PEMICU 6 – BLOK SISTEM SARAF

& KEJIWAAN
FALENISSA INCA B
 LEARNING ISSUE (LI)
1. Menjelaskan nyeri kepala primer
2. Menjelaskan nyeri kepala sekunder
3. Menjelaskan vertigo vestibular (sentral &
perifer)
 Migrain

Tension type
headache
Primer
Cluster headache

Paroxysmal
HEADACHE hemicrania

Subarachnoid
hemicrania

Low pressure
headache
Sekunder
Idiopathic intracranial
hypertension
Chronic daily
headache
Temporal arteritis

Trigeminal neuralgia
Facial pain
Postherpetic
neuralgia
Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012.
Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012.
LO 1 – NYERI KEPALA PRIMER
Brust JCM, editor. Current diagnosis & treatment
neurology. 2nd ed. New York: The McGraw-Hill
Companies Inc.; 2012. Unilateral /Bilateral Photophobia
Berdenyut Phonophobia
MIGRAINE Gejala
Nyeri leher Rhinorea
Mual / muntah Lakrimasi
Genetik
Migraine Klasik (dgn aura) 15-20%
- 50%> serangan 1x /minggu
- durasi > 2 jam dan < 24 jam
Migraine Klasifikasi
Migraine Umum (tanpa aura) 80%
- sering bilateral dan periorbital
- durasi 4-72 jam (dapat
diterminasi oleh muntah)

Faktor pemicu
Fase aura :
Patogenesis
Perubahan aktivitas neuronal

Konsumsi makanan Fase nyeri kepala :

- mengandung nitrit : ham, sosis, salami, bacon - dipicu secara perifer pada neuron
- mengandung MSG trigeminal sensorik primer
- cokelat yg mengandung phenylethylamine - gangguan primer pada jalur
Puasa, emosi, obat-obatan, menstruasi pusat nyeri
Cahaya terang
Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012.
TATALAKSANA
Farmakologi
Medikamentosa
– NSAID: acetaminophen, aspirin
dan kafein di approve FDA utk
mengatasi migren akut
– Agonis 5-HT1 (5-
hydroxytryptamine) per oral, nasal
atau parenteral [Triptan]
– Antagonis Dopamin per oral atau
parenteral
– Obat lain:
• Per oral: acetaminophen +
dichloralphenazone +
isometheptene
• Nasal: butorphanol
• Parenteral: meperidine IV (50-
100mg) pada pasien UGD
Nonfarmakologi
Nutrisi:
• Hindari makanan tertentu →
yang mengandung tiramin
• Pertahankan diet dan intake
cairan yang adekuat
• Perhatikan makanan-makanan
tertentu yang menimbulkan
gejala
• Batasi intake kafein
• Suplementasi → riboflavin,
koenzim Q10, magnesium
Remig VM, Weeden A. Medical nutrition therapy for
neurologic disorders. In Mahan LK, Stump SE, Raymond JL,
editors. Krause’s food and nutrition care process (chapter
41). 13th ed. St Louis: Saunders; 2012: p. 923-55.
Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012.
Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012.
 CLUSTER HEADACHE
Cepat dan berat
Selalu Unilateral
Tipe nyeri Tidak berdenyut
Konstan
Penyebab
Durasi 15 menit – 3 jam
belum
diketahui Pria > Wanita (4:1)
Epidemiologi
15 kasus per 100.000 orang
Cluster Aktivasi hipotalamus membuat
Headache Patogenesis ritme dan cluster nyeri mengikuti
irama sirkadian

- Sensasi terbakar pada lateral

Faktor pemicu hidung atau terasa tekanan pada
belakang mata
- Infeksi konjungtiva unilateral,
Gejala
lakrimasi
Konsumsi alkohol
- Kongesti nasal ipsilateral,
Konsumsi obat vasodilator
rhinorea
- Miosis atau ptosis ipsilateral
Brust JCM, editor. Current diagnosis & treatment - Keringat ipsilateral wajah/dahi
neurology. 2nd ed. New York: The McGraw-Hill
Companies Inc.; 2012.
- Agitasi
Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012.

TATALAKSANA
A. Acute Treatment
• Prompt relief of pain is achieved
by
– Inhalation of 100% oxygen (7-12
L/min for 15-20 minutes)
– Sumatriptan SC (6 mg, repeated
once per attack if necessary)
• Alternative abortive treatments
include intranasal
– Sumatriptan, zolmitriptan, or
lidocaine, subcutaneous octreotide.
B. Maintenance Prophylaxis
•Verapamil (80 mg three times daily or
sustained-release 240 mg/d; doses of
720 mg/d may be required).
• Anticonvulsants :
•valproic acid (500-2,000 mg/d),
gabapentin (300-3,600 mg/d), and
topiramate (50-200 mg/d)
•Melatonin (10 mg/d)
C. Transitional Prophylaxis
•Prednisone (40 to 80 mg/d orally for 1
week) and then discontinued by
tapering the dose over the following
week.
•Intravenous methylprednisolone or
dihydroergotamine may be useful as
well.
Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012.
 Tekanan
TENSION TYPE HEADACHE
Kontraksi otot leher dan (TTH)
otot scalp

Mekanisme
Tension
Faktor pemicu tidak
Headache
diketahui

Tipe nyeri Epidemiologi Gejala

Rasa seperti ditekan Terjadi 35 – 78% - Tidak ada mual/muntah

Bilateral, tidak berdenyut
Tidak diperberat oleh aktivitas
Intensitas ringan hingga sedang
Durasi 30 menit – 7 jam
Dapat terjadi sampai 10 episode
dalam wkt kurang dari 1 hari
Wanita > Pria - Tidak terjadi gangguan
pengelihatan
- Photophobia atau phonophobia
tapi tidak keduanya
Brust JCM, editor. Current diagnosis & treatment
neurology. 2nd ed. New York: The McGraw-Hill
Companies Inc.; 2012.
Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012.
TATALAKSANA

• Same agents used for • For prophylactic

migrain treatment :
• Acute attacks – Amitriptyline,
– Aspirin, nonsteroidal nortriptyline, or
anti-inflammatory drugs, imipramine is often
or acetaminophen. effective, and
propranolol
– Tension-type headache
in migraineurs may • Massage, physical
respond to triptans. therapy, and relaxation
techniques

Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012.

MANISFESTASI MIGRAINE CLUSTER TENSION
KLINIS

KARAKTERISTIK Pulsatil Seperti ditusuk Tertekan dan terikat

NYERI

KEPARAHAN Sedang - Sangat berat Ringan – sedang

berat

LOKASI Biasanya Selalu unilateral ( Bilateral, biasanya

unilateral okular, frontal, mengenai kepala dan
temporal ) leher

DURASI 4- 72 jam 30 menit – 3 jam 30 menit – 7 hari

FREKUENSI Episodik 2 hari sekali hingga Biasanya < 15 hari/bulan
8x/hari

GEJALA Mual, Lakrimasi, nasal atau Tidak ada atau fotofobia

PENYERTA muntah, konjungtiva kongesti atau fonofobia ringan
fonofobia, dan rhinorhea
fotofobia
TRIGEMINAL NEURALGIA
• Etiologi : Penekanan saraf Faktor pemicu
trigeminal oleh neoplastik, Infeksi, • Berbicara, mengunyah, tersenyum
Ggg. Otot2 yg punya hubungan dgn • Minum air panas / Dingin
kepala, Ketegangan otot kepala,
leher bahu • Sikat gigi, menyisir rambut,
bercukur, makan
• Patfis : Tic doloreux nyeri
mengikuti distribusi N. V, nyeri Pemeriksaan :MRI
kuat, dan tajam Farmakoterapi : Carbamazepine /
• FR : Wanita > laki2 Baclofen, Neurosurgical treatment
• Gejala :
- Nyeri tiba2, tajam, superficial
unilateral seperti ditusuk/ dibakar
(mandibular &maxillary)
- Sensasi nyeri di wajah di picu
beberapa stimulus

Brust JCM, editor. Current diagnosis & treatment

neurology. 2nd ed. New York: The McGraw-Hill
Companies Inc.; 2012.
Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012.
LO 2 – NYERI KEPALA SEKUNDER
 GIANT CELL ARTERITIS/TEMPORAL ARTERITIS

• Epidemiology
– Women, <60 years
• Characterized pathologically
– Subacute granulomatous inflammation (consisting of
lymphocytes, neutrophils, and giant cells).
• Symptom
– Nonspecific headache  unilateral or bilateral
– Scalp tenderness  especially apparent when lying with the
head on a pillow or brushing the hair
– Jaw claudication  Pain or stiffness in the jaw during chewing
– Ocular involvement  transient visual obscurations in one or
both eyes lasting minutes to a few hours
– Ophthalmic artery  visual loss

Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012: 146-7
Treatment
• Initial therapy :
– Prednisone 60 to 100 mg/d orally.
– The dose is decreased, usually after 1 to 2 months,
depending on the clinical response.

• Alternatively, treatment can be started :

– Intravenous methylprednisolone (500-1,000 mg every
12 hours for 2 days)
– The sedimentation rate returns rapidly toward normal
with prednisone therapy and must be maintained
within normal limits as the drug dose is tapered over 1
to within 2 to 3 days after institution of therapy,
associatedblindness is usually irreversible.

Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012: 146-7
MENINGITIS/ENSEFALITIS
Pathophisiology
• Headache is a prominent
feature of inflammation of the
brain (encephalitis) or its
meningeal coverings
(meningitis)
– Caused by bacterial, viral, or
other infections, as well as
granulomatous processes,
neoplasms, or chemical
irritants.
• The pain
– Inflammation of intracranial
painsensitive structures,
including blood vessels at the
base of the brain.
Diagnose
•Headache
•Throbbing in character,
bilateral, and occipital or
nuchal in location.
•Its severity  sitting
upright, moving the head,
compressing the jugular
vein, or performing other
maneuvers (eg: sneezing,
coughing)
•Photophobia
Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012: 144-5
SINUSITIS

• Acute sinusitis  produce pain and tenderness

localized to the affected frontal or maxillary sinuses.
Inflammation in the ethmoidal or sphenoidal sinuses
produces a deep midline pain behind the nose.
• Sinusitis pain is increased by bending forward and by
coughing or sneezing.
• Treated
– Vasoconstrictor nose drops (eg : phenylephrine, 0.25%,
instilled every 2-3 hours), antihistamines, and antibiotics.
In refractory cases, surgical sinus drainage may be
necessary.

Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012: 149
HIPERTENSI INTRAKRANIAL IDIOPATIK

• Epidemiology
– Women, third decade, obese
• Diffuse increase in intracranial pressure that can cause
headache of variable character :
– Papilledema, pulsatile tinnitus, visual loss, and diplopia (from
abducens [VI] nerve palsy).
• Pathogenesis : impaired CSF absorption

• Treatment :
– Acetazolamide (1-2 g/d) or topiramate
– Corticosteroids
• But have untoward side effects, and papilledema tends to rebound
when they are discontinued.
– Obese patients should be encouraged to lose weight.

Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012: 149
HIPERTENSI INTRAKRANIAL IDIOPATIK

• Epidemiology
– Women, third decade, obese
• Diffuse increase in intracranial pressure that can cause
headache of variable character :
– Papilledema, pulsatile tinnitus, visual loss, and diplopia (from
abducens [VI] nerve palsy).
• Pathogenesis : impaired CSF absorption

• Treatment :
– Acetazolamide (1-2 g/d) or topiramate
– Corticosteroids
• But have untoward side effects, and papilledema tends to rebound
when they are discontinued.
– Obese patients should be encouraged to lose weight.

Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012: 149
HIPERTENSI INTRAKRANIAL IDIOPATIK

• Epidemiology
– Women, third decade, obese
• Diffuse increase in intracranial pressure that can cause
headache of variable character :
– Papilledema, pulsatile tinnitus, visual loss, and diplopia (from
abducens [VI] nerve palsy).
• Pathogenesis : impaired CSF absorption

• Treatment :
– Acetazolamide (1-2 g/d) or topiramate
– Corticosteroids
• But have untoward side effects, and papilledema tends to rebound
when they are discontinued.
– Obese patients should be encouraged to lose weight.

Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012: 149
Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012: 149
INTRACRANIAL MASS

• Headaches + brain tumors are most often 

nonspecific in character, mild to moderate in
severity, dull and steady in nature, and
intermittent.
• The pain is characteristically : bifrontal, worse
ipsilaterally, and aggravated by a change in
position or by maneuvers that increase
intracranial pressure (ex. coughing, sneezing, and
straining)
• Maximal on awakening in the morning, nausea
and vomiting

Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012: 147
Aminof MJ, et al. Clinical neurology. 9th edition. Lange: 2012: 147
 LO 3 – MENJELASKAN VERTIGO
VESTIBULAR (SENTRAL & PERIFER)
DEFINITION • Most vertigo is caused by an acute asymmetry or imbalance
of neural activity between the left and right vestibular
system.
• Peripheral  tinnitus / hearing loss, nausea, vomiting
• Central  diplopia, dysarthria, dysphagia, or other symptoms
of brainstem dysfunction indicate a central process. Ability to
walk or maintain posture may be more impaired with central
disease
ETIOLOGY Spontaneus Vertigo : Positional vertigo :
• Single prolonged • Peripheral
episode • BPPV
• Vestibular neuronitis • Central
• Labyrinthine
concussions
• Lateral medullary /
cerebellar infarction
• Recurrent episodes
• Meniere disease
• Perilymph fistula
• Migraine
• Posterior circulation
ischemia
Neurology blueprints Ed.3 & clinical neurology lange Ed.7
SIGN AND • Statement that objects in the
SYMPTOM environment have spun
around/moved rhythmically in one
direction/that a sensation of
whirling of the head & body
• Up & down movement of the body,
usually the head
• Floor or wall may seem to tilt/to
sink/rise up
• In walking the patient may have
had sensation of leaning/ being
pulled to the ground/to one side or
another (static tilt)
• Being drawn by strong magnet
Vestibular neuronitis
- present as an acute unilateral
peripheral vestibulopathy
- Spontaneous, nausea,
vomiting, nystagmus
unilateral
- Onset : over minutes to hour cerebellum
- Recovery represent central
compensation for the loss of
peripheral vestibular function
• Oscillopsia  illusionary movement
of the environment
• Abruptness & severity  virtually
throw the patient to the ground
• Mildest form  vertigo+nausea,
vomitting, palor, perspiration, some
difficulty with walking
Labyrinthine concussion
- May result from head injury
irrespective of whether there
is an associated skull fracture
- Hearing loss, tinnitus
Infarction of the labyrinth, brainstem, or
- Deafness, nystagmus, weakness,
ataxia, or sensory changes that
clearly indicate a central process
SIGN AND Meniere disease
SYMPTOM - Episodic vertigo, nausea, vomiting, fluctuating but
progressive hearing loss, tinnitus, sensation of fullness
or pressure in the ear
- Caused by an intermittent increase in endolymphatic
volume

Perilymph fistula
- Disruption of the lining of the endolymphatic system
- Patient reports hearing a “pop” at the time of a sudden
increase in middle ear pressure with sneezing, nose
blowing, coughing, straining
- Abrupt onset of vertigo

Neurology blueprints Ed.3 & clinical neurology lange Ed.7

 BENIGN POSITIONAL PAROXYSMAL VERTIGO (BPPV)

DEFINITION • Precipitated by changes in position, maybe associated severe

nausea and vomiting
• The attacks are brief, usually lasting seconds to minutes
• Attacks occur most frequently when the individual is reclining in
bed at night or upon awakening in the morning

PATOPHYSIOLOGY • BPPV results from freely moving crystals of calcium carbonate

within one of the semicircular canals
• Head is stationary  crystal settle in the most deprendent part of
the canal (usually posterior)
• head movement  the crystals move more slowly than the
endolymph within which they lie
• Their inertia causes illusion of movement (vertigo)

DIAGNOSIS • Diagnosis is established by demonstrating the characteristic

downbeating and torsional nystagmus with the dix-hallpike test.

Neurology blueprints Ed.3 & clinical neurology lange Ed.7

Adam and Victor’s Principle of Neurology. 10th edition
Diagnosis (Dix-Hallpike maneuver)

Adam and Victor’s Principle of Neurology. 10th

edition
Adam and Victor’s Principle of Neurology. 10th
edition
 Treatment

Adam and Victor’s Principle of Neurology. 10th edition

PENYAKIT MENIERE

• Penyakit meniere : penyakit multifaktorial yg

menyebabkan kelainan di telinga dalam,
manifestasi vertigo episodik + ggg
pendengaran fluktuatif.

• Patofisiologi
– Teori hidrops endolimfatik
– Korelasi dengan kondisi metabolik, hormon, alergi,
stres

Buku neurologi FKUI

• Tanda dan gejala :
– Vertigo, tinitus, gangguan pendengaran
– 2 tahap
• Tahap fluktuasi
• Tahap neural

• Diagnosis
– Anamnesis
• Onset dan durasi vertigo
• Faktor pencetus dan yg memperberat
• Gejala lain yg menyertai
– PF & neuro : defisit neurologis
– PP : audiometri, EKG, BAEP

• DD : migren basilar
• Prognosis : baik dan dapat sembuh spontan

Buku neurologi FKUI