primary headache kuliah fk uwks
TRANSCRIPT
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Sakit Kepala
dr. Teddy wijatmiko Sp.SFK UWKS lecture
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Headache/ Nyeri Kepala
18,9% kunjungan ke RSDS17,4% kunjungan ke RSCM42% kunjungan praktek sore Sp.S90% merupakan primary headache
NYERI
Pengalaman sensorik & emosional yg tidakmenyenangkan terkait kerusakan jaringan,baik aktual maupun potensial atau yangdigambarkan 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%
HEADACHE/ Nyeri Kepala
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 Kraniala. sinus, vein besar & aferennyab. artery dura materc. artery basis cranium d. duramater
II. STRUCTURE ekstra kranial a. skin, skin head, jar. Sub.kutan, fasia, muscle
head/neck. b. mukosa c. artery-artery d. Structure from eye, ear & nose
III. Nervous: V, VII, IX, X, C1 C2 C3
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1. Parenkim brain2. Ependyma, pleksus choroid3. Piamater, membrana arachnoidea & duramater4. Bone skull
STRUCTURE NOT SENSITIVE PAIN
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A. intracranial:1. Iritasi meningen
Ex: Meningitis Perdarahan Sub Arachnoid (SAH)
2. Penarikan or peregangan arteri intracranial:
Tumor Absces Hematoma intracranial
TIK : hidrosefalus, BIH TIK : post Lumbal Headache
PATOFISIOLOGY Headache General :
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3. Vasodilatasi arteri intra kranial
Toksic caused infection “With drawl” caffein Hipoglikemia, Hipoksia,
Hiperkapnea drug vasodilator Post attack Epilepsi Insufiensi sirculation brain
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1. dilatasi cabang A. carotis externa Migren “Cluster headache”
2. inflammation artery ekstrakranial “Giant cell” arterytis 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
B. BERSUMBER ESKTRA KRANIAL
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PRACTICAL CLASSIFICATION HEADACHE
1.Headache Primer Tension headache Migrain Cluster headache
2. Headache Secunder
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ALGORTHM DIAGNOSIS HeadacheHeadache
PRIMERSecunder
TTH Migrain Cluster Headach
e
infection – Tanda2 infection(Color/Dolor/Robor)
Trauma
history
Trauma
Tumor-Trias-Headache chronic
progresif-vomit
proyektil-Papil edema
Vascular-acute-Defisit Neurologis fokal
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DIAGNOSIS AND TESTING
Detailed History and ExaminationDetailed History and Examination
Primary Headache?n Preliminary DiagnosisPrimary Headache?n Preliminary Diagnosis
NONO
SecondaryHeadacheSecondaryHeadache
DiagnosticTesting
DiagnosticTesting
AtypicalFeatures
YESYES
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RED FLAGS “SNOOP T”
Older: new onset and progressive headache, especially in middle-age >50
Systemic symptoms (fever, weight loss) or secondary 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)
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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 UNDERLYING DISEASE!
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HEADACHE QUALITY LOCATION DURATION FREQUENCYASSOCIATED SYMPTOMS
Common migraine
Throbbing Unilateral head / Ifteral head
6 – 48 hours Sporadic (often several times montlly)
Nausea, vomiting, malaise, photophobia
Classic migraine
Throbbing Unilateral head 3 – 12 hours Sporadic (often several times monthly)
Visual prodrome, vomiting, nausea, malaise, photobhobia
Cluster Boring, sharp
Unilateral head (especially orbit)
12 – 120 minutes
Closely bunched clusters with long remissions
Ipsilateral tearing, facial flushing, nasal stuffiness, Horners’s syndrome
Psychogenic/ Chronic TTH
Dull, pressure
Diffuse, Ifteral Frontal, temporal suboccipital
Oftem unremitting
May be constant Almost daily
Depression, anxiaty Pericranial tenderness
Trigeminal meuralgia
Lancinating Fifth nerve distribution
Brief (15-60 second)
Many times daily
Identifiable trigger zone
Tabel 1 . Important features of pain in the evaluation of chronic recurrent headaches
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PHYSICAL FINDING POSSIBLE ETIOLOGY
Optic atropy, papiledema Mass lesion, hydrocephalus, benign intracranial hypertensionon
Focal neurologic abnormality (hemiparese aphasia)
Mass lesion
Stiff neck Subarachnoid hemorrhage, meningitis, cervical arthritis
Retinal 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 Pericranial muscle
TTH/Muscle Contraction Headache
Tabel 2. Important physical findings ini the evaluation of 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 min–7 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<15 day/monthPeripheral pain mechanismTx NSAID, ParasetamolChronic≥ 15 day/month, ≥ 3 monthsCentral pain mechanismTx Amitriptilin
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Tension Type Headache TTH
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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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Drug evidence Clinical effect Role Route
Analgesic & NSAIDAsetaminofen A ++ Acute PO
Aspirin A ++
Mefenamic acid A ++
Ibuprofen A ++
Naproxen A ++
Ibuprofen+caffein A ++
AntidepresanAmitriptilin A +++ preventive PO
Maprotilin B +
Mianserin B ++
Sulpride C +
Fluvoxamine B ++
Muscle relaxantsTizanidine B ++ Acute&preventive PO
Eperisone B ++
OthersAlprazolam B ++ Acute&preventive PO
Etizolam C ++
prochloperazine C ? Acute IV
chlorpromazine C ?
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A Hierarchical Classification of Compounds Efficacy
-------- 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 4–72 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); Sakai
and Igarashi (1997)†Prevalence measured over a few years
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Prevalence of migraine by sex and age
FemalesMales30
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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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Migraine
A. The Aura
B. The Attack
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Penatalaksanan migrain
1. Hindari pencetus2. Terapi abortif Non spesifik Spesifik3. 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 spesifikObat 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
ErgotAngka rekurensi rendahMenginduksi drug overuse headache dg cepatMaksimal diberikan10 hari/bulanEfek samping : parestesi, muntahKontra indikasiPenyakit kardio, serebrovaskular, hipertensi,
gagal ginjal, kehamilan dan laktasi
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TRIPTAN
Efikasi lebih baik dibanding ergotSediaan obat di Indonesia sulit di dapat (hanya
ada sumatriptan)Efek samping : nyeri dada, parestesi, fatikKontra indikasi : Penyakit kardio, serebrovaskular,
hipertensi, gagal ginjal, kehamilan dan laktasi
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Terapi prevensi migrain
1. Serangan >2-8 kali/bln2. Berlangsung >48 jam3. Pengobatan akut tdk efektif4. Ada kontra indikasi terapi abortif, efek
samping, atau cenderung overuse5. Gejala luar biasa ( migrain basiler, hemiplegi,
aura memanjang)6. Permintaan pasien
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Terapi prevensi migrainKonsensus Nasional III Nyeri Kepala PERDOSSI 2010
Obat Dosis mg/hari evidence
betablockermetoprolol 50-200 A
propanolol 40-240 A
Calcium channel blockerFlunarizine (Frego) 5-10 A
Anti epilepticValproic acid 500-1800 A
Topiramat 25-100 A
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Sefalgia sekunder
stroke• Wanita 75 th di bawa ke IRD
RS krn mendadak sakit kepala, hemiparese kiri
Trauma• Anak 15 th terkena pemukul
baseball di pelipis. Sesaat setelah terkena pukulan ia tidak sadar sebentar ± 15 mnt lalu bangun lagi. Ia mengeluh sakit kepala namun keadaannya saat itu baik saat dibawa ke IRD. Empat jam kemudian saat diobservasi ia mengeluhkan sakit kepalanya bertambah hebat dan kejang. Pupil sebelah kanan midriasis
Infeksi
• Pria 40 th , pengusaha mengeluh sakit kepala 2 bln, disertai demam sumer-sumer, sering diare dan sariawan .Ia mengkonsumsi narkoba berhenti sjk 1 th silam. Dibawa ke IRD oleh keluarganya krn bicara meracau.
Tumor
• Wanita 35 th, sakit kepala 8 bln bertambah hebat terutama saat bangun dan bersin, memakai kontrasepsi suntik 3 bulan
Degenerasi
• Wanita 79 th datang ke poli dengan keluhan sakit kepala hilang timbul ± 2 th.Sering lupa ± 3-4 th dan tidak mampu berbelanja lagi krn kesulitan melakukan perhitungan ringan. Sekarang sulit tidur dan sering terlihat seperti berbicara sendiri
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TERIMA KASIH
ATAS PERHATIANNYA