•Pain sensitive structures in head:
–The dura mater
–The arteries in the meninges.
–Larger cerebral arteries.
–Cranial Nerves V, IX, X.
–Upper cervical nerves.
–Head and neck muscles.
•Not necessarily muscle tension.
•Mild to moderate severity.
•Worse with exertion.
•Treatment with NSAID, ASA or Acetaminophen.
•Throbbing, usually unilateral.
•Pathophysiology: serotonin mediated cerebrovascular dilation and stimulation of pain fibers.
•Moderate to severe and disabling.
•Can last hours to days.
- 1.Triggers include
- menses, ETOH, stress, foods.
- 2.Patient wants to be
- in quiet dark room.
•Unilateral or bilateral.
•Severe photophobia and phonophobia.
•Nausea and vomiting.
Precedes in 10 %. Flashing lights, weakness, numbness, field defects.
- e.g. sumitriptan (Imitrex®)
–Calcium Channel Blockers
- 1.Available in pill, injection, nasal spray. Can cause vasoconstriction (Contraindicated in CAD).
- 2.Premedicate for nausea. Causes vasoconstriction.
- 3.Red wine, cheese,
- MSG, caffeine, fermented food, aspartame, chocolate.
•Occur in clusters for weeks to months.
•Vasodilation in trigeminal area.
•Severe stabbing orbital, supraorbital or temporal pain.
•Lasts 30-90 minutes.
- •Associated with tearing, miosis,
- ptosis, conjunctival injection.
Patient paces is restless.
Cluster Headache Treatment
•High flow O2.
•Prophylaxis: Calcium Channel Blockers (Verapamil).
Differential Diagnosis of
1.ESR. Temporal artery biopsy.
2.Severe lacinating pain triggered by touch.
•None indicated if diagnosis is clear.
•CT or MRI for trauma, focal deficits.
•LP for suspected infection.
•Autoimmune degeneration of CNS.
•More common in Europeans.
•Possible viral trigger.
•Variable symptoms and course.
Course and Progression
- Relapsing Remitting
- Clearly defined relapses with full or partial recovery.
- Primary Progressive
- Disease progressive from onset.
- Secondary Progressive
- Begins as relapsing-remitting then becomes progressive.
- Progressive Relapsing
- Progressive disease with periods of acute exacerbation progression
MS Clinical Symptoms
•Numbness and Tingling.
–For acute exacerbations.
–Do not change long-term prognosis
–Multiple Side Effects.
1.Give with food. Risk of hyperglycemia, PUD, fluid retention, osteoporosis, psychosis, depression, poor wound healing.
- 2.Flu like symptoms, skin reactions, depression.
- Monitor CBC, LFTs.
Other Medications for Symptoms
•Bethanechol for Flaccid Bladder.
- or Tolterodine (Detrol®)
- for Bladder Spasms.
•Baclofen for muscle spasms.
Decrease in seizure threshold
MS Exacerbation Triggers
Nursing Care for MS
•Management of Immobility.
•Management of Elimination.
•Management of Safety.
•Arrange Home Care, PT/OT/Speech
- 1.Establish baseline.
- 2.Coping, social resources, family relationships.
- 3.Neuropathic, spastic. Medications, positioning, massage etc.
- 4.Skin, Pulmonary, DVT risk.
- 5.Bladder, Constipation. High risk of UTI,
- impaction. May need I+O cath or disimpaction.
- 6.Fall risk. Aspiration risk.
- Medications, Adequate rest, Avoidance of stress, infection.
•Disease of Basal Ganglia.
•Degeneration of substantia nigra.
•Imbalance of dopamine and acetylcholine.
•Incidence increases with age.
•♂ greater than ♀ 3:2.
- •Can be triggered by neurotoxins or
•Loss of postural reflexes.
- •Clinical diagnosis
- 1.Slowly progressive.
- 2.Pill rolling, Resting.
- 3.Difficulty initiating movement.
- 4.Stiffness, cog-wheel.
- 5.No diagnostic test.
•Loss of arm swing.
Complications of Immobility
- •Dopamine Agonists: Ropinirole (Requip®), Pramipexole
- (Mirapex®), rotigotine (Neupro®)
- 1.L-dopa crosses BB
- barrier. C dopa prevents enzyme
- breakdown in periphery.
- Orthostatic hypotension, psychosis, N/V, dyskinesias, looses
- 2.Stimulates dopamine
- receptors. Edema, sedation, N/V,
- orthostatic hypotension, psychosis, compulsive behavior.
- 3.Blocks COMT
- enzyme. Decreases breakdown of L-Dopa.
- 4.Primarily for
- tremor. Anticholinergic side effects.
5.Combination of Sinemet and Comtan.
•Deep Brain Stimulation (DBS)
- placed in chest
Nursing Care for Parkinson’s
•Protect from injury.
- •Assess for therapeutic or adverse effects of
•Timing of medication.
•Autoimmune disease of neuromuscular junction.
•Worsens with exertion improves with rest.
- •Affects eye movements, chewing, swallowing,
- speaking, breathing.
- •Exacerbations triggered by stress, menses,
- pregnancy, trauma, infection, illness, medications, temperature extremes.
Antibodies attack Ach receptors
Medications to Avoid
•Acetylcholine receptor antibodies.
- muscle response with repetition.
- acting acetylcholinesterase blocker Endrophonium
–Improvement indicates MG.
–Atropine on hand
•Neostigmine (Prostigmine®) an anticholinesterase inhibitor.
•Immunosuppressants Azathioprine (Imuran®).
•Myasthenic Crisis: Severe exacerbation of muscle weakness.
–Impacts swallowing and breathing.
- •Cholinergic Crisis: Similar
- presentation. Caused by excessive Neostigmin or other cholinergic drugs.
•Differentiate with Tensilon Test.
•Assess Respiratory Status.
- •Schedule Neostigmine to coincide with meals
- or periods of activity.
•Plan frequent rest periods.
- •Degeneration of motor neurons in brain and
- spinal cord.
•Onset age 40-70. ♂ >♀ 2:1.
- •Progressive weakness, dysarthria, dysphagia,
- respiratory failure.
•Need for advanced directives.
•Autosomal dominant inheritance.
•Higher incidence in Europeans.
•Onset age 30-50.
- •Deficit of Acetylcholine and GABA leads to
- excessive Dopamine.
- •Causes chorea, ataxia, psychosis and
- •Treatment is symptomatic: Haldol,
- SSRIs, Clonazepam (Klonopin®)
A 45 year old women with Myasthenia Gravis
presents to the Emergency Department (ED) with trouble swallowing and
difficulty breathing. Which of the
following are true:
- Her symptoms will improve with Neostigmine (Prostigmine®)
- –B) A Tensilon test will be needed to establish the
- etiology of the crisis.
- –C) Acetylcholine Receptor antibodies will be
–D) None of the above.
A 78 year old male is experiencing worsening
of hiS’s Disease. He notes that he is “freezing” and has difficulty walking in
the late afternoon. Which action
should the home health nurse take?
- Review his medication dosage and scheduling, and discuss with the physician.
- Encourage him to nap when this happens.
- Tell him to increase the duration of his morning walk to strengthen his