Curriculum Vitae

• Nama : Prof DR Dr Hasan Sjahrir SpS(K),

• Jabatan/Pangkat : Guru besar Neurologi FK USU Medan/IV E
• Tempat lahir: Kediri, 30-9-1947
• Menikah, 2 anak
• Jabatan/Posisi saat ini
1. Ketua Komisi A Dewan Guru Besar USU
2. Ketua Departemen Neurologi FK USU Medan
3. Ketua Dewan Pertimbangan Fakultas FK USU Medan
4. Anggota Dewan Penasehat Pengurus Pusat Asosiasi Profesor Indonesia
5. Ketua II Pengurus Pusat Perdossi & Koordinator Nasional Kelompok Studi
6. Penasehat Kelompok Studi Nyeri Kepala Perdossi
7. Anggota International Headache Society
8. Ketua AAzI Wilayah Sumut
9. Ketua Pokdi Neurotraumatologi & Vertigo Perdossi Cab.Medan
10. Anggota Honorary Editorial Advisory Board Asia MIMS Indonesia
11. Anggota Editorial Board Medical Progress Journal Asia
12. Anggota Medical Advisory Board PT ASKES
11/1/2010 HASANSJAHRIR
1
 Clinical and management of
headache in geriatric

Hasan Sjahrir
Department of Neurology
Sumatera Utara University
Medan
http://neurologi.usu.ac.id
11/1/2010 HASANSJAHRIR
 diseases in elderly people

the proportion frequent single diagnoses

• 23.5% dis of the circulatory
system,
• 13.9% cancer,
• 10.6% musculoskeletal system
and connective tissue disease
• 8.1% endocrine, nutritional
and metabolic diseases,
• 7.7% dis of the nervous
system,
• 6.8% mental and behavioural
disorders
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HASANSJAHRIR
• essential hypertension (11.1%),
• breast cancer (3.5%),
• heart failure (3.0%),
• depression (2.6%),
• Parkinson’s disease (2.5%),
• chronic ischemic heart disease
(2.3%).
Jeschke et al. BMC Geriatrics 2010, 10:48
 Headache in the elderly
• Chronic headache in old age 10% of all women and 5%
of all men older than 70 years.
• The incidence of primary headache decreases with
advancing age, while that of secondary headache
increases.
• The clinical characteristics of migraine can also change
with age (reduced pain severity, frequency, location and
vegetative symptom)
• Hypnic headache is a rare primary headache syndrome
that occurs almost exclusively in the elderly
Reinisch VM.et al Schmerz. 2008 Feb;22 Suppl 1:22-30.
11/1/2010 HASANSJAHRIR
 Lifetime Prevalence Headache in elderly
Age (55- 94 years) %
Primary headache 51.7 – 81%
Tension type headache 18.3 – 51.8 %,
women 46.3%
men 34.7%
cranial neuralgias/trigeminal neuralgia 1.6%
Migraine 2.9 - 19.3%
women 28.5 %
and men 8.7%
Other primary headache 1.2%
Secondary headache 15 – 30%
1.Schwaiger
11/1/2010
J et al. Cephalalgia 2009; 2. TCapobianco
HASANSJAHRIR
DJ.Adv.stud.Med.2003
3. Onini MC, Neurol Sci .2010; 31( Suppl 1):S67-S71
 Headache in elderly
• Primary headache
– Late life migrainous accompaniment
– Tension type headache
– Cluster headache
– Hypnic headache
• Secondary headache
– Medication over used headache
– Giant cell arteritis etc
Capobianco DJ.Adv.stud.Med.2003
11/1/2010 HASANSJAHRIR
 Late life migrainous accompaniment
criteria diagnostic
• Visual display (+) (scintillating, fortification)
• Slow/gradual visual or sensory symptoms
• Serial progression from visualsensoryto motor
symptom
• Occurence of identical attacks
• Duration of 20-30 minutes
• Common in 50- 60 years
• Complete resolutions(without sequelae)
• 50% headache without follow accompaniment
• Exlusion of symptomatic etiologies
11/1/2010 HASANSJAHRIR Capobianco DJ.Adv.stud.Med.2003
Late life migrainous accompaniment
therapy

• Ca channel blocker (verapamil)

• Aspirin
• anticonvulsant

11/1/2010 HASANSJAHRIR
 Pharmacoepidemiology of triptans
in older age
• 343 patients (migraine without aura: 72%; chronic
migraine: 26%; migraine with aura: 2%)
• mean age 40.4 ± 10 years
• The number of patients reporting adverse effects
significantly decreased with age (r= -0.230,
p<.005),
• The increase of the tolerability of triptans with age
In the latter, the efficacy and better tolerability
(but not necessarily safety) of triptans could foster
the overuse of these medications
11/1/2010 HASANSJAHRIR
Ferrari A et al.Cephalalgia 2010, 30(7) 847–854
the changes in migraine symptomatology
with age IN ELDERLY
• caused by age-related changes in blood
vessels, the same changes in blood vessels
could also affect triptan tolerability.
• The vasoconstrictive response to triptans
could be more intense in younger subjects
and weaker in older patients.
• increased benefits and reduced adverse
effects of triptans with age, could explain
both the risk of overuse reported for the
elderly
11/1/2010 HASANSJAHRIR
 Treatment
• Treatment of migraine or tension-type
headaches in older patients can be difficult.
• In older patients, higher therapeutic benefits,
together with fewer adverse effects, could
instead foster triptan overuse if migraine
frequency increases.
• If a prophylactic approach is used, the
starting dose should be low and with slow
increases

Swanson JW 2005,
11/1/2010 HASANSJAHRIR
 Chronic daily headache
• A total of 3.9% of elderly population had
CDH, (F/M: 5.6%/1.8%, p < 0.001).
• CTTH being the most common subtype.
• Almost two-thirds of those with CDH had
persistent frequent headaches at follow-up.
• Analgesic overuse was a significant predictor
of a poor outcome. (relative risk = 1.6)

Wang SJ et al. Neurology 2000;54:314

11/1/2010 HASANSJAHRIR
 Hypnic headache syndrome
(“alarm-clock” headache) criteria IHS
• A. Dull headache fulfilling criteria B–D
• B. Develops only during sleep, and awakens
patient
• C. At least two of the following characteristics
– 1. Occurs >15 times per month
– 2. Lasts 15 min after waking
– 3. First occurs after age of 50 years
• D. No autonomic symptoms and no more than one
of nausea, photophobia or phonophobia
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Hypnic headache syndrome symptom
• is rare, sleep-related, begins after 50 years of age.
• more common in women.
• occur at each night, between 1 - 3 A.M.
• headaches begin abruptly, diffuse and throbbing,
and spontaneously resolve in 15 to 180 minutes.
• The pain is usually localized in the front of the
head
• More than 4 attacks/week.
• There are usually no other symptoms ( nausea and
light and sound sensitivity may be present.)
11/1/2010 HASANSJAHRIR
Hypnic headache syndr : Treatment
• Flunarizine 10 mg/day for 1 month before lithium.
• lithium carbonate,
– often poorly tolerated(Lithium side effects included
thirst, tremor, increased urination and confusion.)
– dosages of lithium were 300 mg - 600 mg
– The duration of treatment ranged 2 weeks to 64 month
– The mechanism of lithium for hypnic headache is
unknown. Lithium may increase serotonin production,
serotonergic transmission in the central nervous system
and indirectly increase the nocturnal melatonin level
• caffeine (40-60 mg tablet or as a cup of coffee)
• indomethacin.
11/1/2010 HASANSJAHRIR
 Pathophysiologydysfunction of the brainstem
neural pathways hat regulate the sleep–wake cycle.
• Attacks during REM sleep
suggested cause by
diminished dorsal raphe
nucleus activity.
• The regularity of the episodes
during sleepsuprachiasmic
nuclei of the hypothalamus
are involved.
• connections between the
pain modulating PAG and the
hypothalamus likely playing a
role of the headache.
• A decrease in melatonin
secretion predilection for
the elderly .
11/1/2010
J-F Liang et al. Cephalalgia 2008;
HASANSJAHRIR
William J Mullally et al. Cephalalgia 2010.
 Case study I
• a 68-year-old woman who developed headache her entire
head, are throbbing and fairly severe. Each headache lasts
1 – 2 hours and then spontaneously resolves even without
treatment. The headaches are not associated with any
other symptoms.
• blood tests and MRIs of her brain has been normal.
• She is desperate of these headaches because, curiously,
they only strike her at night, always between 1 and 3 A.M.
She has not had a good night sleep in five years.

DIAGNOSE: Hypnic Headache

11/1/2010 HASANSJAHRIR
 Case study II
• A 58-year-old man with a 2-month of bi-occipital to
bifrontal throbbing headaches awakening him from sleep
4–5 nights per week.
• The headaches occurred at the same time.
• He did not have a history of a primary headache disorder
• The headaches did not occur during the day
• there were no accompanying neurological symptoms,
nausea or autonomic symptoms
• Ibuprofen provided him with some relief
WORKING DIAGNOSIS: HYPNIC HEADACHE
William
11/1/2010 J Mullally and Kathryn EHASANSJAHRIR
Hall. Cephalalgia 2010 30(7) 887–889
A (MRI) scan revealed a heterogeneous mass in the fourth
ventricle with compression of the medulla and pons with
vasogenic oedema of the inferior cerebellum and
obstructive hydrocephalus with transependymal oedema

Pathological
11/1/2010 was consistent with a haemangioblastoma
HASANSJAHRIR
 secondary headache
• Secondary headaches represent one-third of
headaches in the elderly, compared with 10%
in the general population
• secondary headache is greater in older
patients, and they are more likely than the
general population to often experience
polypharmacy and drug interactions

Swanson JW 2005,
11/1/2010 HASANSJAHRIR
 secondary headache in elderly
1. cerebrovascular disease
2. medication-induced headaches
3. Giant cell arteritis
4. drugs that could be etiologic in headaches
– tetracycline,
– bronchodilators,
– vasodilators and antihypertensives,
– sedatives and stimulants,
– antidepressants such as SSRIs,
– reproductive drugs such as estrogen
11/1/2010 HASANSJAHRIR
 Giant cell arteritis (GCA) at 50 – 80 yrs
• GCA and Herpes zoster ophthalmicus (HZO) with
post-herpetic neuralgia (PHN) are commonly seen
in the elderly
• Prevalence 7 – 73 /100.000 Men : women = 4 : 1
• The cause of GCA is currently unknown 
– reactivation of latent varicella zoster virus
(VZV) viral vessel infiltration leading to the
arteritis or by an indirect dysimmune route
(Necrotizing arteritis)
– Systemic granulomatous inflammatory process
(multinuclear giant cell)
Kosa 11/1/2010
SC et al. Cephalalgia, 2010; vol. 30, 2: pp. 239-241.
HASANSJAHRIR
 Giant cell arteritis
• Headache not specific, dull, throbbing
• Scalp Tenderness near temporal occipital area
• Co-morbid polimyalgia rheumatica, malaise,
fatique
• Visual disturbances
• ESR > 50 mm/hr
• Diagnostic : biopsy
• Th/ prednisone 40-80 mg 2 weeks, tappering off
11/1/2010 HASANSJAHRIR Capobianco DJ.Adv.stud.Med.2003
Figure 1. (A) Low-power magnification haematoxylin and eosin
(H&E) section demonstrating lymphocytic infiltration of the
vessel wall with disruption of the internal elastic lamina and
the presence of multinucleated giant cells (arrows).

Kosa S et al. Cephalalgia 2010;30:239-241

Copyright11/1/2010
© by International Headache Society HASANSJAHRIR
 White Matter Lesions in the Elderly
• 163 subyect had severe headache were a mean
age of 69 years, and 58% were women
• Any history of severe headache (not just migraine),
is associated with a significantly increased risk for
white matter hyperintensities (WMHs) (deep
WMH & periventricular WMH) in older individuals
OR was 2.0 (95% confidence interval [CI], 1.3 - 3.1;
P = .002)

Tobias
11/1/2010 Kurth, American AcademyHASANSJAHRIR
of Neurology 62nd Annual Meeting.2010
Management: There are no guideline for therapeutic

 Start low, go slow. Start psychotropics at ¼ to ½ of the

"recommended" starting dose.
 Avoid drugs with a prolonged half-life when possible.
Oxazepam is the preferred benzodiazepine in older
patients.
 Review both prescribed and OTC medications/ vitamins/
herbs with the patient on each visit.
 Give the patient and/or the family a written list of
medications, the purpose of the drug, dosing intervals
and potential side effects. Strive for once or twice a day
dosing.

Tonini MC, Neurol Sci .2010; 31( Suppl 1):S67-S71

HASANSJAHRIR 11/1/2010
King SA. http://www.dcmsonline.org/jax-medicine/1998journals/august98/geriatrics.htm
Management: There are no guideline for therapeutic
• every medication taken there is an indication.
• Encourage the patient & family to report problems with
compliance, (e.g. medication expense, personal fears of
taking drugs, symptoms that may be side effects of drugs.
• Consider the use of anticonvulsants (e.g., valproate
sodium) instead of antipsychotics in dementia patients
with overtly aggressive behavior.
• Try to tailor a drug's known side effects to a patient's
needs; for instance, trazodone may be the ideal selection
for a patient with hypertension, insomnia/anxiety,
depression and chronic pain or neuropathy.
• When a patient has new complaints, remember that drugs
can cause illness.
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 Analgetic for elderly
• Aging causes that alter the pharmacokinetics
and pharmacodynamics of analgesics
increasing the risk of toxicity and drug-drug
interactionsCNS changes lead to an increased
risk of delirium
• A basic principle of the pharmacological
approach in the elderly is to start analgesics at
low dosages and titrate slowly

Davis
11/1/2010 ML. Drugs & Aging: 2003; HASANSJAHRIR
20: 23-57
The most frequently prescribed substances
Neuro-Pharmacotherapy of elderly patients
1. opioids (50.9% of all analgesics) and pyrazolone
(metamizole sodium; 33.7%)
2. benzodiazepine derivates (28.7% of all psycholeptics)
and benzodiazepine related drugs (25.4%),
3. anticholinesterases (18.0%) and memantine (13.4%),
4. amitriptyline (19.3%) and doxepin (7.5%),
5. drugs dopa and dopa-derivates (45.6%) and dopamine
agonists (35.1%),
6. simvastatine (61.6% of all lipid modifying agents).

11/1/2010 HASANSJAHRIR
Jeschke et al. BMC Geriatrics 2010, 10:48
The goal of management among the
elderly
• improvement in pain
• optimisation of activities of daily living
• the lowest possible drug dosages.
• Most successful management strategies
combine pharmacological and
nonpharmacological therapies

Davis
11/1/2010 ML. Drugs & Aging: 2003; HASANSJAHRIR
20: 23-57
 Bank of sperm

11/1/2010 HASANSJAHRIR
 Thank you

11/1/2010 HASANSJAHRIR
Most frequent diagnoses according to age
group
60 – 74 years 75 – 79 years > 80 years
1. Hypertensive 1. Hypertensive 1. Hypertensive
diseases diseases diseases
2. Malignant 2. Other forms of 2. Other forms of
neoplasms, heart disease heart disease
3. Mood [affective] 3. Malignant 3. Ischaemic heart
disorders neoplasms, diseases
4. Dorsopathies 4. Mood [affective] 4. Arthropathies
5. Arthropathies disorders 5. Dorsopathies
6. Episodic and 5. Ischaemic heart 6. Episodic and
paroxysmal diseases paroxysmal
disorders 6. Diabetes mellitus disorders*
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Jeschke et al. BMC Geriatrics 2010, 10:48
 pharmacoepidemiology in the elderly
• Older hypertensive patients (mean age 75 ±
10 years use of ACE inhibitors may reduce the
risk of headache caused by nitrates (OR 0.43;
95% Confidence Intervals: 0.20– 0.90)

11/1/2010 Onder G et al. CephalalgiaHASANSJAHRIR

2003; 23:901–906