Pemicu 5

Divan FL

Characteristics of Pain
Pulsating, throbbing pain is frequently ascribed
to migraine, but it is equally common in patients
with tension headache.
A steady sensation of tightness or pressure is
also commonly seen with tension headache.
The pain produced by intracranial mass lesions is
typically dull and steady.
Sharp, lancinating pain suggests a neuritic
cause such as trigeminal neuralgia.
Ice picklike pain may be described by patients
with migraine, cluster headache, or giant cell
arteritis.

Location of Pain
Unilateral headache is an invariable feature of cluster headache and
occurs in the majority of migraine attacks; most patients with tension
headache report bilateral pain.
Ocular or retroocular pain suggests a primary ophthalmologic
disorder such as acute iritis or glaucoma, optic (II) nerve disease (e.g.,
optic neuritis), or retroorbital inflammation (e.g., Tolosa-Hunt
syndrome). It is also common in migraine or cluster headache.
Paranasal pain localized to one or several of the sinuses, often
associated with tenderness in the overlying periosteum and skin,
occurs with acute infection or outlet obstruction of these structures.
Headache from intracranial mass lesions may be focal (it hurts right
here), but even in such cases it is replaced by bioccipital and bifrontal
pain when the intracranial pressure becomes elevated.
Bandlike or occipital discomfort is commonly associated with tension
headaches. Occipital localization can also occur with meningeal
irritation from infection or hemorrhage and with disorders of the joints,
muscles, or ligaments of the upper cervical spine.
Pain within the first division of the trigeminal nerve (Figure 21B), characteristically described as burning in quality, is a common
feature of postherpetic neuralgia.
Lancinating pain localized to the second or third division of the
trigeminal nerve (Figure 2-1B) suggests tic douloureux.
The pharynx and external auditory meatus are the most frequent

Associated Symptoms
Manifestations of underlying systemic disease can aid in the etiologic diagnosis
of headache and should always be sought.
Recent weight loss may accompany cancer, giant cell arteritis, or
depression.
Fever or chills may indicate systemic infection or meningitis.
Dyspnea or other symptoms of heart disease raise the possibility of subacute
infective endocarditis and resultant brain abscess.
Visual disturbances suggest an ocular disorder (e.g., glaucoma), migraine, or
an intracranial process involving the optic nerve or tract or the central visual
pathways.
Nausea and vomiting are common in migraine and posttraumatic headache
syndromes and can be seen in the course of mass lesions. Some patients with
migraine also report that diarrhea accompanies the attacks.
Photophobia may be prominent in migraine and acute meningitis or
subarachnoid hemorrhage.
Myalgias often accompany tension headaches, viral syndromes, and giant cell
arteritis.
Ipsilateral rhinorrhea and lacrimation during attacks typify cluster
headache.
Transient loss of consciousness may be a concomitant of both migraine
(basilar migraine) and glossopharyngeal neuralgia (cardiac syncope).

Acute Onset
Common Cause

Subarachnoid hemorrhage
Other cerebrovascular diseases
Meningitis or encephalitis
Ocular disorders (glaucoma, acute iritis)

Less Common Cause

Seizures
Lumbar puncture
Hypertensive encephalopathy
Coitus

Subacute Onset

Giant cell (temporal) arteritis

Intracranial mass (tumor, subdural hematoma, abscess)
Pseudotumor cerebri (benign intracranial hypertension)
Trigeminal neuralgia (tic douloureux)
Glossopharyngeal neuralgia
Posttherpetic neuralgia
Hypertension (including pheochromocytoma and the use of monoamine oxidase inhibitors plus tyramine)
Atypical facial pain

Chronic

Migraine
Cluster headache
Tension headache
Cervical spine disease
Sinusitis
Dental disease

Migrain

Definisi
Gangguan periodik yang ditandai oleh nyeri kepala
unilateral yang dapat disertai muntah dan gangguan
visual
Sakit kepala kronik yang menyebabkan nyeri yang
signifikan dalam beberapa jam sampai beberpa hari
Bersifat
rekuren,
dapat
terjadi
secara
unilateral/bilateral
Beberapa migrain didahului oleh gejala sensoris/aura
(classic migrain) seperti melihat kilatan cahaya, blind
spots, perasaan gatal pada tangan dan kaki,
dizziness, fotofobia dan visual scintillations (bright
zigzag lines)
Sering diikuti dengan nausea, vomiting, dan
sensitivitas terhadap cahaya dan suara

Epidemiologi
Merupakan tipe nyeri kepala terbanyak kedua
setelah Tension headaches
Lebih sering ditemukan pada wanita dengan rasio
3:1
Tanpa aura : dengan aura = 4 : 1
Pada anak-anak, migraines lebih sering ditemukan
pada anak laki2 dibandingkan anak perempuan
wanita
80% pasien mendapatkan serangan utama pada
usia 30th
Predileksi umur 30-40th, jarang > 50th
Migrain pd > 55th suspek kelainan inrakranial

Faktor Pencetus
Genetik (70-80%)
Obat2an (kontrasepsi oral, terapi hormon,
vasodilators)
Perubahan hormonal pada wanita
Fluktuasi estrogen (kehamilan, menopause)
Kelelahan / stress emosional

Alkohol dan makanan tertentu

alkohol, keju, makanan asin, kafein

Stimulus sensorik : cahaya terang, cahaya
matahari, suara yg keras, bau/wewangian tertentu
Gangguan pola tidur : jet lag
Perubahan lingkungan

Teikopsia
Migrain dengan
aura

Spektra fortifikasi

Migrain tanpa
aura

migrain

Vertebrobasilar
migraines
Hemiplegic
migraines

Retinal, or
ocular,
migraines

aura
vertigo
Double vision
Paralisis sesisi tubuh
Mirip stroke

Faktor Resiko
Genetik
Usia < 40tahun
Separuh penderita migrain dimulai pada
usia 20 th, paling sering pada usia 30-40
th
Wanita 3x > rentan
Perubahan hormonal pada menstruasi,
kehamilan dan menopause (estradiol <)

Patofisiologi
Vasodilatasi di pembuluh darah besar di otak
Menarik nervus yang mempersarafi di sktr pembuluh
darah
Nervus melepaskan neurotansmitter

Inflamasi, nyeri, dilatasi pembuluh darah

Nyeri kepala

Activation of the TNC May Result in Referred Pain that Could

be Perceived Anywhere along the Trigeminocervical Network

17

Arterial
Activation

Release of
Neurotransmitter

Worsening of Pain

The Migraine Process: Activation of the

Trigeminal Nucleus Caudalis (TNC)

20

Tanda dan gejala

Garis zig zag yang melayang di
pandangan
Kehilangan pengliatan
Pandangan gelap
Kilatan cahaya
Sensasi lain yang mungkin menyertai :
Kesemutan di ekstremitas atau di wajah
Confusion
Kesulitan dalam berbahasa

Nyeri kepala hebat, sering satu sisi

Peka terhadap cahaya
Mual dan muntah
Cutaneous allodynia
Aktivitas normal, tapi berasa sakit (sisir rambut)

Gejala Klinis
HeadacheUnilateral / hemicrania (30-40% are
bilateral)
Moderate to severe pain
Nyeri kepala berdenyut
Terjadi selama 4-72jam
Nyeri memburuk paska aktivitas fisik

Systemic manifestations
Nausea (80-90%)
Vomiting (40-60%)
Photophobia (80%)
Phonophobia (75-80%)
Lightheadedness (70%)

Gejala Aura (20%)

Scotoma (blind spots)

Fortification (zig-zag patterns)
Scintilla (flashing lights)
Unilateral paresthesia/weakness
Hallucinations
Hemianopsia
Rasa tertusuk2 pada lengan dan kaki

Gejala Non Aura

Tidak terdapat aura
Gejala prodormal tidak jelas
Nyeri kepala terjadi saat bangun
tidur
Gejala = gejala tipe klasik
Feelings of elation or intense energy
Cravings for sweets
Thirst
Drowsiness
Irritability or depression

Pemeriksaan Fisik
Melakukan skrining pemeriksaan neurologis
Tidak ada manifestasi fisik tertentu
Adanya photophobia / phonophobia
Adanya gejala sistemic : myalgia, fever, malaise,
weight loss, scalp tenderness, jaw claudication
Kelainan neurologis fokal : confusion, seizures,
gangguan kesadaran, unilateral paralysis or
weakness, Aphasia, syncope
Kelumpuhan N III ocular muscle paralysis,
respons pupil, ptosis
Ophthalmic migraines gangguan visual

Pemeriksaan Penunjang
Computerized tomography (CT)
Dugaan Diagnosa : tumors, infections dan penyebab medik
lain dari nyeri kepala
Magnetic resonance imaging (MRI)
Dugaan Diagnosa : tumors, strokes, aneurysms,
neurological diseases and other brain abnormalities.
Dapat juga digunakan untuk pemeriksaan pembuluh darah
yang menyuplai otak
Spinal tap (lumbar puncture)
Diagnosa : meningitis
In this procedure, a thin needle is inserted between two
vertebrae in your lower back to extract a sample of
cerebrospinal fluid (CSF) for laboratory analysis.

DD

Cluster Headache
Stroke hemoragik/ iskemik
Headache tension
Meningitis
Perdarahan subarachnoid
Tumor otak ( TIK)
Pseudotumor cerebri
Gangguan vaskular (aneurisma)

Komplikasi
Abdominal problems
abdominal pain
bleeding and ulcers

Rebound headaches
Serotonin syndrome

Pengobatan
Serangan migrain lebih dari 3x/bln
profilaksis
Saat serangan dan pencegahan NSAIDs,
ergotamin, valproic

Pencegahan
Hindari faktor pemicu
Istirahat cukup
Olahraga aerobik Jalan santai, berenang,
bersepeda

Cluster Headache

Cluster headache
Termasuk dalam golongan trigeminal autonomic
cephalgias
Serangannya multipel dan berat bersifat unilateral
pada daerah orbital.
Lebih sering pada pria. 4:1
Prevalensinya sekitar 15 kasus per 100.000 orang.
Faktor Resiko

Pria
Usia lebih dari 30 tahun
Vasodilator (misal:alkohol)
Trauma kepala atau operasi sebelumnya

Gejala klinik
Serangan dapat
berlangsung setiap
saat.
1 4 serangan per
hari , 20 menit 3
jam
Bersifat unilateral,
serangan pada
malam hari,
seperti tertusuk
benda tajam

Patogenesis
PET aktivasi hipotalamus posterior
serangan spontan
Dilatasi pembuluhdarah peningkatan
tekanan pada nervus trigeminal
nyeri cluster headaches
Hipotalamus
Genetics
Triggersnitrogliserin, alkohol,
hidrokarbon ( parfum, petolum solven)

Diagnosis
Serangan multipel dari nyeri orbital unilateral,
supraorbital, atau temporal yang berlangsung 15180 menit bila tidak diobati.
Selama nyeri kepala, minimal 1 dari berikut ini:
Konjungtiva yang hipermia, lakrimasi unilateral
atau keduanya
Kongesti nasal ipsilateral, rhinorrhea atau
keduanya
Edema kelopak mata ipsilateral
Berkeringat di wajah atau dahi ipsilateral.
Ptosis, miosis ipsilateral atau keduanya.
Sensasi restlessness atau agitasi.
Frekuensi serangan terbentang dari 1 setiap hari lain
sampai 8 kali perhari.

Terapi
Meliputi terapi simptomatik dan profilaktik.
Simtomatik: inhalasi oksigen, injeksi
sumatriptan.
Profilaksis: kotikosteroid dosis tinggi, verapamil,
divalproex, litium karbonat.

Prognosis
Umumnya menjadi masalah seumur hidup.
Beberapa pasien mengalami complete remissions
setelah menderita serangan rekuren beberapa
tahun.