PAIN

focus on

LBP and HEADACHE

Henny Anggraini Sadeli

Neurological Departement
FMUP
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
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
THE DERMATOMES
 Bagaimana Gejala Nyeri Neuropatik ?

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

 Syndromes of Epiconus, Conus
Syndrome of lumbal-radiculopathy 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 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

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
 Syndromes of Epiconus, Conus
Syndrome of lumbal-radiculopathy 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:
 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 • 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 HA Cranial Neuralgias,Central Pain
abortive : (Neuropathic Pain) Treatment
– o2 inhalation • Antidepressants
– ergot alkaloids, • Anticonvulsants
– triptans • Antiarrhitmic
• Local anesthetic
preventive :
– verapamil
– ergot alkaloid
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)

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

(I.C.H.E.)