Management of

Headache
ANLS, 2016
Jakarta, 16 - 17 Januari 2016
 Objektif

• Algoritma utk menilai dan mengobati pasien

yg datang ke Unit Gawat Darurat dgn keluhan
utama Sefalgia (Headache) atau rasa berputar
(vertigo)
 Pendahuluan
Sakit kepala ungkapan pasien beraneka ragam tapi
dapat dibedakan dalam dua kelompok yaitu : pusing
(dizziness/vertigo) dan sakit Kepala (headache)

1. Headache 2. Dizziness (Vertigo)

- sakit kepala - pusing
- nyeri kepala - tujuh keliling
- kepala berdenyut - kepala terasa enteng
cekot-cekot - kepala terasa goyang
 Headache (Sefalgia)
Pain or discomfort between the orbits
and occiput arising from pain sensitive structures.
 Struktur Kranial/Kepala
yang Peka Nyeri
Peka Nyeri Tidak Peka Nyeri
• Kranial : venous sinuses dgn  Parenchyma Otak
v. aferent
 Ependyma
• Arteri pd basis serebri dan
 Choroid
cabang-cabang arteri besar.
• Arteri dura  Pia
• Dura dekat basis otak dan  Arachnoid
cabang arteri besar.  Dura permukaan konvek
• Semua struktur extrakranial
 Tulang kepala/skull
 Mekanisme Umum
Nyeri Kepala
• Traksi pd pembuluh darah besar intrakranial.
• Distensi, dilatasi pd arteri intrakranial
• Inflammasi dekat struktur peka nyeri
• Tekanan langsung pd n. cranialis atau cervical
• Kontraksi otot penopang kepala atau leher
• Stimulasi karena penyakit mata, telinga,
hidung dan sinus.
 Epidemiologi
• 60-75% orang dewasa mengalami nyeri kepala
1x per tahun.
• 5-10% akan meminta evaluasi dari Dokter
• 2.8 juta orang/thn ke UGD krn nyeri kepala
• Kurang dari 10% pasien UGD dgn keluhan utama
nyeri kepala karena kausa sekunder emergensi.
 CLASSIFICATION of HEADACHE
International Headache Society (IHS)

2004 (WHO ICD-10NA)

I. Primary Headache
II. Secondary Headache
III. Cranial neuralgias central and primary
facial pain and other headaches
 Major Causes of Headache
Primer Headache Secondary Headache
1.Migraine 1.Head trauma
a. migraine w/o aura 2. Vascular disorder
b. migraine w/ aura 3. Nonvascular disorder
c. opthalmoplegic 4. H from substance or their with-
d. migraine complication drawal (acute or chronic)
2. Tension type headache 5. H from noncephalic infection
a. episodic 6. Metabolic
b. chronic 7. H referred from cranium, neck, etc
3. Cluster headache 8. Cranial neuralgia, nerve trunk
a. episodic pain, or deafferentation pain
b. chronic a. trigeminal neuralgia
c. chronic paroxysmal hemicrania b. glossopharyngeal neuralgia
4. Miscellaneous c. occipital neuralgia
a. idiophatic stabbing H d. superior laryngeal neuralgia
b. H associated w/ sexual activities e. n. intermedius neuralgia
 Nyeri Kepala Primer

Tension
Cluster

Migraine
 Headache Red Flags (SNOOPS)
Systemic Symptoms (fever, weight loss)
Neurologic Symptoms or abnormal signs
(confusion, impaire alertness or conciousness)
Onset : sudden, abrupt, or split second
Older : new on set or progressive headache,
especially in patients > 50 (GCA)
Previous Headache history : 1st H or new or different
Headache (change in attack frequency, severity or
clinical feature)
Secondary risk factors (HIV, systemic cancer)
 Headache yang
mengancam Nyawa
• Sub-arachnoid hemorrhage :
perdarahan krn aneurisma sub-arachnoid pecah dan
dapat terjadi rebleeding yang fatal.
• Infeksi susunan saraf pusat :
meningitis bakterialis harus dapat dikenal lebih dini,
supaya terapi antibiotika dapat mencegah kematian
dan mengurangi cacat.
• Edema serebri dan Peninggian TIK : emergensi krn
struktur tengkorak yang keras, sehingga toleransi isi
tengkorak terbatas (hanya 30-50ml). edema atau ↑
TIK dpt menyebabkan herniasi menekan batang otak
dan medula oblongata lalu kematian.
 Algoritma Headache
Keluhan Utama: Headache

Headache Alarms
Anamnesa & Pem Fisik Riwayat Gangguan
Sakit Kepala yang Serius
No Ya

Diagnosa Identifikasi/Singkirkan
Gangguan Sefalgia Primer Etiologi Sefalgia Sekunder
Ya No

Terapi :Sefalgia Primer Identifikasi Sefalgia

Sekunder
 Diagnosa Sefalgia
A. Anamnesa
1. Kapan serangan nyeri kepala yang pertama ?
- akut : SAH, a. carotis diseksi, ruptura AVM,
meningitis, pasca sanggama
- kronik : chronic cluster headache
- serangan pertama kali pd usia > 50 thn : tumor
2. Frekuensi ?
3. Lama serangan ?
4. Berapa kali serangan per hari ?
 Diagnosa Sefalgia .. (2)
5. Sifat nyeri kepala ? tajam, tumpul, berdenyut, dll
- tumor : nyeri tumpul dan konstan
- tension H : nyeri tumpul, konstan spt diikat di

frontal
- cluster H : nyeri tajam berdenyut.
6. Lokasi nyeri ?
- cluster H : retroorbital, unilateral.
- trigeminal N : nyeri spt terstrom didaerah V2, V3
- temporal artritis, tension & cluster : di pelipis
 Diagnosa Sefalgia .. (3)
7. Faktor memperberat ?
- migraine : trigger stereotipe - lelah, stress, kurang
tidur, mens, alkohol, dll
8. Faktor meringankan ?
- migraine : tempat tenang dan redup.
9. Faktor predisposisi timbulnya nyeri ?
- kehamilan/dehidrasi : venous trombosis
- HIV/immunosupressan : meningitis
- polimyalgia rheumatica: giant cell arteritis (GCA)
- sinusitis, glaucoma, caries, hipertensi, dll
 Diagnosa Sefalgia .. (4)
B. Pemeriksaan fisik
- umum; kurus (anoreksia), atau gemuk, dll.
- tanda vital; suhu, tensi, nadi, pernafasan, VAS
- kepala dan THT; scalp tenderness, sinusitis,
keringat di wajah, dan rhinorrhea (cluster H)
- mata; lakrimasi, tekanan bola-mata (glaucoma),
fotophobia, dll
- muskulo-skeletal; myalgia, arthralgia (GCA)
- kulit; rash, herpes, dll
 Diagnosa Sefalgia .. (5)
C. Pemeriksaan neurologik
- kesadaran/keadaan mental; tingkat kesadaran,
iritabel, depressi, dll.
- saraf kranial; papiledema, visus↓, ukuran pupil,
lapang pandang, diplopia, dll.
- sensorimotor; ggn neurologik fokal (hemiparese)
D. Pemeriksaan penunjang
- DPL, LFT(GCA), LP, foto panorama, foto leher
- urine toksikologi (hubungan dgn obat)
- EKG (utk th/ triptan)
 Diagnosa Sefalgia .. (6)
Ad. D. Pemeriksaan Diagnostik
• Computerized tomography
– Hemorrhage, tumor, abscess, AVM
• Lumbar puncture
– Hemorrhage, infection, increased CSF pressure
• Limited indications for MRI, MRA, or Angiography
• Laboratory studies based on suspected etiologies
– ESR: Temporal arteritis
– Carboxyhemoglobin: Carbon monoxide
 Pendahuluan
• Definisi : nyeri kepala episodik yang berlangsung
4 sp 72 jam, dengan gejala yang khas.
• Karakteristik nyeri kepala disertai gejala neurologik
gastrointestinal, dan gejala otonom.
• Insiden wanita 18%, dan pria 6 % .
• Frekwensi, durasi dan disabiliti bervariasi antara
penderita dan di antara serangan.
• Migraine kausa ? diduga gangguan neurobiologik.
• Berhubungan dgn perubahan sensitivitas sistem
saraf dan aktivasi sistem trigeminal-vaskuler.
The new Basic Concept of
Migraine Pathogenesis
 Incidence: Age of First Migraine
Migraine With Aura Migraine Without Aura

20 20
Boys Girls

15 15

10 10

5 5

0
30 20 10 0 30 20 10 0

Years of Age at Onset Years of Age at Onset

]Axis: Incidence (per 1,000 Person-Years)[
.Stewart W, et al. Am J Epidemiol. 1991;134:1111-20
 Women and Migraine
• Menstrual cycle (cyclic↓estrogen levels)
– 60% to 70% report related attacks
– ≈ 60% experience ↑ frequency of attack
• Pregnancy (noncyclic↑ levels of estrogen)
– 55% to 90% report ↓frequency or absence
• Perimenopause (↓estrogen production)
– Many report exacerbation of migraine
• After menopause (noncyclic ↓levels of estrogen)
– Two thirds report marked improvement
 How Migraine Stacks Up
Against Other Common Diseases

12%

:Affected Americans
7%
6%
5%

1%

Rheumatoid Asthma Diabetes Osteoarthritis Migraine

arthritis

From the Centers for Disease Control and Prevention, the US Census
.Bureau, and the Arthritis Foundation
 Common Triggers of Migraine
- Stress
- Tiredness
- Anxiety
- Glare flashing/flickering light
- Irregular eating patterns
- Contraceptive pills
- Menstruation.
- Food containing tyramine
- Food not containing tyramine
 Foods that can trigger Headache
Foods Containing Tyramine Food
Especially when overripe Avocados
If eaten in large quantities Bananas
Made by the fermentation of the soy bean, found in many Asian Bean curd
foods. Miso soup has caused reaction
Can be caused by nonalcoholic brand also. Mainly associated with Beer and ale
imported brands with higher levels of tyramine.
Safe if vacuum packed or fresh Caviar
All are potential headache triggers except the unfermented Cheese
cheeses such as cottage cheese
Especially if overripe Figs
Safe if fresh; dried products are potential triggers caution in resto Fish
Safe only if very fresh; accumulates tyramine very rapidly Liver
 Foods that can trigger Headache
Foods Containing Tyramin Food
In dietary supplements avoid; safe in baked goods Yeast extract
Liquid and powdered protein supplements are potential triggers Protein extra
Safe if fresh; caution in restaurants Meat
Avoid aged varieties such as pepperoni Sausage
Avoid; high levels of tyramine Shrimp
paste
May contain protein extracts, should be avoided Soups
Should be avoided; contains high levels of tyramine; this includes Soy sauce
teriyaki
Generally safe, but red wine may be trigger Wines
May be trigger; ingredient in many prepared foods Milk
 Foods that can trigger Headache
Foods not Containing Tyramine Food
Large amounts will trigger headache Caffeine
Can cause headaches because of the phenolic compounds Chocolate
Especially when overripe Fava beans
Certain preparations cause headache Ginseng
More common with chatreuse and drambuie; cause unknown Liqueurs
Cause unknown Whiskey
 Diagnosis Migraine (SULTANS)
• Criteria 1 :
- Severe
- UniLateral
- Throbbing
- Activity Worsens Headache
• Criteria 2
- Nausea
- Sensitivity to light/sound
 Gejala Migraine
• Migraine :
1. sederhana (tanpa aura)
2. klasik (migraine dengan aura)
• Aura : gejala fokal neurologi yang komplek men-
dahului/bersamaan dgn serangan nyeri kepala.
1. aura visual : zigzag lines, scintillating scotomas,
bright flashes of light, alteration in the size or
shape of objects in the visual field
2. others : paresethesias, aphasia, motor weakness
(unilateral), dysarthria.
Aura Visual Migraine Classic
 Symptoms accompanying severe migraine attacks in 500
patients
Patients affected, % Symptoms
87 Nausea
82 Photophobia
72 Light-headedness
65 Scalp tenderness
56 Vomiting
36 Visual disturbances
26 - photopsia
10 - fortification spectra
33 Paresthesias
33 Vertigo
18 Alteration of consciousness
10 - syncope
4 - seizure
4 - confusional state
16 diarrhea
Source : from NH Raskin, Headache, 2nd ed New York, Churchill, Livingston, 1968: with permission
 Difrensial Diagnosa Sefalgia Primer
Cluster H. Tension H. Migraine Klinik
90 : 10% 40 : 60% 25 : 75% L:P
100% unilateral Difuse bilateral 60% unilat Lateralisasi
Periorbital Difus Frontal, periorbital, Lokasi
temporal, hemicrani
1-3/hr at 3-12/bln 1-30/bln 1-4/bln Frekuensi
Sangat berat ringan/sedang Sedang/berat Derajat nyeri
15menit-3jam Variasi 4-72 jam Durasi
Tajam, bosan Tumpul Berdenyut Sifat nyeri
(+++) (-) (±) Periodisitas
(±) (±) (+++) Riw keluarga
 Difrensial Diagnosa Sefalgia Primer .. 2
Cluster H. Tension H. Migraine Klinik
Gejala lain
(-) (-) (+++) Aura
(+++) (-) (±) Ggn otonom
(±) (-) (+++) Nausea/vomitus
(±) (-) (+++) Foto/fonophobia
exsaserbasi dgn
(-) (-) (+++) gerakan
Headache
Headache
Cluster Headache
 Penatalaksanaan
Tatalaksana Migraine Akut dibagi 4 tipe :
A. Ringan (mild)
- analgesik sederhana
- NSAIDs
- metoclopramide, kalau perlu jika ada mual
atau muntah
B. Sedang (moderate)
- NSAIDs - ergotamine : oral, nasal
- metoclopramide - sumatriptan : oral, nasal
- DHE (Dehidroergotamine) : nasal
 Penatalaksanaan .. 2
Tatalaksana Migraine Akut dibagi 4 tipe :
C. Berat (severe)
- ergotamine rectal (kadar plasma 20x dari oral)
ditambah anti emetic rectal,
- sumatriptan : sc 6mg, nasal spray 5 dan 20mg,
oral 25, 50mg (eropa 100mg)
- DHE : im, nasal
D. Sangat berat (extremely severe)
- ketoralac : im 60 mg
- DHE : iv, ditambah dengan  metoclopramide,
- dopamine antagonists,
- opioid
 Algoritma Th/ migraine Akut

migraine Pts edukasi : diet, OR, rokok , hindari faktor pen-

cetus nilai derajat disabiliti, derajat serangan dan
Intensitas nyeri berdasarkan catatan buku harian

ringan sp sedang ada mual muntah diare berat

aspirin, acetaminofen + antiemetik, anti- Triptans

NSAID (± antiemetik) migraine non oral DHE nasal-spray

Kombinasi analgesik Frek >3/bln, lamanya opioid (codein + analgesik

>48 jam, aura lama, ringan), butorphanol
Respon tdk adekuat Th/ tdk efektif
opioid > kuat, meperidine,
propoxyphene, oxycodone
Th/ = migraine berat Pertimbangkan
Th/ pencegahan
corticosteroid : prednison
 Migraine Treatment
Level of Evidence Drug
B Tylenol
A NSAIDS
A Triptans
A Fiorinal
B Midrin
A Opiates
B DHE
C Steroids
 Triptans
• Meta-analysis of 53 studies showed all the oral
triptans are effective and well tolerated.
• Rizatriptan 10mg, eletriptan 80mg and almotriptan
12.5 mg were the most effective.
• 40-80% two hour headache response.
• Give as early as possible in migraine attack.
• Nasal spray or S/C injection may be more effective.

Oral triptans in acute migraine:a meta-analysis of 53 trials. Ferrari MD. Lancet. 358 (9294):1668-
75. 2001 Nov 17.
 Terapi Non-farmasi
Dapat diberikan tersendiri atau bersama terapi
pencegahan utk meningkatkan perbaikan klinik
- Latihan relaksasi
- Kombinasi biofeedback termal & terapi
relaksasi
- EMG biofeedback
- Terapi cognitive-behavioral
 PENCEGAHAN
* Banyak bukti data klinis bahwa migraine timbul
karena hipereksitabilitas sistem saraf sentral
* Tujuan Terapi Pencegahan :
- Mengurangi frekuensi, derajat, dan durasi
serangan nyeri kepala
- Meningkatkan keberhasilan terapi akut
- Meningkatan fungsi dan mengurangi disabiliti
 Indikasi Terapi Pencegahan
1. Serangan migraine > 2x/bulan dan menimbulkan
disabiliti > 3 hari.
2. Dengan terapi simptomatik ada kontra indikasi
atau tidak efektif.
3. Pemberian terapi abortif > 2 minggu
4. Keadaan khusus migraine misalnya :
serangan migraine menimbulkan hemiplegi atau
gangguan neurologis lainnya.
5. Lama terapi pencegahan (?), biasanya ≥ 6 bln pd
migraine khronik th/ pencegahan terus menerus.
 Medikamentosa utk Terapi
Pencegahan Migraine
Dosis Drug Dosis Drug
TCA  Blocker
10-200 mg/hr Amitriptilin 60-240 mg/hr Propanolol
10-150 mg/hr Imipramine 10-20 mg/hr Timolol
SSRIs NSAIDs
10-80 mg/hr Fluoxetine 325 mg/hr Aspirin
50-200 mg/hr sertraline 250-500 mg/hr Naproxen
150-300 mg/hr OXC 120-480 mg/hr Ca antagonist
500-2000mg/hr divalproex sod Verapamil
2-4mg mg qid Cyprohepta- 2-8 mg/hr Methysergide/
din serotonin antag
 Terapi Pencegahan Migraine
dengan ggn penyerta
Suggeted agents Coexisting disorder
 blocker, Ca channel antagonist Hypertension/angina
TCA, SSRIs Depression
MAO inhibitors Refractory depression
Divalproex sodium Mania
AED Epilepsy
Idem, TCA, SSRIs,  blocker Anxiety
Sedating TCA Insomnia
NSAIDs Arthritis
Ca channel antagonist, divalproat Na Asthma
Migraine Prevention
Evidence Drug
A Valproate
A Amitriptyline
A Propranolol
B Prozac
B Riboflavin
B Gabapentin
B ACE
B Aspirin
B Clonidine
B Verapamil
 Terapi Pencegahan
• Kegagalan terapi pencegahan :
– Diagnosis tidak tepat
– Dosis obat tidak adekuat
– Waktu pemberian tidak adekuat
– Tidak mengenal komorbiditas (depresi, axietas,dll)
– Harapan yg tidak realistik
• Upaya menekan kegagalan th/ pencegahan :
– Kenal komorbiditas
– Kenal rebound efek obat
– Terapi kombinasi farmasi dan non farmasi
 Terapi Headache di UGD
Terapi Primary Headache :
 Tension
 Oral Analgesics (NSAIDS, Acetaminophen)
 Migraine
 Serotonin agonists : Sumatriptan 50 mg PO or 6.0mg S/C
 Narcotics IV or IM
 Cluster
 100% oxygen, 8-10 L/menit, selama 20 menit posisi
duduk, 60% respon dlm waktu 20-30 menit
 Intranasal lidocaine ?
 NSAIDS
 Migraine specific therapies : sumatriptan 6mg S/C
 Pendahuluan
• Vertigo (giddy, dizzy, pusing): berasal dari
bahasa Latin “vertere = memutar” makna
masalah keseimbangan.
• Keluhan nomor 3 terbanyak setelah sefalgi
dan nyeri pinggang.
• Vertigo : adanya sensasi gerakan atau rasa
gerak dr tubuh atau lingkungan sekitarnya
dpt disertai gejala otonom (pucat, keringat
dingin, mual, muntah dan pusing).
 DD/ Vertigo Perifer dan Sentral
Vertigo Sentral Vertigo Perifer
Serangan gradual Keluhan nausea dan vertigo cenderung lebih berat
Keluhan konstan/menetap Serangan tiba-tiba
Gejala rasa goyang dan Episodik
ataxia lebih menonjol
Diplopia Gangguan pendengaran atau tinnitus
Disartria Berhubungan dengan perubahan posisi
Ada gejala batang otak yg Nyeri telinga atau rasa penuh
berdekatan
Gejala spt diayun kuat Rasa lemah pada wajah
(oscillopsia) Seperti baru terserang flu atau demam
Gejala bertambahn berat jika mengedan atau bising
Riwayat minum obat ototoksik
Seperti baru menyelam atau naik pesawat udara
 Features of conditions causing
peripheral Vertigo
Signs Symptoms
Positive Hallpike test Vertigo for seconds at a time Benign positional vertigo
Ataxia, ipsilateral facial weakness Vertigo, deafness Cerebellar pontine angle
tumors(acoustic neuroma,
meningioma, dermoid)
May have positive insufflation test Facial twitching, various degrees of Cholesteatoma
hearing loss.
Positive head-thrust test, Continuous vertigo for hours to Labyrinthitis
decreased hearing. days; decreased hearing
Low-frequncy hearing loss(unilat Episodic vertigo, fluctuating hearing Meniere’s disease
in most cases) loss, ear fullness, roaring tinnitus
Bulging or ruptured tympanic Vertigo Otitis media or tympanic
membrane membrane rupture
Ataxia, oscillopsia Vertigo uncommon since both inner Ototxic drugs
ears affected; hearing loss
Positive insufflation test Popping sound, hearing loss, tinnitus Perilymhtic fistula
Positive head-thrust test Continuous vertigo for hours to days Vestibuler neuritis
 Features of conditions causing
Central Vertigo
Signs Symptoms
Decreased hearing, diplopia, dysarthria, ataxia, Vertigo, tinnitus, headache, Basilar artery
bilateral paresis, bilateral paresthesias, visual aura migraine
decreased level of consciousness.
Truncal or limb ataxia, abnormal Romberg test Mild vertigo Cerebellar infarction
or hemorrhage
Ataxia, optic neuritis Discrete episode of vertigo Multiple sclerosis
lasting several hours to weeks,
usually non-recurrent
Amnesia during seizure, other associated aura Vertigo as part of aura Temporal lobe
symptoms present seizure
May include diplopia, dysphagia, dysarthria, Vertigo lasting for minutes, Vertebrobasilar
and bilateral loss of vission. may be provoked by position insufficiency
Ipsilat Horner’s synd, facial numbness, loss of Vertigo, nausea or vomiting, Wallenber syndrome
corneal reflex, paralysis or paresis of the soft dysphagia and dysphonia
palate, pharynx, and larynx
 Patofisiologi
Alat Keseimbangan Tubuh (AKT)
A. Organ vestibuler (> 50%)
B
1. Statis labirin
- utriculus
- sacculus
2. Kinetik labirin
- canalis semicircularis A
- ampula
3. n. vestibularis & gg Scarpa
B. Optokinetik: retina, otot
bola mata, dll
C
C. Somatokinetik: kulit, per-
sendian, otot, dll
Nerve Acusticus
Membranous Labyrinth
 Skema impuls
keseimbangan tubuh
reseptor
gerak posisi - vestibularis bulu
endolymp
tubuh/kepala - visual getar
- propioseptik
Nucl. Vestibular
Serebellum saraf pelepasan NT influx
Kortek serebri vestibular (glutamat)* Ca**
Hipotalamus
Form. retikularis
depolarisasi

NT eksitator (impul aferen) : glutamat, aspartat, asetilkolin,

histamin, substan P. Impul eferent : NT inhibitor antara lain
GABA, glisin, NA, dopamin, serotonin
 I am Dizziness

Vertigo Syncope Disequilibrium ill-defined giddiness

(Sensation of (Sensation of other than vertigo,
motion) Impending faint) syncope or
disequilibrium

Disturbance of Disturbance of Neurologic Psychiatric

vestibular cardiovascular Disorders Disorders
function function
-multiple sensory -hyperventilation
disorders. syndrome
-peripheral -cardiac
-cerebellar dysfunction -anxietas neurosis
-central -vascular orthostatic
-nonfunctioning labyrinths -hysterical idem
hypotension
-extrapyramidal disorders -affective disorder
-drug intoxication -etc
-posterior fossa tumor, etc
 Diagnosis
• Presyncope
– Hipotensi ortostatik: perbedaan tensi pada posisi
baring dgn duduk > 10-15mmHg
– Aritmia cordis: pd pem EKG monitor ditemukan ggn
irama (sinus bradikardi, AF, dll)
– Presyncope vasodepressor: khas anamnesa tdk ada ggn
jantung dan saraf.
– Hiperventilasi : khas gejala berhubungan dgn dispnea
anxietas.
 Diagnosis .. 2
• Psychologis
– Berhubungan dgn gejala akut arau kronik anxietas
– Pasien fokus pada gejala somatik(dizzinya &g ejala
otonom) dibanding rasa cemas krn anxietasnya
• Disequilibrium
– Berjalan langkah lebar dan ataxia, dpt dibedakan
ggn ringan berjalan pada keadaan ggn vestibuler
atau ggn sensorik
– Ggn vestibular bilateral mungkin/tidak disertai ggn
pendengaran, D/timbul ggn pd stimulasi kalori dan
stimulasi putar.
 Diagnosis .. 3
• Vertigo
– BPV: Timbul nystagmus vertikal pd tes Dix-Hallpike,
jika diulang serangan nystagmus berkurang
– Vestibular neuritis: gambaran klinis yg khas timbul
vertigo spontan berlangsung lama, tapi bbrp hari
berangsur ↓, pada pemeriksaan ada ggn vestibular
perifer unilat (nystagmus spontan) tdk ada gejala
neurologi.
– Synd Meniere: vertigo dgn ggn pendengaran nada
rendah yg fluktuatif.
– Migraine: sefalgia dgn vertigo, ggn pendengaran (-)
 Diagnosis .. 4
– VBI:serangan tiba2 tanpa faktur pencetus dalam
waktu bbrp menit hilang, disertai dgn keluhan lain
ggn penglihatan, diplopia, disartri, parese atau ke-
semutan.
– Infark brainstem: sindrom stroke krn lesi sirkulasi
posterior, mudah dikenal krn ada gejala neurologi.
– Infark Cerebeller: dpt samar dgn gejala ggn telinga
bag dlm, biasanya ada gejala ataxia tubuh waktu
berganti posisi, dan gaze evoked nystagmus sbg
indikasi ggn sentral
– C-P angle tumor: diagnosa periksa audiometri dan
MRI dgn kontras utk deteksi tumor yg masih baru
 Pemeriksaan Fisik
dan Neurologi
• Fisik umum
– Perhatikan posture, posisi kepala (cendrung miring kesisi
vestibuler yg fungsi hilang), tdk nyaman.
• Tanda vital
– Cek hipotensi ortostatik, periksa tensi kanan-kiri (ggn a.
subcalvian), cek suhu tubuh.
• THT
– Mata: visus, gerakan bola mata, nystagmus (tes
provokasi), reflek vestibulo-okuler, dll.
– Telinga: memb timpani, pendengaran, dll.
– Cervical: cek pembuluh darah leher (bruits)
 Pemeriksaan Fisik
dan Neurologi .. 2
• cardiovasculer
– Cek denyut jantung, irama jantung, murmur
• Traktus GI
– Keluhan perdarahan lambung, ggn pencernaan.
• Neurologi
– Saraf kranialis: diplopia, disartri, nystagmus, dll
– Sensori-motor: cek fungsi propioseptik, rasa raba, rasa
getar, parese, hipotonia (ggn serebeller).
– koordinasi: cek past pointing, finger to nose, rebound.
– Langkah (gaya berjalan): tes jalan lurus buka/tutup mata,
tandem, tes Romberg
 Pemeriksaan Fisik
dan Neurologi .. 3
Provokasi tes :
-pem garpu tala
-Dix Hallpike maneuver
-Tes kalori
-Reflex vestibulo-ocular
 Tatalaksana dan Terapi

• Terapi kausal
• Terapi simptomatik
– Gol Ca channel blocker (flunarizin)
– Gol antihistamin : sinarizin, prometazin,
difenhidrinat
– Gol fenotiazin : prokloperazin, klorpromazin
– Gol histaminic : betahistine
• Latihan vestibuler
Latihan Vestibuler
 Etiologi Vertigo
• Gangguan sistem vestibuler perifer
– Telinga luar : serumen, benda asing
– Telinga tengah : retraksi memb timpani, OMPA, OM
dgn efusi, labirintis, kolesteatom, rudapaksa dgn
perdarahan.
– Telinga dalam : labirintis akut toksi, trauma, ggn
vaskuler, alergi, hidrops labirin (morbus Meniere),
mabuk gerakan, vertigo postural
– N. VIII: infeksi, trauma, atau tumor
– Inti vestibuler : infeksi, trauma, perdrhan,
trombosis a. serebeli post inferior, tumor, MS
 Etiologi Vertigo .. 2
• Gangguan Susunan Saraf Pusat
– TIA, stroke.
– Infeksi : meningitis, ensefalitis, abses, lues
– Trauma : kepala, labirin
– Tumor
– Migraine
– epilepsi
• Gangguan kardiovaskuler
– Syncope, hipertensi kronis, arteriosklerosis, anemia,
AF paroksismal, stenosis aorta dan insufisiensi, dll.
 Etiologi Vertigo .. 3
• Kelainan endokrin:
– hipoparatiroid, hipotiroid, hipoglikemi, tumor
medula adrenal, keadaan menstruasi, hamil atau
menopause.
• Kelainan mata:
– Kelainan propioseptik
• Intoksikasi:
• Kelainan Psikiatri
– Depresi, neurosa cemas, sindroma hiperventilasi,
dan fobia.
DD/ of Primary Headaches