Headache

Headache (nyeri kepala) adalah nyeri yang dirasakan di atas mata atau telinga, dibagian belakang kepala
(occipital) atau di bagian belakang di atas leher.

Mekanisme dasar nyeri kepala

Traksi pada circle of willis dan cabangnya
Dilatasi pembuluh darah intra dan ekstrakranial
Inflamasi pada struktur intra dan ekstrakranial termasuk meningen
Inflamasi yang melibatkan pembuluh darah
Kontraksi pada otot leher dan scalp
Perubahan pada tekanan intrakranial
Tekanan pada daerah orbita, telinga, nasal/paranasal dan gigi
Tekanan langsung pada serabut saraf nyeri

Tipe Headache
Primary headache
Tipe nyeri kepala yang tidak berhubungan dengan penyakit lain.dapat dibagi menjadi :
1. tension headache
2. migrain headache
3. cluster headche
Secondary headache
Tipe nyeri kepala yang dikarenakan penyakit lain.
1. Tumor otak
2. Stroke
3. Perdarahan subarachnoid
4. Meningitis
5. Efek Withdrawal kafein dan penghentian analgetik, dll

Tension type headache

Merupakan tipe primary headache yang paling banyak

Wanita > pria

90% mengenai dewasa

Bisa terjadi pada anak-anak

Does not have a clear cause

To excess stress or a hectic day
May have a cause that is similar to the cause of migraine headaches

Ada dua tipe,yaitu : 1. Episodic tension headache : biasanya berhubungan dengan faktor stres, dimana
intensitasnya moderat, self-limited dan biasanya responsif tanpa obat, nfrequent episodic : < 1 hari/bulan,
Frequent episodic : >1 dan < 15 hari/bulan (yang paling banyak), 2. Chronic tension headache : sering
kambuh setiap hari dan berhubungan dengan kontraksi otot leher dan scalp. Tipe ini bilateral dan biasanya
occipitofrontal. Terjadi > 15 hari/bulan.

Penyebab :
Tidak ada penyebab yang pasti
Faktor kekakuan otot dan psikogenik dipercaya sebagai penyebab yang paling berhubungan
Abnormalitas pada proses nyeri sentral dan peningkatan sensitifitas nyeri yang ditemukan pada beberapa
individu
Faktor genetik

Potential triggers :
Stres termasuk depresi atau ansietas
Poor posture (Bekerja atau tidur yang salah atau satu posisi dalam waktu lama)
Istirahat yang tidak cukup

Diagnosis Tension Type Headache

IHS diagnostic criteria for tension-type headaches states that 2 of the following characteristics must be
present :
Pressing or tightening (nonpulsatile quality)
Frontal-occipital location
Bilateral - Mild/moderate intensity
Not aggravated by physical activity
Tension-type headache history is as follows:
Duration of 30 minutes to 7 days
No nausea or vomiting (anorexia may occur)
Photophobia and/or phonophobia
Minimum of 10 previous headache episodes; fewer than 180 days per year with headache to be
considered "infrequent"
Bilateral and occipitonuchal or bifrontal pain
Pain described as "fullness, tightness/squeezing, pressure," or "bandlike/viselike"
May occur acutely under emotional distress or intense worry
Insomnia
Often present upon rising or shortly thereafter
Muscular tightness or stiffness in neck, occipital, and frontal regions
Duration of more than 5 years in 75% of patients with chronic headaches
Difficulty concentrating
No prodrome
Pemeriksaan fisik yang bisa ditemukan :
Vital sign normal
Pemeriksaan neurologi normal
Adanya kekakuan pada scalp atau leher
Beberapa pasien dengan occipital tension headache merasa sangat kaku saat otot servikal bagian atas
dipalpasi
Nyeri berhubungan dengan fleksi pada leher dan kekakuan saat otot paraservikal diregangkan harus bisa
dibedakan dengan gejala iritasi meningeal

Diagnosis Banding
Migrain in chronic form characteristic features disappear and pain is less severe
Neck problemsmuscle tenderness of tension type headache may involve the neck
Medication overuse headacheconsider in patiens taking opioid or combination analgesics for an
average of 10 days/month
Terapi Non farmakologi
Diet
Terapi fisik
Terapi farmakologi
Obat
Ibuprofen

Ketoprofen

Aspirin

Dosis
200800 mg

25 mg

Level
rekomendasi
A

Keterangan
Efek samping
gastrointestinal, risiko
perdarahan
Efek samping seperti
ibuprofen

5001000 mg

Efek samping seperti

ibuprofen

Naproxen

375550 mg

Efek samping seperti

ibuprofen

Diklofenak

12,5100 mg

Efek samping seperti

ibuprofen, hanya dosis 12,525 mg yang diuji pada TTH

Parasetamol

1000 mg (oral)

Recommendation TTH therapy

A Efek samping gastrointestinal

lebih sedikit disbanding
NSAIDs

Acute therapy
individual attacks

for

1. simple analgesia
Aspirin
mg

5001000

NSAID
Paracetamol
effective
placebo
effective
NSAIDS

more
than
less
than

Combination
drugs
containing simple
analgesics
and
caffeine are helpful
2. Muscle relaxant
3. Opioids or sedatives
should not be used as
impair alertness and
can cause overuse and
dependence

Preventif :
Best evidence adalah amitriptilin 75-150 mg/hari atau nortriptilin. Berguna pada
nyeri dan kekakuan otot. Dimulai dengan dosis rendah dan ditingkatkan tiap
minggu.
Prognosis :
45 % of adults with frequent or chronic tension type headche will go intoremission
39 % will carry on with frequent headaches
16 % will carry on with chronic headache
Poor prognosis associated with : Presence of chronic headache at baseline, coexisting migraine, not being married, sleep problems. Good prognosis associated
with : older age and absence of chronic tension type headache at baseline.
Important message intervene early before headaches become chronic

Migraine Headache
Second most common type
About 12% of the population in US
Affect children as well as adults
Before puberty, boys = girls
After puberty, women > men
6% of men and up to 18% of women

Penyebab
Ada banyak teori yang menjelaskan kemungkinan penyebab terjadinya migrain

 Adanya kombinasi antara vasodilatasi dan release bahan kimia dari nervus sekitar
vaskular
Selama serangan migrain, arteri temporalis melebar. Dimana pelebaran ini
menyebabkan nervus disekitarnya mengeluarkan bahan kimia yang
menyebabkan proses inflamasi dan nyeri
Adanya aktifitas sistem simpatis : menyebabkan mual,muntah,diare, kulit dingin
dan sensitif terhadap cahaya dan suara.

Diagnosis
Gejala :
Serangan kronik ataupun rekuren
Nyeri berdenyut pada satu tempat (forehead, sekitar mata atau belakang kepala)
Biasanya unilateral dan bisa juga bilateral.
Biasanya dipengaruhi aktifitas harian
Adanya peningkatan aktifitas simpatis
Serangan antara 4-72 jam
Lebih baik pada kondisi baring dan ruangan gelap
40-60% ada warning symptom beberapa jam
mengantuk,iritabilitas, fatigue, depresi atau euforia

atau

hari

sebelumnya

20% berhubungan dengan aura

Aura yang paling sering : flashing, zigzag patern biasanya dimulai di tengah
lapangan pandang dan adanya skotoma pada lapangan pandang (blind spot)
Ada juga aura berupa sensasi seperti ditusuk jarum pada tangan atau leher atau
mulut serta halusinasi auditorik dan abnormal pengecapan dan penciuman.

Terapi

 Abortive
1. Analgesics: asetaminofen, NSAID
2. Preparat ergot : ergotamin
3. Triptan
Profilaksis
1. Antiepileptik : asam valproat, topiramat
2. Antidepresan trisiklik : amitriptilin
3. Antihipertensi : betabloker, CCB
Prevensi
1. Avoiding factors (triggers) that cause the headaches, such as stress, sllep
disturbances, fasting, hormones, bright or flickering lights, unusual odors,
cigarette smoke, alcohol, aged cheeses, chocolate, monosodium glutamate,
caffeine, perubahan cuaca.
2. Preventing headaches with medications (prophylactic medications)
Prophylactic treatment of migraine

Drug

Usual Adult Daily

Dose

Common Side Effects

Propranolol1

80240 mg

Fatigue, lassitude,
depression, insomnia,
nausea, vomiting,
constipation.

Amitriptyline

10150 mg

Sedation, dry mouth,

constipation, weight gain,
blurred vision, edema,
hypotension, urinary
retention.

Imipramine

10150 mg

Similar to those of
amitriptyline (above).

Sertraline

50200 mg

Anxiety, insomnia,
sweating, tremor,
gastrointestinal
disturbances.

Fluoxetine

2060 mg

Similar to those of sertraline

(above).

Cyproheptadi 1220 mg
ne

Sedation, dry mouth,

epigastric discomfort,
gastrointestinal
disturbances.

Clonidine

0.20.6 mg

Dry mouth, drowsiness,

sedation, headache,
constipation.

Verapamil2

80160 mg

Headache, hypotension,
flushing, edema,
constipation. May aggravate
atrioventricular nodal heart
block and congestive heart
failure.

Other Beta blockers (eg, timolol and metoprolol) have also been used.

Other calcium channel antagonists (eg, nimodipine, nicardipine, and diltiazem)

have also been used.
Botulinum toxin type A injected locally into the scalp is effective for prophylaxis in
some patients. The antiseizure agents valproic acid (5001500 mg), gabapentin
(9002400 mg), and topiramate (50200 mg) are also effective and are detailed in
Table 243. Valproic acid should be avoided during pregnancy.
Calcium channel antagonist drugs may decrease the frequency of attacks after an
interval of several weeks, but the severity and duration of attacks are not
influenced.
They should not to be used with beta blockers. The angiotensin-converting enzyme
receptor blocker, candesartan, may also be affective and is undergoing evaluation.
Cluster Headache
Lebih banyak menyerang pria > wanita
Paling banyak dimulai pada usia 30 tahun

 Patofisiologi dan etiologi masih belum jelas

Pencetus bisa dari rokok dan alkohol
Klasifikasi CH :
Episodic CH : dimana ada 2 serangan yang berlangsung selama 7 hari dalam
setahun dan dipisahkan interval bebas serangan 1 bulan atau lebih
Chronic CH : serangan lebih satu kali dalam setahun tanpa remisi ataupun clusterfree interval kurang dari 1 bulan
Symptoms of Cluster Headaches
Headaches that come in group
Lasting weeks or month
Separated by pain-free periods of months or years
During the period, pain occurs once or twice daily, but some patients may more
than twice daily
Each episode lasts from 30 minutes to one and one-half hours
The same time everyday and often awaken the patient at night
Pain is excruciating and located unilaterally around one eye
The pain as feeling like a hot poker in the eye
Affected eye may become red, inflamed, and watery
Nose on the affected side : congested and runny
Tend to be restless
Often pace the floor, bang their heads against a wall, and can be driven to
desperate measures
More common in males than females
Kriteria Diagnosis
A. At least five attacks fulfilling criteria B through D
B. Severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to 180
minutes (untreated)
C. Headaches associated with at least one of the following signs on the pain side :
1. conjunctival injection
2. Lacrimation
3. Nasal congestion
4. Rhinorrhea

5. Forehead and facial sweating

6. Miosis
7. Ptosis
8. Eyelid edema
D. Frequency of attacks : one attack every other day to eight attacks per day

Terapi
Pharmacologic management of cluster headache (CH) may be classified into 2
general approaches as follows:
Abortive/symptomatic (eg, oxygen, triptans, ergot alkaloids, and anesthetics)
Preventive/prophylactic (eg, calcium channel blockers, mood stabilizers, and
anticonvulsants

Secondary Headaches
1. Extracranial disorder
Carotid or vertebral artery dissection (which also causes neck pain)
Dental disorders (eg. Infection, TMJ dysfunction)
Glaucoma
Sinusitis

2. Intracranial disorders
Brain tumors and other masses
Chiari type I malformation
CSF leak with low-pressure headache
Hemorrhage (intracerebral, subdural, subarachnoid)
Idiopathic intracranial hypertension
Infections (eg. Abscess, encephalitis, meningitis, subdural empyema)
Obstructive hydrocephalus
Vascular disorders (eg.vascular malformations, vasculitis, venous sinus
thrombosis)
3. Systemic disorders
Acute severe hypertension
Bacteremia
Fever
Giant cell arteritis
Hypercapnia
Hypoxia (including altitude sickness)
Viral infections & viremia
4. Drugs and toxins
Analgesic overuse
Caffeine withdrawal
Carbon monoxide
Hormones (eg, estrogen)
Nitrates
Proton pump inhibitors