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Consultant neurologist
Head, Department of Neurology
Sumatera Utara University
Member of International Headache Society
Chair Advisory of Indonesian Headache
study Group
Headache
sefalgia = NYERI KEPALA
epidemiology
prevalence
life
time
of
headache are 90% male and
96% female
Migraine
6 - 9% man, 15-18% woman.
Young adult age
Genetic factor 70%
PREVALENCE MIGRAINE
female
male
Epidemiology in Indonesia
(hospital base)
Prevalence life time TTH 78%
Episodic TTH 63% male 56% ,female
71%
TTH chronic 3% male 2 % ,female 5%
ETTH(Indonesia 31%, Medan 9.8%)
CTTH (Indonesia 24%, Medan 44%)
Migraine =10% (Indonesia)
Without aura( Medan 6.3%)
with aura (Medan 1.8%)
Pathophysiology theory of
headache
1.Sensitization
2.theory vasodilatation
3.activation
trigeminovascular
4.Steril inflammation neuron
5.cortical spreading
depression,
6.activation rostral
brainstem
7.activity imbalance brain
stem nuclei regulating
antinoception with
vascular control
8.etc
HEADACHE CLASSIFICATION
PRIMARY HEADACHE
1. Migraine
2. Tension Type Headache
3. Cluster Headache & other trigeminal
autonomic chephalalgias
4. Other primary headache
SECONDARY HEADACHE
Other headache, cranial neuralgia,
central or primary facial pain
International Headache
Classification (IHS)2004
1. Migraine
1.1 Migraine without aura
1.2 Migraine with aura
1.2.1
1.2.2
1.2.3
1.2.4
1.2.5
1.2.6
Typical aura
Hemiplegic migraine
Basilar migraine
Cyclical vomiting
Abdominal migraine
Benign paroxysmal
vertigo childhood
4. RETINAL MIGRAINE
5. COMPLICATIONS OF MIGRAINE
6. PROBABLE MIGRAINE
Chronic migraine
Status migrainosus
Persistent aura without infarctio
Migrainous infarction
Migraine-triggered seizures
Unilateral
Pulsating
Moderate or severe pain
Agravation by physical activity
Sporadic hemiplegic
migraine
criteria idem FHM
No family history
Normal CT Scan &
EEG
Retinal migraine
Rare
At least 2 attacks scintillating,
scotoma, blindness
Unilateral (only one eye)
Follows with migraine with aura
No attributed to another
disorders
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%),
Kelman L. Cephalalgia 2007; 27:394402.
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%).
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/sweety
2.Tension-type headache
2.1 Infrequent episodic tension-type
headache
2.1.1 Infrequent episodic tension-type headache
associated with pericranial tenderness
2.1.2 Infrequent episodic tension-type headache
not associated with pericranial tenderness
4. Other primary
headaches
Primary stabbing headache
4.1
4.2 Primary cough headache
4.3 Primary exertional headache
4.4 Primary headache associated with
sexual activity
4.4.1 Preorgasmic headache
4.4.2 Orgasmic headache
4.5 Hypnic headache
4.6 Primary thunderclap headache
4.7 Hemicrania continua
4.8. New daily-persistent headache (NDPH)
Hypnic headache
(alarm clock headache)
Attack during sleep
> 15 X /month
15-30 minutes
Age > 50 years
Bilateral
Mild-moderate
5. Headache attributed to
head and/or neck trauma
5.1 Acute posttraumatic headache
5.1.1 Acute posttraumatic headache
attributed to moderate or severe head injury
5.1.2 Acute posttraumatic headache
attributed to mild head injury
Medication over-use
triptan, ergotamines, opioid,
combination analgesic > 10
days/month
Simple analgesic > 15 days/months
MENSTRUAL
MIGRAINE
38
39
TERAPI
Triptan:
starting 3 days before the anticipated
onset of MAM and continuing for 6 days.
Aspirin 500-1000 mg
Aspirin 900 mg+metoclopramide 10 mg
Naproxen sod 750-1250 mg
Ibuprofen 400-2400 mg
Paracetamol 500 mg+aspirin 500 mg+ caffein
130 mg
Abortif specific:
Triptan,
dihydroergotamine,
ergotamine
42
Propranolol
40320 mg twice daily
Timolol
20-60 mg daily
Pizotifen
0.5 mg 1.5 mg/daily
Flunarizine
5 10 mg/daily
Amitriptyline
25150 mg at bedtime
Divalproate
4001500 mg twice daily
Topiramate
25200 mg daily
Therapy TTH
:pharmacological
Analgetic : 2 days/week (Avoiding
medication overuse )
Aspirin 1000 mg/day, parasetamol 1000 mg/day,
NSAIDs, NSAIDs and acetaminophen (with or without
caffeine), butalbital
Antidepressant:
Sedating : amitriptilin, doxepin, imipramin,
trazodone
Non sedating: fluoxetine, sertraline, bupropion
Antianxiety:
benzodiazepin,: buspiron, lorazepam,
alprazolam, diazepam
Therapy behaviour:
Biofeedback, stress management therapy,
conseling, relaxation therapy, cognitive behaviour
th/
Cluster Headache
Acute
Paroxysmal
Hemicrania
None
SUNCT
Syndrome
None
Indomethacin (A)
May, et al.2006
Lenaerts, 2008
48
VERTIGO
Prof.Hasan Sjahrir MD
PhD
Department of
Neurology
Sumatera Utara
University, Medan
epidemiology
Vertigo is a common complaint in the
general population
In population-based studies:
Vertigo occurs in 47% of people1, 2
Vertigo accounts for 2530% of dizziness
presentations3
What is vertigo?
Vertigo is:
A type of dizziness
Specifically, a sensation of movement
typically characterised by feelings of
rotation or spinning
Dizziness: trouble feeling of body balance
to vinicity room = giddiness
Vertigo come from Latin word vertere
with the meaning spinning turning around.
Baloh RW. Lancet 1998;352:1841-6. Mukherjee A et al. JAPI 2003;51:1095-101.
Sloane PD et al. Ann Intern Med 2001;134:823-32
Subjective Vertigo:
The patient feels himself/herself moving
in a static environment
2. System visual
3. system proprioceptive ,
4. cerebellar ,
5. systemic haemostatic
6. psychogenic
Vestibular system
Central
Nuclei vestibuler at
medulla oblongata,
cerebelum and
Connecting Central
Pathway
peripheral
end organ vestibuler
canalis semisircularis
utriculus
sacculus
saccu-endolimpaticus
ganglia vestibularis
Scarpey
nervus vestibuler.
Vertigo episodes
Vertigo episodes:
are characterised by a sensation of
movement, usually spinning or rotating
vary in intensity and duration
are usually unpredictable
are often accompanied by:
nausea
vomiting
imbalance
anxiety
sweating
nystagmus
Vertigo: causes
Etiology
1. BPPV(Benign paroxysmal positional vertigo)
2. Stroke /TIA
3. Menieres syndrome
4. Migren vertebrobasiler
5. Spasmofilia
6. Parese vestibular unilateral
7. Parese vestibular bilateral
8. Nistagmus
9. Dysfunction middle ear
10.Dysfunction ganglia basalis
11.Ataxia serebellar
12.Epilepsi
Vertigo/ dizziness
I.Vestibulogenic
dizziness
Vertigo central (sec
vestibular
disorders)
Vertigo peripheral
(primary vestibular
disorders)
II.Non Vestibular
causes of
dizziness:
-Cerebellar disorders
-Hyperventilation
syndrome :anxiety
-Psychogenic dizziness :
hysterical
-postural
hypotension,paroxysmal
sinus tachycardi
-anemia,dehidrasi
subclavian steal
syndrome
Minutes or hours
A day or more
BPPV
Menieres disease
Vestibular neuritis
Perilymph fistula
Multiple sclerosis
Ischaemia impacting
on the brain stem
Migraine
Transient ischemic attack
Current management
options
Effective management requires
identification of vertigo type and cause
Aim of treatment:
Treat the underlying cause
Pharmacotherapy
Particle repositioning procedure
Surgery
Manage symptoms
Pharmacotherapy
pharmacotherapy
Treatments to manage vertigo symptoms
Vestibular suppressants
Meclizine, dimenhydrinate, diazepam
Anti-emetics
Prochlorperazine, metoclopramide
Causal
Menieres disease
Diuretics
Transtympanic gentamicin
Migraine
Beta-blockers
Calcium channel blockers
Tricyclic amines
Treatment
Peripheral causes
BPPV
Labyrinthine concussion
Vestibular rehabilitation
Menieres disease
Labyrinthitis
Perilymph fistula
Vestibular neuritis
Central causes
Migraine
Vascular disease
Cerebellopontine tumours
Surgery
Baloh RW. Lancet 1998;352:18416. Goebel JA. Otolaryngol Clin North Am 2000;33:48393.
The end