PAIN

focus on

LBP and HEADACHE

Henny Anggraini Sadeli

Neurological Departement
FMUP
 PAIN
is unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in term of such damage ( IASP, 1986 )

Nociceptive pain Neuropathic pain Functional pain

Inflammatory pain

Musculoskeletal pain Neuralgia Headache

Painful neuropathy Fibromyalgia
CPSP IBS
Mixed type pain

Low back pain

Neck pain
CTS
 Bagaimana Gejala Nyeri Neuropatik ?

HAS/Neuro/RSHS-FKUP Nyeri Spontan Nyeri dibangkitkan stimulus

 Visual Analog Scales
No Excruciating
pain pain

0 10

Complete No
pain relief pain relief

0 Note: Lines must be exactly 100 mm long

10
McQuay, 1998.

FACES SCALES
 LOW BACK PAIN
(NYERI PUNGGUNG BAWAH)

• Nyeri di antara sudut iga terbawah dan

lipat bokong bawah yaitu di daerah lumbal
atau lumbo-sakral dan sering disertai
dengan penjalaran nyeri kearah tungkai-
kaki
 Pain sensitive L-S structures
• Skin, subcutaneous, adipose tissue
• Muscles
• Facet joints, sacroiliaca joints
• Post/ant.longitudinal lig.
• Periosteum vertebra (fascia,tendon,aponeurosis)
• Nerve roots
• Blood vessels (spinal joint,sacroiliaca joint, verteb,
L-S muscles)
 Low Back Pain

Nonspecific LBP radicular syndrome Seriuos pathology

Red Flags

Cancer/neoplasm
Infection
Vertebral fracture
Cauda equina syndrome/
Severe neuro. deficit
 Syndromes of Epiconus, Conus
lumbal-radicular pain and Cauda Equina
 Risk Factors of LBP
• Physical : 35 – 55 y
past history of LBP

• Occupational : vibration
bending, twisting
heavy lifting
low job satisfaction

• Psychosocial : attitudes
cognition
fear-avoidance beliefs
depression
anxiety
distress and related emotion
 Acute LBP  subacute  chronic LBP
6-12 w >3mo

Yellow Flags
• Recognition of psychosocial factors
as predictors of chronicity and
obstacles to recovery
 Management of
acute nonspecificLBP
• Diagnostic triage :
History taking and
physical examination to exclude red flags
Neurological examination (including Lassegue test)
• Reassurance
• Early and progressive activation
• Analgetics (?): acetaminophen / NSAID
consider muscle relaxants
• Recognition yellow flags
 Management of Chronic
nonspecific LBP
• Behavioral therapy
• Education
• Intensive exercise therapy
Multidisciplinary
WHO step ladder, CA pain
 HEADACHE

ALL ACHES AND PAINS LOCATED IN THE HEAD

ORBITA  OCCIPUT
HAS/P3D
 The International Classification of Headache Disorders
ICHD 2 ( IHS 2004 )

The Primary Headaches

Migraine
Tension-type headache (TTH)
Cluster headache
Other primary headaches

The Secondary Headaches

Headache attributed to head and/or neck trauma
Headache attributed to cranial or cervical vascular disorders
Headache attributed to non-vascular intracranial disorders
Headache attributed to a substance or its withdrawal
Headache attributed to infection
Headache attributed to disorder of homoeostasis
Headache or facial pain attributed disorder of cranial, neck, eyes, ears,
nose, sinuses, teeth, mouth or other facial or cranial structures
Headache attributed to psychiatric disorders

Cranial Neuralgias, central & primary facial pain & other headaches
Cranial neuralgias & central causes of facial pain
Others headache, cranial neuralgias & central or primary facial pain
PAIN SENSITIVE CRANIAL STRUCTURES
• Skin,subcutan., muscle
• Extracranial arteries
• Skull periosteum
• Eye,ear, nasal cavities,
sinuses
• Intracran.venous sinuses,
large vein, pericavernous
structures
• Basis dura, meningeal
arteries, prox.ant/middle
cerebral A, IC int.carotis A
• Superf.temporal A
• Cranial nerves:II.III,V,IX,X,C1-3
THE ROLE OF NEUROTRANSMITTER :
SEROTONIN (5 HT)
THE ENDOGENOUS PAIN CONTROL MECHANISM -> OPIOID
GABA
 MECHANISMS OF CRANIAL PAIN :

 TRACTION ON OR DILATATION OF THE INTRACRANIAL ARTERIES

 DISTENTION OF EXTRACRANIAL ARTERIES
 TRACTION ON OR DISPLACEMENT OF THE LARGE INTRACRANIAL VEINS OR
DURAL ENVELOPE
 COMPRESSION, TRACTION OR INFLAMATION OF THE CRANIAL AND SPINAL
NERVES
 SPASM, INFLAMATION & TRAUMA TO CRANIAL & CERVICAL MUSCLE
 DISEASE OF THE TISSUES OF THE SCALP, FACE, EYE, NOSE, EAR AND NECK

 MENINGEAL IRRITATION
 INTRACRANIAL MASS LESION
 RAISED INTRACRANIAL PRESSURE
LOWERED INTRACRANIAL PRESSURE : LP HEADACHE
HISTORY taking:
 ATTACK ONSET
 QUALITY
 SEVERITY
 LOCATION
 MODE OF ONSET
 TIME, INTENSITY, CURVE, DURATION
 CONDITION WHICH EXACERBATE / RELIEVE THE PAIN
 ASSOCIATED FEATURES
 SOCIAL HISTORY, FAMILY HISTORY
 PAST HEADACHE HISTORY
 HEADACHE IMPACT
HAS/NEURO
 Faktor pencetus Nyeri Kepala

Stres
Kurang/kebanyakan tidur
Tidak/telat makan
Bau menyengat : parfum,rokok
Lingkungan: cahaya silau/berkedip,gaduh
ketinggian,panas,lembab
ruang berasap
Makanan/minuman

HAS/Neuro/Bdg/04
RED FLAGS of HEADACHE
 Secondary Headache Red Flags
“SSNOOP”
• Systemic symtoms (fever, weight loss) or
• Secondary risk factors : underlying diseases
(HIV,systemic cancer)
• Neurologic symtoms or abnormal signs (confusion,
impaired alertness,or consciousness)
• Onset: sudden,abrupt, or split-second (first,worst)
• Older: new onset and progressive headache, especially
in middle age>50 (giant cell arteritis)
• Previous headache history or headache progression:
pattern change, first headache or different
(change in attack frequency, severity, or clinical pictures)
 MIGRAINE

HAS/P3D
 Tension Type Headache
• Psychologic factors
• Muscle contraction and myofacial tenderness
• Vascular factorsn : NO
• Humoral factors : 5HT
• Central factors : central pain control system

Episodic TTH : infrequent & frequent ETTH

Chronic TTH
Assosiated with disorder of pericranial muscles
Unassociated with disorder of pericranial muscles
Probable TTH (ICHD-2)
CLUSTER HEADACHE
YOUNG ADULT MEN ( M : F = 5 : 1 )
UNILATERAL PAIN

HAS/NEURO
Trigeminal neuralgia & Post Herpetic Neuralgia

HAS/P3D
 HEADACHE TREATMENT

• PRIMARY • SECONDARY
HEADACHE HEADACHE
TREATMENT TREATMENT
Abortive Causal
Preventive Symtomatic : Analgesic
 PRIMARY HEADACHE TREATMENT
TTH MIGRAINE

Abortive : Abortive :
Simple analg : acetaminophen/ Simple analg : acetaminophen/
ASA/NSAID ASA/ NSAID
Specific analg : ergot alkaloids
( ergotamine/ DHE )/
triptan
Antiemetics : metoclopramide/
domperidone
Preventive :
Amitriptylin
Preventive :
Anticonvulsants /
Adrenoceptor blockers (propranolol)/
Antidepressants/
Ca-channel blockers
Nonpharmacologic therapy
Nonpharmacologic therapy
CLUSTER CRANIAL NEURALGIA
HEADACHE (Neuropathic Pain)

abortive : • Antidepressants : TCA,SNRI

– O2 inhalation • Anticonvulsants
– ergot alkaloids • Local anesthetics
– triptans
• Nonpharmacologic therapy

preventive :
– verapamil
– ergot alkaloid
Nonpharmacologic tx
Penanganan tanpa obat
Edukasi
Mengenal & menghindari faktor pencetus

Modifikasi perilaku
Latihan
Relaksasi
Biofeedback
Terapi perilaku kognisi
Terapi fisik
TENS (transcutaneus electric
nerves stimulation)

HAS/Neuro/Bdg
 Neuropathic pain

Inflammatory pain
(PERDOSSI,2001)