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HEADACHESProf. dr. Basjiruddin ahmad, Sp.S (K)Fakultas Kdoktran !ni"rsitas Andalas#S. Dr. $. DjamilPadan%
3
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Hada&h In medical terminology : cephalgia Headache is defined as pain in the head that is
located above the eyes or the ears, behind thehead (occipital), or in the back of the upperneck, and has many causes
Majority of headaches are benign and selflimiting,secondary headache can life-threating conditionssuch as encephalitis,meningitis, tumor, cerebralhemorrhage, etc
!early universal e"perience #revalance :- $ year periode of %& '
- a life time of %%' iagnosis : areful history, e"amination and
diagnostic testing
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*imilar headaches can have different cause dependon the pain-sensitive structures, include:+Intracranial structures
ura near vessels
ranial nerves , II, I, ircle of .illisy Meningeal arteries /arge veins
01"ternal to the skull *calp and neck muscles ervical nervus and roots utaneous nerves and skin Mucosa of the paranasal sinuscs 2eeth
1"ternal carotid arteries
Pain'snsiti" stru&turs
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PAIN SENSITIVE CRANIAL STRUCTURES
*kin, subcutan, muscle 1"tracranial arteries *kull periosteum 1ye, ear, nasal cavities,
sinuses
Intracranial venous sinuses,large veins, pericavernousstructures
0asis duramater, meningealarteries, pro"imal anteriormiddle cerebral arteries,
carotis interna arteries *uperficial temporal arteries ranial nerves: ! II, ! III,
! , ! I, ! ,$-3
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!erves *upply*plancno cranium supply by cranial nerve , II,I and
!euro cranium, structures e"ternal to the skull(including scalp and neck muscle), are suppliedby nnspinalis $, 4, 3
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Location luster headaches al.ays unilateral 5&' migraines: are unilateral, some could be
spread become bilateral
2rigeminal neuralgia: uccurs unilaterally in thesecond and third trigeminal distribution 0rain tumor: bilateral or unilateral 2ension headache bilateral
Duration Migraine 6-74 hours in adults luster headache $8-$9& minutes 2ension type headche 3& minutes-days 2rigeminal neuralgia a fe. seconds 4minutes
Headache
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2.o types of headache: Primary headache,are not associated .ith
other diseases, for e"ample tension headache,migraine, cluster headache
Secondary headache, are caused byassociated diseases; may be minor or seriousand life threatening
2ension headache is the most common type of
primary headache, and more common among .omenthan men
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Classi&ation of primar hada&h(intrnational hada&h so&it *+ modid)
1. Migraine
a Migraine .ithout aura
bMigraine hemiplegic migraine
c 0asiler migraine
d
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3 luster headache and chronic paro"ismal
hemicraniaa luster headacheb hroic paro"ismal hemicrania
6 Headache associated .ith head trauma
8 Headache associated .ith vascular disease:infarction, hematoma, subarachnoid hemorrhage acutearterial hypertension
5 Headache associated .ith metabolicabnormality, dypo"ia, dialysis
7 Headache associated .ith intracranialdisordera Infection= abscessb 2umorc >ranulamotor disease
Classi&ation...
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9 Headache associated .ith us order of neck,eye, sinus, teeth
a ranial neuralgiab 2rigeminal neuralgiac >lossopharyngeal neuralgia
%
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$i%rain
Migraine is a chronic condition of recurrent attacks,due to changes in the brain and surrounding bloodvessels
#ain located in the forehead, around eye, or back ofhead, unilateral
?sually aggravated by daily activities, like .alkingupstairs etc
!ausea, vomiting, cold hands, facial pallor 2ypically last from 6-74 hours and vary in fre@uency
from daily to fe.er than $ per year +ffects about $8' or the population (.omen : men
A 3 : $) B 9&' migraineurs have other members in the
family
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Smptoms
Vary from person to personFive phases often to be identified: Prodrome: feeling ChighD, irritable, depressed,
funny taste of smell
ura: visual disturbance preceedes headachaphase, blind spots (scotoma), flashing, colorful orlose vision on one side (hemianopia)
!eadache: on one side of the head, 3&' spreadon both sides
2hrobbing pain, E9&' nauseated, and some vomit 7&' photophobia and phonophobia !eadache termination: pain usually goes a.ay
.ith sleep Postdrome: inability to eat, fatigue, problem .ith
concentration may linger after pain disappeared
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Phase of Acute Migrain
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"auses 1"act cause is not clearly understood
1"perts believe :+ combination of the e"pansion of blood vesselsand the release of certain chemicals, .hichcauses inflamation and pain2he chemicals dopamine and serotonine can
cause blood vessels to act abnormally if theypresent in abnormal amounts, or if the bloodvessels are unusually sensitive to them
Triggers ertain foods : chocolate, cheese, nuts, alcohol,
and M*> (monosodium glutamate) *tress and tension or physical stress 0irht control pills (estrogen) *moking Missing a meal may bring on a headache
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ssociated symptoms
#efore headache5&' migrainous have prodrome in hour before:Irritability, depression, eupharia small
hypertensiveDuring headacheMigraine: by nausea in %&', vomiting E 8&'
Foto=fobo sensitivity in 9&'
!asal congestion
luster : ipsilateral ptosis, miosis in 3&'ysability
fter headache2ired, drained, depression, decreased mental
acuity
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Migraine $ithout aura %common migraine& 0enign periodic headache lasting several hours,
.ithout preceding focal neurologic symptoms
?nilateral pain, nausea or vomitting, positive familyhistory, respon to ergotamin, scalp tenderness in9&'
Migraine $ith aura %c'assic migraine& Headache associate .ith characteristic premonitory
sensory, motor, or visual symptoms isual G scotomas or hallucinations (usually in centralvisual field) paracentral scotoma e"pands 4& to 48minutes
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#asi'ar migraine
0rainstem signs, including vertigo, dysarthria, diplopia;occur as sole neurologic symptoms of migraine in 48'
!emip'egic migraine Hemiparesis migraine may occur during prodrome; lasts
4& to 3& minutes
More severe: hemiplegia for days to .eeks headachesubsides
Familial from autosomal dominant
(ptha'mop'egic migraine +ttasck of periorbital pain and vomiting for $ to 6 days omplete third nerve palsy follo.s, often including
pupillary dilation, loss of lihgt response May persist days to 4 months
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iagnosis criteria). Migraine $ithout aura
a +t least 8 attacks fulfilling b cb +ttacks lasting 6-74 hc uring headache
!ausea and=or vomiting photophobi, phonofobi Headache .ith 4 of tha follo.ing
?nilateral, pulsating @uality Moderate severe intensity +ggravation by .alking stairs or similar activity
)). Migraine $ith aura$ +t least 4 attacks fulfilling b4 3 of the follo.ing
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$ana%mnt
cute treatment
Immediate administration of full dose ofagent at attack onset
Mild headache : aspirin, acetaminophen0utalbital and caffeine added if necessaryIbuprofen, napro"en often useful
Isometheptene compounds effective formild-to-moderate Dstress headacheD
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Moderate*to*severe headache:ergotamine (oral or suppository); sumatritan(oral intranasal, subcutaneous dose),iJatriptan, Jolmitriptan, naratriptan,2riptans indicated for attack fre@uency E 4 to3 per month
"ontra indications: Hypertension *troke oronary artery disease
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Severe headache: dihydroergotamine(parenteral, nasal spray) IntravenousprochlorperaJine, metoclopramide,
dihydroergotamine"hronic dai'y headache: amitriptyline,nortriptyline, anti depresants, valproat,
topiramate
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Prophy'a+is
aily administration re@uired 1ffect lags 4.eeks
Medications include:propanolol, amitriptiline,verapamil, valproat
+dditional drug include topiramate, Jonisamide
Probabi'ity of success5&' to 78'drug maybe tappered after 8 month
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-nsion Hada&h
+ tension headache is the most commonheadache and yet itKs not clear understood
>enerally produces mild to moderate pain, in theback of neck at the base of the skull feeling a
tight band around head *ymptoms can last from 3& minutes to an entire
.eek, or nearly all the time (never free fromheadache)
#atients e"perience: 2enderness on scalp, neck and shoulder muscles ifficulty sleeping (insomnia), fatigue, instability /ost of appetite, difficulty concentrating
*omeimes may be severe
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The causes sti'' continue to debate e+actcause are unno$n
-esearches no$ be'ieve
hanges among certain brain chemicals Gserotonine, endorphine and numerous otherchemicals G that help nerves communicate
2he process activate pain path.ays to the brainand to interfere .ith the brainKs ability to
supress the pain 2ight muscles in the neck=scalp contribute to a
headache, on the other hand, the tight musclesmay be a result of these chemical changes
auses
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Muscle tension that may cause Tension
Type Headache
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Potntial -ri%%rs
*tress epression, an"iety /ack of sleep or changes in sleep routine
#oor posture; lack of physical activity Lorking in a.k.ard positions Hormonal changes; menstruation,
pregnancy
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Classi&ation of -nsion Hada&h
1. /pisodic tension*type headache %/TT!&is defined as recurrent episodes of headache(older term: tension hedache, muscle contraction headache)
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I #ressing, tighthening nonpulsating @uality Mild or moderate intensity
0ilateral location
II !o nausea or vomiting !o aggravation by .alking stairs or
same =e"ercise
!o or one of phono-photophobia
Chara&tristi& -nsion tp hada&h
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Dia%nosti& &ritria E--H
haracteristic I and II .ith :+ +t least $& previous headache episodes
number of days .ith such headche $9&=y($8=mo)
0 Headche lasting from 9& min-7 days
Dia%nosti& &ritria of C--H Include characteristic + and 0 .ith :
+varage headache fre@uent $8 days=month($9& days=year) for 5 months
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T$o ris of "TT!
- +nalgesic rebound
- ormobidity
?se of combination analgesics should belimited to days or 46 tablets
**I (*erotinin *elective euptake
Inhibitor) drugs may administered as aprevention (fluo"etin)
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-ratmnt
2he goal is to relieve symptoms andprevent future headaches
#revention is the best treatment If possible, remove or control headache
triggers Medications :
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Pr"ntion *tress management strategies ela"ation e"cercises >ood posture .hen .orking, reading,
activities 1nough sleep and rest
Massage of sore muscles /ifestyle changes
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Clustr hada&h
/pisodic: most common type
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linical features #eriorbital, temporal, ma"illary pain begins
.ithout .arning, peaks .ithin 8 minutes
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2reatment2o abort attack : o"ygen inhalation($&m/=min via nonrebreathing mask),
intranasal topical lidocaine, sumatriptan 2oprevent further attacks during bout:prednisone, methysergide, ergotamine,verapamil
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Post&on&ussion hada&h
Follo. severe or trivial head injury(including head trauma .ithout loss of
consciousness)
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Brain Tumor Headache
hief complaint in 3&' of patints .ith braintumor: deep, dull aching @uality, moderateintensity, intermitten, .orsened by e"ertion
or change in position, associated .ithnausea and vomiting Headache disturbssleep in about $&' omiting precedesheadache by .eeks in posterior fossa brain
tumor
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#frn&s
+dams #rinciples of neurology 5th ed Mc>ra. Hill $%%7
Harsono, 0uku +jar !eurologi, 0ab II Harsono, apita selekta neurologi, 0ab II MaJJoni#MerrittsNs !eurology Handbook 4nd ed
resden /ippincott Lilliam Lilkins 4&&7 1vans L Hanbook of headache #hiladelphia
/ipincott Lilliam Lilkins, $%%% Headache .ikipedia Mayo clinic com
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Thank You