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Headache
In medical terminology : cephalgia Headache is defined as pain in the head that is located above the eyes or the ears, behind the head (occipital), or in the back of the upper neck, and has many causes Majority of headaches are benign and self limiting, secondary headache can life-threating conditions such as encephalitis,meningitis, tumor, cerebral hemorrhage, etc. Nearly universal experience Prevalance :- 1 year periode of 90 % - a life time of 99% Diagnosis : Careful history, examination and diagnostic testing
Painsensitive structures
Similar headaches can have different cause depend on the pain-sensitive structures, include:
A. Intracranial structures
Dura near vessels Cranial nerves V, VII, IX, X Circle of willisy Meningeal arteries Large veins
Scalp and neck muscles Cervical nervus and roots Cutaneous nerves and skin Mucosa of the paranasal sinuscs Teeth External carotid arteries
Nerves Supply
Splancno cranium supply by cranial nerve V, VII, IX and X Neuro cranium, structures external to the skull (including scalp and neck muscle), are supplied by nn.spinalis C1, C2, C3
Headache
Location
Duration
Cluster headaches always unilateral 60% migraines: are unilateral, some could be spread become bilateral Trigeminal neuralgia: uccurs unilaterally in the second and third trigeminal distribution Brain tumor: bilateral or unilateral Tension headache bilateral Migraine 4-72 hours in adults Cluster headache 15-180 minutes Tension type headche 30 minutes-days Trigeminal neuralgia a few seconds < 2minutes
1. Migraine
a. Migraine without aura b. Migraine hemiplegic migraine c. Basiler migraine d. Opthalmoplegic migraine e. Complications of migraine
Classification...
4. Headache associated with head trauma 5. Headache associated with vascular disease : 6. Headache associated with metabolic abnormality, dypoxia, dialysis 7. Headache associated with intracranial disorder
a. Infection/ abscess b. Tumor c. Granulamotor disease
Ice pick, cold stimulus, benign cough headache benign sex headache
Migraine
Migraine is a chronic condition of recurrent attacks, due to changes in the brain and surrounding blood vessels Pain located in the forehead, around eye, or back of head, unilateral Usually aggravated by daily activities, like walking upstairs etc Nausea, vomiting, cold hands, facial pallor Typically last from 4-72 hours and vary in frequency from daily to fewer than 1 per year Affects about 15% or the population (women : men = 3 : 1) 80% migraineurs have other members in the family
Symptoms
Throbbing pain, >80% nauseated, and some vomit 70% photophobia and phonophobia
Headache termination : pain usually goes away with sleep Postdrome : inability to eat, fatigue, problem with concentration may linger after pain disappeared
Causes
Triggers
Exact cause is not clearly understood Experts believe : A combination of the expansion of blood vessels and the release of certain chemicals, which causes inflamation and pain. The chemicals dopamine and serotonine can cause blood vessels to act abnormally if they present in abnormal amounts, or if the blood vessels are unusually sensitive to them Certain foods : chocolate, cheese, nuts, alcohol, and MSG (monosodium glutamate) Stress and tension or physical stress Birht control pills (estrogen) Smoking Missing a meal may bring on a headache
Associated symptoms
Before headache 60% migrainous have prodrome in hour before: Irritability, depression, eupharia small hypertensive During headache Migraine: by nausea in 90%, vomiting > 50% Foto/fobo sensitivity in 80% Nasal congestion Cluster : ipsilateral ptosis, miosis in 30% Dysability After headache Tired, drained, depression, decreased mental acuity
Benign periodic headache lasting several hours, without preceding focal neurologic symptoms Unilateral pain, nausea or vomitting, positive family history, respon to ergotamin, scalp tenderness in 80%
Headache associate with characteristic premonitory sensory, motor, or visual symptoms Visual scotomas or hallucinations (usually in central visual field) paracentral scotoma expands 20 to 25 minutes
Basilar migraine
Brainstem signs, including vertigo, dysarthria, diplopia; occur as sole neurologic symptoms of migraine in 25%
Hemiplegic migraine
Hemiparesis migraine may occur during prodrome; lasts 20 to 30 minutes More severe: hemiplegia for days to weeks headache subsides Familial from autosomal dominant
Opthalmoplegic migraine
Attasck of periorbital pain and vomiting for 1 to 4 days. Complete third nerve palsy follows, often including pupillary dilation, loss of lihgt response. May persist days to 2 months. Onset may occur in childhood
II.
Nausea and/or vomiting photophobi, phonofobi Headache with 2 of tha following Unilateral, pulsating quality Moderate severe intensity Aggravation by walking stairs or similar activity
One or more reversible aura Aura gradually over more than 4 minutes No aura lasts more than 60 minutes Headache (some with migraine without aura) follow aura with a free interval
Management
Acute treatment
Immediate administration of full dose of agent at attack onset
Mild headache : aspirin, acetaminophen. Butalbital and caffeine added if necessary. Ibuprofen, naproxen often useful. Isometheptene compounds effective for mild-to-moderate stress headache
Moderate-to-severe headache: ergotamine (oral or suppository); sumatritan (oral intranasal, subcutaneous dose), Rizatriptan, zolmitriptan, naratriptan, Triptans indicated for attack frequency > 2 to 3 per month Contra indications :
Hypertension Stroke Coronary artery disease
Severe headache : dihydroergotamine (parenteral, nasal spray). Intravenous prochlorperazine, metoclopramide, dihydroergotamine Chronic daily headache : amitriptyline, nortriptyline, anti depresants, valproat, topiramate
Prophylaxis Daily administration required. Effect lags 2 weeks Medications include: propanolol, amitriptiline, verapamil, valproat Additional drug include topiramate, zonisamide. Probability of success 60% to 75% drug maybe tappered after 5 month
Tension Headache
A tension headache is the most common headache and yet its not clear understood Generally produces mild to moderate pain, in the back of neck at the base of the skull feeling a tight band around head Symptoms can last from 30 minutes to an entire week, or nearly all the time (never free from headache) Patients experience:
Tenderness on scalp, neck and shoulder muscles Difficulty sleeping (insomnia), fatigue, instability Lost of appetite, difficulty concentrating
Causes
The causes still continue to debate exact cause are unknown Researches now believe :
Changes among certain brain chemicals serotonine, endorphine and numerous other chemicals that help nerves communicate The process activate pain pathways to the brain and to interfere with the brains ability to supress the pain Tight muscles in the neck/scalp contribute to a headache, on the other hand, the tight muscles may be a result of these chemical changes
Potential Triggers
Stress Depression, anxiety Lack of sleep or changes in sleep routine Poor posture; lack of physical activity Working in awkward positions Hormonal changes; menstruation, pregnancy Overuse of headache medication
2.
Occur on 15 days a month or more for at least three months 20% of CTTH are primary (daily from the onset) Duration and severity are similar with ETTH, although pain is daily and continous , and tenderness of scalp and neck
Characteristic I and II with : A. At least 10 previous headache episodes number of days with such headche <180/y (<15/mo) B. Headche lasting from 80 min-7 days Include characteristic A and B with : Avarage headache frequent 15 days/month (180 days/year) for 6 months
Two risk of CTTH: - Analgesic rebound - Cormobidity Use of combination analgesics should be limited to days or 24 tablets SSRI (Serotinin Selective Reuptake Inhibitor) drugs may administered as a prevention (fluoxetin)
Treatment
The goal is to relieve symptoms and prevent future headaches Prevention is the best treatment If possible, remove or control headache triggers Medications :
Over-the-counter (OTC) analgesics such aspirin, acetaminophen, may combine with caffeine and NSAID, ibuprofen, ketoproven Anti depressant : amitriptilin Non sedating muscle relaxant Combination of bulbital and acetaminophen
Prevention
Stress management strategies Relaxation excercises Good posture when working, reading, activities Enough sleep and rest Massage of sore muscles Lifestyle changes
Cluster headache
Episodic : most common type. One to three short-lived attacks of periorbital pain daily for 4 to 8 weeks, then pain-free interval for about 1 year Chronic: begins de novo or evolve from episodic type. Attacks similar no susteined remission. M:F=8:1 Onset ages 20 to 50
Clinical features
Periorbital, temporal, maxillary pain begins without warning, peaks within 5 minutes. Often excruciating, deep, nonfluctuating, explosive. Strictly unilateral. Attack last 30 to 120 minutes. Frequently with ipsilateral lacrimation, red eye, nasal stuffiness, lid ptosis, nausea
Treatment
To abort attack : oxygen inhalation (10mL/min via nonrebreathing mask), intranasal topical lidocaine, sumatriptan. To prevent further attacks during bout: prednisone, methysergide, ergotamine, verapamil
Post-concussion headache
Follow severe or trivial head injury (including head trauma without loss of consciousness). Often with vertigo, impaired memory and concentration, mood changes for months or years (post-concussion syndrome)
References
Adams RD. Principles of neurology 6th ed Mc Graw Hill 1997 Harsono, Buku Ajar Neurologi, Bab II Harsono, Kapita selekta neurologi, Bab II Mazzoni.P.Merritts`s Neurology Handbook. 2nd ed Dresden. Lippincott William & Wilkins. 2007 Evans RW. Hanbook of headache. Philadelphia Lipincott William & Wilkins, 1999 Headache wikipedia Mayo clinic com
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