HEADACHE

Setyawati Asih Putri

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

Migraine treatment in 1200 BC

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HAS/NEURO
 THE ROLE OF NEUROTRANSMITTER :
SEROTONIN (5 HT)
THE ENDOGENOUS PAIN CONTROL MECHANISM -> OPIOID
GABA
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 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

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 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

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 INSENSITIVE TO PAIN

 BONY SKULL
 PIA - ARACHNOID & DURA OVER THE
CONVEXITY OF THE BRAIN
 BRAIN PARENCHYMA
 EPENDYMA, CHOROID PLEXUS

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 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

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 MECHANISMS OF CRANIAL PAIN
 TRACTION ON OR DILATATION OF THE INTRACRANIAL
ARTERIES
 DISTENTION OF EXTRACRANIAL ARTERIES
 TRACTION ON OR DISPLACEMENT OF THE LARGE
INTRACRANIAL VEINS OR DURAL ENVELOPE
 COMPRESSION, TRACTION OR INFLAMATION OF THE
CRANIAL AND SPINAL NERVES
 SPASM, INFLAMATION & TRAUMA TO CRANIAL & CERVICAL
MUSCLE
 DISEASE OF THE TISSUES OF THE SCALP, FACE, EYE, NOSE,
EAR AND NECK
 MENINGEAL IRRITATION AND
RAISED/LOWERED INTRACRANIAL PRESSURE
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 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

HAS/NEURO
 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
HAS/Neuro/Bdg/04
 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

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HAS/NEURO
HAS/NEURO
 PHYSICAL EXAMINATION :

INSPECTION

PALPATION

AUSCULTATION

 head, neck and nervous system

Is the examination abnormal ?

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CLUSTER HEADACHE

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 The Secondary Headache

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 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

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MIGRAINE PATHOPHYSIOLOGY
 VASOCONTRICTION (AURA) & VASODILATATION (HEADACHE)
 GENETIC FACTORS
 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

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Phases of Migraine

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HAS/NEURO
HAS/Neuro S1/Bdg/04 ( Evans, 2000 )
HAS/NEURO
Hemiplegic Migraine : sporadic, familial (147/291)
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 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
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 Chronic Migraine/Tranformed Migraine

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 Hormonal Fluctuation Migraine-triggered seizures
HAS/Neuro/Bdg/04
( Evans, 2000 )
 Terapi Farmaka

Pengobatan Abortif/ Akut :

Reda / hilangkan nyeri kepala
Cegah nyeri kepala berlanjut

Pengobatan Preventif/Pencegahan :
Kurangi frekwensi
Kurangi beratnya nyeri kepala

Obat pereda nyeri ( analgesik ) :

analgesik biasa,OAINS
analgesik spesifik
analgesik ajuvan
HAS/Neuro/Bdg/04
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)
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 Cortex
PAIN
Phonophobia
Photophobia 5-HT1B
Thalamus receptor
Trigeminal
ganglion
Intracranial
Vasoconstriction

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

Adapted from Hargreaves et al. Can J Neurol Sci 1999 Nov;26 Suppl 3:S12-9 HAS/Neuro/Bdg/04
Penanganan nonfarmaka
Edukasi
Mengenal & menghindari faktor pencetus

Modifikasi perilaku
Latihan
Relaksasi
Biofeedback
Terapi perilaku kognisi

Terapi fisik
TENS (transcutaneus electric
nerves stimulation)

HAS/Neuro/Bdg/04
 TENSION-TYPE HEADACHE
• Infrequent Episodic TTH-iFETTH (<1d/mo or <12 d/yr)
• Frequent Episodic TTH - FETTH (>12d and < 180d/yr)

• Chronic TTH- CTTH

assosiated with disorder of pericranial muscles

not associated with disorder of pericranial muscles

• Probable TTH

HAS/NEURO 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
HAS/NEURO
 TTH TREATMENT
ABORTIVE :

• ANALGESICS :

ACETAMINOPHEN, ASA, NSAID

PREVENTIVE :

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

NONPHARMACOLOGIC :

• RELAXATION, BIOFEEDBACK

• PSYCHOTHERAPY

• ACCUPUNCTURE ?

• BOTULINUM TOXIN A ?

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 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

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CLUSTER HEADACHE
YOUNG ADULT MEN ( M : F = 5 : 1 )
UNILATERAL PAIN

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 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
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HAS/NEURO
 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

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 PAROXYSMAL HEMICRANIA

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

SUNCT :~ TGN
LAMOTRIGINE
GABAPENTIN
TOPIRAMATE

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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 )
 HEADACHE ATTRIBUTED TO
HEAD/-NECK TRAUMA
• Acute/chronic post traumatic headache
• Acute/chronic attributed to whiplash injury
• Headache attributed to traumatic intracranial
hematome : epi (to24h)/sub(24-72h)dural hematome
• Acute/chronic headache attributed to others
head/neck trauma
• Post-craniotomy headache
 within 7 d
</= or > 3 mo
 HEADACHE ATTRIBUTED TO
CRANIAL/VASCULAR DISOEDER
• Ischemic stroke or TIA
• Non traumatic intracranial hemorrhage
• Unruptured vascular malformation
• Arteritis/vasculitis
• Carotid or Vertebral artery pain
• Cerebral venous trombosis
• Other intracranial vscular disorder
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 Posterior communicating aneurysm

STROKE HAS/NEURO
 TEMPORAL ARTERITIS
( GIANT-CELL ARTERITIS, CRANIAL ARTERITIS )

 INFLAMATORY DISEASE OF CRANIAL ARTERIES

 AGED >50 YEARS,

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 TEMPORAL ARTERITIS
( GIANT-CELL ARTERITIS, CRANIAL ARTERITIS )

 PATIENTS FEEL GENERALLY UNWELL,

LOSE WEIGHT, LOW GRADE FEVER, ANEMIA,
MYALGIA
 BSE 
 THROMBOSIS OF THE OPTHALMIC, POSTERIOR
CILLIARY ARTERIES  BLINDNESS !!

DIAGNOSIS : BIOPSY

TREATMENT : PREDNISON 75mg/d10mg/d

3mo 12mo HAS/NEURO
 HEADACHE ATTRIBUTED TO NONVASCULAR
INTRACRANIAL DISORDER

• High/low CSS fluid pressure

• Non-infectious inflammatory disease (ADEM, SLE)
• Intracranial neoplasma
• Intrathecal injection
• Epileptic seizure
• Chiari malformation type I
• HaNDL(syndrome of transient headache and neurolog. deficits with CSS lymphocytosis )
• Others
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High CSF pressure : Hydrocephalus Isotope : leakage CSF low CSF pressure

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HAS/NEURO
 Chiari type I malformation
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 HEADACHE ATTRIBUTED TO
SUBSTANCE OR ITS WITHDRAWAL

• Headache induced by acute substance use or exposure

(NO, PDEi, CO, alcohol, food/additives/MSG,cocaine,
cannabis, histamine, CGRP, medication adverse
event,others substance)
• Medication-overuse headache (MOH)
• Chronic adverse event medication
• Substance withdrawal (caffein, opioid,oestrogen, others)

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 MOH
• Ergotamine, Triptan >/=10 d/mo , >/= 3mo
• Opioid
• Combination medication
(simple analgs+opioid,bulbital,caffeine)

• Simple Analgesics >/=15 d/mo , >/= 3mo

• Others

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 HEADACHE ATTRIBUTTED TO INFECTION

• Intracranial infection
(meningitis,encephalitis,absess, subdural
empyema)
• Systemic infection (bacterial, viral,others)
• HIV/AIDS
• Chronic post-infection headache
(meningitis bacterialis)

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 HEADACHE ATTRIBUTTED TO
DISORDER OF HOMOEOSTASIS

• Hypoxia/ hypercapnia (high altitude,diving,sleep apnoe)

• Dialysis headache
• Arterial hypertension (phaeochromocytoma, hipertensive
crisis/encephalopathy, pre/eclamsia,acutepressorresponse
to exogen.agent:cocaine,sympathomimetics)
• Hypothyroidism
• Fasting (>16h)
• Cardiac cephalalgia
• Others

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 HEADACHE/FACIAL PAIN ATTRIBUTTED TO
DISORDER OF CRANIUM, NECK, EYES,EARS, NOSE, SINUSES,
TEETH, MOUTH OR OTHER FACIAL/CRANIAL STRUCTURES

• Disorder of cranial bone

• Disorder of neck (cervicogenic H, retropharingeal
tendonitis,craniocervical dystonia)
• Disorder of eyes (glaucoma,refractive errors,squint,
inflamatory)
• Disorder of ears
• Rhinosinusitis
• Disorder of teeth, jaws,related structures
• TMJ disorder
• Others

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 HEADACHE ATTRIBUTTED TO
PSYCHIATRIC DISORDER

• Somatisation disorder
• Psychotic disorder

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 CHRONIC DAILY HEADACHE
• PRIMARY CDH
• TRANSFORM MIGRAINE/CM
• CTTH >4 h
• NDPH
• HC

• CLUSTER H
• PAROXISMAL HEMICRANIA <4 h
• HYPNIC H
• IDIOPATHIC STABBING H

• SECONDARY CDH
• POST TRAUMATIC H
• CERVICAL SPINE DISORDERS
• HEADACHE ASSOC WITH VASCULAR DISORDERS
• HEADACHE ASSOC WITH NON-VASCULAR INTRACRAN. DISORDERS
• OTHERS (TMJ DIS. SINUS INFECTION)

Silberstein SD, Lipton RB, Goadsby PJ,99

 CRANIAL NEURALGIA,
CENTRAL AND PRIMARY FACIAL PAIN
AND OTHER HEADACHES (1)
• Trigeminal Neuralgia
• Glossopharingeal Neuralgia
• N.intermedius Neuralgia
• Superior Laryngeal Neuralgia
• Nasociliary Neuralgia
• Supraorbital Neuralgia
• Other terminal branch Neuralgias
• Occipital Neuralgia
• Neck-tongue syndrome

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 CRANIAL NEURALGIA,
CENTRAL AND PRIMARY FACIAL PAIN
AND OTHER HEADACHES (2)

• External compression headache

• Cold-stimulusheadache
• Compression/irritation/distortion cranial nerve/ upper
cervical roots
• Optic Neuritis
• Ocular Diabetic Neuropathy
• Head/facial pain attributted to herpes zooster
• Tolosa-Hunt Syndrome
• Ophtalmoplegic ‘migraine’
• Central facial pain (anaesthesia dolorosa, post-
stroke,MS,idiopathic, burning mouth syndrome )
• Others HAS/NEURO
Ophtalmoplegic ‘migraine’
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POSTHERPETIC NEURALGIA

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 POSTHERPETIC NEURALGIA
 BURNING / STABBING PAIN
 HYPERESTHESIA, ALLODYNIA

TREATMENT : - ANTICONVULSANTS :
GBP,PGB,CBZ,PHT
- ANTIDEPRESSANTS :TCA
- TOPICAL

PREVENTION PHN : - ACYCLOVIR 5X800mg 7d

- TCA ANTIDEPRESSANT
- CORTICOSTEROID

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 TRIGEMINAL NEURALGIA
(TIC DOULOUREX)
 MIDDLE AGE
 PAROXISMS OF INTENS, STABBING PAIN
N V2,3
 A FEW SECONDS / MINUTES
 INVOLUNTARY WINCES (TIC)
 TRIGGERED BY:
STIMULATION (TOUCH, TICKLE)
MOVEMENT OF THE FACE, LIPS, GUMS:
SHAVING, BRUSHING, TALKING, CHEWING

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 Trigeminal division involved in TG

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 Trigger Area

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ETIOLOGY :
IDIOPATHIC
SYMPTOMATIC:
MULTIPLE SCLEROSIS,
ANEURYSM OF THE A. BASILAR,
CPA TUMOR, COMPRESSION OF THE N V
TREATMENT :
ANTICONVULSANTS: CBZ, OXCB,GBP,LMG, PHT,CLZ,
BACLOFEN
CAUSAL

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GLOSSO PHARYNGEAL NEURALGIA

 INTENSE AND PAROXYSMAL PAIN IN THE

THROAT -TONSILLAR FOSSA
 MAY BE RADIATE TO THE EAR
 N. IX , AURICULAR BRANCH OF N X
 TRIGGERED BY SWALLOWING, TALKING,
CHEWING, ETC.
 ± BRADYCARDIA, SYNCOPE

TREATMENT : - ANTICONVULSANTS
- SURGICAL
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Occipital neuralgia HAS/NEURO
Beberapa Analgesik Terapi Abortif Nyeri Kepala

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HAS/NEURO (Rowbotham MC, Petersen KL, 2001)