HEADACHE

Prof. Hasan Sjahrir MD PhD

Consultant neurologist
Head, Department of Neurology
Sumatera Utara University
Member of International Headache Society
Chair Advisory of Indonesian Headache study Group

Headache
sefalgia = NYERI KEPALA

definition: pain / unpleasant sensation of the

head as long as chin until cervicooccipital

epidemiology
prevalence life time of headache are 90%
male and 96% female
Migraine
6 - 9% man, 15-18% woman.
Young adult age
Genetic factor 70%

PREVALENCE MIGRAINE

female

male

Epidemiology in Indonesia
(hospital base)
Prevalence life time TTH 78%
Episodic TTH 63% male 56% ,female 71%
TTH chronic 3% male 2 % ,female 5%
ETTH(Indonesia 31%, Medan 9.8%)
CTTH (Indonesia 24%, Medan 44%)
Migraine =10% (Indonesia)
Without aura( Medan 6.3%)
with aura (Medan 1.8%)

Prevalence in Indonesia (2004)

outpatient clinic
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Sefalgia
Osteo arthritis
Stroke
LBP + OA 7.3%
Insomnia 4.0%
Epilepsy
Vertigo
Bells palsy
LBP+HNP 2.5%
Neuropathy

42 %
9.5%
7.7%

3.8%
3.6%
3.2%
2.3%

1. Migraine wthout aura 6-10%

2. Migraine with aura
1.8%
3. ETTH
31%
4. CTTH
24%
5. Cluster Headache 0.5%
6. Mixed Hx
14%
7. Post trauma cap syndr
14%
8. Secondary Headache 3%
9. Chronic Daily Headache 9%
10.Chronic Paroksismal Hemikrania
1%

Headache verbal Scale

0 = no headache
1 : mild headache, ADL normal
2 : moderate headache, ADL a mild disturbed
(no need take a rest)
3 : severe headache : ADL very disturbed
(need take a rest/ admitted to hospital).

Pathophysiology theory of headache

1.
2.
3.
4.
5.
6.
7.

Sensitization
theory vasodilatation
activation trigeminovascular
Steril inflammation neuron
cortical spreading depression,
activation rostral brainstem
activity imbalance brain stem nuclei
regulating antinoception with
vascular control
8. etc

HEADACHE CLASSIFICATION

PRIMARY HEADACHE
1. Migraine
2. Tension Type Headache
3. Cluster Headache & other trigeminal
autonomic chephalalgias
4. Other primary headache

SECONDARY HEADACHE
Other headache, cranial neuralgia, central
or primary facial pain

International Headache Classification

(IHS)2004
1. Migraine
1.1 Migraine without aura
1.2 Migraine with aura

1.3
1.4
1.5
1.6

1.2.1
1.2.2
1.2.3
1.2.4
1.2.5
1.2.6

Typical aura with migraine headache

Typical aura with non-migraine headache
Typical aura without headache
Familial hemiplegic migraine(FHM)
Sporadic hemiplegic migraine
Basilar type migraine

Childhood periodic syndromes that are commonly precursors of migraine

Retinal migraine
Complications of migraine
Probable migraine

IHS classification of MIGRAINE 2004

1.MIGRAINE WITHOUT AURA
2. MIGRAINE WITH AURA

3. CHILDHOOD PERIODIC SYNDROME

Typical aura
Hemiplegic migraine
Basilar migraine
Cyclical vomiting
Abdominal migraine
Benign paroxysmal
vertigo childhood

4. RETINAL MIGRAINE

5. COMPLICATIONS OF MIGRAINE

6. PROBABLE MIGRAINE

Chronic migraine
Status migrainosus
Persistent aura without infarctio
Migrainous infarction
Migraine-triggered seizures

Migraine without aura ( IHS 2004)

A. At least 5 attacks
B. Hx attacks lasting 4-72 hrs
C. Hx has 2 following characteristics:
A.
B.
C.
D.

Unilateral
Pulsating
Moderate or severe pain
Agravation by physical activity

D. During Hx 1 of the following

A. Nausea and/or vomiting
B. Phonophobia and photophobia

E. Not attributed to another disorder

hasan sjahrir

Migraine Hx with Typical aura

1. Aura :visual,sensoris,speech,5- 1 hr
2. At least 2 attack, 4- 72 hours
3. Unilateral
4. Throbbing
5. Moderate/severe intensity
6. Nausea/vomiting or/and
7. Phonopobia/photopobia
8. Without motor weakness

Familial Hemiplegic Migraine

Genetik, chromosome 1 & 19
Headache fulfilling criteria migraine with
typical aura
Aura hemiparese 60 mnts
Cerebellar ataxia (20%)
Onset suddenly
60% patients FHM have symptom of basilar
type

Sporadic hemiplegic migraine

criteria idem FHM
No family history
Normal CT Scan & EEG

Basilar type migraine

Sign & symptoms of fossa posterior disorders

Disartria,
Vertigo
Tinnitus, deafness
Diplopia
Ataxia
Bilateral parestesia
unconciousness
Headache fulfilling criteria migraine without aura

1.3 Childhood periodic syndromes that are

commonly precursors of migraine
1.3.1 Cyclical vomiting
2.5% schoolchildren
Recurrent unexplained nausea & vomiting 4x /hours 5
days
No sign of gastrointestinal disease

1.3.2 Abdominal migraine

12% of schoolchildren
Abdominal pain, anorexia, nausea, vomiting

1.3.3 Benign paroxysmal vertigo of childhood

At least 5 attacks severe vertigo

Resolve within few minutes-hour
no neurological deficit
Normal vestibular function
EEG normal

Retinal migraine
Rare
At least 2 attacks scintillating, scotoma,
blindness
Unilateral (only one eye)
Follows with migraine with aura
No attributed to another disorders

1.5 Complications of migraine

1.5.1 Chronic migraine

Migraine without aura

> 15 days
> 3 months
No attributed to another disorders
without Medication over used

1.5.2 Status migrainosus

Severe headache migraine > 72 jam
No attributed to another disorders

1.5.3 Persistent aura without infarction

1.5.4 Migrainous infarction
1.5.5 Migraine-triggered seizures

The triggers or precipitants of the acute migraine attack.

1207 pts migraine of whom 75.9% reported triggers.

Stress (79.7%),
hormones in women
(65.1%),
not eating (57.3%),
weather (53.2%),
sleep disturbance
(49.8%),
perfume or odour
(43.7%),
neck pain (38.4%),
Kelman L. Cephalalgia 2007; 27:394402.

light(s)(38.1%),
alcohol (37.8%),
smoke (35.7%),
sleeping late (32.0%),
heat (30.3%),
food(26.9%),
exercise (22.1%)
sexual activity
(5.2%).

Food as Trigger factor of migraine

MAYOR
MSG
wine /vodka/bier
Cheese
Chocolate
Yogurt/yeast
citrus fruits
Buttermilk, milk

MINOR
nuts
Fried foods
Popcorn
Chile peppers
Seafoods
Pork / livers
Salty food/sweety

2.Tension-type headache
2.1 Infrequent episodic tension-type headache
2.1.1 Infrequent episodic tension-type headache associated with
pericranial tenderness
2.1.2 Infrequent episodic tension-type headache not associated
with pericranial tenderness

2.2 Frequent episodic tension-type headache

2.2.1 Frequent episodic tension-type headache associated with
pericranial tenderness
2.2.2 Frequent episodic tension-type headache not associated
with pericranial tenderness

2.1 Infrequent episodic TTH

A. At least 10 episodes occurring on <1 d/mo (<12 d/y)
and fulfilling criteria B-D
B. Headache lasting from 30 min to 7 d
C. Headache has 2 of the following characteristics:
1. bilateral location
2. pressing/tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity
D. Both of the following:
1. no nausea or vomiting (anorexia may occur)
2. no more than one of photophobia or phonophobia
E. Not attributed to another disorder

2.1 Infrequent episodic TTH

ICHD-II. Cephalalgia 2004; 24 (Suppl 1)

International Headache Society 2003/4

2.2 Frequent episodic tension-type

headache
At least 10 attacks/episodes occuring on 1- 15
days/month, for < 3 months
Headaches lasting from 30 minutes 7days

2.3 Chronic tension-type headache

2.3.1 Chronic tension-type headache Associated with
pericranial tenderness
2.3.2 Chronic tension-type headache Not associated
with pericranial tenderness
2.4 Probable tension-type headache
2.4.1 Probable infrequent episodic tension-type
headache
2.4.2. Probable frequent episodic tension-type
headache
2.4.3.Probable chronic tension-type headache

2.3 Chronic TTH

A. Headache occurring on 15 d/mo (180 d/y) for >3 mo
and fulfilling criteria B-D
B. Headache lasts hours or may be continuous
C. Headache has 2 of the following characteristics:
1. bilateral location
2. pressing/tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity
D. Both of the following:
1. not >1 of photophobia, phonophobia, mild nausea
2. neither moderate or severe nausea nor vomiting
E. Not attributed to another disorder

2.3 Chronic TTH

ICHD-II. Cephalalgia 2004; 24 (Suppl 1)

International Headache Society 2003/4

3. Cluster headache and other trigeminalautonomic cephalalgias

3.1 Cluster headache
3.1.1 Episodic cluster headache
3.1.2 Chronic cluster headache
3.2 Paroxysmal hemicrania
3.2.1 Episodic paroxysmal hemicrania
3.2.2 Chronic paroxysmal hemicrania(CPH)
3.3 Short-lasting unilateral neuralgiform headache with
conjunctival injection and tearing (SUNCT)
3.4 Probable trigeminal autonomic cephalalgia
3.4.1 Probable cluster headache
3.4.2 Probable paroxysmal Hemicrania
3.4.3 Probable SUNCT

3.1 Cluster headache

A. At least 5 attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital
and/or temporal pain lasting 15-180 min if untreated
C. Headache is accompanied by 1 of the following:
1. ipsilateral conjunctival injection and/or lacrimation
2. ipsilateral nasal congestion and/or rhinorrhoea
3. ipsilateral eyelid oedema
4. ipsilateral forehead and facial sweating
5. ipsilateral miosis and/or ptosis
6. a sense of restlessness or agitation
D. Attacks have a frequency from 1/2 d to 8/d
E. Not attributed to another disorder

3.1 Cluster headache

ICHD-II. Cephalalgia 2004; 24 (Suppl 1)

International Headache Society 2003/4

3.2 Paroxysmal hemicrania

A. At least 20 attacks fulfilling criteria B-D
B. Attacks of severe unilateral orbital, supraorbital or
temporal pain lasting 2-30 min
C. Headache is accompanied by 1 of the following:
1. ipsilateral conjunctival injection and/or lacrimation
2. ipsilateral nasal congestion and/or rhinorrhoea
3. ipsilateral eyelid oedema
4. ipsilateral forehead and facial sweating
5. ipsilateral miosis and/or ptosis
D. Attacks have a frequency >5/d for > half of the time,
although periods with lower frequency may occur
E. Attacks are prevented completely by therapeutic doses
of indomethacin
F. Not attributed to another disorder

3.2 Paroxysmal hemicrania

ICHD-II. Cephalalgia 2004; 24 (Suppl 1)

International Headache Society 2003/4

4. Other primary headaches

4.1 Primary stabbing headache

4.2 Primary cough headache
4.3 Primary exertional headache
4.4 Primary headache associated with sexual activity
4.4.1 Preorgasmic headache
4.4.2 Orgasmic headache
4.5 Hypnic headache
4.6 Primary thunderclap headache
4.7 Hemicrania continua
4.8. New daily-persistent headache (NDPH)

4.4 Primary headache

associated with sexual activity
4.4.1 Preorgasmic headache
A.Dull ache in the head and neck associated with
awareness of neck and/or jaw muscle contraction
and fulfilling criterion B
B.Occurs during sexual activity and increases with
sexual excitement
C.Not attributed to another disorder

4.4 Primary headache associated

with sexual activity
4.4.2 Orgasmic headache
A.Sudden severe (explosive) headache fulfilling
criterion B
B.Occurs at orgasm
C.Not attributed to another disorder
ICHD-II. Cephalalgia 2004; 24 (Suppl 1)

International Headache Society 2003/4

Hypnic headache
(alarm clock headache)
Attack during sleep
> 15 X /month
15-30 minutes
Age > 50 years
Bilateral
Mild-moderate

5. Headache attributed to head and/or

neck trauma
5.1 Acute posttraumatic headache
5.1.1 Acute posttraumatic headache attributed to
moderate or severe head injury
5.1.2 Acute posttraumatic headache attributed to mild
head injury

5.2 Chronic posttraumatic headache

5.2.1 Chronic posttraumatic headache attributed to
moderate or severe head injury
5.2.2 Chronic posttraumatic headache attributed to
mild head injury

8.2 Medication Overuse Headache

8.2.1 Ergotamine-overuse headache
8.2.2 Triptans-overuse headache
8.2.3 Analgesics-overuse headache
8.2.4 opioid-overuse headache
8.2.5 Combination medication-overuse headache Other
substance overuse
8.2.6. Headache attributed to other medication
overuse(code to specify substance)
8.2.7. Probable medication overuse headache (code to
specify substance)

Medication over-use
triptan, ergotamines, opioid, combination
analgesic > 10 days/month
Simple analgesic > 15 days/months

13. Cranial neuralgias and central causes

of facial pain
13.1 Trigeminal neuralgia
13.1.1 Classical trigeminal neuralgia
13.1.2 Symptomatic trigeminal neuralgia
13.2 Glossopharyngeal neuralgia
13.2.1 Classical glossopharyngeal neuralgia
13.2.2 Symptomatic glossopharyngeal
neuralgia(code to specify aetiology)

MENSTRUAL
MIGRAINE

MAM = Migraine Associated with Menses

38

"the mechanism of menstrually associated

headache appears to be related to declining
estrogen levels."

American Academy of Neurology 55th Annual Meeting 2003

39

TERAPI
Triptan:
starting 3 days before the anticipated onset of MAM
and continuing for 6 days.

American Academy of Neurology 55th Annual Meeting 2003

41

Therapy acute migraine

Abortif non specific:

Aspirin 500-1000 mg
Aspirin 900 mg+metoclopramide 10 mg
Naproxen sod 750-1250 mg
Ibuprofen 400-2400 mg
Paracetamol 500 mg+aspirin 500 mg+ caffein 130 mg

Abortif specific:
Triptan,
dihydroergotamine,
ergotamine

42

summary for treatment of acute attacks

of migraine
Triptans (serotonin1B/1D receptor agonists)
Sumatriptan
nasal spray evidence A 5-10 mg nasal spray
Sumatriptan SC
A 6 mg SC
Oral triptans
Naratriptan A 1-2.5 mg po
Rizatriptan A 10 mg po
Sumatriptan
A 50mg po
Zolmitriptan
A 2.5-5 mg po
DHE nasal spray A 0.5 nasal spray
Antiemetic : Prochlorperazine B , Metoclopramide

Preventive treatment migraine

Propranolol 40320 mg twice daily

Timolol
20-60 mg daily
Pizotifen
0.5 mg 1.5 mg/daily
Flunarizine
5 10 mg/daily
Amitriptyline 25150 mg at bedtime
Divalproate
4001500 mg twice daily
Topiramate
25200 mg daily

Indication for Prophylaxis Migraine

US Headache Consortium Guidelines, Bigal, 2006, Loder, 2005

1. Migraine duration is greater than 48 hours

2. Acute medications are ineffective/failure,
contraindicated, have side effect of drug or likely to be
overused medications
3. Attacks produce profound disability (occurs > 2 days
per month) prolonged aura, or true migrainous
infarction
4. Attacks occur > 2 more times per week, even with
adequate acute care treatment with the risk of
developing rebound headache
5. Patient preference forhasan
preventive
therapy
sjahrir
45

Therapy TTH :pharmacological

Analgetic : 2 days/week (Avoiding medication
overuse )
Aspirin 1000 mg/day, parasetamol 1000 mg/day, NSAIDs,
NSAIDs and acetaminophen (with or without caffeine), butalbital

Antidepressant:
Sedating : amitriptilin, doxepin, imipramin, trazodone
Non sedating: fluoxetine, sertraline, bupropion

Antianxiety:
benzodiazepin,: buspiron, lorazepam, alprazolam, diazepam

Therapy TTH : non pharmacology

Avoid the triggers
Avoid daily usage of analgetic, sedative
Physical Therapy :
Masage, manual therapy, compress, traction, acupuncture,
transcutaneous electrical nerve stimulation (TENS), anaestesi
injection at trigger point, improved sleep positioning with
orthopedic pillows

Therapy behaviour:
Biofeedback, stress management therapy, conseling,
relaxation therapy, cognitive behaviour th/

EFNS guidelines on the treatment of cluster headache and

other trigeminal-autonomic cephalalgias.
Therapy

Cluster Headache

Acute

100% oxygen, 15 l/min (A)

Sumatriptan 6 mg, subcutaneous
(A)
Sumatriptan 20 mg nasal (A)
Zolmitriptan 5 mg nasal (A/B)
Zolmitriptan 10 mg nasal (A/B)

Preventive Verapamil (A)

Steroids (A)

Paroxysmal
Hemicrania
None

SUNCT
Syndrome
None

Indomethacin (A)

(A denotes effective, B denotes probably effective

May, et al.2006
Lenaerts, 2008

48

VERTIGO

Prof.Hasan Sjahrir MD PhD

Department of Neurology
Sumatera Utara University,
Medan

epidemiology
Vertigo is a common complaint in the general
population
In population-based studies:
Vertigo occurs in 47% of people1, 2

Vertigo accounts for 2530% of dizziness presentations3

In people aged over 75 years:

40% of women and 30% of men report some form of
postural disturbance2

1.Yardley L et al. Br J Gen Pract 1998;48:1131-35. 2.Sixt E, Landahl S Age Ageing 1984;16:3938.
3. Hanley K et al. Br J Gen Pract 2001;51:66671. 4.Toupet M et al. Rev SFORL 2004;83:5763.

What is vertigo?
Vertigo is:
A type of dizziness
Specifically, a sensation of movement typically
characterised by feelings of rotation or spinning
Dizziness: trouble feeling of body balance to
vinicity room = giddiness
Vertigo come from Latin word vertere with the
meaning spinning turning around.
Baloh RW. Lancet 1998;352:1841-6. Mukherjee A et al. JAPI 2003;51:1095-101.
Sloane PD et al. Ann Intern Med 2001;134:823-32

Vertigo can be objective or

subjective
Objective Vertigo:
The patients perceives that the environment is
moving round him/her

Subjective Vertigo:
The patient feels himself/herself moving in a static
environment

Mukherjee A et al. JAPI 2003;51:1095-101. Salvinelli F et al. Clin Ter 2003;154:341-8

Balance, ability to realize to position, arranged

by integration of
1. system vestibular
1. Static labyrinth :
Utriculus & sacculus : gravity
2. Kinetic labyrinth
Canalis semicircularis rotation

2.
3.
4.
5.
6.

System visual
system proprioceptive ,
cerebellar ,
systemic haemostatic
psychogenic

Vestibular system
Central
Nuclei vestibuler at
medulla oblongata,
cerebelum and Connecting
Central Pathway

peripheral
end organ vestibuler
canalis semisircularis
utriculus
sacculus
saccu-endolimpaticus
ganglia vestibularis Scarpey
nervus vestibuler.

Vertigo episodes
Vertigo episodes:
are characterised by a sensation of movement,
usually spinning or rotating
vary in intensity and duration
are usually unpredictable
are often accompanied by:

nausea
vomiting
imbalance
anxiety
sweating
nystagmus

Baloh RW. Lancet 1998;352:18416. Mukherjee A et al. JAPI 2003;51:1095101.

Salvinelli F, Firrisi L, Casale M, et al. Clin Ter 2003;154:3418.

Vertigo: causes

Etiology
1. BPPV(Benign paroxysmal positional vertigo)
2. Stroke /TIA
3. Menieres syndrome
4. Migren vertebrobasiler
5. Spasmofilia
6. Parese vestibular unilateral
7. Parese vestibular bilateral
8. Nistagmus
9. Dysfunction middle ear
10.Dysfunction ganglia basalis
11.Ataxia serebellar
12.Epilepsi

Vertigo/ dizziness
I.Vestibulogenic dizziness
Vertigo central (sec
vestibular disorders)
Vertigo peripheral (primary
vestibular disorders)

II.Non Vestibular causes of

dizziness:
-Cerebellar disorders
-Hyperventilation syndrome
:anxiety
-Psychogenic dizziness :
hysterical
-postural
hypotension,paroxysmal sinus
tachycardi
-anemia,dehidrasi
subclavian steal syndrome

BPPV is the most common cause of vertigo

% patients per 100 cases

Survey of 625 ENT specialists in France

Cause of vertiginous symptoms

Toupet M et al. Rev SFORL 2004;83:5763.

Benign Paroxysmal Positional Vertigo (BPPV) is

a common type of vertigo
BPPV is typically caused by free-floating particles
in the endolymph of the posterior semicircular
canal
These particles are likely to be otoconia, displaced
from the utricle of the vestibular apparatus
Most patients are effectively treated by a simple
repositioning procedure that aims to return the
otoconia to the utricle

Parnes LS, Agrawal SK, Atlas J. CMAJ 2003;169:681 93.

Duration of vertigo episode can provide an

indication of underlying cause
Duration of vertigo episodes

Seconds

Minutes or hours

A day or more

BPPV

Menieres disease

Vestibular neuritis

Perilymph fistula

Multiple sclerosis

Migraine

Ischaemia impacting
on the brain stem

Transient ischemic attack

Salvinelli F et al. Clin Ter 2003;154:3418.

Vertigo: current treatment options

Current management options

Effective management requires identification of
vertigo type and cause
Aim of treatment:
Treat the underlying cause
Pharmacotherapy
Particle repositioning procedure
Surgery

Manage symptoms
Pharmacotherapy

Promote long-lasting neural reorganisation

Vestibular rehabilitation exercises
Baloh RW. Lancet 1998;352:18416. Mukherjee A et al. JAPI 2003;51:1095-101.

pharmacotherapy
Treatments to manage vertigo symptoms
Vestibular suppressants
Meclizine, dimenhydrinate, diazepam

Anti-emetics
Prochlorperazine, metoclopramide

Causal
Menieres disease
Diuretics
Transtympanic gentamicin

Migraine
Beta-blockers
Calcium channel blockers
Tricyclic amines

Vertebrobasilar insufficiency or transient ischaemic attacks

Antiplatelet agents

Treatment is dependent on vertigo type

Vertigo type

Treatment

Peripheral causes
BPPV

Canalith repositioning manoeuvre

Labyrinthine concussion

Vestibular rehabilitation

Menieres disease

Low-salt diet, diuretic, surgery, transtympanic gentamicin

Labyrinthitis

Antibiotics, removal of infected tissue, vestibular rehabilitation

Perilymph fistula

Bed rest, avoidance of straining

Vestibular neuritis

Brief course of high-dose steroids, vestibular rehabilitation

Central causes
Migraine

Beta-blockers, calcium channel blockers, tricyclic amines

Vascular disease

Control of vascular risk factors, e.g., antiplatelet agents

Cerebellopontine tumours

Surgery

Baloh RW. Lancet 1998;352:18416. Goebel JA. Otolaryngol Clin North Am 2000;33:48393.

The end