Muscle Contraction Tension Headache

Tension Type Headache

Nyeri kepala : Rasa nyeri atau rasa tidak enak

pada bagian atas kepala dari daerah orbita sampai ke

daerah occiput dan tengkuk

Bagian kepala yang peka terhadap nyeri

1. Kulit kepala2. Otot-otot kepala3. Periosteum4. Duramater5. Pembuluh darah intrakranial /

ekstrakranial6. Organ / alat sekitar kepala

2. Bedakan NK primer dan sekunder

Primary headaches atau Idiopathic

headaches

– The headache is itself the disease

– No organic lesion in the beackground

– Treat the headache

Secondary headaches atau Symptomatic

headaches

– The headache is only a symptomatic of an other underlying disease

– Treat the underlying disease

• Nyeri yang berasal dari bangunan intrakranial tidak dirasakan didalam rongga tengkorak melainkan akan diproyeksikan ke permukaan dan dirasakan di daerah distribusi saraf yang bersangkutan.

• Nyeri yang berasal dari dua pertiga bagian depan kranium, di fosa kranium tengah dan depan, serta di supratentorium serebeli dirasakan di daerah frontal, parietal, di dalam atau belakang bola mata dan temporal bawah. Nyeri ini disalurkan melalui cabang pertama nervus Trigeminus.

• Nyeri yang berasal dari bangunan di infratentorium serebeli di fosa posterior biasanya diproyeksikan ke belakang telinga, di atas persendian serviko-oksipital atau diatas kuduk.

• Nervi kraniales IX dan X &saraf spinal C1, C2 & C3 berperan untuk perasaan dibagian infratentorial.

• Bangunan peka nyeri ini terlibat melalui berbagai cara yaitu oleh peradangan, traksi, kontraksi otot dan dilatasi pembuluh darah.

• Nyeri yang berhubungan dengan penyakit mata, telinga & hidung cenderung di frontal pada permulaannya.

• Nyeri kepala yang bertambah hebat

menunjukkan kemungkinan massa intrakranial yang membesar (hematoma subdural, anerysma, tumor otak)

• Pada nyeri kepala, sensitisasi terdapat di nosiseptor meningeal dan neuron trigeminal sentral

• lnervasi sensoris p.d intrakranial sebagian besar berasal dr. ganglion trigeminal dlm serabut sensoris yg mengandung neuropeptid, dimana jumlah & peranannya yg paling besar CGRP(Calcitonin Gene Related Peptide), kemudian diikuti oleh SP(substance P), NKA(Neurokinin A), pituitary adenylate cyclase activating peptide (PACAP), NO, prostaglandin E2, bradikinin, 5-HT & ATP

• Menurut H.G.Wolf terdapat 6 mekanisme dasar yang menimbulkan nyeri kepala yang berasal dari sumber intrakranial :

• Tarikan pada vena yang berjalan ke sinus venosus dari permukaan otak dan pergeseran sinus-sinus venosus utama.

• Tarikan pada A. Meningea media • Tarikan pada pembuluh-pembuluh arteri besar di otak atau

tarikan pada cabang-cabangnya. • Distensi dan dilatasi pembuluh-pembuluh nadi intrakranial

(A.Frontalis, A. Temporalis, A. Discipitalies) • Inflamasi pada atau sekitar struktur kepala yang peka terhadap

nyeri meliputi kulit kepala, periosteum, • Tekanan langsung pada nervus cranialis V, IX, X saraf spinal

dan cervikalis bagian atas yang berisi banyak serabut aferen rasa nyeri.

PENDAHULUAN

• International Headache Society(HIS)2004 Primary Headaches: Migraine, Tension type Headache; Cluster Headache and other trigeminal-autonomic cephalgias and Other Primary Headaches

• Tension-type headaches (TTHs) are characterized by pain that is usually mild or moderate in severity and bilateral in distribution. Unilateral pain may be experienced by 10-20% of patients. Headache is a constant, tight, pressing, or bandlike sensation in the frontal, temporal, occipital, or parietal area (with frontal and temporal regions most common)

• TTH is the most common type of headache, and it is classified as episodic (ETTH) or chronic (CTTH). It had various ill-defined names in the past including tension headache, stress headache, muscle contraction headache, psychomyogenic headache, ordinary headache, and psychogenic headache.

• The International Headache Society (IHS) defines TTH more precisely and differentiates between the episodic and the chronic types.

Episodic tension-type headacheEpisodic tension-type headache• At least 10 previous headaches fulfilling the following criteria;

number of days with such headache fewer than 15 per month • Headaches lasting from 30 minutes to 7 days • At least 2 of the following pain characteristics:

– Pressing/tightening (nonpulsating) quality – Mild or moderate intensity (may inhibit but does not prohibit

activities) – Bilateral location – No aggravation from climbing stairs or similar routine physical

activity • Both of the following:

– No nausea or vomiting – Photophobia and phonophobia absent or only one present

• Secondary headache types not suggested or confirmed

Chronic tension-type headache• Average headache frequency of more than 15 days

per month for more than 6 months fulfilling the following criteria

• At least 2 of the following pain characteristics: – Pressing/tightening (nonpulsating) quality – Mild or moderate intensity (may inhibit but does not prohibit

activities) – Bilateral location – No aggravation from climbing stairs or similar routine

physical activity • Both of the following:

– No vomiting – No more than one of the following: nausea, photophobia, or

phonophobia • Secondary headache types not suggested or

confirmed

Pathophysiology• Pathogenesis of TTH is complex and

multifactorial, with contributions from both central and peripheral factors.

• In the past, various mechanisms including vascular, muscular, and psychogenic factors were suggested.

• The more likely cause of these headaches is believed now to be abnormal neuronal sensitivity and pain facilitation, not abnormal muscle contraction.

• TTH is associated with exteroceptive suppression (ES2), abnormal platelet serotonin, and decreased cerebrospinal fluid beta-endorphin.

• pathophysiologic mechanisms may be responsible for TTHextracranial myofascial nociception Headache is not related directly to muscle contraction, and possible hypersensitivity of neurons in the trigeminal nucleus caudalis has been suggested.

Imaging Studies• Neuroimaging studies are important to rule out

secondary causes of headache, including neoplasms and cerebral hemorrhage.

• MRI imaging shows the greatest detail of cerebral structures and is especially useful in evaluating the posterior fossa.

• CT scan with contrast is a viable alternative but is inferior to MRI for viewing structures in the posterior fossa.

• Neuroimaging is indicated if the headaches are atypical in any way or if they are associated with abnormalities in the neurologic examination.

Various precipitating factors

• One half of patients with TTH identify stress or hunger as a precipitating factor.

• Stress - Usually occurs in the afternoon after long stressful work hours

• Sleep deprivation• Uncomfortable stressful position and/or bad

posture• Irregular meal time (hunger)

THERAPY

• The goals of pharmacotherapy are to relieve the headache, reduce morbidity, and prevent complications.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)These agents inhibit inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis. They generally are used in mild to moderately severe headaches; however, they also may be effective for severe headaches.

Drug Name Ibuprofen (Motrin, Advil)

Description First choice for treatment of headache, especially during pregnancy and breastfeeding.

Adult Dose 400-800 mg PO q8h, not to exceed 3200 mg/d

Pediatric Dose <12 years: Not recommended>12 years: Administer as in adults

ContraindicationsDocumented hypersensitivity; active peptic ulcer disease; renal or hepatic impairment; concomitant or recent use of anticoagulants; hemorrhagic conditions

InteractionsProbenecid may increase toxicity; may decrease effects of loop diuretics; may increase serum lithium levels; may prolong PT if given with anticoagulants

Pregnancy B - Usually safe but benefits must outweigh the risks.

Precautions Long-term use enhances potential for adverse effects, particularly gastropathy or nephropathy

Drug Name Naproxen sodium (Anaprox, Naprelan)


Adult Dose 275 mg PO tid or 550 mg PO bid

Pediatric Dose <12 years: Not recommended>12 years: Administer as in adults

ContraindicationsDocumented hypersensitivity; active peptic ulcer disease; renal or hepatic impairment; concomitant or recent use of anticoagulants; hemorrhagic conditions

Interactions Probenecid may increase toxicity; may increase serum lithium levels; may prolong PT if given with anticoagulants


Precautions Long-term use enhances potential for adverse effects, particularly gastropathy or nephropathy

Drug Category: AnalgesicsThese agents can be used for abortive therapy.

Drug Name Acetaminophen (Tylenol, Aspirin Free Anacin, Feverall, Tempra)


Adult Dose 650-1000 mg PO initially; dose may be repeated if necessary after 6h

Pediatric Dose

<3 years: Not established3-6 years: 10 mg/kg/dose PO; not to exceed 720 mg/d6-12 years: 10 mg/kg/dose PO; not to exceed 2.6 g/d>12 years: Administer as in adults

Contraindications Documented hypersensitivity; active peptic ulcer disease; renal or hepatic impairment; concomitant or recent use of anticoagulants; hemorrhagic conditions

InteractionsProbenecid may increase toxicity; may increase serum lithium levels; anticoagulants may prolong PT; may interfere with barbiturates, carbamazepine, ethyl alcohol, hydantoins, rifampin, sulfinpyrazone, and other drugs


PrecautionsClass A in pregnancy for short-term use; should not be used in higher and daily doses; long-term use enhances potential for adverse effects, particularly gastropathy or nephropathy

Drug Name Nortriptyline (Pamelor, Aventyl HCl)

Description Has demonstrated effectiveness in treatment of pain.

Adult Dose 25-100 mg PO hs; not to exceed 200 mg/d

Pediatric DoseChildren: 0.1 mg/kg PO hs; increase as tolerated, not to exceed 0.5-2

mg/d hsAdolescents: 25-50 mg/d PO; increase gradually to 100 mg/d

Contraindications Documented hypersensitivity; narrow-angle glaucoma; MAOIs within 14 d

Interactions Cimetidine may increase levels; may increase PT in patients stabilized with warfarin

Pregnancy D - Unsafe in pregnancy

PrecautionsPatients with cardiac conduction disturbances or history of

hyperthyroidism or renal or hepatic impairment; avoid using in elderly patients

Drug Category: AntidepressantsThese drugs increase the synaptic concentration of serotonin and/or norepinephrine in CNS by inhibiting their reuptake by the presynaptic neuronal membrane.Cymbalta can also be helpful for patients who have coexisting depression.

Drug Name Amitriptyline (Elavil)

Description Has demonstrated effectiveness in treatment of pain.

Adult Dose 25-100 mg PO hs; not to exceed 150 mg/d

Pediatric Dose Children: 0.1 mg/kg PO hs; increase as tolerated, not to exceed 0.5-2 mg/d qhsAdolescents: 25-50 mg/d PO; increase gradually to 100 mg/d

Contraindications Documented hypersensitivity; narrow-angle glaucoma; MAOIs within 14 d

Interactions

Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram


Precautions Caution in cardiac conduction disturbances, history of hyperthyroidism, renal or hepatic impairment; avoid using in elderly patients

Drug Name Fluoxetine (Prozac)

Description Has potent specific 5-HT uptake inhibition with fewer anticholinergic and cardiovascular adverse effects than TCAs.

Adult Dose 10 mg PO on waking; can be increased q2wk; not to exceed 60 mg/d

Pediatric Dose Not established

Contraindications Documented hypersensitivity; pregnancy and lactation; severe renal or hepatic disease

InteractionsSerious, potentially fatal reactions such as autonomic instability may occur with concurrent MAOIs; other antidepressants, phenothiazines, group IC anti-arrhythmics, cimetidine, phenytoin, phenobarbital, digoxin, and warfarin

Pregnancy C - Safety for use during pregnancy has not been established.

PrecautionsAnxiety, insomnia or drowsiness, tremor, anorexia, anorgasmia, and other sexual dysfunctions have been reported; nausea, flulike symptoms, and agitation that resolve within 1-2 wk also are noted

Drug Category: Serotonin reuptake inhibitorsThese agents specifically inhibit presynaptic reuptake of serotonin. May be considered as an alternative to TCAs.

Drug Name Paroxetine (Paxil)

Description Atypical nontricyclic antidepressant with potent specific 5-HT uptake inhibition and fewer anticholinergic and cardiovascular adverse effects than TCAs.

Adult Dose 10 mg/d PO initially; titrate prn; not to exceed 50 mg/d





PrecautionsAnxiety, insomnia or drowsiness, tremor, anorexia, anorgasmia, and other sexual dysfunctions have been reported; nausea, flulike symptoms, and agitation that resolve within 1-2 wk also noted

Drug Name Sertraline (Zoloft)

Description Atypical nontricyclic antidepressant with potent specific 5-HT uptake inhibition and fewer anticholinergic and cardiovascular adverse effects than TCAs.

Adult Dose Start at 50 mg/d PO; increase at weekly intervals after several weeks; not to exceed 200 mg/d





PrecautionsAnxiety, insomnia or drowsiness, tremor, anorexia, anorgasmia, and other sexual dysfunctions have been reported; nausea, flulike symptoms, and agitation that resolve within 1-2 wk also are noted

Drug Name Magnesium chloride (Slow-Mag, Mag-Delay)

Description Magnesium metabolism may have a significant role in both the etiology and the treatment of muscle contraction tension headache.

Adult Dose 1-2 tab PO qd/bid


Contraindications Documented hypersensitivity; heart block; Addison disease; myocardial damage; severe hepatitis

Interactions

Concurrent use with nifedipine may cause hypotension and neuromuscular blockade; may also worsen neuromuscular blockade seen with aminoglycosides, tubocurarine, vecuronium, and succinylcholine; magnesium may increase CNS effects and toxicity of CNS depressants, betamethasone, and ritodrine


Precautions

May alter cardiac conduction leading to heart block in digitalized patients; monitor respiratory rate, deep tendon reflex, and renal function when administered parenterally; caution when administering magnesium dose since may produce significant hypotension or asystole

Drug Category: Electrolyte supplementsElectrolytes such as magnesium may help in the treatment of tension headache.

Patient Education

Advise the patient to take the following actions: • Avoid stressful situations if possible • Maintain a regular sleep schedule • Exercise regularly • Eat balanced meals • Avoid uncomfortable stressful positions and bad

posture • Avoid eyestrain • Try biofeedback and relaxation techniques

KESIMPULAN

• Tension type headache didapati gejala yg menonjol nyeri tekan yg bertambah pd palpasi jr.miofascial perikranial.

• Impuls nosiseptif dr otot perikranial yg menjalar ke kepala mengakibatkan timbulnya nyeri kepala & nyeri yang bertambah pada daerah otot maupun tendon tempat insersinya.

• TTH kondisi stress mental, non-physiological motor stress, dan miofasial lokal yang melepaskan zat iritatif atau kombinasi dari ke tiganya yang menstimuli perifer mengaktivasi struktur persepsi supraspinal painke sentral modulasi yg masing2 individu mempunyai sifat self limiting yg berbeda beda dlm hal intensitas nyeri kepalanya

• Mediator kimiawi substansi endogen : serotonin (dilepas dr platelet), bradikinin (dilepas dr belahan precursor plasma molekul kallin) & Kalium (yg dilepas dari sel otot), SP & CGRP dari aferens otot berperan sebagai stimulan sensitisasi terhadap nosiseptor otot skelet. Pada saat ini peran miofascial thdp timbulnya tension type headache.

• Pada penelitian Bendtsen tabun 1996 terhadap penderita chronic tension type headache (yang dikutip oleh Bendtsew8) teryata otot yang mempunyai nilai Local tenderness score tertinggi adalah otot Trapezeus, insersi otot leher dan otot sternocleidomastoid.

Muscle Contraction Tension Headache

Documents

Transcript of Muscle Contraction Tension Headache