PAIN
focus on
LBP and HEADACHE
Department Of Neurology
dr. Hasan Sadikin Hospital Padjadjaran University
Definition of PAIN
Pain is unpleasent sensory and emotional
experience associated with actual or potential
tissue damage, or discribed in term of such
damage ( IASP, 1986 )
Types of pain :
Nociceptive pain, inflamatory pain
Neuropathic pain
 Combination
Pain Clinical Diagnosis
• History taking
• Physical examination, Neurological exam.
• Laboratory examination :
Lab.
Neurophysiology exam.
Neuroimaging
Visual Analog Scales
Excruciating
pain
No
pain
0
10
Complete
pain relief
No
pain relief
0
McQuay, 1998.
Note: Lines must be exactly 100 mm long
FACES SCALES
10
THE DERMATOMES
Bagaimana Gejala Nyeri Neuropatik ?
HAS/Neuro/RSHS-FKUP
Nyeri Spontan
Nyeri dibangkitkan stimulus
Syndrome of lumbal-radiculopathy
Syndromes of Epiconus, Conus
and Cauda Equina
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 tungkaikaki
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)
Estimated Prevalence of NeP
Indonesia : 40% population, men>women
hospital based : 3-17%
HAS/Neuro/RSHS-FKUP
Low Back Pain
Triage diagnostik LPB
LBP nonspesifik
Sindroma radikuler Kelainan patologik serius
“ Red Flags “
HAS/Neuro/2005
(Agency for Health Care Policy and Research, Bigos 1994)
Low Back pain
• Seriuos pathology: neoplasm
infection
fracture
cauda equina syndrome
• Ischialgia, radicular syndrome
• Nonspecific LBP
Syndrome of lumbal-radiculopathy
Syndromes of Epiconus, Conus
and Cauda Equina
Low Back Pain
• Diagnostic triage
• History taking and physical examination to
exclude red flags
• Neurological examination (including
Lassegue test)
• Consider psychosocial factors if there is no
improvement
• X-rays, MRI ??
Red Flags of LBP
•
•
•
•
Cancer
Infection
Vertebral fractur
Cauda equina syndrome or
Severe neurological deficit
Acute  subacute  chronic
Yellow Flags
• Recognition of psychosocial factors
as predictors of chronicity and
obstacles to recovery
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
Management of
acute LBP
•
•
•
•
Diagnostic classification, D/ triage
Reassurance
Early and progressive activation
Analgetics ?: acetaminophen
NSAID
consider muscle relaxants
• Recognition yellow flags
HAS/P3D
Management of Chronic LBP
• Behavioral therapy
• Education
• Intensive exercise therapy
Multidisciplinary
HEADACHE
HAS/P3D
HEADACHE
DEFINITION :
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
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
MECHANISM OF CRANIAL PAIN (con’d)
 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:
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








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)
HAS/P3D
HAS/P3D
CLUSTER HEADACHE
YOUNG ADULT MEN ( M : F = 5 : 1 )
UNILATERAL PAIN
HAS/NEURO
Tension Type Headache
•
•
•
•
•
Psychologic factors
Muscle contraction and myofacial tenderness
Vascular factorsn : NO
Humoral factors : 5HT
Central factors : central pain control system
HAS/P3D
PHYSICAL EXAMINATION
NEUROLOGICAL EXAMINATION
Trigeminal neuralgia
HAS/P3D
HEADACHE TREATMENT
• PRIMARY
HEADACHE
TREATMENT
Abortive
Preventive
• SECONDARY
HEADACHE
TREATMENT
Causal
Symtomatic : Analgesic
PRIMARY HEADACHE TREATMENT
TTH
Abortive :
Simple analg : acetaminophen/
ASA/NSAID
Preventive :
Amitriptylin
Nonpharmacologic therapy
MIGRAINE
Abortive :
Simple analg : acetaminophen/
ASA/ NSAID
Specific analg : ergot alkaloids
( ergotamine/ DHE )/
triptan
Antiemetics : metoclopramide/
domperidone
Preventive :
Anticonvulsants /
Adrenoceptor blockers (propranolol)/
Antidepressants/
Ca-channel blockers
Nonpharmacologic therapy
CLUSTER HA
abortive :
– o2 inhalation
– ergot alkaloids,
– triptans
preventive :
– verapamil
– ergot alkaloid
Cranial Neuralgias,Central Pain
(Neuropathic Pain) Treatment
• Antidepressants
• Anticonvulsants
• Antiarrhitmic
• Local anesthetic
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/04
(PERDOSSI,2001
HAS/Neuro/2004
Antikonvulsants
(Rowbotham MC, Petersen KL, 2001)
HAS/Neuro/RSHS-FKUP
(PERDOSSI,2001)
Mononeuropahies
(I.C.H.E.)