DEFINISI NYERI

International Association for the Study of Pain (IASP)

Pengalaman sensorik dan emosional yang

tidak menyenangkan akibat kerusakan jaringan,
baik aktual maupun potensial, atau yang
digambarkan dalam bentuk kerusakan tersebut.
KLASIFIKASI NYERI
I. Nyeri sederhana / fisiologik
Nyeri timbul oleh berbagai stimuli yg
tidak menimbulkan kerusakan jaringan

II. Nyeri patologik / klinis

1. Nyeri nosiseptik
Nyeri timbul oleh berbagai stimuli yg
menimbulkan kerusakan jaringan (somatik,
viseral, nyeri rujuk/referred pain)
2. Nyeri neuropatik
3. Nyeri idiopatik / psikogenik
 KLASIFIKASI NYERI

NYERI

N. NOSISEPTIF N. PSIKOGENIK

N. Somatik N. NEUROPATIK
N. Viseral
Referred Pain Perifer
Sentral
DEFINISI
NYERI NOSISEPTIF:
Nyeri yang timbul bila reseptor nyeri (nosiseptor)
teraktivasi.

NYERI NEUROPATIK:
Nyeri yang timbul akibat lesi atau disfungsi pada susunan
saraf

NYERI PSIKOGENIK:
Nyeri dengan faktor psikogen tanpa sebab organik.
 The Pain Pathway

Pain Perception
Brain

Dorsal Root Dorsal Horn

Ganglion

Spinal Cord
Nociceptor Gottschalk A et al. Am Fam Physician. 2001;63:1979-84.
Fields HL et al. Harrison’s Principles of Internal Medicine. 1998:53-8.
KEPEKAAN JARINGAN INTRA DAN EKSTRA
KRANIUM TERHADAP NYERI
 Jaringan penutup kranium, semuanya banyak atau sedikit
bersifat peka terhadap nyeri, teristimewa arteri-arteri lebih
peka.
 Struktural intrakranial yang bersifat peka terhadap nyeri
adalah sinus venosus besar dan anak-anak venanya dari
permukaan otak, bagian-bagian dari duramater pada
basis arteri-arteri dural, dan arteri-arteri serebral pada
basis otak.
 Kranium (termasuk vena diploika dan emissary),
parenchim otak, sebagian besar duramater, sebagian
besar piamater dan arachnoid, batas ependimal dari
ventrikel dan pleksus –pleksus khoroideus adalah tidak
peka terhadap nyeri.
INTERNATIONAL CLASSIFICATION
of
HEADACHE DISORDERS (ICHD-II)

2nd edition

(ICHD-II)

ICHD-II. Cephalalgia 2004; 24 (Suppl 1) ©International Headache Society 2003/4

 Classification

Part 1:
Primary headache disorders
Part 2:
Secondary headache disorders
Part 3:
Cranial neuralgias, central and primary
facial pain and other headaches

ICHD-II. Cephalalgia 2004; 24 (Suppl 1) ©International Headache Society 2003/4

 Primary or secondary
headache?

Primary:

• no other causative disorder

ICHD-II. Cephalalgia 2004; 24 (Suppl 1) ©International Headache Society 2003/4

 Primary or secondary
headache?

Secondary
(ie, caused by another disorder):
• new headache occurring in close temporal
relation to another disorder that is a known
cause of headache
• coded as attributed to that disorder
(in place of previously used term associated
with)

ICHD-II. Cephalalgia 2004; 24 (Suppl 1) ©International Headache Society 2003/4

 Classification

Part 1: The primary headaches

1. Migraine
2. Tension-type headache
3. Cluster headache
and other trigeminal autonomic cephalalgias
4. Other primary headaches

ICHD-II. Cephalalgia 2004; 24 (Suppl 1) ©International Headache Society 2003/4

 Classification
Part 2: The secondary headaches
5. Headache attributed to head and/or neck
trauma
6. Headache attributed to cranial or cervical
vascular disorder
7. Headache attributed to non-vascular
intracranial disorder
8. Headache attributed to a substance or its
withdrawal
9. Headache attributed to infection
ICHD-II. Cephalalgia 2004; 24 (Suppl 1) ©International Headache Society 2003/4
 Classification
Part 2: The secondary headaches
10.Headache attributed to disorder of
homoeostasis
11. Headache or facial pain attributed to
disorder of cranium, neck, eyes, ears, nose,
sinuses, teeth, mouth or other facial or
cranial structures
12. Headache attributed to psychiatric
disorder

ICHD-II. Cephalalgia 2004; 24 (Suppl 1) ©International Headache Society 2003/4

 Classification

Part 3: Cranial neuralgias, central

and primary facial pain and other
headaches
13. Cranial neuralgias and central causes of
facial pain
14. Other headache, cranial neuralgia, central
or primary facial pain

ICHD-II. Cephalalgia 2004; 24 (Suppl 1) ©International Headache Society 2003/4

Migraine
Description:
Recurrent headache disorder manifesting in
attacks lasting 4-72 hours. Typical characteristics
of the headache are unilateral location, pulsating
quality, moderate or severe intensity, aggravation
by routine physical activity and association with
nausea and/or photophobia and phonophobia.
Status migrainosus
A debilitating migraine attack lasting for more
than 72 hours.
Migraine
Diagnostic criteria:
A. At least 5 attacks1 fulfilling criteria B-D
B. Headache attacks lasting 4-72 hours (untreated or
unsuccessfully treated)2;3;4
C. Headache has at least two of the following
characteristics:
1. unilateral location5;6
2. pulsating quality7
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine
physical activity (eg, walking or climbing stairs)
D. During headache at least one of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia8
E. Not attributed to another disorder9
Patofisiologi
 The neurovascular (trigeminovascular) theory,
one of the oldest, states that intracranial
vasoconstriction is responsible for migraine
aura, and the subsequent rebound
vasodilatation and activation of perivascular
nociceptive nerves results in headache. Wolff et
al
 In 1944, Leao proposed the theory of Cortikal
Spreading Depression (CSD) to explain the
mechanism of migraine with aura.
Patofisiologi 2
 Positron emission tomography (PET) scanning
demonstrates that blood flow is reduced
moderately during a migraine attack.
 In 1977, Sicuteri : a state of dopaminergic
hypersensitivity is present in patients with
migraine. Interest in this theory has been
renewed recently. A variety of prodromal
symptoms (eg, yawning, irritability, nausea,
vomiting) can be attributed to relative
dopaminergic stimulation.
Patofisiologi 3
 Another theory proposes that deficiency of
magnesium in the brain triggers a chain of
events, starting with platelet aggregation and
glutamate release and, finally, resulting in the
release of 5-HT, which is a vasoconstrictor.
2. TENSION-TYPE HEADACHE
(TTH)
2.1 Infrequent episodic tension-type headache
2.1.1 Infrequent episodic tension-type headache associated with pericranial
tenderness
2.1.2 Infrequent episodic tension-type headache not associated with
pericranial tenderness
2.2 Frequent episodic tension-type headache
2.2.1 Frequent episodic tension-type headache associated with pericranial
tenderness
2.2.2 Frequent episodic tension-type headache not associated with
pericranial tenderness
2.3 Chronic tension-type headache
2.3.1 Chronic tension-type headache associated with pericranial tenderness
2.3.2 Chronic tension-type headache not associated with pericranial
tenderness
2.4 Probable tension-type headache
2.4.1 Probable infrequent episodic tension-type headache
2.4.2 Probable frequent episodic tension-type headache
2.4.3 Probable chronic tension-type headache
Infrequent episodic tension-type headache

Description:
Infrequent episodes of headache lasting minutes
to days. The pain is typically bilateral, pressing
or tightening in quality and of mild to moderate
intensity, and it does not worsen with routine
physical activity. There is no nausea but
photophobia or phonophobia may be present.
Infrequent episodic tension-type headache
Diagnostic criteria:
A. At least 10 episodes occurring on <1 day per month on
average (<12 days per year) and fulfilling criteria B-D
B. Headache lasting from 30 minutes to 7 days
C. Headache has at least two of the following characteristics:
1. bilateral location
2. pressing/tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity such as
walking or climbing stairs
D. Both of the following:
1. no nausea or vomiting (anorexia may occur)
2. no more than one of photophobia or phonophobia
E. Not attributed to another disorder1
Pathofisiologi
Stress may cause contraction of neck and
scalp muscles, although no evidence
confirms that the origin of pain is
sustained muscle contraction.
 Stress and/or anxiety
 Poor posture
 Depression
 Psychological or social problems
Pengobatan Sakit Kepala Tipe
Tegang
 Analgetika
 Anti ansietas
 Anti depresan
 Relaksan otot
 Terapi relaksasi
 Nasehat
 Olah raga  Meditasi
 Olah seni  Rekreasi / hobi
 Membaca
3.1 Cluster headache
Description:
Attacks of severe, strictly unilateral pain which is orbital,
supraorbital, temporal or in any combination of these
sites, lasting 15-180 minutes and occurring from once
every other day to 8 times a day. The attacks are
associated with one or more of the following, all of which
are ipsilateral: conjunctival injection, lacrimation, nasal
congestion, rhinorrhoea, forehead and facial sweating,
miosis, ptosis, eyelid oedema. Most patients are restless
or agitated during an attack.
3.1 Cluster headache
Diagnostic criteria:
A. At least 5 attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital and/or
temporal pain lasting 15-180 minutes if untreated
C. Headache is accompanied by at least one of the following:
1. ipsilateral conjunctival injection and/or lacrimation
2. ipsilateral nasal congestion and/or rhinorrhoea
3. ipsilateral eyelid oedema
4. ipsilateral forehead and facial sweating
5. ipsilateral miosis and/or ptosis
6. a sense of restlessness or agitation
D. Attacks have a frequency from one every other day to 8 per day
E. Not attributed to another disorder
Pengobatan Migren / Klaster
I. Migren akut
 Analgetika
 NSAID
 Ergotamin
 Gol triptan
II. Terapi preventif
 Flunarizine
 Pizatifen
 Cyproheptadin
III. Nasehat : Hindari “5K” es, coklat, keju
Other primary headaches
4.1 Primary stabbing headache
4.2 Primary cough headache
4.3 Primary exertional headache
4.4 Primary headache associated with sexual
activity
4.4.1 Preorgasmic headache
4.4.2 Orgasmic headache
4.5 Hypnic headache
4.6 Primary thunderclap headache
4.7 Hemicrania continua
4.8 New daily-persistent headache (NDPH)
 Classification
Part 2: The secondary headaches
5. Headache attributed to head and/or neck
trauma
6. Headache attributed to cranial or cervical
vascular disorder
7. Headache attributed to non-vascular
intracranial disorder
8. Headache attributed to a substance or its
withdrawal
9. Headache attributed to infection
ICHD-II. Cephalalgia 2004; 24 (Suppl 1) ©International Headache Society 2003/4
 Classification
Part 2: The secondary headaches
10.Headache attributed to disorder of
homoeostasis
11. Headache or facial pain attributed to
disorder of cranium, neck, eyes, ears, nose,
sinuses, teeth, mouth or other facial or
cranial structures
12. Headache attributed to psychiatric
disorder

ICHD-II. Cephalalgia 2004; 24 (Suppl 1) ©International Headache Society 2003/4

Diagnostic criteria for secondary
headaches:
A. Headache with one (or more) of the following
[listed] characteristics1;2 and fulfilling criteria C
and D
B. Another disorder known to be able to cause
headache has been demonstrated
C. Headache occurs in close temporal relation to
the other disorder and/or there is other
evidence of a causal relationship
D. Headache is greatly reduced or resolves within
3 months (this may be shorter for some
disorders) after successful treatment or
spontaneous remission of the causative
disorder3
 Classification

Part 3: Cranial neuralgias, central

and primary facial pain and other
headaches
13. Cranial neuralgias and central causes of
facial pain
14. Other headache, cranial neuralgia, central
or primary facial pain

ICHD-II. Cephalalgia 2004; 24 (Suppl 1) ©International Headache Society 2003/4

Classical trigeminal neuralgia
Description:

Trigeminal neuralgia is a unilateral disorder characterised

by brief electric shock-like pains, abrupt in onset and
termination, limited to the distribution of one or more
divisions of the trigeminal nerve. Pain is commonly
evoked by trivial stimuli including washing, shaving,
smoking, talking and/or brushing the teeth (trigger
factors) and frequently occurs spontaneously.
Classical trigeminal neuralgia
Diagnostic criteria:
A. Paroxysmal attacks of pain lasting from a fraction of a
second to 2 minutes, affecting one or more divisions of
the trigeminal nerve and fulfilling criteria B and C
B. Pain has at least one of the following characteristics:
1. intense, sharp, superficial or stabbing
2. precipitated from trigger areas or by trigger factors
C. Attacks are stereotyped in the individual patient
D. There is no clinically evident neurological deficit
E. Not attributed to another disorder
Pengobatan Neuralgia
Trigeminus

 Karbamazepin
 Suntikan lokal
 Operasi
Sakit kepala yang SERIUS
 Sakit kepala yang hebat
 Sakit kepala yang progresif
 Sakit kepala yang disertai
 kesadaran menurun
 kebingungan
 demam tinggi
 gangguan pengelihatan
 gangguan keseimbangan
 kelemahan
TERIMAKASIH