DAFTAR RIWAYAT HIDUP

DATA PRIBADI

Nama : Prof. Dr. dr. Suroto, Sp.S (K) FAAN

TTL : Surakarta, 5 November 1948
Agama : Islam
Pangkat : Guru Besar I. PenyakitSarafGol.IV/e

RIWAYAT PENDIDIKAN
RIWAYAT ORGANISASI
Tahun 1977 : DokterdariFakultasKedokteran UNS Tahun 1977-sekarang : IkatanDokter Indonesia (IDI)
Tahun 1987 : DokterspesialisPenyakitSarafdariFakultasKedokteran UNAIR Tahun 1987-sekarang : PERDOSSI
Tahun 1992 : CBR fellowship, Tottori University, Japan Tahun 1990-sekarang : World Federation of Neurology (WFN)
Tahun 2001 : S3 dariIlmuKedokteran UNAIR Tahun 2007-sekarang : American Academy of Neurology (AAN)
Tahun 2003 : KonsultanSerebrovaskulerdari KNI
Tahun 2008-sekarang : World Stroke Organization (WSO)
Tahun 2015 : FAAN dari America Academy of Neurology
Tahun 2015-sekarang : European Academy of Neurology (EAN)

RIWAYAT PEKERJAAN
1977-1981 : Ketua Lab Farmakologi FK UNS
1988-1994 : KetuaJurusanMedik FK UNS
4/18/2014
1994-1998 : Dekan FK UNS
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2005-sekarang : Ketua Lab/ SMF I.PenyakitSaraf FK UNS/ RS Dr. Moewardi
 Headache in
Out-Patients Clinic

Suroto
Dept of Neurology, Fac of Medicine
Sebelas Maret University
Defferentiating headache and vertigo

 Headache or Cephalalgia: A pain in the head with the pain being

above the eyes or the ears, behind the head (occipital), or in the
back of the upper neck.
 ICHD 3: Headache: Pain located above the orbitomeatal line
 The word “cephalal” : head and “algesia”: ache

 Vertigo: is a feeling that you are dizzily turning

around or that things are dizzily turning about you.
 The word "vertigo" comes from the Latin
"vertere", to turn + the suffix "-igo", a condition = a
condition of turning about).

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Of all the painful states, Headache is the most frequent
reason for seeking medical help.

 95% of young women and 91% of young men

experienced headache during a 12-month period;
- 18% of these women and 15% of these men consulted a
physician because of their headache.

Headache is usually a benign symptom but

occasionally it is the manifestation of a serious illness.

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 Pain Sensitive Structure in the Head

Sensitive Non Sensitive

Extracranial Extracranial
 Skin, muscles, fascia  Skull (except periosteum)
 Blood vessels
 Mucosa of sinuses
 Dental structure

Intracranial
 Large arteries near circle of
Willis
 Large venous sinuses
 Dural arteries and parts of dura
Intracranial
 Parenchyma of brain
 Pia mater, arachnoid mater,
parts of duramater
 Ependyma, choroid plex
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 Headache can occur as a result of:

1. Distension, traction or dilatation of intra-cranial or extra-

cranial arteries,
E.g. - After taking nitrates.
-After eating monosodium glutamate.
- Extreme rise of BP.
- After ingestion of alcohol.

2. Traction or displacement of large intracranial veins or their

dural envelope.
3. Compression, traction or inflammation cranial or spinal
nerves. 6
Contd..

4. Spasm, inflammation or trauma to cranial & cervical

muscles & apophyseal joints in the upper part of spine.
5. Meningeal irritation & raised ICP.
6. Headache of ocular origin:
eg. sustained contraction of extra ocular muscles, acute
glaucoma, and iridocyclitis.

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CLASSIFICATION OF HEADACHE

 Primary headaches  Secondary headaches

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

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Primary, Idiopathic Headache

1.Tension type headache

2. Migraine
3. Cluster headache
4. Miscellaneous primary headache:
Idiopathic stabbing headache.
Cold stimulus headache .
Headache associated with sexual activity .

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Secondary, Symptomatic Headache

5. Headache associated with head and/neck trauma.

6. Headache associated with vascular disorder.
7. Headache associated with non vascular intracranial disorder.
8. Headache associated with substances or its withdrawal
9. Headache associated with infection.
10. Headache associated with homeostasis disorder.
11. Headache or facial pain associated with disorders of cranial or
facial structures.
12. Headache attributed to psychiatric disorder
13. Painful cranial neuropathies and other facial pains
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14. Other headache disorders
 DIAGNOSTIC APPROACH
OF HEADACHE
HISTORY AND EXAMINATIONS SHOULD CLARIFY:

 THE PATIENT HAS PRIMARY OR SECONDARY HEADACHE

 IS THERE ANY URGENCY

 IN CASE OF PRIMARY HEADACHE:

 ONLY THE HEADACHE ATTACKS SHOULD BE TREATED

(“ATTACK THERAPY”),

 OR PROPHYLACTIC THERAPY IS ALSO NECESSARY

(“PREVENTIVE THERAPY, INTERVAL THERAPY”)

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History Taking:

1.Age, sex:
 Migraine headache – more frequent in teenagers & young adults,
higher occurrence in female.
 Cluster headache – almost exclusively in males.
 Cranial arteritis – more frequently in late middle age & in elderly.

2.Quality of pain:
 Tension headache – pressing, squeezing, tight or heavy.
 Migraine headache – throbbing or pounding.
 Headache due to intracranial lesion – relatively mild.
 Acute SAH- pain tends to be explosive & intense.

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History Taking: Cont’d

3. Location of headache:
As a general rule localized headache is of greater significance than diffuse
headache.
 Tension headache – typically generalized, band like or bioccipital.
 Migraine with aura – often unilateral & frequently more prominent
interiorly.
 Migraine without aura – frequently bilateral.
 Cluster headache – invariably limited to the same side of the head in any
given attacks & usually periorbital.
 Sinusitis – fontal/ethmoidal, head position
 Cranial arteritis – manifested by localized temporal headache.
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History Taking: Cont’d

4. Associated symptoms:
 Tension headache – often associated with other psycho-physiologic
disturbances.
 Cluster headache – typically associated with ipsilateral lacrimation,
conjuctival injection, rhinorrhoea, & facial flushing.
 Intracranial mass lesion – associated symptoms are more prominent
than headache. Some intra-cerebral lesion may exhibit seizure or
vomiting.
 Cranial arteritis – systemic symptoms as fever, anorexia & rheumatic
symptoms.

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History Taking: Cont’d

5. Precipitating & aggravating factors:

 Tension headache & vascular headache – induced or
aggravated by emotional factors.

 Intraventricular & posterior fossa tumour – may be

accentuated by change in the head position, coughing &
Valsalva maneuver.

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History Taking: Cont’d

6. Frequency, duration & diurnal variation:

 Tension headache – long duration -- often persist & may worsen as the
day progress.
 Migraine headache – the frequency is variable & unpredictable.
Although usual variation is from 4 - 72 hrs, they may persist for days.
 Cluster headache – occur repetitively over a period of weeks or
months. Often there are 1 or 2 attacks daily. The headache typically
nocturnal & of brief duration (30 min to a few hours).
 Headache due to meningeal cause – acute in onset.

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 Migraine vs Stroke
 A migraine: severe headache that can induce nausea, vomiting, and
sensitivity to light, sounds, and smells
 Migraine aura:
- In up to 30 percent
- Aura/warning: visual disturbances, numbness, speech difficulties
 These warning signs are very similar to the symptoms of a stroke.
 Stroke symptoms:
• Numbness or weakness on one side of the body
• Vision loss
• Trouble understanding speech
• Slurred speech
• Headache
• Dizziness
• Disorientation
 Several factors can help determine: onset, visual disturbances, pre-
history 18
Sudden vs. gradual.
 Strokes occur suddenly.
 Migraine aura: occur more gradually, evolving over several mints
 Migraine aura: accompanying headache intensifies to a peak.
Positive vs. negative visual disturbances.
 Migraine aura: experience additional stimuli, such as flashing
lights or zigzagging lines
 Stroke: detracts from vision.
 Stroke: not realize immediately that the vision has been impaired
until begin bumping into things.
History vs. no history of migraines.
 Migraine aura: tend to be the same every time.,
 First migraine aura: it’s less common – in children
 Stroke: for the first time late in life
 If pts have never a migraine before or if migraine migraine
deviates from its normal course  get to an emergency room as
soon as possible to rule out a stroke or TIA. 19
PHYSICAL EXAMINATION:

1. General physical examination:

 Flushed face, lacrimation, and unilateral rhinorrhoea –
cluster headache.
 Systemic sign (fever, weight loss, anaemia) – infectious
disease, specific infection of CNS, metastatic disease of brain
&/or meninges.

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PHYSICAL EXAMINATION:

2. Neurological examination:
 No neurological abnormality – tension headache.
 Permanent residual damage – Evidence of cerebral ischaemia – small
percentage of migraine
 Horner’s syndrome – sometimes during migraine headache (rarely
permanent).
 Localizing sign – expanding IC-SOL.
 Papilledema -  ICP due to IC-SOL.
 Bruits over the eyes/cranium – vascular malformation.
 Sign of meningeal irritation – lesion affecting the meninges.
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Investigations

 Blood Examination.
 Skull & Cervical Spine Imaging.
 CT Scan of the head.
 MRI & MRA of the brain.
 Eye & ENT evaluation.
 Cardiologic & renal evaluation.

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When to scan a patient with headache

 First or worst headache, particularly if of sudden onset.

 Headache of increasing frequency or severity.
 Increased frequency of vomiting and headache.
 Headache triggered by coughing, straining or postural
changes.
 Persistent physical symptoms or signs after attack.
 Meningism, confusion, impairment of consciousness or
seizures.
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 Red flag for secondary headache -
Silberstein SD et al

Flag Descriptions/example
Systemic symptoms or secondary Fever,W-loss,or known cancer,HIV,
risk factors immunosupression or thrombotic risks
Neurological symptoms or signs Confusion,impaired alertness/drowsy,
persistent focal signs >1h
Onset First and worst headache,sudden abrupt
from sleep, or progressively worsening
Older New onset at age and progressive
(Giant cell arteritis)
Previous headache history Significant change in features, freq. or
severity
Triggered headache By valsalva, exertion,

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HEADACHE OF SOME SERIOUS ILLNESS:
Meningitis:
• Acute severe headache – rapid evolution, minutes to hours.
• Site - generalized or bi-occipital or bi-frontal.
• Associated with fever, photophobia, nausea and vomiting.
• Neck stiff on forward bending, Kernig and Brudzinski signs.
• LP – diagnostic .

SAH:
• Acute severe headache – rapid evolution, minutes to hours.
• Site – generalized.
• Not associated with fever.
• Neck stiffness – on forward bending.
• LP – diagnostic. 25
 Brain tumor:

• Site – unilateral or generalized headache.

• Worse in the early morning & improves during day.
• Worsen with exertion, change in position, bending,
lifting or coughing.
• Associated with nausea, vomiting.
• Impaired mentation, focal sign, seizures, and
papilloedema – present.

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Temporal arteritis/giant cell arteritis:

 Age – older patients (>50 yrs).

 Site – uni/bilateral & is located temporally in 50% patients.
 Character – dull & boring with superimposed lancinating
 Appears gradually over a few hours before peak intensity • Worse at
night & is often aggravated by exposure to cold.
 Associated with polymyalgia rheumatica, jaw claudication, fever &
weight loss.
 Scalp tenderness . Temporal artery & less commonly occipital artery
may be tender.
 ESR - .
 Temporal artery biopsy – diagnostic.
 Treatment – prednisolone 80 mg daily for 4-6 wks.
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 Moewardi Hospital
Headache Out Patient Clinic

 Jan-Jun 2018  116 HA pts

 M 44 ( %), F 72 ( %)
 Age 28-61 yo (mean 45.6 yo)
 Mostly not serious illness
 20 ( 17%): CVA, AVM, SOP, Inf

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 Moewardi Hospital
Headache Out Patient Clinic
Jan-Jul, 2018

Problem n %
TTH 63 54.3
Migraine 21 18.1
ENT problem 9 7.8
Dental problem 6 5.2
Intracranial SOP 6 5.2
Ischemic stroke 4 3.4
ICH 3 2.6
AVM 2 1.7
Intracranial Infection 2 1.7
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 Summary
 Headache is usually a benign symptom but occasionally it is the
manifestation of a serious illness.

 Primary headache: tension headache, migraine, cluster headache

 Secondary headache: the headache is only a symptom of an other

underlying disease

 Accurate history taking is fundamental in making diagnosis

 Need for further investigation: determined by red flag symptoms

 Dr Moewardi out pts clinic: TTH, migrain, secondary headache

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