Primary Headache & Vertigo Sucipto, MD
Primary Headache & Vertigo
Sucipto, MD
Nyeri
• Pengalaman sensorik dan emosional yang tidak menyenangkan karena kerusakan jaringan yang sebenarnya atau yang potensial atau yang dideskribsikan sebagai kerusakan/ proses kerusakan jaringan
Nyeri kepala
• Rasa nyeri atau tidak enak pada bagian atas kepala dari daerah orbita sampai daerah oksiput
90% of adults have at least one headache/year
90% are of primary type
2.8 million annual ED visits for headache
Bangunan peka nyeri intrakranial meliputi : • Duramater dasar tengkorak• Nervus kranialis V, IX, dan X• Bagian proksimal arteri karotis interna dan
cabangnya dekat sirkulus Willisi• Arteri meningea media dan anterior• Saraf spinal bagian atas• Inti sensorik talamus
Bangunan peka nyeri ekstrakranial : • Periosteum tulang tengkorak• Kulit, jaringan subkutan, otot• Otot leher• Saraf servikal 2 dan 3• Mata, telinga, gigi• Sinus• Orofaring• Membran mukosa hidung
Classification & Epidemiology
h Tension h Migraineh Cluster
78% 16%
0.1%
Primary Headache Lifetime Prevalence
h Feverh Metabolic disorderh Disorders of nose/sinusesh Head traumah Disorders of eyesh Vascular disorders
63%22%15%
4%3%1%
Secondary Headache
Migrain
Migren
• Adalah nyeri kepala paroksismal, biasanya unilateral, berdenyut, bersifat familial, serangan berakhir dalam waktu 4-72jam, interval bebas nyeri kurang dari 1 jam, disertai gejala mual/ muntah dan atau fotofbia/ fonofobia, yang dapat didahului aura
Aura vs Prodromal
AuraGejala neurologik fokal yg kompleks yg mendahului/ menyertai migrain
• Aura visualpositif: cahaya berbagai warnanegatif: skotomacampuranzigzag
• Aura sensorikparestesia hemisensorik
• Aura motorikhemiparesedisfagia/ kesulitan bicara
Prodromal• Hiperaktif/hipoaktif• depresi• Mendambakan jenis makanan
tertentu• Gerakan mengunyah• Perasaan lemah lelah lesu• Kurang nafsu makan• Perasaan sensitif terhadap
sentuhan, suara, bau-bauan, cahaya
• Sering kencing
Visual aura
Migraine Without Aura
h Durationh 4-72 h if untreated or unsuccessfully treated
h Pain characteristics (at least 2)hUnilateral location (bilateral in 30-40%)h Pulsating qualityhModerate to severe intensityh Aggravation by walking stairs or similar physical activity
h Associated symptoms (at least 1)h Nausea, vomiting, or bothh Photophobia or phonophobia
International Headache Society Diagnostic Criteria
Aura characertistics (at least 3 )› One or more fully reversible aura symptoms indicating focal cerebral
cortical or brain-stem dysfunction› At least 1 aura symptom develops gradually over >4 minutes or 2 or
more symptoms occur in succession› No single aura symptom lasts > 60 minutes› Headache begins within 60 minutes of aura onset
Type of aura› Scotoma (blind spots)› Fortification (zig-zag patterns)› Scintilla (flashing lights)› Unilateral paresthesia/weakness› Hemianopsia
Migraine With AuraInternational Headache Society Diagnostic Criteria
Jenis-jenis• Dengan Aura tipikal
– Aura gradual <1jam– reversibel
• Dengan aura yang lama (prolonged aura)– Aura 1jam < x < 7 hari
• Familial hemiplegik• Basilar
– Aura batang otak/lobus oksipital
• Aura tanpa nyeri kepala• Serangan aura akut
– Aura < 5menit• Oftalmoplegik
– Gejala:kelumpuhan otot penggerak bola mata
• retinal – Mono okuler skotoma
atau buta < 1jam
• Sindrom periodik pada anak– Vertigo paroksismal benigna– Hemiplegik alternans
• Komplikasi migrain– Status migrenous
serangan >72jam, interval bebas nyeri <4jam
– Migren infarkaura >7hari atau ada infark di neuroimajing
• Jenis lain2• Campuran dg TTH
Migren varians• Eksersional• Menusuk idiopatik• Hemikrania paroksismal
kronis• Hemikrania paroksismal
episodik• Hemikrania kontinua
Terapi non farmakologis• Psikologi: reassurance, stress management• Fisiologi: latihan relaksasi, aerobik reguler• Edukasi tidur yang cukup• Hindari pencetus:
– Aktivitas fisik– Lingkungan– Emosi, stres, depresi, cemas– Kelaparan, hipoglikemia– Merokok– Tidur kurang/ berlebih– Hormon: menstruasi, hamil trisemester pertama, kontrasepsi oral– Makanan: keju, alkohol, kafein, coklat, gula yang pekat, makanan
berfermentasi (tapai), sayuran kacang, bawang, asinan, mengandung nitrit, nitrat, glutamat, sulfid
Terapi farmakologis
• Non Spesifik– NSAID: asetaminofen 500mg, 2-6 tab/hari, Naproksen
3x275mg atau 1-2 x 500mg, Diclofenac 3x50mg atau 1-2x 100mg, Asam Asetilsalisilat 500mg, 2-6 tab/hari
– Opioid: lemah kodein, kuat morfin– Antiemetik: domperidon, metoklopramide
• Spesifik– Triptan: sumatriptan (25mg,50mg,100mg dapat diulang
tiap 2jam max 200mg), zolmitriptan, naratriptan, rizatriptan– Ergotamine: ergotamin tartrat 1mg+kafein 100mg 2 tab
dapat diulang setelah 1jam max 6tab
Profilaksis
Indikasi• Intensitas sangat berat: menganggu aktivitas• Frekwensi > 2-3x/minggu• Hemiplegic migrain atau aura memanjang• Serangan > 48 jam
Profilaksis..(2)
• Beta bloker: propanolol, timolol, nadolol, metaprolol, atenolol
• Antidepresan trisiklik: protriptilin, desipramin, amitriptilin, doksepin, nortriptilin, imipramin
• Antagonis serotonin: Metisergid, Pizotifen• Antihistamin: siproheptadin• Antikonvulsan: asam valproat• Inhibitor MAOA• Antagonis kalsium: flunarizin, nifedipin, nimodipin,
verapamil, diltiazem
Migraine Pathophysiology
• Not clearly understood– Vascular Theory – Neurovascular Theory
• Vascular theory (Wolff et al in 1940s and 1950s) :Intracranial vasoconstriction (aura) rebound vasodilatation activation of perivascular nociceptive nerves (headache)
Neurovascular theory Cortical spreading depression (Leao,1944) causing aura
Neuronal excitation in the cortical gray matter waves that Spread at the rate of 2-6 mm/min followed by a wave of neuronal suppression blood vessels simultaneously dilate & constrict aura
Brainstem activationOnce the CSD occurs H+ & K+ ions diffuse to the piamater activate C-fiber meningeal nociceptors releases a proinflammatory soup (eg, CGRP) plasma extravasation (sterile neurogenic inflammation of the trigeminovascular complex trigeminal system activated stimulates the cranial vessels to dilate dilatation of blood vessels headache
Neurochemical basis of CSD : release of potassium or glutamate from neural tissue depolarizes the adjacent tissue releases more neurotransmitters propagating the spreading depression
Why these neurons are more excitable in certain patients is not entirely clear genetic defect ??? (in familial hemiplegic migraine)
Tension Type headache
Nyeri Kepala tipe tegang
• Konstan dan terus menerus, pasien tidak pernah merasa bebas dari sakit
• Berat seperti ditimpa, seperti ikat kepala, seperti diperas, mau meledak, teras kosong
• Tempat tidak karakteristik• Frekuensi, intensitas sangat berfluktuasi
Tension Headache
h Durationh 30 min to 7 days
h Pain characteristics (at least 2)h Pressing/tightening qualityhMild to moderate severityh Bilateral fronto-occipital locationhNo aggravation by routine physical activity
h Associate symptoms (must have both)hNo nausea or vomitinghNo more than one of : anorexia, photophobia, phonophobia
International Headache Society Diagnostic Criteria
Terapi • Terapi non farmakologi
– Fisioterapi– Psikoterapi
• Terapi farmakologi– Analgetik, NSAID– Antidepresan
• Relaksan otot oral– Efek sentral
• Mirip mefenesin: eperison HCl, klornefesin, karisoprodol, klorzoksazon, tolperison
• Antagonis GABA: baklofen, diazepam• Imidazon: tizanidin HCl
– Efek perifer: dantrolen Na
Cluster
Cluster Headache
h Durationh 15 to 180 minutes untreated
h Pain characteristicsh Severe unilateral orbital, supraorbital, or temporal pain
h Associated symptoms (at least 1, ipsilateral to pain)h Conjunctival injection, LacrimationhNasal congestion, Rhinorrheah Forehead and facial swellinghMiosis, Ptosish Eyelid Edema
h Frequencyh between 1 every other day to 8/day
International Headache Society Diagnostic Criteria
Patofisiologi
The underlying pathophysiology is not completely understood› Involvement of a biological clock within the hypothalamus › Central disinhibition of the nociceptive and autonomic
pathways
sakit pada CH berasal dari kompleks sinus cavernosus. Kemudian rasa sakit diteruskan oleh saraf simpatik dan para simpati kemudian diteruskan ke batang otak. Penyebab sakit masih kontroversi antara hipoksemia, hipocapnea, factor imunoligic dan vasoregulator.
Jenis Cluster
• Periodisitas tidak tergolongkan• Episodik
– Serangan 7 hari s/d 1 tahun– Masa bebas nyeri ≥ 14 hari
• Kronik– Serangan ≥ 1 tahun– Tanpa masa bebas nyeri atau < 14 hari
• Kronik tidak remisi sejak onset– Sejak onset Tanpa masa bebas nyeri atau < 14 hari
• Kronik yg episodik: Remisi-tidak ada remisi-remisi
Terapi Abortif• Ergotamin tartrat• Metilsergide• Litium karbonat 360-600mg/hari • injeksi lidocain 1%• Verapamil 120-200mg/hariPreventif• Metilsergid 4-10mg/hari• Kortikosteroid prednison 60-80 mg/hari• Sodium divalproat• Klorpromazin• Konidin transdermal• Ergotamine tartrat 2-3 x 2mg• Indometasin 150mg• Litium karbonat 300-1500mg/hari• Verapamil 120-200 mg/hari
Migrain Tension-Type (TTH) Sakit kepala klasterLokasi Umumnya unilateral Bilateral Unilateral (tidak
berpindah)Intensitas Sedang-berat
Diperberat Aktivitas rutin
Ringan-sedang
Tidak diperberat aktivitas rutin
Berat
Durasi 4-72 jam 30 menit-7 hari 15-180 menitFrekwensi Sporadik, beberapa
kali sebulanKonstan Beberapa kali dalam
semingguKualitas Berdenyut Seperti ditekan/penuh Berat (bervariasi)Gejala Penyerta Dapat disertai
nausea, muntah, aura visual, fotofobia dan fonofobia
Disertai lelah dan ngantuk, biasanya timbul saat depresi/ansietas. Tidak disertai nausea, fotofobia, maupun fonofobia.
Dapat disertai gejala autonomic contohnya: lakrimasi, injeksi konjungtiva, kongesti nasal, rhinorhea, miosis, ptosis, edema palpebra.
Gender Wanita>Pria Wanita>Pria Pria>Wanita
Vertigo
Balance Function and DysfunctionInteraction of Vestibular, Visual and Proprioceptive systems
Balance dyfunction
dizziness
Central Nervous system
Muscle and joint sensory receptors
Postural control via
muscles
Goebel JA. Otolaryngol Clin North Am 2000;33:483–93. Shepard NT, Solomon D. Otolaryngol Clin North Am 2000;33:455–69
Controls eye
movements
Eye Skin pressure receptorsInner ear
(vestibular system)
Reseptor alat keseimbangan
• Reseptor alat keseimbangan tubuh di perifer berperan dalam proses transduksi yang terdiri dari:• Reseptor mekanis di vestibulum berespon
terhadap gerakan angular dan linier kepala dan terhadap gravitasi.
• Reseptor cahaya di retina • Reseptor mekanis di otot, kulit dan persendian
• Saraf aferen berperan dalam proses transmisi menghantarkan impuls ke pusat keseimbangan otak. Saraf aferen ini terdiri dari:– Saraf vestibularis– Saraf optikus– Saraf spino vestibulo serebralis
• Pusat-pusat keseimbangan, berperan dalam proses modulasi, komparasi, integrasi/koordinasi dan persepsi. Terdiri dari :• Inti vestibularis• Serebellum• Korteks serebri• Hipotalamus• Inti okulomotorius• Formasio retikularis
Fisiologi Keseimbangan
• Sinyal informasi untuk alat keseimbangan tubuh ditangkap oleh reseptor vestibuler, visual, dan proprioseptif.
• reseptor vestibuler memiliki peranan yang paling besar, yaitu >50%.
• Arus informasi berlangsung intensif bila ada gerakan atau perubahan gerakan dari kepala atau tubuh.
Etiologi
1. Keadaan lingkungan Motion sickness (mabuk darat, mabuk laut)
2. Obat-obatan Alkohol Gentamisin
3. Kelainan sirkulasi Transient ischemic attack
ETIOLOGI (2)4. Kelainan di telinga
Endapan kalsium pada salah satu kanalis semisirkularis di dalam telinga bagian dalam
Infeksi telinga bagian dalam karena bakteri Herpes zooster Labirintitis (infeksi labirin di dalam telinga) Peradangan saraf vestibuler Penyakit Meniere
5. Kelainan neurologis Sklerosis multipel Patah tulang tengkorak yang disertai cedera pada labirin,
persarafannya atau keduanya Tumor otak Tumor yang menekan saraf vestibularis.
Teori Vertigo
• Konflik sensoris: ransangan diatas ambang fisiologis exessive discoordination information
• Neural mismatch: ransangan gerakan yang sedang dihadapi tidak sesuai dengan memori
• Ketidakseimbangan saraf otonomik: dominan Parasimpatis timbul sind vertigo, dominan Simpatis gejala menghilang
• Neurohormonal: hipotalamus mengeluarkan CRF aktivasi simpatis
4 jenis Dizziness
DIZZINESS
Vertigo Vertigo Presyncope DysequilibiumVesibular Non-vestibular
Ilusi berputar Ilusi melayang Rasa akan pingsan tungkai tak stabil ∆ ∆ ∆ ∆Sistem - Sistem Sistem SistemVestibular Visual, Proprioseptif Kardiovaskular serebelar, spinal - Psikogenik
“Spinning” “Light-headed” “ Fainting” “Falling”
Vertigo
Hal Vestibular Non vestibular
Sifat vertigo berputar Malayang, sempoyongan
Sifat serangan episodik Kontinyu
Mual muntah + -
Gangguan pendengaran +/- -pencetus Gerakan kepala Objek visual
situasi - Orang ramai
Letak lesi vestibular Somatosensorik/ propioseptif, visual
VERTIGO VESTIBULAR
Baloh RW. Lancet 1998;352:1841–6. Mukherjee A et al. JAPI 2003;51:1095-101. Puri V, Jones E. J Ky Med Assoc 2001;99:316–21. Salvinelli F et al. Clin Ter 2003;154:341–8. Strupp M, Arbusow V, Curr Opin Neurol 2001;14:11–20.
Peripheral
Involving:- Inner ear- Vestibular nerve
Central
Involving CNS structures:
- Brainstem- Cerebellum- Cerebrum
VERTIGO vestibulerPERIFER vs SENTRAL
Gejala Peripheral Central
Awitan Mendadak Perlahan
Mual, muntah
Berat Bervariasi
Gejala pendengaran Sering
Jarang
Gejala Nerologik fokal - Sering
Kompensasi/resolusi
Cepat
Lambat
Gerakan kepala + +/-
Baloh RW. Otolaryngol Head Neck Surg 1998;119:55–9. Puri V, Jones E. J Ky Med Assoc 2001;99:316–21.
Vertigo of Peripheral origin: causes
Condition Details
Benign paroxysmal positional vertigo (BPPV)
Brief, position-provoked vertigo episodes caused by abnormal presence of particles in semicircular canal
Meniere’s disease An excess of endolymph, causing distension of endolymphatic system
Vestibular neuronitis Vestibular nerve inflammation, most likely due to virus
Acute labyrinthitis Labyrinth inflammation due to viral or bacterial infection
Labyrinthine infarct Compromises blood flow to the labyrinthine
Labyrinthine concussion
Damage to the labyrinthine after head trauma
Perilymph fistula Typically caused by labyrinth membrane damage resulting in perilymph leakage into the middle ear
Autoimmune inner ear disease
Inappropriate immunological response that attacks inner ear cells
Decre
asi
ng
fre
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Baloh RW. Lancet 1998;352:1841–6. Mukherjee A et al. JAPI 2003;51:1095-101. Parnes LS et al. CMAJ 2003;169:681– 93. Puri V, Jones E. J Ky Med Assoc 2001;99:316–21. Salvinelli F et al. Clin Ter 2003;154:341–8.
Vertigo of Central origin: causes
Condition Details
Migraine Vertigo may precede migraines or occur concurrently
Vascular disease Ischaemia or haemorrhage in vertebrobasilar system can affect brainstem or cerebellum function
Multiple sclerosis Demylination disrupts nerve impulses which can result in vertigo
Vestibular epilepsy
Vertigo resulting from focal epileptic discharges in the temporal or parietal association cortex
Cerebellopontine tumours
Benign tumours in the internal auditory meatus
Decr
easi
ng
fre
qu
en
cy
Baloh RW. Lancet 1998;352:1841–6. Mukherjee A et al. JAPI 2003;51:1095-101. Salvinelli F et al. Clin Ter 2003;154:341–8. Solomon D. Otolaryngol Clin North Am 2000;33:579–601. Strupp M, Arbusow V, Curr Opin Neurol 2001;14:11–20.
nistagmus
perifer Sentral
Latensi +, 2-20 detik -
Vertigo + +/-
fatique + -
Arah Telinga bawah Telinga atas/ bervariasi
Lama <1menit >1menit
Diagnosis
• Tes kalori• Tes dix hallpike• ENG
– Tes melirik– Tes posisional
• Tes sakadik• Head shaking test• Tracking test
TREATMENT OF VERTIGOCURRENT TREATMENT OPTIONS
1. Symptomatic Pharmacotherapy 2. Treatment for Specific Conditions
● Pharmacotherapy ● Particle repositioning procedure (in BPPV) ● Surgery
3. Rehabilitative ● Vestibular Rehabilitation Therapy
4. Prevention of aggravating factor ● Diet control ● Life-style changes
Baloh RW. Lancet 1998;352:1841–6. Mukherjee A et al. JAPI 2003;51:1095-101.
1. SYMPTOMATIC TREATMENT
I. ANTIVERTIGO Vestibular Suppressant 1. Ca channel blocker : Flunarizin 2. Histaminic : Betahistine 3. Antihistamin : Difenhidramine, sinarisin4. Antikolinergik5. Monoaminergik6. Benzodiazepin7. Histamine8. Beta bloker9. Anti epileptik II. ANTIEMETIC Prochlorperazine, metoclopramide.
III. Psychoaffective Clonazepam, diazepam for anxiety and panic attack
Treatment for Specific Conditions
PERIPHERAL VERTIGO
● BPPV Canalith repositioning manoeuvre (Brandt-
Daroff, Epley, Semont maneuvre)
● Meniere’s disease Low-salt diet, diuretic, surgery, transtympanic
gentamicin
● Labyrinthitis Antibiotics, removal of infected tissue,
vestibular rehabilitation
● Vestibular neuritis Steroids, vestibular rehabilitation
● Labyrinthine concussion Vestibular rehabilitation
● Perilymph fistula Bed rest, avoidance of straining
CENTRAL VERTIGO
MigraineBeta-blockers, calcium channel
blockers, tricyclic amines, anticonvulsants
Vascular diseaseControl of vascular risk factors,
antiplatelet /antikogulan agents
CPA tumoursSurgery
Specific Treatment for BPPV
1. Office Treatment ● Epley maneuver ● Semont maneuver
2. Home Treatment ● Brandt-Daroff Exercises
30 sec
30 sec
30 sec
Epley maneuver
Other name:• Canalith repositioning• Particle repositioning
Time Exercise Duration---------------------------------------------Morning 5 X 10 minNoon 5 X 10 minEvening 5 X 10 min---------------------------------------------
Brandt-Daroff maneuver
Cawthorne Cooksey exercises
Pendekatan klinisCephalgia
Anamnesis
• Onset• Lokasi • Frekwensi• Durasi, keparahan, sifat• Dampak• Aura atau prodromal• Gejala lain yang menyertai:
injeksi membran mukus, gangg GI, polyuria
• Gangg mood• Gangg penglihatan• Faktor yang memicu• Faktor yang meredakan• Pengaruh posisi tubuh• Gangg tidur• RPS: stress• RPK• RPD
PF
• Tenderness • Injeksi konjungtiva• Papiledema• Refleks pupil• Diplopia• Posisi bola mata• Kelopak mata• Motorik wajah• Sensorik wajah
Sakit kepala yg berbahaya
Pasien dgn keluhan sakit kepala
Anamnesis dan pemeriksaan fisik
Tanda sakit kepala yg berbahaya
Ya Tdk Anamnesis Sakit kepala primer- Tension-Headache- Migren- Chronic daily Headache
Pemeriksaan penunjang utk eksplorasi penyebab sakit kepala sekunder (MRI, CT scan, laboratorium, foto torak dll)
Anamnesis Sakit kepala yg berbahaya
• Onset• Persisten• Progressive• Usia• Adanya penyakit lain
Onset : sakit kepala yg berbahaya
• Onset sakit kepala yg jelas• Sakit kepala berat yang mendadak• Onset < 6 bln dianggap berbahaya sampai
terbukti tdk berbahaya
Persisten : sakit kepala yg berbahaya
• Sakit kepala yg terus menerus, tidak berkurang dalam 24 jam
• Respon terhadap pengobatan minimal
Progressive : sakit kepala yg berbahaya
• Membandingkan dlm kurun waktu tertentu• Kualitasnya : makin hebat• Gangguan pd aktifitas sehari-hari• Respon terhadap pengobatan : butuh dosis
obat yg lebih besar• Adanya gejala penyerta lainnya.
Usia : sakit kepala yg berbahaya
• Usia sgt muda atau usia tua• Usia > 55 thn selalu dianggap berbahaya
sampai terbukti tidak berbahaya• Anak
Penyakit lain – Keluhan lain
• Demam• Muntah• Gejala Neurologi
– Tanda peningkatan tekanan intrakranial• Riwayat keganasan• Diagnosis HIV atau IDU
HEADACHE RED FLAGS• Systemic symptoms or illness
including fever, persistent or progressive vomiting, stiff neck, pregnancy, cancer, immunocompromised state, anticoagulated
• Neurologic signs or symptomsincluding altered mental status, focal neurologic symptoms or signs, seizures, or papilledema
• Onset is new especially in those age 40 years / older or sudden
• Other associated conditions eg, headache is subsequent to head trauma, awakens patient from sleep, or is worsened by Valsalva maneuvers
• Prior headache history that is different eg, headaches now are of different pattern or are rapidly progressive in severity or frequency
When such red flags are present, neuroimaging (CT or MRI) is indicated to investigate secondary causes of headache
Venkatesan A. headache red flags. John Hopkins University. Downloaded from http://www.medscape.com/viewarticle/537504_2
Diagnostic alarms of Headache Headache alarm Differential Diagnosis Work up
Headache begins after age of 30
Temporal arteritis, mass lesion
Erythrocyte sedimentation rate, neuroimaging
Sudden onset headache SAH, mass lession Neuroimaging, LP
Acclerating pattern of headache
Mass lesion, subdural hematoma, medication overuse
Neuroimaging, drug screen
New onset headache in a patient with cancer or HIV
Meningitis, brain abcess, toxoplasmosis, metastases
Neuroimaging, LP
Headache with systemic illness (fever, stiff neck, rash)
Meningitis, encephalitis, systemic infection, vascular disease
Neuroimaging, LP, blood test
Focal neurologic simptom or sign of disease
Mass lessions, AVM, stroke, colagen vascular disease
Neuroimaging, colagen vascular evaluation
Papiledema Mass lessions, pseudotumor, meningitis
Neuroimaging, LP
Silberstein SD, Lipton RB and Dalessio DJ. Overview, diagnosis and classification of headache in Wolfs Headache and other head pain . Oxford: Oxford University Press. 2001. p20