1. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Focus on Headache
(Relates to Chapter 59, “Nursing Management: Chronic Neurologic Problems,” in the textbook)
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2. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Headache
Probably the most common type of pain experienced by humans
Majority of people have functional headaches
Migraine or tension-type headaches
The remainder of people have organic headaches caused by intracranial or extracranial disease.
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3. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Headache
Not all cranium tissues are sensitive to pain.
Pain-sensitive structures include venous sinuses, dura, cranial blood vessels, divisions of the trigeminal nerve, facial nerve, glossopharyngeal nerve, vagus nerve, and the first three cervical nerves.
Thus headache pain can arise from both intracranial and extracranial sources.
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Headache
Classification from the International Headache Society diagnostic criteria
Primary classifications
Tension-type
Migraine
Cluster
Secondary headaches include headaches caused by conditions such as sinus infection, neck injury, and stroke.
Characteristics of primary headaches are shown in Table 59-1.
A patient may have more than one type of headache.
History and neurologic examination are diagnostic keys to determining the type of headache.
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5. Tension-Type Headache
Most common type
Bilateral, bandlike feeling of pressure around the head
Constant, squeezing tightness
Not aggravated by physical activity
Often subcategorized into
Episodic
Chronic
Tension-type headaches are usually of mild or moderate intensity.
Tension-type headaches can last from minutes to days.
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6. Tension-Type Headache Etiology and Pathophysiology
Mechanism in all patients with tension-type headaches has neurovascular factors similar to those involved in migraine headaches.
Neuronal sensitivity and pain facilitation are abnormal, and muscle contraction is not abnormal.
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7. Tension-Type Headache Clinical Manifestations
No nausea or vomiting
May involve sensitivity to light and sound
May occur intermittently
Can have combination of migraine and tension-type headaches
Headaches may occur intermittently for weeks, months, or even years.
Patients with migraine headaches may experience tension-type headaches between migraine attacks.
{See next slide for figure of pain locations.}
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8. Pain Location for Common Headache Syndromes
A, Tension headache is often described as a feeling of a weight in or on the head and/or a band squeezing the head.
B, Migraine headache is described as an intense, throbbing or pounding pain that involves one temple. The pain usually is unilateral (on one side of the head), although it can be bilateral.
C, Cluster headache pain is focused in and around one eye, and is often described as sharp, penetrating, or burning.
Fig Location of pain for common headache syndromes. A, Tension headache is often described as
feeling of a weight in or on the head and/or a band squeezing the head. B, Migraine headache is
described as an intense, throbbing or pounding pain that involves one temple. The pain usually is
unilateral (on one side of the head), although it can be bilateral. C, Cluster headache pain is focused in
and around one eye, and is often described as sharp, penetrating, or burning.
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9. Tension-Type Headache Diagnostic Studies
Careful history taking
Electromyography may be performed.
May reveal sustained contraction of neck, scalp, or facial muscles
May not show increased tension even when test is done during headache
Conversely, patients with diagnosed migraine headaches may show increased muscle tension on EMG.
If tension-type headache is present during physical examination, increased resistance to passive movement of the head and tenderness of the head and neck may be present.
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Migraine Headache
Recurring
Characterized by unilateral or bilateral throbbing pain
Triggering event or factor
Strong family history
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Migraine Headache
Manifestations associated with neurologic and autoimmune nervous system function
More common in females than males
In United States, prevalence highest in those of lower socioeconomic status
The most common age for onset of migraine is between 20 and 30 years.
Migraine affects as many as 17% of females and 6% of males in the United States.
Risk factors for migraine include family history, low level of education, low socioeconomic status, high workload, and frequent tension-type headaches.
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12. Migraine Headache Etiology and Pathophysiology
Evidence suggests vascular, muscular, and biochemical factors are involved.
Exact cause is unknown.
People who have migraines have a state of neuronal hyperexcitability in the cerebral cortex, especially in the occipital cortex.
Approximately 70% of those with migraine have a first-degree relative who also had migraine headaches.
Migraine is associated with seizure disorders, Tourette’s syndrome, ischemic stroke, asthma, depression, and anxiety.
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13. Migraine Headache Etiology and Pathophysiology
Can be preceded by an aura and prodrome
May precede by days or hours
Aura associated with wave of oligemia, beginning at occipital lobe and spreading forward
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14. Migraine Headache Etiology and Pathophysiology
May be precipitated or triggered by
Food
Hormonal fluctuations
Head trauma
Physical exertion
Fatigue
Stress
Pharmacologic agents
Food triggers include chocolate, cheese, oranges, tomatoes, onions, monosodium glutamate, aspartame, red wine, and alcohol.
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15. Migraine Headache Clinical Manifestations
Subdivided into five categories
Two most important are
Migraine with aura
Migraine without aura
Migraine without aura is the most common.
Migraine with aura occurs in only 10% of migraine headache episodes.
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16. Migraine Headache Clinical Manifestations
Aura
May start 10 to 30 minutes before the start of headache
May include sensory dysfunction, motor dysfunction, dizziness, confusion, and even loss of consciousness
An aura is a complex of neurologic symptoms characterized by visual (e.g., bright lights, scotomas [patchy blindness], visual distortions, zig zag lines), sensory (hearing voices or sounds that do not exist, strange smells), and/or motor (e.g., weakness, paralysis, feeling that limbs are moving) phenomena.
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17. Migraine Headache Clinical Manifestations
Clinical manifestations with migraines
Generalized edema
Irritability
Pallor
Nausea, vomiting
Sweating
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18. Migraine Headache Clinical Manifestations
During headache, some patients “hibernate.”
Seek shelter from noise, light, odors, people, and problems
Headache is described as steady, throbbing pain that matches the pulse.
The headache may last 4 to 72 hours.
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19. Migraine Headache Clinical Manifestations
Pain is usually unilateral but may switch to other side in another episode.
Symptoms may worsen over time.
Severity is varied.
Not all migraines are disabling.
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20. Migraine Headache Diagnostic Studies
No specific laboratory or radiologic tests
Diagnosis is usually made from history.
Neurologic and diagnostic examinations are normal.
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21. Migraine Headache Diagnostic Studies
IHS criteria are used as clinical basis.
Neuroimaging techniques are not recommended unless abnormal findings are found on examination.
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Cluster Headache
Rare form of headache
Characterized by repeated headaches that occur for weeks or months at a time, followed by periods of remission
One of the most severe forms of head pain
These headaches occur in less than 0.1% of the population.
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23. Cluster Headache Etiology and Pathophysiology
Neither cause nor pathophysiologic mechanism is known.
Extracranial vasodilation occurs in affected part of face.
Trigeminal nerve is implicated.
The trigeminal nerve is implicated in the production of pain, but cluster headaches also involve dysfunction of intracranial blood vessels, the sympathetic nervous system, and pain modulation systems.
Because of the circadian rhythmicity of the headaches, the hypothalamus is believed to play a role.
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24. Cluster Headache Clinical Manifestations
Sharp stabbing
Intense pain typically lasting from a few minutes to 3 hours
Pain is usually located around the eye, radiating to the temple, forehead, cheek, nose, or gums.
The pain of cluster headache is sharp and stabbing, which contrasts with the pulsing pain of the migraine headache.
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25. Cluster Headache Clinical Manifestations
Other manifestations include
Swelling around the eye
Lacrimation
Facial flushing or pallor
Rhinitis
Constriction of the pupil
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26. Cluster Headache Clinical Manifestations
During the headache, patient is often agitated and restless.
Headaches occur with regularity.
Usually occur at same time of day
Typically last daily for 2 weeks to 3 months, then into remission for months or years
They can occur every other day and as often as 8 times a day.
Clusters usually occur at the same time each day, during the same seasons of the year.
Alcohol is the only dietary trigger. Strong odors and napping are other triggers.
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27. Cluster Headache Diagnostic Studies
Diagnosis may be based primarily on history.
Headache diaries are helpful.
CT scan, MRI, or MRA may be performed to rule out aneurysm, tumor, or infection.
Lumbar puncture is sometimes used to rule out other disorders that may cause similar symptoms.
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Headache Other Types
Can be first symptom of a more serious illness
Can accompany subarachnoid hemorrhage; brain tumors; other intracranial masses; arteritis; vascular abnormalities; trigeminal neuralgia; diseases of the eyes, nose, and teeth; and systemic illness
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Headache Other Types
Symptoms may vary greatly.
Clinical evaluation must be thorough.
Personality
Life adjustment
Environment
Family situation
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30. Headache Collaborative Care
If no systemic underlying disease is found, therapy is directed toward functional type of headache.
Symptomatic and prophylactic therapies are used.
Including drugs, medications, yoga, biofeedback, cognitive-behavioral therapy, and relaxation training
Table 59-2 outlines the general workup for a patient with headache to rule out any intracranial or extracranial disease.
Table 59-3 summarizes current therapies for prophylaxis and symptomatic relief of common headaches.
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31. Headache Collaborative Care
Drug therapy
Tension-type headache
Nonopioid analgesic is used alone or in combination with a sedative, muscle relaxant, tranquilizer, or codeine.
Many of these drugs have serious side effects. Caution the patient about the long-term use of aspirin and aspirin-containing drugs because they can cause upper gastrointestinal (GI) bleeding and coagulation abnormalities in susceptible patients.
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32. Headache Collaborative Care
Drug therapy
Migraine headache
Goal of acute migraine attack is to terminate or reduce symptoms.
Mild to moderate headache can obtain relief with aspirin or acetaminophen.
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33. Headache Collaborative Care
Drug therapy
Migraine headache
For moderate to severe, triptans have become first line of therapy.
Affect selected serotonin receptors
Reduce neurogenic inflammation of cerebral blood vessels
Produce vasoconstriction
An example of a triptan is sumatriptan (Imitrex). Sumatriptan is available in various forms: oral, subcutaneous, nasal spray.
Some patients respond better to one triptan than to others, so health care providers need to be knowledgeable about all of them.
Triptans should be taken at the first symptom of migraine headache.
The combination drug sumatriptan/naproxen (Treximet) combines a triptan with an antiinflammatory drug.
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34. Headache Collaborative Care
Drug therapy
Migraine headache
Preventive treatment
Topiramate (Topamax)
Valproic acid (Depakote)
β-adrenergic blockers
Selective serotonin reuptake inhibitors
Calcium channel blockers
Divalproex, clonidine, and thiazides
Botox
The decision to initiate prophylactic treatment is individually determined based on frequency and severity of headaches, as well as on any disability due to headaches.
Topiramate must be used for 2 to 3 months to determine its effectiveness. Not all patients will become pain free on this medication.
Botulinum toxin A (BOTOX) has been used in the prophylactic treatment of chronic daily headaches and migraines that do not respond to other medications. It may take 2 to 3 months of injections in the scalp and temple before the frequency and severity of migraine headaches are lessened.
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35. Headache Collaborative Care
Drug therapy
Cluster headache
Drug therapy not as useful as for other headaches
Prophylactic drugs may include verapamil, lithium, ergotamine, divalproex, or NSAIDs.
Methysergide may be used prophylactically when the cluster headache recurs at a known time.
Intranasal administration of lidocaine has also been shown to abort cluster headaches.
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36. Headache Collaborative Care
Drug therapy
Cluster headache
Acute treatment is inhalation of 100% oxygen delivered at a rate of 6 to 8 L per minute for 10 to 20 minutes.
Sumatriptan also effective for acute cluster headache
Invasive nerve blocks and ablative neurosurgical procedures have been used for refractory cluster headaches.
A drawback to this treatment with oxygen is that the patient must have continuous access to the oxygen supply.
Deep brain stimulation has also been used for refractory cluster headaches.
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37. Headache Nursing Management
Nursing assessment
Health history
Seizures, cancer, stroke, trauma, asthma or allergies, mental illness, stress, menstruation, exercise, food, bright lights, noxious stimuli
Medications
Surgery and other treatments
Subjective and objective data that should be obtained from a patient with headache are presented in Table 59-4.
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38. Headache Nursing Management
Nursing assessment
Health history (cont’d)
Specific details about the headache
Location
Type of pain
Onset
Frequency
Duration, time of day
Relation to outside events
The nurse may suggest that the patient keep a diary of headache episodes with specific details. This type of record can be of great help in determining the type of headache and the precipitating events.
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39. Headache Nursing Management
Nursing assessment (cont’d)
Objective data
Anxiety or apprehension
Diaphoresis, pallor, unilateral flushing with cheek edema, conjunctivitis
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40. Headache Nursing Management
Nursing diagnoses
Acute pain
Anxiety
Hopelessness
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41. Headache Nursing Management
Planning
Have decreased or no pain
Experience increased comfort and reduced anxiety
Demonstrate understanding of triggering events and treatment strategies
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42. Headache Nursing Management
Planning
Use positive coping strategies to deal with chronic pain.
Experience ↑ quality of life
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43. Headache Nursing Management
Nursing implementation
Daily exercise, relaxation periods, and socializing help reduce recurrence and should be encouraged.
Suggest alternative pain management such as relaxation, meditation, yoga, and self-hypnosis.
The most effective therapy may be to help patients examine their lifestyle, recognize stressful situations, and learn to cope with them more appropriately. Help the patient identify precipitating factors and develop ways to avoid them.
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44. Headache Nursing Management
Nursing implementation (cont’d)
Massage and heat packs can help with tension-type.
Patient should make a written note of medications to prevent accidental overdose.
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45. Headache Nursing Management
Nursing implementation (cont’d)
Teach patient about prophylactic treatment.
Dietary counseling for food triggers
Avoid smoking and smoke exposure and other environmental triggers.
The patient needs to be encouraged to eliminate foods that may provoke headaches, such as chocolate, cheese, oranges, tomatoes, onions, monosodium glutamate, aspartame, alcohol (particularly red wine), excessive caffeine, and fermented or marinated foods.
A teaching guide for the patient with a headache is presented in Table 59-5.
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Case Study
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Case Study
25-year-old woman presents to clinic with throbbing headaches with photosensitivity.
Her headaches become so intense, they cause nausea and occasionally vomiting.
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Case Study
She states that the OTC pain medication has not provided much relief for her pain.
She began to develop the intermittent headaches about a year ago.
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Case Study
She believes her headaches have been getting worse over time.
To obtain relief, she usually shuts herself in a dark room.
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Case Study
She has a family history of headaches.
MRI and CT are negative for abnormalities.
She is diagnosed with migraine headaches.
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Discussion Questions
What can you tell her about treatment with medications?
What alternative therapies may help her?
What possible triggers should she avoid?
There are medications for prevention of the occurrence of headache and for acute treatment of a migraine attack.
Biofeedback and relaxation techniques.
Certain foods, smoking, alcohol, and caffeine.
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