PRIMARY HEADACHE IN

CLINICAL PRACTICE

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 Headache/ Nyeri Kepala
18,9% kunjungan ke RSDS
17,4% kunjungan ke RSCM
42% kunjungan praktek sore Sp.S
90% merupakan primary headache

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 NYERI

Pengalaman sensorik & emosional yg tidak

menyenangkan terkait kerusakan jaringan,
baik aktual maupun potensial atau yang
digambarkan dalam bentuk kerusakan tsb.
PATOFISOLOGI NYERI

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 HEADACHE/ Nyeri Kepala

 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%

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 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 Kranial

a. sinus, vein besar & aferennya
b. artery dura mater
c. 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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 STRUCTURE NOT SENSITIVE PAIN

1. Parenkim brain
2. Ependyma, pleksus choroid
3. Piamater, membrana arachnoidea &
duramater
4. Bone skull

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 PATOFISIOLOGY Headache General :

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

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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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 B. BERSUMBER ESKTRA KRANIAL

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

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1. Headache Primer
 Tension headache
 Migrain
 Cluster headache
2. Headache Secunder

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 Headache

PRIMER
Secunder

TTH Migrain Cluster

Headache infection Trauma Tumor Vascular
– Tanda2 history -Trias -acute
infection -Defisit
(Color/Dolor/ Trauma -Headache
chronic Neurologis
Robor) fokal
progresif
-vomit
proyektil
-Papil edema

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 DIAGNOSIS AND TESTING
Detailed History and Examination

NO Primary Headache?
 Preliminary Diagnosis

YES
Secondary
Headache Atypical
Features
Diagnostic
Testing

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 RED FLAGS “SNOOP T”
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
Older: new onset and progressive headache, especially in
middle-age >50
Previous headache history: first headache or different
(change in attack frequency, severity, or clinical features)

Triggered headache (valsava, exertion)

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 Standar kompetensi dokter
Headache
Tension type headache 1 2 3A 3B 4

Migrain 1 2 3A 3B 4

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 Kompetensi 3
• Mampu membuat diagnosis klinik
berdasarkan pemeriksaan fisik dan
pemeriksaan tambahan yang diminta oleh
dokter (misalnya : pemeriksaan laboratorium
sederhana atau X-ray).
• Dokter dapat memutuskan dan memberi
terapi pendahuluan, serta merujuk ke
spesialis yang relevan
bukan kasus gawat darurat  3 A
kasus gawat darurat  3 B
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 Kompetensi 4

• Mampu membuat diagnosis klinik

berdasarkan pemeriksaan fisik dan
pemeriksaan tambahan yang diminta oleh
dokter (misalnya : pemeriksaan laboratorium
sederhana atau X-ray).
• Dokter dapat memutuskan dan mampu
menangani problem itu secara mandiri
hingga tuntas.

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 Classification of headaches
• Primary headaches • Secondary headaches
• OR Idiopathic headaches • OR Symptomatic headaches

– THE HEADACHE IS ITSELF – THE HEADACHE IS ON LY A

THE DISEASE SYMPTOM OF AN OTHER
– NO ORGANIC LESION IN THE UNDERLYING DISEASE
BEACKGROUND – TREAT THE UNDERLYING
– TREAT THE HEADACHE! DISEASE!

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

ASSOCIATED
HEADACHE QUALITY LOCATION DURATION FREQUENCY
SYMPTOMS
Common Throbbing Unilateral head / 6 – 48 hours Sporadic (often Nausea, vomiting,
migraine Ifteral head several times malaise,
montlly) photophobia
Classic Throbbing Unilateral head 3 – 12 hours Sporadic (often Visual prodrome,
migraine several times vomiting, nausea,
monthly) malaise,
photobhobia
Cluster Boring, sharp Unilateral head 12 – 120 Closely bunched Ipsilateral tearing,
(especially orbit) minutes clusters with facial flushing, nasal
long remissions stuffiness, Horners’s
syndrome

Psychogenic/ Dull, pressure Diffuse, Ifteral Oftem May be constant Depression, anxiaty
Chronic TTH Frontal, temporal unremitting Almost daily Pericranial
suboccipital tenderness
Trigeminal Lancinating Fifth nerve Brief (15-60 Many times daily Identifiable trigger
meuralgia distribution second) zone

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 PHYSICAL FINDING POSSIBLE ETIOLOGY
Optic atropy, papiledema Mass lesion, hydrocephalus, benign
intracranial hypertensionon
Focal neurologic abnormality (hemiparese Mass lesion
aphasia)
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 TTH/Muscle Contraction Headache
muscle

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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/month
Peripheral pain mechanism
Tx NSAID, Parasetamol
Chronic
≥ 15 day/month, ≥ 3 months
Central pain mechanism
Tx Amitriptilin

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Tension Type
TTH
Headache

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 Treatment of TTH
Evidence A : multipel RCT
B : 1 RCT
C : Consensus
Clinical effect :
+ few people improved
++ Some people improved
+++ Most people improved

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Drug evidence Clinical effect Role Route

Analgesic & NSAID

Asetaminofen A ++ Acute PO
Aspirin A ++
Mefenamic acid A ++
Ibuprofen A ++
Naproxen A ++
Ibuprofen+caffein A ++

Antidepresan
Amitriptilin A +++ preventive PO
Maprotilin B +
Mianserin B ++
Sulpride C +
Fluvoxamine B ++

Muscle relaxants
Tizanidine B ++ Acute&preventive PO
Eperisone B ++

Others
Alprazolam B ++ Acute&preventive PO
Etizolam C ++
prochloperazine C ? Acute IV
chlorpromazine C ?

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-------- 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 • ausea
• ni • Lite and sound
• ateral ensitivity
• hrobbing
• Ctivity worsens

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 World prevalence of migraine
Switzerland 13%
Denmark 10%

France 8%†

USA 12%
Japan 8%
Italy 16%

 1-year prevalence rates

 Population-based studies
Chile 7%  IHS criteria (or modified)

Rasmussen and Olesen (1994); Rasmussen (1995);

Lipton et al (1994); Lavados and Tenhamm (1997);33 Sakai
†Prevalence measured over a few years and Igarashi (1997)
 Prevalence of migraine by
sex and age
Migraine prevalence (%) Females
30 Males
25

20
15

10
5
0
20 30 40 50 60 70 80 100
Age (years)
The American Migraine Study (n=2479 migraine sufferers)

Lipton and Stewart34

(1993)
 Migraine Patients Suffer From Pain
and Symptoms

Moderate to severe pain

99%

Photophobia 81%

Phonophobia 77%

Nausea 74%

Vomiting 30%

0 20 40 60 80 100
Percentage of patients reporting symptom

Adapted from Lipton et al. Headache. 2001.

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 Migraine Remains Underdiagnosed
and Undertreated

100
Percentage of patients

75

48% 49%
50

25 23% 23%

5%
0
MD diagnosis Rx medication OTC medication Both Rx No medication
only only and OTC

Lipton et al. Neurology. 2002.

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Migraine

A. The Aura

B. The Attack

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 UNDIAGNOSED MIGRAINE SUFFERERS OFTEN
RECEIVE OTHER MEDICAL DIAGNOSES

Tension-type HA 32%

Sinus HA 42%

0% 10% 20% 30% 40% 50%

Lipton RB et al. Headache. 2001. 44

 Penatalaksanan migrain
1. Hindari pencetus
2. Terapi abortif
 Non spesifik
 Spesifik
3. 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
• Tempat yang terang

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 Terapi abortif non spesifik
Obat 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
Ergot
Angka rekurensi rendah
Menginduksi drug overuse headache dg cepat
Maksimal diberikan10 hari/bulan
Efek samping : parestesi, muntah
Kontra indikasi
Penyakit kardio, serebrovaskular, hipertensi,
gagal ginjal, kehamilan dan laktasi

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TRIPTAN

Efikasi lebih baik dibanding ergot

Sediaan obat di Indonesia sulit di dapat (hanya
ada sumatriptan)
Efek samping : nyeri dada, parestesi, fatik
Kontra indikasi : Penyakit kardio, serebrovaskular,
hipertensi, gagal ginjal, kehamilan dan laktasi

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 Terapi prevensi migrain
1. Serangan >2-8 kali/bln
2. Berlangsung >48 jam
3. Pengobatan akut tdk efektif
4. Ada kontra indikasi terapi abortif, efek
samping, atau cenderung overuse
5. Gejala luar biasa ( migrain basiler, hemiplegi,
aura memanjang)
6. Permintaan pasien
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 Terapi prevensi migrain
Konsensus Nasional III Nyeri Kepala PERDOSSI 2010
Obat Dosis mg/hari evidence
betablocker
metoprolol 50-200 A
propanolol 40-240 A
Calcium channel blocker
Flunarizine (Frego) 5-10 A
Anti epileptic
Valproic acid 500-1800 A
Topiramat 25-100 A
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 Mechanism of action
• Non selective Calcium antagonist
• Anti dopaminergic
• H1 antihistamine
• (Stabilizers vasomoticity)
• Raises excitatory threshold in CSD
• Protects against hypoxia
• Reduces epileptic neuronal activity
• Effect on Calmodulin

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 Indications

• Prophylaxis of migraine
• Symptoms of vertigo

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 Contra-indications
• Parkinson’s disease
• History of depression
• Breast feeding
• (Pregnancy)
Caution
• Elderly
• Hepatic disease

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 Adverse effects

• Weight gain
• Sedation
• Depression
• Headache/insomnia/asthenia/GI disturbance

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 Interactions

• Alcohol
• Hypnotics /tranquilizers
• Anticholinergics
• Anticonvulsants

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 P. Louis,
Headache 1980 21:235-239,
• Belgium general practice
• 3month double blind no crossover
• 10mg v placebo
• 58 patients
• 57% v 14% reduction migraine attacks

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 C. Frenken
Clin Neurol Neurosurg 1984 Vol 86 Pt 1 17-20

• Netherlands primary care

• 35 patients
• 12 weeks
• 10mg v placebo
• 75% reduction in active v 31% placebo

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 G. Mendenopoulous
Cephalalgia 1985 ;5:31-7

• Greek secondary care

• 20 patients
• Placebo v 10mg 3-4 months
• 50% reduction v 30% increase in placebo
• No side effects occured

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 PS Sorenson
Cephalalgia 1986 ;6:7-14.
• Danish secondary care
• 29 patients
• Double blind crossover trial
• 16 weeks treatment period
• 10mg v placebo
• 50% reduction in migraine frequency in last 4
weeks (15% placebo)

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 HC Deiner et al
Cephalalgia 2002;22:209-221
• 808 patients
• Double blind 16 week treatment phase
• 10mg(5days/week) v 5mg v Propranolol
160mg
• Responders (50% reduction)
5mg:46%. 10mg:53%. Propranolol:48%
• Drop out due to adverse effects
5mg:16.7%. 10mg: 19.3%. Propranolol:16.7%

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 Sorensen PS
Headache 31:650-655 1991
• 149 patients
• Double blind 10mg v Metoprolol 200mg
• 16weeks treatment phase
• Both 37% reduction migraine days /month
• 8% depression v 3% with Metoprolol

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Cluster
Headache

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RESUME-1
MIGREN
symptom CLUSTER TTH
Classic general
Permulaan akut akut akut Pelan-pelan
(onset)
Lama attack Beberapa lebih lama 10 mnt – 2 Berjam-jam
jam – 1 hari jam s/d berhari-
hari
Frekwensi Periodik Periodik Periodik dlm setiap hari
serangan setahun
symptom Skotom Kabur aneka (-) (-)
Prodromal auditory, ragam
tactile psikik
vertigo

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 RESUME - 2
MIGREN
symptom CLUSTER TTH
Classic general
gejala ikutan - GIT, Dapat tanpa Muka sembab (-)
nausea, gejala ikutan Hyperlacrimasi
vomit Rhinorrhea
- dilatation Hyperhidrasi

atemporalis
Lokalisasi Satu sisi Bermacam- Satu sisi Dahi, kuduk
macam

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ATAS PERHATIANNYA

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