Chapter: Medical Surgical Nursing: Management of Patients With Neurologic Dysfunction

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Headache

Headache, or cephalgia, is one of the most common of all human physical complaints.

Headache

Headache, or cephalgia, is one of the most common of all human physical complaints. Headache is actually a symptom rather than a disease entity; it may indicate organic disease (neurologic or other disease), a stress response, vasodilation (migraine), skeletal muscle tension (tension headache), or a combination of factors. A primaryheadache is one for which no organic cause can be identified.These types of headache include migraine, tension-type, and clus-ter headaches (Lin, 2001). Cranial arteritis is another common cause of headache. A classification of headaches was issued by the Headache Classification Committee of the International Headache Society in 1988; an abbreviated list is shown in Chart 61-6.

 

Migraine is a symptom complex characterized by periodicand recurrent attacks of severe headache. The cause of migraine has not been clearly demonstrated, but it is primarily a vascular disturbance that occurs more commonly in women and has a strong familial tendency. The typical time of onset is puberty, and the incidence is highest in adults 20 to 35 years of age. There are seven subtypes of migraine, including migraine with and without aura. Most patients have migraine without an aura.

 

Tension headaches tend to be more chronic than severe and areprobably the most common type of headache. Cluster headaches are a severe form of vascular headache. They are seen five times more frequently in men than women (Greenberg, 2001).

Inflammation of the cranial arteries is characterized by a severe headache localized in the region of the temporal arteries. The in-flammation may be generalized (in which cranial arteritis is part of a vascular disease) or focal (in which only the cranial arteries are involved). Cranial arteritis is a cause of headache in the older population, reaching its greatest incidence in those older than 70 years of age.

 

A secondary headache is a symptom associated with an or-ganic cause, such as a brain tumor or an aneurysm. Most headaches do not indicate serious disease, although persistent headaches re-quire further investigation. Serious disorders related to headache include brain tumors, subarachnoid hemorrhage, stroke, severe hypertension, meningitis, and head injuries.

Assessment and Diagnostic Evaluation

The diagnostic evaluation includes a detailed history, a physical assessment of the head and neck, and a complete neurologic ex-amination. Headaches may manifest differently within an indi-vidual over the course of a lifetime, and the same type of headache may present differently from patient to patient. The health his-tory focuses on assessing the headache itself, with emphasis on the factors that precipitate or provoke it. Patients are asked to de-scribe headaches in their own words.

 

Because headache is often the presenting symptom of various physiologic and psychological disturbances, a general health his-tory is an essential component of the patient database. Headache may be a symptom of endocrine, hematologic, gastrointestinal, infectious, renal, cardiovascular, or psychiatric disease. Therefore, questions addressed in the health history should cover major medical and surgical illness as well as a body systems review.

The medication history can provide insight into the patient’s overall health status. Antihypertensive agents, diuretic medica-tions, anti-inflammatory agents, and monoamine oxidase in-hibitors are a few of the categories of medications that can provoke headaches. Although sometimes exaggerated in importance, emo-tional factors can play a role in precipitating headaches. Stress is thought to be a major initiating factor in migraine headaches; therefore, sleep patterns, level of stress, recreational interests, appetite, emotional problems, and family stressors are relevant (Cunningham, 2000). There is a strong familial tendency for headache disorders, and a positive family history may help in making a diagnosis.

A direct relationship may exist between exposure to toxic sub-stances and headache. Careful questioning may uncover chem-icals to which a worker has been exposed. Under the Right to Know law, employees have access to the material safety data sheets (commonly referred to as MSDSs) for all the substances with which they come in contact in the workplace. The occupa-tional history also includes assessment of the workplace as a pos-sible source of stress and a possible ergonomic basis for muscle strain and headache.

 

A complete description of the headache itself is crucial. The age at onset of headache; the headache’s frequency, location, and duration; the type of pain; factors that relieve and precipitate the event; and associated symptoms are reviewed. The data obtained should include the patient’s own words about the headache in response to the following questions:

 

·      What is the location? Is it unilateral or bilateral? Does it ra-diate?

 

·      What is the quality—dull, aching, steady, boring, burning, intermittent, continuous, paroxysmal?

 

·      How many headaches occur during a given time?

 

·      What are the precipitating factors, if any (environmental, such as sunlight and weather change; foods; exertion; other)?

 

·      What makes the headache worse (coughing, straining)?

 

·       What time (day or night) does it occur?

 

·      Are there any associated symptoms, such as facial pain, lacrimation (excessive tearing), or scotomas (blind spots in the field of vision)?

 

·      What usually relieves the headache (aspirin, NSAIDs, ergot preparation, food, heat, rest, neck massage)?

 

·      Does nausea, vomiting, weakness, or numbness in the ex-tremities accompany the headache?

 

·      Does the headache interfere with daily activities?

 

·       Do you have any allergies?

 

·       Do you have insomnia, poor appetite, loss of energy?

 

·       Is there a family history of headache?

 

·      What is the relationship of the headache to lifestyle or phys-ical or emotional stress?

 

·      What medications are you taking?

 

Diagnostic testing is often not helpful in the investigation of headache as there are often few objective findings. In patients who demonstrate abnormalities on the neurologic examination, CT, cerebral angiography, or MRI may be used to detect under-lying causes, such as tumor or aneurysm. Electromyography (EMG) may reveal a sustained contraction of the neck, scalp, or facial muscles. Laboratory tests may include complete blood count, erythrocyte sedimentation rate, electrolytes, glucose, cre-atinine, and thyroid hormone levels.

Pathophysiology

The cerebral signs and symptoms of migraine result from dys-function of the brain stem pathways that normally modulate sensory input (Goadsby, Lipton & Ferrari, 2002). Abnormal me-tabolism of serotonin, a vasoactive neurotransmitter found in platelets and cells of the brain, plays a major role. The headache is preceded by a rise in plasma serotonin, which dilates the cerebral vessels, but migraines are more than just vascular headaches. Theexact mechanism of pain in migraine is not completely understood but is thought to be related to the cranial blood vessels, the inner-vation of the vessels, and the reflex connections in the brain stem.

 

Migraines can be triggered by menstrual cycles, bright lights, stress, depression, sleep deprivation, fatigue, overuse of certain medications, and certain foods containing tyramine, monosodium glutamate, nitrites, or milk products. Foods in these categories include aged cheese and many processed foods. Use of oral con-traceptives may be associated with increased frequency and sever-ity of attacks in some women.

 

Emotional or physical stress may cause contraction of the muscles in the neck and scalp, resulting in tension headache. The pathophysiology of cluster headache is not fully understood. One theory is that it is due to dilation of orbital and nearby extracra-nial arteries. Cranial arteritis is thought to represent an immune vasculitis in which immune complexes are deposited within the walls of affected blood vessels, producing vascular injury and in-flammation. A biopsy may be performed on the involved artery to make the diagnosis.

Clinical Manifestations

MIGRAINE

 

The migraine with aura can be divided into four phases: pro-drome, aura, the headache, and recovery (headache termination and postdrome).

Prodrome.

The prodrome phase is experienced by 60% of pa-tients with symptoms that occur hours to days before a migraine headache. Symptoms include depression, irritability, feeling cold, food cravings, anorexia, change in activity level, increased urina-tion, diarrhea, or constipation. Patients usually experience the same prodrome with each migraine headache.

Aura Phase.

Aura occurs in up to 31% of patients who have mi-graines (Goadsby et al., 2002). The aura usually lasts less than an hour and may provide enough time for the patient to take the prescribed medication to avert a full-blown attack (described in a later section). This period is characterized by focal neurologic symptoms. Visual disturbances (ie, light flashes and bright spots) are common and may be hemianopic (affecting only half of the visual field). Other symptoms that may follow include numbness and tingling of the lips, face, or hands; mild confusion; slight weakness of an extremity; drowsiness; and dizziness.

This period of aura corresponds to the painless vasoconstric-tion that is the initial physiologic change characteristic of classic migraine. Cerebral blood flow studies performed during migraine headaches demonstrate that during all phases of the attack, cere-bral blood flow is reduced throughout the brain, with subsequent loss of autoregulation and impaired CO2 responsiveness.

Headache Phase.

As vasodilation and a decline in serotonin lev-els occur, a throbbing headache (unilateral in 60% of patients) intensifies over several hours. This headache is severe and inca-pacitating and is often associated with photophobia, nausea, and vomiting. Its duration varies, ranging from 4 to 72 hours (Goadsby et al., 2002).

Recovery Phase.

In the recovery phase (termination and post-drome), the pain gradually subsides. Muscle contraction in the neck and scalp is common, with associated muscle ache and lo-calized tenderness, exhaustion, and mood changes. Any physical exertion exacerbates the headache pain. During this postheadache phase, patients may sleep for extended periods.

OTHER HEADACHE TYPES

 

The tension headache is characterized by a steady, constant feel-ing of pressure that usually begins in the forehead, temple, or back of the neck. It is often bandlike or may be described as “a weight on top of my head.”

Cluster headaches are unilateral and come in clusters of one to eight daily, with excruciating pain localized to the eye and orbit and radiating to the facial and temporal regions. The pain is accompa-nied by watering of the eye and nasal congestion. Each attack lasts 30 to 90 minutes and may have a crescendo–decrescendo pattern (Greenberg, 2001). The headache is often described as penetrat-ing and steady.

Cranial arteritis often begins with general manifestations, such as fatigue, malaise, weight loss, and fever. Clinical manifestations associated with inflammation (heat, redness, swelling, tenderness, or pain over the involved artery) usually are present. Sometimes a tender, swollen, or nodular temporal artery is visible. Visual problems are caused by ischemia of the involved structures.

Prevention

Prevention begins by having the patient avoid specific triggers that are known to initiate the headache syndrome. Preventive medical management of migraine involves the daily use of one or more agents that are thought to block the physiologic events lead-ing to an attack. Medication therapy should be considered for mi-graine if attacks occur 3 to 4 days per month (Goadsby et al., 2002). Treatment regimens vary greatly, as do patient responses; thus, close monitoring is indicated.

 

There are several proven or widely used medications for the prevention of migraine. Two beta-blocking agents, propranolol (Inderal) and metoprolol (Lopressor), inhibit the action of beta-receptors—cells in the heart and brain that control the dilation of blood vessels. This is thought to be a major reason for their an-timigraine action. Other medications that are prescribed for mi-graine prevention include amitriptyline hydrochloride (Elavil), divalproex (Valproate), flunarizine, and several serotonin antag-onists (Goadsby et al., 2002).

 

Calcium antagonists (verapamil HCl) are widely used but may require several weeks at a therapeutic dosage before improvement is noted. Calcium-channel blockers are not as effective as beta-blockers for prevention but may be more appropriate for some patients, such as those with bradycardia, diabetes mellitus, or asthma (Goadsby et al., 2002).

 

Alcohol, nitrites, vasodilators, and histamines may precipitate cluster headaches. Eliminating these factors helps in preventing the headaches (Silberstein & Rosenberg, 2000). Prophylactic medication therapy may include beta-blockers, ergotamine tar-trate (occasionally), lithium, naproxen (Naprosyn), and methy-sergide (Sansert); such therapy is effective in 20% to 40% of cases (Greenberg, 2001).

Medical Management

Therapy for migraine headache is divided into abortive (sympto-matic) and preventive approaches. The abortive approach, best employed in patients who suffer less frequent attacks, is aimed at relieving or limiting a headache at the onset or while it is in progress. The preventive approach is used in patients who expe-rience more frequent attacks at regular or predictable intervals and may have medical conditions that preclude the use of abortive therapies (Evans & Lipton, 2001).

 

The triptans, serotonin receptor agonists, are the most specific antimigraine agents available. These agents cause vasoconstriction, reduce inflammation, and may reduce pain transmission. The five triptans in routine clinical use include sumatriptan (Imitrex), naratriptan (Amerge), rizatriptan (Maxalt), zolmitrip-tan (Zomig), and almotriptan (Goadsby et al., 2002). Numerous serotonin receptor agonists are under study.

Ergotamine preparations (taken orally, sublingually, subcuta-neously, intramuscularly, by rectum, or by inhalation) may be ef-fective in aborting the headache if taken early in the migraine process. They are low in cost. Ergotamine tartrate acts on smooth muscle, causing prolonged constriction of the cranial blood vessels. Each patient’s dosage is based on individual needs. Side effects in-clude aching muscles, paresthesias (numbness and tingling), nau-sea, and vomiting. Cafergot, a combination of ergotamine and caffeine, can arrest or reduce the severity of the headache if taken at the first sign of an attack (Karch, 2002).

Perhaps the most widely used triptan is sumatriptan succinate (Imitrex); it is available in oral, intranasal, and subcutaneous prepa-rations and is effective for the treatment of acute migraine and clus-ter headaches in adults (McAlhany, 2001). The subcutaneous form usually relieves symptoms within an hour and is available in an auto-injector for immediate patient use, although it is expensive in this form. Sumatriptan has been found to be effective in relieving mod-erate to severe migraines in a large number of adult patients. Suma-triptan may cause chest pain and is contraindicated in patients with ischemic heart disease (Goadsby et al., 2002). Careful administra-tion and dosing instructions to patients are important to prevent adverse reactions such as increased blood pressure, drowsiness, muscle pain, sweating, and anxiety. There are possible interactions when taken in conjunction with St. John’s wort (Karch, 2002).

 

Many of the triptan medications are available in a variety of formulations, such as nasal sprays, inhalers, suppositories, or in-jections; however, 80% of patients prefer the oral formulations (Goadsby et al., 2002). None of these medications should be taken concurrently with medications containing ergotamine due to the potential for a prolonged vasoactive reaction (Karch, 2002).

The medical management of an acute attack of cluster head-aches may include 100% oxygen by face mask for 15 minutes, ergotamine tartrate, sumatriptan, steroids, or a percutaneous sphenopalatine ganglion blockade (Greenberg, 2001).

 

The medical management of cranial arteritis consists of early administration of a corticosteroid to prevent the possibility of loss of vision due to vascular occlusion or rupture of the involved artery (Greenberg, 2001). The patient is instructed not to stop the medication abruptly because this can lead to relapse. Anal-gesic agents are prescribed for comfort.

Nursing Management

When migraine or the other types of headaches described above have been diagnosed, the goals of nursing management are to en-hance pain relief. It is reasonable to try nonpharmacologic inter-ventions first, but the use of pharmacologic agents should not be delayed. The goal is to treat the acute event of the headache and to prevent recurrent episodes. Prevention involves patient educa-tion regarding precipitating factors, possible lifestyle or habit changes that may be helpful, and pharmacologic measures.

RELIEVING PAIN

 

Individualized treatment depends on the type of headache and differs for migraine, cluster headaches, cranial arteritis, and ten-sion headache (Greenberg, 2001; Silberstein & Rosenberg, 2000). Nursing care is directed toward treatment of the acute episode. 

A migraine or a cluster headache in the early phase requires abortive medication therapy instituted as soon as possible. Some headaches may be prevented if the appropriate medications are taken before the onset of pain. Nursing care during a fully devel-oped attack includes comfort measures such as a quiet, dark en-vironment and elevation of the head of the bed to 30 degrees. In addition, symptomatic treatment such as antiemetics may be in-dicated (Goadsby et al., 2002).

 

Symptomatic pain relief for tension headache may be obtained by application of local heat or massage. Additional strategies may include the use of analgesic agents, antidepressant medications, and muscle relaxants.

HOME AND COMMUNITY-BASED CARE

 

Teaching Patients Self-Care.

Headaches, especially migraines,are more likely to occur when the patient is ill, overly tired, or stressed. Nonpharmacologic therapies are important and include patient education about the type of headache, its mechanism (if known), and appropriate changes in lifestyle to avoid triggers. Regular sleep, meals, exercise, avoidance of peaks and troughs of relaxation, and avoidance of dietary triggers may be helpful in avoiding headaches (Goadsby et al., 2002; Rice, 2000).

 

The patient with tension headaches needs teaching and reas-surance that the headache is not due to a brain tumor. This is a common unspoken fear. Stress reduction techniques, such as biofeedback, exercise programs, and meditation, are examples of nonpharmacologic therapies that may prove helpful. Patients and their families need to be reminded of the importance of follow-ing the prescribed treatment regimen for headache and keeping follow-up appointments. In addition, they are reminded of the importance of participating in health promotion activities and recommended health screenings to promote a healthy lifestyle. See Chart 61-7 for a home care checklist for the patient with mi-graine headaches.


Continuing Care.

The National Headache Foundation provides a list of clinics in the United States and the names of physicians who specialize in headache and who are members of the American Association for the Study of Headache.

 

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