primary headache kuliah stikes upload.pptx

7/28/2019 primary headache kuliah stikes upload.pptx

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Sakit Kepala

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Headache/ Nyeri Kepala

18,9% kunjungan ke RSDS

17,4% kunjungan ke RSCM

42% kunjungan praktek sore Sp.S

90% merupakan primary headache

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NYERI

Pengalaman sensorik & emosional yg tidak

menyenangkan terkait kerusakan jaringan,

baik aktual maupun potensial atau yang

digambarkan dalam bentuk kerusakan tsb.


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PATOFISOLOGI NYERI

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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%

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HEADACHE/ Nyeri Kepala


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Derajat Nyeri Kepala

(Praktis)

Ringan : pekerjaan/aktifitas sehari2

normal.Sedang : aktifitas berat terganggu

Berat : aktifitas sehari-hari terganggu

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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-arteryd. Structure from eye, ear & nose

III. Nervous: V, VII, IX, X, C1 C2 C3

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1. Parenkim brain

2. Ependyma, pleksus choroid

3. Piamater, membrana arachnoidea &

duramater

4. Bone skull

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STRUCTURE NOT SENSITIVE PAIN


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A. intracranial:1. Iritasi meningen

Ex: Meningitis Perdarahan Sub Arachnoid (SAH)

2. Penarikan or peregangan arteriintracranial:

Tumor Absces

Hematoma intracranial TIK : hidrosefalus, BIH TIK : post Lumbal Headache

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PATOFISIOLOGY Headache General :


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3. Vasodilatasi arteri intra

kranial

Toksic caused infection

With drawlcaffein Hipoglikemia, Hipoksia,Hiperkapnea

drug vasodilator

Post attack Epilepsi Insufiensi sirculation brain

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1. dilatasi cabang A. carotis externa MigrenCluster headache

2. inflammation artery ekstrakranial

Giant cellarterytis 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

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B. BERSUMBER ESKTRA KRANIAL


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1.Headache Primer

Tension headache

Migrain

Cluster headache

2. Headache Secunder

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Headache

PRIMERSecunder

TTH Migrain ClusterHeadache infection

Tanda2infection

(Color/Dolor/

Robor)

Trauma

history

Trauma

Tumor

-Trias

-Headachechronic

progresif

-vomit

proyektil

-Papil edema

Vascular-acute-DefisitNeurologis

fokal

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DIAGNOSIS AND TESTING

Detailed History and Examination

Primary Headache? Preliminary Diagnosis

NO

Secondary

Headache

Diagnostic

Testing

AtypicalFeatures

YES

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RED FLAGS SNOOP T

Older: new onset and progressive headache, especially in

middle-age >50

Systemic symptoms (fever, weight loss) orsecondary 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


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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 UNDERLYINGDISEASE!

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HEADACHE QUALITY LOCATION DURATION FREQUENCYASSOCIATED

SYMPTOMSCommonmigraine

Throbbing Unilateral head /Ifteral head

6 48 hours Sporadic (oftenseveral timesmontlly)

Nausea, vomiting,malaise,photophobia

Classicmigraine

Throbbing Unilateral head 3 12 hours Sporadic (oftenseveral timesmonthly)

Visual prodrome,vomiting, nausea,malaise,photobhobia

Cluster Boring, sharp Unilateral head(especially orbit)

12 120minutes

Closely bunchedclusters withlong remissions

Ipsilateral tearing,facial flushing, nasalstuffiness, Hornerss

syndrome

Psychogenic/Chronic TTH

Dull, pressure Diffuse, IfteralFrontal, temporalsuboccipital

Oftemunremitting

May be constantAlmost daily

Depression, anxiatyPericranialtenderness

Trigeminalmeuralgia

Lancinating Fifth nervedistribution

Brief (15-60second)

Many times daily Identifiable triggerzone

Tabel 1 . Important features of pain in the evaluation of chronicrecurrent headaches

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PHYSICAL FINDING POSSIBLE ETIOLOGY

Optic atropy, papiledema Mass lesion, hydrocephalus, benignintracranial hypertensionon

Focal neurologic abnormality (hemipareseaphasia)

Mass lesion

Stiff neck Subarachnoid hemorrhage, meningitis,

cervical arthritisRetinal 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 Pericranialmuscle

TTH/Muscle Contraction Headache

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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)

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Tension Type headache

10 attacks lasting 30 min7 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

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TTH Classification

Episodic


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Tension TypeHeadacheTTH

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Treatment of TTH

Evidence A : multipel RCT

B : 1 RCT

C : ConsensusClinical effect :

+ few people improved

++ Some people improved+++ Most people improved

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D id Cli i l ff t R l R t


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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 ?

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-------- 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)

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Migraine

The most common disabling headache

The most common headache visits

Unknown causes

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Migraine Criteria

5 attacks lasting 472 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

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SULTANS: two from column A, one from

column B

evere

ni

ateral hrobbing

Ctivity worsens

ausea

Lite and sound

ensitivity

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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); Sakaiand Igarashi (1997)Prevalence measured over a few years

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Prevalence of migraine by

sex and age

FemalesMales30

25

20

15

10

5

020 30 40 50 60 70 80 100

Migraine prevalence (%)

Age (years)

Lipton and Stewart (1993)

The American Migraine Study (n=2479 migraine sufferers)

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Mi i


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Migraine

A. The Aura

B. The Attack

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Penatalaksanan migrain

1. Hindari pencetus

2. Terapi abortif

Non spesifik Spesifik

3. Terapi preventif

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Pencetus Migraine

Kurang atau kebanyakan tidur

Kelelahan

Stres dan kecemasan

Terlambat makan

Perubahan hormonal

Makanan (MSG, nitrit (pengawet) ,aspartam (pemanis

buatan)) Cahaya terang

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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

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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

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TRIPTAN

Efikasi lebih baik dibanding ergot

Sediaan obat di Indonesia sulit di dapat (hanyaada sumatriptan)

Efek samping : nyeri dada, parestesi, fatik

Kontra indikasi : Penyakit kardio, serebrovaskular,hipertensi, gagal ginjal, kehamilan dan laktasi

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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

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Sefalgia sekunder

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stroke Wanita 75 th di bawa ke IRD

RS krn mendadak sakitkepala, hemiparese kiri


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Trauma Anak 15 th terkena pemukul

baseball di pelipis. Sesaatsetelah terkena pukulan iatidak sadar sebentar 15mnt lalu bangun lagi. Iamengeluh sakit kepala

namun keadaannya saat itubaik saat dibawa ke IRD.Empat jam kemudian saatdiobservasi ia mengeluhkansakit kepalanya bertambahhebat dan kejang. Pupilsebelah kanan midriasis


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Infeksi

Pria 40 th , pengusaha

mengeluh sakit kepala 2

bln, disertai demam

sumer-sumer, seringdiare dan sariawan .Ia

mengkonsumsi narkoba

berhenti sjk 1 th silam.

Dibawa ke IRD olehkeluarganya krn bicara

meracau.


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Tumor

Wanita 35 th, sakit

kepala 8 bln bertambah

hebat terutama saat

bangun dan bersin,memakai kontrasepsi

suntik 3 bulan


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Degenerasi

Wanita 79 th datang kepoli dengan keluhansakit kepala hilangtimbul 2 th.Sering

lupa 3-4 th dan tidakmampu berbelanja lagikrn kesulitan melakukanperhitungan ringan.

Sekarang sulit tidur dansering terlihat sepertiberbicara sendiri


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ATAS PERHATIANNYA

primary headache kuliah stikes upload.pptx

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