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Download Headaches: Migraine, Cluster and Tension
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Headaches: Migraine, Cluster and Tension CHAMINDA UNANTENNE RN, MS, MSN Types of Headaches Primary Headaches – These do not need Imaging Migraine Cluster Tension Cranial Neuralgia and Facial pain Trigeminal Neuralgia 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 Location Severity Duration Exacerbating Factors Relieving Factors Medication Tried Family History 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 Paroxysmal attacks – 1-2 min Character of pain: intense, sharp, superficial or stabbing Precipitated from trigger areas or trigger factors No clinical evidence or neurological deficits 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, Most patients will get better 1/3 will not response to medications: they maybe benefitted from surgical options. 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. Severe or very severe unilateral orbital, supra orbital and/or temporal pain lasting 15-180 min if untreated. Ipsilateral conjunctival injection and/lacrimation. Ipsilateral nasal congestion and/or rhinorrhea. Ipsilateral eye lid edema. Ipsilateral facial or forehead sweating. Ipsilateral meiosis or ptosis. Sense of restlessness or agitation, 1-2 attacks per day up to 8 attacks per day. Suicide is a concern. Treatment Oxygen 10-15L/MIN via NRB SQ Sumatriptan- 4-6mg. Dihydroergotamine – 0.5-1mg IM/IV Zolmitriptan 10 mg IN Ergotamine Tartrate 1-2mg po/pr Intranasal Lidocaine 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 Criteria for diagnosis of chronic Migraines > 15 days headache days per month. > lasts at least 4 hours. Tension Headaches Lasts 30 minutes to 7 days Has at least 2 of the following characteristics Bilateral location Pressing/tightening( non-pulsating) quality Mild or moderate intensity( a variant from Migraines) Not aggravated by routine physical activity No nausea/vomiting Not more than one of photophobia or phenophobia Treatment- Tension Headache Anti- Inflammatory Acetaminophen, Ibuprofen, Ketoprofen, Neproxen, Indomethacin, Celecoxib, ASA, Isometheptene Compound. Management- Life style changes Stress management Trigger avoidance EMG- guided bio feedback Cognitive/behavioral therapy Acupuncture 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. Someone with morning headaches can be due to a mass or tumor. CT scan MRI In general/ nursing interventions Taking a good history is important Treat migraines early and avoid narcotics Nonpharmacological strategy is important Headache > 10 days get checked out Drug Therapy Migraine: aura due to hypo perfusion of the brain. Followed by reflex hyper perfusion and arterial dialation. Arterial dilation due to release of bradykinins and serotonin. 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 Assess for contraindications Base line physical assessment Assess for neurological status Monitor for complaints of extremity numbness and tingling Vital sx, EKG LAB: Liver profile and renal function Nursing diagnosis Acute pain related to vasoconstrictive effects Risk for injury related to change in peripheral sensation.
