HEADACHESHEADACHES

Prof. dr. Basjiruddin ahmad, Sp.S (K)Prof. dr. Basjiruddin ahmad, Sp.S (K)Fakultas Kedokteran Universitas AndalasFakultas Kedokteran Universitas Andalas

RS. Dr. M. DjamilRS. Dr. M. DjamilPadangPadang

Headache Headache In medical terminology : cephalgiaIn medical terminology : cephalgia Headache is defined as pain in the head that is Headache is defined as pain in the head that is

located above the eyes or the ears, behind the located above the eyes or the ears, behind the head (occipital), or in the back of the upper neck, head (occipital), or in the back of the upper neck, and has many causesand has many causes

Majority of headaches are benign and self limiting, Majority of headaches are benign and self limiting, secondary headache can life-threating conditions secondary headache can life-threating conditions such as encephalitis,meningitis, tumor, cerebral such as encephalitis,meningitis, tumor, cerebral hemorrhage, etc.hemorrhage, etc.

Nearly universal experienceNearly universal experience Prevalance :- 1 year periode of 90 %Prevalance :- 1 year periode of 90 %

- a life time of 99%- a life time of 99% Diagnosis : Careful history, examination and Diagnosis : Careful history, examination and

diagnostic testingdiagnostic testing

Similar headaches can have different cause depend Similar headaches can have different cause depend on the pain-sensitive structures, include:on the pain-sensitive structures, include:A.A. Intracranial structuresIntracranial structures

– Dura near vesselsDura near vessels– Cranial nerves V, VII, IX, XCranial nerves V, VII, IX, X– Circle of willisyCircle of willisy– Meningeal arteriesMeningeal arteries– Large veinsLarge veins

B.B. External to the skullExternal to the skull– Scalp and neck musclesScalp and neck muscles– Cervical nervus and rootsCervical nervus and roots– Cutaneous nerves and skinCutaneous nerves and skin– Mucosa of the paranasal sinuscsMucosa of the paranasal sinuscs– TeethTeeth– External carotid arteriesExternal carotid arteries

Pain–sensitive structuresPain–sensitive structures

PAIN SENSITIVE CRANIAL STRUCTURES

Skin, subcutan, muscle Extracranial arteries Skull periosteum Eye, ear, nasal cavities,

sinuses Intracranial venous sinuses,

large veins, pericavernous structures

Basis duramater, meningeal arteries, proximal anterior middle cerebral arteries, carotis interna arteries

Superficial temporal arteries Cranial nerves: N II, N III, N

V, N IX, N X,C1-3

Nerves SupplyNerves SupplySplancno cranium supply by cranial nerve V, VII, Splancno cranium supply by cranial nerve V, VII, IX and XIX and X

Neuro cranium, structures external to the skull Neuro cranium, structures external to the skull (including scalp and neck muscle), are supplied (including scalp and neck muscle), are supplied by nn.spinalis C1, C2, C3by nn.spinalis C1, C2, C3

LocationLocation Cluster headaches always unilateralCluster headaches always unilateral 60% migraines: are unilateral, some could be 60% migraines: are unilateral, some could be

spread become bilateralspread become bilateral Trigeminal neuralgia: uccurs unilaterally in the Trigeminal neuralgia: uccurs unilaterally in the

second and third trigeminal distributionsecond and third trigeminal distribution Brain tumor: bilateral or unilateralBrain tumor: bilateral or unilateral Tension headache bilateralTension headache bilateralDurationDuration Migraine 4-72 hours in adultsMigraine 4-72 hours in adults Cluster headache 15-180 minutesCluster headache 15-180 minutes Tension type headche 30 minutes-daysTension type headche 30 minutes-days Trigeminal neuralgia a few seconds < 2minutes Trigeminal neuralgia a few seconds < 2minutes

HeadacheHeadache

Two types of headache:Two types of headache:– Primary headachePrimary headache,, are not associated with are not associated with

other diseases, for example tension headache, other diseases, for example tension headache, migraine, cluster headachemigraine, cluster headache

– Secondary headacheSecondary headache, are caused by , are caused by associated diseases; may be minor or serious associated diseases; may be minor or serious and life threateningand life threatening

Tension headache is the most common type of Tension headache is the most common type of primary headache, and more common among women primary headache, and more common among women than menthan men

Classification of primary headache Classification of primary headache (international headache society 1988 modified)(international headache society 1988 modified)

1. Migraine1. Migrainea.a. Migraine without auraMigraine without aura

b.b. Migraine hemiplegic migraineMigraine hemiplegic migraine

c.c. Basiler migraineBasiler migraine

d.d. Opthalmoplegic migraineOpthalmoplegic migraine

e.e. Complications of migraineComplications of migraine

2.2. Tension type headacheTension type headachea.a. Episodic tension type headache (ETTH)Episodic tension type headache (ETTH)

b.b. Chronic tension type headache (CTTH)Chronic tension type headache (CTTH)

3.3. Cluster headache and chronic paroxismal Cluster headache and chronic paroxismal hemicraniahemicraniaa.a. Cluster headacheCluster headacheb.b. Chroic paroxismal hemicraniaChroic paroxismal hemicrania

4.4. Headache associated with head traumaHeadache associated with head trauma5.5. Headache associated with vascular diseaseHeadache associated with vascular disease : :

infarction, hematoma, subarachnoid hemorrhage acute infarction, hematoma, subarachnoid hemorrhage acute arterial hypertensionarterial hypertension

6.6. Headache associated with metabolic Headache associated with metabolic abnormality, dypoxia, dialysis abnormality, dypoxia, dialysis

7.7. Headache associated with intracranial Headache associated with intracranial disorderdisordera.a. Infection/ abscessInfection/ abscessb.b. TumorTumorc.c. Granulamotor diseaseGranulamotor disease

Classification...Classification...

8.8. Headache associated with us order of neck, Headache associated with us order of neck, eye, sinus, teetheye, sinus, teeth

a.a. Cranial neuralgiaCranial neuralgiab.b. Trigeminal neuralgiaTrigeminal neuralgiac.c. Glossopharyngeal neuralgiaGlossopharyngeal neuralgia

9.9. Other type of headacheOther type of headacheIce pick, cold stimulus, benign cough headache benign Ice pick, cold stimulus, benign cough headache benign sex headachesex headache

10.10. Headache not classifableHeadache not classifable

Migraine Migraine Migraine is a chronic condition of recurrent attacks, Migraine is a chronic condition of recurrent attacks,

due to changes in the brain and surrounding blood due to changes in the brain and surrounding blood vesselsvessels

Pain located in the forehead, around eye, or back of Pain located in the forehead, around eye, or back of head, unilateralhead, unilateral

Usually aggravated by daily activities, like walking Usually aggravated by daily activities, like walking upstairs etcupstairs etc

Nausea, vomiting, cold hands, facial pallor Nausea, vomiting, cold hands, facial pallor Typically last from 4-72 hours and vary in frequency Typically last from 4-72 hours and vary in frequency

from daily to fewer than 1 per yearfrom daily to fewer than 1 per year Affects about 15% or the population (women : men = Affects about 15% or the population (women : men =

3 : 1)3 : 1) ±± 80% migraineurs have other members in the family 80% migraineurs have other members in the family

Symptoms Symptoms Vary from person to personVary from person to person

Five phases often to be identifiedFive phases often to be identified : :– ProdromeProdrome : feeling “high”, irritable, depressed, : feeling “high”, irritable, depressed,

funny taste of smellfunny taste of smell– AuraAura : visual disturbance preceedes headacha : visual disturbance preceedes headacha

phase, blind spots (scotoma), flashing, colorful or phase, blind spots (scotoma), flashing, colorful or lose vision on one side (hemianopia)lose vision on one side (hemianopia)

– HeadacheHeadache : on one side of the head, 30% spread on : on one side of the head, 30% spread on both sidesboth sides

Throbbing pain, >80% nauseated, and some vomitThrobbing pain, >80% nauseated, and some vomit 70% photophobia and phonophobia70% photophobia and phonophobia

– Headache terminationHeadache termination : pain usually goes away : pain usually goes away with sleepwith sleep

– PostdromePostdrome : inability to eat, fatigue, problem with : inability to eat, fatigue, problem with concentration may linger after pain disappearedconcentration may linger after pain disappeared

Phase of Acute MigrainPhase of Acute Migrain

CausesCauses Exact cause is not clearly understoodExact cause is not clearly understood Experts believe : Experts believe :

A combination of the expansion of blood vessels A combination of the expansion of blood vessels and the release of certain chemicals, which and the release of certain chemicals, which causes inflamation and pain. causes inflamation and pain. The chemicals dopamine and serotonine can The chemicals dopamine and serotonine can cause blood vessels to act abnormally if they cause blood vessels to act abnormally if they present in abnormal amounts, or if the blood present in abnormal amounts, or if the blood vessels are unusually sensitive to themvessels are unusually sensitive to them

TriggersTriggers Certain foods : chocolate, cheese, nuts, alcohol, Certain foods : chocolate, cheese, nuts, alcohol,

and MSG (monosodium glutamate)and MSG (monosodium glutamate) Stress and tension or physical stressStress and tension or physical stress Birht control pills (estrogen)Birht control pills (estrogen) Smoking Smoking Missing a meal may bring on a headacheMissing a meal may bring on a headache

Associated symptomsAssociated symptoms

Before headacheBefore headache– 60% migrainous have prodrome in hour before:60% migrainous have prodrome in hour before:– Irritability, depression, eupharia small Irritability, depression, eupharia small

hypertensivehypertensiveDuring headacheDuring headache

– Migraine: by nausea in 90%, vomiting > 50%Migraine: by nausea in 90%, vomiting > 50%Foto/fobo sensitivity in 80%Foto/fobo sensitivity in 80%Nasal congestionNasal congestion

– Cluster : ipsilateral ptosis, miosis in 30%Cluster : ipsilateral ptosis, miosis in 30%– DysabilityDysability

After headacheAfter headache– Tired, drained, depression, decreased mental Tired, drained, depression, decreased mental

acuityacuity

Migraine without aura (common migraine)Migraine without aura (common migraine) Benign periodic headache lasting several hours, Benign periodic headache lasting several hours,

without preceding focal neurologic symptomswithout preceding focal neurologic symptoms Unilateral pain, nausea or vomitting, positive family Unilateral pain, nausea or vomitting, positive family

history, respon to ergotamin, scalp tenderness in history, respon to ergotamin, scalp tenderness in 80%80%

Migraine with aura (classic migraine)Migraine with aura (classic migraine) Headache associate with characteristic premonitory Headache associate with characteristic premonitory

sensory, motor, or visual symptomssensory, motor, or visual symptoms Visual – scotomas or hallucinations (usually in central Visual – scotomas or hallucinations (usually in central

visual field) paracentral scotoma expands 20 to 25 visual field) paracentral scotoma expands 20 to 25 minutesminutes

Basilar migraineBasilar migraine– Brainstem signs, including vertigo, dysarthria, diplopia; Brainstem signs, including vertigo, dysarthria, diplopia;

occur as sole neurologic symptoms of migraine in 25%occur as sole neurologic symptoms of migraine in 25%

Hemiplegic migraineHemiplegic migraine– Hemiparesis migraine may occur during prodrome; lasts Hemiparesis migraine may occur during prodrome; lasts

20 to 30 minutes20 to 30 minutes– More severe: hemiplegia for days to weeks headache More severe: hemiplegia for days to weeks headache

subsidessubsides– Familial from autosomal dominantFamilial from autosomal dominant

Opthalmoplegic migraineOpthalmoplegic migraine– Attasck of periorbital pain and vomiting for 1 to 4 days. Attasck of periorbital pain and vomiting for 1 to 4 days. – Complete third nerve palsy follows, often including Complete third nerve palsy follows, often including

pupillary dilation, loss of lihgt response. pupillary dilation, loss of lihgt response. – May persist days to 2 months. Onset may occur in May persist days to 2 months. Onset may occur in

childhoodchildhood

Diagnosis criteriaDiagnosis criteriaI.I. Migraine without auraMigraine without aura

a.a. At least 5 attacks fulfilling b & cAt least 5 attacks fulfilling b & cb.b. Attacks lasting 4-72 hAttacks lasting 4-72 hc.c. During headacheDuring headache

- Nausea and/or vomitingNausea and/or vomiting- photophobi, phonofobiphotophobi, phonofobi- Headache with 2 of tha followingHeadache with 2 of tha following- Unilateral, pulsating qualityUnilateral, pulsating quality- Moderate severe intensityModerate severe intensity- Aggravation by walking stairs or similar activityAggravation by walking stairs or similar activity

II.II. Migraine with auraMigraine with aura1.1. At least 2 attacks fulfilling bAt least 2 attacks fulfilling b2.2. 3 of the following3 of the following

- One or more reversible auraOne or more reversible aura- Aura gradually over more than 4 minutesAura gradually over more than 4 minutes- No aura lasts more than 60 minutesNo aura lasts more than 60 minutes- Headache (some with migraine without aura) follow Headache (some with migraine without aura) follow

aura with a free intervalaura with a free interval

ManagementManagement

Acute treatmentAcute treatmentImmediate administration of full dose of Immediate administration of full dose of agent at attack onsetagent at attack onsetMild headache : aspirin, acetaminophen. Mild headache : aspirin, acetaminophen. Butalbital and caffeine added if necessary. Butalbital and caffeine added if necessary. Ibuprofen, naproxen often useful. Ibuprofen, naproxen often useful. Isometheptene compounds effective for Isometheptene compounds effective for mild-to-moderate ”stress headache”mild-to-moderate ”stress headache”

Moderate-to-severe headacheModerate-to-severe headache:: ergotamine (oral or suppository); sumatritan ergotamine (oral or suppository); sumatritan (oral intranasal, subcutaneous dose), (oral intranasal, subcutaneous dose), Rizatriptan, zolmitriptan, naratriptan, Rizatriptan, zolmitriptan, naratriptan, Triptans indicated for attack frequency > 2 to Triptans indicated for attack frequency > 2 to 3 per month3 per month

Contra indicationsContra indications : : HypertensionHypertension StrokeStroke Coronary artery disease Coronary artery disease

Severe headacheSevere headache : dihydroergotamine : dihydroergotamine (parenteral, nasal spray). Intravenous (parenteral, nasal spray). Intravenous prochlorperazine, metoclopramide, prochlorperazine, metoclopramide, dihydroergotaminedihydroergotamine

Chronic daily headacheChronic daily headache : amitriptyline, : amitriptyline, nortriptyline, anti depresants, valproat, nortriptyline, anti depresants, valproat, topiramatetopiramate

ProphylaxisProphylaxis

Daily administration required. Effect lags 2 Daily administration required. Effect lags 2 weeksweeks

Medications Medications include: propanolol, amitriptiline, propanolol, amitriptiline, verapamil, valproatverapamil, valproat

Additional drug include topiramate, zonisamide.Additional drug include topiramate, zonisamide.

Probability of successProbability of success 60% to 75% 60% to 75%

drug maybe tappered after 5 monthdrug maybe tappered after 5 month

Tension HeadacheTension Headache A tension headache is the most common A tension headache is the most common

headache and yet it’s not clear understoodheadache and yet it’s not clear understood Generally produces mild to moderate pain, in the Generally produces mild to moderate pain, in the

back of neck at the base of the skull feeling a back of neck at the base of the skull feeling a tight band around headtight band around head

Symptoms can last from 30 minutes to an entire Symptoms can last from 30 minutes to an entire week, or nearly all the time (never free from week, or nearly all the time (never free from headache)headache)

Patients experience:Patients experience:– Tenderness on scalp, neck and shoulder musclesTenderness on scalp, neck and shoulder muscles– Difficulty sleeping (insomnia), fatigue, instabilityDifficulty sleeping (insomnia), fatigue, instability– Lost of appetite, difficulty concentratingLost of appetite, difficulty concentrating

Someimes may be severeSomeimes may be severe

The causes still continue to debate exact The causes still continue to debate exact cause are unknowncause are unknownResearches now believe :Researches now believe :– Changes among certain brain chemicals – Changes among certain brain chemicals –

serotonine, endorphine and numerous other serotonine, endorphine and numerous other chemicals – that help nerves communicatechemicals – that help nerves communicate

– The process activate pain pathways to the brain The process activate pain pathways to the brain and to interfere with the brain’s ability to and to interfere with the brain’s ability to supress the painsupress the pain

– Tight muscles in the neck/scalp contribute to a Tight muscles in the neck/scalp contribute to a headache, on the other hand, the tight muscles headache, on the other hand, the tight muscles may be a result of these chemical changesmay be a result of these chemical changes

Causes

Muscle tension that may cause Tension Muscle tension that may cause Tension Type HeadacheType Headache

Potential TriggersPotential Triggers

StressStress Depression, anxietyDepression, anxiety Lack of sleep or changes in sleep routineLack of sleep or changes in sleep routine Poor posture; lack of physical activityPoor posture; lack of physical activity Working in awkward positionsWorking in awkward positions Hormonal changes; menstruation, Hormonal changes; menstruation,

pregnancypregnancy Overuse of headache medicationOveruse of headache medication

Classification of Tension HeadacheClassification of Tension Headache

1.1. Episodic tension-type headache (ETTH)Episodic tension-type headache (ETTH)is defined as recurrent episodes of headacheis defined as recurrent episodes of headache(older term: tension hedache, muscle contraction headache)(older term: tension hedache, muscle contraction headache)

– Occur on fewer than 15 days a monthOccur on fewer than 15 days a month– Lasting a few minutes to few hoursLasting a few minutes to few hours– Scalp and neck muscle tenderness in addititon to head Scalp and neck muscle tenderness in addititon to head

painpain– Risk of developing chronic form over yearsRisk of developing chronic form over years

2.2. Chronic tension-type headache (CTTH)Chronic tension-type headache (CTTH)– Occur on 15 days a month or more for at least three Occur on 15 days a month or more for at least three

monthsmonths– 20% of CTTH are primary (daily from the onset) 20% of CTTH are primary (daily from the onset) – Duration and severity are similar with ETTH, although Duration and severity are similar with ETTH, although

pain is daily and continous , and tenderness of scalp and pain is daily and continous , and tenderness of scalp and neckneck

I.I. Pressing, tighthening nonpulsating qualityPressing, tighthening nonpulsating quality• Mild or moderate intensityMild or moderate intensity• Bilateral locationBilateral location

II.II. No nausea or vomitingNo nausea or vomiting• No aggravation by walking stairs or No aggravation by walking stairs or

same /exercisesame /exercise• No or one of phono-photophobiaNo or one of phono-photophobia

Characteristic Tension type headache

Diagnostic criteria ETTHDiagnostic criteria ETTH • Characteristic I and II with :Characteristic I and II with :

A.A. At least 10 previous headache episodes At least 10 previous headache episodes number of days with such headche <180/y number of days with such headche <180/y (<15/mo)(<15/mo)

B.B. Headche lasting from 80 min-7 daysHeadche lasting from 80 min-7 days

Diagnostic criteria of CTTHDiagnostic criteria of CTTH• Include characteristic A and B with :

Avarage headache frequent 15 days/month (180 days/year) for 6 months

Two risk of CTTH:Two risk of CTTH:

- Analgesic rebound- Analgesic rebound

- Cormobidity- Cormobidity Use of combination analgesics should be Use of combination analgesics should be

limited to days or 24 tabletslimited to days or 24 tablets SSRI (Serotinin Selective Reuptake SSRI (Serotinin Selective Reuptake

Inhibitor) drugs may administered as a Inhibitor) drugs may administered as a prevention (fluoxetin)prevention (fluoxetin)

Treatment Treatment

The goal is to relieve symptoms and The goal is to relieve symptoms and prevent future headachesprevent future headaches

Prevention is the best treatmentPrevention is the best treatment If possible, remove or control headache If possible, remove or control headache

triggerstriggers Medications :Medications :

– Over-the-counter (OTC) analgesics such Over-the-counter (OTC) analgesics such aspirin, acetaminophen, may combine with aspirin, acetaminophen, may combine with caffeine and NSAID, ibuprofen, ketoprovencaffeine and NSAID, ibuprofen, ketoproven

– Anti depressant : amitriptilinAnti depressant : amitriptilin– Non sedating muscle relaxantNon sedating muscle relaxant– Combination of bulbital and acetaminophenCombination of bulbital and acetaminophen

Prevention Prevention Stress management strategiesStress management strategies Relaxation excercisesRelaxation excercises Good posture when working, reading, Good posture when working, reading,

activitiesactivities Enough sleep and restEnough sleep and rest Massage of sore musclesMassage of sore muscles Lifestyle changes Lifestyle changes

Cluster headacheCluster headache

EpisodicEpisodic : most common type. One to three : most common type. One to three short-lived attacks of periorbital pain daily for short-lived attacks of periorbital pain daily for 4 to 8 weeks, then pain-free interval for 4 to 8 weeks, then pain-free interval for about 1 yearabout 1 year

ChronicChronic: begins de novo or evolve from : begins de novo or evolve from episodic type. Attacks similar no susteined episodic type. Attacks similar no susteined remission.remission.

M : F = 8 : 1M : F = 8 : 1

Onset ages 20 to 50Onset ages 20 to 50

Clinical featuresClinical features– Periorbital, temporal, maxillary pain begins Periorbital, temporal, maxillary pain begins

without warning, peaks within 5 minutes.without warning, peaks within 5 minutes.– Often excruciating, deep, nonfluctuating, Often excruciating, deep, nonfluctuating,

explosive. explosive.

Strictly unilateral. Attack last 30 to 120 Strictly unilateral. Attack last 30 to 120 minutes. minutes.

Frequently with ipsilateral lacrimation, red Frequently with ipsilateral lacrimation, red eye, nasal stuffiness, lid ptosis, nauseaeye, nasal stuffiness, lid ptosis, nausea

TreatmentTreatmentTo abort attack : oxygen inhalation To abort attack : oxygen inhalation (10mL/min via nonrebreathing mask), (10mL/min via nonrebreathing mask), intranasal topical lidocaine, sumatriptan. To intranasal topical lidocaine, sumatriptan. To prevent further attacks during bout: prevent further attacks during bout: prednisone, methysergide, ergotamine, prednisone, methysergide, ergotamine, verapamilverapamil

Post-concussion headachePost-concussion headache

Follow severe or trivial head injury (including Follow severe or trivial head injury (including head trauma without loss of consciousness). head trauma without loss of consciousness). Often with vertigo, impaired memory and Often with vertigo, impaired memory and concentration, mood changes for months or concentration, mood changes for months or years (post-concussion syndrome)years (post-concussion syndrome)

Brain Tumor HeadacheBrain Tumor Headache

Chief complaint in 30% of patints with brain Chief complaint in 30% of patints with brain tumor: deep, dull aching quality, moderate tumor: deep, dull aching quality, moderate intensity, intermitten, worsened by exertion intensity, intermitten, worsened by exertion or change in position, associated with or change in position, associated with nausea and vomiting. Headache disturbs nausea and vomiting. Headache disturbs sleep in about 10%. Vomiting precedes sleep in about 10%. Vomiting precedes headache by weeks in posterior fossa brain headache by weeks in posterior fossa brain tumortumor

ReferencesReferences Adams RD. Principles of neurology 6th ed Mc

Graw Hill 1997 Harsono, Buku Ajar Neurologi, Bab II Harsono, Kapita selekta neurologi, Bab II Mazzoni.P.Merritts`s Neurology Handbook. 2nd ed

Dresden. Lippincott William & Wilkins. 2007 Evans RW. Hanbook of headache. Philadelphia

Lipincott William & Wilkins, 1999 Headache wikipedia Mayo clinic com

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