STEP 1 :

1. Hemicrania : lokasi sebagian kepala

STEP 2 :

1. Mengapa nyeri muncul saat aktivitas, saat terkena cahaya?

2. Apa pengaruh coklat dan keju terhadap keluhan sakit kepala?
3. Apa diagnosis dan diagnosis bandingnya? Pemeriksaan penunjangnya?
4. Apa hubungan keluhan pasien dgn riwayat penyakit ibunya?
5. Bagaimana terapi dari scenario?
6. Bagaimana anatomi, histologi, fisiologi dari Sistem Saraf?
7. Mengapa saat menstruasi dan stress memperburuk sakit kepalanya?
8. Mengapa sebelum sakit kepala muncul terdapat blurr vision?
9. Mengapa sakit kepala hanya di satu sisi?
10. Apa saja factor resiko dari skenario?
11. Apa komplikasi dari scenario di atas?
STEP 3 :

1. Explain about anatomic, histologic, and physiology of neurology system?

Neurology sytem classification into two
a. Peripheral : autonomy and somatic
b. Central : spinal cord and encephalon
Encephalon divide it into forebrain (telencephalon and Diencecephalon), midbrain
(mesencephalon), hindbrain(metencephalon, myelencephalon)

a. Telencephalon  amygdala, cerebral fork, ganlia basal, hippocampus

b. Diencephalon  thalamus and hypothalamus for detecting temperature, H2O,
emotion
c. Mesencephalon  tectum segmentum

Cover layers of cerebrum :

a. Skin
b. Periosteum
c. Bone
d. Peristeal
Durameter
e. Meningeal
f. Subduran space
g. Arachnoid
h. Subarachnoid space
Between subarachnoid and arachnoid there is a CSF
i. Piameter
j. White matter

There is 5 septa : falx cerebri, tentorium cerebrii. Falx cerebelli, cella diaphragm, cacum meckeli

Area intracranial sensitive of pain (spinosus, n.cranialis, n. trigeminus,

Intracranial but not sensitive of pain there are bone, brain parencim, brain ventricle, plexus
choroideus

Histology superficial neuron, structure :

a. Dendrites as receive
b. Body cell
c. Nucleus
d. Nodus Ranvier as acceleration impuls
e. Myelin as capsule
f. Schwann cell
g. Axon terminal as transmitter

2. Why does headache arise when she having activity and worsen in light place?
Neuron have some gene, familial
Type 1 : calcium channel
Type 2 : calcium
Type 3 : neuron voltage
When she have activity and have the gene familial  muscle activity do some potential
action  channel had neuron has  regulation glutamatargic system  synaps  to
take the receptors N metil  receive the transmitter  rise synaptic neurons.

The pain : the structure of rise synaptic neurons  get stimulate the pain
3. Why when she on period and stress emerged her headache?
Patfis :
Cortical spreading
Somenone migraine with aura  there’s stimulation of activitation of neuron  it can
happen depolarization cellular  the aura, primary cortex  activated nervus
trigeminus and become headache

On period stage  low neurotransmitter

On stress  neurotransmitter become  effect the concentration and anxiety 
depolarization cellular happens  stimulate the nervus trigeminus (V) take out the
neuropeptida  more headache
4. Why before she gets headache there is blurr vision for some minutes?
In cerebri there is occipital lobus ( gyrus lingua and cunea)  fun : visualization 
vascularization in occipital, nitric oxide affect occipital lobus  blurr vision for 15 mnt
 maybe there is a pain but not much.

Nausea and vomiting : trigger the trigeminus nervus

5. Why does headache happen just in one side?
Headache is stimulating in the
Classified headache :
- Extracranial : cutis, subcutis
- Intracranial : meninges and
- Start from linea orbitol until posterior  headache in the facial under in the lineal
orbital  stimulate in s
 Characteristic migraine is pain unilateral, berdenyut, disertai mual muntah, occurs 4-72
hours , fotopobia.

6. Apa pengaruh coklat dan keju terhadap keluhan sakit kepala?

7. Apa hubungan keluhan pasien dgn riwayat penyakit ibunya?
8. Apa saja factor resiko dari skenario?
9. What is diagnosis and different diagnosis?
Diagnosis : Migrain
DD: cluster headache, hormonal headache , tension headache, dissection syndrome,
amneurism cerebral

EEG :
-migrain  pulsated
-cluster  tertusuk jarum
-tension  wave
Diagnosis we can ask from the pain, onset, the location of pains, physical examination.
Pemeriksaan penunjang : radiology, MRI, CT scan,
To differentiate the tumor or neoplasma. Pungsi lumbal for
Metabolism glucose, EEG to found slow or discrete activity or increase beta wave in
back posterior.
How to lead diagnosis :
Divided in two part :
a. Migraine without aura  headache minimal 72 hours, minimal to some size
unilateral, pulsated, intensity moderate to severe with physical activity or not and
the one of them nausea and vomiting, fotopobia, sensitive of sound,
b. Not related headache
c. Migrain with aura  comes periodic, reverse one with neurology sign, vocal
neurology, reversible sign, can happens 5-20 minutes.

With aura  disfunction less than60 minutes

-Prodormal : few hours to days)

-Headache : unilateral from temporal occurs progressive and worsen in the light, fotopobia,
vomiting, nausea. 2 classification :

Unilateral  it has blurry vision, other sign lign nausea, vomiting

Tension headache  bilateral occurs variable. Mostly be better in minutes

Cluster headache  Idiopathic , unilateral, aroun the eyes, onset explosive 30 mnts, dilatation
of pupil

Hormonal headache  estrogen level low, it has relation of sinusitis press the other nervus or
structure surrounded.

In this case the physical examination are enough

a. primary :

b. secondary :

-Postdromal : anorexia, psikomotor

10. Apa komplikasi dari scenario di atas?

11. Bagaimana terapi dan edukasi dari scenario?

STEP 4

Mind Mapping
 STEP 7:
1. Explain about anatomic, histologic, and physiology of neurology system?
2. Why does headache arise when she having activity and worsen in light place?
Reseptor fotik sinyal-

Neuron hipereksabilitas- impulsnya cepat

Aktivasi oliver nucteal nucleus yg sebabkan aktivasi SSN (berhubungan k. mucus yg
berhubungan dg pusat muntah mengakibatkan vimiting dan nusea. Setelah itu
vasodilatasi p. darah sekitar- depolarisasi neuron- menambah sakit kepala
Mechanical deformation ocular(p darah mata)- mata menjadi tegang- impuls saraf +
kuat
Aktivasi nosireseptor trigeminalsakit kepala
Fotofobia 1: udah pusing, liat cahaya pusing tambah 9jadi pusing banget)
Fotofobia 2: udah ousing, liat cahaya tapi b aja
Fotofobia 3: pusing gegara liat cahaya
3. Why when she on period and stress emerged her headache?
Menstruasi:
Kelainan kromosom 9
FHM mengatur chanel2/na pump impuls saraf terus menerus
Esterogen: bias modulasi mediator inflamasi (prostaglandin) sebabkan vasodilatasi
Depresi:
CSD aktivasi rilis glutamate. Potassium dll. Jika glutamatic system meningkat maka
impuls berjln lbh cpt. Mk sensitif
Saat stress:
Hipotalamus, battang otak, korteks,..
4. Why before she gets headache there is blurr vision for some minutes?
5. Why does headache happen just in one side?
6. Apa pengaruh coklat dan keju terhadap keluhan sakit kepala?
 7. Apa hubungan keluhan pasien dgn riwayat penyakit ibunya?
8. Apa saja factor resiko dari skenario?

Behavioral
Fasting
Emotions
Sleep disturbances
Stress
Exercise
Environmental
Bright light/visual stimuli
Odors
Weather changes
Cigarette smoke
Infectious
Upper respiratory infections
Dietary
Caffeinated beverages
Alcoholic beverages
Aged cheeses
Chocolate
Ice cream
Chemical
Monosodium glutamate
Tyramine
Nitrates
Aspartame
Hormonal
Menstruation
Dikutip dari : (Martin and Behbehani, 2007).
Gambar 2.1. Frequency of individual triggers occurring at least occasionally
(%)
dikutip dari : (Kelman, 2007).
 9. What is diagnosis and different diagnosis?
a. Migraine without aura
Previously used terms: Common migraine; hemicrania simplex
Description: Recurrent headache disorder manifesting in attacks lasting 4–72 hours Typical
characteristics of the headache are unilateral location, pulsating quality, moderate or severe
intensity, aggravation by routine physical activity and association with nausea and/or
photophobia and phonophobia.
b. Migraine with aura
Previously used terms: Classic or classical migraine; ophthalmic, hemiparaesthetic,
hemiplegic or aphasic migraine; migraine accompagne´e; complicated migraine.
Description: Recurrent attacks, lasting minutes, of unilateral fully reversible visual, sensory
or other central nervous system symptoms that usually develop gradually and are usually
followed by headache and associated migraine symptoms.

10. Apa komplikasi dari scenario di atas?

11. Bagaimana terapi dan edukasi dari scenario?

Defenisi nyeri secara umum menurut International Association for Study of Pain (IASP) adalah suatu
pengalaman sensorik dan emosional yang tidak menyenangkan yang berkaitan dengan kerusakan
jaringan yang sudah atau berpotensi terjadi

Nyeri didaerah kepala sendiri dibagi menjadi dua, yaitu nyeri kepala dan nyeri fasial. Nyeri kepala
adalah rasa nyeri pada daerah diatas garis orbitomeatal yaitu diatas kepala memanjang dari orbita
sampai kedaerah belakang kepala, sedangkan pada nyeri fasial adalah rasa nyeri pada daerah wajah
yaitu dibawah garis orbitomeatal contohnya pada neuralgia trigeminal.

Klasifikasi The International Headache Society (IHS) pada tahun 1988 membagi nyeri kepala atau
cephalgia menjadi dua kategori utama, yaitu nyeri kepala primer dan nyeri kepala sekunder. Nyeri
kepala primer adalah nyeri kepala tanpa penyebab yang jelas dan tidak berhubungan dengan
penyakit lain, mencakup Tension type headache, migraine dan nyeri kepala cluster. Sedangkan nyeri
kepala sekunder terjadi akibat gangguan organik lain, seperti infeksi, trauma, tumor, dan
perdarahan

Migrain sendiri berasal dari bahasa Yunani yaitu hemicranias (hemi : setengah, cranium : tengkorak
kepala) adalah nyeri kepala yang umumnya unilateral yang berlangsung selama 4 - 72 jam, sekitar
2/3 penderita migraine predileksinya unilateral, dengan sifat nyeri yang berdenyut, dan lokasi nyeri
umumnya di daerah frontotemporal dan diperberat dengan aktivitas fisik. Prevalensi migraine lebih
sering pada perempuan dibanding laki-laki, diperkirakan dua sampai tiga kali lebih sering pada
perempuan

Migraine has two major types: 1.1 Migraine without aura is a clinical syndrome characterized by
headache with specific features and associated symptoms; 1.2 Migraine with aura is primarily
characterized by the transient focal neurological symptoms that usually precede or sometimes
accompany the headache. Some patients also experience a prodromal phase, occurring hours or days
before the headache, and/or a postdromal phase following headache resolution. Prodromal and
postdromal symptoms include hyperactivity, hypoactivity, depression, cravings for particular foods,
repetitive yawning, fatigue and neck stiffness and/or pain.