Nursing 4 Lecture 9 Headaches

  1. Important to remember!:
    Patients are encouraged to keep a headache diary and report any changes to the HCP
  2. Migraine Headaches:
    • -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
  3. What is aura?
    A sensation such as visual changes that signals the onset of a headache or seizure

    *Occurs immediatley before an episode
  4. Migraine: Common triggers
    Caffeine & Red Wine

    *A typical migraine is unilateral and throbbing pain in the head that is worse behine one eye or ear
  5. What are the 3 categories of Migraines?
    • 1. Migraines with aura
    • 2. Migraines without aura
    • 3. Atypical- less common and includes mestraul and cluster migraines
  6. The impact of Headaches:
    • -Loss of productivity
    • -Some disability
    • -Healthcare utilization


    -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
  7. The three "R" approach for Headaches:
    Recognize migraine sx

    Respond and see HCP

    Relieve pain and assess sx
  8. Tension Headaches:
    • -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
  9. Tension Headaches: Management
    -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
  10. Migraines w/o an Aura:
    • -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
  11. Headache History:
    • -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
  12. Migraine: Preventative Therapy
    • -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
  13. Migraine: Complementary Therapy
    Laying down with cold cloth on forehead

    **If patient falls asleep, leave undisturbed
  14. TEACH!:
    Importance of no smoking, adequate sleep and rest, exercise, and balanced diet
  15. Migraine: Abortive Therapy
    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
  16. Triptan Precautions:
    • -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
  17. Midrin:
    -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
  18. Ergotamine Preparation:
    -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
  19. Other drugs for migraines:
    -Opiods & barbituates

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

    • aka rescue medications
  20. Goals of Migraine Treatment:
    • -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
  21. Acute Treatment of Migraine:
    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
  22. Prevention Medication:
    • -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
  23. Daily Medications:
    • Beta Blockers
    • Tricyclic antidepressants
    • Divalproex
    • Ca blockers (esp in migraine with aura)
  24. Cluster Headache:
    • -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
  25. Cluster Headaches: Treatment
    -Triptans, egotamine preparations, and antiepileptic drugs, calcium channel blockers (verampamil), lithium, corticosteroids, OTC capsaicin, melatonin, and glucosamine
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Nursing 4 Lecture 9 Headaches
Nursing 4 Lecture 9 Headaches