HEADACHE

Dr. Betty Soedaly Sp. S

 HEADACHE
ALL ACHES AND PAINS LOCATED IN THE HEAD.
ORBITA  OCCIPUT

Migraine treatment in 1200 BC

THE ROLE OF NEUROTRANSMITTER :
SEROTONIN (5 HT)
THE ENDOGENOUS PAIN CONTROL MECHANISM -> OPIOID
GABA
The International Classification of Headache Disorders
ICHD 2 ( 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
 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
 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 NV

BACK OF THE HEAD, NECK C 1, 2, 3
INSENSITIVE TO PAIN

 BONY SKULL
 PIA
- ARACHNOID & DURA OVER THE
CONVEXITY OF THE BRAIN
 BRAIN PARENCHYMA
 EPENDYMA, CHOROID PLEXUS
 HISTORY :
 AGE AT ONSET
 ATTACK ONSET
 QUALITY
 SEVERITY
 LOCATION, RADITION OF PAIN
 MODE OF ONSET :early warning symtom, aura
 TIME, INTENSITY, CURVE, DURATION
 CONDITION WHICH EXACERBATE / RELIEVE THE PAIN
 ASSOCIATED FEATURES
 PREVIOUS TREATMENT
 GENERAL HEALTH
 SOCIAL HISTORY, FAMILY HISTORY
 PAST HEADACHE&HEALTH HISTORY
 HEADACHE IMPACT
 EMOTIONAL STATE
 Catatan Harian Nyeri Kepala
nama : …………………………………

Hari/Tgl Mulai Akhir Berat Gejala Disabilitas Obat Pencetus

NK NK NK penyerta NK NK
(jam) (jam) (nilai 0-3) (nilai 0-4) (nilai 0-3)
_______________________________________________________________________

Berat nyeri kepala : 0:tak ada 1:ringan 2:sedang 3:berat

Gejala Penyerta : 0:tak ada 1:mual 2:muntah 3:peka cahaya 4:peka suara
Disabilitas : 0:tak ada 1:ringan 2:sedang 3:berat
Faktor Pencetus Nyeri Kepala

Stres, relaksasi setelah stres

Kurang/kebanyakan tidur
Ubah jadwal
Tidak/telat makan
Bau menyengat : parfum,rokok
Lingkungan: cahaya silau/berkedip,gaduh
ketinggian,panas,lembab
ruang berasap
Makanan/minuman
Obat
Hormonal
Trauma kapitis
PHYSICAL EXAMINATION :

INSPECTION

PALPATION

AUSCULTATION

 head, neck and nervous system

Is the examination abnormal ?

CLUSTER HEADACHE
MIGRAINE
 Migraine without aura
 Migraine with aura (typical aura with/wo
non/migraine headache, Fam/sporadic HM,
basilar-type M)
 Childhood periodic syndrome (cyclical vomiting,
abdominal M,BPV of childhood)
 Retinal Migraine
 Complications of migraine (chronic M,Status M,
persistent aura wo infarction, migranous
infarction), M triggered seizure)
 Probable migraine
MIGRAINE PATHOPHYSIOLOGY
 GENETIC FACTORS
 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
 N. O.
 Mg , DA DEFICIENCY
 EAA : GLU
 DEFECTIVE ENDOGENOUS PAIN CONTROL SYSTEM
 MIGRAINE TRIGGERS, i.e. : HORMONAL FLUCTUATION, EMOTION,
FATIGUE, FASTING, METEOROLOGIGAL CHANGES, DIETARY FACTORS
 Phases of Migraine

HAS/NEURO
HAS/Neuro S1/Bdg/04 ( Evans, 2000 )
 Migrainous Vertigo
 Childhood : Benign Paroxysmal Vertigo :
Vertigo, nystagmus, maybe cyclic. vomit.,paroxys. Torticollis
Migraine equivalent?
Ceased spontaneously ( mo-yr)
 Adult : 7% pts in dizziness clinic, 9% pts in migraine clinic
Basilar-type M
Benign recurrent vertigo : Spontan.vertigo, young/middle-aged
no cochlear/neuro.
Symtoms : female>,fam.hystory, precipitat.fact(+)
Tx: pizotifen, propranolol

Abnormality of the vestibular system

Circulation disturbances of internal auditory artery
Hormonal Fluctuation Migraine-triggered seizures
( Evans, 2000 )
Terapi Farmaka

Pengobatan Abortif/ Akut :

Reda / hilangkan nyeri kepala
Cegah nyeri kepala berlanjut

Pengobatan Preventif/Pencegahan :
Kurangi frekwensi
Kurangi beratnya nyeri kepala
TREATMENT :
Pre-emptive : domperidone, ergot
a. ABORTIVE : 2-3 d/w
- ANALGESICS :
ACETAMINOPHEN, ASA, NSAID, combination tx
SPECIFIC DRUGS : - ERGOT ALKALOIDS
( ERGOTAMINE T, DHE ) max 10mg/w
- ANTIEMETICS : - TRIPTAN (C.I! )
METOCLOPRAMIDE, DOMPERIDONE

b. PREVENTIVE : episodic, short-term,chronic(3-6mo)

>2-4attacks/mo& disability >2d
CI , overused
- ANTICONVULSANTS (valproate,topiramate,gabapentin)
- ADRENOCEPTOR BLOCKERS (propranolol,nadolol,timolol,atenolol,metoprolol )
- ANTIDEPRESSANTS (amitriptyline)
- Ca-CHANNEL BLOCKERS (flunarizine,verapamil)
 Cortex
PAIN
Phonophobia
Photophobia 5-HT1B
Thalamus receptor
Trigeminal
ganglion
Intracranial
Vasoconstriction

Autonomic activation
Nausea, Emesis
Trigeminal 5-HT1D Receptor
nucleus caudalis Trigeminal
Decreased pain Inhibition
signal transmission

Adapted from Hargreaves et al. Can J Neurol Sci 1999 Nov;26 Suppl 3:S12-9
Penanganan nonfarmaka
Edukasi
Mengenal & menghindari faktor pencetus

Modifikasi perilaku
Latihan
Relaksasi
Biofeedback
Terapi perilaku kognisi

Terapi fisik
TENS (transcutaneus electric
nerves stimulation)
 TENSION-TYPE HEADACHE
• Infrequent Episodic TTH-iFETTH (<1d/mo or <12 d/yr)
• Frequent Episodic TTH - FTTH (>12d and < 180d/yr)
• Chronic TTH- CTTH
assosiated with disorder of pericranial muscles
not associated with disorder of pericranial muscles

• Probable TTH

ICHD-2
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
HYPERVENTILATION SYNDROME
Tension Type Headache
 Psychologic factors
 Muscle contraction and myofacial

tenderness
 Vascular factorsn : NO
 Humoral factors : 5HT
 Central factors : central pain control system
TTH TREATMENT
ABORTIVE :

 ANALGESICS :

ACETAMINOPHEN, ASA, NSAID

PREVENTIVE :

 ANTIDEPRESSANTS : AMITRIPTYLINE (6MO, / 2-3MO)

NONPHARMACOLOGIC :

 RELAXATION, BIOFEEDBACK

 PSYCHOTHERAPY

 ACCUPUNCTURE ?

 BOTULINUM TOXIN A ?
CLUSTER HEADACHE &
other trigeminal autonomic cephalalgias

 Cluster headache ( episodic, chronic CH)

 Paroxismal hemicrania (episodic, chronic PH)
 SUNCT ( short-lasting unilateral neuralgiform
headache attacks with conjunctival injection and
tearing)
 Probable trigeminal autonomic cephalalgias
CLUSTER HEADACHE
YOUNG ADULT MEN ( M : F = 5 : 1 )
UNILATERAL PAIN
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
TREATMENT OF THE CLUSTER HA
 ABORTIVE :
◦ 100% O2 INHALATION
◦ TRIPTANS SC
◦ ERGOT ALKALOIDS
◦ TOPICAL LA : LIDOCAINE 4-6%NASAL DROPS
◦ ANALGESICS?
◦ OTHERS : OCREOTIDE, OLANZAPINE

 PREVENTIVE : SHORT/LONG-TERM
Short-term : triptan, ergot, corticosteroid
Long-term :
◦ VERAPAMIL
◦ LITHIUM
◦ CHLORPROMAZINE
◦ ERGOT ALKALOIDS
◦ TOPIRAMATE
◦ CORTICOSTEROID
◦ OCCIP NERVE BLOCKADE

NO ALCOHOL
PAROXYSMAL HEMICRANIA

  CLUSTER HEADACHE
 SHORTER LASTING ( 2 - 45’), MORE FREQUENT
 MOSTLY FEMALES
 ABSOLUTE EFFECTIVENESS OF INDOMETHACIN

SUNCT :~ TGN
LAMOTRIGINE
GABAPENTIN
TOPIRAMATE
OTHERS PRIMARY HEADACHES
 Primary stabbing headache
 Primary cough headache
 Primary exertional headache
 Headache associated with sexual activity
 Hypnic headache
 Thunderlap headache
 Hemicrania Continua
 NDPH ( new daily persistent headache )
Beberapa Analgesik Terapi Abortif Nyeri Kepala
(Rowbotham MC, Petersen KL, 2001)