3), (
83.3), ( 83.3 )
( 33.3), ( 33.3)
allodynia ( 33.3)
( 83.3), (
66.7), ( 50)

Greater occipital
1 (,
) (/4 )

21

22

4 22.67 40.53 18.8330.97

(p=0.06) 2
(, )
(/4 ) 4
124.17186.16 105.33177.53
(p=0.22) 3 (,
) (/4 )
4 6.0014.70 2.334.08
(p=0.05)
3

1 2

Vol.31 NO.2 2015

4 61.678.33, 54.5014.83
61.673.88 HIT-6 score
1 4
(p=0.26 0.12 )
allodynia
allodynia 2
1 allodynia
4
1 allodynia
Greater occipital
Greater
occipital 3

,
,
(allodynia)
naproxen
tramadol
Greater occipital
(VAS),
Greater occipital, allodynia,
HIT-6 score 5 , 1
4 (3)
VAS
5.172.79
5 , 1 4
1.832.04, 5.51.51 5.51.64
5 , 1 4 ( p=0.43,
0.12 0.12)
HIT-6 score , 1

naproxen 4
5,167.675,079.09 4,208.335,308.99 ./
/4 (p=0.24) Tramadol
1,700.002,723.97 1,325.002,789.94 .//
4 (p=0.04) ( 4)

4
6.349.38
3 ,
1
6.009.18

()

3
(/4 )

1
0
0
480
464
0
0
2 ,
100
75
4
21
0
0
3 , ,
0
36
24
19
0
0
4
36
2
48
8
36
4
5
0
0
180
80
0
0
6 ,
0
0
9
40
0
0
: = (/4 ), = (/4 ), 1 = , 2 =
, 3 =

Pt.NO.

Chronic migraine
5
AMT 50 ./, TPM 25 ./
Migraine without aura
10
AMT 50 ./, Atenolol 50 ./, GBP 200 ./

Migraine without aura

3
AMT 10 ./, Propranolol 80 ./
4
43

Migraine without aura

6
AMT 50 ./, Propranolol 80 ./, VPA 500 ./
20
AMT 50 ./, Atenolol 25 ./
5
50
Chronic migraine
Chronic migraine
6
AMT 50 ./, Flunarizine 10 ./, Propranolol 80 ./
6
44

: AMT=Amitriptyline, TPM=Topiramate, GBP=Gabapentin, VPA=Valproate

Pt.NO. ()
1
36
2
46
3
35

1
Vol.31 NO.2 2015

Thai Journal of Neurology

23

Naproxen

7,000
0
0
1,200
0
2,000

Tramadol

7,000
0
0
500
0
450

0
0
0
0
Ace 5,000
0

Others

0
0
0
0
0
0

1
14,000
14,000
2
7,000
250
3
2,000
1,750
4
6,000
6,250
5
2,000
3,000
6
0
0
: = 4 , = 4

Pt.NO.

4 ./ 4

VAS
Occipital tenderness
Allodynia
HIT-6 Score
Before 5 min 1 Wk 4 Wk Before
5 min 1 Wk 4 Wk Before
5 min 1 Wk 4 Wk Before 1 Wk 4 Wk
1
7
4
7
6
N
N
N
N
P
N
N
N
60
64
60
2
5
3
5
5
N
N
N
N
N
N
N
N
58
52
56
3
0
0
7
6
P
N
N
N
P
N
N
P
60
40
60
4
8
4
3
3
P
N
N
N
N
N
N
N
78
75
68
5
6
0
6
8
N
N
N
N
N
N
N
N
60
36
66
6
5
0
5
5
P
N
N
N
N
N
N
N
54
60
62
: Before= 4 , 5 min= 5 , 1 wk= 1 , 4 wk= 4 P=Positive, N=Negative
Occipital tenderness= Greater Occipital

Pt.NO.

3 Greater Occipital

24
Vol.31 NO.2 2015

Vol.31 NO.2 2015

Thai Journal of Neurology

5 , , HIT-6 score

1(/4 )
2(/4 )
3(/4 )
5
1
4
HIT-6 score 1
HIT-6 score 4
Naproxen (./ 4 ) 4
Tramadol (./ 4 ) 4

Greater occipital

3 (, )

(VAS)
5 , allodynia,
,
tramadol naproxen,
Greater occipital 4
GONB

cervicogenic headache, cluster headache,
occipital neuralgia GONB

open label study retrospective study


(refractory

P-value
0.06
0.22
0.05
0.43
0.12
0.12
0.26
0.12
0.24
0.04

migraine)
(migraine with medication overuse headache)


(fixed site injection)

( 6)
GONB



Greater occipital
3 4 6
54-85 2

Grading system
3 (, )
(p=0.05)
1 (, )

25

26

(p=0.06)
6.349.38
Greater occipital

Ashkenazi
and Young6 Single injection GON block
lidocaine and triamcinolone lidocaine
90
20

1

(VAS)
5
3.34 ( 5.172.79
1.832.04, p=0.43) 1 4
(5.51.51 5.51.64
) allodynia
allodynia (2 )
2 4 (1 )

allodynia

Young et al.4
Greater occipital lidocaine
bupivacaine allodynia
5

Greater occipital

allodynia

Vol.31 NO.2 2015

Greater occipital
3
4 6
54-85 2 tramadol
325 ./ 4 (p=0.04)
naproxen 959.34 ./
4 (p=0.24)
Greater occipital 4
Caputi and Firetto15

GONB


7,

3
5
suboccipital
9

Greater occipital
,

Greater occipital
HIT-6 score
1

,
1

Thai Journal of Neurology

Vol.31 NO.2 2015

6 ( Ashkenazi et al 2)

Gawel and
Rothbart

Caputi and
Firetto

Bovim and Sand

Ashkenazi and
Young

Study design

97 A single or repeated GON Headache improvement in 54%

block(s) using lidocaine of subjects for up to 6 months
and methylprednisolone

Retrospective

27 Repeated GON and SON Headache improvement in 85%

blocks using bupivacaine of subjects for up to 6 months

Retrospective

14 A single GON block with or

without SON block using
lidocaine and epinephrine
19 A single GON block using

Head pain reduction in 6% of Retrospective

subjects at 30 minutes

A significant decrease in head Prospective,

pain in
lidocaine and triamcinol 90% of subjects
non-controlled
one, and TPIs using lido-
caine

Greater occipital

, allodynia
Greater occipital

, ,


, ,

Greater occipital
,

(Acknowledgement)

1.

2.

3.

Goadsby PJ, Lipton RB, Ferrari MD. Migraine--current

understanding and treatment. N Engl J Med 2002
;346:257-70.
Ashkenazi A, Blumenfeld A, Napchan U, Narouze S,
Grosberg B, Nett R, et al. Peripheral nerve blocks and
trigger point injections in headache management - a
systematic review and suggestions for future research.
Headache 2010 ;50:943-52.
Levin M. Nerve blocks in the treatment of headache.
Neurotherapeutics 2010 ;7:197-203.

27

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4.

5.

6.

7.

8.

9.

10.
11.

12.
13.

14.

15.

Young W, Cook B, Malik S, Shaw J, Oshinsky M. The first

5 minutes after greater occipital nerve block. Headache
2008 ;48:1126-8.
Afridi SK, Shields KG, Bhola R, Goadsby PJ. Greater
occipital nerve injection in primary headache syndromes-prolonged effects from a single injection. Pain 2006
;122:126-9.
Ashkenazi A, Young WB. The effects of greater occipital
nerve block and trigger point injection on brush allodynia
and pain in migraine. Headache 2005;45:350-4.
Blumenfeld A, Ashkenazi A, Grosberg B, Napchan U,
Narouze S, Nett B, et al. Patterns of use of peripheral
nerve blocks and trigger point injections among headache practitioners in the USA: Results of the American
Headache Society Interventional Procedure Survey
(AHS-IPS). Headache 2010 ;50:937-42.
Sahai-Srivastava S, Subhani D. Adverse effect profile of
lidocaine injections for occipital nerve block in occipital
neuralgia. J Headache Pain 2010 ;11:519-23.
Weibelt S, Andress-Rothrock D, King W, Rothrock J.
Suboccipital nerve blocks for suppression of chronic
migraine: safety, efficacy, and predictors of outcome.
Headache 2010 ;50:1041-4.
The International Classification of Headache Disorders:
2nd edition. Cephalalgia 2004;24 Suppl 1:9-160.
Young WB, Marmura M, Ashkenazi A, Evans RW. Expert
opinion: greater occipital nerve and other anesthetic
injections for primary headache disorders. Headache
2008 ;48:1122-5.
Tobin J, Flitman S. Occipital nerve blocks: when and
what to inject? Headache2009 ;49:1521-33.
Tobin J, Flitman S. Treatment of migraine with occipital
nerve blocks using only corticosteroids. Headache2011
;51:155-9.
Ashkenazi A, Matro R, Shaw JW, Abbas MA, Silberstein
SD. Greater occipital nerve block using local anaesthetics alone or with triamcinolone for transformed migraine:
a randomised comparative study. J Neurol Neurosurg
Psychiatry 2008 ;79:415-7
Caputi CA, Firetto V. Therapeutic blockade of greater
occipital and supraorbital nerves in migraine patients.
Headache 1997 ;37:174-9

Vol.31 NO.2 2015

Thai Journal of Neurology

Vol.31 NO.2 2015

50 80
1
7.2 1,000 2
60-90

3
4
(International League
Against Epilepsy ;ILAE) , (International Bureau
for Epilepsy ;IBE) (World
Health Organization ; WHO)

(out of the shadows)

1,3, 2,3

1,3, 2,3

3

1

29

30

5

360
38
46.6
15

73
6

11
28
43.0

(atonic seizures)
(absence seizures)
37.3 76.5

64
27

8

..2548
6
.. 2554 7

11 1.9
2 0.9

80.3
92.7 33.6

Vol.31 NO.2 2015

(absence seizures) 8




(atonic seizures)
(absence seizures) 55.6
58.7 25.4
24.6
1.6

5.3 9
10



13.8, 18.2 50.2

57.1, 62.6, 40.9, 30.5 65.0

11

(caregivers)
27.7
41.0

2

4.8, 22.9 65.1

Vol.31 NO.2 2015

65.1
74.7
42.2

12

1,581

25.6
36.8
28
21.8
44.3

13




(
9.2, 27.8)
(
37.5, 55.9)

10

Thai Journal of Neurology

2


33.3 53.6

49, 31.7 28.5
31.3
63.5

43,
42, 39.8, 42.1 38



40.4 32




47.6
5 2

23 85.7
25 99.2

31

32

25
26
3.1 24 25
103.9
11.5 22

35
37.8

22 24 38
39.7 26
3.1
92.2
22 17

25
70.6 22 56 24
33.0

24
57.9 23 25
10.8 11.6 3

27
28 23.8
58
62.8 13.2 29
19
67.327, 14.328 51.929
44.527
22.828 8427,

Vol.31 NO.2 2015

6028 30.929
67
52 29 15.8
4 30
54
27
23
12.7

25.612 () 14.5 ()11

20
47.6

27 62.8
2.8 5
20
53.6 17 33.3 14
20 27
23.8
25 0.8

Thai Journal of Neurology

Vol.31 NO.2 2015

18.2 ()10 22.9 ()11
27.8 ()13
27.7 11

50.2 ()10 65.1
()11 27
67.3 29 51.9
24
10.9 25 11.5
62.6 ()10
67.5 ()11
63.5
14 16 17 1921
43, 42, 39.8, 42.1 38

26 3.1 22
38 24 39.7


57.1
62.6 40.9
30.5
65.0 10

25 28
36.8
21.8
44.3
12
29
15.8 25

70.6

735
646 837 65.111 27
6 74.7
42.2
11
23 25 10.8 11.6




5.3


(atonic seizures)
(absence seizures) 55.6
58.7 9
33.6
(absence seizures)8 25.4
24.6
1.6
41.0

2 11





10

33

34

1.

2.

41.0
2

/

Vol.31 NO.2 2015

3.
(.)

4.

 1 2 3 4 5 6 7 8 9

() () () () () () () () ()
5

0.9
53.4
36.3/ -/73.0
6

1.0
10.8 37.3/62.7 82.4
26.5 2.0/24.5/6.9
7.8
63.7
20.0
8
0.0
0.0
43.6/33.6 28.2
33.6
-/41.8/9.1
19.1
50.9
26.5
12 25.6
44.3/ -/47.1
7

0.9
1.9
48.6/40.2 72.0
43.0 5.6/22.4/4.7
9.3
83.2
3.7
9
0.8
4.8
55.6/58.7 74.6
24.6 1.8/22.2/6.3 15.1
19.0
0.0

10

8.4
18.2
37.4
40.9/ -/62.6
11

14.5
22.9
57.8
60.2/-/67.5
65.1
74.7
13

-
1.8
9.2
66.0/20.2 61.3
37.5
68.4/-/3.8
1.6
30.6
2.0
-
3.8
27.8 63.6/20.2 77.0
55.9
65.4/-/4.2
5.6
33.6
14.0
1 / 2 3
/ 4
5 6 /
/ 7 8
9

1 ( )
Vol.31 NO.2 2015

Thai Journal of Neurology

35


/
/
/

4.9
5.5

10.4
31.7
55.3
6.9
40.4

20.8

35
49
43
75
44
-

15
2008

20
4

14
2002

27.8

39.8
60.9

28.5

66.9
-

44.0

42.1
81.3

19.0
-

33.3

63.5
-

41.5
31.3

20
2012

53.6
47.6

32

43

38
73

32
-

21
2000

52

42
80

69
-

16
17
18 19
2000
2013
2005
2006

33.3
4.9
23
5.3
-

2 ( )

36
Vol.31 NO.2 2015

35
25
38
17
56
-

22
2012

85.7
46.3
37.8
54.8
10.8

23
2012

55.0
10.9
40.6
24.7
39.7
33.0
57.9

24
2011

3 ( )

99.2
11.5
70.6
11.6

25
2013

26
2012

13.4
3.1
3.1
92.2
-

Vol.31 NO.2 2015

Thai Journal of Neurology

37


/ / /

/
/

27
2009

23.8
62.8
12.7
67.3
44.5
84
67
-

4 ( )

28
2010
Students
58
13.2
12.4
14.3
22.8
60
52
41.6

/
29
2013

19
22.5
51.9
30.9
15.8
58.9
57.8
50.6

38

Vol.31 NO.2 2015

Thai Journal of Neurology

Vol.31 NO.2 2015

1.

2.

3.

4.

5.
6.

7.

8.

9.

10.

11.

12.

Meinardi H, Scott RA, Reis R. et al. The treatment gap

in epilepsy: the current situation and the way forward.
Epilepsia 2001; 42: 136-49.
Asawavichienjinda T, Sitthi-Amorn C, Tanyanont W.
Prevalence of epilepsy in rural Thailand: a populationbased study. J Med Assoc Thai 2002; 85: 1066-73.
Shorvon S, Farmer P. Epilepsy in developing countries:
a review of epidemiological, sociocultural and treatment
aspects. Epilepsia 1988; 29:S36-S45.
Tiamkao S, Sawanyawisuth K, Towanabut S, Visudhipun
P. Seizure attacks while driving: Quality of life in persons
with epilepsy. Can J Neurol Sci 2009; 36: 475-9.
Kankirawatana P. Epilepsy awareness among school
teachers in Thailand. Epilepsia 1999; 497-501.
Tiamkao S, Auevitchayapat N, Arunpongpaisal S. et al.
Knowledge of epilepsy among teachers in Khon Kaen
Province, Thailand. J Med Assoc Thai 2005; 88: 1802-8.
Tiamkao S, Pranboon S, Singhpoo K, Ariyanuchitkul
S, Sawanyawisuth K, Integrated Epilepsy Research
Group Khon Kaen University. Knowledge, attitudes and
practices towards epilepsy of teachers in Khon Kaen
Province. 2011. (during submission process)
Tiamkao S, Tiamkao S, Auevitchayapat N, Arunpongpaisal S, Chaiyakum A, Jitpimolmard S, Phuttharak W,
Phunikhom K, Saengsuwan M J, Vannaprasaht S. Basic
knowledge of epilepsy among medical students. J Med
Assoc Thai 2007; 90:2271-6.
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K, Singhpoo K, Integrated Epilepsy Research Group
Khon Kaen University. Knowledge, attitudes and practices towards epilepsy of healthcare providers. 2011.
(during submission process)
Saengsuwan J, Boonyaleepan S, Srijakkot J, Sawanyawisuth K, Tiamkao S; Integrated Epilepsy Research
Group. Factors associated with knowledge and attitudes
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Saengsuwan J, Laohasiriwong W, Boonyaleepan S,
Sawanyawisuth K, Tiamkao S; Integrated Epilepsy
Research Group. Knowledge, attitudes, and care techniques of caregivers of PWE in northeastern Thailand.
Epilepsy Behav 2013 ;27:257-63.
Saengpattrachai M, Srinualta D, Lorlertratna N, et al.
Public familiarity with, knowledge of, and predictors of
negative attitudes toward epilepsy in Thailand. Epilepsy
Behav 2010;17:497-505.

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Tiamkao S, Sawanyawisuth K, Singhpoo K, Ariyanuchitkul

S, Ngamroop R. Difference of knowledge, attitudes, and
behaviors towards epilepsy between populations in municipal and nonmunicipal areas. Psychology Research
and Behavior Management2013:6; 111-6.
Rambe AS, Sjahrir H. Awareness, attitudes and understanding towards epilepsy among school teachers in
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Thacker AK, Verma AM, Ji R. et al. Knowledge awareness and attitude about epilepsy among schoolteachers
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Kelantan, Malaysia. Neurol J Southeast Asia 2000:5:55-60.
Harimanana A, Chivorakul P, Souvong V. et al. Is insufficient knowledge of epilepsy the reason for low levels
of healthcare in the Lao PDR?. BMC Health Services
Research 2013:13:41.
Ab Rahman AF. Awareness and knowledge of epilepsy
among students in a Malaysian university. Seizure 2005:14:
593-6.
Cuong LQ, Thien DD, Jallon P. Survey of public awareness, attitudes, and understanding toward epilepsy in
Nhan Chinh, Hanoi, Vietnam, in 2003. Epilepsy & Behav
2006:8;176-80.
Bhalla D, Chea K, Hun C. et al. Population-based study of
epilepsy in Cambodia associated factors, measures
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Pan AB, Lim SH. Public awareness, attitudes and understanding toward epilepsy among Singaporean Chinese.
Neurol J Southeast Asia 2000:5:5-10.
Chung K, Ivey L, Guo W. et al. Knowledge, attitudes,
and Practice towards epilepsy (KAPE) survey of Chinese
and Vietnamese Colledge Students in the U.S. Berkeley
Scientific Journal 2010;13:39-44.
Alkhamra H, Tannous A, Hadidi M, et al. Knowledge and
attitudes toward epilepsy among school teachers and
counselors in Jordan. Epilepsy & Behav 2012:24;430-4.
Mecarelli O, Capovilla G, Romeo A, et al. Knowledge and
attitudes toward epilepsy among primary and secondary schoolteachers in Italy. Epilepsy & Behav 2011;22:
285-92.
Toli T, Sourtzi P, Tsoumakas K, et al. Association between
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Bagic D, Mastilica M, Bagic A. A five-year follow up

study of the general public awareness and perception
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Ezeala-Adikaibe BA, Achor JU, Onwukwe J, et al.
Knowledge, attitude and practice towards epilepsy
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Njamnshi AK, Yepnjio FN, Zoung-Kanyi Bissek AC,
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191-200.

Vol.31 NO.2 2015

Thai Journal of Neurology

Vol.31 NO.2 2015

49
13
2557
:
4
:
1

6

4

: 2534
(bipolar disorder)
risperidone 2 1
2 2557
disorganized behaviors
paliperidone long acting
150 4 ( 23
2557)

risperidone 2
1 2
paliperidone 150
4
valproic acid 200
2
lorazepam 2
1
trihexyphenidyl 2
1
simvastatin 20
1
amlodipine 10
1

Neuroleptic Malignant
Syndrome
Paliperidone Long Acting
Injection
Oral Risperidone
Intramuscular Haloperidol
1,
2

1, 2
2

41

42

:
Vital signs : BP 116/68 mmHg, T 36.4c, PR 67
bpm, RR 18/min, O2 saturation : 99%
General apperance : slow response
HEENT : mild pale conjunctiva
Cardiovascular system: regular rhythm, normal
S1 S2, no murmur
Respiratory system: normal breath sound
Abdomen: soft, not tender, impalpable of liver
and spleen
Extremities: no pitting edema
Neurological examination:
Consciousness: drowsiness
Speech: normal
Gait: cannot be evaluated
Cranial nerve: within normal limit
Motor system: generalized muscle spasticity,
no motor weakness
Sensory system: cannot be evaluated
Deep tendon reflex: 2+
:
Blood chemistry: BUN 5.9 mg/dl creatinine 1.2
mg /dl, sodium 114 mEq/L, potassium 2.7 mEq/L,
HCO3 35.2 mEq/L, Cl 62 mEq/L, Ca 9.2 mg/dL, PO4
3.5 mg/dL, Mg 1.8 mg/dL,
Complete blood count: Hb 11/1 g/dl, Hct
31.2%, WBC 1,050/mm3, Platelet 264,000/mm3,
PMN 41.9%, lymphocyte 11.4%, monocyte 9.1%,
eosinophil 0%, basophil 0.3%
Liver function test: AST 92 u/L, ALT 43 u/L,
ALP74u/L

haloperidol 5 30
2

Vol.31 NO.2 2015

14 2557 15 2557
risperidone 2
2 2
( 8 ) 16 2557
(38C)
115 /
WBC 14,000, CPK 3269 u/L
neuroleptic malignant syndrome
(NMS) risperidone,
haloperidol bromocriptine, lorazepam

Problem List:
Neuroleptic malignant syndrome (NMS)
Hyponatremia
:
NMS

49
4
disorganized behaviors
risperidone
4 8
haloperidol 5
2 paliperidone
long acting 2


creatine phosphokinase (CPK)
neuroleptic malignant syndrome
(NMS) NMS
serotonin syndrome (SS)
serotonergic drugs
selective serotonin reuptake inhibitors(SSRI),
monoamine oxidase inhibitors(MAOIs)
anticholinergic syndrome fluctuating conscious, tachycardia

Vol.31 NO.2 2015

Thai Journal of Neurology

bowel sound normal pupil

anticholinergic anticholinergic

NMS
dopamine
antagonist

NMS 2,000
4
NMS

6
5

Neuroleptic Malignant Syndrome; NMS

Neuroleptic Malignant Syndrome; NMS

1 dopamine
dopamine
NMS .. 1956
chlorpromazine
NMS

high potency haloperidol

NMS

NMS 2

NMS

NMS

6
2-3
7-10

30 6 NMS
3
1, 6
1
2

NMS

0.02-3.21, 3
10-553 NMS

1
NMS

43

44

Vol.31 NO.2 2015

1 NMS7

DSM-IV-TR

A Criteria A 1. 2. Criteria B
2 (mutism)
B

(leukocytosis)
Criteria C viral
encephalitis Criteria D
A d i t y a n j e e 4 Major Features 1.
Criteria
2 2 2. 3. Hyperthermia (> 39C
autonomic dys- ) 4. Autonomic dysfunction (> 90/
function
), (> 25/)
DBP 15 mmHg SBP
30 mm Supportive Features 1. CPK
2.
Levenson Cri- 3 (major symptoms) 1. 2. 3.
teria
2 CPK (minor symptoms)
4

Pope Criteria 3 Major Criteria 1. Hyperthermia (> 37.5C) 2. EPS (

2 3 2 ) lead-pipe rigidity, cogwheeling, sialorrhea,
retrospective oculogyric crisis, retrocollis, opisthotonos, trismus, dysphagia,
criteria
choreiform movements, dyskinetic movements, Festinating gait,
flexor-extensor posturing 3. Autonomic dysfunction (
2 ) DBP
20 mmHg ( 30
baseline) ( 25 baseline)
Retrospective criteria 1.
(Clouded consciousness) 2. (> 15,000) 3. CPK
> 300 U/L

Thai Journal of Neurology

Vol.31 NO.2 2015

2 NMS DSM-58
1.
2.
3.
4.
5.
6.

dopamine antagonist dopamine agonist 72

( >100.4F >38.0C 2 )

()
creatinine kinase ( 4 )

- 25 baseline
- (SBP DBP > 25% baseline)
- (DBP 20 mmHg SBP 25
mmHg 24 )
-
-
-
7. 50 baseline respiratory distress
8. metabolic neurological disorder
NMS

extrapyramidal
4
NMS


6



3

NMS creatinine
phosphate kinase (CPK)

NMS6
9
NMS
(heat stroke)


extrapyramidal 6
3

45

46

Vol.31 NO.2 2015

3 6

NMS

dopamine high
potency haloperidol, fluphenazine, trifluoperazine
chlorpromazine, prochlorperazine
10

11
dopamine
levodopa
NMS
lithium, desipramine 6
NMS

catatonia

Thai Journal of Neurology

Vol.31 NO.2 2015

dopamine

NMS
(exhaustion) 4
NMS
dopamine

dopamine
NMS
dopamine

NMS
dopamine homovalinic
acid dopamine

NMS

dopamine
NMS4

dopamine
catecholamine

NMS

4
NMS 1

1 NMS4

NMS

NMS

(electroconvulsive therapy; ECT)6

4

47

Stage V: severe NMS

Stage IV: moderate NMS

Stage III: mild, early NMS

Stage I: drug-induced
parkinsonism
Stage II: drug-induced
catatonia

(First-Line Interventions)

anticholinergic drugs

lorazepam (12

46 )
lorazepam (12

38C (100.4F)
46 )
100
lorazepam (12

3840C (100.4 104F) 46 ) bromocriptine (2.55
100120 nasogastric [NG]

tube 8 ) amantadine (100

NG tube
8 )
dantrolene (12.5
6
40C (104F) 48
120 ) bromocriptine (2.55

nasogastric [NG]
tube 8 ) amantadine (100
NG tube
8 )

Woodbury stage

4 6

electroconvulsive
therapy (610 )

electroconvulsive
therapy (610 )

(Second-Line
Interventions)

48

Vol.31 NO.2 2015

Thai Journal of Neurology

Vol.31 NO.2 2015

(supportive
therapy)

2 12
NMS

6
NMS

NMS


NMS 5

5 NMS

Benzodiazepines

lorazepam
1-2 4-6

Dopamine agonist amantadine 200-400

bromocriptine 2.5-5 2-3
45

Dantrolene

first line
catatonic behavior

bromocriptine

dantroline I.V. 1-2.5

1 6
48

80
50
calcium channel blockers

49

50

Vol.31 NO.2 2015

NMS
haloperidol 5
2
2
risperidone paliperi-

done long acting injection 3

NMS

risperidone CYP2D6
9-OH-risperidone (paliperidone)


5-HT2a dopamine (D2)
paliperidone 50
risperidone
13
NMS risperidone
paliperidone
.. 2014 risperidone 44
paliperidone 4 10
risperidone

CYP2D6
14
paliperidone
NMS

6-9
10
paliperidone long acting injection
3

15, 16

Thai Journal of Neurology

Vol.31 NO.2 2015

haloperidol 2 haloperidol
high potency
D2

17

NMS haloperidol

NMS risperidone
haloperidol

NMS
risperidone haloperidol lorazepam
bromocriptine
4

NMS


high potency
D2



NMS

NMS
benzodiazepines, dopamine agonist dantrolene
2
49
NMS paliperidone long

acting injection risperidone haloperidol

1

1.

2.

3.

4.
5.

6.
7.

8.

9.

10.

11.

Velamoor VR. Neuroleptic malignant syndrome. Recognition, prevention and management. Drug Saf 1998;19:7382.
Gupta S, Nihalani ND. Neuroleptic Malignant Syndrome:
A Primary Care Perspective. Prim Care Companion J Clin
Psychiatry 2004;6:191-4.
Su YP, Chang CK, Hayes RD, et al. Retrospective chart
review on exposure to psychotropic medications associated with neuroleptic malignant syndrome. Acta
Psychiatr Scand 2014;130:52-60.
Strawn JR, Keck PE, Jr., Caroff SN. Neuroleptic malignant
syndrome. Am J Psychiatry 2007;164:870-6.
Kasantikul D, Kanchanatawan B. Neuroleptic malignant
syndrome: a review and report of six cases. J Med Assoc
Thai 2006;89:2155-60.
Berman BD. Neuroleptic malignant syndrome: a review
for neurohospitalists. Neurohospitalist 2011;1:41-7.
Hall RCW HR, Chapman M. Neuroleptic malignant
syndrome in the elderly: diagnostic criteria, incidence,
risk factors, pathophysiology, and treatment. Clinical
Geriatrics 2006;14:8.
Association. AP. Diagnostic and statistical manual of
mental disorders. 5th ed. Arlington: American Psychiatric
Publishing; 2013.
Patil BS, Subramanyam AA, Singh SL, Kamath RM. Low
serum iron as a possible risk factor for neuroleptic malignant syndrome. Int J Appl Basic Med Res 2014;4:117-8.
Belvederi Murri M, Guaglianone A, Bugliani M, et al.
Second-Generation Antipsychotics and Neuroleptic Malignant Syndrome: Systematic Review and Case Report
Analysis. Drugs R D 2015.
Nakamura M, Yasunaga H, Miyata H, Shimada T,
Horiguchi H, Matsuda S. Mortality of neuroleptic malignant syndrome induced by typical and atypical antipsychotic drugs: a propensity-matched analysis from the
Japanese Diagnosis Procedure Combination database.
J Clin Psychiatry 2012;73:427-30.

51

52

12.

13.

14.

15.

16.

17.

Casamassima F, Lattanzi L, Perlis RH, et al. Neuroleptic

malignant syndrome: further lessons from a case report.
Psychosomatics 2010;51:349-54.
lamo C L-MF. The pharmacological role and clinical
applications of antipsychotics active metabolites: risperidone and paliperidone (9-OH risperidone). Clin Exp
Pharmacol 2013;3:12.
Ochi S, Kawasoe K, Abe M, et al. A case study: neuroleptic malignant syndrome with risperidone and CYP2D6
gene variation. Gen Hosp Psychiatry 2011;33:640 e1-2.
Samtani MN, Vermeulen A, Stuyckens K. Population
pharmacokinetics of intramuscular paliperidone palmitate in patients with schizophrenia: a novel once-monthly,
long-acting formulation of an atypical antipsychotic. Clin
Pharmacokinet 2009;48:585-600.
Bishara D. Once-monthly paliperidone injection for the
treatment of schizophrenia. Neuropsychiatr Dis Treat
2010;6:561-72.
Konikoff F, Kuritzky A, Jerushalmi Y, Theodor E. Neuroleptic malignant syndrome induced by a single injection of
haloperidol. Br Med J (Clin Res Ed) 1984;289:1228-9.

Vol.31 NO.2 2015

JOURNAL READING
Vol.31 NO.2 2015

multiple sclerosis (MS) acquired

central nervous system demyelinating syndromes
(CNS ADS)

MS
myelin base


CNS ADS
human papillomavirus (HPV)
2-4

MS acquired central
nervous system demyelinating syndromes (CNS
ADS)

: nested case-control study

: ~3.5
Kaiser Permanente Southern California (KPSC)
vaccine Kaiser
Immunization Tracking System(KITS)
(case identification) :
ICD 9
(International Classification of Diseases, Ninth
Revision) 1 2551-31 2554
340, 341.0,341.22, 341.8, 341.9, 377.30,
377.32, 377.39, and 336.39
3556
MS McDonald criteria ADEM
consensus definitions for pediatric acute disseminated encephalomyelitis TM consensus
definitions for idiopathic transverse myelitis

Thai Journal of Neurology

VACCINATION AND
NEUROLOGICAL
COMPLICATION?

: Langer-Gould A, Qian L, Tartof SY, et al.

Vaccines and the risk of multiple sclerosis and
other central nervous system demyelinating diseases.
JAMA Neurol 2014;71:1506-13.

. 1,
.. 2

.
1, .. 2
1
, 2


.

53

54

(control selection):

1: 5 (1 )
KPSC
: 3
KITS

(booted dose) (initial dose)

- Engerix B (GlaxoSmithKline Biologics), Recombivax HB (Merck

Sharp&Dohme Corp), Any HepB-containing vaccine
includes single antigen HepBvaccines,Pediarix
(GlaxoSmithKline),and HepB containing vaccines
not otherwise specified
- HPV Gardasil (Merck Sharp &
Dohme Corp)
- measles, mumps,
rubella, polio, and varicella
- influenza; tetanus,
pertussis, and diphtheria and varicella-zoster
:
- white Hispanic, white
non-Hispanic, black, Asian/Pacific Islander, Native
American/Alaskan, and multiple/other/unknown
- ICD-9 250
ICD-9 411-414 428
ICD-9 491 492 ICD-9 403 581-583
585-588 ICD-9 571-573
- 6
ICD-9 001-139
-
6
:
- conditional logistic regression, odds
ratio (OR) 95% CI
14 30 42

Vol.31 NO.2 2015

90 180 1 3
HPV 9-26 1
2550
-
2 50
50
50

MS, clinical isolated syndrome
(CIS), acute disseminated encephalomyelitis
(ADEM) 780 MS 427
54.7 optic neuritis 177 22.7
transverse myelitis 122 15.6 other
forms of CIS 33 4.2 ADEM 21
2.7



6
MS
other forms of CIS
4.0 3.3
ADS
ADEM 42 1
HPV MS other
forms of CIS 39.1
38.1

3
2
(adjusted OR, 1.03; 95%CI, 0.86-1.22)
50
30

Thai Journal of Neurology

Vol.31 NO.2 2015

24 CNS
ADS 30 24
MS 11 optic neuritis (ON) 9 transverse myelitis (TM) 3 ADEM 1
30
14 36
8
14

nested case-control study

MS CNS ADS
50
30
30
autoimmunity autoactive T cell
(molecular mimicry)

MS

MS
2

3 3.1 2.8 (OR, 3.1; 95%CI, 1.5-6.3 OR,
2.8; 95% CI, 1.2-6.4 ) 2
11

CNS ADS
human papillomavirus (HPV) 2-4
11 MS
HPV
MS

HPV MS

MS other CNS ADS 3

30 50

..

MS demyelinating
disease
30

50

4-6

Guillain Barre syndrome 55



4-6

55

56

0.67

carbamazepine







1.

2. carbamazepine

3.

4.

5.

6.

Vol.31 NO.2 2015

..

..

Vol.31 NO.2 2015

1.
2.

3.

1.
1-.4

2. carbamazepine
5-7
carbamazepine
Steven Johnson syndrome toxic epidermal necrolysis
HLA-B* 1502
carbamazepine

HLA-B* 1502
carbamazepine
3.






4.

Thai Journal of Neurology

website

5.

phenobarbital


valproate topiramate
6.

1.

57

58

2.
HLA-B* 1502
carbamazepine



3.
8,9,10.24

4.
10-14

5.
15-25


drug interaction
levetiracetam, depakine,
topiramate phenobarbital

6.
26,27

Vol.31 NO.2 2015

1.

2.

3.

4.

5.

6.

Saengsuwan J, Laohasiriwong W, Boonyaleepan S,

Sawanyawisuth K, Tiamkao S; Integrated Epilepsy
Research Group. Knowledge, attitudes, and care
techniques of caregivers of PWE in northeastern
Thailand. Epilepsy Behav 2013 ;27:257-63.
Tiamkao S, Auevitchayapat N, Arunpongpaisal S, Chaiyakum A, Jitpimolmard S, Phuttharak W, Phunikhom K,
Saengsuwan J, Saetang S, Tiamkao S, Vannaprasaht S.
Knowledge of epilepsy among teachers in Khon Kaen
Province, Thailand.J Med Assoc Thai 2005 ;88:1802-8.
Tiamkao S, Tiamkao Si, Auevitchayapat N, Arunpongpaisal S, Chaiyakum A, Jitpimolmard S, Phuttharak W,
Phunikhom K, Saengsuwan M J, Vannaprasaht S. Basic
knowledge of epilepsy among medical students. J Med
Assoc Thai 2007;90:2271-6.
Saengsuwan J, Boonyaleepan S, Srijakkot J, Sawanyawisuth K, Tiamkao S; Integrated Epilepsy Research
Group.Factors associated with knowledge and attitudes
in persons with epilepsy. Epilepsy Behav 2012 ;24:23-9.
Tiamkao S, Jitpimolmard J, Sawanyawisuth K, Jitpimolmard S. Cost minimization of HLA-B*1502 screening
before prescribing carbamazepine in Thailand.Int J Clin
Pharm 2013;35:608-12.
Kulkantrakorn K, Tassaneeyakul W, Tiamkao S, Jantararoungtong T, Prabmechai N, Vannaprasaht S, Chumworathayi P, Chen P, Sritipsukho P. HLA-B*1502 strongly

Thai Journal of Neurology

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7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

predicts carbamazepine-induced Stevens-Johnson

syndrome and toxic epidermal necrolysis in Thai patients
with neuropathic pain. Pain Pract 2012 ;12:202-8.
Tassaneeyakul W, Tiamkao S, Jantararoungtong T,
Chen P, Lin SY, Chen WH, Konyoung P, Khunarkornsiri
U, Auvichayapat N, Pavakul K, Kulkantrakorn K, Choonhakarn C, Phonhiamhan S, Piyatrakul N, Aungaree T,
Pongpakdee S, Yodnopaglaw P. Association between
HLA-B*1502 and carbamazepine-induced severe cutaneous adverse drug reactions in a Thai population.
Epilepsia. 2010;51:926-30.
Tiamkao S, Towanabut S, Dhiravibulyn K, Pranboon S,
Sawanyawisuth K, The Epilepsy Society of Thailand,
Integrated Epilepsy Research Group, Khon Kaen University. Is the Thailand epilepsy service adequate to help
patients? Neurology Asia 2013; 18: 271 7.
, , ,
.
.
2554; 6: 1927.
Tiamkao S, Sawanyawisuth K, Towanabut S, Visudhipun
P; Thai QOL Epilepsy Investigators. Seizure attacks while
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