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Headaches /Reading and Sharing

According to Dunphy, Winland-Brown, Porter, & Thomas (2015), headaches are classified into four groups including tension, migraine and cluster, muscle contraction and vascular, and inflammatory. Assessing a patient’s history can assist the healthcare provider in determining if the headaches are benign versus that which requires immediate attention. Banting & Meriano (2017), state that dangerous causes of headaches include those occurring with trauma, infectious, malignant, hemorrhagic, vasculitis, or special circumstances, such as after diving, foreign travel, or exposure to carbon monoxide. Decompensating or altered gait, mental status changes, or descriptors of sudden headaches being thunderclap in nature or the worst headache ever, also require immediate and further investigation.

Cluster Headaches:

Headaches that have a sudden onset, sever in pain. Can affect orbital, supraorbital, temporal, or any combination of sites, that is unilateral in location. Cluster headaches have a duration of 15 mins to 2 hours. Frequency can be from every other day to several times per day. Patients will often express feeling of agitation during that time of an attack. Often called cluster headache, Horton’s headache, ciliary neuralgia, erythromelagia of the head or erythroprosopalgia of bing.

Incidence/ Prevalence: Only occurs in a small percentage of the population (0.05-1%). Occurs in males five times more than females between the ages of 20-40. May be inherited in up to 20% of cases.

Pathophysiology/Etiology: Pathophysiology is controversial, but is felt to be a result in the posterior hypothalamic gray matter becoming activated, resulting in activation of in the trigeminal and parasympathetic areas.

Physical assessment and examination: As the primary care provider you may find that a patient will report having an attack during a conjunctival infection or lacrimation. May be associated with nasal congestion, rhinorrhea, facial sweating, or Horner’s syndrome. Horner’s syndrome usually are signs and symptoms associated with one side of the face with signs presenting with small pupils, drooping of the upper eyelid, delayed dilation of the pupil, and often lacks sweating in one side of the face or only a portion of the face, complain of agitating during an attack (Mayo Clinic, 2018).

Evidence-Based treatment: 

  • Episodic: Prophylactic treatment should be initiated at the onset of the cluster and tapered.
  • Acute: Inhaling 100% oxygen via face mask at 12-15L/min, this works in 60-80% of patients. Utilization of sumatriptan, zolmitriptan.
  • Chronic: Again, start prophylactic treatment, increasing doses until control is obtained.

Medications to consider for episodic and chronic cases: Verapamil 240mg po in a day and increase to 960 mg in a day. Given in 3 doses may be more effective then extended release. Topiramate 50 mg po 2 times daily and may be given in addition to the verapamil. Lithium 200 mg po 3 times daily (this will require frequent monitoring of lithium levels). Methysergide 1-2 mg po 3 times daily, ergotamine tartrate 3-4 mg in a day, given during clusters. Prednisone 60 mg po daily for one week, with a taper (Ferri, 2018).

 

Migraine Headaches:

Migraine headaches are a particular type of recurrent headache that can be debilitating for the affected individual. They can occur with or without preceding focal neurologic symptoms or have an atypical presentation (Ferri, 2018). Migraine headaches are typically severe and throbbing, and last from 4 to 72 hours, they accompanied by either or both of nausea or vomiting and photophobia or phonophobia (Warren, 2017). The pain from migraines may occur all over the head but typically is localized to a hemisphere; migraine pain is throbbing in character, of moderate or severe intensity, and made worse by exercise (Ferri, 2018).

Incidence/Prevalance: Migraine incidence increases from infancy, peaks during the 30’s and typically decreases over time; peak ages are between 18 and 49 years of age (Ferri, 2018). There is a 3:1 female (18% of females) to male (6% of males) ratio of migraine sufferers and more than 50% of migraine sufferers have an affected family member (Ferri, 2018). Migraines are often hereditary and there is a familial predisposition, 50%.

Pathophysiology/Etiology: Migraines are often hereditary and so acquiring a thorough family history is important in order to determine a diagnosis for the headache sufferer. The pathophysiology of migraines is not clear; however, there is evidence supporting that a primary neuronal event can result in trigeminovascular reflex which causes neurogenic inflammation (Migraine, 2017; Ferri, 2018).

Physical assessment and examination: Migraine sufferers appear normal between migraine headache episodes. Migraines are generally unilateral, individuals can be photosensitive and sound sensitive, the pain can last for days, nausea and vomiting may occur, and some migraines may cause visual disturbances called an aura (McCance & Huether, 2014). The diagnosis of migraine without aura should include: at least five migraine headache attacks that fulfill criteria; headache lasting 4 to 72 hours; and two of the following unilateral location, pulsating quality, moderate or severe pain, and aggravation or avoidance of routine physical activity (Ferri, 2018). Nausea and/or vomiting and photophobia and phonophobia are generally consist during a migraine headache episode. Migraine with aura usually involve visual disturbances, such as flashes of light or wavy, zigzag vision. Sometimes migraine sufferers with auras may consist of touching sensations (sensory), movement (motor) or speech (verbal) disturbances, or muscular weakness (Migraine, 2017). The diagnosis of migraine with aura includes at least two migraine attacks, symptoms of aura is fully reversible,  Diagnostic tests such as a computed tomography (CT) scan or a magnetic resonance image (MRI) with or without contrast is recommended if the individual with headaches has noticed a change in the frequency, severity, has begun having seizures with their headache, has developed personality changes, or shows any abnormal neurological findings (Dunphy, Winland-Brown, Porter, & Thomas, 2015, p. 128).

Evidence-Based treatment:

  • Acute: NSAID (ketorolac, ibuprofen, naproxen). Triptans, such as rizatriptan 5 or 10 mg at time of headache, repeating every 2 hrs as needed with a max dose of 30 mg in a day. Eletriptan can be given in the same way with dosages of 20 or 40 mg tabs with a max of 80 mg in a day.
  • Chronic: Prophylaxis treatment
  • Episodic: Prophylaxis treatment

Patients should be encouraged to keep a headache diary that records the number of headaches, the severity, alleviating factors, and precipitating factors (stress, foods, alcohol, environmental factors, etc.). The patient should try to avoid known triggers that precipitate migraine headaches, such as alcohol, smoking tobacco, caffeine, and dietary factors; reducing stress, relaxation training, and minimizing sleep, meal, and exercise disturbances may help prevent migraine headaches.

The patient’s account of headache symptoms is important to determine if the headache symptoms may be life-threatening. For example, symptoms of a subarachnoid hemorrhage may include an intense sudden onset of head pain and this can be a life-threatening condition if not treated appropriately as soon as possible (Warren, 2017). Other urgent headache causes are transient ischemia attacks or cerebral vascular attacks. Pharmacologic therapy for mild migraines include: aspirin; ibuprofen; acetaminophen; the combination of acetaminophen, aspirin and caffeine (Excedrin Migraine) may ease moderate migraine pain (Ferri, 2018). Moderate to severe migraine therapy includes triptans, and if necessary for additional relief, intravenous antiemetics (Ferri, 2018). Prophylaxis for migraine headaches include the avoidance of triggers, beta blocker medication, tricyclic antidepressants, the antiepileptic medication topiramate, valporic acid, and Botox injections. Patients should be seen by their primary monthly to follow-up on migraine therapy. A referral to neurology should be initiated if the affected individual if treatment is not effective. As a chronic migraine sufferer, it has been quite the road to determine effective prophylaxis. Patients suffering from migraines may benefit from combination therapies such as: triptans, NSAIDs, massage, aroma therapy, topical numbing substances, and others.

 

Tension Headaches:

Highly prevalent and primary cause of headaches. Tension headaches are not associated with complaints of nausea or vomiting.

Incidence/Prevalence: Most common type of headache accounting for 70% of patients who seek care from their primary care provider. Women are affected more than men.

Pathophysiology/Etiology: No longer related to a psychological problem, often a heterogeneous disorder that can have many pathophysiological mechanisms. Also, not associated with muscle contraction.

Physical assessment and examination: Patient may complain of the headache from less than once a month to chronic, Have to have at least 10 headaches, lasting 30 mins to 7 days. . Patient with tension headaches may also have light and sound sensitivity. Concurrent conditions may be anxiety, depression, overuse of analgesics. Pericranial tenderness during palpation on the exam.

Treatment: Combination of nonpharmacological and pharmacological. Having patients modify their sleep, acupuncture, cognitive-behavioral therapy, relax training.

  • Acute: NSAIS, acetaminophen, Caffeine.
  • Preventative Treatment: Amtiriptyline 10-50 mg is the first choice (Ferri, 2018).

 

 

References:

Banting, J., & Meriano, T. (2017). Headache. Journal of Special Operations Medicine: A Peer Reviewed Journal for SOF Medical Professionals, 17(2), 108-111.

Chawla, J. (2018). Migraine Headache. Retrieved from https://emedicine.medscape.com/article/1142556-overview

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D.J. (2015). Primary care: The art and science of advanced practice nursing (4th ed.). Philadelphia, PA: F.A. Davis Company.

Ferri, F.F. (2018). Ferri’s Clinical Advisor 2018: 5 Books in 1. Philadelphia, PA. ELSEVIER

Mayo Clinic (2018). Horner’s Syndrome. Retrieved from https://www.mayoclinic.org/diseases-conditions/horner-syndrome/symptoms-causes/syc-20373547

McCance, K., & Huether, S. (2014). Pathophysiology: The Biologic Basis for Disease in Adults and Children, 7th Edition. St Louis: Mosby.

Migraine. (2017, April 26). Mayo Clinic. Retrieved March 3, 2018, from https://www.mayoclinic.org/diseases-conditions/migraine-headache/symptoms-causes/syc-20360201

Warren, E. (2017). Neurological Symptoms in primary care Part 3: Headache. Practice Nurse, 47(3), 16-19.

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