Transcript Headaches: Migraine, Cluster and Tension

Headaches: Migraine, Cluster and Tension
CHAMINDA UNANTENNE RN, MS, MSN
Types of Headaches
Primary Headaches – These do not need Imaging
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Migraine
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Cluster
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Tension
Cranial Neuralgia and Facial pain
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Trigeminal Neuralgia
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Occipital Neuralgia
Secondary headaches
Sinus, Temporal Arteritis, Low Pressure Headaches, Carotid Artery Dissection, Cerebral Vein Thrombosis, Subarachnoid Hemorrhage, Subdural Hemorrhage,
Hypertension, Menningitis.
Secondary Headaches
SNOOP
Systemic signs or symptoms
Neuralgic signs or symptoms
Onset
Old age
Progression of an existing headache disorder
FIRST WORST, CURSED, OR FIFTY FIRST
Taking History
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Location
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Severity
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Duration
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Exacerbating Factors
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Relieving Factors
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Medication Tried
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Family History
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Physical Localizing Findings
Case Study # 1
23 year old female, left sided stabbing pain for three weeks. Brief,
comes and goes, debilitating pain. Has been to the ER 3 times.
Medications have not been helpful. Head CT normal. All other exams
also normal.
Answer: Trigeminal Neuralgia
Possible: Cluster Headache: but usually lasts 1-2 hours at a time.
TMJ
Trigeminal Neuralgia
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Paroxysmal attacks – 1-2 min
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Character of pain: intense, sharp, superficial or stabbing
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Precipitated from trigger areas or trigger factors
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No clinical evidence or neurological deficits
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Not attributed to another disorder
Examples: if you fan at a patients face or brushing teeth can
exacerbate pain.
Treatment
Carbamezapine/oxycarbamezapine, Gabapentin, Phentoin, Lamotrigine, Baclofen, Clonazepam, TCA( TRICYCLIC), Valproate,
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Most patients will get better
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1/3 will not response to medications: they maybe benefitted from surgical options.
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If the patient is young and female it could be MS. Another possibility is a mass or a tumor.
Case # 2
30 year old male, stabbing pain behind right eye, pain wakes him at night, pain last
hours at a time, right eye injected, nose runs, OTC medications have not been
helpful, no family history of headaches.
Headache type: Cluster: have to have at least 5 attacks, one sided and comes in
clusters.
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Severe or very severe unilateral orbital, supra orbital and/or temporal pain
lasting 15-180 min if untreated.
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Ipsilateral conjunctival injection and/lacrimation.
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Ipsilateral nasal congestion and/or rhinorrhea.
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Ipsilateral eye lid edema.
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Ipsilateral facial or forehead sweating.
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Ipsilateral meiosis or ptosis.
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Sense of restlessness or agitation, 1-2 attacks per day up to 8 attacks per day.
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Suicide is a concern.
Treatment
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Oxygen 10-15L/MIN via NRB
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SQ Sumatriptan- 4-6mg.
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Dihydroergotamine – 0.5-1mg IM/IV
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Zolmitriptan 10 mg IN
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Ergotamine Tartrate 1-2mg po/pr
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Intranasal Lidocaine
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Prednisone x 3 days in between short term treatment and
preventative treatment.
Preventative Medicine
Verapamil 240mg-720mg/day, Lithium 150-300 mg( also for Bipolar),
Depakote, Topamax, and histamine desensitization.
Case # 3
Severe throbbing headaches weekly, photophobia, phonophobia,
osmophobia, nausea and vomiting, Tylenol, BC’s, Iboprofen, Excedrin has
not helped, Mother and aunt has “sick” headaches.
Answer: Migraine ( also known as sick headaches- known to throw up).
 Headaches last 4-72 hours. Pedi patients much shorter
Exhibits two of the following characteristics
 Unilateral location
 Pulsating quality
 Moderate to severe pain( mild headaches not migraines)
 Aggravated by routine physical activity
 During headaches patient may experience N/V, photophobia, &
phonophobia.
Causes of Migraine
Central Generator
Neuronal hyper-excitability with events initiated centrally in brain stem or
cortex.
Peripheral pain mechanism
Neurogenic inflammation, vasodilation.
Pain signals are transduced centrally at the level of the trigeminal nucleus
caudilis in the lower brain stem.
Treatment
Short half life Triptans for standard Migrains
 Zomig, Relpax, Axert, Imitrex, Maxalt.
Long half life Triptans – 8-12 hour half life
 Treximet, Amerge
Other Treatments for Migraines
DHE- Give anti- nausea meds first can be nauseating
 NSAIDS ex Tordol
 Fiorocet, Dolgic plus
 MGSO4
 Avoid narcotics
Other Medications
Amitriptyline, Divalproex Sodium ( Depakote), Topiramate, Butterbur( herb,
propranolol, Timolol, Topramate, Botox ( must have symptoms at least 15
days per month to receive botox).
Other treatments- life style changes
Regular sleep, regular exercise, regular meals, adequate water in take,
stress management
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Criteria for diagnosis of chronic
Migraines
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> 15 days headache days per month.
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> lasts at least 4 hours.
Tension Headaches
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Lasts 30 minutes to 7 days
Has at least 2 of the following characteristics
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Bilateral location
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Pressing/tightening( non-pulsating) quality
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Mild or moderate intensity( a variant from Migraines)
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Not aggravated by routine physical activity
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No nausea/vomiting
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Not more than one of photophobia or phenophobia
Treatment- Tension Headache
Anti- Inflammatory
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Acetaminophen, Ibuprofen, Ketoprofen, Neproxen, Indomethacin,
Celecoxib, ASA, Isometheptene Compound.
Management- Life style changes
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Stress management
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Trigger avoidance
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EMG- guided bio feedback
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Cognitive/behavioral therapy
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Acupuncture
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Physical therapy
Case #4
645 year old male, daily moderate halocranial headaches, improves
as the day goes on, Tylenol gives some relief, left hand weakness on
exam.
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Someone with morning headaches can be due to a mass or tumor.
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CT scan
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MRI
In general/ nursing interventions
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Taking a good history is important
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Treat migraines early and avoid narcotics
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Nonpharmacological strategy is important
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Headache > 10 days get checked out
Drug Therapy
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Migraine: aura due to hypo perfusion of the brain.
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Followed by reflex hyper perfusion and arterial dialation.
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Arterial dilation due to release of bradykinins and serotonin.
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Treatment: narcotics, control of sound and light, ergot derivatives,
and triptans.
Ergot Derivatives: constrict cranial blood vessels and decrease
pulsation of cranial arteries. It also blocks alpha adrenergic and
serotonin receptor sites in the brain. Prototype is Ergotamine.
Contraindications include allergy to the drug, CAD, hypertension and
PVD. If combines with beta blockers, risk of peripheral ischemia and
gangrene is increased.
Drug Therapy
Triptans.
Prototype is Sumatripan. MAC: binds to serotonin receptor sites to
cause vasoconstriction of cranial vessels. First choice drug for migraine
and cluster headaches. Its used for treatment of acute migraines but
not to prevent migraines. Adverse effects are related to
vasoconstriction. Combining triptans with ergot containing drugs can
cause prolonged vasoconstriction.
Key points:
Migraines are caused by arterial dilation in the brain and it’s treatment
is geared towards arterial contraction. With arterial constriction other
body systems can be effected. Ex cardiac, peripheral vasculature ets.
Nursing Considerations
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Assess for contraindications
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Base line physical assessment
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Assess for neurological status
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Monitor for complaints of extremity numbness and tingling
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Vital sx, EKG
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LAB: Liver profile and renal function
Nursing diagnosis
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Acute pain related to vasoconstrictive effects
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Risk for injury related to change in peripheral sensation.