Nursing 4 Lecture 9 Headaches

Patients are encouraged to keep a headache diary and report any changes to the HCP

• -Chronic episodic disorder
• -Long duration because usually lasting longer than 4 hours
• -Tend to be familial and genetic
• -More common in women
• -Mediated via trigeminal vascular symptoms and its central projections

A sensation such as visual changes that signals the onset of a headache or seizure

*Occurs immediatley before an episode

Caffeine & Red Wine

*A typical migraine is unilateral and throbbing pain in the head that is worse behine one eye or ear

• 1. Migraines with aura
• 2. Migraines without aura
• 3. Atypical- less common and includes mestraul and cluster migraines

• -Loss of productivity
• -Some disability
• -Healthcare utilization

PRIORITY CARE= PAIN MANAGEMENT

-Neuroimaging recommended in patients >50 y/o with new onset headaches, especially women

-Women with history of migraines with visual symptoms have an increased risk for stroke

Recognize migraine sx

Respond and see HCP

Relieve pain and assess sx

• -Has an early age onset but it most prevalent in middle age
• -Frequency of 2.9 days/month
• -Most common long term duration headache lasting more than 4 hours

• -Caused by stress and tension
• -Neck and shoulder muscle tenderness and bilateral pain at the base of skull and forehead
• -Hard to distinguish between migraines because classic sx of migranes are: N/V, photophobia, phonophobia, and aggravation headache can occur with both

-NSAIDS and acetaminophen

*ibuprofen and caffeine may be more effective than NSAIDS alone

Peppermint oil applied topically or orally works for some patients to control pain

• **Develop routine sleep pattern
• **Healthy diet
• **Incorporate exercise

Tizanidine (muscle relaxant) and depakote (antiepileptic) can help prevent headaches

Opiates and barbituates on short term basis but are very addictive and used sparingly

• Antianxiety and antidepressants may also be needed

• -Attack lasts 4 to 72 hours
• -Unilateral
• -Pulsating
• -Moderate to severe
• -Aggravated by movement
• -One associated symptom: N&V, photophobia, phonophobia, anorexia, and sensitive scalp

• -Onset
• -Location
• -Duration
• -Frequency
• -Severity
• -Quality
• -Associated features
• -Aggravating/precipitating factors
• -Ameliorating factors
• -Family status
• -Occupation
• -Recent life events
• -Drug/alcohol use
• -Sexual activity
• -Family history
• -Past headache history
• -Impact of headache
• -Medical history

• -Used when occur more than 2x weekly, interferes with ADL's, and not relieved by acute tx
• -HCP initially prescribe NSAID's, beta blockers, and antiepileptic drugs

Proproanlol & Timolol= Only approved beta blockers

• Topiramate (topamax)= most common AED used
• -Should be used in low doses
• -Reports of suicides with high doses
• *Important for trigger avoidance and management

Laying down with cold cloth on forehead

**If patient falls asleep, leave undisturbed

Importance of no smoking, adequate sleep and rest, exercise, and balanced diet

Aimed at alleviating pain during the aura phase or soon after headaches started

• Mild Migraines:
• -may be relieved by tylenol, NSAIDS, antiemetics, metoclopramide w/ NSAID to promote gastric emptying and decrease vomiting

• Severe Migraines:
• -Triptan preparations, ergotamine derivatives, and isometheptene combinations are used
• *POTENTIAL S/E: REBOUND HEADACHE

• -Relieve headache and associated sx
• -Contraindicated in patients with ischemic heart disease, peripheral vascular disease, and prinzmetals angina

• Teach:
• -Take as soon as sx develop
• -Report chest pain or tightness to HCP
• -Take birth control because they are not safe in pregnancy
• -Common s/e: flushing, tingling, hot sensations, ten to subside once used to drug, should not be taken with SSRI antidepressant or St. Johns Wort
• Examples: zolmitriptan (zomig), eletriptan (relpax), sumatriptan (imitrax) available in tabs, injections, and nasal spray

-Combination drug containing APAP

-Isometheptene & dichloralphenazone

Most common isometheptene combination for tx of migraines and an excellent option when ergotamine preparations are not tolerated or do not work

-Cafergot taken at beginning of headache & can take up to 6 tabs in 24 hours or use rectal suppository

-Dihydroergotamine (DHE) given IV, IM, or nasal spray with antiemetic if pain control and relief of nausea not achieved with other drugs (aka rescue medication)

**Not given w/ in 24 hours of triptan drug

-Opiods & barbituates

-Should be avoided if at all possible because addictive, some opiods can cause headaches

• aka rescue medications

• -Reducting the frequency and severity of attacks, and associated disability
• -Improving quality of life
• -Reducing reliance on ineffective, poorly tolerated, or unwanted acute pharmacotherapies
• -Avoiding escalation of mediation for acute headache
• -Reducing distress and psychological symptoms associated with migraine
• -Educating and involving patient in treatment decisions and treatment course

Treat attacks rapidly and consistently:

• -Restore the patients ability to function
• -Educate the patient about early recognition and early intervention
• -Minimize the use of rescue medications
• -Promote self care and reduce need for physcian or hospital visits
• -Promote cost effective therapy
• -Minimize or eliminate therapy related adverse events

• -2 or more attacks per month that produce aggregate disability of 3+ days/month
• -Contraindications to or lack of efficacy of acute migraine medications
• -The need for acute treatment more than 2x/week
• -Special headache conditions, such as meiplegic migraine, basilar migraine, migraine with prolonged aura, or migrainous infarction

• Beta Blockers
• Tricyclic antidepressants
• Divalproex
• Ca blockers (esp in migraine with aura)

• -Brief intense unilateral pain that generally occurs in Spring and Fall
• -More common in men
• -Related to over reactive hypothalamus
• -Most common short duration headache
• -Pain can radiate to forhead, temple, or cheek

Patient often paces, walks, or sits and rocks during an attack

• Onset pain:
• -Relaxation
• -Napping
• -Rapid eye movement (REM sleep)

• During Attack:
• -Teach patient to wear sunglasses and to sit facing away from the window to help decrease exposure to light and glare
• -100% O2 via face mask 7 to 10 L/min usually administered typicially with patient in sitting position; administer for 15 to 30 minutes and discontinue when headache relieved

*Explain importance of consistent sleep-wake cycle

• Precipitating Factors:
• -Bursts of anger
• -Prolonged anticipation
• -Excessive physical activity and excitement

• -Intense pain deep and around the eye
• -Lasts 8 to 24 hours/day for 4 to 12 weeks followed by remission for 9 months to a year
• -Average duration: 30 to 90 minutes

• Assess:
• -Pain is unilateral, excrutiating, non-throbbing
• -Ipsilateral (same side) tearing of the eye
• -Facial sweating
• -Rhinorrhea (runny nose) or congestion
• -Miosis (constriction of pupils)
• -Ptosis (drooping eyelid)
• -Eyelid edema
• -Bradycardia
• -Flushing/pallor of the face
• -Increased IOP
• -Increased skin temp
• -N/V may occur
• -Patient may become restless and agitated from intense pain

• Surgery:
• -Purcutaneous stereotactic rhizotomy and deep brain stimulation can be done but have major complications and are last resort

-Triptans, egotamine preparations, and antiepileptic drugs, calcium channel blockers (verampamil), lithium, corticosteroids, OTC capsaicin, melatonin, and glucosamine