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Problems with the brain
- Headaches
- it is a diffused pain in various parts of the head with the pain not confined to the area of distribution of nerve
- Primary: margraine,tension and cluster
- Secondary: brain tumor, infection
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Assessment of Headaches
- Questions to ask: PRSQT?
- - start, alleviating/aggrevating factors, quality,
- Ask about triggers:
- - smells, lights, parfum, stress, diet, lack of sleep, dehydration, caffiene
- Headache diary
- - what were u doing before it started
- - how long
- - how it feels
- prevent, proactive, propholatic meds
- sometimes we can eliminate triggers
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Questions
- time
- character
- cause
- response
- state of health between attacks
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Headache assessment
- consider dx other than primary h/a if 'red flag' present call MD
- S- systemic symptoms- goes beyond h/a ie fever, diarrehea
- N- neurologic symptoms- chx (new) seeing double
- O- onset- immediate, delay
- O- older than 50 or younger than 5
- P- previous h/a different patterns- different from what you experienced before
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Management of h/a prevention
ABCDEF
- A- a full night of sleep ie 6-8 hrs have a good pattern
- B- breakfast, lunch and dinner
- C- caffeine, alcohol limits- sometimes alcohol is used as therapy
- D- decrease stress
- E- exercise- release endorphines keeps blood flowing serotonin
- F- fluids
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Migraine h/a
- chronic, episodic disorder of complex symptoms usually lasting 4-72 hrs
- risk:
- familial- 80%
- women- r/t estrogen
- hx of anxiety or depression
- and other chronic diseases
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migraine triggers
- menstrual cycle
- bright lights glare
- stress, anger
- depression, fatigue
- food/beverage
- (aged cheese, chocolate, nuts, cured meats, nitrate containing food such as processed meats, and monosodium glutamate (MSG), nutrasweet
- alcohol esp red wine
- caffeine
- overuse/withdrawl
- certain drugs
- distrupted sleep
- skipped meals
- odors, smoke
- dehydration
- pain (back, chronic)
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Patho of migraine h/a
- unknown
- neurological, chemical, inflammatory
- inflammatory: vascular perman, vasospasms, chx in blood flow
- release of chemical mediators
- stimulates noscios? receptor- pain receptor
- mediated in the brain
- blood vessels in the brain overract to a trigger- spasms of the arteries
- arterial constriction and decrease in cerebral blood flow
- cerebral hypoxia may occur
- platelte clump together and serotonin is releases
- other arteries dilate triggers of prostagladins and other substances that inc sensitivity to pain
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other theories for patho of migraine
- incr glutamate in brain
- cortical spreading depression
- - impulses neuro chemical
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clinical manifestation of migraine h/a
- often unilateral pulsating pain
- mod-severe pain intensity
- last b/w 4-72 hrs
- usually proceeding by a trigger
- associated with n/v, photophobia, phonophobia
- aggrav: normal activity- like ADL's
- may have aura- neurological symptoms
- - can feel it coming on
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Phrases of migraine
- Prodrome phrase= hours/days before a migraine feel it, visual, sensory
- aura or no aura phrase- not all have this but it could be few secs to hour visual, auditory, sensory- feel it before it happens
- headache phrase- extricuating pain can interfere with adl's
- recovery phrase- pain subside, fatigue
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Nx management of migraine
non pharm
- quiet, dark room
- - make pt comfortable
- - relaxation techniques
- - HOB 30 degree
- - recognize triggers and cope
- - cognitive behavioral therapy
- - pt education- national h/a foundation
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Migraine pharm
- abortive/rescue therapy
- - acetaminophen, NSAIDS (mild drugs)
- - OTC agents (anti inflam, aspirin, caffiene- becareful vasospasms)- excederine migraine- caffiene activates more tylenol work better. becare ful cause too much caffeine can cause more vasospasms
- - triptan preps (Imitrix)
- MOA: SSR agonist - serotonin receptors chx decr vasospasms, dec pain
- S/E: vasocontriction, mindful of HTN, MI contraindicated
- NI: teach to take as soon as you feel h/a
- inj SC
- Nasal w/nausea- works 10-15mins
- oral- 30 mins
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More pharm migraine
abortive/rescue
- abortive/rescue therapy
- - Erotamine preps (Ergomar, Cadergot)
- MOA- act on smooth muscles of cranium, dec vasospasms and pain
- S/e: fatigue and weakness
- NI: take early
- adjuncts: antiemtics and anti anx- lorazapam, ativan, CNS gaba
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migraine pharm tx
preventative or prophylactive management
- if patient has 3-4 migraines/month affecting life- should be on preventative therapy
- beta blocker- dec vasospasms, vasodilator
- Ca channel blocker- not as effective as BB but if can't tolerate it- dec vasospasms
- anti seizure meds- (topamax, neurotonin)
- antidepressants- elavil
- - hx of depression works with topamax unknown
- ace inhi
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Tension h/a
- most common type of chronic long duration h/a last 30 mins to 7 days
- dull, pressing, tightening non pulsatile pain
- usually bilateral location
- does not worsen with activity
- nausea not involved
- may have photo/phonophobia
- episodic or chronic
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PAtho tension type h/a
- patho unclear
- one theory: that is results from sustained tension of the muscles of the scalp and neck which can be associated with both emotional and physical stress, poor posture, fatigue
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management of tension h/a
- assessment
- non pharm management
- acetaminophen, NSAIDS
- fiorcet (tylenol, caffeine, butabital)- used for migraine, barbituate muscle relaxation
- amitriptyline (TCA)
- muscle relaxants
- anticonvulsants (depakote) prevention
- beta- titrate up, se fatigue, report dizziness, syncope
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Cluster H/a
- unilaterial, acute onset
- pain: intense, severe piercing
- come in clusters of 1-8 daily at same time/d
- accompanied by watering of the eye, eyelid swelling, ptosis and nasal congestion
- each attack last 15 mins- 3 hours
- paces, irritable
- suicide h/a
- waking you up at night
- resovles and then may come back again
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patho of clusters
- not fully understood
- vasoreactivity and inflammation of nerves
- changes in trieminal neve or facial
- structural chx and overractive hypothalamus
- changes in SNS
- r/t to nerves
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tx of cluster h/a
- prevention
- - non pharm
- - ca channel blockers- DOC
- - prednisolone- steriod HD inflamm of nerve branches
- - Ergotamine pr s/e: episodic give at first sign of h/a s/e is cardiac
- acute:
- -tx- 100% O2 for 15 - 20 mins to achieve vasocontrition??- decr vasospasms/contriction
- - imitrex sc
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