NYERI KEPALA

FREDDY SITORUS
 NYERI KEPALA

• Nyeri kepala adalah sensasi tidak nyaman yang

dirasakan di daerah kepala akibat segala hal yang
merusak atau berpotensi mengakibatkan kerusakan
structural
• Areanya mencakup intracranial dan ekstrakranial
(termasuk wajah) yang memang banyak memiliki
struktur peka nyeri
• Nyeri kepala merupakan alarm untuk melindungi
bagian kepala yang terdiri dari organ-organ vital
seperti otak dan panca indra
 DEFINITION OF HEADACHE

• Headache:
A pain in the head with the pain being above the
eyes or the ears, behind the head (occipital), or in
the back of the upper neck (WHO)
• Headache:
Pain located in the head, above the orbitomeatal
line and/or nuchal ridge( ICHD3,2018)
• All headaches are considered primary headaches or
secondary headaches.
 ICHD III – BASIC ORGANIZATION

• Part 1: Primary headaches

• Part 2: Secondary headaches
• Part 3: Cranial Neuralgias, etc.
• The Appendix
 Classification

Part 1: The primary headaches

1. Migraine
2. Tension-type headache
3. Trigeminal autonomic cephalalgias

4. Other primary headache disorders

ICHD 3. Cephalalgia 2018; 38: 1–211. © 2018 International Headache Society

 Classification

Part 2: The secondary headaches

5. Headache attributed to trauma or injury to the head
and/or neck
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
10. Headache attributed to disorder of homoeostasis
11. Headache or facial pain attributed to disorder of the
cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other fa-
cial or cervical structure
12. Headache attributed to psychiatric disorder

ICHD 3. Cephalalgia 2018; 38: 1–211. © 2018 International Headache Society

 Primary or secondary
headache?
Primary:
• no other causative disorder
PRIMARY OR SECONDARY
Secondary HEADACHE?
(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

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

 • The ventricular ependyma,
choroid plexus, pial veins,
and much of the brain parenchima
are not pain producing.
.
DIAGNOSIS
 ALGORTHM DIAGNOSIS Headache

Headache

PRIMER
Secunder
Other
Primary
Headaches
TTH Migrain Cluster
Headache Trauma Tumor Vascular
infection history -Trias -acute
– Tanda2 Trauma -Headache -Defisit
infection chronic Neurologis
(Color/Dolor/ progresif fokal
Robor) -vomit
proyektil
-Papil edema
 HISTORY

Establishing a diagnoses when a patient

presents with a headache depends almost
entirely on taking an accurate patient history
and physical exam.
“Listen to the patient. He
is telling you the
diagnosis”
Sir William Osler (1849-1919)
“The headache history has
to be taken, not received”

Professor Peter Goadsby

Clinical interview:

Most of the information needed to

classify a headache is obtained by the
clinical interview.

The physician should know:

• When the headaches began.
• Whether the headache is episodic or
continuous.
• If episodic, the frequency and
duration of attacks.
Clinical Characteristics:

The physician should know the 4 main

clinical characteristics of the headache:

• Quality (pressing, throbbing, etc.)

• Intensity (mild, moderate, or severe)
• Location (unilateral, bilateral, etc.)
• Response (to routine physical
activities)
Symptoms:

The physician should know whether the headache has associated

symptoms and should document the association, paying close
attention to the following:
• Nausea
• Vomiting
• Hypersensitivity to light (photophobia)
• Hypersensitivity to noise (phonophobia)
• Auras (focal neurologic symptoms)

Also obtain detailed information about use of analgesics,

including non-prescription meds
 HEADACHE EVALUATION

• History (duration, onset, frequency)

• Is there a family history of headache?
• Are there any known causes of headache?
• What is the typical location(s)?
• What does the pain feel like?
• What makes it worse?
• What makes it better?
• What are the results of past evaluations?
• Are there associated symptoms? Exam findings?
• What is the patient’s sex?
 Tabel 1 . Important features of pain in the evaluation of chronic
recurrent headaches

ASSOCIATED
HEADACHE QUALITY LOCATION DURATION FREQUENCY
SYMPTOMS
Common Throbbing Unilateral head / 6 – 48 hours Sporadic Nausea, vomiting,
migraine Ifteral head (often several malaise,
times montlly) photophobia
Classic Throbbing Unilateral head 3 – 12 hours Sporadic Visual prodrome,
migraine (often several vomiting, nausea,
times monthly) malaise,
photobhobia
Cluster Boring, Unilateral head 12 – 120 Closely Ipsilateral tearing,
sharp (especially orbit) minutes bunched facial flushing,
clusters with nasal stuffiness,
long Horners’s
remissions syndrome
Psychogenic/ Dull, Diffuse, Ifteral Oftem May be Depression,
Chronic TTH pressure Frontal, temporal unremitting constant anxiaty Pericranial
suboccipital Almost daily tenderness
Trigeminal Lancinating Fifth nerve Brief (15-60 Many times Identifiable
meuralgia distribution second) daily trigger zone
Tabel 2. Important physical findings ini the evaluation of headache

PHYSICAL FINDING POSSIBLE ETIOLOGY

Optic atropy, papiledema Mass lesion, hydrocephalus, benign
intracranial hypertensionon
Focal neurologic abnormality (hemiparese Mass lesion
aphasia)
Stiff neck Subarachnoid hemorrhage, meningitis,
cervical arthritis
Retinal hemorrhages Ruptured aneurysm, malignant
hypertensionon
Cranial bruit arteryovenous malformation
Thickened, tender temporal arteryes Temporal arterytis
Trigger point for pain Trigeminal neuralgia
Lid ptosis, third nerve palsy, dilated pupil Cerebral aneurysm
Spasm and tenderness of Pericranial TTH/Muscle Contraction Headache
muscle
MIGRAINE
 1. MIGRAINE
RECLASSIFICATION 2004-2013

2004 2013 & 2018

1.1 Migraine without aura 1.1 Migraine without aura
1.2 Migraine with aura 1.2 Migraine with aura
1.3 Chronic migraine
1.4 Retinal migraine
1.4 Complications of migraine
1.5 Complications of migraine
(including 1.5 Probable migraine
1.5.1 Chronic migraine) 1.6 Episodic syndromes that
1.6 Probable migraine may be associated with
1.3 Childhood periodic migraine
syndromes
 1. Migraine
1.1 Migraine without aura
1.2 Migraine with aura
1.3 Chronic migraine
1.4 Complications of migraine
1.5 Probable migraine
1.6 Episodic syndromes that may be associated with migraine

ICHD 3. Cephalalgia 2018; 38: 1–211. © 2018 International Headache Society

 1.1 Migraine without aura
A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 h (untreated or unsuccessfully
treated)
C. Headache has 2 of the following characteristics:
1. unilateral location
2. pulsating quality
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical
activity (eg, walking, climbing stairs)
D. During headache 1 of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia
E. Not better accounted for by another ICHD-3 diagnosis

ICHD 3. Cephalalgia 2018; 38: 1–211. © 2018 International Headache Society

 1.5.1 Probable migraine without aura

A. Attacks fulfilling all but one of criteria A-D for

1.1 Migraine without aura
B. Not fulfilling ICHD-3 criteria for any other headache dis-
order
C. Not better accounted for by another ICHD-3 diagnosis

ICHD 3. Cephalalgia 2018; 38: 1–211. © 2018 International Headache Society

 1.2 Migraine with aura

A. At least 2 attacks fulfilling criteria B and C

B. 1 of the following fully reversible aura symptoms:
1. visual; 2. sensory; 3. speech and/or language; 4. motor;
5. brainstem; 6. retinal
C. 3 of the following 6 characteristics:
1. 1 aura symptom spreads gradually over ≥5 min
2. 2 symptoms occur in succession
3. each individual aura symptom lasts 5-60 min
4. 1 aura symptom is unilateral
5. 1 aura symptom is positive
6. aura accompanied, or followed in <60 min, by headache
D. Not better accounted for by another ICHD-3 diagnosis

ICHD 3. Cephalalgia 2018; 38: 1–211. © 2018 International Headache Society

 1.5.2 Probable migraine with aura

A. Attacks fulfilling all but one of criteria A-C for

1.2 Migraine with aura or any of its subforms
B. Not fulfilling ICHD-3 criteria for any other headache disorder
C. Not better accounted for by another ICHD-3 diagnosis

ICHD 3. Cephalalgia 2018; 38: 1–211. © 2018 International Headache Society

 Migraine

A. The Aura

B. The Attack
 PRODROME

• Vague premonitory symptoms that begin from 12 to

36 hours before the aura and headache
• Symptoms include
• Yawning
• Excitation
• Depression
• Lethargy
• Craving or distaste for various foods
Duration – 15 to 20 min
 AURA

Aura is a warning or signal before

onset of headache
Symptoms
• Flashing of lights
• Zig-zag lines
• Difficulty in focussing

Duration : 15-30 min

AURA

• “cortical spreading
depression”
• Spreading activation ,
followed by a wave of
spreading depression
• Oligemia spread from
occipital lobe forward ,
speed 2-6 mm/minute
AURA VISUAL MIGRAINE CLASSIC
DD/ OF PRIMARY HEADACHES
 HEADACHE

• Headache is generally unilateral and is associated

with symptoms like:
Anorexia
Nausea
Vomiting
Photophobia
Phonophobia
Tinnitus
• Duration is 4-72 hrs
 POSTDROME
(RESOLUTION PHASE)

Following headache, patient complains of

• Fatigue
• Depression
• Severe exhaustion
• Some patients feel unusually fresh
Duration: Few hours or up to 2 days
PATHOPHYSIOLOGY
Headache 2018;58:4-16)
 Abnormal Cerebral cortex, thalamus or
Neuronal activity hypothalamus in response to
stress, emotion.

‡
Activates nociceptive
Instability in release of trigeminovascular
neuropeptides e.g., system and causes
Substance P, neurokinin A, prolong pain
calcitonin gene-related
polypeptide, serotonin

Initiate Activates
inflammatory trigeminovascular
response, system, which in turn,
Promote sensitizes stimulate pain
vasodilation and surrounding stimulating neurons in
plasma protein tissues and brain stem and upper
extravasations. produce headache spinal cord
Tension Type
Headache
 2. Tension-type headache (TTH)

2.1 Infrequent episodic tension-type headache

2.2 Frequent episodic tension-type headache
2.3 Chronic tension-type headache
2.4 Probable tension-type headache

ICHD 3. Cephalalgia 2018; 38: 1–211. © 2018 International Headache Society

 2.1 Infrequent episodic TTH

A. At least 10 episodes of headache occurring on <1

d/mo
(<12 d/y) and fulfilling criteria B-D
B. Lasting from 30 min to 7 d
C. 2 of the following 4 characteristics:
1. bilateral location
2. pressing or tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity
D. Both of the following:
1. no nausea or vomiting
2. no more than one of photophobia or phonophobia
E. Not better accounted for by another ICHD-3 diagnosis

ICHD 3. Cephalalgia 2018; 38: 1–211. © 2018 International Headache Society

 2.2 Frequent episodic TTH

A. At least 10 episodes occurring on 1-14 d/mo for >3

mo
(12 and <180 d/y) and fulfilling criteria B-D
B. Lasting from 30 min to 7 d
C. 2 of the following 4 characteristics:
1. bilateral location
2. pressing or tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity
D. Both of the following:
1. no nausea or vomiting
2. no more than one of photophobia or phono-
phobia
E. Not better accounted for by another ICHD-3 dia-
gnosis
ICHD 3. Cephalalgia 2018; 38: 1–211. © 2018 International Headache Society
 2.3 Chronic TTH

A. Headache occurring on 15 d/mo on average for

>3 mo (180 d/y), fulfilling criteria B-D
B. Lasting hours to days, or unremitting
C. 2 of the following 4 characteristics:
1. bilateral location
2. pressing/tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity
D. Both of the following:
1. not >1 of photophobia, phonophobia, mild nausea
2. neither moderate or severe nausea nor vomiting
E. Not better accounted for by another ICHD-3 diagnosis

ICHD 3. Cephalalgia 2018; 38: 1–211. © 2018 International Headache Society

 Dilemmas in Diagnosing Migraine
• Visual aura
– only 15-20% of migraineurs
• Head pain can be non-throbbing
– in ~40% of patients
• Head pain can be bilateral
– in ~ 43% of patients1
• Sinus pain and pressure, stuffiness, rhinorrhea &
weather association is often present
– in up to 97% of migraine attacks2
• Neck pain is often present
– in up to 75% of migraine attacks3

1. Data on File. GlaxoSmithKline.

2. Cady RK, et al. Poster presented at:10th IHC; June 29-July 2, 2001; New York
NY.
TENSION-TYPE HEADACHE OR MIGRAINE

Mild
Moderate
Severe Aura
Unilateral
Vomiting
Bilateral
Photophobia Aggravated
by Activity
Nausea
Throbbing
Pressure

Tension-Type Migraine
© 2002 Primary Care Network
TREATMENT OF
MIGRAINE

Higher risk of drug abuse

Higher chance of misdiagnosis
Some doctors misunderstand
 TREATMENT OF MIGRAINE

• Despite better diagnostic capabilities and efforts to

improve public awareness and education, it is
estimated that approximately 50% of migraineurs go
undiagnosed or mismanaged to this day.
• Many self-treat, or are treated inappropriately for sinus
or other non-migrainous types of headache.
Vestibular
Disorders Association 2014
 MANY MIGRAINE SUFFERERS
REMAIN UNDIAGNOSED

56%
Diagnosed Migraine

44%
Undiagnosed Migraine

Diamond S et al. Headache. 2007;47(3):355-363.

THERAPY – GENERAL CONSIDERATIONS

• Reduce Severity
• Reduce Frequency
• Improve
• Quality of life
• Function
• Early therapy is usually
better!
• More aggressive therapy
usually better!
ACUTE TREATMENT PRINCIPLES

• Treat attacks rapidly and consistenly

• Tailor treatment to the patient
• Minimize adverse event and cost
• Limit 3 days per week or less
 ABORTIVE THERAPY

• Simple analgesics alone or in combination with other

compounds have provided relief for mild to moderately
severe headaches and sometimes even for severe
headaches.
• Acute treatment is most effective when given within 15
minutes of pain onset and when pain is mild.
• The use of abortive medications must be limited to 2-3
days a week to prevent development of a rebound
headache phenomenon.
 ABORTIVE THERAPY: MILD TO
MODERATE (NON SPECIFIC)

• NSAIDS
• Ibuprofen
• Naproxen
• Diclofenac
• Tolfenamic acid
• Indomethacin suppository
• Aspirin
• Tylenol
• Combinations
 ABORTIVE THERAPY: ERGOT
(SPECIFIC).

 Ergot family
Ergotamine-
It is secondary metabolite obtained from ergot fungus
Dihydroergotamine- available in inject able form.

The structure shares some similarit with neurotransmittor serotonin.

Acts as agonist, bind to 5-HT1,

More effective when given during early migraine

attacks
 ABORTIVE THERAPY:
TRIPTANS (SPECIFIC)

• Options
• Sumatriptan (subq/nasal/oral)
• Almotriptan (oral)
• Eletriptan (oral)
• Frovatriptan (oral)
• Naratriptan (oral)
• Rizatriptan (oral/ODT)
• Zolmitriptan (oral)
 WHY THE NEED FOR
PROPHYLAXIS ?

• Abortive drugs should not be used more than

2-3 times a week
• Long-term prophylaxis improves quality of
life by reducing frequency and severity of
attacks
• 80% of migraineurs may require prophylaxis
 TREATMENT: PREVENTION

• Definitely consider: • Might consider:

• Disabling headaches > 2x per • Contraindication to acute
month therapy
• Poor relief from abortive • Failure of acute therapy
therapy
• Preference for preventative
• Uncommon migraine therapy
• Basilar
• Hemiplegic
Preventive

Abortive

Symptom-Relief

Preventive
 1.4 Complications of migraine

1.4.1 Status migrainosus

1.4.2 Persistent aura without infarction
1.4.3 Migrainous infarction
1.4.4 Migraine aura-triggered seizure

ICHD 3. Cephalalgia 2018; 38: 1–211. © 2018 International Headache Society

 TREATMENT OF TTH

• Control of pain
• Control of problems of muscles
• Increase pain threshold : TCAs
• Control of aggravating factors : insomnia, depression,
emotional problems
 MANAGEMENT OF TENSION HA

• Remove precipitating factors

• Insomina
• Posture
• Lack of exercise
• Nervousness
• Depression
• Antidepressants
• Save pain killers!!
Cluster
Headache
 CLUSTER HEADACHE

• Occurrence: 6 times more common in men than

women
• Onset usually third or fourth decade
• Attacks
• Often awaken the patient
• Come in clusters and recur at regular, often annual, intervals
• Common triggers: alcohol and nitroglycerin
• Characteristic: unilateral and periorbital; excruciating, burning, and knife-
like pain; often associated with lacrimation, conjunctival injection,
rhinorrhea, and miosis
• Last 15 min to 3 h
 3.1 Cluster headache

A. At least 5 attacks fulfilling criteria B-D

B. Severe or very severe unilateral orbital, supraorbital and/or
temporal pain lasting 15-180 min (when untreated)
C. Either or both of the following:
1. 1 of the following ipsilateral symptoms or signs:
a) conjunctival injection and/or lacrimation; b) nasal
congestion and/or rhinorrhoea; c) eyelid oedema;
d) forehead and facial sweating; e) miosis and/or
ptosis
2. a sense of restlessness or agitation
D. Frequency from 1/2 d to 8/d for > half the time when active
E. Not better accounted for by another ICHD-3 diagnosis

ICHD 3. Cephalalgia 2018; 38: 1–211. © 2018 International Headache Society

•To terminate an attack, high-flow oxygen maybe used with a face
mask. This is highly effective and is very safe.

•Sumatriptan injectable, zolmitriptan nasal spray, or

dihydroergotamine (DHE) injections, can also help terminate an
attack. Sumatriptan and DHE injections are FDA approved for acute
treatment of cluster headache.

•Zolmitriptan nasal spray is approved in the European Union for

acute treatment of cluster
RESUME-1
MIGREN
symptom CLUSTER TTH
Classic general
Permulaan acut acut acut Pelan-pelan
(onset)
Lama attack Beberapa more lama 10 minutes – Berhour-
hour – 1 hari 2 hour hour s/d
berhari-hari
Frekwensi Periodik bbrp Periodik Periodik in each hari
attack x/bln akhir minggu setahun
(pre
menstrual)
symptom Skotom Kabur aneka (-) (-)
Prodromal auditory, ragam
tactile psikik
vertigo
 RESUME - 2
MIGREN
symptom CLUSTER TTH
Classic general
symptom - GIT, Dapat Muka sembab (-)
ikutan nausea, WITHOUT Hyperlacrimasi
vomit symptom Rhinorrhea
- dilatation ikutan
Hyperhidrasi

atemporalis
Lokalisasi one side Bermacam- one side Dahi, kuduk
macam
HEADACHE RED FLAGS
 Headache Secunder

1) Headache in meningitis
- Headache is first symptom
- slowly, worst, in back head
- with fever & MS (+)
2) Headache in SAH
- suddenly, all head, tight
- with vomit projectile
- decrease counciousness
- MS +++
3) Headache in tumor brain
- chronic progresif
- Papil edema (+)
- vomit projectile
- with symptom neurologic focal
4) Headache in Arthritis cervical
- Headache with in neck
- if move head
 Workup of Potential Secondary
Headache
• Neuroimaging
• ED- Head CT
• Outpatient - MRI
• ESR/CRP in patients > age 50
• Special settings
• LP
• Vascular imaging
• EEG for specific indication
 COVERAGE GUIDANCE :
NEUROIMAGING FOR HEADACHE
APPROVED BY HERC 8/8/2013; REAFFIRMED 1/14/2016

• Neuroimaging is not recommended for coverage in

patients with a defined tension or migraine type of
headache, or a variation of their usual headache (e.g.
more severe, longer in duration, or not responding to
drugs).
• Neuroimaging is recommended for coverage with
headache when a RED FLAG is present.
CONTOH KASUS
 KASUS 1

• Seorang perempuan berusia 32 tahun mengeluh nyeri kepala

sebelah yang didahului dengan melihat bitnik-bitnik hitam
disertai kilatan cahaya. Penglihatan tersebut berlangsung sekitar
30 menit dan diikuti nyeri kepala sebelah kanan. Nyeri kepala
terasa berdenyut dan semakin hebat dengan visual analog scale
(VAS) 8, tidak didapatkan deficit neurologis dalam pemeriksaan
fisik. Pasien sering mengalami nyeri kepala seperti ini sejak
remaja. Apakah diagnosis pada pasien tersebut?
a. Tension headache
b. Nyeri Kepala Klaster
c. Tumor otak
d. Migren dengan aura
e. Migren tanpa aura
 KASUS 2

Seorang pasien perempuan usia 28 tahun dating ke IGD dengan keluhan

nyeri kepala sebelah kiri disertai nyeri pada mata kiri. Intensitas nyeri
cukup berat (VAS 9-10) dengan durasi sekitar 3-4 jam. Nyeri dirasakan
seperti tertekan, berdenyut, atau ditusuk-tusuk. Saat serangan maa kiri
menjadi merah, berair, dan sangat silau melihat cahaya. Nyeri hilang timbul
dengan frekuensi hingga 3 kali dalam sehari, bahkan membuat terbangun
pada malam hari karena nyerinya. Pasien pernah mengalami nyeri seperti
ini kira-kira 7 tahun yang lalu dan berulang setiap tahun.
Apa diagnosis pasien tersebut?
a. Migren tanpa aura
b. Migren dengan aura
c. SOL (space occupaying lesion) intracranial
d. Nyeri kepala klister
 LANJUTAN…

Seorang pasien perempuan usia 28 tahun dating ke IGD dengan keluhan

nyeri kepala sebelah kiri disertai nyeri pada mata kiri. Intensitas nyeri
cukup berat (VAS 9-10) dengan durasi sekitar 3-4 jam. Nyeri dirasakan
seperti tertekan, berdenyut, atau ditusuk-tusuk. Saat serangan maa kiri
menjadi merah, berair, dan sangat silau melihat cahaya. Nyeri hilang
timbul dengan frekuensi hingga 3 kali dalam sehari, bahkan membuat
terbangun pada malam hari karena nyerinya. Pasien pernah mengalami
nyeri seperti ini kira-kira 7 tahun yang lalu dan berulang setiap tahun.
Apa ciri khas yang mengarah diagnosis kepada pasien tersebut?
a. Nyeri kepala berdenyut
b. Nyeri kepala sebelah
c. Nyeri kepala hebat
d. Keterlibatan mata
 KASUS 3

Seorang perempuan berusia 47 tahun dating dengan keluhan nyeri

kepala sejak 3 hari sebelumnya. Nyeri dirasakan seperti terikat
diseluruh bagian kepala. Nyeri kepala diperberat dengan aktivitas,
seperti terlalu lama didepan computer atau terlalu lama membaca dan
berkurang dengan istirahat. Pemeriksaan fisik dalam batas normal
Apakah diagnosis pasien tersebut?
a. Tession type-headache
b. Nyeri kepala klister
c. Tumor otak
d. Migren dengan aura
e. Migren tanpa aura
 KASUS 4

Seorang perempuan 78 tahun dating dengan keluhan nyeri seperti tertusuk

pada pipi kanan, daerah atas rahang, dan sekitar hidung sejak 8 bulan
sebelumnya. Nyeri terasa berat (VAS 8-9) hingga mengganggu tidur dan
aktivitas sehari-hari pasien. Nyeri kadang muncul saat mengunyah atau
menelan, dan menyebar kearah telinga dan tenggorokan. Pasien pernah
mendapat karbamazepin, tetapi semakin lama dikatakan tidak ampuh
menghilangkan nyeri. Pasien memiliki Riwayat angina pektoris tidak stabil
Apakah diagnosis pasien tersebut diatas?
a. Cluster headache
b. Nyeri akibat gigi berlubang
c. Migren
d. Neuralgia trigeminal
 KASUS 5

Seorang laki-laki 24 tahun dating ke IGD dengan nyeri kepala hebat

sejak 1 hari. Nyeri kepala dirasakan diseluruh kepala terus meneru,
dan tidak diengaruhi aktivitas. Intensitas nyeri VAS 7-8. Pasien masih
sadar penuh, tetapi demam 39 derajat Celsius sejak sehari sebelumnya.
Pemeriksaan neurologis ditemukan kaku kuduk dan ruam kulit.
Pemeriksaan laboratorium terdapat leukositosis 21.000/mm2
Apakah diagnosis kerja yang paling memungkinkan pada pasien ini?
a. Perdarahan subaraknoid
b. Ensefalitis viral
c. Meningitis bakterialis
d. Epidural hematom
 KASUS 6

Seorang perempuan 26 tahun, staf keuangan, dating ke poliklinik dengan

keluhan nyeri leher belakang sejak 8 bulan. Nyeri dirasakan hilang timbul
dengan intensitas sedang dan tidak berdenyut, sekitar 1-2 kali seminggu.
Nyeri menjalar ke kepala bagian belakang, bahu kanan, dan sekitar eajah
sisi kanan, terutama bila pasien sedang banyak kerjaan dan kurang tidur.
Tidak ada Riwayat demam, penurunan berat badan, dan mual muntah.
Pemeriksaan fisik menunjukkan postur kepala kedepan. Saat palpasi leher
terapa spasme pada m. trapezius bilateral dan m paravertebral sevikalis,
tidak ada deficit neurologis. Pasien merasa nyeri saat gerakan hiperekstensi
kepala secara pasif. Pemeriksaan rontgen servikal menunjukkan hasil
straight cervical
Apakah diagnosis paling mungkin pada pasien ini?
a. HNP servikal
b. Nyeri kepala servikogenik
c. Neuralgia trigeminal
d. Migren tanpa aura
 KASUS 7

Seorang perempuan 37 tahun dating ke poliklinik dengan keluhan

nyeri kepala sejak setahun lalu. Nyeri kepala terutama dirasakan
disisi kanan kepala. Awalnya nyeri kepala memiliki frekuensi satu
kali seminggu, hilang timbul dan durasi sekitar setengah hari, dan
intensitas ringan. Namun, sejak 1 bulan terakhir, nyeri muncul setiap
hari, terus menerus, dan intensitas sedang-berat. Saat datang, pasien
sadar namun terlihat kesakitan (VAS 8-9) dan bingung, serta bicara
kadang tidak sesuai dengan pertanyaan.
Pemeriksaan lanjutan apa yang paling utama dikerjakan untuk
mengetahui penyakit yang mendasari nyeri kepala pasien?
a. Analisis cairan otak
b. MRI
c. Angiografi
d. CT- Scan
THANK YOU