Primary Headache & Vertigo

Sucipto, MD

Nyeri

• Pengalaman sensorik dan emosional yang tidak menyenangkan karena kerusakan jaringan yang sebenarnya atau yang potensial atau yang dideskribsikan sebagai kerusakan/ proses kerusakan jaringan

Nyeri kepala

• Rasa nyeri atau tidak enak pada bagian atas kepala dari daerah orbita sampai daerah oksiput

90% of adults have at least one headache/year

90% are of primary type

2.8 million annual ED visits for headache

Bangunan peka nyeri intrakranial meliputi : • Duramater dasar tengkorak• Nervus kranialis V, IX, dan X• Bagian proksimal arteri karotis interna dan

cabangnya dekat sirkulus Willisi• Arteri meningea media dan anterior• Saraf spinal bagian atas• Inti sensorik talamus

Bangunan peka nyeri ekstrakranial : • Periosteum tulang tengkorak• Kulit, jaringan subkutan, otot• Otot leher• Saraf servikal 2 dan 3• Mata, telinga, gigi• Sinus• Orofaring• Membran mukosa hidung

Classification & Epidemiology

h Tension h Migraineh Cluster

78% 16%

0.1%

Primary Headache Lifetime Prevalence

h Feverh Metabolic disorderh Disorders of nose/sinusesh Head traumah Disorders of eyesh Vascular disorders

63%22%15%

4%3%1%

Secondary Headache

Migrain

Migren

• Adalah nyeri kepala paroksismal, biasanya unilateral, berdenyut, bersifat familial, serangan berakhir dalam waktu 4-72jam, interval bebas nyeri kurang dari 1 jam, disertai gejala mual/ muntah dan atau fotofbia/ fonofobia, yang dapat didahului aura

Aura vs Prodromal

AuraGejala neurologik fokal yg kompleks yg mendahului/ menyertai migrain

• Aura visualpositif: cahaya berbagai warnanegatif: skotomacampuranzigzag

• Aura sensorikparestesia hemisensorik

• Aura motorikhemiparesedisfagia/ kesulitan bicara

Prodromal• Hiperaktif/hipoaktif• depresi• Mendambakan jenis makanan

tertentu• Gerakan mengunyah• Perasaan lemah lelah lesu• Kurang nafsu makan• Perasaan sensitif terhadap

sentuhan, suara, bau-bauan, cahaya

• Sering kencing

Visual aura

Migraine Without Aura

h Durationh 4-72 h if untreated or unsuccessfully treated

h Pain characteristics (at least 2)hUnilateral location (bilateral in 30-40%)h Pulsating qualityhModerate to severe intensityh Aggravation by walking stairs or similar physical activity

h Associated symptoms (at least 1)h Nausea, vomiting, or bothh Photophobia or phonophobia

International Headache Society Diagnostic Criteria

Aura characertistics (at least 3 )› One or more fully reversible aura symptoms indicating focal cerebral

cortical or brain-stem dysfunction› At least 1 aura symptom develops gradually over >4 minutes or 2 or

more symptoms occur in succession› No single aura symptom lasts > 60 minutes› Headache begins within 60 minutes of aura onset

Type of aura› Scotoma (blind spots)› Fortification (zig-zag patterns)› Scintilla (flashing lights)› Unilateral paresthesia/weakness› Hemianopsia

Migraine With AuraInternational Headache Society Diagnostic Criteria

Jenis-jenis• Dengan Aura tipikal

– Aura gradual <1jam– reversibel

• Dengan aura yang lama (prolonged aura)– Aura 1jam < x < 7 hari

• Familial hemiplegik• Basilar

– Aura batang otak/lobus oksipital

• Aura tanpa nyeri kepala• Serangan aura akut

– Aura < 5menit• Oftalmoplegik

– Gejala:kelumpuhan otot penggerak bola mata

• retinal – Mono okuler skotoma

atau buta < 1jam

• Sindrom periodik pada anak– Vertigo paroksismal benigna– Hemiplegik alternans

• Komplikasi migrain– Status migrenous

serangan >72jam, interval bebas nyeri <4jam

– Migren infarkaura >7hari atau ada infark di neuroimajing

• Jenis lain2• Campuran dg TTH

Migren varians• Eksersional• Menusuk idiopatik• Hemikrania paroksismal

kronis• Hemikrania paroksismal

episodik• Hemikrania kontinua

Terapi non farmakologis• Psikologi: reassurance, stress management• Fisiologi: latihan relaksasi, aerobik reguler• Edukasi tidur yang cukup• Hindari pencetus:

– Aktivitas fisik– Lingkungan– Emosi, stres, depresi, cemas– Kelaparan, hipoglikemia– Merokok– Tidur kurang/ berlebih– Hormon: menstruasi, hamil trisemester pertama, kontrasepsi oral– Makanan: keju, alkohol, kafein, coklat, gula yang pekat, makanan

berfermentasi (tapai), sayuran kacang, bawang, asinan, mengandung nitrit, nitrat, glutamat, sulfid

Terapi farmakologis

• Non Spesifik– NSAID: asetaminofen 500mg, 2-6 tab/hari, Naproksen

3x275mg atau 1-2 x 500mg, Diclofenac 3x50mg atau 1-2x 100mg, Asam Asetilsalisilat 500mg, 2-6 tab/hari

– Opioid: lemah kodein, kuat morfin– Antiemetik: domperidon, metoklopramide

• Spesifik– Triptan: sumatriptan (25mg,50mg,100mg dapat diulang

tiap 2jam max 200mg), zolmitriptan, naratriptan, rizatriptan– Ergotamine: ergotamin tartrat 1mg+kafein 100mg 2 tab

dapat diulang setelah 1jam max 6tab

Profilaksis

Indikasi• Intensitas sangat berat: menganggu aktivitas• Frekwensi > 2-3x/minggu• Hemiplegic migrain atau aura memanjang• Serangan > 48 jam

Profilaksis..(2)

• Beta bloker: propanolol, timolol, nadolol, metaprolol, atenolol

• Antidepresan trisiklik: protriptilin, desipramin, amitriptilin, doksepin, nortriptilin, imipramin

• Antagonis serotonin: Metisergid, Pizotifen• Antihistamin: siproheptadin• Antikonvulsan: asam valproat• Inhibitor MAOA• Antagonis kalsium: flunarizin, nifedipin, nimodipin,

verapamil, diltiazem

Migraine Pathophysiology

• Not clearly understood– Vascular Theory – Neurovascular Theory

• Vascular theory (Wolff et al in 1940s and 1950s) :Intracranial vasoconstriction (aura) rebound vasodilatation activation of perivascular nociceptive nerves (headache)

Neurovascular theory Cortical spreading depression (Leao,1944) causing aura

Neuronal excitation in the cortical gray matter waves that Spread at the rate of 2-6 mm/min followed by a wave of neuronal suppression blood vessels simultaneously dilate & constrict aura

Brainstem activationOnce the CSD occurs H+ & K+ ions diffuse to the piamater activate C-fiber meningeal nociceptors releases a proinflammatory soup (eg, CGRP) plasma extravasation (sterile neurogenic inflammation of the trigeminovascular complex trigeminal system activated stimulates the cranial vessels to dilate dilatation of blood vessels headache

Neurochemical basis of CSD : release of potassium or glutamate from neural tissue depolarizes the adjacent tissue releases more neurotransmitters propagating the spreading depression

Why these neurons are more excitable in certain patients is not entirely clear genetic defect ??? (in familial hemiplegic migraine)

Tension Type headache

Nyeri Kepala tipe tegang

• Konstan dan terus menerus, pasien tidak pernah merasa bebas dari sakit

• Berat seperti ditimpa, seperti ikat kepala, seperti diperas, mau meledak, teras kosong

• Tempat tidak karakteristik• Frekuensi, intensitas sangat berfluktuasi

Tension Headache

h Durationh 30 min to 7 days

h Pain characteristics (at least 2)h Pressing/tightening qualityhMild to moderate severityh Bilateral fronto-occipital locationhNo aggravation by routine physical activity

h Associate symptoms (must have both)hNo nausea or vomitinghNo more than one of : anorexia, photophobia, phonophobia

International Headache Society Diagnostic Criteria

Terapi • Terapi non farmakologi

– Fisioterapi– Psikoterapi

• Terapi farmakologi– Analgetik, NSAID– Antidepresan

• Relaksan otot oral– Efek sentral

• Mirip mefenesin: eperison HCl, klornefesin, karisoprodol, klorzoksazon, tolperison

• Antagonis GABA: baklofen, diazepam• Imidazon: tizanidin HCl

– Efek perifer: dantrolen Na

Cluster

Cluster Headache

h Durationh 15 to 180 minutes untreated

h Pain characteristicsh Severe unilateral orbital, supraorbital, or temporal pain

h Associated symptoms (at least 1, ipsilateral to pain)h Conjunctival injection, LacrimationhNasal congestion, Rhinorrheah Forehead and facial swellinghMiosis, Ptosish Eyelid Edema

h Frequencyh between 1 every other day to 8/day

International Headache Society Diagnostic Criteria

Patofisiologi

The underlying pathophysiology is not completely understood› Involvement of a biological clock within the hypothalamus › Central disinhibition of the nociceptive and autonomic

pathways

sakit pada CH berasal dari kompleks sinus cavernosus. Kemudian rasa sakit diteruskan oleh saraf simpatik dan para simpati kemudian diteruskan ke batang otak. Penyebab sakit masih kontroversi antara hipoksemia, hipocapnea, factor imunoligic dan vasoregulator.

Jenis Cluster

• Periodisitas tidak tergolongkan• Episodik

– Serangan 7 hari s/d 1 tahun– Masa bebas nyeri ≥ 14 hari

• Kronik– Serangan ≥ 1 tahun– Tanpa masa bebas nyeri atau < 14 hari

• Kronik tidak remisi sejak onset– Sejak onset Tanpa masa bebas nyeri atau < 14 hari

• Kronik yg episodik: Remisi-tidak ada remisi-remisi

Terapi Abortif• Ergotamin tartrat• Metilsergide• Litium karbonat 360-600mg/hari • injeksi lidocain 1%• Verapamil 120-200mg/hariPreventif• Metilsergid 4-10mg/hari• Kortikosteroid prednison 60-80 mg/hari• Sodium divalproat• Klorpromazin• Konidin transdermal• Ergotamine tartrat 2-3 x 2mg• Indometasin 150mg• Litium karbonat 300-1500mg/hari• Verapamil 120-200 mg/hari

Migrain Tension-Type (TTH) Sakit kepala klasterLokasi Umumnya unilateral Bilateral Unilateral (tidak

berpindah)Intensitas Sedang-berat

Diperberat Aktivitas rutin

Ringan-sedang

Tidak diperberat aktivitas rutin

Berat

Durasi 4-72 jam 30 menit-7 hari 15-180 menitFrekwensi Sporadik, beberapa

kali sebulanKonstan Beberapa kali dalam

semingguKualitas Berdenyut Seperti ditekan/penuh Berat (bervariasi)Gejala Penyerta Dapat disertai

nausea, muntah, aura visual, fotofobia dan fonofobia

Disertai lelah dan ngantuk, biasanya timbul saat depresi/ansietas. Tidak disertai nausea, fotofobia, maupun fonofobia.

Dapat disertai gejala autonomic contohnya: lakrimasi, injeksi konjungtiva, kongesti nasal, rhinorhea, miosis, ptosis, edema palpebra.

Gender Wanita>Pria Wanita>Pria Pria>Wanita

Vertigo

Balance Function and DysfunctionInteraction of Vestibular, Visual and Proprioceptive systems

Balance dyfunction

dizziness

Central Nervous system

Muscle and joint sensory receptors

Postural control via

muscles

Goebel JA. Otolaryngol Clin North Am 2000;33:483–93. Shepard NT, Solomon D. Otolaryngol Clin North Am 2000;33:455–69

Controls eye

movements

Eye Skin pressure receptorsInner ear

(vestibular system)

Reseptor alat keseimbangan

• Reseptor alat keseimbangan tubuh di perifer berperan dalam proses transduksi yang terdiri dari:• Reseptor mekanis di vestibulum berespon

terhadap gerakan angular dan linier kepala dan terhadap gravitasi.

• Reseptor cahaya di retina • Reseptor mekanis di otot, kulit dan persendian

• Saraf aferen berperan dalam proses transmisi menghantarkan impuls ke pusat keseimbangan otak. Saraf aferen ini terdiri dari:– Saraf vestibularis– Saraf optikus– Saraf spino vestibulo serebralis

• Pusat-pusat keseimbangan, berperan dalam proses modulasi, komparasi, integrasi/koordinasi dan persepsi. Terdiri dari :• Inti vestibularis• Serebellum• Korteks serebri• Hipotalamus• Inti okulomotorius• Formasio retikularis

Fisiologi Keseimbangan

• Sinyal informasi untuk alat keseimbangan tubuh ditangkap oleh reseptor vestibuler, visual, dan proprioseptif.

• reseptor vestibuler memiliki peranan yang paling besar, yaitu >50%.

• Arus informasi berlangsung intensif bila ada gerakan atau perubahan gerakan dari kepala atau tubuh.

Etiologi

1. Keadaan lingkungan Motion sickness (mabuk darat, mabuk laut)

2. Obat-obatan Alkohol Gentamisin

3. Kelainan sirkulasi Transient ischemic attack

ETIOLOGI (2)4. Kelainan di telinga

Endapan kalsium pada salah satu kanalis semisirkularis di dalam telinga bagian dalam

Infeksi telinga bagian dalam karena bakteri Herpes zooster Labirintitis (infeksi labirin di dalam telinga) Peradangan saraf vestibuler Penyakit Meniere

5. Kelainan neurologis Sklerosis multipel Patah tulang tengkorak yang disertai cedera pada labirin,

persarafannya atau keduanya Tumor otak Tumor yang menekan saraf vestibularis.

Teori Vertigo

• Konflik sensoris: ransangan diatas ambang fisiologis exessive discoordination information

• Neural mismatch: ransangan gerakan yang sedang dihadapi tidak sesuai dengan memori

• Ketidakseimbangan saraf otonomik: dominan Parasimpatis timbul sind vertigo, dominan Simpatis gejala menghilang

• Neurohormonal: hipotalamus mengeluarkan CRF aktivasi simpatis

4 jenis Dizziness

DIZZINESS

Vertigo Vertigo Presyncope DysequilibiumVesibular Non-vestibular

Ilusi berputar Ilusi melayang Rasa akan pingsan tungkai tak stabil ∆ ∆ ∆ ∆Sistem - Sistem Sistem SistemVestibular Visual, Proprioseptif Kardiovaskular serebelar, spinal - Psikogenik

“Spinning” “Light-headed” “ Fainting” “Falling”

Vertigo

Hal Vestibular Non vestibular

Sifat vertigo berputar Malayang, sempoyongan

Sifat serangan episodik Kontinyu

Mual muntah + -

Gangguan pendengaran +/- -pencetus Gerakan kepala Objek visual

situasi - Orang ramai

Letak lesi vestibular Somatosensorik/ propioseptif, visual

VERTIGO VESTIBULAR

Baloh RW. Lancet 1998;352:1841–6. Mukherjee A et al. JAPI 2003;51:1095-101. Puri V, Jones E. J Ky Med Assoc 2001;99:316–21. Salvinelli F et al. Clin Ter 2003;154:341–8. Strupp M, Arbusow V, Curr Opin Neurol 2001;14:11–20.

Peripheral

Involving:- Inner ear- Vestibular nerve

Central

Involving CNS structures:

- Brainstem- Cerebellum- Cerebrum

VERTIGO vestibulerPERIFER vs SENTRAL

Gejala Peripheral Central

Awitan Mendadak Perlahan

Mual, muntah

Berat Bervariasi

Gejala pendengaran Sering

Jarang

Gejala Nerologik fokal - Sering

Kompensasi/resolusi

Cepat

Lambat

Gerakan kepala + +/-

Baloh RW. Otolaryngol Head Neck Surg 1998;119:55–9. Puri V, Jones E. J Ky Med Assoc 2001;99:316–21.

Vertigo of Peripheral origin: causes

Condition Details

Benign paroxysmal positional vertigo (BPPV)

Brief, position-provoked vertigo episodes caused by abnormal presence of particles in semicircular canal

Meniere’s disease An excess of endolymph, causing distension of endolymphatic system

Vestibular neuronitis Vestibular nerve inflammation, most likely due to virus

Acute labyrinthitis Labyrinth inflammation due to viral or bacterial infection

Labyrinthine infarct Compromises blood flow to the labyrinthine

Labyrinthine concussion

Damage to the labyrinthine after head trauma

Perilymph fistula Typically caused by labyrinth membrane damage resulting in perilymph leakage into the middle ear

Autoimmune inner ear disease

Inappropriate immunological response that attacks inner ear cells

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Baloh RW. Lancet 1998;352:1841–6. Mukherjee A et al. JAPI 2003;51:1095-101. Parnes LS et al. CMAJ 2003;169:681– 93. Puri V, Jones E. J Ky Med Assoc 2001;99:316–21. Salvinelli F et al. Clin Ter 2003;154:341–8.

Vertigo of Central origin: causes

Condition Details

Migraine Vertigo may precede migraines or occur concurrently

Vascular disease Ischaemia or haemorrhage in vertebrobasilar system can affect brainstem or cerebellum function

Multiple sclerosis Demylination disrupts nerve impulses which can result in vertigo

Vestibular epilepsy

Vertigo resulting from focal epileptic discharges in the temporal or parietal association cortex

Cerebellopontine tumours

Benign tumours in the internal auditory meatus

Decr

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ng

fre

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en

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Baloh RW. Lancet 1998;352:1841–6. Mukherjee A et al. JAPI 2003;51:1095-101. Salvinelli F et al. Clin Ter 2003;154:341–8. Solomon D. Otolaryngol Clin North Am 2000;33:579–601. Strupp M, Arbusow V, Curr Opin Neurol 2001;14:11–20.

nistagmus

perifer Sentral

Latensi +, 2-20 detik -

Vertigo + +/-

fatique + -

Arah Telinga bawah Telinga atas/ bervariasi

Lama <1menit >1menit

Diagnosis

• Tes kalori• Tes dix hallpike• ENG

– Tes melirik– Tes posisional

• Tes sakadik• Head shaking test• Tracking test

TREATMENT OF VERTIGOCURRENT TREATMENT OPTIONS

1. Symptomatic Pharmacotherapy 2. Treatment for Specific Conditions

● Pharmacotherapy ● Particle repositioning procedure (in BPPV) ● Surgery

3. Rehabilitative ● Vestibular Rehabilitation Therapy

4. Prevention of aggravating factor ● Diet control ● Life-style changes

Baloh RW. Lancet 1998;352:1841–6. Mukherjee A et al. JAPI 2003;51:1095-101.

1. SYMPTOMATIC TREATMENT

I. ANTIVERTIGO Vestibular Suppressant 1. Ca channel blocker : Flunarizin 2. Histaminic : Betahistine 3. Antihistamin : Difenhidramine, sinarisin4. Antikolinergik5. Monoaminergik6. Benzodiazepin7. Histamine8. Beta bloker9. Anti epileptik II. ANTIEMETIC Prochlorperazine, metoclopramide.

III. Psychoaffective Clonazepam, diazepam for anxiety and panic attack

Treatment for Specific Conditions

PERIPHERAL VERTIGO

● BPPV Canalith repositioning manoeuvre (Brandt-

Daroff, Epley, Semont maneuvre)

● Meniere’s disease Low-salt diet, diuretic, surgery, transtympanic

gentamicin

● Labyrinthitis Antibiotics, removal of infected tissue,

vestibular rehabilitation

● Vestibular neuritis Steroids, vestibular rehabilitation

● Labyrinthine concussion Vestibular rehabilitation

● Perilymph fistula Bed rest, avoidance of straining

CENTRAL VERTIGO

MigraineBeta-blockers, calcium channel

blockers, tricyclic amines, anticonvulsants

Vascular diseaseControl of vascular risk factors,

antiplatelet /antikogulan agents

CPA tumoursSurgery

Specific Treatment for BPPV

1. Office Treatment ● Epley maneuver ● Semont maneuver

2. Home Treatment ● Brandt-Daroff Exercises

30 sec

30 sec

30 sec

Epley maneuver

Other name:• Canalith repositioning• Particle repositioning

Time Exercise Duration---------------------------------------------Morning 5 X 10 minNoon 5 X 10 minEvening 5 X 10 min---------------------------------------------

Brandt-Daroff maneuver

Cawthorne Cooksey exercises

Pendekatan klinisCephalgia

Anamnesis

• Onset• Lokasi • Frekwensi• Durasi, keparahan, sifat• Dampak• Aura atau prodromal• Gejala lain yang menyertai:

injeksi membran mukus, gangg GI, polyuria

• Gangg mood• Gangg penglihatan• Faktor yang memicu• Faktor yang meredakan• Pengaruh posisi tubuh• Gangg tidur• RPS: stress• RPK• RPD

PF

• Tenderness • Injeksi konjungtiva• Papiledema• Refleks pupil• Diplopia• Posisi bola mata• Kelopak mata• Motorik wajah• Sensorik wajah

Sakit kepala yg berbahaya

Pasien dgn keluhan sakit kepala

Anamnesis dan pemeriksaan fisik

Tanda sakit kepala yg berbahaya

Ya Tdk Anamnesis Sakit kepala primer- Tension-Headache- Migren- Chronic daily Headache

Pemeriksaan penunjang utk eksplorasi penyebab sakit kepala sekunder (MRI, CT scan, laboratorium, foto torak dll)

Anamnesis Sakit kepala yg berbahaya

• Onset• Persisten• Progressive• Usia• Adanya penyakit lain

Onset : sakit kepala yg berbahaya

• Onset sakit kepala yg jelas• Sakit kepala berat yang mendadak• Onset < 6 bln dianggap berbahaya sampai

terbukti tdk berbahaya

Persisten : sakit kepala yg berbahaya

• Sakit kepala yg terus menerus, tidak berkurang dalam 24 jam

• Respon terhadap pengobatan minimal

Progressive : sakit kepala yg berbahaya

• Membandingkan dlm kurun waktu tertentu• Kualitasnya : makin hebat• Gangguan pd aktifitas sehari-hari• Respon terhadap pengobatan : butuh dosis

obat yg lebih besar• Adanya gejala penyerta lainnya.

Usia : sakit kepala yg berbahaya

• Usia sgt muda atau usia tua• Usia > 55 thn selalu dianggap berbahaya

sampai terbukti tidak berbahaya• Anak

Penyakit lain – Keluhan lain

• Demam• Muntah• Gejala Neurologi

– Tanda peningkatan tekanan intrakranial• Riwayat keganasan• Diagnosis HIV atau IDU

HEADACHE RED FLAGS• Systemic symptoms or illness

including fever, persistent or progressive vomiting, stiff neck, pregnancy, cancer, immunocompromised state, anticoagulated

• Neurologic signs or symptomsincluding altered mental status, focal neurologic symptoms or signs, seizures, or papilledema

• Onset is new especially in those age 40 years / older or sudden

• Other associated conditions eg, headache is subsequent to head trauma, awakens patient from sleep, or is worsened by Valsalva maneuvers

• Prior headache history that is different eg, headaches now are of different pattern or are rapidly progressive in severity or frequency

When such red flags are present, neuroimaging (CT or MRI) is indicated to investigate secondary causes of headache

Venkatesan A. headache red flags. John Hopkins University. Downloaded from http://www.medscape.com/viewarticle/537504_2

Diagnostic alarms of Headache Headache alarm Differential Diagnosis Work up

Headache begins after age of 30

Temporal arteritis, mass lesion

Erythrocyte sedimentation rate, neuroimaging

Sudden onset headache SAH, mass lession Neuroimaging, LP

Acclerating pattern of headache

Mass lesion, subdural hematoma, medication overuse

Neuroimaging, drug screen

New onset headache in a patient with cancer or HIV

Meningitis, brain abcess, toxoplasmosis, metastases

Neuroimaging, LP

Headache with systemic illness (fever, stiff neck, rash)

Meningitis, encephalitis, systemic infection, vascular disease

Neuroimaging, LP, blood test

Focal neurologic simptom or sign of disease

Mass lessions, AVM, stroke, colagen vascular disease

Neuroimaging, colagen vascular evaluation

Papiledema Mass lessions, pseudotumor, meningitis

Neuroimaging, LP

Silberstein SD, Lipton RB and Dalessio DJ. Overview, diagnosis and classification of headache in Wolfs Headache and other head pain . Oxford: Oxford University Press. 2001. p20