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HEADACHE

I Made Oka Adnyana

HEADACHE

Definition:
Headache: Pain above the head
from orbita occiput.
Facial pain: Pain bellow
orbitomeatal line, above the neck
and the front of the ear.
Headache should be
defferentiated with vertigo.

MECHANISMS OF
HEADACHE
Headache occur doe to stimulation of pain sensitive
craniale structur.
Pain sensitive craniale structur.
Extracraniale structurs :
Skin, periosteum, muscle( m. frontalis
superfecial, m.occipitalis.
Extracranial arteries.
Structur of the eye, ear, nasal cavities
and sinus

Intracraniale structures :
Intracraniale venous sinuses
Part of the dura at the base of brain.
Arteries with in the dura and piaaraachnoid, and particulary the proximal
parts of the anterior and midle cerebral
arteries. And the intracranila segment of the
internal carotid ertery.

CLASSIFICATION OF
HEADACHE
A. Primary headache.
1. Migraine.
2. Tension type headache.
3. Cluster headache
4. Other primary headache.
- Primary cough headache.
-. Primary exertional headache.
-. Primary headache associated
with sexual activity.

CLASSIFICATION OF
HEADACHE (cont).
Hypnic headache.
Primary thunderclap headache.
Hemicranial continua.
New daily persistent headache
(NDPH)
B. Secondary headache (Organic cause
headache).
-

RED FLAG
Red flag in history.
1. Abrupt onset of new type of severe headache.
2. Worst headache the patient ever had.
3. Progressive worsening of headache over period of
days or weeks.
4. Headache precipitated by exertion (exercise, coughing,
sneezing, bending over, or sexual exciment).
5. Headache accompanied by generalized illness or
fever, nausea,vomiting, or stiff neck.
6. Headache accompanied by neurological symptoms
( aphasia, poor coordination, focal weakness or
numbness,drowsiness, decrease in hiher intelectual
function in personality).

RED flag on examination.


1. Abnormal vital sign ( increase blood
presurre, heart rate, or temperature).
2. Change in higher intellectual
functions or cognition.
3. Alterration in level of conciousness
4. Sign of meningeal irritation.
5. Pailledema.
6. Presence of focal neurlogical signs
(hemipharesis, hemisensory loss,
ataxia, or patholgical reflexes

HEADACHE

RED FLAG

NO

YES

PRIMARY
HEADACHE
SECONDARY HEADACHE
PRIMARY HEADACHE
(ATYPICAL SIGN)
NO
PRIMARY
HEADACHE

YES

TENSION TYPE HEADACHE.


- The common primary headache.
- Most complain for out patient.

ETHIOLOGY
1.
2.
3.
4.
5.
6.
7.

Oromanibular disfunction
Psychology stress
Anxiety
Depresi
Muscle stress
Drug abuse
Delution phenomena

CLINICAL SYMPTON.
1. Episodic pain, last a few minutes day.
2. Bilateral location, pressing/tightening
must be not throbbing.
3. Mild to moderate intensity.
4. Not aggravated by routine physical
activity.
5. No nausea or vomiting.
6. No photophobia and phonophobia, but
one of the two can be present.

TENSION TYPE
HEADACHE

A.Infrequent tension type


headache:
At least 10 episodes occuring
on < 1 day per month on
average (<12 days per year)
1. Infrequyuent episodic TTH.
Associated with pericranial
tenderness.
2. Infrequyuent episodic TTH.
Associated not pericranial
tenderness.

TENSION TYPE HEADACHE


(cont)

B. Frequent tension type


headache:
At least 10 episodes occuring
on > 1 but < 15 days per
month for at least (> 12 and
<180 per year)
1. Frequyuent episodic TTH.
Associated with pericranial
tenderness.
2. Frequyuent episodic TTH.
Associated not pericranial

TENSION TYPE HEADACHE


(cont).

C. Chronic tension type


headache:
headache occuring on > 15
days per mont on agerage for
> 3 months (> 180 days per
years).
Headache lasts hours or may be
continous.
1. Chronic TTH. associated with
pericranial tenderness.
2. Chronic TTH. not associated

TREATMENT.
1. Simple analgetic
- Aspirin, acetaminophen
2. NSAIDs (ibuprophen, sod. naproxen,
sod, diclofenac).
3. Combination analgetic, sedative, minor
transquilizer.

TREATMENT.
4. Muscle relaxant: tizaniden, eperison hcl,
baclophen and diazepam.
5. Injection botox.
6. Non farmacology treatment.
- Cognitive behavior theraphy
- Relaxation.
- Physiotheraphy.

CLUSTER HEADACHE
= Migrainus neuralgia, Horton
headache, histamine headache.
Clinical sign.
1. Severa headache, unilateral , orbital, supra orbital or
temporal.
2. Frequency: 1-8 time/day.
3. Follow by:
- conjuctival injection
- lacrimation
- nasal congestion.
- rhinorrhea.
- Forhead and facial sweating.
- Miosis and ptosis,
4. Not attributed to another this order.

CLUSTER HEADACHE
A. Episodic cluter headache
attacks occurirng I periods lasting 7 days to 1 year
seperated by pain-free periods lasting 1 month or
longer.
B. Chronic cluter headache
attacks occurring for more than 1 year without
remission or with remission lasting less than 1
month.

TREATMENT.
1. Oksigen 100%, 7 lt/minutes (10-15 minutes).
Combination 1-2 mg ergotamin and oksigen
100%.
2. Sumatriptan
- subcutan 6 mg (5-15mg).
3. Zolmatriptan 5 mg.
4. Dehydroergotamin (o,5-1,5mg).
5. Ergotamin 1-2 mg sup.
6. Analgetic and narcotic.

PROPHYLACTIC
1. Ergotamine 1-2 mg, verapamil 360480mg)
2. Metisergid 1-2 mg( 3-4 time/day).
3. Kortiokosteroid (prednisolon 60-80
mg).
4. Lithium carbonate.
5. Sodium valproate.
6. Pizotipen
7. Nerve block.

PREVENTION
1. Avoid precipitated factor.
2. Sleep regulation.
3. Avoid stress, smooking, and
excessive working.

MIGRAINE
PATHOPHYSIOLOGY 0
1. Cortical spreading depression (Leo)

Figure 4.5 Line drawing (panel


a) of the spreading oligemia
observed with studies of cerebral
blood flow (CBF) during aura
after Lauritzen. Adapted with
permission from Lauritzen M.
Cortical spreading depression as a
putative migraine mechanism.
Trends Neurosci 1987;10:813,
with permission from
Elsevier Science. Panel b
illustrates the variable time course
and relationship of the changes in
cerebral blood flow and the
symptomatology of migraine.
Adapted with permission from
Olesen J, Friberg L, SkyhojOlesen T, et al. Timing and
topography of cerebral blood
flow, aura and headache during
migraine attacks. Ann Neurol
1990;28:7918

PATHOPHYSIOLOGY (CONTINUES)
2.
2. System
System trigeminovascular
trigeminovascular

MIGRAINE.
A. Migraine with out aura = common
migraine.
A. Recurrent headache (5 X).
B. Headache last with in 4 72 hours.
C. Headache has at least two of the following
characteristic:
1. Unilateral.
2. Throbbing or pulsating headache.
3. Moderate or severe pain intensity.
4. Aggravated by routine physical activity such as
bending, climbing stairs.

D. During headache at least one of the following:


A.Nause and or vomiting.
B.Photophobia and phonophobia.
E.Not atributed to another disorder

B. Migraine with aura = classic


migraine, opthalmic, hemiphlegic,
aphasia, complicated migraine.
1. Recurent headache.
2. Aura sympton precede headache ( 5-20
minute) and last less than 60 minute.
3. Headache is throbing or pulsating.

MANAGEMENT.
A. General principles.
Avoid precipitated factor.
1.
2.
3.
4.

Food (chocoate, ice cream, mono sodium


glutamate).
Stress
Changing climate.
Sleep regulation.

B. Abortive treatment.
Attenttion:
1.
2.
3.
4.
5.

Rapid and constant effect of the drug.


Minimal/ with out side effect.
Long term effect to prevent recurrent headache.
Drug efectiveness that help patients return back
to normal activity.
Unexpensive and avaible

Pengobatan berhasil?
1. Bebas nyeri 2 jam setelah pengobatan.
2. Perbaikan skala nyeri kepala 2 (sedang),
atau 3 (berat) menjadi sekala nyeri 1
(ringan) atau skal 0 , sesudah 2 jam.
3. Efikasi pengobatan konsisten pada 2-3
kali serangan.
4. Tidak ada nyeri kepala berulang dan
tidak ada pemakaian obat lagi
dalam/pada waktu 24 sesudah
pengobatan berhasil

Drug for abortive treatment.


1. Ergotamin derivat.
- Ergotamin tartrat
- Dehydroergotamin.
2. Triptan
- sumtriptan
3. Analgetic
- Acetaminophen.
- Paracetamol.
- NSAIDs.

PROPHYLACTIC
1. Recurrent migraine, disturb daily avtivities.
2. More than 2 times attack/week.
3. Failure abortive treatment or exceed abortive
treatment.
4. Side efect with abortive treatment.
5. Patient choise.
6. Uncommon migraine ( hemiphlegic migraine,
basilar migraine, migraine with prolonged
aura, aura infarc migraine).

General principal preventif


treatment.
1. Reduce frquensi, intensity of headache.
2. Increase respond to teratment.
3. Increase daily acitivity living, and
reduce disability.

DRUG FOR
PROPHYLACTIC
1. Beta blocker ( propanolol, metoprolol, timolol
2.
3.
4.
5.
6.

Efective for; hypertension, angina.


Antidepresant; amitriptilin, flouxetin.
Calcium chanel blocker: flunarizin,
nimodipin, nipedipin, verapamil.
Anti convulsant: sodium valproate,
gabapentine, taporamate.
Serotonon antagonis: metisergid, pozotifen.
Botox ( botolinum toxin). .

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