Case Report Session CEPHALGIA (MIGRAIN WITHOUT AURA)

Oleh : Fuji Fitria Nanda Ghea Kananda Latifah Aprianda Saputra Jumadia Happy Rezki Pratama Sadeli Dian 07120010 07923080 0810313252 0810313 0810312080 07120 07120

Pembimbing :

Prof.dr. H. Basjiruddin Ahmad,Sp.S (K) Dr. Yuliarni Syafrita,Sp.S (K)

Bagian Neurologi RSUP Dr. M. Djamil Padang Fakultas Kedokteran Universitas Andalas 2013 1

Head Pain (Cephalgia)

I. Preliminary Headache or cephalgia is pain or discomfort in the head, local or generalized and can spread to the face, eyes, teeth, jaw and neck. Structures in the head that is sensitive to the pain of skin are fascia, muscles, arteries and intracerebral extras, meninges, basic fossa anterior, posterior fossa, tentorium serebeli, sinus venosus, nerves V, VII, IX, X, radix posterior C2, C3, eyeballs, nasal cavity, sinus cavity, dentin and dental pulp. While the brain is not sensitive to pain. On the structure, there is nerve endings are easy stimulated by pain there are: 1. 2. 3. 4. 5. Traction or sinus venosus shifts and branches of cortical. Traction, dilatation or inflammation of the arteries intra and extracranial. Traction, shift or disease which affect cranial nerves and cervical. Changes in intracranial pressure. Diseases in tissue of the scalp, face, eyes, nose, ears and neck.

Cephalgia will be a problem, both for the sufferer and the docter, if occur chronic or recurrent chronic. In this case, sefalgia often to be a single symptom or the are most striking symptoms. II. Clinical Manifestations Special history of headache include: 1. Types of pain weight, pulse, pull, tie, moving, feeling empty 2. Onset Onset in elderly people - an increase in ICP(hidrocephalus, tumor, sub-arachnoidhaemorrhage) Chronic - tension headaches, post trauma, neurosis, sinusitis Acute - non-traumatic hemorrhage, meningitis, glaucoma 3. frequency (periodicity) constantly - tension headaches episode migraine 4. long of pain migraine - in hours tension headaches - day-month trigeminal neuralgia - sting, second-minute 5. when pain cluster headache: during sleep - pain when I wake up tension headaches: afternoon and evening more often, emotional stimulation

migraine; spark of light, weather, alcohol trigeminal neuralgia: provocate by swallowing, talking, toothbrush 6. quality and intensity migraine: intense pulse (hard to work) cluster headache: beats like a drill tension headaches: like wearing a heavy helmet 7. accompanying symptoms migraine: vomiting, vertigo, diplopia cluster: ipsilateral ptosis, miosis, red conjunctiva tension headaches: photo and phonophobia. Ask also about the precipitation factors, factors that aggravate or alleviate headaches, sleep patterns, emotional factors / stress, family history, history of head trauma, history of medical illness (inflammation of meningen, hypertension, typhoid fever, sinusitis, glaucoma, etc.), history surgery, history of allergies, PMS (in women), a history of drug use (analgesics, narcotics, tranquilizers, vasodilators, etc.) Special inspection include palpation of the skull to look for deformities, tenderness and lumps. Muscle palpation to determine the tone and tenderness nape area. Tactile superficial temporal artery and carotid artery communists. Examination of the neck, eyes, nose, throat, ears, mouth and teeth should be done. Complete neurological examination, emphasis on brain function include funduscopy, motor function, sensory and coordination. Headaches can be a primary form of migraine, cluster headache, muscle tension headache, and secondary as posttraumatic headache, organic headache as part of disease lesions persisted space (brain tumor, abscess, subdural hematoma, etc.), subarachnoid hemorrhage, trigeminal neuralgia post herpetic, systemic diseases (anemia, polycythemia, hypertension, hypotension, etc.), after the lumbar puncture, systemic intracranial infection, nasal and paranasal sinus disease, caused by toxic materials and eye disease. Headache showed signs of danger and require evaluation support: Severe headache the first time that arise suddenly The most severe headache ever experienced Progressive severe headache for several days or weeks Headache that occurs when physical exercise, coughing, sneezing, or bending. Headache accompanied by common diseases or fever, nausea, vomiting or stiff neck 3

 Headache accompanied by neurological symptoms (aphasia, poor coordination, focal weakness or numbness, drowsiness, decreased intellectual function, and decreased visual acuity changes personality) III. Additional Examination 1. Ro's head picture - look at the structure of the skull 2. Ro cervical photos - determine the spondiloartrosis and cervical fractures 3. CT Scans / MRI - the headache of a possible intracranial disease (tumor, subarachnoid hemorrhage, AVM, etc.) 4. EEG - done when there is a history of seizures, decreased consciousness, Tauma head or presinkop 5. Photo of paranasal sinuses - see the sinusitis 6. Angiography - for specific cases such as aneurysms 7. LP - infection, intracranial hemorrhage 8. EMG - the continuous contraction of muscles in the neck, the back and front of the head 9. Labor - examination of blood chemistry MIGRAINE Migraines are sometimes called headache or headache is a throbbing headache often accompanied by nausea, vomiting. Patients are usually sensitive to light, sounds and even smells. Headache is most often only on one side of the head alone, sometimes move to the next, but can on both sides of the head at the same time. Migraines are sometimes a little difficult to distinguish from other types of headaches. Headache due to interference caused by sinus or tension neck muscles have symptoms similar to the symptoms of migraine. Migraine can occur with other diseases such as asthma and depression. The disease is very severe, such as a tumor or infection, can also cause similar symptoms of migraine. But this is very rare. Causes of Migraines The exact cause of migraine is still not so clear. It is estimated, hyperactivity of brain's electrical impulses which increase blood flow in the brain, resulting in brain blood vessel dilation and inflammation. Dilation and inflammation causing pain and other symptoms, such as nausea. 4

More severe inflammation that occurs, the more severe migraine suffered. It is known that genetic factors contribute to the onset of a migraine. Migraine Symptoms Early Symptoms: One or two days before a migraine arises, patients usually experience early symptoms such as weakness, excessive yawning, really want a kind of food (chocolate for example), irritable, and restless. Aura: Only found in classical migraine. It usually occurs within 30 minutes prior to the onset of a migraine. Aura can be shaped visual disturbances such as seeing wavy lines, bright lights, dark spots, or can not see objects clearly. Another aura symptoms are tingling or tingling in the hands. Some people can not pronounce the words properly, feel numbness in the hand, shoulder, or face, or feeling weak on one side of the body, or feeling confused. Patients may experience only one symptom or several kinds of symptoms, but these symptoms did not occur simultaneously but alternately. An aura symptoms usually disappear when headache or other aura symptoms arise. But sometimes the aura symptoms persisted at the beginning of a headache. Headache and accompanying symptoms: Patients feel the throbbing pain on one side of the head, often felt behind the eyes. Pain can switch on the side next to the next attack, or on both sides. The pain ranges from moderate to severe. Other symptoms that often accompany the headache include: Excessive sensitivity to light, sound, and smell Nausea and vomiting Symptoms of more severe if physical activity Without treatment, the headache usually resolves itself within 4 to 72 hours. Late symptoms: After headache recovery, the patient may feel pain in the muscles, fatigue, or even feel the excitement of the brief. These symptoms disappear within 24 hours after the disappearance of headaches

Migraine Triggers Migraines can be triggered by foods, stress, and changes in daily routine activities, although it is unclear how and why it can cause migraines. Migraine Triggers include: Consumption of certain foods, like chocolate, MSG, and coffee Excessive Sleep or lack of sleep Do not eat Changes in weather or air pressure Stress or emotional distress A very pungent smell or smoke The light is very bright or reflected sunlight.

Around the world, about 25% of female migraine and 10% of men. Women are two to three times more likely to get migraines than men. Migraine is most common on adults (aged between 20 to 5o years), as the adding the age the severity and the frequency decreases. Migraine is usually a lot about teenagers. In fact, children can experience migraine with or without aura. Greater risk of migraine in people who have a family history of migraine. Genetic Aspects of Migraine The existence of a genetic link to migraine has long been recognized, though not found in Mendelian inheritance pattern consistent. This suggests a pattern of inheritance varies and the possibility of multiple genes that interact with environmental factors in the pattern of multifactorial. Clear pattern of inheritance of familial hemiplegic migraine are on, which is a rare subtype of migraine with aura, which has an autosomal dominant pattern. Classification Migraine headache is a recurrent episodic pain syndrome, which is classified into 3 types: migraine without aura, migraine with aura and migraine variants. 1.Migren without aura Migraine without aura is the most common type, is found in about 80% of all migraine sufferers. Migraine without aura may begin in nociceptive neurons in the blood vessels. Walking 6

pain signals from afferent vessels to the primary and then to the trigeminal ganglion, and ultimately achieve kaudalis trigeminal nucleus, an area of pain processing in the brain stem. Active neurons in the CNS and then express c-fos gene repressed by butabarbital in the nucleus kaudatus. During a migraine attack, many physiological functions such as impaired sensory processing disorders that cause photophobia or phonophobia, GI motility disorders that cause nausea and vomiting, autonomic disorders, or cerebral disorders that can cause cognitive and mood changes. 2.Migren with aura Migraines with aura are more likely to undergo a series of changes neurobiologik 24-48 hours before the onset of headache. Usually neurobiologik change begins and ends before the onset of headache. Quality deployment focal neurologic symptoms typical aura suggests that cortical spreading depression is similar to what happens when a wave of electrical depolarization walked across the cortex and the neurons that stimulate neuronal function is impaired and there trigeminal activation. It is known that the spreading depression requires the activity of the receptor N-methyl-D-aspartate glutamate. Typical aura symptoms include visual and sensory changes such as abnormal sharp flashes of light or feel or taste or smell something, and motor deficits and speech (aphasia). Aura can also be cavernosometry as numbness in one arm or one side of the face. 3.Varian Migraine Migraines Oftlamoplegik This type is rare. Symptoms include periorbital pain attacks accompanied by vomiting, lasting 1 to 4 days. Once the pain has subsided, ipsilateral ptosis occurs later in a few hours going palsy N. III overall resulting in dilation of the pupil and the response to light is lost. Oftalmoplegia last a few days to 2 months. After experiencing many attacks, oftalmoparesis be settled. This syndrome usually starts from childhood, in contrast with Tolosa Hunt syndrome (oftalmoplegia the pain) that occurs in adults. Penyangatan on N. III on MRI suggests that there are inflammatory processes cranial neuropathy than migraine disease. 7

Retinal Migraine Attack monookuler scotoma or blindness lasting less than one hour and can be repeated and followed by headache with no ocular abnormalities encountered structural and vascular disorders. Complications of Migraine 1. Status Migrenosus; Attacks migraine headache that lasted more than 72 hours. (headachefree interval of less than 4 hours). 2. Migraines infarction / complicated migraine; One or more symptoms of a migraine aura that is not perfect in 7 days to recover and / or may be associated with abnormalities in myocardial ischemic confirmation on inspection neuroimaging. Pathogenesis It is not yet known with certainty factors causing migraine. From the investigation of existing, allegedly as a neurological disorder, a change in the sensitivity of the nervous system and activation of the trigeminal system vaskular.

1. Neurological disorders Everyone has a different threshold of migraine vary, according to the neurovascular reaction to sudden changes in the environment. With the level of vulnerability of different then there is a dependence balance between excitation and inhibition at different levels of the nerve.

2. Sensitivity change of the nervous system Diffuse projections to the cortex serebri locus ceruleus can experience the

oligmia cortical and possibly spreading the depresision.

3. Activation of the trigeminal vascular The mechanism of migraine manifes as trigeminal vascular refleks unstable with segmental defects in pain pathways. Segmental defects that include excessive afferent will follow kortibular excessive encouragement. With the stimulation of afferent blood vessels, the cause throbbing pain. 8

Another possibility terntang migraine pathogenesis based on neurogenic inflammation in the tissue intrakanal. There are several things that can aggravate migraine complaints. The following are types of conditions that can aggravate migraine complaints, including adalah: 1. Stress, hurry, anger or conflict 2. The smell of smoke or fumes, cigarette smoke, changes in air and blinding light 3. Menstruasi, birth control pills, estrogen treatment 4. Lack of sleep or too much sleep 5. Alkohol 6. Too much physical exercise 7. Use of certain drugs Trigger Factors Many people with migraine headaches may recognize one or more triggers that initiate pain attacks. Triggers often are red wine, chocolate, pungent smell, flickering light, emotional stress, irregular life cycle, alcohol, caffeine, nicotine, and foods that contain lots of pure sugar like other headache symptoms. Standard examination is conducted by using the criteria of the International Headache Society, a person is diagnosed migraine if you have 5 or more headache attacks without aura (or 2 attacks with aura) who recovered within 4 to 72 hours without treatment, followed by symptoms of nausea, vomiting, or sensitive to light and sound. Examination Migraine symptoms that arise need to be tested by further investigation to rule out other diseases and other possible causes of headache. Further examination is: 1. MRI or CT scan, brain hemorrhage. 2. Lumbar puncture, performed if the estimated meningitis or brain hemorrhage. which can be used to get rid of the tumor and

Medikamentosa Used to stop migraine attacks, meliputi: 1. Non Steroid Anti-Inflammatory (NSAID), such as aspirin, ibuprofen, which is the firstline drug for reducing migraine symptoms. 9

2. Triptans (serotonin receptor agonists). The drug is administered to stop the acute migraine attack quickly. Triptans are also used to prevent menstrual migraines. 3. Ergotamine, for example Cafegot, these drugs are not as effective as triptans in treating migraine. 4. Midrin, is a drug consisting of isometheptana, acetaminophen, and dikloralfenazon. 5. Analgesic, containing butalbital are often satisfactory in the treatment of 6. Opioid analgesics, in general, the intermediary field yielded disappointing results.

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REFERENCES

1. Aminoff MJ, Greenberg DA, Simon RP. Clinical neurology. 6th ed. USA McGrawHill. 2005. p.85-7. 2.Raskin NH, Green MW. Migraine and other headache. In Rowland PL (editor). Merritts neurology. 11th ed. USA Lippincot William & Wilkins. 2005. p. 982-6. 3.Sjahrir H, Samino, Ali W (editor). Konsensus nasional penanganan nyeri kepala di Indonesia. Jakarta PERDOSSI. 1999. 4.Singh MK. Muscle Contraction Tension Headache. cited from

www.emedicine.medscape.com. 2009. 5.Sastrodiwijo S, Kusuma P, Markam S, Nyeri Kepala Menahun. Bagian Neurologi: FKUI. Penerbit Universitas Indonesia, Jakarta. 1986. 6.Nyeri Kepala : Gangguan Kesadaran di Bidang Penyakit Syaraf. Bagian Neurologi FK UNAND Padang. 7.Nyeri Kepala. Kapita Selekta Kedokteran. Jilid 2. Editor Mansjoer A. Penerbit Media Ausclapius. FKUI. Jakarta . 2000 : hal 34 36.

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CASE REPORT

A male patient aged 51 years to the hospital clinic. Dr. M. Djamil Padang on 1 February 2013 by:

Main complaint Headache since 2 days ago

History of Disease - Headache since 2 days ago, the head pain, especially in the left, as drawn pain and throbbing, constant, long pain about 30 minutes, and increased headache arises when the smell of cigarette smoke and see the light and glare when walking, pain decreases with rest or sleep. Headache patients over 5x in the last 72 hours of patient nausea and vomiting as 1x, vomiting does not spray, contains what is eaten. - Sight blurred objects (-) - Tension in the neck (-) - Decreased appetite from illness. History of past illness - History collided head since 1 year ago - No history of hypertension. - No history of diabetes mellitus Family history of disease - Younger sister complained of headache same like the patients. - History of hypertension was present the patient's father suffering hypertension. Physical examination General condition Awareness Blood pressure Pulse rate Frequency breath : Medium : CMC : 120/80 mmHg : 80x/menit : 20x / min 12

Temperature Nutrition Status Intermus

: 36.5 0 C : Good

Head : no abnormalities detected Eyes : conjunctiva anemis (-), sclera jaundice (-) Pupil isokor, diameter 3 mm Ear : no abnormalities

Nose : no abnormalities Mouth : no abnormalities Neck : no enlarged lymph nodes Thorak Pulmonal Inspection Palpation Percussion : symmetric : difficult rated : resonant

Auscultation : vesicular, ronchi (-), wheezing (-) Cardio Inspection Palpation Percussion : Ictus not visible : Ictus cordis palpable 1 finger medial LMCS RIC V : heart within the normal limits

Auscultation : regular rhythm, murmur (-) Abdomen Inspection: not enlarged Palpation: liver and spleen not palpable. Percussion: timpani Auscultation: BU (+) N Vertebral Corpus Genitalia : no abnormalities : not checked

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Status Neurologikus A brain membrane excitability: stiff neck :(-) Kernig : (-) laseque : (-) brudzunski I : (-) brudinski II: (-) Signs of increased Intracranial Presure projectile vomiting: (-) progressive headache: (-) Brain Nerves 1. Nervi cranial NI : Smell Good N II : sharp eyesight N / N, field vision N / N, see the color of + / + N III, IV, VI : isokor pupil, diameter 3 mm, light reflex + / +, lateral eye movements to + / + NV : both sensory and motor good N VII : symmetric faces, plika nasolabialis symmetrical, eyes closed + / +, moving the forehead + / +, pout (+), whistling (+) N VIII : no abnormalities N IX : vomiting reflex (+) NX : swallowing good , articulation clear N XI : turn his head (+), shrug (+) N XII : tongue no deviation 2. Coordination How to Walk: Normal, Test supination (+), test finger nose (+), finger nose test (+), dysarthria (-) 3. Motor: Ekstremitas superior Movement Strength Tonus Trofi Ekstremitas inferior Movement Strength Dekstra active 5/5/5 eutonus eutrofi Dekstra active 5/5/5 Sinistra active 5/5/5 eutonus eutrofi Sinistra active 5/5/5

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Tonus Trofi

eutonus eutrofi

eutonus eutrofi

4. Sensory : good sensibility in soft or rough 5. Autonomic functions : bowel and bladder control, secretion of sweat (+) 6. Physiological reflexes Biceps: + / + Triceps: + / + APR: + / + KPR: + / + 7. Pathological reflexes Babinski: - / Chaddock: - / Oppenheim: - / Gordon: - / Schaffer: - / Hoffman Trommer: - / 8. Noble function: either Clinical Diagnosis Diagnosis Topic Diagnosis Etiology : Migraine without aura : Intracranial : idiopathic

Secondary Diagnosis : Examination advice : Management 1. General Rest Avoid precipitating factors 2. Special Mefenamic acid 2 x 500 mg Diazepam 2 x 2 mg Sahobion 1 x 1 Prognosis Quo ad Vitam: bonam Quo ad sanam: bonam

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DISCUSSION It has been examined by a male patient aged 50 years who came to the clinic of Dr RS. M Djamil Padang, with a diagnosis of migraine without aura. Clinical diagnosis is made by history and physical examination obtained from anamnesis headache since 2 days ago, head pain, especially in the left, as drawn pain and throbbing, constant, long pain about 30 minutes, headache arise and grow when the smell of cigarette smoke and see the light glare and when walking, pain decreases with rest or sleep. Headache patients over 5 x in 72 hours. Patients nausea and vomiting as 1x, vomiting does not spray, contains what is eaten. No objects blurred vision. There is no tension in the neck. History collided head there since 1 year ago. Since then patients often suffer from headaches, intermittent, more and more frequent and more severe when the patient's stress. Each time the pain, patients often buy medicines at the drugstore. Patients fulfilling diagnostic criteria Head Pain Perdossi 2005 adaptation of the IHS (International Headache Society) is a headache more than 5 times in 4-72 hours. Headache meet 2 of the following characteristics: unilateral, pulsating, moderate or severe intensity, gain weight with physical activity. In these patients found unilateral headache, moderate intensity, headache increases with physical activity. During headache accompanied by one of the following: nausea and or vomiting, photophobia and phonophobia. This is due to the brain's electrical impulses hiperaktiftas increase blood flow in the brain, resulting in brain blood vessel dilation and inflammation. Dilation and inflammation causing pain and other symptoms, such as nausea. More severe inflammation that occurs, the more severe migraine suffered. In these patients found to nausea, vomiting, and photophobia. Patients also have a family history of migraine that younger patients themselves. The existence of a genetic link to migraine has long been recognized, though not found in Mendelian inheritance pattern consistent. This suggests a pattern of inheritance and the possibility of varying genes. It is known that genetic factors contribute to the onset of migraine multiple factors that interact with the environment in multifactorial pattern. Clear pattern of inheritance of familial hemiplegic migraine are on, which is a rare subtype of migraine with aura, which has an autosomal dominant pattern.

From the physical examination found komposmentis patient awareness, there is no sign of sensory meningeal, signs of increased intracranial pressure and no other neurological examination within normal limits. In patients 16 with no laboratory examination.

Treatment is carried out in patients given Mefenamic Acid 2 x 500 mg, 2 x 2 mg Diazepam sahobion 1 x 1. After that, patients are advised to beristirehat and should sleep, compress the affected area with cold water constricts blood vessels and avoid trigger factors in patients such as stress, cigarette smoke or from food.

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