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HEADACHES

BASJIRUDDIN A
BAGIAN NEUROLOGI FK-UNAND
RS. DR. M. DJAMIL PADANG

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

Pain–sensitive 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

B. External to the skull





Scalp and neck muscles
Cervical nervus and roots
Cutaneous nerves and skin
Mucosa of the paranasal sinuscs
Teeth
External carotid arteries

are supplied by nn.spinalis C1. structures external to the skull (including scalp and neck muscle). C2. IX and X Neuro cranium. C3 . VII.Nerves Supply Splancno cranium supply by cranial nerve V.

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 Duration     Migraine 4-72 hours in adults Cluster headache 15-180 minutes Tension type headche 30 minutes-days Trigeminal neuralgia a few seconds < 2minutes .Headache Location      Cluster headaches always unilateral 60% migraines: are unilateral.

for example tension headache. migraine. are caused by associated diseases. cluster headache – Secondary headache. and more common among women than men . are not associated with other diseases. may be minor or serious and life threatening Tension headache is the most common type of primary headache. Two types of headache: – Primary headache.

Migraine hemiplegic migraine c. Chronic tension type headache (CTTH) . Basiler migraine d. Tension type headache f. Episodic tension type headache (ETTH) g. Migraine without aura b. Opthalmoplegic migraine e.Classification of primary headache (international headache society 1988 modified) 1. Complications of migraine 2. Migraine a.

Tumor c. Cluster headache b. Headache associated with vascular disease : infarction. Granulamotor disease . 3. dialysis 7.. Headache associated with metabolic abnormality. subarachnoid hemorrhage acute arterial hypertension 6.Classification. Infection/ abscess b. Cluster headache and chronic paroxismal hemicrania a. hypoxia. hematoma. Headache associated with intracranial disorder a. Chroic paroxismal hemicrania 4. Headache associated with head trauma 5..

8. Glossopharyngeal neuralgia 9. sinus. Headache not classifable . teeth a. eye. Headache associated with disorders of neck. cold stimulus. Trigeminal neuralgia c. Cranial neuralgia b. Other type of headache Ice pick. benign cough headache benign sex headache 10.

unilateral Usually aggravated by daily activities. around eye. due to changes in the brain and surrounding blood vessels Pain located in the forehead. like walking upstairs etc Nausea.Migraine        Migraine is a chronic condition of recurrent attacks. vomiting. or back of head. 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 .

blind spots (scotoma). flashing. colorful or lose vision on one side (hemianopia) – Headache : on one side of the head. problem with concentration may longer after pain disappeared . and some vomit 70% photophobia and phonophobia – Headache termination : pain usually goes away with sleep – Postdrome : inability to eat. depressed. fatigue. 30% spread on both sides   Throbbing pain. irritable. >80% nauseated. funny taste of smell – Aura : visual disturbance preceedes headache phase.Symptoms  Vary from person to person Five phases often to be identified : – Prodrome : feeling “high”.

alcohol.Causes   Exact cause is not clearly understood Experts believe : A combination of the expansion of blood vessels and the release of certain chemicals. and MSG (monosodium glutamate) Stress and tension or physical stress Birth control pills (estrogen) Smoking Missing a meal may bring on a headache . or if the blood vessels are unusually sensitive to them Triggers      Certain foods : chocolate. cheese. nuts. which causes inflamation and pain. The chemicals dopamine and serotonine can cause blood vessels to act abnormally if they present in abnormal amounts.

Associated symptoms Before headache – 60% migrainous have prodrome in hour before: – Irritability. miosis in 30% – Dysability After headache – Tired. euphoria smell hypertensive During headache – Migraine: by nausea in 90%. decreased mental acuity . depression. vomiting > 50% Foto/fobo sensitivity in 80% Nasal congestion – Cluster : ipsilateral ptosis. drained. depression.

positive family history. respon to ergotamin. nausea or vomitting. scalp tenderness in 80% Migraine with aura (classic migraine)   Headache associate with characteristic premonitory sensory. or visual symptoms Visual – scotomas or hallucinations (usually in central visual field) paracentral scotoma expands 20 to 25 minutes . motor. without preceding focal neurologic symptoms Unilateral pain.Migraine without aura (common migraine)   Benign periodic headache lasting several hours.

including vertigo. loss of light response. lasts 20 to 30 minutes – More severe: hemiplegia for days to weeks headache subsides – Familial from autosomal dominant  Opthalmoplegic migraine – Attack of periorbital pain and vomiting for 1 to 4 days. often including pupillary dilation. diplopia. Onset may occur in childhood . occur as sole neurologic symptoms of migraine in 25%  Hemiplegic migraine – Hemiparesis migraine may occur during prodrome. – May persist days to 2 months. Basilar migraine – Brainstem signs. – Complete third nerve palsy follows. dysarthria.

Migraine without aura a. Nausea and/or vomiting photophobi. During headache       II.fulfilling b & c b. At least 2 attacks fulfilling b 2. pulsating quality Moderate severe intensity Aggravation by walking stairs or similar activity Migraine with aura 1. Attacks lasting 4-72 h c.Diagnosis criteria I. At least 5 attacks . phonofobi Headache with 2 of tha following Unilateral. 3 of the following     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 .

acetaminophen. Isometheptene compounds effective for mild-to-moderate ”stress headache” . Butalbital and caffeine added if necessary. naproxen often useful.Management Acute treatment Immediate administration of full dose of agent at attack onset Mild headache : aspirin. Ibuprofen.

Triptans indicated for attack frequency > 2to 3 per month Contra indications :    Hypertension Stroke Coronary artery disease .Moderate-to-severe headache: ergotamine (oral or suppository). naratriptan. subcutaneous dose). Rizatriptan. sumatriptan (oral intranasal. zolmitriptan.

nasal spray). anti depresants. metoclopramide. dihydroergotamine Chronic daily headache : amitriptyline. Intravenous prochlorperazine.Severe headache : dihydroergotamine (parenteral. nortriptyline. topiramate . valproat.

amitriptiline. valproat Additional drug include topiramate. Effect lags 2 weeks Medications include: propanolol. verapamil. Probability of success 60% to 75% drug maybe tappered after 5 month . zonisamide.Prophylaxis Daily administration required.

or nearly all the time (never free from headache) Patients experience: – Tenderness on scalp. fatigue. 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. instability – Lost of appetite.Tension Headache     A tension headache is the most common headache and yet it’s not clear understood Generally produces mild to moderate pain. neck and shoulder muscles – Difficulty sleeping (insomnia). difficulty concentrating  Some times may be severe .

the tight muscles may be a result of these chemical changes . on the other hand.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 brain’s ability to supress the pain – Tight muscles in the neck/scalp contribute to a headache.

menstruation.Potential Triggers Stress  Depression. pregnancy  Overuse of headache medication  . anxiety  Lack of sleep or changes in sleep routine  Poor posture. lack of physical activity  Working in awkward positions  Hormonal changes.

Classification of Tension Headache 1. Episodic tension-type headache (ETTH) is defined as recurrent episodes of headache (older term: tension hedache. although pain is daily and continous . muscle contraction headache) – Occur on fewer than 15 days a month – Lasting a few minutes to few hours – Scalp and neck muscle tenderness in addititon to head pain – Risk of developing chronic form over years 2. Chronic tension-type headache (CTTH) – 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. and tenderness of scalp and neck .

Pressing.Characteristic Tension type headache I. tighthening non pulsating quality  Mild or moderate intensity  Bilateral location II. No nausea or vomiting  No aggravation by walking. up stairs or as same exercise  No or one of phono-photophobia .

tighthening non pulsating quality No nausea or vomiting Characteristic I and II with : II. Pressing.Diagnostic criteria ETTH  I. A. At least 10 previous headache episodes number of days with such headche <180/y (<15/mo) B. Headache lasting from 80 min-7 days Diagnostic criteria of CTTH  Include characteristic A and B with : Avarage headache frequent 15 days/month (180 days/year) for 6 months .

Analgesic rebound .Two risk of CTTH: .Cormobidity  Use of combination analgesics should be limited to days or use until 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. acetaminophen. ketoproven – Anti depressant : amitriptilin – Non sedating muscle relaxant – Combination of butalbital and acetaminophen . remove or control headache triggers  Medications :  – Over-the-counter (OTC) analgesics such aspirin. ibuprofen. may combine with caffeine and NSAID.

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. Attacks similar no sustained remission. M:F=8:1 Onset ages 20 to 50 . 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.

deep.Clinical features – Periorbital. peaks within 5 minutes. Frequently with ipsilateral lacrimation. red eye. lid ptosis. nasal stuffiness. explosive. temporal. nonfluctuating. Strictly unilateral. maxillary pain begins without warning. nausea . Attack last 30 to 120 minutes. – Often excruciating.

ergotamine. verapamil . sumatriptan. intranasal topical lidocaine. To prevent further attacks during bout: prednisone. methysergide.Treatment To abort attack : oxygen inhalation (10mL/min via nonrebreathing mask).

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Often with vertigo. impaired memory and concentration.Post-concussion headache Follow severe or trivial head injury (including head trauma without loss of consciousness). mood changes for months or years (post-concussion syndrome) .

worsened by exertion or change in position. associated with nausea and vomiting. intermitten. moderate intensity. Vomiting precedes headache by weeks in posterior fossa brain tumor . dull aching quality. Headache disturbs sleep in about 10%.Brain Tumor Headache Chief complaint in 30% of patients with brain tumor: deep.

Buku Ajar Neurologi. 2007 Evans RW. Lippincott William & Wilkins. Bab II Mazzoni. Kapita selekta neurologi.Merritts`s Neurology Handbook. Bab II Harsono. Hanbook of headache. Philadelphia Lipincott William & Wilkins.References        Adams RD. 1999 Headache wikipedia Mayo clinic com . 2nd ed Dresden.P. Principles of neurology 6th ed Mc Graw Hill 1997 Harsono.

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