HEADACHE

Prof. DR.dr.Hasan Sjahrir SpS(K)

Consultant neurologist
Department of Neurology
Sumatera Utara University
Member of InternaDonal Headache Society
Chair Advisory of Indonesian Headache study Group

Headache

sefalgia = NYERI KEPALA

definition: pain / unpleasant sensation of the head

as long as chin until cervicooccipital

epidemiology
prevalence life >me of headache are 90%
male and 96% female

Migraine
6 - 9% man, 15-18% woman.
Young adult age
Gene>c factor 70%

PREVALENCE MIGRAINE

female

male

Epidemiology in Indonesia
(hospital base)
Prevalence life >me TTH 78%
Episodic TTH 63% male 56% ,female 71%
TTH chronic 3% male 2 % ,female 5%
ETTH(Indonesia 31%, Medan 9.8%)
CTTH (Indonesia 24%, Medan 44%)
Migraine =10% (Indonesia)
Without aura( Medan 6.3%)
with aura (Medan 1.8%)

Prevalence in Indonesia (2004)

outpa>ent clinic

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Sefalgia

Osteo arthri>s
Stroke

LBP + OA 7.3%
Insomnia 4.0%
Epilepsy
Ver>go
Bells palsy 3.2%
LBP+HNP 2.5%
Neuropathy 2.3%

42 %
9.5%
7.7%
3.8%
3.6%

1. Migraine wthout aura 6-10%

2. Migraine with aura
1.8%
3. ETTH

31%
4. CTTH

24%
5. Cluster Headache 0.5%
6. Mixed Hx
14%
7. Post trauma cap syndr 14%
8. Secondary Headache 3%
9. Chronic Daily Headache 9%
10.Chronic Paroksismal
Hemikrania

1%

Headache verbal Scale

0 = no headache
1 : mild headache, ADL normal
2 : moderate headache, ADL a mild disturbed
(no need take a rest)
3 : severe headache : ADL very disturbed
(need take a rest/ admiTed to hospital).

Pathophysiology theory of headache

1. Sensi>za>on
2. theory vasodilata>on
3. ac>vation trigeminovascular
4. Steril inamma>on neuron
5.cor&cal spreading depression,
6. ac>va>on rostral brainstem
7. ac>vity imbalance brain stem nuclei
regula&ng an&nocep&on with
vascular control
8. etc

HEADACHE CLASSIFICATION

1. PRIMARY HEADACHE
1.
2.
3.
4.

Migraine
Tension Type Headache
trigeminal autonomic chephalalgias
Other primary headache

2. SECONDARY HEADACHE
3. Painful cranial neuropathies, other
facial pains and other headaches

Part two: The secondary headaches

5. Headache attributed to trauma or injury to the head and/
or neck
6. Headache attributed to cranial or cervical vascular
disorder
7. Headache attributed to non-vascular intracranial
disorder
8. Headache attributed to a substance or its withdrawal
9. Headache attributed to infection
10. Headache attributed to disorder of homoeostasis
11. Headache or facial pain attributed to disorder of
cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or
other facial or cranial structure
12. Headache attributed to psychiatric disorder

Part three: Painful cranial neuropathies, other

facial pains and other headaches
13. Painful cranial neuropathies and other facial pains
Trigeminal neuralgia
Glossopharyngeal neuralgia Nervus intermedius (facial
nerve) neuralgia
Occipital neuralgia
Optic neuritis
Headache attributed to ischaemic ocular motor nerve
palsy
Tolosa-Hunt syndrome
Paratrigeminal oculosympathetic (Raeders) syndrome
Recurrent painful ophthalmoplegic neuropathy
Burning mouth syndrome (BMS)
Persistent idiopathic facial pain (PIFP)
Central neuropathic pain

1. Migraine
1.1.Migraine without aura
1.2.Migraine with aura
1.2.1 Migraine with typical aura
1.2.1.1 Typical aura with headache
1.2.1.2 Typical aura without headache
1.2.2 Migraine with brainstem aura
1.2.3 Hemiplegic migraine
1.2.3.1 Familial hemiplegic migraine (FHM)
1.2.3.2 Sporadic hemiplegic migraine
1.2.4 Retinal migraine
1.3.Chronic migraine

1.4.Complications of migraine
1.4.1 Status migrainosus
1.4.2 Persistent aura without infarction
1.4.3 Migrainous infarction
1.4.4 Migraine aura-triggered seizure
1.5.Probable migraine
1.5.1 Probable migraine without aura
1.5.2 Probable migraine with aura
1.6. Episodic syndromes that may be associated with
migraine
1.6.1 Recurrent gastrointestinal disturbance
1.6.1.1 Cyclical vomiting syndrome
1.6.1.2 Abdominal migraine
1.6.2 Benign paroxysmal vertigo
1.6.3 Benign paroxysmal torticollis

Migraine without aura

A. At least 5 aTacks
B. Hx aTacks lasDng 4-72 hrs
C. Hx has 2 following characterisDcs:
A. Unilateral
B. PulsaDng
C. Moderate or severe pain
D.AgravaDon by physical acDvity
D. During Hx 1 of the following
A. Nausea and/or vomiDng
B. Phonophobia and photophobia
E. Not aTributed to another disorder
hasan sjahrir

1.2 Migraine with aura

A. At least two attacks fulfilling criteria B and C
B. One or more of the following fully reversible aura
symptoms:
1. visual
2. sensory
3. speech and/or language
4. motor
5. brainstem
6. retinal
C. At least two of the following four characteristics
1. at least one aura symptom spreads gradually Over >5
minutes, and/or two or more symptoms occur in succession
2. each individual aura symptom lasts 5-60 minutes
3. at least one aura symptom is unilateral
4. the aura is accompanied, or followed within 60
minutes, by headache

.2.1 Migraine with typical aura

A. At least two attacks fulfilling criteria B and C
B. Aura consisting of
visual,
sensory and/or speech/ language symptoms,
each fully reversible,
but no motor, brainstem or retinal symptoms
C. At least two of the following four characteristics
1. at least one aura symptom spreads gradually Over >5
minutes, and/or two or more symptoms occur in succession
2. each individual aura symptom lasts 5-60 minutes
3. at least one aura symptom is unilateral
4. the aura is accompanied, or followed within 60
minutes, by headache

Familial Hemiplegic Migraine

GeneDk, chromosome 1 & 19
Headache fullling criteria migraine with
typical aura
Aura hemiparese 60 mnts
Cerebellar ataxia (20%)
Onset suddenly
60% paDents FHM have symptom of basilar
type

Sporadic hemiplegic migraine

criteria idem FHM
No family history
Normal CT Scan & EEG

Basilar type migraine

Sign & symptoms of fossa posterior disorders

Disartria,
VerDgo
Tinnitus, deafness
Diplopia
Ataxia
Bilateral parestesia
unconciousness
Headache fullling criteria migraine without aura

ReDnal migraine
Rare
At least 2 aTacks scinDllaDng, scotoma,
blindness
Unilateral (only one eye)
Follows with migraine with aura
No aTributed to another disorders

1.5 ComplicaDons of migraine

1.5.1 Chronic migraine
Migraine without aura
> 15 days
> 3 months
No afributed to another disorders
without Medica>on over used
1.5.2 Status migrainosus
Severe headache migraine > 72 jam
No afributed to another disorders
1.5.3 Persistent aura without infarc>on
1.5.4 Migrainous infarc>on
1.5.5 Migraine-triggered seizures

The triggers or precipitants of the acute migraine afack.

1207 pts migraine of whom 75.9% reported triggers.

light(s)(38.1%),
alcohol (37.8%),
smoke (35.7%),
sleeping late
(32.0%),
heat (30.3%),
food(26.9%),
exercise (22.1%)
sexual ac>vity
(5.2%).

Stress (79.7%),
hormones in women
(65.1%),
not eating (57.3%),
weather (53.2%),
sleep disturbance
(49.8%),
perfume or odour
(43.7%),
neck pain (38.4%),

Kelman L. Cephalalgia 2007; 27:394402.

Food as Trigger factor of migraine

MAYOR
MSG
wine /vodka/bier
Cheese
Chocolate
Yogurt/yeast
citrus fruits
Bufermilk, milk

MINOR
nuts
Fried foods
Popcorn
Chile peppers
Seafoods
Pork / livers
Salty food/sweety

Therapy acute migraine

Abor>f non specic:
Aspirin 500-1000 mg
Aspirin 900 mg+metoclopramide 10 mg
Naproxen sod 750-1250 mg
Ibuprofen 400-2400 mg
Paracetamol 500 mg+aspirin 500 mg+ caein 130 mg
Abor>f specic:
Triptan,
dihydroergotamine,
ergotamine
27

summary for treatment of acute a8acks of

migraine

Triptans (serotonin1B/1D receptor agonists)

Sumatriptan
nasal spray evidence A 5-10 mg nasal spray
Sumatriptan SC A 6 mg SC
Oral triptans






Naratriptan
A 1-2.5 mg po
Rizatriptan A 10 mg po

Sumatriptan
A 50mg po

Zolmitriptan
A 2.5-5 mg po
DHE nasal spray A 0.5 nasal spray
AnDemeDc : domperidone B Prochlorperazine B ,
Metoclopramide B

2.Tension-type headache
2.1 Infrequent episodic tension-type headache
Infrequent episodic tension-type headache
associated with pericranial tenderness
Infrequent episodic tension-type headache not
associated with pericranial tenderness
2.2 Frequent episodic tension-type headache
Frequent episodic tension-type headache associated
with pericranial tenderness
Frequent episodic tension-type headache not
associated with pericranial tenderness

Infrequent episodic tension-type headache

A. At least 10 episodes of headache occurring on <1
day per month on average (<12 days per year)
and fulfilling criteria B-D"
B. Lasting from 30 minutes to 7 days "
C. At least two of the following four characteristics:"
" "1. bilateral location "
" "2. pressing or tightening (non-pulsating) quality
" "3. mild or moderate intensity "
" "4. not aggravated by routine physical activity "
" "such as walking or climbing stairs "
D. Both of the following:"
" "1. no nausea or vomiting "
" "2. no more than one of photophobia or"
" "phonophobia

2.2 Frequent episodic tension-type

headache
A. At least 10 episodes of headache occurring on 1- 14 days
per month on average for >3 months (>12 and <180 days
per year) and fulfilling criteria B-D
B. Lasting from 30 minutes to 7 days
C. At least two of the following four characteristics:"
"
"1. bilateral location "
"
"2. pressing or tightening (non-pulsating) quality
"
"3. mild or moderate intensity "
"
"4. not aggravated by routine physical activity "
"
"such as walking or climbing stairs "
D. Both of the following:"
"
"1. no nausea or vomiting "
"
"2. no more than one of photophobia or"
"
"phonophobia

 2.3 Chronic tension-type headache

2.4 Probable tension-type headache

2.3.Chronic tension-type headache

A. Headache occurring on >15 days per month on average
for >3 months (>180 days per year), ful- filling criteria BD
B. Lasting hours to days, or unremitting
C. At least two of the following four characteristics:
1. bilateral location
2. pressing or tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity such as
walking or climbing stairs
D. Both of the following:
1. no more than one of photophobia, phonophobia
or mild nausea
2. neither moderate or severe nausea nor vomiting

Therapy TTH :pharmacological

Analge>c : 2 days/week (Avoiding medica>on overuse )
Aspirin 1000 mg/day, parasetamol 1000 mg/day,
NSAIDs, NSAIDs and acetaminophen (with or without
caeine), butalbital
An>depressant:
Seda>ng : amitrip>lin, doxepin, imipramin, trazodone
Non seda>ng: uoxe>ne, sertraline, bupropion
An>anxiety:
benzodiazepin,: buspiron, lorazepam, alprazolam,
diazepam

Therapy TTH : non pharmacology

Avoid the triggers
Avoid daily usage of analgeDc, sedaDve
Physical Therapy :
Masage, manual therapy, compress, tracDon,
acupuncture, transcutaneous electrical nerve
sDmulaDon (TENS), anaestesi injecDon at trigger point,
improved sleep posiDoning with orthopedic pillows
Therapy behaviour:
Biofeedback, stress management therapy, conseling,
relaxaDon therapy, cogniDve behaviour th/

3. trigeminal-autonomic cephalalgias (TACs)

3.1 Cluster headache
3.1.1 Episodic cluster headache
3.1.2 Chronic cluster headache
3.2 Paroxysmal hemicrania
3.2.1 Episodic paroxysmal hemicrania
3.2.2 Chronic paroxysmal hemicrania(CPH)
3.3 Short-lasting unilateral neuralgiform headache

attacks

Short-las>ng unilateral neuralgiform headache with

conjunc>val injec>on and tearing (SUNCT)
3.4 Probable trigeminal autonomic cephalalgia
3.4.1 Probable cluster headache
3.4.2 Probable paroxysmal Hemicrania
3.4.3 Probable SUNCT

Cluster headache
Attacks of severe,
strictly unilateral pain
which is orbital, supraorbital, temporal or in any
combination of these sites,
lasting 15180 minutes and occurring from once
every other day to eight times a day.
The pain is associated with
ipsilateral conjunctival injection, lacrimation,
nasal congestion, rhinorrhoea,
forehead and facial sweating,
miosis, ptosis and/or eyelid oedema,
and/or with restlessness or agitation.

EFNS guidelines on the treatment of cluster headache and

other trigeminal-autonomic cephalalgias.

Therapy

Acute

Cluster Headache

Paroxysmal
Hemicrania

SUNCT
Syndrome

100% oxygen, 15 l/min (A)

Sumatriptan 6 mg, subcutaneous
(A)
Sumatriptan 20 mg nasal (A)
None
Zolmitriptan 5 mg nasal (A/B)
Zolmitriptan 10 mg nasal (A/B)

Verapamil (A)
Preventiv
Steroids (A)
e

None

Indomethacin (A)

(A denotes effective, B denotes probably effective

May, et al.2006

Lenaerts, 2008

42

3.2 Paroxysmal hemicrania

A. At least 20 attacks fulfilling criteria B-D
B. Attacks of severe unilateral orbital, supraorbital or
temporal pain lasting 2-30 min
C. Headache is accompanied by 1 of the following:
1. ipsilateral conjunctival injection and/or lacrimation
2. ipsilateral nasal congestion and/or rhinorrhoea
3. ipsilateral eyelid oedema
4. ipsilateral forehead and facial sweating
5. ipsilateral miosis and/or ptosis
D. Attacks have a frequency >5/d for > half of the time,
although periods with lower frequency may occur
E. Attacks are prevented completely by therapeutic doses
of indomethacin
F. Not attributed to another disorder

3.2 Paroxysmal hemicrania

ICHD-II. Cephalalgia 2004; 24 (Suppl 1)

International Headache Society 2003/4

4. Other primary headaches

4.1 Primary stabbing headache

4.2 Primary cough headache
4.3 Primary exer>onal headache
4.4 Primary headache associated with sexual ac>vity
4.4.1 Preorgasmic headache
4.4.2 Orgasmic headache
4.5 Hypnic headache
4.6 Primary thunderclap headache
4.7 Hemicrania con>nua
4.8. New daily-persistent headache (NDPH)

4.4 Primary headache

associated with sexual activity
4.4.1 Preorgasmic headache
A.Dull ache in the head and neck associated with
awareness of neck and/or jaw muscle contraction
and fulfilling criterion B
B.Occurs during sexual activity and increases with
sexual excitement
C.Not attributed to another disorder

4.4 Primary headache associated

with sexual acDvity
4.4.2 Orgasmic headache
A.Sudden severe (explosive) headache fulfilling
criterion B
B.Occurs at orgasm
C.Not attributed to another disorder
ICHD-II. Cephalalgia 2004; 24 (Suppl 1)

International Headache Society 2003/4

Hypnic headache

(alarm clock headache)

Afack during sleep
> 15 X /month
15-30 minutes
Age > 50 years
Bilateral
Mild-moderate

5. Headache afributed to head and/or

neck trauma

5.1 Acute posfrauma>c headache

5.1.1 Acute posfrauma>c headache afributed to
moderate or severe head injury
5.1.2 Acute posfrauma>c headache afributed to mild
head injury

5.2 Chronic posfrauma>c headache

5.2.1 Chronic posfrauma>c headache afributed to
moderate or severe head injury
5.2.2 Chronic posfrauma>c headache afributed to
mild head injury

8.2 MedicaDon Overuse Headache

8.2.1 Ergotamine-overuse headache
8.2.2 Triptans-overuse headache
8.2.3 Analgesics-overuse headache
8.2.4 opioid-overuse headache
8.2.5 CombinaDon medicaDon-overuse headache Other
substance overuse
8.2.6. Headache aTributed to other medicaDon overuse
(code to specify substance)
8.2.7. Probable medicaDon overuse headache (code to
specify substance)

Medica>on over-use
triptan, ergotamines, opioid, combinaDon
analgesic > 10 days/month
Simple analgesic > 15 days/months

MENSTRUAL
MIGRAINE

MAM = Migraine Associated with Menses

51

"the mechanism of menstrually associated

headache appears to be related to declining
estrogen levels."

American Academy of Neurology 55th Annual Mee>ng 2003

52

Pure menstrual migraine without aura

Diagnostic criteria:
A. Attacks, in a menstruating woman,1 fulfilling criteria for 1.1 Migraine without aura and criterion B
below
B. Documented and prospectively recorded
evidence over at least three consecutive cycles
has confirmed that attacks occur exclusively on
day 1 2 (i.e. days -2 to +3) of menstruation in at
least two out of three menstrual cycles and at no
other times of the cycle.

Menstrually related migraine without aura

Diagnostic criteria:
A. Attacks, in a menstruating woman,1 fulfilling
criteria for 1.1 Migraine without aura and criterion B
below
B. Documented and prospectively recorded
evidence over at least three consecutive cycles has
confirmed that attacks occur on day 1 2 (i.e. days
-2 to +3) of menstruation1 in at least two out of
three menstrual cycles, and additionally at other
times of the cycle.

Non-menstrual migraine without aura

Diagnostic criteria:
A. Attacks, in a menstruating woman, fulfilling criteria for 1.1 Migraine without aura and criterion B
below
B. Attacks do not fulfil criterion B for A1.1.1 Pure
menstrual migraine without aura or A1.1.2
Menstrually related migraine without aura.

THE END