Download - Cephalgia.Unni Krishnan.S.V JIPMER
Presented by,Unni Krishnan.SV
M.Sc Nursing – II YEAR COLLEGE OF NURSING –JIPMER
eadache→Cephalgia ; 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.
DEFINITION
Headache 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 patient’s 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
1. Pain usually occurs when peripheral nociceptors are stimulated in response to tissue injury, visceral distension, or other factors.
2. In such situations, pain perception is a normal physiologic response mediated by a healthy nervous system.
3. Pain can also result when pain-producing pathways of the peripheral or central nervous system (CNS) are damaged or activated inappropriately.
4. 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
Primary Headache Incidence % Secondary Headache Incidence % 1. Migraine 16 1. Systemic infection 63 2. Tension Type 69 2. Head injury 4 3. Cluster 0.1 3. Vascular disorders 1 4. Idiopathic stabbing 2 4. Subarachnoid hemorrhage <1 5. Exertional 1 5. Brain tumor 0.1
Source: The Headaches. Philadelphia, Lippincott Williams and Wilkins
2005
Clinical evaluation of acute new onset headache• History 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
Investigating HeadacheIs any special investigation warranted?
When there is diagnostic difficulty or history suggests a serious disorder, investigation becomes obligatory!
CT-Scan
MRI
Lumbar Puncture
Blood Count/ESR
HEADACHE SYMPTOMS THAT SUGGESTS A SERIOUS UNDERLYING
DISORDER
1. Worst headache ever
2. First severe headache
3. Subacute worsening over days or weeks
4. Abnormal neurologic examinations
5. Fever or unexplained systemic signs
6. Vomiting that precedes headache
7. Pain induced by bending, lifting or cough
8. Pain that disturbs sleep or presents immediately upon awakening
9. Known systemic illness
10.Onset after age 55 pain associated with local tenderness, eg., region of temporal
artery
TYPES OF HEAD ACHE
Types Primary
secondary
Source :International Headache Society
PRIMARY HEADACHE
A primary headache is a headache that is due to the headache condition itself and not due to another cause.
Source :International Headache Society
TYPES OF PRIMARY HEADACHE
1. Migraine 2. Tension Type 3. Cluster 4. Idiopathic stabbing 5. Exertional
Source :International Headache Society
SECONDARY HEADACHE
A secondary headache is a headache that 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)Migraine• Migraine without aura• Migraine with aura• Retinal migraine• Childhood periodic syndrome• Complications of migraine• Migraneous disorders not fulfilling above criteria
2) Tension-type headache (TTH)• Episodic tension-type headache• Frequent episodic tension-type headache• Chronic tension-type headache• Headache of the tension – type not fulfilling above criteria 3)Cluster headache and chronic paroxysmal hemicrania• Cluster headache• Chronic Paroxysmal hemicrania• Cluster headache- like disorder not fulfilling above criteria
4)Miscellaneous headaches unassociated with structural lesion
Idiopathic stabbing headachePrimary cough headacheExternal compression headaceadacheBenign exertional headacheCold stimulus headacheBenign cough headache headache associated with sexual activity
Secondary headaches
5)Headache attributed to head and/or neck trauma
• Acute post-traumatic headache• Chronic post-traumatic headache
6)Headache associated with vascular disorder• Headache attributed to ischaemic stroke or transient ischaemic attack• intracranial haemorrhage• intracerebral haemorrhage• Headache attributed to subarachnoid haemorrhage (SAH)• unruptured vascular malformation• Arteritis• Carotid or vertebral dissection• Venous thrombosis• Arterial hypertension• Head ache associated with other vascular disorder
7)Headache associated with non-vascular intracranial disorder
• High cerebrospinal fluid pressure• Low cerebrospinal fluid pressure• Intracranial infection intracranial sarcoidosis• Headache related to intrathecal injections• Intacranial neoplasm• Headache associated with other intracranial disorder
8)Headache attributed to a substance or its withdrawal
• Headache induced by acute substance use or exposure
• Headache induced by chronic substance use or exposure
• Headache from substance withdrawl (acute or chronic)
9)Headache associated with noncephalic infection• Viral infection• Bacterial infection• Headache 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 structures
• cranial bone• Neck• Eyes• Ears• Nose and sinuses• Teeth,jaws, and related structure• Temporomandibular joint disease
12)Cranial neuralgias, nerve trunk pain,deafferentation pain
Persistent (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 world’s top 20 leading causes of disability.
• Afflicts approximately 15% of women and 6% of men.
• Females are most commonly affected during the menstrual cycle( Research finding )
Etiology
• Migraines may run in families• Changes in hormone levels during a woman's
menstrual cycle or with the use of birth control pills
• Changes in sleep patterns• Exercise or other physical stress• Missed meals• Smoking 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
products• Foods containing tyramine, which includes red wine, aged
cheese, smoked fish, chicken livers, figs, and certain beans• Fruits (avocado, banana, citrus fruit)• Meats containing nitrates (bacon, hot dogs, salami, cured
meats)• Onions
Clinical Features • Nausea• Photophobia• Lightheadedness• Scalp tenderness• Vomiting • Visual disturbances like photopsia,fortification spectra • Paresthesias• Vertigo • Alteration of consciousness like syncope seizure,
confusional state • Diarrhea
Pathophysiology• Headache 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 …..
• 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 tract
• Acute 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 Wolff• Pain is based on dilatation of cranial vessels• Migraine 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 CGrP• CGrP 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 1
• Repeated 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 significantly by anti-inflammatory 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, fluctuates 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- fluctuating, 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 10–12 L/min for 15–20 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 (25–75 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, inflammation, infection, medication etc This is
managed by using valproate, and gabapentin.
Secondary headache • Low CSF volume headache• Raised CSF pressure headache• Post-traumatic headache
Other secondary type head aches includes • Hemicrania Continua• Cough Headache• Exertional Headache• Sex Headache• Stabbing Headache
Head ache occurs due to structural problems • MENINGITIS• INTRACRANIAL HEMORRHAGE• BRAIN TUMOR• TEMPORAL ARTERITIS• GLAUCOMA
NURSING MANAGEMENT• The 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 30º
• May allow cold or hot compress on the forehead.
• May decrease pain by introduction of pressure or massage.
HeadacheNursing Management
• Nursing assessment• Health history
• Seizures, cancer, stroke, trauma, asthma or allergies, mental illness, stress, menstruation, exercise, food, bright lights, noxious stimuli
• Medications• Surgery and other treatments
63
HeadacheNursing Management
• Nursing assessment• Health history (cont’d)
• Specific details about the headache • Location• Type of pain• Onset• Frequency• Duration, time of day• Relation to outside events
64
HeadacheNursing Management
•Nursing assessment (cont’d)•Objective data
• Anxiety or apprehension• Diaphoresis, pallor, unilateral flushing with cheek edema, conjunctivitis
65
Headache Nursing Management
• Nursing diagnoses • Acute pain• Anxiety• Hopelessness
66
HeadacheNursing Management
• Planning • Have decreased or no pain• Experience increased comfort and reduced anxiety• Demonstrate understanding of triggering events and
treatment strategies
67
HeadacheNursing Management
• Planning • Use positive coping strategies to deal with
chronic pain.• Experience ↑ quality of life
68
Headache Nursing Management
• Nursing implementation• Daily 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
Headache Nursing Management
• Nursing implementation (cont’d)• Massage and heat packs can help with tension-type.• Patient should make a written note of medications to
prevent accidental overdose.
70
Headache Nursing Management
• Nursing implementation (cont’d)• Teach patient about prophylactic treatment.• Dietary counseling for food triggers• Avoid smoking and smoke exposure and other
environmental triggers.
71
Case Study
72
Case Study
• 25-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 ago
73
Case Study -Davidsons Clinical Practice For Junior Doctors
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.
74
Case Study -Davidsons Clinical Practice For Junior Doctors
Discussion Questions
1. What can you tell her about treatment with medications?
2. What alternative therapies may help her?
3. What possible triggers should she avoid?
75
Case Study -Davidsons Clinical Practice For Junior Doctors
Causes
Organic 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
Pathophysiology
Where does the pain exist?
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. One fourth 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 self medication use of analgesics.One fourth of the students had migraine associated disability
but only 6% realized that they had migraine.
Bibliography
• Ropper AH, Samuels MA. Adams and Victor’s Principles of Neurology. Boston;McGraw Hill Education: 2012
• Donaghy M, Brain’s Diseases Of The Nervous System. Oxford. Oxford university press: 2009
• Hauser SL, Josephson AS. Harrison’s Neurology in Clinical Medicine. Newyork: McGraw Hill; 2013
• Daroff RB, Fenichel GM, Jankovic K, Maziotta JV. Bradley’s Neurology in Clinical Practice. Philaldelphia, Elsevier Saunders; 2012
• Fauci AS, Harrison TR. Harrisons Principles of Internal Medicine. Newyork: McGraw Hill; 2008
• Davidsons case book for JUNIOR DOCTORS -