Sakit Kepala

Headache/ Nyeri Kepala

18,9% kunjungan ke RSDS 17,4% kunjungan ke RSCM 42% kunjungan praktek sore Sp.S 90% merupakan primary headache

NYERI

Pengalaman sensorik & emosional yg tidak menyenangkan terkait kerusakan jaringan, baik aktual maupun potensial atau yang digambarkan dalam bentuk kerusakan tsb.

PATOFISOLOGI NYERI

HEADACHE/ Nyeri Kepala

DEFINITION Pain on head area Pain in face, pharynx, larynx & neck are not include. Osteo arthritis cervicalis is include Epidemiology

TTH 35-78% (CTTH 3%) Migrain 18% female, 6% men

Cluster 0.015%
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Derajat Nyeri Kepala (Praktis)

Ringan : pekerjaan/aktifitas sehari2 normal. Sedang : aktifitas berat terganggu Berat : aktifitas sehari-hari terganggu

STRUCTURE PAIN SENSITIVE

I. STRUCTURE Intra Kranial a. sinus, vein besar & aferennya b. artery dura mater c. artery basis cranium d. duramater II. STRUCTURE ekstra kranial a. skin, skin head, jar. Sub.kutan, fasia, muscle head/neck. b. mukosa c. artery-artery d. Structure from eye, ear & nose III. Nervous: V, VII, IX, X, C1 C2 C3

STRUCTURE NOT SENSITIVE PAIN

1. Parenkim brain 2. Ependyma, pleksus choroid 3. Piamater, membrana arachnoidea & duramater 4. Bone skull

PATOFISIOLOGY Headache General : A. intracranial: 1. Iritasi meningen Ex: Meningitis Perdarahan Sub Arachnoid (SAH) 2. Penarikan or peregangan arteri intracranial: Tumor Absces Hematoma intracranial TIK : hidrosefalus, BIH TIK : post Lumbal Headache

3. Vasodilatasi arteri intra kranial Toksic caused infection With drawl caffein Hipoglikemia, Hipoksia, Hiperkapnea drug vasodilator Post attack Epilepsi Insufiensi sirculation brain

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B. BERSUMBER ESKTRA KRANIAL

1. dilatasi cabang A. carotis externa Migren Cluster headache 2. inflammation artery ekstrakranial Giant cell arterytis temporalis 3. contraction muscle Tension headache Secondary muscle contraction headache Ex: - mal occlusion teeth - spondylosis cervicalis 4. inflammation/Penekanan N. V, N. IX Neuralgia trigeminus Neuralgia glossopharingeus 5. inflammation in mucosa nose, sinus
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1. Headache Primer Tension headache Migrain Cluster headache 2. Headache Secunder

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Headache

PRIMER

Secunder

TTH

Migrain

Cluster Headache

infection Tanda2 infection (Color/Dolor/ Robor)

Trauma history Trauma

Tumor -Trias -Headache chronic progresif -vomit proyektil -Papil edema

Vascular -acute -Defisit Neurologis fokal

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DIAGNOSIS AND TESTING

Detailed History and Examination NO YES Secondary Headache Diagnostic Testing
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Primary Headache?
Preliminary Diagnosis

Atypical Features

RED FLAGS SNOOP T

Systemic symptoms (fever, weight loss) or
secondary risk factors (HIV, systemic cancer)

Neurologic symptoms or abnormal signs (confusion, impaired

alertness, or consciousness)

Onset: sudden, abrupt, or progressively worsening Older: new onset and progressive headache, especially in
middle-age >50

Previous headache history: first headache or different

(change in attack frequency, severity, or clinical features)

Triggered headache (valsava, exertion)

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Classification of headaches
Primary headaches Secondary headaches OR Idiopathic headaches OR Symptomatic headaches
THE HEADACHE IS ITSELF THE DISEASE NO ORGANIC LESION IN THE BEACKGROUND TREAT THE HEADACHE! THE HEADACHE IS ON LY A SYMPTOM OF AN OTHER UNDERLYING DISEASE TREAT THE UNDERLYING DISEASE!

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Tabel 1 . Important features of pain in the evaluation of chronic recurrent headaches

HEADACHE Common migraine Classic migraine QUALITY Throbbing LOCATION Unilateral head / Ifteral head Unilateral head DURATION 6 48 hours FREQUENCY Sporadic (often several times montlly) Sporadic (often several times monthly) Closely bunched clusters with long remissions ASSOCIATED SYMPTOMS Nausea, vomiting, malaise, photophobia Visual prodrome, vomiting, nausea, malaise, photobhobia Ipsilateral tearing, facial flushing, nasal stuffiness, Hornerss syndrome Depression, anxiaty Pericranial tenderness Identifiable trigger zone

Throbbing

3 12 hours

Cluster

Boring, sharp

Unilateral head (especially orbit)

12 120 minutes

Psychogenic/ Chronic TTH Trigeminal meuralgia

Dull, pressure

Diffuse, Ifteral Frontal, temporal suboccipital Fifth nerve distribution

Oftem unremitting Brief (15-60 second)

May be constant Almost daily Many times daily

Lancinating

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PHYSICAL FINDING Optic atropy, papiledema

POSSIBLE ETIOLOGY Mass lesion, hydrocephalus, benign intracranial hypertensionon

Focal neurologic abnormality (hemiparese aphasia)

Stiff neck

Mass lesion
Subarachnoid hemorrhage, meningitis, cervical arthritis

Retinal hemorrhages
Cranial bruit Thickened, tender temporal arteryes Trigger point for pain Lid ptosis, third nerve palsy, dilated pupil Spasm and tenderness of Pericranial muscle

Ruptured aneurysm, malignant hypertensionon

arteryovenous malformation Temporal arterytis Trigeminal neuralgia Cerebral aneurysm TTH/Muscle Contraction Headache

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TTH (Headache Type Spasm/ Tension Type Headache TTH)

OVERVIEW:
The most common (90%) headache Responsive to over the counter med 5% visits When disabling conjunction with migraine Spectrum of migraine Beware of medication overuse headache (MOH)

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Tension Type headache

10 attacks lasting 30 min7 days 2 of the following 4
Bilateral Not pulsating Mild or moderate intensity Not aggravated by routine physical activity

No nausea or vomiting One or neither photophobia or phonophobia Not attributable to another disorder
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TTH Classification
Episodic <15 day/month Peripheral pain mechanism Tx NSAID, Parasetamol Chronic 15 day/month, 3 months Central pain mechanism Tx Amitriptilin
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Tension Type Headache

TTH

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Treatment of TTH
Evidence A : multipel RCT B : 1 RCT C : Consensus Clinical effect : + few people improved ++ Some people improved +++ Most people improved
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Drug

evidence

Clinical effect

Role

Route

Analgesic & NSAID

Asetaminofen Aspirin Mefenamic acid Ibuprofen Naproxen A A A A A ++ ++ ++ ++ ++ Acute PO

Ibuprofen+caffein

++

Antidepresan
Amitriptilin Maprotilin Mianserin A B B +++ + ++ preventive PO

Sulpride
Fluvoxamine

C
B

+
++

Muscle relaxants
Tizanidine Eperisone B B ++ ++ Acute&preventive PO

Others
Alprazolam Etizolam prochloperazine chlorpromazine B C C C ++ ++ ? ? 24 Acute IV Acute&preventive PO

-------- Ibuprofen (400 mg) + Caffein (200 mg) -------- Ibuprofen (400 mg)=Ketoprofen (50 mg)
-------- Ibuprofen (200 mg) = Ketoprofen (25 mg) = Naproxen (275 mg) -------- Aspirin/Paracetamol (500-1000 mg) + Caffein (30 mg) -------- Aspirin (500-1000 mg) = Paracetamol (500-1000 mg)

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Migraine
The most common disabling headache The most common headache visits Unknown causes

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Migraine Criteria

5 attacks lasting 472 h 2 of the following 4

Unilateral Pulsating Moderate or severe intensity Aggravation by routine physical activity Nausea and/or vomiting Photophobia and phonophobia

1 of the following

Not attributable to another disorder

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SULTANS: two from column A, one from column B

evere ni ateral hrobbing Ctivity worsens
ausea Lite and sound ensitivity

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World prevalence of migraine

Denmark 10% France 8% Switzerland 13%

USA 12% Italy 16%

Japan 8%

Chile 7%

1-year prevalence rates Population-based studies IHS criteria (or modified)

Rasmussen and Olesen (1994); Rasmussen (1995); Lipton et al (1994); Lavados and Tenhamm (1997); 30 Sakai and Igarashi (1997)

Prevalence measured over a few years

Prevalence of migraine by sex and age

Migraine prevalence (%) 30 25 20 15 10 5 0 20 30 40 50 60 Age (years) 70 80 100 Females Males

The American Migraine Study (n=2479 migraine sufferers)

Lipton and Stewart31 (1993)

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Migraine

A. The Aura

B. The Attack

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Penatalaksanan migrain
1. 2. 3. Hindari pencetus Terapi abortif Non spesifik Spesifik Terapi preventif

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Pencetus Migraine
Kurang atau kebanyakan tidur Kelelahan Stres dan kecemasan Terlambat makan Perubahan hormonal Makanan (MSG, nitrit (pengawet) ,aspartam (pemanis buatan)) Cahaya terang
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Terapi abortif non spesifik

Obat ASA Dosis, mg 1000 mg oral Evidence A

ASA ibuprofen
Naproxen Parasetamol Diklofenac

1000 mg IV 200-800mg, oral

500-1000mg oral 1000 mg oral,supp 50-100 mg oral

A A
A A A

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Terapi abortif spesifik

Ergot
Angka rekurensi rendah Menginduksi drug overuse headache dg cepat Maksimal diberikan10 hari/bulan Efek samping : parestesi, muntah Kontra indikasi Penyakit kardio, serebrovaskular, hipertensi, gagal ginjal, kehamilan dan laktasi
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TRIPTAN

Efikasi lebih baik dibanding ergot Sediaan obat di Indonesia sulit di dapat (hanya ada sumatriptan) Efek samping : nyeri dada, parestesi, fatik Kontra indikasi : Penyakit kardio, serebrovaskular, hipertensi, gagal ginjal, kehamilan dan laktasi

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Terapi prevensi migrain

1. 2. 3. 4. Serangan >2-8 kali/bln Berlangsung >48 jam Pengobatan akut tdk efektif Ada kontra indikasi terapi abortif, efek samping, atau cenderung overuse 5. Gejala luar biasa ( migrain basiler, hemiplegi, aura memanjang) 6. Permintaan pasien
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Terapi prevensi migrain Konsensus Nasional III Nyeri Kepala PERDOSSI 2010
Obat Dosis mg/hari evidence

betablocker
metoprolol propanolol 50-200 40-240 A A

Calcium channel blocker

Flunarizine (Frego) 5-10 A

Anti epileptic
Valproic acid 500-1800 A

Topiramat

25-100

A
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Sefalgia sekunder

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stroke
Wanita 75 th di bawa ke IRD RS krn mendadak sakit kepala, hemiparese kiri

Trauma
Anak 15 th terkena pemukul baseball di pelipis. Sesaat setelah terkena pukulan ia tidak sadar sebentar 15 mnt lalu bangun lagi. Ia mengeluh sakit kepala namun keadaannya saat itu baik saat dibawa ke IRD. Empat jam kemudian saat diobservasi ia mengeluhkan sakit kepalanya bertambah hebat dan kejang. Pupil sebelah kanan midriasis

Infeksi
Pria 40 th , pengusaha mengeluh sakit kepala 2 bln, disertai demam sumer-sumer, sering diare dan sariawan .Ia mengkonsumsi narkoba berhenti sjk 1 th silam. Dibawa ke IRD oleh keluarganya krn bicara meracau.

Tumor
Wanita 35 th, sakit kepala 8 bln bertambah hebat terutama saat bangun dan bersin, memakai kontrasepsi suntik 3 bulan

Degenerasi
Wanita 79 th datang ke poli dengan keluhan sakit kepala hilang timbul 2 th.Sering lupa 3-4 th dan tidak mampu berbelanja lagi krn kesulitan melakukan perhitungan ringan. Sekarang sulit tidur dan sering terlihat seperti berbicara sendiri

ATAS PERHATIANNYA

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