primary headache kuliah fk uwks

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Sakit Kepala

dr. Teddy wijatmiko Sp.SFK UWKS lecture

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Headache/ Nyeri Kepala

18,9% kunjungan ke RSDS17,4% kunjungan ke RSCM42% kunjungan praktek sore Sp.S90% merupakan primary headache

NYERI

Pengalaman sensorik & emosional yg tidakmenyenangkan terkait kerusakan jaringan,baik aktual maupun potensial atau yangdigambarkan dalam bentuk kerusakan tsb.

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PATOFISOLOGI NYERI

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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%

HEADACHE/ Nyeri Kepala

Derajat Nyeri Kepala(Praktis)

Ringan : pekerjaan/aktifitas sehari2

normal.

Sedang : aktifitas berat terganggu

Berat : aktifitas sehari-hari terganggu

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STRUCTURE PAIN SENSITIVE

I. STRUCTURE Intra Kraniala. sinus, vein besar & aferennyab. artery dura materc. 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

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1. Parenkim brain2. Ependyma, pleksus choroid3. Piamater, membrana arachnoidea & duramater4. Bone skull

STRUCTURE NOT SENSITIVE PAIN

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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

PATOFISIOLOGY Headache General :

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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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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

B. BERSUMBER ESKTRA KRANIAL

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PRACTICAL CLASSIFICATION HEADACHE

1.Headache Primer Tension headache Migrain Cluster headache

2. Headache Secunder

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ALGORTHM DIAGNOSIS HeadacheHeadache

PRIMERSecunder

TTH Migrain Cluster Headach

e

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 ExaminationDetailed History and Examination

Primary Headache?n Preliminary DiagnosisPrimary Headache?n Preliminary Diagnosis

NONO

SecondaryHeadacheSecondaryHeadache

DiagnosticTesting

DiagnosticTesting

AtypicalFeatures

YESYES

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RED FLAGS “SNOOP T”

Older: new onset and progressive headache, especially in middle-age >50

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

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• OR Idiopathic

headaches

– THE HEADACHE IS ITSELF THE DISEASE

– NO ORGANIC LESION IN THE BEACKGROUND

– TREAT THE HEADACHE!

• Secondary headaches• OR Symptomatic

headaches

– THE HEADACHE IS ON LY A SYMPTOM OF AN OTHER UNDERLYING DISEASE

– TREAT THE UNDERLYING DISEASE!

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HEADACHE QUALITY LOCATION DURATION FREQUENCYASSOCIATED SYMPTOMS

Common migraine

Throbbing Unilateral head / Ifteral head

6 – 48 hours Sporadic (often several times montlly)

Nausea, vomiting, malaise, photophobia

Classic migraine

Throbbing Unilateral head 3 – 12 hours Sporadic (often several times monthly)

Visual prodrome, vomiting, nausea, malaise, photobhobia

Cluster Boring, sharp

Unilateral head (especially orbit)

12 – 120 minutes

Closely bunched clusters with long remissions

Ipsilateral tearing, facial flushing, nasal stuffiness, Horners’s syndrome

Psychogenic/ Chronic TTH

Dull, pressure

Diffuse, Ifteral Frontal, temporal suboccipital

Oftem unremitting

May be constant Almost daily

Depression, anxiaty Pericranial tenderness

Trigeminal meuralgia

Lancinating Fifth nerve distribution

Brief (15-60 second)

Many times daily

Identifiable trigger zone

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

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PHYSICAL FINDING POSSIBLE ETIOLOGY

Optic atropy, papiledema Mass lesion, hydrocephalus, benign intracranial hypertensionon

Focal neurologic abnormality (hemiparese aphasia)

Mass lesion

Stiff neck Subarachnoid hemorrhage, meningitis, cervical arthritis

Retinal hemorrhages Ruptured aneurysm, malignant hypertensionon

Cranial bruit arteryovenous malformation

Thickened, tender temporal arteryes Temporal arterytis

Trigger point for pain Trigeminal neuralgia

Lid ptosis, third nerve palsy, dilated pupil

Cerebral aneurysm

Spasm and tenderness of Pericranial muscle

TTH/Muscle Contraction Headache

Tabel 2. Important physical findings ini the evaluation of 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 min–7 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/monthPeripheral pain mechanismTx NSAID, ParasetamolChronic≥ 15 day/month, ≥ 3 monthsCentral pain mechanismTx Amitriptilin

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Tension Type Headache TTH

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Treatment of TTH

Evidence A : multipel RCT B : 1 RCT C : ConsensusClinical effect : + few people improved ++ Some people improved +++ Most people improved

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Drug evidence Clinical effect Role Route

Analgesic & NSAIDAsetaminofen A ++ Acute PO

Aspirin A ++

Mefenamic acid A ++

Ibuprofen A ++

Naproxen A ++

Ibuprofen+caffein A ++

AntidepresanAmitriptilin A +++ preventive PO

Maprotilin B +

Mianserin B ++

Sulpride C +

Fluvoxamine B ++

Muscle relaxantsTizanidine B ++ Acute&preventive PO

Eperisone B ++

OthersAlprazolam B ++ Acute&preventive PO

Etizolam C ++

prochloperazine C ? Acute IV

chlorpromazine C ?

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A Hierarchical Classification of Compounds Efficacy

-------- 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 4–72 h• 2 of the following 4

– Unilateral– Pulsating– Moderate or severe intensity– Aggravation by routine physical activity

• 1 of the following– Nausea and/or vomiting– Photophobia and phonophobia

• 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

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

USA 12%

Chile 7%

Japan 8%Italy 16%

Denmark 10%

France 8%†

Switzerland 13%

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

and Igarashi (1997)†Prevalence measured over a few years

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Prevalence of migraine by sex and age

FemalesMales30

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15

10

5

020 30 40 50 60 70 80 100

Migraine prevalence (%)

Age (years)

Lipton and Stewart (1993)

The American Migraine Study (n=2479 migraine sufferers)

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Migraine

A. The Aura

B. The Attack

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Penatalaksanan migrain

1. Hindari pencetus2. Terapi abortif Non spesifik Spesifik3. 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 spesifikObat Dosis, mg Evidence

ASA 1000 mg oral A

ASA 1000 mg IV A

ibuprofen 200-800mg, oral A

Naproxen 500-1000mg oral A

Parasetamol 1000 mg oral,supp A

Diklofenac 50-100 mg oral A

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Terapi abortif spesifik

ErgotAngka rekurensi rendahMenginduksi drug overuse headache dg cepatMaksimal diberikan10 hari/bulanEfek samping : parestesi, muntahKontra indikasiPenyakit kardio, serebrovaskular, hipertensi,

gagal ginjal, kehamilan dan laktasi

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TRIPTAN

Efikasi lebih baik dibanding ergotSediaan obat di Indonesia sulit di dapat (hanya

ada sumatriptan)Efek samping : nyeri dada, parestesi, fatikKontra indikasi : Penyakit kardio, serebrovaskular,

hipertensi, gagal ginjal, kehamilan dan laktasi

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Terapi prevensi migrain

1. Serangan >2-8 kali/bln2. Berlangsung >48 jam3. Pengobatan akut tdk efektif4. Ada kontra indikasi terapi abortif, efek

samping, atau cenderung overuse5. Gejala luar biasa ( migrain basiler, hemiplegi,

aura memanjang)6. Permintaan pasien

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Terapi prevensi migrainKonsensus Nasional III Nyeri Kepala PERDOSSI 2010

Obat Dosis mg/hari evidence

betablockermetoprolol 50-200 A

propanolol 40-240 A

Calcium channel blockerFlunarizine (Frego) 5-10 A

Anti epilepticValproic acid 500-1800 A

Topiramat 25-100 A

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Sefalgia sekunder

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

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TERIMA KASIH

ATAS PERHATIANNYA