HEADACHES

3
Prof. dr. Basjiruddin ahmad, Sp.S (K)
Fakultas Kedokteran Universitas Andalas
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

Painsensitive 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

PAIN SENSITIVE CRANIAL STRUCTURES

Skin, subcutan, muscle

Extracranial arteries
Skull periosteum
Eye, ear, nasal cavities,
sinuses
Intracranial venous sinuses,
large veins, pericavernous
structures
Basis duramater, meningeal
arteries, proximal anterior
middle cerebral arteries,
carotis interna arteries
Superficial temporal arteries
Cranial nerves: N II, N III, N
V, N IX, N X,C1-3

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
[Link] 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. Migraine hemiplegic migraine
c. Basiler migraine
d. Opthalmoplegic migraine
e. Complications of migraine

2. Tension type headache

f. Episodic tension type headache (ETTH)
g. 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, dypoxia, dialysis
7. Headache associated with intracranial
disorder
a. Infection/ abscess
b. Tumor
c. Granulamotor disease

8. Headache associated with us order 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 headacha
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 linger after pain disappeared

Phase of Acute Migrain

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
Birht 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, eupharia small
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
Attasck of periorbital pain and vomiting for 1 to 4 days.
Complete third nerve palsy follows, often including
pupillary dilation, loss of lihgt 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
Headache (some with migraine without aura) follow
aura with a free interval

Management
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

Moderate-to-severe headache:
ergotamine (oral or suppository); sumatritan
(oral intranasal, subcutaneous dose),
Rizatriptan, zolmitriptan, naratriptan, Triptans
indicated for attack frequency > 2 to 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

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 its 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

Someimes 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 brains 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

Muscle tension that may cause Tension

Type Headache

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

[Link] 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

[Link] 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 nonpulsating quality

Mild or moderate intensity

Bilateral location

II. No nausea or vomiting

No aggravation by walking stairs or

same /exercise
No or one of phono-photophobia

Diagnostic criteria ETTH

Characteristic I and II with :
A. At least 10 previous headache episodes
number of days with such headche <180/y
(<15/mo)
B. Headche 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 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 bulbital 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 susteined
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 patints 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