Primary headache kuliah fk uwks
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1. A 75-year-old woman presented to the emergency department with sudden onset of left-sided weakness and headache, consistent with symptoms of a stroke. 2. A 15-year-old boy developed worsening headache and seizures hours after being hit in the temple with a baseball bat during a game, suggesting a possible head injury or intracranial bleed. 3. A 40-year-old businessman reported a 2-month history of intermittent headaches, fever, diarrhea, and mouth sores, with a history of drug use, raising concerns for an infectious etiology like meningitis given his symptoms.
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Primary headache kuliah fk uwks
- 2. Headache/ Nyeri Kepala 18,9% kunjungan ke RSDS 17,4% kunjungan ke RSCM 42% kunjungan praktek sore Sp.S 90% merupakan primary headache 2
- 3. NYERI Pengalaman sensorik & emosional yg tidak menyenangkan terkait kerusakan jaringan, baik aktual maupun potensial atau yang digambarkan dalam bentuk kerusakan tsb.
- 5. DEFINITION Pain on head area Pain in face, pharynx, larynx & neck are not include. Osteo arthritis cervicalis is include Epidemiology TTH 35-78% (CTTH 3%) Migrain 18% female, 6% men Cluster 0.015% 5 HEADACHE/ Nyeri Kepala
- 6. Derajat Nyeri Kepala (Praktis) Ringan : pekerjaan/aktifitas sehari2 normal. Sedang : aktifitas berat terganggu Berat : aktifitas sehari-hari terganggu 6
- 7. STRUCTURE PAIN SENSITIVE I. STRUCTURE Intra Kranial a. sinus, vein besar & aferennya b. artery dura mater c. artery basis cranium d. duramater II. STRUCTURE ekstra kranial a. skin, skin head, jar. Sub.kutan, fasia, muscle head/neck. b. mukosa c. artery-artery d. Structure from eye, ear & nose III. Nervous: V, VII, IX, X, C1 C2 C3 7
- 8. 1. Parenkim brain 2. Ependyma, pleksus choroid 3. Piamater, membrana arachnoidea & duramater 4. Bone skull 8 STRUCTURE NOT SENSITIVE PAIN
- 9. A. intracranial: 1. Iritasi meningen Ex: Meningitis Perdarahan Sub Arachnoid (SAH) 2. Penarikan or peregangan arteri intracranial: Tumor Absces Hematoma intracranial TIK : hidrosefalus, BIH TIK : post Lumbal Headache 9 PATOFISIOLOGY Headache General :
- 10. 3. Vasodilatasi arteri intra kranial Toksic caused infection “With drawl” caffein Hipoglikemia, Hipoksia, Hiperkapnea drug vasodilator Post attack Epilepsi Insufiensi sirculation brain 10
- 11. 1. dilatasi cabang A. carotis externa Migren “Cluster headache” 2. inflammation artery ekstrakranial “Giant cell” arterytis temporalis 3. contraction muscle Tension headache Secondary muscle contraction headache Ex: - mal occlusion teeth - spondylosis cervicalis 4. inflammation/Penekanan N. V, N. IX Neuralgia trigeminus Neuralgia glossopharingeus 5. inflammation in mucosa nose, sinus 11 B. BERSUMBER ESKTRA KRANIAL
- 12. 1. Headache Primer Tension headache Migrain Cluster headache 2. Headache Secunder 12
- 13. Headache PRIMER Secunder TTH Migrain Cluster Headache infection – Tanda2 infection (Color/Dolor/ Robor) Trauma history Trauma Tumor -Trias -Headache chronic progresif -vomit proyektil -Papil edema Vascular -acute -Defisit Neurologis fokal 13
- 14. DIAGNOSIS AND TESTING Detailed History and Examination Primary Headache? Preliminary Diagnosis NO Secondary Headache Diagnostic Testing Atypical Features YES 14
- 15. RED FLAGS “SNOOP T” Older: new onset and progressive headache, especially in middle-age >50 Systemic symptoms (fever, weight loss) or secondary risk factors (HIV, systemic cancer) Neurologic symptoms or abnormal signs (confusion, impaired alertness, or consciousness) Onset: sudden, abrupt, or progressively worsening Previous headache history: first headache or different (change in attack frequency, severity, or clinical features) Triggered headache (valsava, exertion) 15
- 16. Classification of headaches • Primary headaches • OR Idiopathic headaches – THE HEADACHE IS ITSELF THE DISEASE – NO ORGANIC LESION IN THE BEACKGROUND – TREAT THE HEADACHE! • Secondary headaches • OR Symptomatic headaches – THE HEADACHE IS ON LY A SYMPTOM OF AN OTHER UNDERLYING DISEASE – TREAT THE UNDERLYING DISEASE! 16
- 17. HEADACHE QUALITY LOCATION DURATION FREQUENCY ASSOCIATED SYMPTOMS Common migraine Throbbing Unilateral head / Ifteral head 6 – 48 hours Sporadic (often several times montlly) Nausea, vomiting, malaise, photophobia Classic migraine Throbbing Unilateral head 3 – 12 hours Sporadic (often several times monthly) Visual prodrome, vomiting, nausea, malaise, photobhobia Cluster Boring, sharp Unilateral head (especially orbit) 12 – 120 minutes Closely bunched clusters with long remissions Ipsilateral tearing, facial flushing, nasal stuffiness, Horners’s syndrome Psychogenic/ Chronic TTH Dull, pressure Diffuse, Ifteral Frontal, temporal suboccipital Oftem unremitting May be constant Almost daily Depression, anxiaty Pericranial tenderness Trigeminal meuralgia Lancinating Fifth nerve distribution Brief (15-60 second) Many times daily Identifiable trigger zone Tabel 1 . Important features of pain in the evaluation of chronic recurrent headaches 17
- 18. PHYSICAL FINDING POSSIBLE ETIOLOGY Optic atropy, papiledema Mass lesion, hydrocephalus, benign intracranial hypertensionon Focal neurologic abnormality (hemiparese aphasia) Mass lesion Stiff neck Subarachnoid hemorrhage, meningitis, cervical arthritis Retinal hemorrhages Ruptured aneurysm, malignant hypertensionon Cranial bruit arteryovenous malformation Thickened, tender temporal arteryes Temporal arterytis Trigger point for pain Trigeminal neuralgia Lid ptosis, third nerve palsy, dilated pupil Cerebral aneurysm Spasm and tenderness of Pericranial muscle TTH/Muscle Contraction Headache 18
- 19. TTH (Headache Type Spasm/ Tension Type Headache TTH) OVERVIEW: The most common (90%) headache Responsive to over the counter med 5% visits When disabling conjunction with migraine Spectrum of migraine Beware of medication overuse headache (MOH) 19
- 20. Tension Type headache • 10 attacks lasting 30 min–7 days • 2 of the following 4 – Bilateral – Not pulsating – Mild or moderate intensity – Not aggravated by routine physical activity • No nausea or vomiting • One or neither photophobia or phonophobia • Not attributable to another disorder 20
- 21. TTH Classification Episodic <15 day/month Peripheral pain mechanism Tx NSAID, Parasetamol Chronic ≥ 15 day/month, ≥ 3 months Central pain mechanism Tx Amitriptilin 21
- 23. Treatment of TTH Evidence A : multipel RCT B : 1 RCT C : Consensus Clinical effect : + few people improved ++ Some people improved +++ Most people improved 23
- 24. Drug evidence Clinical effect Role Route Analgesic & NSAID Asetaminofen A ++ Acute PO Aspirin A ++ Mefenamic acid A ++ Ibuprofen A ++ Naproxen A ++ Ibuprofen+caffein A ++ Antidepresan Amitriptilin A +++ preventive PO Maprotilin B + Mianserin B ++ Sulpride C + Fluvoxamine B ++ Muscle relaxants Tizanidine B ++ Acute&preventive PO Eperisone B ++ Others Alprazolam B ++ Acute&preventive PO Etizolam C ++ prochloperazine C ? Acute IV chlorpromazine C ? 24
- 25. -------- Ibuprofen (400 mg) + Caffein (200 mg) -------- Ibuprofen (400 mg)=Ketoprofen (50 mg) -------- Ibuprofen (200 mg) = Ketoprofen (25 mg) = Naproxen (275 mg) -------- Aspirin/Paracetamol (500-1000 mg) + Caffein (30 mg) -------- Aspirin (500-1000 mg) = Paracetamol (500-1000 mg) 25
- 26. Migraine • The most common disabling headache • The most common headache visits • Unknown causes 26
- 27. Migraine Criteria • 5 attacks lasting 4–72 h • 2 of the following 4 – Unilateral – Pulsating – Moderate or severe intensity – Aggravation by routine physical activity • 1 of the following – Nausea and/or vomiting – Photophobia and phonophobia • Not attributable to another disorder 27
- 28. 28
- 29. SULTANS: two from column A, one from column B • evere • ni • ateral • hrobbing • Ctivity worsens • ausea • Lite and sound ensitivity 29
- 30. World prevalence of migraine 1-year prevalence rates Population-based studies IHS criteria (or modified) USA 12% Chile 7% Japan 8% Italy 16% Denmark 10% France 8%† Switzerland 13% Rasmussen and Olesen (1994); Rasmussen (1995); Lipton et al (1994); Lavados and Tenhamm (1997); Sakai and Igarashi (1997)†Prevalence measured over a few years 30
- 31. Prevalence of migraine by sex and age Females Males30 25 20 15 10 5 0 20 30 40 50 60 70 80 100 Migraine prevalence (%) Age (years) Lipton and Stewart (1993) The American Migraine Study (n=2479 migraine sufferers) 31
- 32. 32
- 33. Migraine A. The Aura B. The Attack 33
- 34. 34
- 35. Penatalaksanan migrain 1. Hindari pencetus 2. Terapi abortif Non spesifik Spesifik 3. Terapi preventif 35
- 36. Pencetus Migraine • Kurang atau kebanyakan tidur • Kelelahan • Stres dan kecemasan • Terlambat makan • Perubahan hormonal • Makanan (MSG, nitrit (pengawet) ,aspartam(pemanis buatan)) • Cahaya terang 36
- 37. Terapi abortif non spesifik Obat Dosis, mg Evidence ASA 1000 mg oral A ASA 1000 mg IV A ibuprofen 200-800mg, oral A Naproxen 500-1000mg oral A Parasetamol 1000 mg oral,supp A Diklofenac 50-100 mg oral A 37
- 38. Terapi abortif spesifik Ergot Angka rekurensi rendah Menginduksi drug overuse headache dg cepat Maksimal diberikan10 hari/bulan Efek samping : parestesi, muntah Kontra indikasi Penyakit kardio, serebrovaskular, hipertensi, gagal ginjal, kehamilan dan laktasi 38
- 39. TRIPTAN Efikasi lebih baik dibanding ergot Sediaan obat di Indonesia sulit di dapat (hanya ada sumatriptan) Efek samping : nyeri dada, parestesi, fatik Kontra indikasi : Penyakit kardio, serebrovaskular, hipertensi, gagal ginjal, kehamilan dan laktasi 39
- 40. Terapi prevensi migrain 1. Serangan >2-8 kali/bln 2. Berlangsung >48 jam 3. Pengobatan akut tdk efektif 4. Ada kontra indikasi terapi abortif, efek samping, atau cenderung overuse 5. Gejala luar biasa ( migrain basiler, hemiplegi, aura memanjang) 6. Permintaan pasien 40
- 41. Terapi prevensi migrain Konsensus Nasional III Nyeri Kepala PERDOSSI 2010 Obat Dosis mg/hari evidence betablocker metoprolol 50-200 A propanolol 40-240 A Calcium channel blocker Flunarizine (Frego) 5-10 A Anti epileptic Valproic acid 500-1800 A Topiramat 25-100 A 41
- 43. stroke • Wanita 75 th di bawa ke IRD RS krn mendadak sakit kepala, hemiparese kiri
- 44. Trauma • Anak 15 th terkena pemukul baseball di pelipis. Sesaat setelah terkena pukulan ia tidak sadar sebentar ± 15 mnt lalu bangun lagi. Ia mengeluh sakit kepala namun keadaannya saat itu baik saat dibawa ke IRD. Empat jam kemudian saat diobservasi ia mengeluhkan sakit kepalanya bertambah hebat dan kejang. Pupil sebelah kanan midriasis
- 45. Infeksi • Pria 40 th , pengusaha mengeluh sakit kepala 2 bln, disertai demam sumer-sumer, sering diare dan sariawan .Ia mengkonsumsi narkoba berhenti sjk 1 th silam. Dibawa ke IRD oleh keluarganya krn bicara meracau.
- 46. Tumor • Wanita 35 th, sakit kepala 8 bln bertambah hebat terutama saat bangun dan bersin, memakai kontrasepsi suntik 3 bulan
- 47. Degenerasi • Wanita 79 th datang ke poli dengan keluhan sakit kepala hilang timbul ± 2 th.Sering lupa ± 3-4 th dan tidak mampu berbelanja lagi krn kesulitan melakukan perhitungan ringan. Sekarang sulit tidur dan sering terlihat seperti berbicara sendiri