NYERI KEPALA

Dr.Amsar AT, SpS

Bagian / SMF Saraf
FK Unri / RS Arifin Achmad
Pekanbaru
 What is a headache

pain in the head that is located

above the eyes or the ears,
behind the head (occipital),
or in the back of the upper neck.
 Bagian yg peka nyeri

Intrakranial Ekstrakranial
sinus venosus otot
arteri besar kulit
telinga tengah periosteum
leptomeningeal arteri
saraf kranial
Bgn tidak peka nyeri

parenkhim
ventrikel
meningen bgn atas
tulang tengkorak
 Basic Mechanisms of Pain in Headache
• Traction on the Circle of Willis and its branches
• Dilatation of intra- and extra-cranial vessels
• Inflammation of intra- and extra-cranial structures
including meninges
• Inflammation involving blood vessels
• Sustained contraction of neck and scalp muscles
• Changes in intracranial pressure
• Pressure within orbits, ears, nasal/paranasal
cavities, and teeth
• Direct pressure on nerve containing pain fibers
 Tipe nyeri kepala
• Primary headache
- not associated with other diseases.
– migraine headaches,
– tension headaches,
– cluster headaches
• Secondary headache
- caused by associated disease.
- minor or
- serious and life threatening.
 Secondary headache
• serious and life threatening,
- brain tumor
- strokes
- subarachnoid hemorrhages
- meningitis
• less serious but common conditions
- withdrawal from caffeine
- discontinuation of analgesics.
 INTERNATIONAL CLASSIFICATION OF HEADACHE TYPE
% Frequency in General Practice

Type Percentage
Tension type headache 45
Migraine 30
With disease of the eye/sinuses <8
With systemic infection 7
With head trauma 3
With drugs 2
With cerebrovascular disease <1
With other intracranial disease <1
With metabolic disease <1
Cluster headache <1
Neuralgias <1
 Primary headache
• Tension headaches ;
most common type ;
as many as 90% of adults,
women > men.
• Migraine headaches :
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
• Cluster headaches :
a rare type,
affecting 0.1% of the population.
85% are men
average age is 28-30 years,
may begin in childhood.
 What causes
primary headaches
 Tension headache

• 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.
 Cause of Migraine headache

• a combination of vasodilatation and the release of

chemicals from nerve fibers that coil around the blood
vessels.
• during a migraine attack, the temporal artery enlarges.
• enlargement of the temporal artery stretches the nerves
that coil around the artery and causes the nerves to
release chemicals.
• chemicals cause inflammation, pain, and further
enlargement of the artery.
• increasing enlargement of the artery magnifies the pain.
 Cause of Migraine headache
• activate the sympathetic nervous system
– in the intestine causes nausea, vomiting,
and diarrhea.
– delays emptying of the stomach thereby
prevents oral medications from entering
the intestine and being absorbed.
– decreases the circulation of blood, and this
leads to pallor of the skin as well as cold
hands and feet.
– contributes to the sensitivity to light and
sound sensitivity as well as blurred vision.
Cluster headache
• does not have a clear cause,
• alcohol and cigarettes can
precipitate attacks.
 Symptoms of tension headaches
• often begin in the back of the head and upper neck
• as a band-like tightness or pressure.
• as a band of pressure encircling the head
• with the most intense pain over the eyebrows.
• usually is mild (not disabling) and bilateral.
• not associated with an aura
• seldom associated with nausea, vomiting, or
sensitivity to light and sound.
• sporadically, infrequently, without a pattern
• can occur frequently and even daily in some people.
• most people are able to function.
 Diagnostic Criteria for
Episodic Tension Type Headache
 Symptoms of migraine headaches

• chronic condition of recurrent attacks.

• throbbing pain that involves one temple (forehead,
around the eye, or back of the head).
• unilateral, about a third of the time the pain is
bilateral.
• unilateral headaches typically change sides from one
attack to the next.
• usually is aggravated by daily activities
• nausea, vomiting, facial pallor, cold hands, cold feet,
• sensitivity to light and sound.
• prefer to lie in a quiet, dark room during an attack.
• a typical attack lasts between 4 and 72 hours.
 Symptoms of migraine headaches

• 40%-60% of migraine attacks are preceded by

premonitory (warning) symptoms lasting hours
to days.
• include sleepiness, irritability, fatigue,
depression or euphoria, yawning, and cravings
for sweet or salty foods.
• patients and their family members usually know
that when they observe these warning symptoms
that a migraine attack is beginning.
 Symptoms of migraine headaches
• 20% are associated with an aura.
• aura precedes the headache, occasionally it may occur
simultaneously with the headache.
• The most common auras are
– 1) flashing, brightly colored lights in a zigzag pattern
(fortification spectra), usually starting in the middle of the
visual field and progressing outward and
– 2) a hole (scotoma) in the visual field, also known as a blind
spot.
• Some elderly migraine sufferers may experience only the
visual aura without the headache.
• A less common aura consists of pins-and-needles
sensations in the hand and the arm on one side or
around the mouth and the nose on the same side.
• Other auras include auditory (hearing) hallucinations
and abnormal tastes and smells.
 Symptoms of migraine headaches

• Complicated migraines are accompanied by neurological

dysfunction.
• The part of the body that is affected by the dysfunction
is determined by the part of the brain that is responsible
for the headache.
– Vertebrobasilar migraines are characterized by
dysfunction of the brainstem The symptoms include
fainting as an aura, vertigo and double vision.
– Hemiplegic migraines are characterized by paralysis
or weakness of one side of the body, mimicking a
stroke, usually temporary, but sometimes it can last
for days.
 Symptoms of migraine headaches

• approximately 24 hours after a migraine

attack, the sufferer may feel drained of energy,
• may experience a low-grade headache along
with sensitivity to light and sound.
• some sufferers may have recurrences of the
headache during this period.
Diagnostic Criteria for Migraine
Diagnostic Criteria for Migraine
 Symptoms of cluster headaches
• headaches that come in groups (clusters)
• lasting weeks or months,
• 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 every day 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.
Diagnostic Criteria for Cluster Headache
 IHS Criteria for the General Diagnosis
of Cluster Headache

Headache Description Autonomic Symptoms

(All 4) (Any 2)
Severe headache Rhinorrhea
Unilateral Lacrimation
Duration of 15–180 min Facial sweating
Orbital, periorbital, or temporal Miosis
locatio Eyelid edema
Conjunctival injection
Ptosis
 Characteristics of Primary Headache Disorders

Migraine Tension-Type Cluster

Location Unilateral Bilateral Strictly unilateral

Intensity Moderate/severe Mild/moderate Severe

Duration 4 to 72 hours 30 min to 7 days 15 to 90 min

Quality Throbbing Pressing/tightening Severe

Associated
Yes No Yes -- autonomic
symptoms

Gender Female > male Female > male Male > female
 Are primary headaches
dangerous?
• tension headaches have not been shown to
lead to neurological dysfunction or brain
damage.
• this is true of migraine headaches.
However, there is a rare association of
migraine headaches and stroke,
particularly in sufferers of complicated
migraines.
• cluster headaches need to be differentiated
from more serious neurological conditions,
there is no known danger of cluster
headaches leading to stroke.
 Treatment for migraine

• Abortive
– analgesik ; acetaminophen, nsaid
– preparat ergot ; ergotamin
– triptan
• Prophylactive
– antiepileptic : topiramat, asam valproat
– trisiklik anti depressan ; amitriptilin
– anti hipertensi ; betablocker, CCB
 Migraine prophylaxis

• to reduce attack frequency, severity,

and/or duration;
• to improve responsiveness to acute
attacks, and
• to reduce disability.
 Migraine prophylaxis

• more than 2 migraine attacks per month.

• single attacks that last longer than 24 hours.
• cause major disruptions in the patient's
lifestyle.
• abortive therapy fails or is overused.
• complicated migraine.
How are migraine headaches prevented?

1). avoiding factors ("triggers") that cause the

headaches, and
2). preventing headaches with medications
(prophylactic medications).
 Migraine trigger
• stress,
• sleep disturbances,
• fasting,
• hormones,
• bright or flickering lights,
• unsual odors,
• cigarette smoke,
• alcohol,
• aged cheeses,
• chocolate,
• monosodium glutamate,
• caffeine.
• perubahan cuaca,
Secondary headache
Secondary Headaches

• Extracranial disorder
• Intracranial disorder
• Systemic disorder
• Drugs and toxins

36
 Extracranial disorders
 Carotid or vertebral artery dissection
(which also causes neck pain)
 Dental disorders (eg, infection,
tmj dysfunction)
 Glaucoma
 Sinusitis
 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)
 Systemic disorders:
 Acute severe hypertension
 Bacteriemia
 Fever
 Giant cell arteritis
 Hypercapnia
 Hypoxia (including altitude sickness)
 Viral infections & viremia
 Drugs and toxins:
 Analgesic overuse
 Caffeine withdrawal
 Carbon monoxide
 Hormones (eg, estrogen)
 Nitrates
 Proton pump inhibitors
How are secondary headaches
diagnosed?

– a complete patient history

– a physical examination and
– laboratory and
– radiology tests .
 History and physical
examination :
 mode of onset of the headache
 age of the patient
 location of the headache
 associated fever and neck stiffness
 associated mental deterioration, seizures,
or weakness
 associated temporary weakness of the
extremities or facial muscles
 recent head trauma
 mode of onset
• patients with a subarachnoid
hemorrhage typically having a sudden
onset of severe headache
• sometimes the headache of
subarachnoid hemorrhage is triggered
by exertion such as sex.
• pain of recurrent migraine headaches
tends to build up gradually.
 The age of the patient

• temporal arteritis occurs in older people,

rare in younger than 50.
• primary headaches often starting at a
young age.
• new onset of a headache after 50 years
or onset of a new type of headache
suggests a secondary headache and
should prompt testing.
Location of the headache

Headaches that persistently

occur on the same side often are
secondary headaches associated
with, for example, brain tumors
or arteriovenous malformations
 Associated fever and neck stiffness

• bacterial meningitis is a rapidly progressive

and life-threatening disease with fever,
headaches, stiff neck, and deterioration in
mental function.
• a virus infection causes death of brain
tissue. Symptoms include fever, headache,
and deterioration in mental function.
• Early treatment with antibiotics and anti-
viral agents can decrease the extent of brain
damage and improve survival.
 Associated mental deterioration,
seizures, or
weakness of the extremities or face,
which can be symptoms of brain
tumors.
 Associated temporary weakness of the
extremities or facial muscles
• which can be symptoms of transient
ischemic attack (TI A )
• transient ischemic attacks are
warning signals for future strokes
• headache also can accompany strokes
and intracerebral bleeding
 Recent head trauma

Headaches soon after trauma to

the head may be caused by
subdural or epidural
hematomas.
 Time questions
a) Why consulting now?
b) How recent in onset?
c) How frequent and what temporal
pattern
d) How long lasting?
 Character questions

a) Intensity of pain?
b) Nature and quality of pain?
c) Site and spread of pain?
d) Associated symptoms?
 Cause questions

a) Predisposing and/or trigger factors?

b) Aggravating and/or relieving factors?
c) Family history of similar headache?
Response to headache questions

a) What does the patient do during the

headache?
b) How much is activity (function) limited
or prevented?
c) What medication has been and is used,
and in what manner?
State of health between attacks

a) Completely well, or residual or

persisting symptoms?
b) Concerns, anxieties, fears about
recurrent attacks and/or their
cause?
 Headache Red Flags

Systemic symptoms: fever, weight loss

Neurological symptoms or abnormal signs:
confusion, impaired alertness or consciousness
Onset: sudden, abrupt or split-second
Older: new onset or progressive headache,
especially in patients > 50 yo
Previous headache history: first or new or different
headache
Secondary risk factors: systemic cancers, HIV
Red Flag Headaches
 When should one consult a neurologist for
headaches?
• Severe ("the worst ever")
• Different than the usual headaches
• Starts suddenly during exertion
• Aggravated by exertion, coughing, bending, or sexual
activity
• Associated with persistent nausea and vomiting
• Associated with stiff neck, fever, dizziness, blurred
vision, slurred speech, unsteady gait, weakness or
unusual sensations of the arm or leg, excessive
drowsiness or confusion
When should one consult a neurologist for
headaches?

• Associated with seizures

• Associated with recent head trauma
• Not responding to treatment and is getting
worse
• Disabling, and interfering with work and the
quality of life
• Requires more than the recommended dose
of over-the-counter analgesics for relief
 Headache at a glance
• The head is one of the most common sites of pain in the body.
• The most common types of headache can be classified as
1) primary,
2) secondary
• The most common types of primary headaches are
1) tension type,
2) migraine, and
3) cluster.
• Tension headaches are the most common type of primary headache
• Secondary headaches are a symptom of an injury or an underlying illness.
• Patients should seek medical care for
• new onset headaches,
• fever,
• stiff neck, seizure
• change in behavior,
• vomiting,
• weakness or change in sensation.
• Most headaches can be managed in primary care
• The history is a crucial step in the correct diagnosis
• The presence of warning symptoms in the history and/or physical
signs on examination warrant investigation and may indicate
appropriate specialist referral
P u s i i i i i n g……
Aduuhh… Mamii…,
kepalaku…...!!??
Terima kasih

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