Headache

HEADACHELuhu Avianto TapiheruDepartment of Neurology Faculty of Medicine Muhammadiyah UniversityMedan*

Definition of painPain 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 painNeuropathic painMixed pain Combination *

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THE ROLE OF NEUROTRANSMITTER : SEROTONIN (5 HT) THE ENDOGENOUS PAIN CONTROL MECHANISM -> OPIOID GABA

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ALL ACHES AND PAINS LOCATED IN THE HEAD

ORBITA OCCIPUTHEADACHE DEFINITION :*

The International Classification of Headache DisordersICHD 2 International Headache Society 2004 ( IHS 2004 )

The Primary Headaches Migraine Tension-type headache (TTH) Cluster headache Other primary headachesThe 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 disordersCranial Neuralgias, central & primary facial pain & other headaches Cranial neuralgias & central causes of facial pain Others headache, cranial neuralgias & central or primary facial pain*

SKIN, SUBCUTANEUS TISSUEMUSCLESEXTRACRANIAL ARTERIESPERIOSTEUM OF THE SKULLEYE, EAR, NASAL CAVITIES, SINUSES, TEETH, OROPHARYNX PAIN SENSITIVE STRUCTURES OF THE HEAD:*

VENOUS SINUSESDURA AT THE BASE OF THE BRAIN ARTERIES within DURA & PIA ARACHNOIDMIDDLE MENINGEAL & SUPERFICIAL TEMPORAL ARTERIESN II, N III, N V, N IX, N XC 1, 2, 3SENSORY NUCLEI OF THE THALAMUSBRAIN STEM PERIAQUEDUCTAL GRAY MATTERPAIN SENSITIVE STRUCTURES OF THE HEAD (cond)*

INSENSITIVE TO PAINBONY SKULLPIA - ARACHNOID & DURA OVER THE CONVEXITY OF THE BRAIN BRAIN PARENCHYMAEPENDYMA, CHOROID PLEXUS*

SUPRATENTORIAL STRUCTURES ANT / MED FOSSAE N V - N V 1-2 INFRATENTORIAL STRUCTURES C 1, 2, 3 POST FOSSAE N IX, N X ANT, 2/3 OF THE HEAD N V BACK OF THE HEAD, NECK C 1, 2, 3NOCICEPTOR :*

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MECHANISMS OF CRANIAL PAIN :TRACTION ON OR DILATATION OF THE INTRACRANIAL ARTERIESDISTENTION OF EXTRACRANIAL ARTERIESTRACTION ON OR DISPLACEMENT OF THE LARGE INTRACRANIAL VEINS OR DURAL ENVELOPE COMPRESSION, TRACTION OR INFLAMATION OF THE CRANIAL AND SPINAL NERVESSPASM, INFLAMATION & TRAUMA TO CRANIAL & CERVICAL MUSCLE*

MECHANISM OF CRANIAL PAIN (cond)DISEASE OF THE TISSUES OF THE SCALP, FACE, EYE, NOSE, EAR AND NECKMENINGEAL IRRITATION AND RAISED/LOWERED INTRACRANIAL PRESSURE*

ATTACK ONSETQUALITYSEVERITYLOCATIONMODE OF ONSETTIME, INTENSITY, CURVE, DURATIONCONDITION WHICH EXACERBATE / RELIEVE THE PAINASSOCIATED FEATURESSOCIAL HISTORY, FAMILY HISTORYPAST HEADACHE HISTORYHEADACHE IMPACT

HISTORY :*

Faktor pencetus Nyeri Kepala

StresKurang/kebanyakan tidurTidak/telat makanBau menyengat : parfum,rokokLingkungan: cahaya silau/berkedip,gaduh ketinggian,panas,lembab ruang berasapMakanan/minumanHAS/Neuro/Bdg/04*

PHYSICAL EXAMINATION :

INSPECTION PALPATION AUSCULTATION*

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The Secondary Headache*

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)MIGRAINE*

MAKANAN SEBAGAI FAKTOR PENCETUS MIGREN MAYORMSGWine, vodka, birKeju, coklat, yoghurtCitrus fruitsButtermilk, coklat susuYeast

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MINORKacang-kacanganFried foodsPopcornChile peppersSeafoodsPork/liverTerlampau asin/manis

MAKANAN SEBAGAI FAKTOR PENCETUS MIGREN *

MIGRAINEMIGRAINE WITHOUT AURAMIGRAINE WITH AURATYPICAL AURA WITH MIGRAINE HEADACHETYPICAL AURA WITH NON MIGRAINE HEADACHETYPICAL AURA WITHOUT HEADCHEFAMILIAL HEMIPLEGIC MIGRAINE (FHM)SPORADIC HEMIPLEGIC MIGRAINEBASILAR TYPE MIGRAINECHILDHOOD PERIODIC SYNDROMES THAT ARE COMMONLY PRECURSORS OF MIGRAINECYCLICAL VOMITINGABDOMINAL MIGRAINEBENIGN PAROXYSMAL VERTIGO OF CHILDHOOD*

RETINAL MIGRAINECOMPLICATIONS OF MIGRAINECHRONIC MIGRAINESTATUS MIGRAINOSUSPERSISTENT AURA WITHOUT INFARCTIONMIGRAINOUS INFARCTIONMIGRAINE-TRIGGERED SEIZURESPROBABLE MIGRAINEPROBABLE MIGRAINE WITHOUT AURAPROBABLE MIGRAINE WITH AURAPROBABLE CHRONIC MIGRAINE

MIGRAINE*

MIGRAINE WITHOUT AURAPaling sedikit ada 5 serangan, 4-72 jamUnilateralBerdenyutModerate/severe intensityNausea/vomitingFonophobia/FotophobiaTidak ada hubungan dengan penyakit lain

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MIGRAINE WITH AURAAura : visual, sensoris, speech, 5 menit-1 jamPaling sedikit ada 2 serangan, 4-72 jamUnilateral/homonimNyeri kepala sesuai dengan migraine without aura :BerdenyutModerate/severe intensityNausea/vomitingFonofobia/fotofobia

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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

HEADACHMIGRAINE WITH AURA*

FAMILIAL HEMIPLEGIC MIGRAINEGenetik, kromosom 1&19Kriteria sesuai dengan migraine with auraAura hemiparese 60 menit-1 jamCerebellar ataxia (20%)Onset bisa tiba-tiba60% pasien FHM mempunyai gejala basillar typeSPORADIC HEMIPLEGIC MIGRAINEKriteria idem FHMNo family history

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BASILAR TYPE MIGRAINEGambaran gejala gangguan fossa posteriorDisartriaVertigoTinnitus, pendengaran berkurangDiplopiaAtaxiaBilateral parestesiapenurunan kesadaranNyeri kepala sesuai dengan kriteria migraine without aura

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CYCLICAL VOMITING2.5% schoolchildrenRecurrent unexplained nausea & vomiting 4x dalam 1 jam-5 hariNo sign of gastrointestinal disease

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ABDOMINAL MIGRAINE12% of schoolchildrenAbdominal pain, anorexia, nausea, vomiting1-72 jam

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BENIGN PAROXYSMAL VERTIGO OF CHILDHOODPaling tidak 5 serangan severe vertigoMenghilang sendiri dalam beberapa menit-jamNo neurological deficitNormal vestibular functionEEG normalMultipleTiba-tiba dengan episode secara sporadik gejala gangguan keseimbangan, anxiety, nistagmus, muntah

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RETINAL MIGRAINEJarangPaling tidak ada 2x serangan scintillating, scotoma, blindnessHanya 1 mata sajaDiikuti serangan nyeri kepala migrenTidak ada penyakit lain

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COMPLICATIONS OF MIGRAINECHRONIC MIGRAINEMigraine without aura> 15 hari/bulannya> 3 bulanTanpa ada tanda medication over usedSTATUS MIGRAINOUSSevere headache migraine > 72 jamTidak ada hubungan dengan penyakit lainPERSISTENT AURA WITHOUT INFARCTIONAura symptom menetap > 1 mingguPada pemeriksaan neuroimaging tidak ada infark

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MIGRAINOUS INFARCTIONJarangSatu atau lebih aura typical yang menetap selama 1 jamPada neuroimaging nampak infarkDaerah infark sesuai dengan gejala auraMIGRAINE TRIGGERED SEIZURESeizure yang timbul sesuai dengan kriteria epilepsi yang muncul pada saat serangan atau 1 jam sesudah serangan migrenMigralepsy

COMPLICATIONS OF MIGRAINE*

Phases of Migraine*

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MIGRAINE PATHOPHYSIOLOGYVASOCONTRICTION (AURA) & VASODILATATION (HEADACHE)CORTICAL SPREADING DEPRESSIONOLIGAEMIA PROPAGATING ACROSS THE CORTEX POSTERIOR TO FRONTALACTIVATION OF THE TRIGEMINO-VASCULAR SYSTEMSEROTONIN (5-HT) : VESSELS, PLATELET, NEURONAMINERGIC BRAINSTEM NUCLEI - MIGRAINE GENERATOR - CORTICAL HYPEREXITABILITYMIGRAINE TRIGGERS, i.e. : HORMONAL FLUCTUATION, EMOTION, FATIGUE, FASTING, METEOROLOGIGAL CHANGES, DIETARY FACTORS*

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TREATMENT Pengobatan pada fase akut migraineTerapi non spesifikAnalgetika antara lain : parasetamol, asam asetil salisilatAnti inflamasi non steroiid (AINS)Anti emetika : domperidon, metoklopramidTerapi SpesifikErgotamin derivat : sudah jarang dipergunakan ; ergotamin tartrat, dihidroergotamin5HTI (5-Hidroksi Triptamin) agonis : sumatriptan, naratriptan, zoimitriptan*

TREATMENTPengobatan Profilaksis MigrainePenyekat Beta : propanolol, timolol, dllAntidepressan trisiklik : protriptilin, desipiramin, amitriptilinAntagonis serotonin : metisergid, pizotifenAntihistamin : siproheptadinAntikonvulsan : asam valproat, topiramatAntagonis kalsium : flunarizin, dll

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CLUSTER HEADACHE*

Umur 20-45 tahun1-250 priaPria : Wanita = 4 : 1Intermittent, short lasting 15-180 menit, selalu pada waktu yang sama/tahun/siklusNyeri sangat, sharp, boring, drilling, unilateral, periorbitalIpsilateral, rhinorrhea, lakrimasi, conjunctival hiperemia, kepala berkeringat, Horners syndrome

CLUSTER HEADACHE*

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

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PATHOPHYSIOLOGY OF THE CLUSTER HEADACHEPAROXYSMAL PARASYMPATHETIC DISCHARGE OF THE GREATER SUPERFICIAL PETROSAL NERVE & SPHENOPALATINE GANGLIONSWELLING OF THE ARTERIAL WALL OF THE INTERNAL CAROTID ARTERYHISTAMINE RELEASEHYPOTHALAMIC MECHANISM*

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Terapi AbortifOksigen murni inhalasi dengan memakai masker oksigen 8-10 L/menit selama 15 menitErgotamin tartratKombinasi oksigen dan ergotamine tartratTetes hidung Lidocaine 4%SumatriptanIndomethasinTREATMENT OF THE CLUSTER HEAD ACHE*

Terapi Preventif :MetisergidKortikosteroidErgotamin tartratKlorpromazinLithium karbonatVerapamilTerapi Operatif : Bila dengan obat-obatan gagal

TREATMENT OF THE CLUSTER HEAD ACHE*

CHRONIC PAROXYSMAL HEMICRANIA CLUSTER HEADACHESHORTER LASTING ( 2 - 45), MORE FREQUENTMOSTLY FEMALESABSOLUTE EFFECTIVENESS OF INDOMETHACIN*

TENSION TYPE HEADACHE*

TENSION-TYPE HEADACHEPRESSING, TIGHTENING, FULLNESSMILD TO MODERATE INTENSITYBILATERALNO NAUSEA OR VOMITTINGPHOTOPHOBIA OR PHONOPHOBIA MAY BE PRESENT

WOMEN > MEN, MIDDLEAGECOINCIDE WITH ANXIETY & DEPRESSION*

TENSION TYPE HEADACHEINFREQUENT EPISODIC TENSION-TYPE HEADACHEINFREQUENT EPISODIC TENSION-TYPE HEADACHE ASSOCIATED WITH PERICRANIAL TENDERNESSINFREQUENT EPISODIC TENSION-TYPE HEACHE NOT ASSOCIATED WITH PERICRANIAL TENDERNESS

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FREQUENT EPISODIC TENSION-TYPE HEADACHEFREQUENT EPISODIC TENSION-TYPE HEADACHE ASSOCIATED WITH PERICRANIAL TENDERNESSFREQUENT EPISODIC TENSION-TYPE HEADACHE NOT ASSOCIATED WITH PERICRANIAL TENDERNESSCHRONIC TENSION-TYPE HEADACHECHRONIC TENSION TYPE HEADACHE ASSOCIATED WITH PERICRANIAL TENDERNESSCHRONIC TENSION-TYPE HEADACHE NOT ASSOCIATED WITH PERICRANIAL TENDERNESS

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

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INFREQUENT EPISODIC TENSION-TYPE HEADACHEDeskripsi :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*

Kriteria diagnostikPaling tidak terdapat 10 episode serangan dalam < 1 hari/bulan (atau < 12 hari/tahun)Nyeri kepala berakhir dalam 30 menit-7 hariNyeri kepala paling tidak ada 2 gejala khas :Lokasi bilateralMenekan, mengikat, tidak berdenyutIntensitas ringan atau sedang (mild or moderate)Tidak ada mual/muntah, mungkin ada fonofobia/fotofobiaSama sekali tidak ada hubungannya dengan penyakit nyeri kepala lain

INFREQUENT EPISODIC TENSION-TYPE HEADACHE*

INFREQUENT EPISODIC TENSION TYPE HEADACHE ASSOCIATED WITH PERICRANIAL TENDERNESSEpisoda 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 TENDERNESSEpisoda sesuai dengan A - E, tanpa ada gejala pertambahan nyeri tekan pada daerah perikranial terhadap palpasi manual

INFREQUENT EPISODIC TENSION-TYPE HEADACHE*

FREQUENT EPISODIC TENSION-TYPE HEADACHEKriteria DiagnostikPaling 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 hariNyeri kepala paling tidak ada 2 gejala khas :Lokasi bilateralMenekan, mengikat, tidak berdenyutIntensitas ringan atau sedang (mild or moderate)Tidak ada mual/muntah, mungkin ada fonofobia/fotofobiaSama sekali tidak ada hubungannya dengan penyakit nyeri kepala lain

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FREQUENT EPISODIC TENSION-TYPE HEADACHE ASSOCIATED WITH PERICRANIAL TENDERNESSEpisoda sesuai dengan A - E ditambah gejala nyeri tekan yang bertambah pada daerah perikranial terhadap palpasi manualFREQUENT EPISODIC TENSION TYPE HEADACHE NOT ASSOCIATED WITH PERICRANIAL TENDERNESSEpisoda sesuai dengan A - E, tanpa adanya pertambahan pericranial tenderness

FREQUENT EPISODIC TENSION-TYPE HEADACHE*

CHRONIC TENSION TYPE HEADACHEKriteria diagnostikNyeri 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 menerusNyeri kepala paling tidak ada 2 gejala khas :Lokasi bilateralMenekan, mengikat, tidak berdenyutIntensitas ringan atau sedang (mild or moderate)Tidak memberat dengan aktivitas fisikTidak ada mual/muntah, mungkin ada fonofobia/fotofobiaSama sekali tidak ada hubungannya dengan penyakit nyeri kepala lain

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CHRONIC TENSION TYPE HEADACHECHRONIC TENSION-TYPE HEADACHE ASSOCIATED WITH PERICRANIAL TENDERNESSNyeri kepala yang sesuai A E tsb, disertai penambahan pericranial tenderness pada palpasi manualTENDERNESS CHRONIC TENSION-TYPE HEADACHE NOT ASSOCIATED WITH PERICRANIALNyeri kepala yang sesuai A - E tsb, tanpa disertai penambahan pericranial tenderness pada palpasi manual

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PROBABLE TENSION-TYPE HEADACHEDijumpai memenuhi kriteria TTH akan tetapi kurang satu kriteria untuk TTH bercampur dengan salah satu kriteria probable migrainePROBABLE INFREQUENT EPISODIC TENSION-TYPE HEADACHEEpisode memenuhi kriteria ETTH akan tetapi kurang satu kriteria saja dan tidak memenuhi kriteria migraine without aura, dan tidak ada hubungan dengan penyakit nyeri kepala lainnyaPROBABLE FREQUENT EPISODIC TENSION TYPE HEADACHEEpisode 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

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TTH TREATMENT ANALGESICS : ACETAMINOPHEN, ASA, NSAID

ANTIDEPRESSANTS PSYCHOTHERAPY*

TEMPORAL ARTERITIS ( GIANT-CELL ARTERITIS, CRANIAL ARTERITIS )

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TEMPORAL ARTERITIS ( GIANT-CELL ARTERITIS, CRANIAL ARTERITIS )

INFLAMATORY DISEASE OF CRANIAL ARTERIESAGED >50 YEARS, INTENS THROBBING /NON THROBBING HEADACHE SHARP / STABBING PAINUNILATERAL, SOMETIMES BILATERALA SUPERFICIAL TEMPORALIS: THICKED, TENDER, WITHOUT PULSATION NODULES ON THE SCALP*

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PATIENTS FEEL GENERALLY UNWELL, LOSE WEIGHT, LOW GRADE FEVER, ANEMIA, MYALGIA BSE THROMBOSIS OF THE OPTHALMIC, POSTERIOR CILLIARY ARTERIES BLINDNESS !!

DIAGNOSIS : BIOPSY

TREATMENT : PREDNISONTEMPORAL ARTERITIS ( GIANT-CELL ARTERITIS, CRANIAL ARTERITIS )( Contd )*

POSTHERPETIC NEURALGIA

ASSOCIATED WITH A VESICULAR ERUPTIONHERPES ZOSTER VIRUSBURNING / STABBING PAIN, HYPERESTHESIA, ALLODYNIA

TREATMENT : - ANTICONVULSANTS - ANTIDEPRESSANTS

PREVENTION PHN : - ACYCLOVIR, - TCA ANTIDEPRESSANT*

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TRIGEMINAL NEURALGIA (TIC DOULOUREX)*

TRIGEMINAL NEURALGIA (TIC DOULOUREX)Sakit hebat, tiba-tibaPada distribusi sensorik nervus trigeminusEtiologi:Degeneratif ganglion GasseriPenekanan akar N.V oleh:TumorPembuluh darah (arteriosklerosis)Demyelinasi akar N.VParoksismal discharge neuron pada inti spinal N.V

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Gambaran KlinisUsia pertengahan tuaUsia muda o/k : multiple sclerosis, tumor, aneurismaNyeri bersifat paroksismal pada distribusi:mandibula/ maksila regio optalmik jarang (5%)Dapat mengenai sisi wajahNyeri dapat dicetuskan dengan:mengunyah, minum, meraba wajah, gosok gigi, bercukur, cuci muka, hembusan angin pada wajah

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PROSEDUR DIAGNOSTIK1. X-Ray2. Scanning Dasar tengkorak

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PENGOBATANMedikamentosa (analgetik ajuvan)Gabapentin, Fenitoin, ValproatKarbamazepin pilihan utamaTCAsOperatif

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PROGNOSISSebagian besar dapat dikontrol dengan Analgesik ajuvanPemakaian obat dapat di stop bila 6 bulan bebas rasa sakit

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Terima kasih*