CEPHALGIA

dr. Yusmahenry Galindra SpS

Staf Neurology
University Batam
Batam
 CEPHALGIA
DEFINITION :

Rasa sakit atau tidak nyaman antara

orbita dan kepala yang berasal dari
Struktur sensitive rasa nyeri.
 The International Classification of Headache Disorders
ICHD 2 ( IHS 2004 )

The Primary Headaches

Migraine
Tension-type headache (TTH)
Cluster headache
Other primary headaches

The Secondary Headaches

Headache attributed to head and/or neck trauma
Headache attributed to cranial or cervical vascular disorders
Headache attributed to non-vascular intracranial disorders
Headache attributed to a substance or its withdrawal
Headache attributed to infection
Headache attributed to disorder of homoeostasis
Headache or facial pain attributed disorder of cranial, neck, eyes, ears,
nose, sinuses, teeth, mouth or other facial or cranial structures
Headache attributed to psychiatric disorders

Cranial Neuralgias, central & primary facial pain & other headaches
Cranial neuralgias & central causes of facial pain
Others headache, cranial neuralgias & central or primary facial pain
PAIN SENSITIVE CRANIAL STRUCTURES
 Skin,subcutan., muscle
 Extracranial arteries
 Skull periosteum
 Eye,ear, nasal cavities,
sinuses
 Intracran.venous sinuses,
large vein, pericavernous
structures
 Basis dura, meningeal
arteries, prox.ant/middle
cerebral A, IC int.carotis A
 Superf.temporal A
 Cranial
nerves:II.III,V,IX,X,C1-3
 MECHANISMS OF CRANIAL PAIN :

 TRACTION ON OR DILATATION OF THE INTRACRANIAL

ARTERIES
 DISTENTION OF EXTRACRANIAL ARTERIES
 TRACTION ON OR DISPLACEMENT OF THE LARGE
INTRACRANIAL VEINS OR DURAL ENVELOPE
 COMPRESSION, TRACTION OR INFLAMATION OF THE
CRANIAL AND SPINAL NERVES
 SPASM, INFLAMATION & TRAUMA TO CRANIAL & CERVICAL
MUSCLE
 MECHANISM OF CRANIAL PAIN (con’d)

 DISEASE OF THE TISSUES OF THE SCALP, FACE, EYE,

NOSE, EAR AND NECK

 MENINGEAL IRRITATION AND

RAISED/LOWERED INTRACRANIAL PRESSURE
HISTORY :
 ATTACK ONSET
 QUALITY
 SEVERITY
 LOCATION
 MODE OF ONSET
 TIME, INTENSITY, CURVE, DURATION
 CONDITION WHICH EXACERBATE / RELIEVE THE PAIN
 ASSOCIATED FEATURES
 SOCIAL HISTORY, FAMILY HISTORY
 PAST HEADACHE HISTORY
 HEADACHE IMPACT
 Faktor pencetus Nyeri Kepala

Stres
Kurang/kebanyakan tidur
Tidak/telat makan
Bau menyengat : parfum,rokok
Lingkungan: cahaya silau/berkedip,gaduh
ketinggian,panas,lembab
ruang berasap
Makanan/minuman

HAS/Neuro/Bdg/04
Red Flag Nyeri Kepala
 Anamnesa:
 Nyeri kepala tiba-tiba berat baru terjadi.
 Bertambah berat progresif
 Terjadi pada waktu batuk, mengedan, aktivitas.
 Mengantuk, bingung
 Kejang, pingsan
 Makin kronik, Myalgia, Atralgia
 Gangguan penglihatan progresif
 Kelemahan, kikuk, kehilangan keseimbangan
 Onset usia
 Pemeriksaan fisik
 Tanda-tanda vital abnormal :febris, hipertensi
 Gangguan kesadaran
 Rangsang meningen positif
 Papil edema
 Pupil anisokor/reaksi cahaya –
 parese, anestesia, hemiparese
 Refleks asimetri,refleks patologik
APABILA DIJUMPAI TANDA-TANDA
BAHAYA NYERI KEPALA, MAKA NYERI
KEPALA TERMASUK NYERI KEPALA
SEKUNDER,

APABILA TIDAK ADA TANDA-TANDA

BAHAYA MAKA TERMASUK NYERI
KEPALA PRIMER.
The Secondary Headache
 MIGRAINE
 Genetik >80% sebelum 30 tahun
 PERIODIC, 4 - 72 jam
 UNILATERAL, OCCASIONALLY BILATERAL
 NYERI KEPALA BERDENYUT
 MODERATE OR SEVERE PAIN
 MUNTAH
MUAL
 SENSITIVITY TO LIGHT & NOISE
( PHOTOPHOBIA & PHONOPHOBIA
 at least 5 attacks
 2 CLINICAL SYNDROMES OF THE MIGRAINE

a. COMMON MIGRAINE
MIGRAINE WITHOUT AURA

b. CLASSIC / NEUROLOGIC MIGRAINE

MIGRAINE WITH AURA
 MIGRAINE
PATHOPHYSIOLOGY
 VASOCONTRICTION (AURA) & VASODILATATION
(HEADACHE)
 CORTICAL SPREADING DEPRESSION
 OLIGAEMIA PROPAGATING ACROSS THE CORTEX
POSTERIOR TO FRONTAL
 ACTIVATION OF THE TRIGEMINO-VASCULAR SYSTEM
 SEROTONIN (5-HT) : VESSELS, PLATELET, NEURON
 AMINERGIC BRAINSTEM NUCLEI
- MIGRAINE GENERATOR
- CORTICAL HYPEREXITABILITY
 N. O.
 MIGRAINE TRIGGERS, i.e. : HORMONAL FLUCTUATION,
EMOTION, FATIGUE, FASTING, METEOROLOGIGAL
CHANGES, DIETARY FACTORS
TREATMENT :

a. ABORTIVE :
- ANALGESICS :
ACETAMINOPHEN, ASA, NSAID
SPECIFIC DRUGS : - ERGOT ALKALOIDS
( ERGOTAMINE, DHE )
- ANTIEMETICS : - TRIPTAN
METOCLOPRAMIDE, DOMPERIDONE

b. PREVENTIVE :
- ANTICONVULSANTS
- ADRENOCEPTOR BLOCKERS ( PROPRANOLOL )
- ANTIDEPRESSANTS
- Ca-CHANNEL BLOCKERS
 TENSION-TYPE HEADACHE
 PRESSING, TIGHTENING, FULLNESS
 MILD TO MODERATE INTENSITY
 BILATERAL
 NO NAUSEA OR VOMITTING
 PHOTOPHOBIA OR PHONOPHOBIA MAY
BE PRESENT

 WOMEN > MEN, MIDDLEAGE

 COINCIDE WITH ANXIETY &
DEPRESSION
 TENSION-TYPE HEADACHE

Episodic TTH : infrequent & frequent ETTH

Chronic TTH
Assosiated with disorder of pericranial muscles
Unassociated with disorder of pericranial muscles

Probable TTH
ICHD-2
 TTH TREATMENT

 ANALGESICS :

ACETAMINOPHEN, ASA, NSAID

 ANTIDEPRESSANTS

 PSYCHOTHERAPY
CLUSTER HEADACHE
 YOUNG ADULT MEN ( M : F = 5 : 1 )
UNILATERAL PAIN
ORBITAL, SUPRAORBITAL, TEMPORAL
INTENSE NON THROBBING
LASTING 15’ - 3 HOURS ; CLUSTER

 ASSOCIATED SIGNS:
NASAL CONGESTION, RHINORRHEA,
CONJUNCTIVAL INJECTION, LACRIMATION,
MIOSIS, PTOSIS, EYELID EDEMA, FOREHEAD AND
FACIAL SWEATING
 PATHOPHYSIOLOGY OF THE
CLUSTER HEADACHE

 PAROXYSMAL PARASYMPATHETIC
DISCHARGE OF THE GREATER SUPERFICIAL
PETROSAL NERVE & SPHENOPALATINE
GANGLION
 SWELLING OF THE ARTERIAL WALL OF THE
INTERNAL CAROTID ARTERY
 HISTAMINE RELEASE
 HYPOTHALAMIC MECHANISM
TREATMENT OF THE CLUSTER HA
 ABORTIVE :
 O2 INHALATION
 ERGOT ALKALOIDS,
 TRIPTANS

 PREVENTIVE :
 VERAPAMIL
 ERGOT ALKALOID
CHRONIC PAROXYSMAL HEMICRANIA

  CLUSTER HEADACHE
 SHORTER LASTING ( 2 - 45’), MORE
FREQUENT
 MOSTLY FEMALES
 ABSOLUTE EFFECTIVENESS OF
INDOMETHACIN
POSTHERPETIC NEURALGIA
 ASSOCIATED WITH A VESICULAR ERUPTION
 HERPES ZOSTER VIRUS
 BURNING / STABBING PAIN, HYPERESTHESIA,
ALLODYNIA

TREATMENT : - ANTICONVULSANTS
- ANTIDEPRESSANTS

PREVENTION PHN : - ACYCLOVIR,

- TCA ANTIDEPRESSANT
 TRIGEMINAL NEURALGIA
(TIC DOULOUREX)

 MIDDLE AGE
 PAROXISMS OF INTENS, STABBING PAIN
N V2,3
 A FEW SECONDS / MINUTES
 INVOLUNTARY WINCES (TIC)
 TRIGGERED BY:
STIMULATION (TOUCH, TICKLE)
MOVEMENT OF THE FACE, LIPS, GUMS:
SHAVING, BRUSHING, TALKING, CHEWING
ETIOLOGY :
IDIOPATHIC
SYMPTOMATIC:
MULTIPLE SCLEROSIS,
ANEURYSM OF THE A. BASILAR,
CPA TUMOR, COMPRESSION OF THE N V

TREATMENT :
ANTICONVULSANTS
CAUSAL
 STRUKTUR NYERI PADA
KEPALA
 SKIN, SUBCUTANEUS TISSUE
 MUSCLES
 EXTRACRANIAL ARTERIES
 PERIOSTEUM OF THE SKULL
 EYE, EAR, NASAL CAVITIES,
SINUSES, TEETH, OROPHARYNX
 STRUKTUR PAIN SENSITIVE
DIKEPALA

 VENOUS SINUSES
 DURA AT THE BASE OF THE BRAIN
ARTERIES within DURA & PIA ARACHNOID
 MIDDLE MENINGEAL &
SUPERFICIAL TEMPORAL ARTERIES
 N II, N III, N V, N IX, N X
 C 1, 2, 3
 SENSORY NUCLEI OF THE THALAMUS
 BRAIN STEM PERIAQUEDUCTAL GRAY MATTER
NOCICEPTOR :

 SUPRATENTORIAL STRUCTURES
ANT / MED FOSSAE N V - N V 1-2

 INFRATENTORIAL STRUCTURES C 1, 2, 3
POST FOSSAE N IX, N X

 ANT, 2/3 OF THE HEAD NV

BACK OF THE HEAD, NECK C 1, 2, 3
Phases of Migraine
 TEMPORAL ARTERITIS
( GIANT-CELL ARTERITIS, CRANIAL ARTERITIS )

 INFLAMATORY DISEASE OF CRANIAL ARTERIES

 AGED >50 YEARS,
 INTENS THROBBING /NON THROBBING HEADACHE
SHARP / STABBING PAIN
 UNILATERAL, SOMETIMES BILATERAL
 A SUPERFICIAL TEMPORALIS: THICKED, TENDER,
WITHOUT PULSATION NODULES ON THE SCALP
 TEMPORAL ARTERITIS
( GIANT-CELL ARTERITIS, CRANIAL ARTERITIS )
( Cont’d )

 PATIENTS FEEL GENERALLY UNWELL,

LOSE WEIGHT, LOW GRADE FEVER, ANEMIA,
MYALGIA
 BSE 
 THROMBOSIS OF THE OPTHALMIC, POSTERIOR
CILLIARY ARTERIES  BLINDNESS !!

DIAGNOSIS : BIOPSY

TREATMENT : PREDNISON
 GLOSSO PHARYNGEAL NEURALGIA

 INTENSE AND PAROXYSMAL PAIN IN THE

THROAT -TONSILLAR FOSSA
 MAY BE RADIATE TO THE EAR
 N. IX , AURICULAR BRANCH OF N X
 TRIGGERED BY SWALLOWING, TALKING,
CHEWING, ETC.
 ± BRADYCARDIA, SYNCOPE

TREATMENT : - ANTICONVULSANTS
- SURGICAL