Nyeri Kepala

oleh
Dr.Amsar AT, SpS
Bagian Saraf FK UNRI

What is a headache
pain in the head that is located above the eyes or the ears, behind the head, or in the back of the upper neck.

Causes of headaches
1. Primary headaches
- not associated with other diseases. - Examples ; - migraine headaches, - tension headaches, - cluster headaches

2. Secondary headaches
- caused by associated disease. - may be : - minor or - serious and life threatening.

How common are primary and secondary headaches?

Primary headache
Tension headaches ; most common type ; as many as 90% of adults, women > men. Migraine headaches : second most common type. about 12% of the population in US affect children as well as adults. before puberty, boys = girls after puberty, women > men. 6% of men and up to 18% of women Cluster headaches : a rare type, affecting 0.1% of the population. 85% are men average age is 28-30 years, may begin in childhood.

Secondary headaches
serious and life threatening,
- brain tumors,
- strokes, meningitis, and - subarachnoid hemorrhages

less serious but common conditions

- withdrawal from caffeine and
- discontinuation of analgesics.

Symptoms of tension headaches

often begin in the back of the head and upper neck as a band-like tightness or pressure. as a band of pressure encircling the head with the most intense pain over the eyebrows. usually is mild (not disabling) and bilateral. not associated with an aura seldom associated with nausea, vomiting, or sensitivity to light and sound. Sporadically, infrequently, without a pattern can occur frequently and even daily in some people. most people are able to function.

Symptoms of migraine headaches

chronic condition of recurrent attacks. throbbing pain that involves one temple (in the forehead, around the eye, or back of the head). unilateral, a third of the time the pain is bilateral. unilateral headaches typically change sides from one attack to the next. usually is aggravated by daily activities nausea, vomiting, facial pallor, cold hands, cold feet, sensitivity to light and sound. prefer to lie in a quiet, dark room during an attack. a typical attack lasts between 4 and 72 hours.

Symptoms of migraine headaches

An estimated 40%-60% of migraine attacks are preceded by premonitory (warning) symptoms lasting hours to days. The symptoms may include sleepiness, irritability, fatigue, depression or euphoria, yawning, and cravings for sweet or salty foods. Patients and their family members usually know that when they observe these warning symptoms that a migraine attack is beginning.

Symptoms of migraine headaches

20% are associated with an aura. aura precedes the headache, occasionally it may occur simultaneously with the headache. The most common auras are
1) flashing, brightly colored lights in a zigzag pattern (fortification spectra), usually starting in the middle of the visual field and progressing outward and 2) a hole (scotoma) in the visual field, also known as a blind spot.

Some elderly migraine sufferers may experience only the visual aura without the headache. A less common aura consists of pins-and-needles sensations in the hand and the arm on one side or around the mouth and the nose on the same side. auditory (hearing) hallucinations and abnormal tastes and smells.

Symptoms of migraine headaches

Complicated migraines are accompanied by neurological dysfunction. The part of the body that is affected by the dysfunction is determined by the part of the brain that is responsible for the headache. Vertebrobasilar migraines are characterized by dysfunction of the brainstem The symptoms include fainting as an aura, vertigo and double vision. Hemiplegic migraines are characterized by paralysis or weakness of one side of the body, mimicking a stroke, usually temporary, but sometimes it can last for days.

Symptoms of migraine headaches

For approximately 24 hours after a migraine attack, the sufferer may feel drained of energy, may experience a low-grade headache along with sensitivity to light and sound. some sufferers may have recurrences of the headache during this period.

Symptoms of cluster headaches

headaches that come in groups (clusters) lasting weeks or months, separated by pain-free periods of months or years. during the period, pain occurs once or twice daily, but some patients may more than twice daily. each episode lasts from 30 minutes to one and one-half hours. the same time every day and often awaken the patient at night pain is excruciating and located unilaterally around or behind one eye. the pain as feeling like a hot poker in the eye. affected eye may become red, inflamed, and watery. nose on the affected side may become congested and runny. patients with cluster headaches tend to be restless. they often pace the floor, bang their heads against a wall, and can be driven to desperate measures. more common in males than females.

What causes primary headaches

Tension headache
does not have a clear cause. to excess stress or a hectic day. may have a cause that is similar to the cause of migraine headaches.

Cause of Migraine headache

a combination of vasodilatation and the release of chemicals from nerve fibers that coil around the blood vessels. During a migraine attack, the temporal artery enlarges. Enlargement of the temporal artery stretches the nerves that coil around the artery and causes the nerves to release chemicals. The chemicals cause inflammation, pain, and further enlargement of the artery. The increasing enlargement of the artery magnifies the pain.

Cause of Migraine headache

activate the sympathetic nervous system in the body. in the intestine causes nausea, vomiting, and diarrhea. delays emptying of the stomach thereby prevents oral medications from entering the intestine and being absorbed. decreases the circulation of blood, and this leads to pallor of the skin as well as cold hands and feet. contributes to the sensitivity to light and sound sensitivity as well as blurred vision.

Cluster headache
does not have a clear cause, alcohol and cigarettes can precipitate attacks.

Are primary headaches dangerous?

tension headaches have not been shown to lead to neurological dysfunction or brain damage. rare association of migraine headaches and stroke, particularly in sufferers of complicated migraines. cluster headaches need to be differentiated from more serious neurological conditions, there is no known danger of cluster headaches leading to stroke.

Cause secondary headaches

Diseases causing secondary headaches

Tumors in the brain, Subdural hematomas, Epidural hematomas, Infections such as meningitis Strokes Subarachnoid hemorrhages Sudden onset of severe high blood pressure. Temporal arteritis,. Acute angle glaucoma Infections of the sinuses, ear, and teeth Hypothyroidism, Repeated carbon monoxide poisoning Parkinson's disease Medications such as indomethacin, estrogen, progestins, calcium channel blockers, and selective serotonin reuptake inhibitors (antidepressant) Overuse of OTC or prescription analgesik (rebound headache). Cardiac ischemia

Tumors in the brain

including tumors that have spread (metastasized) to the brain from another organ such as the lung or breast

Subdural hematomas
which are collections of blood underneath the dura due to bleeding from ruptured veins. typically occur in elderly individuals after a fall or other trauma to the head. Sometimes the fall can precede the visit to the doctor by weeks, and the elderly patients may not even recall the fall. Symptoms include chronic headaches, change in personality, and weakness of the extremities

Epidural hematomas
which are rapid collections of blood due to the rupture of arteries that run on the inner surface of the skull. usually are the result of skull fractures. The typical story is a head injury that causes a concussion with loss of consciousness and a skull fracture. The return of consciousness is followed by the sudden development of coma caused by an expanding hematoma.

Infections
such as meningitis caused by bacteria tuberculosis, Lyme disease, or cryptococcus Infections of the sinuses (sinusitis), ear (otitis), and teeth

Strokes
due either to blood clots within the arteries of the brain or rupture of the blood vessels in the brain

Subarachnoid hemorrhages
bleeding into the space between the brain and its outer arachnoid lining. most common source of subarachnoid hemorrhage is an aneurysm,

High blood pressure

Sudden onset of severe high blood pressure. Chronic mild to moderate high blood pressure is not a common cause of headache.

Temporal arteritis
a vasculitis of the temporal artery which runs beneath the skin of the temple. occurs primarily in older people and may be associated with fatigue, body aches, and anemia. Without proper treatment, may lead to blindness and strokes.

 Acute angle glaucoma - sudden elevation of pressures inside the eyes Infections of the sinuses, ear, and teeth Hypothyroidism, Repeated carbon monoxide poisoning Parkinson's disease

 Medications
such as indomethacin, estrogen, progestins, calcium channel blockers selective serotonin reuptake inhibitors

 Overuse
of over-the-counter or prescription pain relievers. of pain relievers causes the pain relievers to become less effective. as the effect of the pain reliever wears off, headaches recur (rebound headache).

 Cardiac ischemia
as a cause of either heart attacks or angina, it also may cause a headache. occur with or without the accompanying chest pain of a heart attack or angina. As with angina, may occur with exertion and subside with rest.

How are secondary headaches diagnosed?

as bacterial meningitis, subarachnoid hemorrhage, severe high blood pressure, epidural or subdural hematomas, can cause serious brain damage or even death. timely and accurate diagnosis of secondary headaches is crucial. Special blood tests, CT scans or MRI, and LP are necessary to establish these diagnoses. The challenge for doctors is to decide which patients should undergo these special tests

Tests for secondary headaches

history and physical examination provide the best means for determining the cause of secondary headaches. extremely important that patients with severe headaches undergo examination by a doctor experienced in diagnosing and treating headaches. A few tests may be useful in diagnosing the presence and cause of secondary headaches including blood tests, CT Scan) and MRI scans, and lumbar puncture.

Hystory and physical examination : Information that is important

1. 2. 3. 4. 5. The mode of onset of the headache The age of the patient The location of the headache Associated fever and neck stiffness Associated mental deterioration, seizures, or weakness 6. Associated temporary weakness of the extremities or facial muscles 7. Recent head trauma

1. The mode of onset

subarachnoid hemorrhage having a sudden onset of severe headache pain of recurrent migraine headaches tends to build up gradually. headache of subarachnoid hemorrhage is triggered by exertion such as sex.

2. The age of the patient

Temporal arteritis occurs in older people, rare in younger than 50. primary headaches have many years of similar headaches, often starting at a young age. new onset of a headache > 50 years or onset of a new type of headache suggests a secondary headache

3. The location of the headache

Headaches that persistently occur on the same side often are secondary headaches associated with, for example, brain tumors or arteriovenous malformations

4. Associated fever and neck stiffness

bacterial meningitis is a disease with fever, headaches, stiff neck, and deterioration in mental function. a virus infection causes death of brain tissue. Symptoms include fever, headache, and deterioration in mental function.

5. Associated mental deterioration, seizures, or weakness of the extremities or face, which can be symptoms of brain tumors.

6. Associated temporary weakness of the extremities or facial muscles

which can be symptoms of transient ischemic attack (TIAs). Transient ischemic attacks are warning signals for future strokes that can cause permanent brain damage. Headache also can accompany strokes and intracerebral bleeding

7. Recent head trauma

Headaches soon after trauma to the head may be caused by subdural or epidural hematomas.

Pemeriksaan penunjang
Blood tests An elevated leucocyt infection. An elevated LED temporal arteritis. Abnormal thyroid tests thyroid disorders. CT scan of the head - detecting accumulation of blood such as subdural hematomas and SAB. - detecting brain tumors and strokes infarct

MRI scan of the head detect subdural and epidural hematomas, herpes simplex infection of the brain, strokes, tumors, and arterial aneurysms.

 Lumbar puncture
- can reveal infection (meningitis due to bacteria or tuberculosis) or blood from hemorrhage. - patients with subarachnoid hemorrhage, CT scans are normal, and lumbar punctures are necessary to demonstrate blood

When should one consult a neurologist for headaches?

Severe ("the worst ever") Different than the usual headaches Starts suddenly during exertion Aggravated by exertion, coughing, bending, or sexual activity Associated with persistent nausea and vomiting Associated with stiff neck, fever, dizziness, blurred vision, slurred speech, unsteady gait, weakness or unusual sensations of the arm or leg, excessive drowsiness or confusion

When should one consult a neurologist for headaches?

Associated with seizures Associated with recent head trauma Not responding to treatment and is getting worse Disabling, and interfering with work and the quality of life Requires more than the recommended dose of over-the-counter analgesics for relief

Treatment for tension headaches?

occasional tension headaches or mild migraine headaches that do not interfere with daily activities usually medicate themselves with over-the-counter (OTC, non-prescription) analgesics. Many OTC analgesics are available. OTC analgesics have been shown to be safe and effective for short-term relief of headache (as well as muscle aches, pains, menstrual cramps, and fever) when used according to the instructions on their labels.

Two major classes of OTC analgesics Acetaminophen NSAID

 Acetaminophen
reduces pain and fever by acting on pain centers in the brain. well tolerated and generally is considered easier on the stomach than NSAIDs. cause severe liver damage in high (toxic) doses damage the kidneys when taken in large doses. not be taken more frequently or in larger doses than recommended

NSAIDs
relieve pain by reducing the inflammation that causes the pain

Abortive treatment of migraine

mild symptoms and disability : acetaminophen, NSAIDs, propoxyphene, or a combination of these. moderate disability need oral migraine-specific medications.: triptans and ergot alkaloids (ergotamine and dihydroergotamine).

Triptan
attach to serotonin receptors on the blood vessels and nerves and thereby reduce inflammation and constrict the blood vessels. prescribed for moderate or severe migraines after OTC analgesics and other simple measures failed. can be used as the first treatment for patients with migraines that are causing disability. used early after the migraine begins, before the onset of pain or when the pain is mild. can be expected to abort more than 80% of migraine headaches within 2 hours.

Side effects of triptans

facial flushing, tingling of the skin, and a sense of tightness around the chest and throat. Other less common side effects include drowsiness, fatigue, and dizziness. . should not be given to patients : who have had heart attacks and strokes, or to patients who have symptoms of atherosclerosis such as angina, transient ischemic attacks, and intermittent claudication

Ergots
are medications that abort migraine headaches. cause constriction of blood vessels, but ergots tend to cause more constriction of vessels in the heart and other parts of the body than the triptans, and their effects on the heart are more prolonged than the triptans. not as safe as the triptans. more prone to cause nausea and vomiting than the triptans. cause prolonged contraction of the uterus and miscarriages in pregnant women

How are migraine headaches prevented

1). by avoiding factors ("triggers") that cause the headaches, and 2). by preventing headaches with medications (prophylactic medications).

migraine triggers
Stress and fatigue Changes in weather, season, altitude level or time zone Changes in sleep patterns, including too much or too little sleep Bright lights Unusual odors Certain medications, including cimetidine, fenfluramine, nifedipine and theopylline Low blood sugar, changes in mealtimes, skipped meals or fasting Intense physical exertion, including sexual activity Tobacco, including secondhand smoke

Migraine prophylaxis
The goals of preventive therapy (1) to reduce attack frequency, severity, and/or duration; (2) to improve responsiveness to acute attacks, and (3) to reduce disability.

Migraine prophylaxis
Indications :
1. more than 2 migraine attacks per month. 2. single attacks that last longer than 24 hours. 3. major disruptions in the patient's lifestyle. 4. Abortive therapy fails or is overused. 5. complicated migraine.

Prophylactic drugs
antiepileptics, antidepressants, antihypertensives

Antiepileptics
topiramate are indicated for migraine prophylaxis and are well tolerated. The main adverse effects are weight loss and dysesthesia. Valproic acid is also indicated as a migraine prophylactic and useful as a first-line agent. other antiepileptics, such as gabapentin, lamotrigine, and oxcarbazepine, are limited in migraine.

Tricyclic antidepressants
are good second-line alternatives because of their adverse-effect profile and efficacy. amitriptyline and nortriptyline are most effective,

Antihypertensives
beta-blockers are approved by FDA for migraine prophylaxis, Calcium channel blockers are another possible choice of treatment. Angiotensin-converting enzyme (ACE) inhibitors (eg, lisinopril) and angiotensin-receptor blockers (ARBs, eg, candesartan) have recently shown to be effective for migraine prevention.

What is the treatment of cluster headaches?

abortive and prophylactic. Abortive treatments include inhalation of 100% oxygen at 8-10 liters/minute using a non-rebreathing facemask for 10-15 minutes along with a triptan or an ergot such as DHE A calcium channel blocker, verapamil is the medication of choice for prophylactic treatment Prophylactic medications usually are begun early during a cycle of cluster headaches and continued for two weeks longer than the usual cycle. Because prophylactic medications may take two weeks to be effective, prednisone often is used in decreasing doses for the first two weeks of treatment. Prednisone often can quickly abolish the headaches.

Criteria for General Diagnosis of Episodic TTH

Headache Description
(Any 2)

Associated Symptoms
(Any 1)

Pressing or tightening Mild to moderate intensity Bilateral location No worsening with exertion

No nausea or vomiting Photophobia or phonophobia

Criteria for Migraine without Aura

Headache Descriptions
(Any 2)

Associated Symptoms
(Any 1)

Unilateral Pulsatile quality Moderate to severe pain intensity Aggravation by or causing avoidance of routine physical activity

Nausea and/or vomiting Photophobia and phonophobia

Criteria for the General Diagnosis of Cluster Headache

Headache Description
(All 4)

Autonomic Symptoms
(Any 2)

Severe headache Unilateral Duration of 15180 min Orbital, periorbital, or temporal locatio

Rhinorrhea Lacrimation Facial sweating Miosis Eyelid edema Conjunctival injection Ptosis

Characteristics of Primary Headache Disorders

Migraine Location
Unilateral Moderate/severe 4 to 72 hours Throbbing Yes Female > male

Tension-Type*
Bilateral Mild/moderate 30 min to 7 days Pressing/tightening No Female > male

Cluster
Strictly unilateral Severe 15 to 90 min Severe Yes -- autonomic Male > female

Intensity
Duration Quality Associated symptoms Gender