HEADACHES

BASJIRUDDIN A
BAGIAN NEUROLOGI FK-UNAND
RS. DR. M. DJAMIL PADANG
 Headache
 In medical terminology : cephalgia
 Headache is defined as pain in the head that is
located above the eyes or the ears, behind the
head (occipital), or in the back of the upper neck,
and has many causes
 Majority of headaches are benign and self
limiting,
secondary headache can life-threating conditions
such as encephalitis,meningitis, tumor, cerebral
hemorrhage, etc.
 Nearly universal experience
 Prevalance :- 1 year periode of 90 %
- a life time of 99%
 Diagnosis : Careful history, examination and
diagnostic testing
 Pain–sensitive structures
Similar headaches can have different cause depend
on the pain-sensitive structures, include:
A. Intracranial structures
 Dura near vessels
 Cranial nerves V, VII, IX, X
 Circle of willisy
 Meningeal arteries
 Large veins
B. External to the skull
 Scalp and neck muscles
 Cervical nervus and roots
 Cutaneous nerves and skin
 Mucosa of the paranasal sinuscs
 Teeth
 External carotid arteries
Nerves Supply
Splancno cranium supply by cranial nerve V, VII,
IX and X
Neuro cranium, structures external to the skull
(including scalp and neck muscle), are supplied
by nn.spinalis C1, C2, C3
Headache

Location
 Cluster headaches always unilateral
 60% migraines: are unilateral, some could be
spread become bilateral
 Trigeminal neuralgia: uccurs unilaterally in the
second and third trigeminal distribution
 Brain tumor: bilateral or unilateral
 Tension headache bilateral
Duration
 Migraine 4-72 hours in adults
 Cluster headache 15-180 minutes
 Tension type headche 30 minutes-days
 Trigeminal neuralgia a few seconds < 2minutes
 Two types of headache:
 Primary headache, are not associated with
other diseases, for example tension headache,
migraine, cluster headache
 Secondary headache, are caused by
associated diseases; may be minor or serious
and life threatening
Tension headache is the most common type of
primary headache, and more common among women
than men
 Classification of primary headache
(international headache society 1988 modified)

1. Migraine
a. Migraine without aura
b. Familial hemiplegic migraine
c. Basiler migraine
d. Opthalmoplegic migraine
e. Complications of migraine
2. Tension type headache
a. Episodic tension type headache (ETTH)
b. Chronic tension type headache (CTTH)
Classification...

3. Cluster headache and chronic paroxismal

hemicrania
a. Cluster headache
b. Chroic paroxismal hemicrania
4. Headache associated with head trauma
5. Headache associated with vascular disease :
infarction, hematoma, subarachnoid hemorrhage acute
arterial hypertension
6. Headache associated with metabolic
abnormality, hypoxia, dialysis
7. Headache associated with intracranial
disorder
a. Infection/ abscess
b. Tumor
c. Granulamotor disease
8. Headache associated with disorders of neck,
eye, sinus, teeth
a. Cranial neuralgia
b. Trigeminal neuralgia
c. Glossopharyngeal neuralgia
9. Other type of headache
Ice pick, cold stimulus, benign cough headache benign
sex headache
10. Headache not classifable
 Migraine
 Migraine is a chronic condition of recurrent attacks,
due to changes in the brain and surrounding blood
vessels
 Pain located in the forehead, around eye, or back of
head, unilateral
 Usually aggravated by daily activities, like walking
upstairs etc
 Nausea, vomiting, cold hands, facial pallor
 Typically last from 4-72 hours and vary in frequency
from daily to fewer than 1 per year
 Affects about 15% or the population (women : men
= 3 : 1)
 ± 80% migraineurs have other members in the
family
 Symptoms
 Vary from person to person
Five phases often to be identified :
 Prodrome : feeling “high”, irritable, depressed,
funny taste of smell
 Aura : visual disturbance preceedes headache
phase, blind spots (scotoma), flashing, colorful or
lose vision on one side (hemianopia)
 Headache : on one side of the head, 30% spread
on both sides
 Throbbing pain, >80% nauseated, and some vomit
 70% photophobia and phonophobia
 Headache termination : pain usually goes away
with sleep
 Postdrome : inability to eat, fatigue, problem with
concentration may longer after pain disappeared
Causes
 Exact cause is not clearly understood
 Experts believe :
A combination of the expansion of blood vessels
and the release of certain chemicals, which
causes inflamation and pain.
The chemicals dopamine and serotonine can
cause blood vessels to act abnormally if they
present in abnormal amounts, or if the blood
vessels are unusually sensitive to them
Triggers
 Certain foods : chocolate, cheese, nuts, alcohol,
and MSG (monosodium glutamate)
 Stress and tension or physical stress
 Birth control pills (estrogen)
 Smoking
 Missing a meal may bring on a headache
Associated symptoms
Before headache
60% migrainous have prodrome in hour before:
Irritability, depression, euphoria smell
hypertensive
During headache
Migraine: by nausea in 90%, vomiting > 50%
Foto/fobo sensitivity in 80%
Nasal congestion
Cluster : ipsilateral ptosis, miosis in 30%
Dysability
After headache
Tired, drained, depression, decreased mental
acuity
Migraine without aura (common migraine)
 Benign periodic headache lasting several hours,
without preceding focal neurologic symptoms
 Unilateral pain, nausea or vomitting, positive family
history, respon to ergotamin, scalp tenderness in
80%
Migraine with aura (classic migraine)
 Headache associate with characteristic premonitory
sensory, motor, or visual symptoms
 Visual – scotomas or hallucinations (usually in central
visual field) paracentral scotoma expands 20 to 25
minutes
 Basilar migraine
Brainstem signs, including vertigo, dysarthria, diplopia;
occur as sole neurologic symptoms of migraine in 25%
 Hemiplegic migraine
Hemiparesis migraine may occur during prodrome; lasts
20 to 30 minutes
More severe: hemiplegia for days to weeks headache
subsides
Familial from autosomal dominant

 Opthalmoplegic migraine
Attack of periorbital pain and vomiting for 1 to 4 days.
Complete third nerve palsy follows, often including
pupillary dilation, loss of light response.
May persist days to 2 months. Onset may occur in
childhood
Diagnosis criteria
I. Migraine without aura
a. At least 5 attacks ,fulfilling b & c
b. Attacks lasting 4-72 h
c. During headache
 Nausea and/or vomiting
 photophobi, phonofobi
 Headache with 2 of tha following
 Unilateral, pulsating quality
 Moderate severe intensity
 Aggravation by walking stairs or similar activity
II. Migraine with aura
1. At least 2 attacks fulfilling b
2. 3 of the following
 One or more reversible aura
 Aura gradually over more than 4 minutes
 No aura lasts more than 60 minutes
I. Headache (some with migraine without aura) follow
aura with a free interval
 Management
Mg treatment devided into :
- General Measures - Abortive Therapy
- Pain Relieve Measure - Preventive Therapy

General Measures
Important step :
 Identifying and avoiding HA triggers
 Training in coping strategies or stress
management
 Ensure : Patient understand the nature of the condition
Patient understands the actions of medication
 Provide a contact number incase of problems
enhance compliance and improves patient
satisfaction
Mac Gregor EA. Neurology, 1997;48(suppl 3):S 16-20
Diamons S. Postgrad Med. 2001;109(1)49-60
Acute treatment
Immediate administration of full dose of
agent at attack onset
Mild headache : aspirin, acetaminophen.
Butalbital and caffeine added if necessary.
Ibuprofen, naproxen often useful.
Isometheptene compounds effective for
mild-to-moderate ”stress headache”
Non Specific Abortive therapy

OTCs Analgesics
 Examples : aspirin, ibuproven,
naproxen sodium
 Commonly used, inexpensive, available
 > 60% mg HA pts use non prescription
meds)
 Rebound HA is problem with overuse
Moderate-to-severe headache:
ergotamine (oral or suppository);
sumatriptan (oral intranasal, subcutaneous
dose),
Rizatriptan, zolmitriptan, naratriptan,
Triptans indicated for attack frequency > 2to
3 per month
Contra indications :
 Hypertension
 Stroke
 Coronary artery disease
Severe headache : dihydroergotamine
(parenteral, nasal spray). Intravenous
prochlorperazine, metoclopramide,
dihydroergotamine
Chronic daily headache : amitriptyline,
nortriptyline, anti depresants, valproat,
topiramate
 Preventive Therapy
The US.HA Consortium Guidelines for
prevention therapy identify 3 goals :
1. A reduction in the frequency, severity,
duration attacks
2. An important in the patients responsiveness
to treatment
3. An improvement in the patient function and
reduction disability

Morey SS. J. Am Fam Phys Vo. 62/N10 November 15.2000

Prophylaxis
Daily administration required. Effect lags 2
weeks
Medications include: propanolol, amitriptiline,
verapamil, valproat
Additional drug include topiramate, zonisamide.
Probability of success 60% to 75%
drug maybe tappered after 5 month
 Tension Headache
 A tension headache is the most common
headache and yet it’s not clear understood
 Generally produces mild to moderate pain, in the
back of neck at the base of the skull feeling a
tight band around head
 Symptoms can last from 30 minutes to an entire
week, or nearly all the time (never free from
headache)
 Patients experience:
Tenderness on scalp, neck and shoulder muscles
Difficulty sleeping (insomnia), fatigue, instability
Lost of appetite, difficulty concentrating

 Some times may be severe

Causes
The causes still continue to debate exact
cause are unknown
Researches now believe :
 Changes among certain brain chemicals –
serotonine, endorphine and numerous other
chemicals – that help nerves communicate
 The process activate pain pathways to the brain
and to interfere with the brain’s ability to
supress the pain
 Tight muscles in the neck/scalp contribute to a
headache, on the other hand, the tight muscles
may be a result of these chemical changes
 Potential Triggers
 Stress
 Depression, anxiety
 Lack of sleep or changes in sleep routine
 Poor posture; lack of physical activity
 Working in awkward positions
 Hormonal changes; menstruation,
pregnancy
 Overuse of headache medication
Classification of Tension Headache

1. Episodic tension-type headache (ETTH)

is defined as recurrent episodes of headache
(older term: tension hedache, muscle contraction headache)
 Occur on fewer than 15 days a month
 Lasting a few minutes to few hours
 Scalp and neck muscle tenderness in addititon to head
pain
 Risk of developing chronic form over years
2. Chronic tension-type headache (CTTH)
 Occur on 15 days a month or more for at least three
months
 20% of CTTH are primary (daily from the onset)
 Duration and severity are similar with ETTH, although
pain is daily and continous , and tenderness of scalp and
neck
Characteristic Tension type headache

I. Pressing, tighthening non pulsating quality

 Mild or moderate intensity
 Bilateral location
II. No nausea or vomiting
 No aggravation by walking, up stairs or as
same exercise
 No or one of phono-photophobia
 I. Pressing,
Diagnostic criteria ETTH tighthening non
pulsating quality
 Characteristic I and II with : II.
No nausea or
vomiting
A. At least 10 previous headache episodes
number of days with such headche <180/y
(<15/mo)
B. Headache lasting from 80 min-7 days

Diagnostic criteria of CTTH

 Include characteristic A and B with :
Avarage headache frequent 15 days/month
(180 days/year) for 6 months
Two risk of CTTH:
- Analgesic rebound
- Cormobidity
 Use of combination analgesics should be
limited to days or use until 24 tablets
 SSRI (Serotinin Selective Reuptake
Inhibitor) drugs may administered as a
prevention (fluoxetin)
 Treatment
 The goal is to relieve symptoms and
prevent future headaches
 Prevention is the best treatment
 If possible, remove or control headache
triggers
 Medications :
 Over-the-counter (OTC) analgesics such aspirin,
acetaminophen, may combine with caffeine
and NSAID, ibuprofen, ketoproven
 Anti depressant : amitriptilin
 Non sedating muscle relaxant
 Combination of butalbital and acetaminophen
Prevention
 Stress management strategies
 Relaxation excercises

 Good posture when working, reading,

activities
 Enough sleep and rest

 Massage of sore muscles

 Lifestyle changes
 Cluster headache
Episodic : most common type. One to three
short-lived attacks of periorbital pain daily for
4 to 8 weeks, then pain-free interval for
about 1 year
Chronic: begins de novo or evolve from
episodic type. Attacks similar no sustained
remission.
M:F=8:1
Onset ages 20 to 50
Clinical features
 Periorbital, temporal, maxillary pain begins
without warning, peaks within 5 minutes.
 Often excruciating, deep, nonfluctuating,
explosive.
Strictly unilateral. Attack last 30 to 120
minutes.
Frequently with ipsilateral lacrimation, red
eye, nasal stuffiness, lid ptosis, nausea
Treatment
To abort attack : oxygen inhalation
(10mL/min via nonrebreathing mask),
intranasal topical lidocaine, sumatriptan. To
prevent further attacks during bout:
prednisone, methysergide, ergotamine,
verapamil
Post-concussion headache
Follow severe or trivial head injury
(including head trauma without loss of
consciousness). Often with vertigo, impaired
memory and concentration, mood changes
for months or years (post-concussion
syndrome)
 Brain Tumor Headache
Chief complaint in 30% of patients with
brain tumor: deep, dull aching quality,
moderate intensity, intermitten, worsened
by exertion or change in position, associated
with nausea and vomiting. Headache
disturbs sleep in about 10%. Vomiting
precedes headache by weeks in posterior
fossa brain tumor
 References
 Adams RD. Principles of neurology 6th ed Mc
Graw Hill 1997
 Harsono, Buku Ajar Neurologi, Bab II
 Harsono, Kapita selekta neurologi, Bab II
 Mazzoni.P.Merritts`s Neurology Handbook. 2nd
ed Dresden. Lippincott William & Wilkins. 2007
 Evans RW. Hanbook of headache. Philadelphia
Lipincott William & Wilkins, 1999
 Headache wikipedia
 Mayo clinic com
THANK YOU