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Presented by,Unni Krishnan.SVM.Sc Nursing II YEAR COLLEGE OF NURSING JIPMER

EADACHE

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eadacheCephalgia ; one of the most common human complaints. Headache is a symptom rather than a disease.

It is a condition of pain in the head; sometimes neck or upper back pain may also be interpreted as a headache. It ranks amongst the most common local pain complaints.

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DEFINITIONHeadache is defined as pain in the head that is located above the eyes or the ears, behind the head (occipital), or in the back of the upper neck. - IHS-2004

Source :International Headache Society

GENERAL PRINCIPLES Primary headaches are those in which headache and its associated features are the disorder in itself. Primary headache often results in considerable disability and a decrease in the patients quality of life. Secondary headaches are those caused by exogenous disorders. Cont

Source :International Headache Society

GENERAL PRINCIPLES Mild secondary headache, such as that seen in association with upper respiratory tract infections, is common but rarely worrisome. Life-threatening headache is relatively uncommon, but vigilance is required in order to recognize and appropriately treat patients with this category of head pain.

Source :International Headache Society

INCIDENCE Headache Is a Major Public Health Problem

Up to 4% of ED Visits

Over 20 Million Outpatient Visits

78 % of Women and 60% of Men Experienced at Least One Headache in the Year

36% of Women and 19% Men Suffered From Recurrent Headaches

Source :International Headache Society

ANATOMY AND PHYSIOLOGY OF HEADACHE

Pain usually occurs when peripheral nociceptors are stimulated in response to tissue injury, visceral distension, or other factors.In such situations, pain perception is a normal physiologic response mediated by a healthy nervous system. Pain can also result when pain-producing pathways of the peripheral or central nervous system (CNS) are damaged or activated inappropriately. Headache may originate from either or both mechanisms. Cont.

Relatively few cranial structures are pain-producing; these include the scalp, middle meningeal artery, dural sinuses, falx cerebri, and proximal segments of the large pial arteries. The ventricular ependyma, choroid plexus, pial veins, and much of the brain parenchyma are not pain-producing.

Causes of headaches.1. Traction or dilatation of intracranial or extracranial arteries.2. Traction of large extracranial veins3. Compression, traction or inflammation of cranial and spinal nerves4. Spasm and trauma to cranial and cervical muscles.5. Meningeal irritation and raised intracranial pressure6. Disturbance of intracerebral serotonergic projections

Common causes of headache

Source: The Headaches. Philadelphia, Lippincott Williams and Wilkins 2005

Clinical evaluation of acute new onset headacheHistory collection Physical examination Diagnostic assessment

PHYSICAL EXAM Does the patient look ill? Vital signs: fever, BP Neurological exams most important! Fundoscopic exam Cranial nerves Mental Status Meningeal irritation Gait and reflexes Tenderness on palpation

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Investigating HeadacheIs any special investigation warranted?

When there is diagnostic difficulty or history suggests a serious disorder, investigation becomes obligatory!

CT-ScanMRILumbar PunctureBlood Count/ESR

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HEADACHE SYMPTOMS THAT SUGGESTS A SERIOUS UNDERLYING DISORDER

Worst headache everFirst severe headache Subacute worsening over days or weeks Abnormal neurologic examinations Fever or unexplained systemic signs Vomiting that precedes headachePain induced by bending, lifting or cough Pain that disturbs sleep or presents immediately upon awakening Known systemic illnessOnset after age 55 pain associated with local tenderness, eg., region of temporal artery

TYPES OF HEAD ACHE

Source :International Headache Society

PRIMARY HEADACHE

Aprimary headacheis aheadachethat is due to theheadache condition itself and not due to another cause.

Source :International Headache Society

TYPES OF PRIMARY HEADACHE

Migraine Tension Type Cluster Idiopathic stabbing Exertional

Source :International Headache Society

SECONDARY HEADACHE

A secondaryheadacheis aheadachethat is present because of another condition. The management of secondary headache focuses on diagnosis and treatment of the underlying condition.

Source :International Headache Society

TYPES OF SECONDARY HEADACHE 1.Systemic infection E.g.Meningitis, NCC2.Head injury 3.Vascular disorders E.g. Aneurysm Rupture, Stroke 4.Subarachnoid hemorrhage 5.Brain tumor

International headache society classificationPrimary headaches1)MigraineMigrainewithout auraMigraine withauraRetinal migraineChildhood periodic syndromeComplications of migraineMigraneous disorders not fulfilling above criteria

2) Tension-type headache (TTH)Episodictension-type headacheFrequent episodic tension-type headacheChronic tension-type headacheHeadache of the tension type not fulfilling above criteria 3)Cluster headache and chronic paroxysmal hemicraniaCluster headacheChronic Paroxysmal hemicraniaCluster headache- like disorder not fulfilling above criteria

4)Miscellaneous headaches unassociated with structural lesionIdiopathic stabbing headachePrimary cough headacheExternal compression headaceadacheBenign exertional headacheCold stimulus headacheBenign cough headacheheadache associated with sexual activity

Secondary headaches

5)Headache attributed to head and/or neck traumaAcute post-traumatic headacheChronic post-traumatic headache

6)Headache associated with vascular disorderHeadache attributed to ischaemic stroke or transient ischaemic attackintracranial haemorrhageintracerebral haemorrhageHeadache attributed tosubarachnoid haemorrhage(SAH)unrupturedvascular malformationArteritisCarotid or vertebral dissectionVenous thrombosisArterial hypertensionHead ache associated with other vascular disorder

7)Headache associated with non-vascular intracranial disorderHighcerebrospinal fluidpressureLowcerebrospinal fluidpressureIntracranial infection intracranial sarcoidosisHeadache related to intrathecal injectionsIntacranial neoplasmHeadache associated with other intracranial disorder

8)Headache attributed to a substance or its withdrawalHeadache induced by acute substance use or exposureHeadache induced by chronic substance use or exposureHeadache from substance withdrawl (acute or chronic)

9)Headache associated with noncephalic infectionViral infectionBacterial infectionHeadache related to other infection

10)Headache associated with metabolic disorderHypoxiaHypercapniaMixed hypoxia and hypercapniaHypoglycemiaDialysisHeadache related to other metabolic abnormality

11)Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structurescranial boneNeckEyesEarsNose and sinusesTeeth,jaws, and related structureTemporomandibular joint disease

12)Cranial neuralgias, nerve trunk pain,deafferentation painPersistent (in contrast to tic-like)pain of cranial nerve originTrigeminal neuralgiaGlossopharyngeal neuralgiaOccipital neuralgiaCentral causes of head and facial pain other than tic douloureux Facial pain not fulfilling criteria in groups 11 or 1213)Headache not classifiable

PRIMARY HEADACHE

Primary headaches are disorders in which headache and associated features occur in the absence of any exogenous cause .The most common are migraine, tension-type headache, and cluster headache.

MIGRAINE Definition It is a recurrent throbbing headache that typically affects one side of the head and is often accompanied by nausea and disturbed vision. -Wikipedia

INCIDENCE Migraine, the second most common cause of headache.The World Health Organization (WHO) has identified migraine among the worlds top 20 leading causes of disability. Aficts approximately 15% of women and 6% of men.Females are most commonly affected during the menstrual cycle( Research finding )

EtiologyMigraines may run in familiesChanges in hormone levels during a woman's menstrual cycle or with the use of birth control pillsChanges in sleep patternsExercise or other physical stressMissed mealsSmoking or exposure to smoke

Triggering factors of migraine headache Certain foods can trigger migraine attack ;Any processed, fermented, pickled, or marinated foods, as well as foods that contain monosodium glutamate (MSG)Baked foods, chocolate, nuts, peanut butter, and dairy productsFoods containing tyramine, which includes red wine, aged cheese, smoked fish, chicken livers, figs, and certain beansFruits (avocado, banana, citrus fruit)Meats containing nitrates (bacon, hot dogs, salami, cured meats)Onions

Clinical Features NauseaPhotophobiaLightheadednessScalp tendernessVomiting Visual disturbances like photopsia,fortification spectra ParesthesiasVertigo Alteration of consciousness like syncope seizure, confusional state Diarrhea

PathophysiologyHeadache is experienced when there is traction, pressure,displacement, inflammation,or dilation of nociceptors in areas sensitive to pain. Pain is transmitted from the periphery by small myelinated fibers and unmyelinated C-fibers.These fibers terminate in the dorsal horn of the spinalcord and the terminal nucleus caudalis

Cont ..

Secondary neurons from the dorsal horn reach the thalamus through the spinal thalamic pathways.Neurotransmitters also have a role in pain. Substance P, a neuropeptide, is a pain neurotrasmitter for the primary sensory neurons.Interneurons in the dorsal horn use enkephalins and possibly (GABA) as inhibitory neurotransmitters to block pain trasmission.

Cont ..

Anenkephalinis apentapeptideinvolved in regulatingnociceptionin the body. Enkephalin,naturally occurringpeptidethat has potent painkilling effects and is released byneurons in the centralnervous systemand bycellsin the adrenal medulla.39

The ascending pain pathways from the supratentorial space(the anterior and middle fossa) carry pain sensation by the trigeminal (CN V).Pain sensation from the infratentorial space (post fossa) is carried by the glossopharyngeal (CNIX), the vagus (CNX) nerves, and the second and third cervical nerves.The pain pathways ascend through the brain stem to neurons in the midbrain raphe area.

Cont ..

Lateral spinothalamic tractAcute pain(fast pain) carried by a delta fibre (myelinated fibres)Chronic pain (slow pain) carried by C- fibre (non myelinated).Lateral spinothalamic tract carries pain and temperature.

Cont ..

Theories Mutation theory Vascular theory

Mutation theory Proposed by Ducros and Dichgans Migrane is genetically inherited .Mutation in three different genes are responsible for familial hemiplegic migraine (FHM1,FHM2,FHM3)Which is responsible for alteration in cellular excitability that leads to migraine .

Vascular theory Proposed by WolffPain is based on dilatation of cranial vesselsMigraine is so called neurovascular disorder ,which arise due to primary dysfunction of the brain and brain stem.Activation and further sensitization of the trigemino-vascular system ( TGVS).When the TGVS is activated, neuropeptides such as calcitonin gene related peptide (CGrP) and substance P are released from peripheral nerve endings.

Increase in plasma levels of CGrPCGrP plays an important Role in the transmission of meningeal inputs to the brain.Substance P is not released during migraine attacks. For pain generation in migraine there are central as well as peripheral events. The peripheral events include meningeal inflammation, vasodilation, plasma protein extravasations, once the trigeminal system is activated, the central trigeminal nucleus caudalis in the brainstem is activated.

Central sensitization is important for the key clinical manifestations of migraine viz. cutaneous allodynia and for chronic migraine.18

CRITERIA FOR DIAGNOSIS OF MIGRAINE

International Headache Society Classification-2004Criteria 1Repeated attacks of headache lasting 4-72 hours in patients with a normal physical examination ,no other reasonable cause for the headache .Criteria 2With atleast 2 of the following features Unilateral pain Throbbing pain Aggravation by movement Moderate or severe intensity Plus at least 1 of the following features Nausea or vomiting Photophobia Phonophobia

MANAGEMENT OF MIGRAINE HEADACHES

Nonpharmacologic Management Pharmacological Management

Pharmacological Management

Nonsteroidal Anti - Inflammatory Drugs (NSAIDs) - Both the severity and duration of a migraine attack can be reduced signicantly by anti-inammatory agents.eg Aspirin.5-HT1 AgonistsThese drugs can stop an acute migraine attack by maintaining normal serotonin level in blood . Eg.Ergotamine and dihydroergotamineDopamine AntagonistsThese drugs decrease nausea/vomiting and restore normal gastric motility. e.g., chlorpromazine, prochlorperazine, metoclopramide

TENSION-TYPE HEADACHE

The term tension-type headache (TTH) is commonly used to describe a chronic head-pain syndrome characterized by bilateral tight, bandlike discomfort.The pain typically builds slowly, uctuates in severity, and may persist more or less continuously for many days. The headache may be episodic or chronic (present >15 days per month).

Treatment:TENSION-TYPE HEADACHE

Treated and managed with simple analgesics such as acetaminophen, aspirin, or NSAIDs.Behavioral approaches like relaxation Amitriptyline is the only proven treatment

Cluster Headache

Cluster headache is a rare form of primary headache The pain is deep, usually retroorbital, often excruciating in intensity, non- uctuating, and explosive in quality. A core feature of cluster headache is periodicity.

Cluster headache is associated with ipsilateral symptoms of cranial parasympathetic autonomic activation: conjunctival injection or lacrimation, rhinorrhea or nasal congestion, or cranial sympathetic dysfunction such as ptosis.

TREATMENT

oxygen inhalation 1012 L/min for 1520 min following acute attacks Sumatriptan (20 mg) and zolmitriptan (5 mg) nasal sprays are both effective in acute cluster headache

NEUROSTIMULATION THERAPY .

Deep-brain stimulation of the region of the posterior hypothalamic gray matter has proven successful in a substantial proportion of patients. Favorable results have also been reported with the less-invasive approach For occipital nerve stimulation.

Paroxysmal Hemicrania

Paroxysmal hemicrania (PH) is characterized by frequent unilateral, severe, short-lasting episodes of headache.It is managed by Indomethacin (2575 mg tid), which can completely suppress attacks

CHRONIC DAILY HEADACHE

The broad diagnosis of chronic daily headache (CDH) can be applied when a patient experiences headache on 15 days or more per month. CDH is not a single entity; it encompasses a number of different headache syndromes, including chronic TTH as well as headache secondary to trauma, inammation, infection, medication etc This is managed by using valproate, and gabapentin.

Secondary headache

Low CSF volume headacheRaised CSF pressure headachePost-traumatic headache

Other secondary type head aches includes

Hemicrania ContinuaCough HeadacheExertional HeadacheSex HeadacheStabbing Headache

Head ache occurs due to structural problems

MENINGITISINTRACRANIAL HEMORRHAGEBRAIN TUMORTEMPORAL ARTERITISGLAUCOMA

NURSING MANAGEMENTThe goal is to lessen or relieve pain.

Administer abortive medications if needed, as soon as possible.

Provide dark, quiet and peaceful environment.

Elevate head of the patient by 30

May allow cold or hot compress on the forehead.

May decrease pain by introduction of pressure or massage.

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HeadacheNursing ManagementNursing assessmentHealth historySeizures, cancer, stroke, trauma, asthma or allergies, mental illness, stress, menstruation, exercise, food, bright lights, noxious stimuliMedicationsSurgery and other treatments63

Subjective and objective data that should be obtained from a patient with headache are presented in Table 59-4.

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HeadacheNursing ManagementNursing assessmentHealth history (contd)Specific details about the headache LocationType of painOnsetFrequencyDuration, time of dayRelation to outside events

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The nurse may suggest that the patient keep a diary of headache episodes with specific details. This type of record can be of great help in determining the type of headache and the precipitating events.

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HeadacheNursing ManagementNursing assessment (contd)Objective dataAnxiety or apprehensionDiaphoresis, pallor, unilateral flushing with cheek edema, conjunctivitis 65

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Headache Nursing Management Nursing diagnoses Acute painAnxietyHopelessness 66

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HeadacheNursing ManagementPlanning Have decreased or no painExperience increased comfort and reduced anxietyDemonstrate understanding of triggering events and treatment strategies 67

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HeadacheNursing Management Planning Use positive coping strategies to deal with chronic pain.Experience quality of life68

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Headache Nursing ManagementNursing implementationDaily exercise, relaxation periods, and socializing help reduce recurrence and should be encouraged.Suggest alternative pain management such as relaxation, meditation, yoga, and self-hypnosis. 69

The most effective therapy may be to help patients examine their lifestyle, recognize stressful situations, and learn to cope with them more appropriately. Help the patient identify precipitating factors and develop ways to avoid them.

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Headache Nursing ManagementNursing implementation (contd)Massage and heat packs can help with tension-type.Patient should make a written note of medications to prevent accidental overdose. 70

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Headache Nursing ManagementNursing implementation (contd)Teach patient about prophylactic treatment.Dietary counseling for food triggersAvoid smoking and smoke exposure and other environmental triggers. 71

The patient needs to be encouraged to eliminate foods that may provoke headaches, such as chocolate, cheese, oranges, tomatoes, onions, monosodium glutamate, aspartame, alcohol (particularly red wine), excessive caffeine, and fermented or marinated foods. A teaching guide for the patient with a headache is presented in Table 59-5.

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Case Study72

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Case Study25-year-old woman presents to clinic with throbbing headaches with photosensitivity.Her headaches become so intense, they cause nausea and occasionally vomiting. She states that the OTC pain medication has not provided much relief for her pain.She began to develop the intermittent headaches about a year ago73

Case Study -Davidsons Clinical Practice For Junior Doctors

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Cont She believes her headaches have been getting worse over time.To obtain relief, she usually shuts herself in a dark room. She has a family history of headaches.MRI and CT are negative for abnormalities.She is diagnosed with migraine headaches. She believes her headaches have been getting worse over time.To obtain relief, she usually shuts herself in a dark room. She has a family history of headaches.MRI and CT are negative for abnormalities.She is diagnosed with migraine headaches.

74Case Study -Davidsons Clinical Practice For Junior Doctors

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Discussion QuestionsWhat can you tell her about treatment with medications?

What alternative therapies may help her?

What possible triggers should she avoid?

75Case Study -Davidsons Clinical Practice For Junior Doctors

There are medications for prevention of the occurrence of headache and for acute treatment of a migraine attack.Biofeedback and relaxation techniques.Certain foods, smoking, alcohol, and caffeine.75

CausesOrganic Factors such as brain tumors or aneurysmFluid and Electrolyte Imbalance (Dehydration, Fluid volume excess)Medications overuse (NSAIDS, Anti-Hypertensive, Diuretics, etc.)Emotional and Physical stressToxic Substance Exposure

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Pathophysiology

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Where does the pain exist?

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Journal reference Prevalence and characteristics of migraine in medical students Bindu Menon Neeharika KinneraNarayana Medical College, Nellore, Andhra Pradesh, IndiaAnnals of Indian Academy of Neurology2014 Jun 10

68% of medical students had headache. Onefourth of the students had weekly or daily attacks with 31% students reporting increase in their headache intensity and frequency. 44% percent of students had severe headaches. Dizziness, allodynia, and neck stiffness were reported as accompanying symptoms. Trigger factors were identified in 99% students, predominant of which were poor sleep hygiene, environmental changes, head movements, and mental stress. Only 4% of students did regular exercise. 27 %of students reported selfmedication use of analgesics.Onefourth of the students had migraineassociated disability but only 6% realized that they had migraine.

Bibliography Ropper AH, Samuels MA. Adams and Victors Principles of Neurology. Boston;McGraw Hill Education: 2012Donaghy M, Brains Diseases Of The Nervous System. Oxford. Oxford university press: 2009Hauser SL, Josephson AS. Harrisons Neurology in Clinical Medicine. Newyork: McGraw Hill; 2013Daroff RB, Fenichel GM, Jankovic K, Maziotta JV. Bradleys Neurology in Clinical Practice. Philaldelphia, Elsevier Saunders; 2012Fauci AS, Harrison TR. Harrisons Principles of Internal Medicine. Newyork: McGraw Hill; 2008Davidsons case book for JUNIOR DOCTORS -