HEADACHE

Luhu Avianto Tapiheru

Department of Neurology Faculty of Medicine Muhammadiyah University Medan
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Definition of pain
Pain is unpleasent sensory and emotional experience associated with actual or potential tissue damage, or discribed in term of such damage ( IASP, 1986 )

Types of pain :
Nociceptive pain Neuropathic pain

Mixed pain
Combination
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THE ROLE OF NEUROTRANSMITTER : SEROTONIN (5 HT) THE ENDOGENOUS PAIN CONTROL MECHANISM -> OPIOID GABA
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HEADACHE
DEFINITION :
ALL ACHES AND PAINS LOCATED IN THE HEAD ORBITA OCCIPUT

The International Classification of Headache Disorders ICHD 2 International Headache Society 2004 ( IHS 2004 )

The Primary Headaches Migraine Tension-type headache (TTH) Cluster headache Other primary headaches The Secondary Headaches Headache attributed to head and/or neck trauma Headache attributed to cranial or cervical vascular disorders Headache attributed to non-vascular intracranial disorders Headache attributed to a substance or its withdrawal Headache attributed to infection Headache attributed to disorder of homoeostasis Headache or facial pain attributed disorder of cranial, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures Headache attributed to psychiatric disorders Cranial Neuralgias, central & primary facial pain & other headaches Cranial neuralgias & central causes of facial pain Others headache, cranial neuralgias & central or primary facial pain

PAIN SENSITIVE STRUCTURES OF THE HEAD:

SKIN, SUBCUTANEUS TISSUE

MUSCLES
EXTRACRANIAL ARTERIES PERIOSTEUM OF THE SKULL EYE, EAR, NASAL CAVITIES, SINUSES, TEETH, OROPHARYNX
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PAIN SENSITIVE STRUCTURES OF THE HEAD (cond)

VENOUS SINUSES DURA AT THE BASE OF THE BRAIN ARTERIES within DURA & PIA ARACHNOID MIDDLE MENINGEAL & SUPERFICIAL TEMPORAL ARTERIES N II, N III, N V, N IX, N X C 1, 2, 3 SENSORY NUCLEI OF THE THALAMUS BRAIN STEM PERIAQUEDUCTAL GRAY MATTER

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INSENSITIVE TO PAIN

BONY SKULL PIA - ARACHNOID & DURA OVER THE CONVEXITY OF THE BRAIN BRAIN PARENCHYMA

EPENDYMA, CHOROID PLEXUS

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NOCICEPTOR :
SUPRATENTORIAL STRUCTURES
ANT / MED FOSSAE

N V - N V 1-2 C 1, 2, 3

INFRATENTORIAL STRUCTURES

POST FOSSAE

N IX, N X
NV C 1, 2, 3

ANT, 2/3 OF THE HEAD BACK OF THE HEAD, NECK

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MECHANISMS OF CRANIAL PAIN :

TRACTION ON OR DILATATION OF THE INTRACRANIAL ARTERIES

DISTENTION OF EXTRACRANIAL ARTERIES TRACTION ON OR DISPLACEMENT OF THE LARGE INTRACRANIAL VEINS OR DURAL ENVELOPE COMPRESSION, TRACTION OR INFLAMATION OF THE CRANIAL AND SPINAL NERVES SPASM, INFLAMATION & TRAUMA TO CRANIAL & CERVICAL MUSCLE
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MECHANISM OF CRANIAL PAIN (cond)

DISEASE OF THE TISSUES OF THE SCALP, FACE, EYE, NOSE, EAR AND NECK

MENINGEAL IRRITATION AND RAISED/LOWERED INTRACRANIAL PRESSURE

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HISTORY :
ATTACK ONSET QUALITY SEVERITY LOCATION MODE OF ONSET TIME, INTENSITY, CURVE, DURATION CONDITION WHICH EXACERBATE / RELIEVE THE PAIN ASSOCIATED FEATURES SOCIAL HISTORY, FAMILY HISTORY PAST HEADACHE HISTORY HEADACHE IMPACT

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Faktor pencetus Nyeri Kepala

Stres Kurang/kebanyakan tidur Tidak/telat makan Bau menyengat : parfum,rokok Lingkungan: cahaya silau/berkedip,gaduh ketinggian,panas,lembab ruang berasap Makanan/minuman

HAS/Neuro/Bdg/04

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PHYSICAL EXAMINATION :
INSPECTION PALPATION

AUSCULTATION

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The Secondary Headache

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MIGRAINE

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MIGRAINE
FAMILIAL DISORDER >80% BEFORE 30 YEARS OF AGE PERIODIC, 4 - 72 HOURS UNILATERAL, OCCASIONALLY BILATERAL PULSATING INTENSITY MODERATE OR SEVERE PAIN NAUSEA, VOMITTING SENSITIVITY TO LIGHT & NOISE ( PHOTOPHOBIA & PHONOPHOBIA)
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MAKANAN SEBAGAI FAKTOR PENCETUS MIGREN

MAYOR
MSG Wine, vodka, bir Keju, coklat, yoghurt Citrus fruits Buttermilk, coklat susu Yeast

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MAKANAN SEBAGAI FAKTOR PENCETUS MIGREN

MINOR
Kacang-kacangan Fried foods Popcorn Chile peppers Seafoods Pork/liver Terlampau asin/manis

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MIGRAINE

MIGRAINE WITHOUT AURA MIGRAINE WITH AURA

TYPICAL AURA WITH MIGRAINE HEADACHE TYPICAL AURA WITH NON MIGRAINE HEADACHE TYPICAL AURA WITHOUT HEADCHE FAMILIAL HEMIPLEGIC MIGRAINE (FHM) SPORADIC HEMIPLEGIC MIGRAINE BASILAR TYPE MIGRAINE

CHILDHOOD PERIODIC SYNDROMES THAT ARE COMMONLY PRECURSORS OF MIGRAINE

CYCLICAL VOMITING ABDOMINAL MIGRAINE BENIGN PAROXYSMAL VERTIGO OF CHILDHOOD

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MIGRAINE

RETINAL MIGRAINE COMPLICATIONS OF MIGRAINE

CHRONIC MIGRAINE STATUS MIGRAINOSUS PERSISTENT AURA WITHOUT INFARCTION MIGRAINOUS INFARCTION MIGRAINE-TRIGGERED SEIZURES

PROBABLE MIGRAINE
PROBABLE MIGRAINE WITHOUT AURA PROBABLE MIGRAINE WITH AURA PROBABLE CHRONIC MIGRAINE

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MIGRAINE WITHOUT AURA

Paling sedikit ada 5 serangan, 4-72 jam Unilateral Berdenyut Moderate/severe intensity Nausea/vomiting Fonophobia/Fotophobia Tidak ada hubungan dengan penyakit lain

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MIGRAINE WITH AURA

Aura : visual, sensoris, speech, 5 menit-1 jam Paling sedikit ada 2 serangan, 4-72 jam Unilateral/homonim Nyeri kepala sesuai dengan migraine without aura :

Berdenyut Moderate/severe intensity Nausea/vomiting Fonofobia/fotofobia

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MIGRAINE WITH AURA

THE PRODROME: VAGUE PREMONITORY CHANGES IN MOOD AND APPETITE THE AURA: DISTURBANCE OF NERVOUS FUNCTION, i.e.: VISUAL, HEMI-SENSORY SYMPTOMS, HEMI PARESIS, DYSPHASIA, VERTIGO / DIZZINESS AND ATAXIA HEADACH

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FAMILIAL HEMIPLEGIC MIGRAINE

Genetik, kromosom 1&19 Kriteria sesuai dengan migraine with aura Aura hemiparese 60 menit-1 jam Cerebellar ataxia (20%) Onset bisa tiba-tiba 60% pasien FHM mempunyai gejala basillar type
SPORADIC HEMIPLEGIC MIGRAINE Kriteria idem FHM No family history

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BASILAR TYPE MIGRAINE

Gambaran gejala gangguan fossa posterior Disartria Vertigo Tinnitus, pendengaran berkurang Diplopia Ataxia Bilateral parestesiapenurunan kesadaran Nyeri kepala sesuai dengan kriteria migraine without aura

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CYCLICAL VOMITING
2.5% schoolchildren Recurrent unexplained nausea & vomiting 4x dalam 1 jam-5 hari No sign of gastrointestinal disease

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ABDOMINAL MIGRAINE
12% of schoolchildren Abdominal pain, anorexia, nausea, vomiting 1-72 jam

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BENIGN PAROXYSMAL VERTIGO OF CHILDHOOD

Paling tidak 5 serangan severe vertigo Menghilang sendiri dalam beberapa menitjam No neurological deficit Normal vestibular function EEG normal Multiple Tiba-tiba dengan episode secara sporadik gejala gangguan keseimbangan, anxiety, nistagmus, muntah

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RETINAL MIGRAINE
Jarang Paling tidak ada 2x serangan scintillating, scotoma, blindness Hanya 1 mata saja Diikuti serangan nyeri kepala migren Tidak ada penyakit lain

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COMPLICATIONS OF MIGRAINE

CHRONIC MIGRAINE
Migraine without aura > 15 hari/bulannya > 3 bulan Tanpa ada tanda medication over used

STATUS MIGRAINOUS
Severe headache migraine > 72 jam Tidak ada hubungan dengan penyakit lain

PERSISTENT AURA WITHOUT INFARCTION

Aura symptom menetap > 1 minggu Pada pemeriksaan neuroimaging tidak ada infark

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COMPLICATIONS OF MIGRAINE

MIGRAINOUS INFARCTION
Jarang Satu atau lebih aura typical yang menetap selama 1 jam Pada neuroimaging nampak infark Daerah infark sesuai dengan gejala aura

MIGRAINE TRIGGERED SEIZURE

Seizure yang timbul sesuai dengan kriteria epilepsi yang muncul pada saat serangan atau 1 jam sesudah serangan migren Migralepsy
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Phases of Migraine

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MIGRAINE PATHOPHYSIOLOGY

VASOCONTRICTION (AURA) & VASODILATATION (HEADACHE) CORTICAL SPREADING DEPRESSION OLIGAEMIA PROPAGATING ACROSS THE CORTEX POSTERIOR TO FRONTAL ACTIVATION OF THE TRIGEMINO-VASCULAR SYSTEM SEROTONIN (5-HT) : VESSELS, PLATELET, NEURON AMINERGIC BRAINSTEM NUCLEI - MIGRAINE GENERATOR - CORTICAL HYPEREXITABILITY MIGRAINE TRIGGERS, i.e. : HORMONAL FLUCTUATION, EMOTION, FATIGUE, FASTING, METEOROLOGIGAL CHANGES, DIETARY FACTORS 43

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TREATMENT
Pengobatan pada fase akut migraine Terapi non spesifik

Analgetika antara lain : parasetamol, asam asetil salisilat Anti inflamasi non steroiid (AINS) Anti emetika : domperidon, metoklopramid

Terapi Spesifik
Ergotamin derivat : sudah jarang dipergunakan ; ergotamin tartrat, dihidroergotamin 5HTI (5-Hidroksi Triptamin) agonis : sumatriptan, naratriptan, zoimitriptan

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TREATMENT
Pengobatan Profilaksis Migraine Penyekat Beta : propanolol, timolol, dll Antidepressan trisiklik : protriptilin, desipiramin, amitriptilin Antagonis serotonin : metisergid, pizotifen Antihistamin : siproheptadin Antikonvulsan : asam valproat, topiramat Antagonis kalsium : flunarizin, dll

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CLUSTER HEADACHE

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CLUSTER HEADACHE
Umur 20-45 tahun 1-250 pria Pria : Wanita = 4 : 1 Intermittent, short lasting 15-180 menit, selalu pada waktu yang sama/tahun/siklus Nyeri sangat, sharp, boring, drilling, unilateral, periorbital Ipsilateral, rhinorrhea, lakrimasi, conjunctival hiperemia, kepala berkeringat, Horners syndrome

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CLUSTER HEADACHE
Episodic

CH : serangan selama 7 hari-1 tahun dengan interval free 1 bulan atau lebih Chronic CH : serangan selama > 1 tahun tanpa remisi, atau dengan remisi yang berlangsung < 1 bulan

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PATHOPHYSIOLOGY OF THE CLUSTER HEADACHE

PAROXYSMAL PARASYMPATHETIC DISCHARGE OF THE GREATER SUPERFICIAL PETROSAL NERVE & SPHENOPALATINE GANGLION
SWELLING OF THE ARTERIAL WALL OF THE INTERNAL CAROTID ARTERY

HISTAMINE RELEASE
HYPOTHALAMIC MECHANISM
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TREATMENT OF THE CLUSTER HEAD ACHE

Terapi

Abortif

Oksigen murni inhalasi dengan memakai masker oksigen 8-10 L/menit selama 15 menit Ergotamin tartrat Kombinasi oksigen dan ergotamine tartrat Tetes hidung Lidocaine 4% Sumatriptan Indomethasin

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TREATMENT OF THE CLUSTER HEAD ACHE

Terapi

Preventif :

Metisergid Kortikosteroid Ergotamin tartrat Klorpromazin Lithium karbonat Verapamil

Terapi

Operatif : Bila dengan obatobatan gagal

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CHRONIC PAROXYSMAL HEMICRANIA

CLUSTER HEADACHE SHORTER LASTING ( 2 - 45), MORE FREQUENT MOSTLY FEMALES ABSOLUTE EFFECTIVENESS OF INDOMETHACIN
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TENSION TYPE HEADACHE

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TENSION-TYPE HEADACHE

PRESSING, TIGHTENING, FULLNESS MILD TO MODERATE INTENSITY BILATERAL NO NAUSEA OR VOMITTING PHOTOPHOBIA OR PHONOPHOBIA MAY BE PRESENT WOMEN > MEN, MIDDLEAGE COINCIDE WITH ANXIETY & DEPRESSION
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TENSION TYPE HEADACHE

INFREQUENT EPISODIC TENSIONTYPE HEADACHE
INFREQUENT

EPISODIC TENSION-TYPE HEADACHE ASSOCIATED WITH PERICRANIAL TENDERNESS INFREQUENT EPISODIC TENSION-TYPE HEACHE NOT ASSOCIATED WITH PERICRANIAL TENDERNESS

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 FREQUENT EPISODIC TENSIONTYPE HEADACHE

FREQUENT

EPISODIC TENSION-TYPE HEADACHE ASSOCIATED WITH PERICRANIAL TENDERNESS FREQUENT EPISODIC TENSION-TYPE HEADACHE NOT ASSOCIATED WITH PERICRANIAL TENDERNESS

CHRONIC TENSION-TYPE HEADACHE

CHRONIC

TENSION TYPE HEADACHE ASSOCIATED WITH PERICRANIAL TENDERNESS CHRONIC TENSION-TYPE HEADACHE NOT ASSOCIATED WITH PERICRANIAL TENDERNESS

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 PROBABLE TENSION-TYPE HEADACHE

PROBABLE

INFREQUENT EPISODIC TENSION-TYPE HEADACHE PROBABLE FREQUENT EPISODIC TENSIONTYPE HEADACHE PROBABLE CHRONIC TENSION-TYPE HEADACHE

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INFREQUENT EPISODIC TENSION-TYPE HEADACHE

Deskripsi : Nyeri kepala episodik yang infrequent yang berlangsung beberapa menit sampai beberapa hari. Nyeri bilateral, rasa menekan atau mengikat dengan intensitas ringan sampai sedang. Nyeri tidak bertambah dengan aktifitas fisik rutin, tidak didapatkan mual tapi mungkin didapatkan fotofobia atau fonofobia

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INFREQUENT EPISODIC TENSION-TYPE HEADACHE

Kriteria diagnostik Paling tidak terdapat 10 episode serangan dalam < 1 hari/bulan (atau < 12 hari/tahun) Nyeri kepala berakhir dalam 30 menit-7 hari Nyeri kepala paling tidak ada 2 gejala khas :
Lokasi

bilateral Menekan, mengikat, tidak berdenyut Intensitas ringan atau sedang (mild or moderate) Tidak ada mual/muntah, mungkin ada fonofobia/fotofobia

Sama sekali tidak ada hubungannya dengan penyakit nyeri kepala lain
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INFREQUENT EPISODIC TENSION-TYPE HEADACHE

INFREQUENT EPISODIC TENSION TYPE HEADACHE ASSOCIATED WITH PERICRANIAL TENDERNESS

Episoda sesuai dengan A - E, ditambah dengan gejala nyeri tekan yang bertambah pada daerah perikranial terhadap palpasi manual

INFREQUENT EPISODIC TENSION-TYPE HEACHE NOT ASSOCIATED WITH PERICRANIAL TENDERNESS

Episoda sesuai dengan A - E, tanpa ada gejala pertambahan nyeri tekan pada daerah perikranial terhadap palpasi manual
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FREQUENT EPISODIC TENSIONTYPE HEADACHE

Kriteria Diagnostik Paling tidak terdapat 10 episode serangan dalam 1-15 hari/bulan dalam waktu paling tidak selama 3 bulan (atau 12-180 hari per tahunnya) Nyeri kepala berakhir dalam 30 menit-7 hari Nyeri kepala paling tidak ada 2 gejala khas :

Lokasi bilateral Menekan, mengikat, tidak berdenyut Intensitas ringan atau sedang (mild or moderate) Tidak ada mual/muntah, mungkin ada fonofobia/fotofobia

Sama sekali tidak ada hubungannya dengan penyakit nyeri kepala lain
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FREQUENT EPISODIC TENSIONTYPE HEADACHE

FREQUENT EPISODIC TENSION-TYPE HEADACHE ASSOCIATED WITH PERICRANIAL TENDERNESS

Episoda sesuai dengan A - E ditambah gejala nyeri tekan yang bertambah pada daerah perikranial terhadap palpasi manual

FREQUENT EPISODIC TENSION TYPE HEADACHE NOT ASSOCIATED WITH PERICRANIAL TENDERNESS
Episoda sesuai dengan A - E, tanpa adanya pertambahan pericranial tenderness

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CHRONIC TENSION TYPE HEADACHE

Kriteria diagnostik Nyeri kepala yang berasal dari ETH yang timbul > 15 hari/bulannya dalam waktu > 3 bulan (atau > 180 hari/tahun) Nyeri kepala berlangsung beberapa jam atau terus menerus Nyeri kepala paling tidak ada 2 gejala khas :

Lokasi bilateral Menekan, mengikat, tidak berdenyut Intensitas ringan atau sedang (mild or moderate) Tidak memberat dengan aktivitas fisik

Tidak ada mual/muntah, mungkin ada fonofobia/fotofobia

Sama sekali tidak ada hubungannya dengan penyakit nyeri kepala lain
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CHRONIC TENSION TYPE HEADACHE

CHRONIC TENSION-TYPE HEADACHE ASSOCIATED WITH PERICRANIAL TENDERNESS

Nyeri kepala yang sesuai A E tsb, disertai penambahan pericranial tenderness pada palpasi manual

TENDERNESS CHRONIC TENSION-TYPE HEADACHE NOT ASSOCIATED WITH PERICRANIAL

Nyeri kepala yang sesuai A - E tsb, tanpa disertai penambahan pericranial tenderness pada palpasi manual

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Dijumpai memenuhi kriteria TTH akan tetapi kurang satu kriteria untuk TTH bercampur dengan salah satu kriteria probable migraine PROBABLE INFREQUENT EPISODIC TENSIONTYPE HEADACHE
Episode memenuhi kriteria ETTH akan tetapi kurang satu kriteria saja dan tidak memenuhi kriteria migraine without aura, dan tidak ada hubungan dengan penyakit nyeri kepala lainnya

PROBABLE TENSION-TYPE HEADACHE

PROBABLE FREQUENT EPISODIC TENSION TYPE HEADACHE

Episode memenuhi kriteria ETTH frequent akan tetapi kurag satu kriteria saja dan tidak memenuhi kriteria migraine without aura, dan tidak ada hubungan dengan penyakit nyeri kepala lainnya 71

TTH TREATMENT

ANALGESICS :
ACETAMINOPHEN, ASA, NSAID

ANTIDEPRESSANTS PSYCHOTHERAPY
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TEMPORAL ARTERITIS
( GIANT-CELL ARTERITIS, CRANIAL ARTERITIS )

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TEMPORAL ARTERITIS
( GIANT-CELL ARTERITIS, CRANIAL ARTERITIS )
INFLAMATORY DISEASE OF CRANIAL ARTERIES AGED >50 YEARS,

INTENS THROBBING /NON THROBBING HEADACHE

SHARP / STABBING PAIN UNILATERAL, SOMETIMES BILATERAL

A SUPERFICIAL TEMPORALIS: THICKED, TENDER,

WITHOUT PULSATION NODULES ON THE SCALP
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TEMPORAL ARTERITIS ( GIANT-CELL ARTERITIS, CRANIAL ARTERITIS ) ( Contd ) PATIENTS FEEL GENERALLY UNWELL, LOSE WEIGHT, LOW GRADE FEVER, ANEMIA, MYALGIA BSE THROMBOSIS OF THE OPTHALMIC, POSTERIOR

CILLIARY ARTERIES BLINDNESS !!

DIAGNOSIS : BIOPSY

TREATMENT

: PREDNISON

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POSTHERPETIC NEURALGIA
ASSOCIATED WITH A VESICULAR ERUPTION HERPES ZOSTER VIRUS BURNING / STABBING PAIN, HYPERESTHESIA, ALLODYNIA

TREATMENT : - ANTICONVULSANTS - ANTIDEPRESSANTS PREVENTION PHN : - ACYCLOVIR, - TCA ANTIDEPRESSANT

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TRIGEMINAL NEURALGIA (TIC DOULOUREX)

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TRIGEMINAL NEURALGIA (TIC DOULOUREX)

Sakit hebat, tiba-tiba Pada distribusi sensorik nervus trigeminus Etiologi: Degeneratif ganglion Gasseri Penekanan akar N.V oleh: Tumor Pembuluh darah (arteriosklerosis) Demyelinasi akar N.V Paroksismal discharge neuron pada inti spinal N.V 81

Gambaran Klinis

Usia pertengahan tua Usia muda o/k : multiple sclerosis, tumor, aneurisma Nyeri bersifat paroksismal pada distribusi: mandibula/ maksila regio optalmik jarang (5%) Dapat mengenai sisi wajah Nyeri dapat dicetuskan dengan: mengunyah, minum, meraba wajah, gosok gigi, bercukur, cuci muka, hembusan angin pada wajah
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PROSEDUR DIAGNOSTIK
1. X-Ray 2. Scanning Dasar tengkorak

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PENGOBATAN
1.

2.

Medikamentosa (analgetik ajuvan) Gabapentin, Fenitoin, Valproat Karbamazepin pilihan utama TCAs Operatif

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PROGNOSIS

Sebagian besar dapat dikontrol dengan Analgesik ajuvan Pemakaian obat dapat di stop bila 6 bulan bebas rasa sakit

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Terima kasih

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