P A I Nfocus 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 painNeuropathic pain Combination

Pain Clinical Diagnosis

• History taking

• Physical examination, Neurological exam.

• Laboratory examination :

Lab.

Neurophysiology exam.

Neuroimaging

Visual Analog ScalesVisual Analog Scales

00 1010

NoNopainpain

ExcruciatingExcruciatingpainpain

00 1010

CompleteCompletepain reliefpain relief

NoNopain reliefpain relief

McQuay, 1998.Note: Lines must be exactly 100 mm long

FACES SCALES

THE DERMATOMES

Bagaimana Gejala Nyeri Neuropatik ?

HAS/Neuro/RSHS-FKUP

Nyeri Spontan Nyeri dibangkitkan stimulus

Syndromes of Epiconus, Conus and Cauda EquinaSyndrome of lumbal-radiculopathy

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)

Estimated Prevalence of NeP

HAS/Neuro/RSHS-FKUP

Indonesia : 40% population, men>women hospital based : 3-17%

Low Back Pain

Triage diagnostik LPBTriage diagnostik LPB

LBP nonspesifikLBP nonspesifik SindromaSindroma radikulerradikuler KelainanKelainan patologik seriuspatologik serius

“ “ Red FlagsRed Flags “ “

(Agency for Health Care Policy and Research, Bigos 1994)(Agency for Health Care Policy and Research, Bigos 1994)HAS/Neuro/2005

Low Back pain

• Seriuos pathology: neoplasm

infection

fracture

cauda equina syndrome

• Ischialgia, radicular syndrome

• Nonspecific LBP

Syndromes of Epiconus, Conus and Cauda EquinaSyndrome of lumbal-radiculopathy

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

Yellow Flags

• Recognition of psychosocial factors

as predictors of chronicity and

obstacles to recovery

Acute subacute chronic

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

ALL ACHES AND PAINS LOCATED IN THE HEAD

ORBITA OCCIPUT

HEADACHEDEFINITION :

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 :THE ROLE OF NEUROTRANSMITTER : SEROTONIN (5 HT) SEROTONIN (5 HT) THE ENDOGENOUS PAIN CONTROL MECHANISM -> OPIOIDTHE ENDOGENOUS PAIN CONTROL MECHANISM -> OPIOID GABAGABA

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

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

HISTORY taking:

HAS/NEURO

Faktor pencetus Nyeri Kepala

StresKurang/kebanyakan tidurTidak/telat makanBau menyengat : parfum,rokokLingkungan: cahaya silau/berkedip,gaduh ketinggian,panas,lembab ruang berasapMakanan/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

HAS/P3D

Trigeminal neuralgia

HEADACHE TREATMENT

• PRIMARY HEADACHE TREATMENT

Abortive

Preventive

• SECONDARY HEADACHE

TREATMENT

Causal Symtomatic : Analgesic

PRIMARY HEADACHE TREATMENT

TTHAbortive :Simple analg : acetaminophen/

ASA/NSAID

Preventive : Amitriptylin

Nonpharmacologic therapy

MIGRAINEAbortive :Simple analg : acetaminophen/

ASA/ NSAIDSpecific analg : ergot alkaloids ( ergotamine/ DHE )/ triptanAntiemetics : 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

EdukasiMengenal & menghindari faktor pencetus

Modifikasi perilakuLatihanRelaksasiBiofeedbackTerapi perilaku kognisiTerapi fisik

TENS (transcutaneus electric nerves stimulation)

HAS/Neuro/Bdg/04

(PERDOSSI,2001)

HAS/Neuro/2004

(Rowbotham MC, Petersen KL, 2001)

Antikonvulsants

(PERDOSSI,2001)HAS/Neuro/RSHS-FKUP

(I.C.H.E.)

MononeuropahiesMononeuropahies