Alfansuri Kadri

HEADACHE
Definition: pain / unpleasant

sensation of the head as long as chin

until cervicooccipital

Epidemiology
Prevalence life time of headache

are
90% male
96% female

Epidemiology in Indonesia
(hospital based)

Prevalence life time TTH 78%

Episodic TTH 63% male 56% ,female

71%
TTH chronic 3% male 2 % ,female 5%
ETTH(Indonesia 31%)
CTTH (Indonesia 24%)
Migraine = 10% (Indonesia)

Prevalence in Indonesia
outpatient clinic
1. Sefalgia

%
2. Osteo arthritis
9.5%
3. Stroke 7.7%
4. LBP + OA
7.3%
5. Insomnia
4.0%
6. Epilepsy
3.8%
7. Vertigo
3.6%
8. Bells palsy 3.2%
9. LBP+HNP
2.5%
10. Neuropathy 2.3%

42

1. Migraine wthout aura

6-

10%
2. Migraine with aura
1.8%
3. ETTH
31%
4. CTTH
24%
5. Cluster Headache 0.5%
6. Mixed Hx
14%
7. Post trauma cap syndr 14%
8. Secondary Headache
3%
9. Chronic Daily Headache
9%
10.CPH
1%

HEADACHE CLASSIFICATION
PRIMARY HEADACHE

1. Migraine
2. Tension Type Headache
3. Cluster Headache & other
trigeminal autonomic cephalalgias
4. Other primary headache

SECONDARY HEADACHE

Other headache, cranial neuralgia,

central or primary facial pain.
6

MIGRAINE
Definition :

Migraine is a condition of paroxysmal

or occasionally constant headaches
that are the product of primary brain
dysfunction resulting in a
neurovascular reaction in genetically
predisposed individuals.

International Headache
Classification (IHS) 2004
Migraine
1.1 Migraine without aura
1.2 Migraine with aura
1.3 Childhood periodic syndromes that

are
commonly precursors of
migraine
1.4 Retinal migraine
1.5 Complications of migraine
1.6 Probable migraine

1.2 Migraine with aura

1.2.1 Typical aura with migraine
headache
1.2.2 Typical aura with nonmigraine
headache
1.2.3 Typical aura without
headache
1.2.4 Familial hemiplegic
migraine(FHM)
1.2.5 Sporadic hemiplegic migraine
1.2.6 Basilar type migraine

1.3 Childhood periodic

syndromes that are commonly
precursors
of migraine
1.3.1
Cyclical vomiting
2.5% schoolchildren
Recurrent unexplained nausea & vomiting 4x
/hours 5 days
No sign of gastrointestinal disease

1.3.2 Abdominal migraine

12% of schoolchildren
Abdominal pain, anorexia, nausea, vomiting

1.3.3 Benign paroxysmal vertigo of

childhood

At least 5 attacks severe vertigo

Resolve within few minutes-hour
no neurological deficit
Normal vestibular function
EEG normal

10

1.4. Retinal migraine

Rare
At least 2 attacks scintillating,

scotoma, blindness
Unilateral (only one eye)
Follows with migraine with aura
No attributed to another
disorders

11

1.5 Complications of
migraine
1.5.1 Chronic migraine

Migraine without aura

> 15 days
> 3 months
No attributed to another disorders
without Medication over used

1.5.2 Status migrainosus

Severe headache migraine > 72 jam
No attributed to another disorders

1.5.3 Persistent aura without

infarction
1.5.4 Migrainous infarction
1.5.5 Migraine-triggered seizures
12

EPIDEMIOLOGY
Worldwide > 10% of people.
In the United States 6% of men and 18% of

women get a migraine in a given year

lifetime risk of about 18% and 43%
respectively.
In Europe 1228% of people at some point
in their lives migraine
Based on the results of a number of studies,
one year prevalence of migraine ranges from
615% in adult men and from 1435% in
adult women.
13

EPIDEMIOLOGY
Approximately 45% of children aged

< 12 suffer from migraine

Young adult age >>
After menopause, attacks in women
tend to decline dramatically > 70s
equal numbers of male and
female sufferers prevalence
returning to around 5%.
Genetic factor 70 %
14

PREVALENCE MIGRAINE

15

HISTORY
An early written description Ebers papyrus,

written around 1200 BC in ancient Egypt.

Aretaeus of Cappadocia "discoverer" of
migraines second century description
unilateral headache associated with
vomiting, with headache-free intervals in
between attacks.
Galenus of Pergamon used the term
"hemicrania" (half-head), from which the word
"migraine" was derived

16

HISTORY
Ibnu Sina described migraine in his

textbook "El Qanoon fel teb" as

"...small movements, drinking and
eating, and sounds provoke the
pain... the patient cannot tolerate
the sound of speaking and light.
The term "Classic migraine" is no
longer used, and has been replaced
by the term "Migraine with aura"
17

CLINICAL SYMPTOMS
4 phases :
Prodrome
Aura
Headache
postdrome

18

PRODROME PHASE
Occurs in 25 50 % of migraineurs
Gradual onset & evolution over up to

24 hours
Lightheadedness, dulled perception,
irritability, withdrawal, cravings for
particular food, frequent yawning,
elation, and speech difficulties.

19

AURA PHASE
15 25 % of migraine attacks

associated with aura.

Visual symptoms most commonly
Somatosensory
Dysphasia
Gradual onset build up over 5 10
minutes subside within 5 60
minutes.
20

HEADACHE PHASE
Site : unilateral, frontotemporal

occipital
Quality : throbbing / pulsatile,
moderate to severe
Aggravating factors : physical
activity, bright light, loud noise
Duration : 4 72 hours
Associated factors : nausea (90 %),
vomitting (60 %), scalp tenderness.
21

POSTDROME PHASE
Tired
Drained
Aching muscles
Euphoric

22

PATOPHYSIOLOGY
Neuronal hyperexcitability in inter

iktal and pre-headache phase.

Cortical spreading depression (CSD)
Peripheral and central activation of
trigeminal nerve
Periaquaductal gray matter (PAG)
lesion
Genetic
23

DIAGNO
SIS
A. At least 5 attacks
B. Attacks lasting 4-72 hrs
C. Has 2 following characteristics:
A.
B.
C.
D.

Unilateral
Pulsating
Moderate or severe pain
Aggravation by physical activity

D. During attacks 1 of the following

A. Nausea and/or vomiting
B. Phonophobia and photophobia

E. Not attributed to another disorder

24

DIAGNOSIS
The mnemonic POUNDing

(Pulsating, duration of 472 hOurs,

Unilateral, Nausea, Disabling) can
help diagnose migraine.
If 4 of the 5 criteria are met, then the
positive likelihood ratio for
diagnosing migraine is 24.
Detsky ME, McDonald DR, Baerlocher MO, Tomlinson GA, McCrory DC, Booth CM
(September 2006). "Does this patient with headache have a migraine or need
neuroimaging?". JAMA 296 (10): 127483
25

26

AURA
Migraine headache. Frank
visual field loss can also
occur associated with
migraine. This example
shows loss of the entire
right visual field as
described by a person
who experiences
migraines.

27

AURA
Migraine headache.
Example of a central
scotoma as described by a
person who experiences
migraine headaches. Again
note the visual loss in the
center of vision.

28

AURA
Migraine headache.
Example of visual
changes during
migraine. Multiple
spotty scotomata are
described by a person
who experiences
migraine

29

AURA
Migraine headache.
Example of a visual
migraine aura as
described by a person
who experiences
migraines. This patient
reported that these
visual auras preceded
her headache by 20-30
minutes

30

The triggers or precipitants of the

acute migraine attack.
1207 pts migraine of whom 75.9% reported triggers.

Stress (79.7%),
hormones in women (65.1%),
not eating
(57.3%),
weather (53.2%),
sleep disturbance
(49.8%),
perfume or odour
(43.7%),
neck pain
(38.4%),

light(s)
(38.1%),
alcohol
(37.8%),
smoke
(35.7%),
sleeping late
(32.0%),
heat (30.3%),
Food (26.9%),
exercise
(22.1%)
sexual activity
(5.2%).

Kelman L. Cephalalgia 2007; 27:394402.

31

Food as Trigger factor of

migraine
MAYOR
MSG
wine /vodka/bier
Cheese
Chocolate
Yogurt/yeast
citrus fruits
Buttermilk, milk

MINOR
nuts
Fried foods
Popcorn
Chile peppers
Seafoods
Pork / livers
Salty food/sweet

32

INVESTIGATION
Should only be necessary if suspected to

be secondary to another disorder

Alarm symptoms include :

Onset > 50 years

Aura w/ out headache
Aura symptoms that are very brief or very

long
Sudden increase in migraine frequency or
change in migraine characteristics
High fever
Abnormal neurologic examination

33

INVESTIGATION
The role of imaging in patients with

suspected migraine exclude

structural cause for the headache
such as AVMs or tumors.
Contrast enhanced CT satisfactory

34

DIFFERENTIAL DIAGNOSIS
Other primary headaches
Subarachnoid hemmorhage
Drug induced headache
Head injury
Acute obstruction of the CSF pathways
Glaucoma
Raised ICP
Structural intracranial lesion
35

MIGRAINE TREATMENT
Pharmacological treatment
Acute abortive treatment
Spesific
Non-spesific
Preventive (profilaxis) treatment

Non-pharmacological

treatment
36

ABORTIVE TREATMENT : NON

SPESIFIK
DRUG

DOSAGE

PARASETEMOL

500 1000 mg / 6 8
hour

ASPIRIN

500 1000 mg / 4 6
hour

IBUPROFEN

400 800 mg / 6 hour

NAPROXEN SODIUM

275 550 mg/2-6 hour

DICLOFENAC
POTASSIUM

50 100 mg / day single

dose

KETOROLAC

60 mg / i.m / 15 30
mnt max : 120 mg /
day, < 5 days
1 mg / hour max : 4

BUTORPHANOL SPRAY

37

ABORTIVE TREATMENT : NON

SPESIFIK
DRUG

DOSAGE

PROCHLORPERAZINE

25 mg oral or
suppositoria

STEROID
(DEXAMETHASONE,
METIL PREDNISON)

DRUG OF CHOICE
STATUS MIGRENOSUS

38

ABORTIVE TREATMENT :
SPESIFIK
SITUASI KLINIK

PILIHAN OBAT

Gagal dengan
analgetik / NSAID

PILIHAN PERTAMA MENURUT

URUTAN
Sumatriptan 50 mg p.o
Rizatriptan 10 mg p.o
Zolmitriptan 2,5 mg p.o
Almotriptan 12,5 mg p.o
Eletriptan 40 mg p.o
EFEK LAMBAt TAPI TOLERABILITAS
LBH BAIK :
Naratriptan 2,5 mg
Frovatriptan 2,5 mg
NYERI KEPALA YG TIDAK TERLALU
SERING
Ergotamine 1 2 mg p.o
Dihydroergotamine nasal spray 2

39

ABORTIVE TREATMENT
SPESIFIC
Triptans
Dihydroergotamine
Ergotamine

40

ABORTIVE TREATMENT :
SPESIFIK
SITUASI KLINIK

PILIHAN OBAT

Gejala awal mual

muntah atau sulit
menelan obat

Sumatriptan 20 mg nasal spray

Zolmitriptan 5 mg nasal spray

Nyeri kepala yang

sering berulang

Ergotamine 1 2 mg (usually with

caffeine)
Naratriptan 2,5 mg p.o
Almotriptan 12,5 mg p.o
Eletriptan 80 mg p.o
Dihydroergotamine 1 mg / i.m

Muntah awal yang

terus -menerus

Zolmitriptan 5 mg nasal spray

Sumatriptan 6 mg / s.c
Dihydroergotamine 1 mg / i.m
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ABORTIVE TREATMENT :
SPESIFIK
SITUASI KLINIK

PILIHAN OBAT

Menstrually related
headache

SHORT TERM PREVENTION

Ergotamine p.o
Oestrogen patches
Short term NSAID
ACUTE TREATMENT
Triptans
Dihydroergotamine nasal spray /
i.m

Gejala timbul sangat

cepat dan
berkembang cepat

Zolmitriptan 5 mg nasal spray

Sumatriptan 6 mg / s.c
Dihydroergotamine 1 mg / i.m

Muntah awal yang

terus -menerus

Zolmitriptan 5 mg nasal spray

Sumatriptan 6 mg / s.c
Dihydroergotamine 1 mg / i.m

42

Indication for Prophylaxis

Migraine

1. Migraine duration is greater than 48 hours

2. Acute medications are ineffective/failure,

contraindicated, have side effect of drug

or likely to be overused medications
3. Attacks produce profound disability
(occurs > 2 days per month) prolonged
aura, or true migrainous infarction
4. Attacks occur > 2 more times per week,
even with adequate acute care treatment
with the risk of developing rebound
headache
US Headache Consortium Guidelines, Bigal, 2006, Loder,
5.2005
Patient preference for preventive therapy43

PREVENTIVE / PROFILAXIS
TREATMENT
KRITERIA :
Jangka waktu migren berlangsung > 48 jam
Pengobatan akut gagal atau tidak efektif, ada
kontraindikasi, mempunyai efek samping, dan
ada kecenderungan over used medication
Serangan menyebabkan disabilitas parah
(terjadi > 2 hari per bulan)
Aura yg memanjang, atau menjadi infark
migrenosus
Serangan terjadi > 2 kali per minggu, meskipun
telah diberikan pengobatan akut yg adekuat
Permintaan pasien
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PREVENTIVE / PROFILAXIS
TREATMENT
REAKS
JENIS OBAT
DOSIS
I OBAT

PROPANOLOL

40 320 mg 2 x
sehari

2+

PIZOTIFEN

0,5 1,5 mg / hari

2+

METHYSERGIDE

1- 6 mg / hari

4+

VERAPAMIL

160 320 mg / hari

1+

FLUNARIZINE

5 10 mg / hari

2+

AMITRIPTILIN

25 150 mg malam
hari

2+

DIVALPROATE

400 1500 mg 2 x
sehari

2+

GABAPENTINE

900 2400 mg / hari

2+

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MEKANISME OBAT MIGREN

JENIS OBAT

MEKANISME KERJA

ACETAMINOPH Inhibisi sintesa PG di CNS, inhibisi

EN
aktifitas nosisept
ASPIRIN

Inhibisi sintesa PG dan leukotriene

NSAID

Inhibisi sintesa COX, PG,

lipoxygenase & leukotriene, PG
reseptor antagonis

CAFFEINE

Stimulasi reseptor adenosine

ERGOTS

Selective arterial constrictor yg

kuat

OPIOIDS

Stimulasi reseptor opioid endogen

STEROID

Anti inflamasi terhadap inflamasi

neurogenik steril, mengurangi

46

MEKANISME OBAT MIGREN

JENIS OBAT

MEKANISME KERJA

TRIPTANS

Berikatan dengan reseptor 5HT1B, 5HT1D, 5

HT1F, menginhibisi neuronal dengan cara
blokade aferen sensoris pada n.
trigeminal, memblokade pelepasan
vasoaktive peptide & juga proses
inflamasi neurovaskuler di meningens.
Juga efek vasokonstriksi pembuluh darah
serebral & dural.

PIZOTIFEN

5HT2 antagonis

SSRI
ANTIDEPRESSAN

Selective serotonin reuptake inhibitor

CYPROHEPTADINE

Potent 5HT1, & 5HT2 antagonist

BETABLOCKER

Antagonis reseptor 5HT2

47

PROGNOSIS
The risk of stroke increased two- to threefold in

migraine sufferers.
Young adult sufferers and women using
hormonal contraception particular risk.
Women who experience auras twice the risk
of strokes and heart attacks
Migraine sufferers at risk for both thrombotic
and hemorrhagic stroke as well as transient
ischemic attacks.
Death from cardiovascular causes higher in
people with migraine with aura
Etminan M, Takkouche B, Isorna FC, Samii A (2005). "Risk of ischaemic stroke in people with migraine:
Systematic review and meta-analysis of observational studies". BMJ 330 (7482): 63.
Becker C, Brobert GP, Almqvist PM, Johansson S, Jick SS, Meier CR (2007). "Migraine and the risk of
stroke, TIA, or death in the UK (CME).". Headache 47 (10): 137484.
Kurth, T; Kurth T, Gaziano JM, Cook NR, Logroscino G, Diener HC, Buring JE (2006). "Migraine and risk of
cardiovascular disease in women". JAMA 296 (3): 28391.

48

TAKE HOME MESSAGE

Migrain is one of the primary headache
The mnemonic POUNDing (Pulsating, duration of

472 hOurs, Unilateral, Nausea, Disabling) can

help diagnose migraine.
Has several triggers with stress being the most.
Can be treated with pharamacological therapy
(abortive and preventive) and nonpharmacological therapy.
Must be aware of CVD events in the future.

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THANK YOU

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