HEADACHE

Dr. dr. Khairul Putra Surbakti, SpS(K)

Consultant neurologist
Head, Department of Neurology
Universitas Sumatera Utara
Medan, 2022
 Headache =Sefalgia
= Nyeri kepala

Definition:
pain / unpleasant sensation of the head as long as
chin until cervicooccipital
 epidemiology
prevalence “life time” of headache are 90%
male and 96% female

• Migraine
– 6 - 9% man, 15-18% woman.
– Young adult age
– Genetic factor 70%
 PREVALENCE MIGRAINE

female male
 Epidemiology in Indonesia
(hospital base)
• Prevalence life time TTH 78%
• Episodic TTH 63% → male 56% ,female 71%
• TTH chronic 3% →male 2 % ,female 5%
–ETTH(Indonesia 31%, Medan 9.8%)
–CTTH (Indonesia 24%, Medan 44%)
• Migraine =10% (Indonesia)
–Without aura( Medan 6.3%)
–with aura (Medan 1.8%)
 Prevalence in Indonesia (2004)
outpatient clinic

1. Sefalgia 42 % 1. Migraine wthout aura 6-10%

2. Osteo arthritis 9.5% 2. Migraine with aura 1.8%
3. Stroke 7.7% 3. ETTH 31%
4. LBP + OA 7.3% 4. CTTH 24%
5. Cluster Headache 0.5%
5. Insomnia 4.0% 6. Mixed Hx 14%
6. Epilepsy 3.8% 7. Post trauma cap syndr 14%
7. Vertigo 3.6% 8. Secondary Headache 3%
8. Bell’s palsy 3.2% 9. Chronic Daily Headache 9%
10.Chronic Paroksismal Hemikrania
9. LBP+HNP 2.5% 1%
10. Neuropathy 2.3%
 Headache verbal Scale
• 0 = no headache
• 1 : mild headache, ADL normal
• 2 : moderate headache, ADL a mild disturbed
(no need take a rest)
• 3 : severe headache : ADL very disturbed
(need take a rest/ admitted to hospital).
 HEADACHE CLASSIFICATION
• PRIMARY HEADACHE
1. Migraine
2. Tension Type Headache
3. Trigeminal autonomic chephalalgias
4. Other primary headache disorders
 Secondary Headache

5. Headache attributed to trauma or injury to the head and/ or

neck
6. Headache attributed to cranial or cervical vascular disorder
7. Headache attributed to non-vascular intracranial disorder
8. Headache attributed to a substance or its withdrawl
9. Headache attributed to infection
10. Headache attributed to disorder of homeostasis
11. Headache or facial pain attributed to disorder of cranium,
neck, eyes ears, nose, sinuses, mouth, or other facial or cervical
structure
12. Headache attributed to psychiatric disorder
 Painful cranial neuropathies, other facial pains and
other headaches

• Painful lesion of the cranial nerves and other facial pain

• Other headache disorder

Appendix

Appendix
International Classification of Headache
Disorder (ICHD-3 beta version) 2013
ICHD-3 beta version Classification of MIGRAINE 2013

1.MIGRAINE WITHOUT AURA

2. MIGRAINE WITH AURA

3. CHIRONIC MIGRAINE

4. COMPLICATIONS OF MGRAINE

5. PROBABLE MiGRAINE

6. EPISODIC SYNDROMES THAT MAY BE ASSOCIATED WITH MIGRAINE

 Migraine without aura ( ICHD-3 BETA
VERSION 2013)
A. At least 5 attacks
B. Hx attacks lasting 4-72 hrs
C. Hx has ≥ 2 following characteristics:
A. Unilateral
B. Pulsating
C. Moderate or severe pain
D. Agravation by physical activity
D. During Hx ≥ 1 of the following
A. Nausea and/or vomiting
B. Phonophobia and photophobia
E. Not attributed to another disorder
Migraine Hx with Typical aura

1. Aura :visual,sensoris,speech,5’- 1 hr
2. At least 2 attack, 4- 72 hours
3. Unilateral
4. Throbbing
5. Moderate/severe intensity
6. Nausea/vomiting or/and
7. Phonopobia/photopobia
8. Without motor weakness
 Familial Hemiplegic Migraine
• Genetik, chromosome 1 & 19
• Headache fulfilling criteria migraine with
typical aura
• Aura hemiparese →60 mnts
• Cerebellar ataxia (20%)
• Onset suddenly
• 60% patients FHM have symptom of basilar
type
 Sporadic hemiplegic migraine
• criteria idem FHM
• No family history
• Normal CT Scan & EEG
 Basilar type migraine
• Sign & symptoms of fossa posterior disorders
• Disartria,
• Vertigo
• Tinnitus, deafness
• Diplopia
• Ataxia
• Bilateral parestesia
• unconciousness
• Headache fulfilling criteria migraine without aura
 Retinal migraine
• Rare
• At least 2 attacks scintillating, scotoma,
blindness
• Unilateral (only one eye)
• Follows with migraine with aura
• No attributed to another disorders
1.3. Chronic migraine
» Migraine without aura
» > 15 days
» > 3 months
» No attributed to another disorders
» without Medication over used
 1.4 Complications of migraine
– 1.4.1 Status migrainosus
» Severe headache migraine > 72 jam
» No attributed to another disorders
– 1.4.2 Persistent aura without infarction
– 1.4.3 Migrainous infarction
– 1.4.4 Migraine-triggered seizures
1.6 Episodic syndromes that may be associated
with migraine
– 1.6.1.1 Cyclical vomiting
» 2.5% schoolchildren
» Recurrent unexplained nausea & vomiting→ 4x /hours → 5
days
» No sign of gastrointestinal disease
– 1.6.1.2 Abdominal migraine
» 12% of schoolchildren
» Abdominal pain, anorexia, nausea, vomiting
– 1.6.2 Benign paroxysmal vertigo
» At least 5 attacks severe vertigo
» Resolve within few minutes-hour
» no neurological deficit
» Normal vestibular function
» EEG normal
The triggers or precipitants of the acute migraine attack.
1207 pts migraine of whom 75.9% reported triggers.

• Stress (79.7%), • light(s)(38.1%),

• hormones in women • alcohol (37.8%),
(65.1%), • smoke (35.7%),
• not eating (57.3%), • sleeping late (32.0%),
• weather (53.2%), • heat (30.3%),
• sleep disturbance • food(26.9%),
(49.8%), • exercise (22.1%)
• perfume or odour • sexual activity
(43.7%), (5.2%).
• neck pain (38.4%),

Kelman L. Cephalalgia 2007; 27:394–402.

 Food as Trigger factor of migraine
• MAYOR • MINOR
• MSG • nuts
• wine /vodka/bier • Fried foods
• Cheese • Popcorn
• Chocolate • Chile peppers
• Yogurt/yeast • Seafoods
• citrus fruits • Pork / livers
• Buttermilk, milk • Salty food/sweety
2.Tension-type headache
 2.2 Frequent episodic tension-type
headache
• At least 10 attacks/episodes occuring on 1- <
15 days/month, (180 d/year) for > 3 months
• Headaches lasting from 30 minutes – 7days
 2.3 Chronic tension-type headache
– 2.3.1 Chronic tension-type headache Associated with
pericranial tenderness
– 2.3.2 Chronic tension-type headache Not associated
with pericranial tenderness
• 2.4 Probable tension-type headache
– 2.4.1 Probable infrequent episodic tension-type
headache
– 2.4.2. Probable frequent episodic tension-type
headache
– 2.4.3.Probable chronic tension-type headache
3. Cluster headache and other trigeminal-
autonomic cephalalgias
Therapy acute migraine
• Abortif non specific:
• Aspirin 500-1000 mg
• Aspirin 900 mg+metoclopramide 10 mg
• Naproxen sod 750-1250 mg
• Ibuprofen 400-2400 mg
• Paracetamol 500 mg+aspirin 500 mg+ caffein 130 mg
• Abortif specific:
– Triptan,
– dihydroergotamine,
– ergotamine

41
 summary for treatment of acute attacks
of migraine
• Triptans (serotonin1B/1D receptor agonists)
• Sumatriptan
• nasal spray evidence A 5-10 mg nasal spray
• Sumatriptan SC A 6 mg SC
• Oral triptans
• Naratriptan A 1-2.5 mg po
• Rizatriptan A 10 mg po
• Sumatriptan A 50mg po
• Zolmitriptan A 2.5-5 mg po
• DHE nasal spray A 0.5 nasal spray
• Antiemetic : Prochlorperazine B , Metoclopramide B
 Preventive treatment migraine

• Propranolol 40–320 mg twice daily

• Timolol 20-60 mg daily
• Pizotifen 0.5 mg – 1.5 mg/daily
• Flunarizine 5 – 10 mg/daily
• Amitriptyline 25–150 mg at bedtime
• Divalproate 400–1500 mg twice daily
• Topiramate 25–200 mg daily
 Indication for Prophylaxis Migraine
US Headache Consortium Guidelines, Bigal, 2006, Loder, 2005

1. Migraine duration is greater than 48 hours

2. Acute medications are ineffective/failure,
contraindicated, have side effect of drug or likely to be
overused medications
3. Attacks produce profound disability (occurs > 2 days
per month) prolonged aura, or true migrainous
infarction
4. Attacks occur > 2 more times per week, even with
adequate acute care treatment with the risk of
developing rebound headache
5. Patient preference for preventive therapy 45
Therapy TTH :pharmacological
• Analgetic :→ 2 days/week (Avoiding medication
overuse )
• Aspirin 1000 mg/day, parasetamol 1000 mg/day, NSAIDs,
NSAIDs and acetaminophen (with or without caffeine), butalbital

• Antidepressant:
• Sedating : amitriptilin, doxepin, imipramin, trazodone
• Non sedating: fluoxetine, sertraline, bupropion
• Antianxiety:
• benzodiazepin,: buspiron, lorazepam, alprazolam, diazepam
 Therapy TTH : non pharmacology
• Avoid the triggers
• Avoid daily usage of analgetic, sedative
• Physical Therapy :
• Masage, manual therapy, compress, traction, acupuncture,
transcutaneous electrical nerve stimulation (TENS), anaestesi
injection at trigger point, improved sleep positioning with
orthopedic pillows
• Therapy behaviour:
• Biofeedback, stress management therapy, conseling,
relaxation therapy, cognitive behaviour th/
 EFNS guidelines on the treatment of cluster headache and other
trigeminal-autonomic cephalalgias.

Therapy Cluster Headache Paroxysmal SUNCT

Hemicrania Syndrome
Acute 100% oxygen, 15 l/min (A) None None
Sumatriptan 6 mg, subcutaneous
(A)
Sumatriptan 20 mg nasal (A)
Zolmitriptan 5 mg nasal (A/B)
Zolmitriptan 10 mg nasal (A/B)

Preventive Verapamil (A) Indomethacin (A)

Steroids (A)

(A denotes effective, B denotes probably effective May, et al.2006

Lenaerts, 2008 48
 Cranial arteritis

= Temporal arteritis
= Giant cell arteritis (GCA)
• Is a systemic inflammatory vasculitis of
unknown etiology that occurs in older persons
and can result in a wide variety of systemic
neurologic and ophthalmilogic complication
• Is the common form of systemic vasculitis in adults

• Is classified as a large-vessel vasculitis but typically also

involves medium and small arteries, particularly the
superficial temporal arteries

• Most commonly affect the ophthalmic, occipital, , vertebral,

posterior ciliary and proximal vertebral arteries
• Histologically:
is marked by trans mural inflammation of the intima,
media and adventitia of affected arteries as well as
patchy inflammation by lymphocytes

• Etiology:
- The exact etiology is remain unclear
- Genetic, environment and autoimmune factors
have been identified
• A close relationship exist between GCA and
polymyalgia rheumatica
• About 50 % of patient with GCA have underlying
polymyalgia rheumatica
• 15% of individual with polymyalgia rheumatica
develop GCA
• The precise nature of the association is poorly
understood
 Clinical Presentation

• The most commonly reported symptoms

- headache and scalp tenderness
- neck, shoulder and pelvic girdle pain
- Fatique and malaise
-Fever
-Vision loss
- jaw pain
 Diagnosis and blood test

• Physical examination
• Blood test : - Erythrocyte sedimentation rate
- CRP
• Biopsy
• MRI
• PET scan
Red Flags for Secondary Headache
• Systemic symptoms including fever
• Neoplasm history
• Neurologic deficit (including derceased
consciousness)
• Sudden or abrupt onset
• Older age (after 65 years)
• Pattern change or recent onset of new
headache)
 Red Flags for Secondary Headache

• Positional headache
• Precipitate by sneezing, coughing or exercise
• Papiledema
• Progressive headache and atypical
presentations
• Pregnancy or puerperium
 Red Flags for Secondary Headache

• Painful eye with autonomic features

• Post traumatic onset of headache
• Pathology of the immune system such as HIV
• Painkillers overuse and new drug at onset of
headache