HEADACHE

Department of Neurology Faculty of Medicine Hasanuddin University Makassar

Headache

HEADACHE
o One of the most common symptoms in neurology

o 90% of individuals have at least 1 headache/year

o 40% severe, disabling headache o 5% serious underlying neurologic disorder

HEADACHE CURE

DEFINITION
PAIN
SENSORIC & EMOTIONAL EXPERIENCE
UNPLEASANT APPROPRIATE WITH TISSUE / POTENSIAL TISSUE DAMAGE

HEADACHE CURE

DEFINITION
HEADACHE

PAIN SENSATION ON UPPER HEAD AREA, FROM ORBITA TO BACK HEAD AREA (ON THE UPPER ORBITOMEATAL LINE)

FACIAL PAIN

PAIN SENSATION ON FACIAL AREA (ON THE LOWER ORBITOMEATAL LINE)

PATHOPHYSIOLOGY
EXCITATION OF PAIN SENSITIVE STRUCTURES OF THE HEAD OR NECK BY : TRACTION DISTENTION DISPLACEMENT VASCULAR SPASM INFLAMMATION

INTRACRANIAL PAIN-SENSITIVE STRUCTURES

VENOUS SINUS (SAGITAL SINUS)

DURAMATER ARTERIES ( ANTERIOR&MEDIAL MENINGEAL A.) SKULL BASE DURAMATER N. V, N. IX, N. X ARTERIES WHICH FORM WILLISI CIRCLE & THEIR BRANCHES BRAINSTEM PERIAQUADUCTAL GRISSEA SUBSTANCE SENSORIC NUCLEUS OF THALAMUS

HEADACHE CURE

EXTRACRANIAL PAIN-SENSITIVE STRUCTURES

SKIN, SCALP, MUSCLES, TENDON, & FASCIA OF HEAD & NECK SKULL PERIOSTEUM, ESPECIALLY SUPRA ORBITA, TEMPORAL AND LOWER OCCIPITAL ORBITAL SPACE AND ITS CONTAINS PARANASAL SINUS, OROPHARYNX DAN NASAL CAVITY TEETH

OUTER AND MIDDLE PART OF EAR EXTRACRANIAL ARTERIES ARTERIES, NERVES C2 & C3

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PAIN-INSENSITIVE STRUCTURES

SKULL BRAIN PARENCHYM VENTRICULAR EPENDYM CHOROID PLEXUS

BRAIN-CONVEXITY DURAMATER

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PAIN PROJECTION
INTRACRANIAL STRUCTURAL PAIN IS NOT FELT IN SKULL CAVITY BUT PROJECTED TO OTHER PARTS PAIN OF 2/3 CRANIUM (ANTERIOR, MIDDLE, SUPRATENTORIAL CRANIUM FOSSA) PROJECTED TO FRONTAL , PARIETAL, AND TEMPORAL AREA PAIN N.V INFRATENTORIAL PAIN (POSTERIOR FOSSA) PROJECTED TO BACK AREA OF EAR, UPPER AREA OF CERVICO-OCCIPITAL JOINT, UPPER SIDE OF NECK OR LARYNX (GLOSSOPHARYNGEAL NEURALGIA)

PAIN N.IX, X, C1, C2, AND C3

HEADACHE N.Kepala CURE

CAUSES OF HEADACHE & FACIAL PAIN

ACUTE ONSET * OFTEN Subarachnoid Hemorrhage Other CVD : Embolism Meningitis or Encephalitis Occular disturbance (glaucoma, acute iritis) * RARE Seizures Lumbal punction Hypertension Encephalopathy Coitus

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SUBACUTE ONSET
Temporal arterities (Giant cell) Intracranial mass ( tumor, subdural haematom, abscess) Pseudotumor cerebri (benign intracranial hypertension)

Trigeminal neuralgia Postherpetic neuralgia Hypertension Atypical facial pain

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CHRONIC ONSET

Tension headache Migraine

Cluster headache
Cervical spine disease Sinusitis Dental disease

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TRIGEMINAL NEURALGIA

DEFINITION :

Typical N.V facial pain attack, affected 1 branch/more, paroxysmal lancinating pain, pin prick or electrical sting like, occurred in a few seconds, seldom > 20 - 30 sec, followed with curing period for a few sec 1 min & next attack, often followed with lacrimation & muscle contraction, outside attack there are no pain at all. (Rose,CF. 1997)

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CAUSES :
1. IDIOPATHIC TYPE :

NEUROLOGICAL DEFICITS (-)

2. SIMPTOMATIC TYPE :

NEUROLOGICAL DEFICITS (+)

CAUSES :
CEREBELLOPONTIN ANGLE TUMOUR, N.V TUMOUR, VASCULAR MALFORMATION, SCLEROUS MULTIPLE , ETC

FACIALPAIN CURE

CLINICAL MANIFESTATION
PAIN CHARACTERISTIC : SHARP, PRICK, FLASH LIKE / ELECTRICAL STING LOCATION RADIATION PERIODICITY INTENSITY OF PAIN PROVOCATOR TRIGGER ZONES DEACTIVATORS : DISTRIBUTION OF N.V, V2 > V3 : N.V AREA, UNILATERAL (97%) : PAROXYSMAL : VERY PAINFULL : LIGHT TOUCH, CHEWING, BITING : NOSE DAN MOUTH : ANTI CONVULSANT DRUGS, LOCAL ANESTHESIA

DURATION OF ATTACK : < 20-30 SEC, HEALED PERIOD SEC - 1 MIN

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DIFFERENTIAL DIAGNOSIS
POST HERPETIC NEURALGIA

CLUSTER HEADACHE, MIGRAINE GLOSSOPHARYNGEAL NEURALGIA TEMPOROMANDIBULAR DISORDER (COSTENS SYNDROM) SINUSITIS

GIANT CELL ARTERITIS

ATYPICAL FACIAL PAIN

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TREATMENT
1. PHARMACOLOGICAL TREATMENT :

ANTI EPILEPTIC DRUGS : CARBAMAZEPIN (DRUG OF CHOICE), PHENYTOIN, CLONAZEPAM, VALPROIC ACID, LAMOTRIGINE. MUSCLE RELAXANT : BACLOFEN

2. NON PHARMACOLOGICAL TREATMENT :

ACUPUNCTURE SURGERY

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GLOSSOPHARYNGEAL NEURALGIA
1. VERY PAINFULL, SHARP, FLASH -LIKE PAIN 2. UNILATERAL ON DISTRIBUTION AREA OF N.IX (OROPHARYNX, TONSIL, TONGUE, AUDITORY MEATAL) 3. PAROXYSMAL, ATTACK ON GROUP FORM 4. PROVOCATED BY LIGHT TOUCH, SWALLOWING, SPEAKING 5. HEALED BY ANTICONVULSANT DRUGS 6. NO CLINICAL ABNORMALITY

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POST HERPETIC NEURALGIA

1. BEGINS BY VESICULAR SKIN ERUPTION DUE TO ITS
DERMATOMAL DISTRIBUTION 2. GREAT BURNING PAIN WITH SHARP EXACERBATION 3. UNILATERAL, >> N.V.1 AREA

4. CONTINUAL
5. PROVOCATED BY LIGHT TOUCH 6. ASSOCIATED WITH ALLODYNIA 7. >> SENSORIC DISTURBANCE, CORNEAL REFLEX 8. HEALED / MINIMIZED BY ACYCLOVIR, CORTICOSTEROID, ANTIDEPRESANT DRUGS

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GIANT CELL ARTERITIS

RARE IN AGE < 50 SUBACUTE GRANULAMATOUS INFLAMMATION ( LIMPHOCYTE, NEUTROPHYL, & GIANT CELL) RELATED WITH MALAISE, MYALGIA, BODY WEIGHT, FEVER (POLYMYALGIA RHEUMATICA COMPLEX) GREAT PAIN, THROBBING & STINGING UNI OR BILATERAL TEMPORAL AREA INTERMITTENT OR CONTINUE

>> CHEWING
<< WITH STEROID THICKENING & TWISTING ARTERIES

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GIANT CELL (TEMPORAL) ARTERITIS

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ATYPICAL FACIAL PAIN

CHARACTERIZED SIGNS AND SYMPTOMS

VARIATED PAIN VARIATED LOCATIONS, FROM UNILATERAL - WHOLE FACE CONTINUAL, WITH SHARP EXACERBATION PROVOCATED BY STRESS HEALED BY PRECISE THERAPY OFTEN ASSOCIATED WITH PAIN IN OTHER AREAS OF THE BODY

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PRIMARY HEADACHE

(TENSION HEADACHE)

TENSION HEADACHE
OTHER NAMES : MUSCLE CONTRACTION HEADACHE PSYCHOMYOGENIC HEADACHE STRESS HEADACHE ESSENTIAL HEADACHE

IDIOPATHIC HEADACHE
PSYCHOGENIC HEADACHE

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HEADACHE CURE

CLASSIFICATIONS : The Internatinal Headache Society (1988) 1. EPISODIC TENSION HEADACHE A. RELATED WITH PERICRANIAL MUSCLES DISTURBANCE B. NOT RELATED WITH PERICRANIAL MUSCLES DISTURBANCE 2. CHRONIC TENSION HEADACHE A. RELATED WITH PERICRANIAL MUSCLES DISTURBANCE B. NOT RELATED WITH PERICRANIAL MUSCLES DISTURBANCE 3. UNCLASSIFIED TENSION HEADACHE

HEADACHE CURE

CLASSIFICATION : The Internatinal Headache Society (2004)

1. INFREQUENT EPISODIC TENSION TYPE HEADACHE (IETTH)

MINIMAL 10 EPISODE OF ATTACK IN <1 DAY /MONTH (<12 DAYS/ MONTH) HEADACHE LASTING FOR 30 MIN - 7 DAYS BILATERAL, COMPRESSING, TIGHTENING, NOT THROBBING

CHARACTERISTIC OF PAIN LIGHT-MEDIUM

NO NAUSEA / VOMITING MIGHT BE PHONOPHOBIA / PHOTOPHOBIA NO RELATION WITH OTHER DISEASE

1.1 IETTH ASSOCIATED WITH PERICRANIAL TENDERNESS

EPISODE ~ IETTH
FOLLOWED WITH COMPRESSED PERICRANIAL PAIN WHICH INCREASED IN MANUAL PALPATION EPISODE ~ IETTH

1.2 IETTH NOT ASSOCIATED WITH PERICRANIAL TENDERNESS

NOT FOLLOWED WITH COMPRESSED PERICRANIAL PAIN WHICH INCREASED IN MANUAL PALPATION

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CLASSIFICATION : The Internatinal Headache Society (2004)

2. FREQUENT EPISODIC TENSION TYPE HEADACHE (FETTH)

MINIMAL10 EPISODES OF ATTACK IN 1-15 DAYS /MONTH IN MINIMAL 3 MONTHS OR (12 -180 DAYS /YEAR) HEADACHE LASTING FOR 30 MIN - 7 DAYS BILATERAL, COMPRESSING, TIGHTENING, NOT THROBBING CHARACTERISTIC OF PAIN LIGHT-MEDIUM NO NAUSEA / VOMITING MIGHT BE PHONOPHOBIA / PHOTOPHOBIA NO RELATION WITH OTHER DISEASE EPISODE ~ IETTH FOLLOWED WITH COMPRESSED PERICRANIAL PAIN WHICH INCREASED IN MANUAL PALPATION

1.1 FETTH ASSOCIATED WITH PERICRANIAL TENDERNESS

1.2 FETTH NOT ASSOCIATED WITH PERICRANIAL TENDERNESS

EPISODE ~ IETTH
NOT FOLLOWED WITH COMPRESSED PERICRANIAL PAIN WHICH INCREASED IN MANUAL PALPATION

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CLASSIFICATION : The International Headache Society (2004)

3. CHRONIC TENSION TYPE HEADACHE (CTTH)

HEADACHE RESULTS FROM ETTH OCCURED >15 DAYS/ MONTH IN 3 MONTHS (OR >180 DAYS/YEAR)

3.1 CTTH ASSOCIATED WITH PERICRANIAL TENDERNESS

~ CTTH FOLLOWED WITH PRESSED PERICRANIAL PAIN WHICH INCREASED IN MANUAL PALPATION

3.2 CTTH NOT ASSOCIATED WITH PERICRANIAL TENDERNESS

~ CTTH

NOT FOLLOWED WITH STRESSED PERICRANIAL PAIN WHICH INCREASED IN MANUAL PALPATION

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KLASSIFIKASI : The Internatinal Headache Society (2004)

4. PROBABLE TENSION TYPE HEADACHE (PTTH)

FULFILL TTH CRITERIA BUT LESS ONE CRITERIA FOR TTH MIXED WITH ONE CRITERIA OF PROBABLE MIGREN EPISODE FULFILL ETTH CRITERIA BUT LESS ONE CRITERIA OF POINT 1.1 AND NOT FULFILL CRITERIA OF MIGRAINE WITHOUT AURA, AND NO RELATION WITH OTHER HEADACHES EPISODE FULFILL ETTH CRITERIA BUT LESS ONE CRITERIA OF POINT 1.2 AND NOT FULFILL CRITERIA OF MIGRAINE WITHOUT AURA, AND NO RELATION WITH OTHER HEADACHES HEADACHE LASTING FOR > 15 DAYS/MONTH FOR >3 (OR >180 DAYS/YEAR) HEADACHE LASTING FOR HOURS OR CONTINUAL BILATERAL, COMPRESSING, TIGHTENING INTENSITY : LIGHT - MEDIUM NO HEAVY NAUSEA/VOMITING MIGHT BE PHOTOPHOBIA / PHONOPHOBIA NO RELATION WITH OTHER HEADACHEA MIN LAST 2 MONTHS

4.1 PROBABLE INREQUENT EPISODIC TENSION T.HEADACHE

4.1 PROBABLE FREQUENT EPISODIC TENSION T.HEADACHE

4.1 PROBABLE INREQUENT EPISODIC TENSION T.HEADACHE

HEADACHE CURE

PATHOGENESIS

DEFINITE PATHOGENESIS REMAINS UNKNOWN PSYCHOLOGICAL FACTORS : DEPENDENCE, SEXUALITY DISORDER, PERSONALITY CONTROL DISORDER, BROKEN HOME, BROKEN MARRIAGES, BAD WORK NOTES PSYCHOLOGICAL TEST : ANXIETY, DEPRESSION, HYPOCHONDRIASIS LONG LASTING PERICRANIAL MUSCLES CONTRACTION VASCULAR FACTOR : NO EVIDENCE HORMONAL FACTOR : LOW THROMBOCYTE LEVEL PAIN CONTROL MECHANISM

HEADACHE CURE

CLINICAL MANIFESTATION

BILATERAL, INTENSITY : LIGHT - MODERATE PAIN : TIGHT, COMPRESSED BY HEAVY STUFF, PAIN ON HEAD, ESPECIALLY ON FRONTAL & NECK AREA PAIN INCREASED NOON / AFTERNOON, DECREASED AFTER REST NEUROLOGICAL EXAM. NORMAL

HEADACHE CURE

TREATMENT

NON PHARMACOLOGICAL TREATMENT PSYCHOLOGIC PSYCHOTHERAPY PHYSIOLOGIC PHYSIOTHERAPY RELAXATION, MASSAGE , COMPRESS

PHARMACOLOGICAL TREATMENT ANALGESIC SEDATIVA

MINOR TRANQUILIZERS)

BOTULINUM TOXIN A (BOTOX) ACUPUNCTURE, ETC.

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MIGRAINE

HEADACHE CURE

MIGRAINE
DEFINITION :
Familial, recurrent headache, which has wide variation in intensity, frequency, and duration. Headache is commonly unilateral, followed with anorexia, nausea and vomitus . In some cases, followed with neurological disorder.

CURE

MIGRAINE
Women : men = 2 : 1 Most common onset of age : 2nd&3rd decade Activator : red wine, menstruation, hunger, lack of sleep, dazzled light, estrogen, anxiety, perfume Deactivator : sleep, pregnancy, happiness, triptans

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CLASSIFICATION : The International Headache Society (1988) :

1. Migraine without aura (common migraine) 2. Migraine with aura (classic migraine) a. Migraine with typical aura b. Migraine with prolonged aura c. Familial hemiplegic migraine d. Basillar type migraine

e. Migraine with aura without headache

f. Migraine with acute aura 3. Opthalmoplegic migraine 4. Retinal migraine 5. Migraine associated with intracranial disorder 6. Complicated Migraine a. Status migraineous - Without > drug consumption - With > drug consumption b. Infark migraine 7. Unclassified Migraine

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CLASSIFICATION AND WHO ICD-10 NA CODES (1) CLASSIFICATION AND WHO ICD-10 NA CODES (1) (IHS 2003, CEPHALGIA 2004; SUPPL 1: 1-150)

(IHS 2003, CEPHALALGIA 2004; SUPPL 1: 1-150)

Diagnosis (and aetiological ICD-10 code for secondary headache disorders) Migraine Migraine without aura Migraine with aura - 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 precursor of migraine - Cyclical vomiting - Abdominal migraine - Benign paroxysmal vertigo of childhood

IHS ICHD-II code 1. 1.1 1.2 1.2.1 1.2.2 1.2.3 1.2.4 1.2.5 1.2.6 1.3 1.3.1 1.3.2 1.3.3

WHO ICD-10 NA code G43 G43.0 G43.1 G43.10 G43.10 G43.104 G43.105 G43.105 G43.103 G43.82 G43.82 G43.820 G43 821

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CLASSIFICATION AND WHO ICD-10 NA CODES (2) (IHS 2003, CEPHALALGIA 2004; SUPPL 1: 1-150)

ICHD-II ICD-10 NA (and aetiological ICD-10 code for code code IHS WHO Diagnosis secondary headache disorders) 1.4 1.5 1.5.1 1.5.2 1.5.3 1.5.4 1.5.5 1.6 1.6.1 1.6.2 1.6.5 G43.81 G43.3 G43.3 G43.2 G43.3 G433 G43.3 + G40x/G41x G43.83 G43.83 G43.83 G43.83 Retinal migraine Complications of migraine -Chronic migraine -Status migrainosus -Persistent aura without infarction -Migrainous infarction Migraine triggered seizure Probable migraine -Probable migraine without aura -Probable migraine with aura -Probable chronic migraine

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PATHOGENESIS

Remains unknown Neurovascular reaction due to suddenly changes in extracranial and intracranial environment.

Migraine threshold depends on balance in excitation and inhibition in neuronal system level
Unstable trigeminovascular reflex with segmental defect in pain control pathway

Result : interaction between brainstem and cranial vascular migraine

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Pathogenesis

Genetic base There is association between migraine & gene which is coding D2 dopamine receptor (DRD2)(11q23) Vascular Theory

Headache phase in migraine caused by extracranial vasodilatation

Neurological symptoms caused by intracranial vasoconstriction ( widely accepted for years)

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Neuronal Theory
There is association between migraine & abnormal activity of dorsal raphe cell & locus coeruleus

Trigeminovascular System Activation of cells in medular trigeminal caudal nucleus releasing of vasoactive neuropeptide (P substance&calcitonin gene) induction of sterile inflamation soft tissue & vascular edema migraine attack

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CLINICAL MANIFESTATIONS AND DIAGNOSTIC CRITERIAS

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1. Diagnostic Criteria for Migraine without Aura

A. At least 5 attacks B-D B. Duration : 4 72 hours and no headache between attacks

C. At least 2 from characteristic below

1. Unilateral location 2. Pulsating type

3. Intensity : moderate - severe

4. Aggravated by physical activity

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D. During attack, at least one of these below :

1. Nausea or vomitus 2. Photophobia or phonophobia

E. At least one of these below :

1. No abnormalities in anamnesis, physical and neurological examination 2. Suspect of organic abnormalities in anamnesis, physical, and

neurological examination, but no abnormality was found in

neuroimaging and other supported examination

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DIAGNOSTIC CRITERIA FOR MIGRAINE WITH AURA

A. At least 2 attacks ~ B

B. At least 3 from 4 characteristics below :

One or more reversible aura which show hemisphere and or brainstem dysfunction At least one aura developed > 4 min, or 2/more aura occurred simultaneously No aura developed >60 min; if occurred 1 aura, duration is longer Headache followed aura with free pain interval < 60 min, but sometimes occurred before aura

C. At least 1 of these below :

1. No abnormalities found in anamnesis, physical and neurological examination
2.Suspect of organic abnormalities in anamnesis, physical, and neurological examination, but no abnormality was found in neuroimaging and other supported examination

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COMPLICATIONS OF MIGRAINE

1.CHRONIC MIGRAINE 2.STATUS MIGRAINE

3.PERSISTENT AURA WITHOUT INFARCT

4.INFARCT MIGRAINE

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DIFFERENTIAL DIAGNOSIS :

Migraine without aura Tension headache Cluster Headache TIA

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TRIGGER-ATTACK FACTORS

Trauma, psychogenic stress, sleep disorder Exhaustion, climate Foods containing thyramine / MSG Drinks (alcohol, chocolate) Odors Menstruation, contraception pill Barometric changes

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Treatment :
General Treatment
- Physical and mental rest - Avoid trigger factors : physical & physiological stress - Avoid certain foods - Migraine cold compress

Specific Treatment
- Pharmacologic - Non pharmacologic : TENS, psychotherapy, physiotherapy, biofeedback, cognitive therapy, yoga, meditation

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Therapy : Migraine
Abortive therapy :
Non specific - Analgetic, NSAID - Antihistamine - Anti emetic : metoclopramide 10 mg, domperidon 10 mg. - Isometheptene mucate : sympathomimetic vasoactive Specific - Ergotamin tartrat, dihidroergotamin - 5 HT1 agonis : - sumatriptan,nasatriptan, zolmitriptan

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Therapy : Migraine
Prophylaxis - Beta blocker : propanolol, thimolol,athenolol - Tricyclic antidepresant : protriptiline,desipramine, amitriptiline, nortriptiline, imipramine - Serotonin antagonist : methysergide, pizotifen - Antihistamine : siproheptadine - Anticonvulsant : valproic acid - MAO Inhibitor - Calsium antagonist : flunarizine, etc

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CLUSTER HEADACHE
PRIMARY

Unilateral orbital pain,

Supraorbital, temporal
Duration : 15-180 menit Episodic, recurrent

SECONDARY
-

Conjunctival injection, lacrimation Nasal congestion, rhinorrhea,

Sweating on forehead and face

Miosis, ptosis Orbital edema

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Therapy : Cluster headache

Abortive therapy :

O2 100% with face mask 8-10 l/min for 15 min Ergotamin tartrat Lidocaine nasal drops 4% Sumatripthane

Preventive therapy :
Methysergide

Corticosteroide

Ergotamin tartrat
Chlorpromazine Lithium carbonate Verapamile