NYERI KEPALA PRIMER

Dr. Ken Wirastuti, M Kes, Sp.S, KIC

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 ONLY A SYMPTOM OF AN OTHER UNDERLYING DISEASE

TREAT THE UNDERLYING DISEASE!

DEFINISI

• Nyeri kepala mencakup sakit dan nyeriyang berlokasi di kepala

• Aplikasi praktis : rasa tidak nyaman di regio kubah kranii.

• Nyeri fasial, lingual dan pharyngeal tidaktermasuk nyeri kepala.

(Adams & Victor)

EPIDEMIOLOGI (1)

• Nyeri kepala sebagai satu problem pada satuwaktu dalam hidup : pada 40% populasi di Eropa.

• Migren : 12-16% populasi umum.

Perempuan : laki-laki = 3 : 1

• Nyeri kepala tipe tegang :

- > 80% populasi

- 10% berulang secara frequent

- 2-3% kronik

EPIDEMIOLOGI (2)

• Nyeri Kepala Klaster :

- 3 dalam 1000 laki-laki

- 1 dalam 2000 perempuan

• Medication overuse headache :

- 3% pada orang dewasa.

- perempuan : laki-laki = 5 : 1

- 1% pada anak dan remaja

Nyeri Kepala Primer

1. Migrain

2. Nyeri Kepala Tension-type

3. Nyeri Kepala Cluster dan CephalgiaAutonomic Trigeminal Lain.

4. Nyeri Kepala Primer Lain.

Migraine in Women

Migraine 2-3x more common than in men Possibly some hormonal association

14% of women experience migraine associated with haid periods Usually during first 3 days

Risk of migraine increased 10x in women on OCP OCP increase frequency of migraines Attacks occur during placebo week rather than

during active weeks Almost half women experience improvement in

migraine during pregnancy. Migraine frequency decreases in 2/3 women after

menopause

Migraine in childhood

Prevalence 5%

Sex ratio 1:1

Abdominal symptoms often predominant

Semiology of attacks as in adulthood except shorter duration of attacks

Short sleep very effective

Migraine Triggers

Stress Emotion-(anger, anticipation,

anxiety, depression, emotional letdown, exhilaration/excitement, frustration, stress)

Sex Glare-flickering lights/light glare Hypoglycemia Altered Sleep Pattern-

fatigue/sleep deprivation or excessive sleep

Menses Physical exertion Alcohol Smoking/second hand tobacco

smoke Excess caffeine /withdrawal Odours (perfume, exhaust fumes,

paint, solvents)

Foods containing MSG tyramine nitrates phenylethylamine Aspartame chocolate

Drugs Estrogen (eg. OCP) Nitroglycerin Excess analgesic use or

withdrawal (cocaine, cimetidine,

oestrogens, theophylline)

NYERI KEPALA PRIMERMIGREN

TEORI VASKULER

PATOFISIOLOGIMIGREN

KLASIFIKASI MIGREN(IHS 2004)

I. Migren Tanpa Aura

II. Migren Dengan Aura

Migraine Tanpa AuraDeskripsi :

Gangguan nyeri kepala rekuren yang

bermanifestasi dalam serangan-serangan yang

berlangsung 4-72 jam. Karakteristik khas dari

nyeri kepala adalah lokasi unilateral, kualitas

pulsating, intensitas moderat atau

berat,agravasi oleh aktivitas fisik rutin dan

berasosiasi dengan nausea dan/atau

photophobia dan phonophobia.

Migraine Tanpa Aura

Kriteria Diagnostik

A. Setidak-tidaknya 5 serangan yang memenuhi kriteria B-D

B. Serangan Nyeri Kepala Berlangsung 4-72 jam (tak diobati atau diobati tak sukses)

C. Nyeri Kepala mempunyai setidak-tidaknya 2 dari :

1. Lokasi : unilateral

2. Kualitas : pulsating

3. Intensitas Nyeri : Moderat atau Berat

4. Agravasi oleh atau menyebabkan menghindari

aktivitas fisik rutin (misal : berjalan atau mendaki

tangga).

MIGREN DGN AURAGAMBARAN KLINIS

4 Stages of

Migraine

1. Prodrome

2. Aura

3. Headache

4. Postdrome

Migraine Phases

Headache

III

Headache

Blau (1992)

I II

Normal Prodromes Aura

Normal

Appetite

Awake/sleep

Light tolerance

Smell

Noise

Fluid balance

Tired

IV

Postdrome Normal

Light tolerance

Noise

Smell

Fluid balance

Feeling

high or

low

Diuresis

Appetite

Awake/sleep

food tolerance

Normal

Resolution

ACUTE MIGRAINE MEDICATIONS

Nonspecific

NSAIDs

Combination analgesics

Opioids

Neuroleptics/anti-emetics

Corticosteroids

Misc. (divalprolex=sodium valproate and valproic acid in a 1:1), magnesium, lidocaine, propofol)

Specific

Triptans

Ergotamine/DHE

Strategy of acute treatment of migraine attacks

Step care accross or within attacks

1: NSAID

2:triptan

3: ergot

Stratified care

do not go through all the steps, but drug can be chosen depending on the severity of the attack

ACUTE THERAPIES FOR MIGRAINE

Nonspecific Prescription Medications Butorphanol IN (opioid analgesic Ibuprofen/Naproxen sodium Prochlorperazine IV

(phenothiazine class of antipsychotic)

Substantial empirical evidence and pronounced clinical benefit in migraine

Silberstein SD. Neurology. 2000.

Migraine-Specific Medications Triptans DHE

• SC, IM, IN, IV (plus antiemetic)

Ergots

• 1868: use of ergot in the treatment of one-sided headache

• Ergot: potent neurotoxin & vasoconstrictor found in a fungus that grows on rye

• 1925: identified active chemical of ergot (ergotamine)

• 1940’s: ergotamine tartrate became the preferred

treatment for acute migraine

Ergotamine

• Structurally similar to amines,

serotonin, norepinephrine, and

dopamine

• interact with multiple receptors

in these systems

• cause constriction of the blood

vessels

• wide-range of effects

• Problems: avoid if patient has coronary disease; safety margin is small; overdose

5-

hydroxytriptami

ne receptors

• natural 5-HT neurotransmitter called serotonin

• serotonin is involved in migraine

• anti-migraine drugs mimic the action of serotonin

1980’s… discovery of Receptors

• 2 subtypes of serotonin receptors1. 5-HT1B2. 5-HT1D

• Located in brain blood vessels – responsible for constriction

• Calcitonin gene-related peptide (CGRP) blocked

• CGRP - dilation of blood vessels and inflammatory changes in membrane around brain

Triptans

• serotonin identified as a key player in the generation of a migraine attack

• early 1980’s: attempts to synthesize a more selective serotonin agonist

• “migraine medicines of today”

Sumatripta

n

• Acts on receptors at smooth muscle cells of brain vessels (also in peripheral blood vessels like coronary artery = side effects)

• The first selective serotonin agonist approved for the treatment of migraine

• Rapid relief

• Triptans are an advance over ergots

Sumatripta

n

• Relieves pain of migraine and associated symptoms

• 3 dosage forms: oral, nasal, & parenteral

Sumatriptan

Side-effects

• Side effects:– Change in taste– Discomfort in the jaw or mouth– Dizziness– Drowsiness– Lightheadedness– muscle aches– nausea or vomiting

• Rare side effects:– Severe chest pain– Convulsions– Swelling of the eyelids– Shortness of breath and trouble breathing

Zolmitripta

n

• Oral bioavailability improved to ~50% (sumatriptan 14%)

• half-life of 3 hours

• take orally at the onset of headache pain

Zolmitriptan

Side-effects

• Side effects:– Dizziness– Nausea– Sleepiness– Muscle weakness– Chest pain

• Rare side effects:– Severe abdominal pain– Irregular heartbeat– Fever or chills– Loss of appetite– Agitation– Anxiety– Depression

• may cause serious side effects in some people, especially those with a heart or blood vessel disease

Naratriptan

• Oral bioavailability improved to ~60%

• half-life of 5-6 hours

• take orally at the onset of headache pain

Naratriptan

Side-effects

• not as effective as sumatriptan, but has fewer side effects

• Side effects:– Dizziness– Nausea– Sleepiness– Muscle weakness– Chest pain

• Rare side effects:– Acne or skin rash– Anxiety– Blurred vision– Tiredness– Irregular heartbeat

Rizatripta

n

• Oral bioavailability ~40%

• half-life of 2.5 hours

• shows the fastest time of onset!

Rizatripta

n Side-

effects• Side effects:– Dizziness– Nausea– Tiredness– Hot flashes– Chest pain– Shortness of breath

• Rare side effects:– Agitation– Anxiety– Blurred vision– Chills– Confusion– Insomnia– Irregular heartbeat

Nonspecific

Drugs

• NSAIDs

• Beta blockers

• Antidepressants

• Calcium channel blockers

SUMATRIPTAN

• Medikasi paling efektif terhadap serangan migren.

• Dosis : tablet 100mg pada saat onset atau sesudah nyeri kepala menetap.

• Merupakan spesific 5-HT, like agonist yang berikatan dengan reseptor 5-HT

• Mereplikasi efek-efeknya yang menguntungkan dari 5-HT (5 Hydroxy tryptamine) pada perbaikan nyeri kepala migren tanpa efek samping yang berat.

• Bekerja dengan cara : konstriksi pembuluh darah kranial dan mencegah pelepasan peptida-peptida dari terminal-terminal saraf trigeminal memutuskan rangkaian interaksi neurovaskuler.

Nyeri Kepala Tipe Tegang(Tension Type Headache)

Patofisiologi

FaktorPsikologis

Faktor Vaskuler

FaktorHumoral

KontraksiOtot

FaktorSentral

NKTT

NYERI KEPALATIPE TEGANG

NYERI KEPALA TIPE TEGANGCirculus Viciousus : Kontraksi Otot – Iskemia Otot – Nyeri - Stress

Stress EmosionalKetegangan

Depresi

Kontraksi otot ↑terus menerus

Tekanan intraMuskuler ↑

Kompresi Pembuluh

Darah Kecil

IskemiaOtot

Nyeri LokalOtot

Akumulasi MetabolitKatabolit

NYERI KEPALA TIPE TEGANG

Iskemia Otot dan Trigger Point Syndrome

Iskemia Otot

Hipoksia Otot

Nodule Fibrotik Trigger Point Otot

(Trigger Area)

Nyeri Rujukan

Tenderness Rujukan

NYERI KEPALA TIPE TEGANGMIOFASIAL TRIGGER POINT SYNDROME

TRIGGER AREA DI OTOT-OTOTI Trapezius

SternokleidomastoideusSplenius Kapitis

II OksipitalisTemporalisMasseterPterigoideus Internus

Nyeri KepalaNyeri Wajah

NYERI KEPALA TIPE TEGANGMIOFASIAL TRIGGER POINT SYNDROME

NYERI KEPALA TIPE TEGANG

FAKTOR KAUSATIF (IHS 1988)

1. Disfungsi Oromandibuler

2. Stress Psikososial

3. Anxietas

4. Depresi

5. Nyeri KepalaSebagai Waham

6. Stress Otot

7. Overuse Obat

8. Lesi-lesi Struktural

9. Idiopatik

NYERI KEPALA TIPE TEGANG EPISODIK

DESKRIPSI

Episodik nyeri kepala infrequent yang berlangsung

bermenit-menit sampai berhari-hari. Nyerinya

secara khas bilateral, menekan atau kencang dalm

kualitasnya dan ringan sampai moderat

intensitasnya, dan tidak memburuk dengan

aktivitas fisik rutin. Tidak ada nausea namun

photophobia atau phonophobia bisa ada.

NYERI KEPALA TIPE TEGANG EPISODIK

KRITERIA DIAGNOSTIK

A. Setidak-tidaknya 10 episode yang terjadi pada < 1 hari perbulan dalam rata-rata (

NYERI KEPALA TIPE TEGANG EPISODIK

3. Intensitas : ringan atau moderat4. Tidak diagravasi oleh aktivitas fisik

rutin misalnya berjalan atau menaiki tangga.

D. Kedua-duanya dari yang berikut :1. Tidak ada nausea atau vomitus

(anoreksia bisa terjadi)2. Tidak lebih dari satu : photophobia atau

phonophobiaE. Tidak dianggap berasal dari gangguan lain

PERBEDAAN NYERI KEPALA MIGREN DAN NYERI KEPALA TIPE TEGANG

Nyeri Kepala Migren Nyeri Kepala Tipe Tegang

Durasi 4-72 jam 30 menit – 7 hari

Lokasi Unilateral Bilateral

Kualitas Berdenyut Tak berdenyut, tegang, kencang

Intensitas Berat Ringan

Mual + -

Muntah + -

DIAGNOSIS NYERI KEPALAPOLA TEMPORAL NYERI KEPALA

DIAGNOSIS NYERI KEPALAPOLA KRONOLOGIK NYERI KEPALA