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Headaches

Headache

AKA cephalgia One of the most common physical complaints Headache may cause significant discomfort for the person and can interfere with activities and lifestyle Can be indicative of Organic disease [neurologic or other disease] Stress response Migraines Skeletal muscle tension [tension headache] Combo of factors

Headache

Primary headache

no known organic cause migraine, tension headache, and cluster headache brain tumor or aneurysm

Secondary headache is a symptom with an organic cause

Migraines
Characterized by periodic and recurrent attacks of severe headache lasting from4 to 72 hours in adults. Primarily a vascular disturbance that occurs more commonly in women and has a strong familial tendency. The typical time of onset is at puberty, and the incidence is 18% in women and 6% in men

Subtypes

Migraine with and without aura. Tension-type headaches chronic and less severe and are probably the most common type of headache. Cluster headaches severe form of vascular headache. ve times more frequently in men than in women. Cranial arteritisis headache in the older population, reaching its greatest incidence in those older than70 years of age.

Inammation of the cranial arteries is characterized by a severe headache localized in the region of the temporal arteries.

Pathophysiology
Cerebral signs and symptoms of migraine result from dysfunction of the brain stem pathways that normally modulate sensory input. Abnormal metabolism of serotonin, a vasoactive neurotransmitter found in platelets and cells of the brain, plays a major role. The headache is preceded by a rise in plasma serotonin, which dilates the cerebral arteries

Pathophysiology
Migraines can be triggered by menstrual cycles, bright lights, stress, depression, sleep deprivation, fatigue, over use of certain medications, and certain foods containing tyramine, monosodium glutamate, nitrites, or milk products. Food triggers also include aged cheese and many processed foods. Use of oral contraceptives may be associated with increased frequency and severity of attacks in some women

Pathophysiology

Emotional or physical stress

may cause contraction of the muscles in the neck and scalp, resulting in tension headache. Theory caused by dilation of orbital and nearby extracranial arteries. an immune vasculitis in which immune complexes are deposited within the walls of affected blood vessels,

Cluster headache

Cranial arteritisis

Clinical Manifestations

Migraine with aura can be divided into four phases: prodrome aura the headache recovery (headache termination and post-drome).

Clinical Manifestations

Prodrome

Hours to days before migraine Symptoms: depression, irritability, cold feeling, food cravings, anorexia, change in activity level, increased urine output, diarrhea or constipation

Clinical Manifestations

Aura-This is associated with decreased blood ow that is the initial physiologic change characteristic of classic migraine

Can lasts less than 1 hour Focal neurologic symptoms.

Visual disturbances(i.e. light ashes and bright spots) are most common and may be hemianopic (affecting only half of the visual eld).

Other symptoms that may follow include numbness and tingling of the lips, face, or hands; mild confusion; slight weakness of an extremity; drowsiness; and dizziness.

Clinical Manifestations

Headache phase

vasodilation and a decline in serotonin levels occur, Throbbing headache intensies over several hours. This headache is severe and incapacitating Associated with photophobia, nausea, and vomiting. Its duration varies, ranging from 4 to 72hours

Clinical Manifestations

Recovery phase [termination and postdrome] Pain subsides gradually Muscle contraction in the neck & scalp is common, with associated muscle ache and localized tenderness, exhaustion, and mood changes. Any physical exertion exacerbates the headache pain. During this post-headache phase, patients may sleep for extended periods.

Clinical Manifestation

Tension-type headache is characterized by a

steady, constant feeling of pressure that usually begins in the forehead, temple, or back of the neck.

It is often band-like or may be described as a weight on top of my head.

Clinical Manifestations

Cluster headaches

unilateral and come in clusters of one to eight daily, with excruciating pain localized to the eye and orbit and radiating to the facial and temporal regions. The pain is accompanied by watering of the eye and nasal congestion.

Each attack lasts 15 minutes to 3 hours and may have a crescendodecrescendo pattern.

The headache is often described as penetrating.

Clinical Manifestations

Cranial arteritis often begins with general manifestations, such as fatigue, malaise, weight loss, and fever.

Clinical manifestations associated with inammation (heat, redness ,swelling, tenderness, or pain over the involved artery) usually are present. Sometimes a tender, swollen, or nodular temporal artery is visible. Visual problems are caused by ischemia of the involved structures.

Assessment
detailed history, & physical assessment of the head and neck, complete neurologic examination. General and thorough health history Thorough medication history

Antihypertensive agents, diuretic medications, anti-inflammatory agents, and monoamine oxidase (MAO) inhibitors-can provoke headaches.

Assessment of Headache
A detailed description of the headache is obtained. Include medication history and use. The types of headaches manifest differently in different persons and symptoms in one individual may also may change over time. Although most headaches do not indicate serious disease, persistent headaches require investigation. Persons undergoing a headache evaluation require a detailed history and physical assessment with neurologic exam to rule out various physical and psychological causes. Diagnostic testing may be used to evaluate underlying cause if there are abnormalities on the neurologic exam.

Diagnostic
CT cerebral angiography MRI may be used to detect underlying causes, such as tumor or aneurysm. Electromyography (EMG) may reveal a sustained contraction of the neck, scalp, or facial muscles. Laboratory tests: complete blood count, erythrocyte sedimentation rate [ESR], electrolytes, glucose, creatinine, and thyroid hormone levels.

Prevention

Two beta-blocking agents, propranolol (Inderal) and metoprolol (Lopressor),

inhibit the action of beta-receptorscells in the heart and brain that control the dilation of blood vessels. This is thought to be a major reason for their anti-migraine action.

Other medications that are prescribed for migraine prevention include

amitriptyline hydrochloride (Elavil), divalproex (Valproate), unarizine (Sibelium), and serotonin antagonists(Pizotyline)

Calcium antagonists (e.g. verapamil) are widely used but may require several weeks at a therapeutic dosage

Medical Management
Abortive [symptomatic] & preventive approaches Abortive approach

Less frequent attacks; relieve or limit headache at onset or while in progress Experience more frequent attacks regularly or at predictable intervals; may have medical condition that precludes abortive therapies

Preventive approach

Medical Management

Triptans, serotonin receptor agonists, are the most specic antimigraine agents available.

Cause vasoconstriction, reduce inflammation, and may reduce pain transmission. sumatriptan (Imitrex), naratriptan (Amerge), riza-triptan (Maxalt), zolmitriptan (Zomig), and almotriptan(Axert)

The Triptan Family

Medical Management
Sumatriptan succinate [Imitrex]-most widely used for migraine & cluster headaches Injectible Can cause chest pain; contraindicated in ischemic heart disease Adverse effects: increased BP, drowsiness, muscle pain, sweating and anxiety Do not in conjunction w/St. Johns Wort

Medical Management

Ergotamine preparations

Route: PO, sublingual, SQ, IM, rectal or inhalation Abort headaches if taken early in migraine process Action: acts on smooth muscle causing prolonged constriction of cranial blood vessels. Side effects: aching muscles, paresthesia, n/v

Cafergot: combo of ergotamine & caffeine


Arrest or reduce severity of headache if taken at 1st sign of an attack *Triptans should NOT be taken concurrently with meds that contain ergotamine: potential for prolonged vasoactive reaction.

Nursing Management of Headache: Pain


Provide individualized care and treatment Prophylactic medications may be used for recurrent migraines Migraines and cluster headaches requires abortive medications instituted as soon as possible with onset Provide medications as prescribed Provide comfort measures

Quiet, dark room Massage Local heat for tension

Medical Management
Acute

attack of cluster headaches 100%oxygen by facemask for15minutes, ergotaminetartrate, sumatriptan, corticosteroids,or a percutaneous sphenopalatine ganglion blockade.

Medical Management

Cranial arteritis

Early administration of a corticosteroid to prevent the possibility of loss of vision due to vascular occlusion or rupture of the involved artery. The patient is instructed not to stop the medication abruptly, because this can lead to relapse. Analgesic agents are prescribed for comfort.

Nursing Management of Headache: Teaching


Help patient identify triggers and develop a preventive strategies and lifestyle changes for headache prevention Medication instruction and treatment regimen Stress reduction techniques Non-pharmacologic therapies Follow-up care Encouragement of healthy lifestyle and health promotion activities

Nursing Management of Headache: Pain


Provide individualized care and treatment Prophylactic medications may be used for recurrent migraines Migraines and cluster headaches requires abortive medications instituted as soon as possible with onset Provide medications as prescribed Provide comfort measures

Quiet, dark room Massage Local heat for tension

Nursing Management
Teach about migraine headaches Instruct pt about triggers and how to avoid Instruct to avoid foods that contain tyramine: chocolate, cheeses [aged], coffee, dairy products, aged red wines, organ meats, beer, pickled foods, sauerkratut Avoid alcohol Stress management Medication compliance as indicated