Dr. Khairul P. Surbakti, Sp.

S
Departemen Neurologi
FK USU/RSUP H. Adam Malik Medan
1

Head pain = Headache

Definition
a pain or dyscomfort that occurs over the
superior aspect of the head and
occasionally spread to the face,teeth,
jaws, and neck.
Pain sensitive structures :

- Venous sinuses and their cortical

tributaries
- The larges arteries of the base of the brain
2

- the dural lining of the floor of the anterior of posterior fossae

- The 5th, 9th, and 10th cranial nerves
- The first three cervical nerves
These structures contain pain sensitive
nerve
endings that may be stimulated by traction,
imflamation, pressure, neoplastic infiltration,
biochemical substances.
3

 Patient have normal neurologic & physical

examination History is the most important tool

for making a correct diagnosis
If suspicious features are present diagnostic

testing may be necessary

Once secondary headache are excluded

then diagnose one ( or more than one ) specific

primary headache disorder
Headache alarms that suggest the possibilty of

headache disorder

DIAGNOSTICS ALARMS IN THE EVALUATION OF HEADACHE

DISORDERS

Headache alarm

Differential
diagnosis

Possible work-up

Headache begins after

age 50

Temporal arteritis,mass
lesion

ESR,Neuroimaging

Sudden-onset headache

SAH,AVM,mass lesion

Neuroimaging,LP

Accelerating pattern of
headache

Mass
lesion,SDH,Medication
overuse

Neuroimaging,drug
screen

New-onset headache in a
patient with cancer or HIV

Meningitis,brain
abscess,metastasis

Neuroimaging,LP

Headache with systemic

illness ( fever,stiff
neck,rash)

Meningitis,encephalitis,sy
stemic
infection,collagen,vascula
r disease

Neuroimaging,LP,blood
tests

Focal neurologic
symptoms or signs of
diseases (other than
typical aura)

Mass
lesion,AVM,stroke,collage
n,vascular diseases

Neuroimaging,collagen
vascular evaluation

Papilledema

Mass
lesion,pseudotumor,meni
ngitis

Neuroimaging,LP
5

Diffrential Diagnosis of Selected Headache

Disorder
Headache type
Age at onset
Loc.
Duration Severity Quality . Associated( years )

Features

Migraine 10-40
Hemicra hours
nia
to 3 days
severe
phobia

Moderate ThrobNausea,vomit
bing
Photo/phono

Tension type
20-50
Bilateral 30 to 7
days moderate Bandlike none
Cluster 15-40
peri/retro
orbital

Mild to

Unilateral 30-120 Excrucia- Boring,

ting
piercing lacri, nsl cong,
rhino, miosis

Mass lesion
Any
rigidity,neurolo
gic deficits

Variable

Presslike Generally
Ipsilat conj inj,

Intermittn Moderate Dull

Vomit,nuchal

Sub arachnoid
Hemorrhage
neuro deficit

Adult
Global, oc Variable
cipitonuchal
ting

Trigeminal
neuralgia
1st of N.V

50-70
More 2nd Seconds Excrucia- Electric Facial trigger
3rd div.than
ting
shock
point, spasm of
like
facial muscles

Giant cell
>55
arteritis any region
rheumatica

Excrucia- Explosi- Nausea,vomit,

ve
nuch rigid, LOC,

Temporal, Intermit, Variable

continu- arteries, poly

Variable
ous

Tender scalp
myalgia

 Headache is usually a minor symptoms

in metabolic disorder:
- Hyponatremia
- Hypernatremia
- Acid base abnormalities
- Liver and kidney failure

As cerebral cortical function deteriotate

head
ache is no longer a complain

 Causes for concern

1. A new onset headache in a patient over

the
age of 50
2. A sudden onset headache
3. A headache that is subacute in onset and
gets progressively worse over days or
weeks
4. Headache associated with fever, nausea,
vomiting that can not be explored by a
systemic illness
8

5. Headache associated with focal

neurologic
symptoms :
- papilledema
- change in conscious & cognition
- a stiff neck
6. No obvious identifieable headache
etiology
7. New onset headache in a patient with
cancer or HIV
9

IHS 2004 Classification

I. The Primary Headache

1. Migraine
2. Tension Type headache
3. Cluster Headache and other trigeminal
autonomic cephalgias
4. Other Primary Headaches
II. The secondary Headaches
5. Headache attributed to head or/and
neck
trauma
10

6. Headache attributed
vascular disorder
7. Headache attributed
intrcranial disorder
8. Headache attributed
its
withdrawal
9. Headache attributed

to cranial or cevical
to non vascular
to a substance or
to infections

11

10. Headache attributed to homeostasis

11. Headache or facial pain attributed to
cranium, neck, eyes, ears nose, sinuses
teeth, mouth or other facial or cranial
structures
12. Headache attributed to psychiatric
disorder

12

III. Cranial neuralgias, central and

primary facial
pain and other headache
13. Cranial neuralgias and central
causes of
pain
14. Other headache, cranial
neuralgia
central or
primary facial pain
13

IHS 2004 Criteria for

Migraine without aura
Headache description
(Any 2)

Associated symptoms
(Any 1)

Unilateral
Pulsatile quality
Moderate to severe

Nausea and or vomiting

Photophobia

intensity
Aggravated by routine
physical activity

Must have had no previous headache episodes and no

evidence of secondary headache
14

IHS 2004 Criteria for

Type Headache

Tension

Headache description
(Any 2)

Associated symptoms
(Any 1)

Unilateral
Pulsatile quality
Moderate to severe

Nausea and or vomiting

Photophobia

intensity
Aggravated by routine
physical activity
Must have had no previous headache episodes and no
evidence of secondary headache

15

IHS 2004 Criteria for Cluster

headache
Headache description
( All 4 )

Autonomic Symptoms
( Any 2 )

. Severe headache
. Unilateral
. Duration of 15 180 min
. Orbital, periorbital or
temporal location

.
.
.
.
.
.
.

Rhinorrhoea
Lacrimation
Facial sweating
Miosis
Eyelid edema
Conjuctival injection
Ptosis

No evidence of secondary headache disorder

16

History
The following areas of historical
information should be explored:
1.Chronicity
2.Age at onset
3.Duration and frequency of pain
4.Onset to peak time
5.Location
6.Character and severity of pain
7.Premonitory symptoms and aura
17

 Aura : painless headache focal neurologic

symptoms
- Visual : (+) flickering light, spots
or
lines
(-) loss of vision
Sensory : (+) pins & needles
(-) numbness
Speech : dysphasic disorder
18

8. Associated symptoms
9. Precipitating factors
10. Environmental factors
11. Family history
12. Pregnancy and menstruation
13. Medical/surgical history
14. Past Treatments
15. Previous diagnostic tests
19

Physical Examination

1.General Appearance
2.Examination of the head
3.Cervical spine
4.Cranial nerve evaluation
5.Sensory examination
6.Motor Examination
7.Reflexes
20

Laboratory Testing
Laboratory testing is generally
ordered to rule out unsuspected
systemic illness in which headache
or facial pain may be featured :
Anemia
Infection
Diabetes
21

Radiographic Testing
Plain skull radiograph can provide

limited, but useful to evaluate the

patient suffering from headache and
facial pain
Computed Tomography
CT Scan can rapidly identify a wide
variety of life threatening conditions

22

Magnetic Resonance Imaging

Indications for MRI in headache and

facial pain is closely parallel the

indication for CT scanning
The test of choice when evaluating

cervicogenic headache

23

 Lumbar Puncture :

- Infectious causes
- Subarachnoid hemorrhage
LP should not be performed in the

presence
of increased ICP evidenced by
papilledema on funduscopic examination
or finding on CT or MRI scanning
24

 Angiography :

aneurysms
angiomas
AVM
Vascular tumors responsible

for
their headache and facial
pain
25

TREATMENT
I. Migraine
1. Avoid precipitating/triggering factors
Identify these by keeping a diary if
necessary
2. Treatment of acute migraine attack
A. Ancillary measures
. Rest in a quiet dark room
. IVFD if severely dehydrated
B. Non soecific analgesics and antiemetic
26

C. Specific antimigraine agents

. Ergot alkaloids
- Ergotamine 1 mg
- Dihydroergotamine
mesylate 1-2
mg
. Triptans

27

Analgesics with evidence of efficacy

Subtabce

Dose, mg

Level of
recommendati
on

Comment

ASA

1000 (oral)

GIT side effects

ASA

1000 (i.v)

Risk of bleeding

Ibuprofen

200-800

Side effect as ASA

Naproxen

500-1000

Side effect as ASA

Diclofenac

50-100

Including diclof-K

Paracetamol

1000 (0ral)

Caution in Liver &

Kidney failure

10009 (supp.)

ASA plus

250 (oral)

AS for ASA & Mol

Mol plus
Caffein

200-250
50

Metamizol

1000 (oral)

Risk of
agranulocytosis

1000 (i.v)

Risk of hypotension

Phenazon

1000 (oral)

See Paracetamol

Tolfenamic acid

200 (oral)

Side effect as for

28
ASA

Triptans
Substance

Dose, mg

Level Comment

Sumatriptan

25, 50, 100

(oral)
25
(suppository)
10,20 (nasal
spray)
6 ( s.c )

Zolmitriptan

2.5, 5 (oral
including
desintegrating
form)
2.5, 5 (Nasal
spray)

Naratriptan

2.5 (oral)

Rizatriptan

10 (oral)

Almotriptan

12.5 (oral)

100 mg sumatriptan is
reference to all triptans

Less but longer efficacy

than sumatriptan
Probably less side
effects than sumatriptan

29

Antiemetics recommended for the acute

treatment of migraine attack
Substances

Dose, mg

Level

Comment

Metoclopramid
e

10-20 (oral)
20
(suppository)
10 (i.m; i.v,
sc )

Side effect:
dyskinesia,
contraindicate
d in childhood
and in
pregnancy;
also analgesic
efficacy

Domperidon

20-30 (oral)

Side effects
less severe
than in
metoclopramid
e; can be given
to children

30

Recommended substances (drug of first

choice) for prophylactic drug treatment
of migraine
Subtances
Betablockers
Metoprolol
Propanolol
Calcium Channel
blockers
Flunarizine
Antiepileptic drugs
Valproic acid
Topiramate

Daily dose (mg)

Level of
recommendation

50-200
40-240

A
A
A

5-10
500-1800
25-100

A
A

31

Drugs of second choice for migraine

prophylaxis
Substances

Daily dose (mg)

Level of
recommendation

Amitriptyline

50-150

Venlafaxine

75-150

Naproxene

2 x 250-500

Bisoprolol

5-10

32

Drugs of third choice for migraine

prophylaxis
Substances

Daily dose

Level of
recommendation

ASA

300 mg

Gabapentin

1200-1600 mg

Magnesium

24 mmol

Riboflavin

400 mg

Coenzyme Q10

300 mg

Candesartan

16 mg

Lisinopril

20 mg

Methysergide

4-12 mg

33

II. Tension Type Headache

1. Pharmacological therapy
1. Analgesics :
- ASA 1000 mg/day
- acetaminophen 1000 mg/day
- Naproxen 660 ; 750 mg/day
- Ketoprofen 25-50 mg/day
- Ibuprofen 80 mg/day
- Diclofenac 50- 100 mg/day
2. Caffein 65 mg
3. Combination : acetaminophen + Caffeine 40
mg

34

4. Antidepressant
- Amitiptyline 10- 150 mg
- Antianxiety : Benzodiazepine
1. Dietary control
2. Avoid of precipitating factors
3. Avoid of consuming daily analgesics, sedative and
ergotamine
4. Behavioral Therapy : Stress management therapy,
Conseling, Relaxation therapy, cognitive
behavioral
therapy

35

Physical therapy : Massage, Ultrasound,

manual therapy,
Hot Pack, Traction, TENS
(Transcutaneous
electrical
stimulation)
Psychological Therapy : Behavioral cognitive
tharapy

36

III. Cluster Headache

1. Abortive Treatment (Acute attack)

- 100% Oxygen inhalation (facial mask) 7 L/min for

15
minutes ,
- DHE 0.5 1.5 mg I.V
- Sumatriptan ijnection (s.c) 6 mg
- Zolmitriptan 5 mg or 100 mg ( oral )
- Indomethacin ( Rectal suppositoria)
- Opioids
- Gabapentin or Topiramate
- Ergotamine aerosol 0.36 1.08 mg ( 1 3 inhalation
)
effectively proven in 80 % cases.

37

38