P A I N

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P A I Nfocus on LBP and HEADACHE

• Department Of Neurology
• dr. Hasan Sadikin Hospital Padjadjaran University

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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 )
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Types of pain Nociceptive pain, inflamatory
pain Neuropathic pain ? Combination
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Pain Clinical Diagnosis

• History taking
• Physical examination, Neurological exam.
• Laboratory examination
• Lab.
• Neurophysiology exam.
• Neuroimaging
  

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Visual Analog Scales
Excruciatingpain
Nopain
0
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Completepain relief
Nopain relief
0
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Note Lines must be exactly 100 mm long
McQuay, 1998.
FACES SCALES
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THE DERMATOMES
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Bagaimana Gejala Nyeri Neuropatik ?
aaauuuw !

Nyeri Spontan
Nyeri dibangkitkan stimulus
HAS/Neuro/RSHS-FKUP
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Syndromes of Epiconus, Conus and Cauda Equina
Syndrome of lumbal-radiculopathy
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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

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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)

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Estimated Prevalence of NeP
Indonesia 40 population, mengtwomen
hospital based 3-17
HAS/Neuro/RSHS-FKUP
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Low Back Pain
Triage diagnostik LPB
Kelainan patologik serius
Sindroma radikuler
LBP nonspesifik
Red Flags
HAS/Neuro/2005
(Agency for Health Care Policy and Research,
Bigos 1994)
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Low Back pain

• Seriuos pathology neoplasm
• infection
• fracture
• cauda equina
  syndrome
• Ischialgia, radicular syndrome
• Nonspecific LBP

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Syndromes of Epiconus, Conus and Cauda
Equina
Syndrome of lumbal-radiculopathy
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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 ??

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Red Flags of LBP

• Cancer
• Infection
• Vertebral fractur
• Cauda equina syndrome or
• Severe neurological deficit

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Yellow Flags
Acute ? subacute ? chronic

• Recognition of psychosocial factors
• as predictors of chronicity and
• obstacles to recovery

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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

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Management of acute LBP

• Diagnostic classification, D/ triage
• Reassurance
• Early and progressive activation
• Analgetics ? acetaminophen
• NSAID
• consider muscle
  relaxants
• Recognition yellow flags

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HAS/P3D
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Management of Chronic LBP

• Behavioral therapy
• Education
• Intensive exercise therapy
• ?Multidisciplinary

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HEADACHE
HAS/P3D
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HEADACHEDEFINITION
ALL ACHES AND PAINS LOCATED IN THE HEAD ORBITA
? OCCIPUT
HAS/P3D
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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
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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
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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 nervesII.III,V,IX,X,C1-3

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THE ROLE OF NEUROTRANSMITTER SEROTONIN (5
HT) THE ENDOGENOUS PAIN CONTROL MECHANISM -gt
OPIOID GABA
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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

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MECHANISM OF CRANIAL PAIN (cond)

• 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

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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

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HAS/NEURO
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Faktor pencetus Nyeri Kepala Stres Kurang/kebanya
kan tidur Tidak/telat makan Bau menyengat
parfum,rokok Lingkungan cahaya
silau/berkedip,gaduh
ketinggian,panas,lembab
ruang berasap Makanan/minuman
HAS/Neuro/Bdg/04
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RED FLAGS of HEADACHE
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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 agegt50 (giant cell
  arteritis)
• Previous headache history or headache
  progression pattern change, first headache or
  different
• (change in attack frequency, severity, or
  clinical pictures)
• 
  

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HAS/P3D
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HAS/P3D
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• CLUSTER HEADACHE
• YOUNG ADULT MEN ( M F 5 1 )
• UNILATERAL PAIN

HAS/NEURO
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Tension Type Headache

• Psychologic factors
• Muscle contraction and myofacial tenderness
• Vascular factorsn NO
• Humoral factors 5HT
• Central factors central pain control system

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HAS/P3D
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PHYSICAL EXAMINATION NEUROLOGICAL
EXAMINATION
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Trigeminal neuralgia
HAS/P3D
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HEADACHE TREATMENT

• SECONDARY HEADACHE
• TREATMENT
• Causal
• Symtomatic Analgesic

• PRIMARY HEADACHE TREATMENT
• Abortive
• Preventive

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PRIMARY HEADACHE TREATMENT

• 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

• TTH
• Abortive
• Simple analg acetaminophen/
  ASA/NSAID
• Preventive
• Amitriptylin
• Nonpharmacologic therapy

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• CLUSTER HA
• abortive
• o2 inhalation
• ergot alkaloids,
• triptans
• preventive
• verapamil
• ergot alkaloid

• Cranial Neuralgias,Central Pain
• (Neuropathic Pain) Treatment
• Antidepressants
• Anticonvulsants
• Antiarrhitmic
• Local anesthetic

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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
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(PERDOSSI,2001)
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HAS/Neuro/2004
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Antikonvulsants
(Rowbotham MC, Petersen KL, 2001)
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(PERDOSSI,2001)
HAS/Neuro/RSHS-FKUP
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Mononeuropahies
Mononeuropahies
(I.C.H.E.)
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Thank You