Not Tonight; I Have a Headache!
Headache of sudden onset, associated with stiff neck, fever, convulsion, confusion, LOC, head trauma, eye or ear pain, extremity numbness/tingling, or persistent in a headache-free patient, or recurrent in a child.
What is an emergency?
Symptoms such as a headache with fever and a stiff neck (encephalitis), a headache that starts with a thunderclap (migraine), a headache following a head injury (concussion, TBI), a headache with loss of vision or numbness of the arms or legs (CVA), or a headache with a fever (not caused by the flu) are emergent medical conditions.
Children rarely complain of headache but may become lethargic or experience convulsion.
ASA, APAP and NSAIDs
What is meds used for acute treatment for a tension-type headache?
The choice of medications for managing headaches depends on the specific type of headache.
The goals are to reduce the frequency and severity of headaches and to limit or stop a headache when it occurs.
This headache may be characterized as bilateral, frontal-occipital and band-like, constant, dull pain lasting minutes to days.
What is a tension-type headache?
The most common type of headache.
Most people who experience tension headaches have episodic headaches and may cycle for several years.
May occur with or in-between migraines.
TBI, infection, tumors, heredity, and medication ingestion are causes of seizure shared between these two age groups.
Who are infants/children and older adults?
Neonate "other causes" may include genetic neuro and metabolic defects and severe hypoxia.
Childhood "other causes" include acute conditions, such as toxin / poison ingestion, and cerebral infection (meningitis, encephalitis, abscess).
Adult "other causes" include chronic conditions, such as CVD and degenerative neuro diseases.
These include the patient exhibiting eyes closed, side-to-side movement, limb movement out-of-phase, body twisted and writhing, and fluctuation in seizure intensity.
What are characteristics of Psychogenic Non-Epileptic Seizure (PNES) activity?
Psychogenic seizures or events are caused by subconscious thoughts, emotions, or “stress”, not abnormal electrical activity in the brain.
This classification of headache is caused by intra or extra cranial disease.
What is secondary, or organic, headache?
Secondary headaches can occur with serious illnesses such as:
Brain metastases / tumors
Subarachnoid hemorrhage
Intracranial masses,
Vascular abnormalities
Trigeminal neuralgia
Diseases of the eyes, nose, teeth
They may occur associated with systemic illness such as:
Bacteremia, CO poisoning, polycythemia vera
O2, sumatriptan, and ergotamine are commonly used for this.
What is symptomatic treatment of cluster headache?
Alpha blockers are also called alpha-adrenergic blocking agents, alpha-adrenergic antagonists, adrenergic blocking agents and alpha-blocking agents, are a class of pharmacological agents that act as antagonists on α-adrenergic receptors.
Examples of alpha blockers used to treat high blood pressure include: Doxazosin (Cardura) Prazosin (Minipress) Terazosin.
Acute treatment of cluster headache is inhalation of 100% oxygen delivered at a rate of 6 to 8 liters min for 10 - 15 minutes, which may relieve headache by causing vasoconstriction, and by increasing synthesis of serotonin in the central nervous system
This can be repeated after a five minute rest
Many of the same medications used for migraines may treat cluster headaches. Some patients gain relief from a cluster headache by inhaling oxygen or giving sumatriptan.
Ergotamine tartrate (Cafergot, Ergomar), a non-selective α-Adrenergic blocker, may be given in suppository form at bedtime to prevent cluster headaches.
Risk factors for this type of headache include family history, stress, frequent tension-type headaches, and "triggers".
What is a migraine headache?
Migraine headache is a recurring type of headache causing moderate to severe pain characterized as throbbing or pulsing.
The pain is often on one side of the head and may be accompanied by other symptoms, such as nausea and weakness, photophobia (sensitivity to light) and phonophobia (sensitivity to sound).
Migraine is 2 to 3 times more common in females (depending on source). Susceptible to serotonin (low) and estrogen level changes
Triggers may include:
Dietary – fasting, certain foods, meds – overuse of OTC analgesics
Sleep – change in pattern – too much / too little
Hormonal – estrogen changes – menses, PMS, BCPs, HRT, perimenopause / menopause / ovulation
Environment – weather –extreme heat / cold, bright light, odors / pollution (smoke / perfume), altitude
Stress letdown – anticlimactic event (ending a project, finishing presentation, completing exam)
Physical – over-exertion, visual (eye strain), fatigue
This condition consists of two or more un-provoked and continuous / contiguous seizure episodes.
What is epilepsy?
Anti-epileptic meds (AEMs) are necessary; life-saving measures are required (surgery option)
Did you say seizure? A seizure is a single, self-limiting occurrence of “jerky” motor movements. A seizure does not require treatment with anti-epileptic meds or surgery; monitor for safety!
This overgrowth of the gums, first noted in institutionalized epileptic children in the 1960s, is often induced secondary to this medication therapy.
Provide both elements.
What is gingival hyperplasia due to phenytoin (Dilantin) administration?
These three common causes of headache do not require prompt medical attention.
What are hangovers, caffeine withdrawal and medication withdrawal?
Medication Overuse Headache (MOH) or "Rebound" headache is common and are caused by regular, long-term use of medication to treat headaches, such as migraines.
Headache is most common side effect (25%) is associated with ED medications use. Due to vasodilation / shunting of blood from the brain.
Anti-seizure meds, antihypertensives, and antidepressants used in migraine management
What are prophylactic (preventative) meds?
Antiseizure
Valproate (Depakene)
Topiramate (Topamax) do not stop abruptly - seizure risk!
Antihypertensives
ß Adrenergic Blockers (propranolol)
Ca Channel Blockers (verapamil)
Potassium channel blockers
Antidepressants
amitriptyline (Endep)
Serotonin antagonist
Methysergide (Sansert; Deseril)
Keep your eye on these headaches that affect less than 1% of the population, are more common in men aged 20-40 and commonly awake the person from sleep.
What are cluster headaches?
Cluster headaches are a rare form of headache affecting less than 0.1% of the population.
Unilateral lacrimation: tearing in one eye.
Smoking and alcohol ingestion associated.
More common in men between ages 20-40.
Unilateral pain located around or behind the eye that can wake the patient; also nasal congestion, tearing, facial flushing.
Cluster headaches involve repeated headaches that can occur for weeks to months at a time, followed by periods of remission.
Cluster headache is one of the most severe forms of headache, with intense pain lasting from a few minutes to 3 hours. Pain is sharp/stabbing where migraine is a pulsating pain.
Pain is generally located around the eye, radiating to the temple, forehead, cheek, nose, or gums.
Other signs may include swelling around the eye, tearing, facial flushing, pallor, nasal congestion, and constriction of the pupil.
These are the 4 typical seizure phases in order of occurrence.
What are "Prodromal", "Aural" (AKA Pre-ictal), "Ictal", and "Postictal"?
1-Prodromal phase - signs or activity that precede a seizure.
2-Aural (Pre-ictal)phase – sensory warning.
3-Ictal phase – full seizure activity.
4-Postictal phase – recovery period after seizure.
Long an accepted intervention in the treatment of acute seizure activity, this practice is no longer advocated due to threat to dentition and respiratory function.
What is to insert an oral airway?
A 2016 article in the online Journal of Clinical Medicine advocates that no oral airway be inserted during active seizure activity..."Because of suppression of the gag reflex during SE, the patient should be placed in the left lateral decubitus position, if possible, to decrease chances of aspiration of gastric contents. Bite block application and oropharyngeal airway adjuvants may be dangerous for rescuers to apply and are not recommended; if an adjuvant airway device is needed during SE, a nasopharyngeal airway should be placed [16]. Bite block or any oropharyngeal airway adjuvants place the healthcare provider at risk of trauma (e.g., biting, tooth lacerations) during an acute seizure and potentially act as a source for upper airway obstruction."
This classification of headache is not caused by disease or another medical condition.
What is a primary, or functional, headache?
Primary or “Functional” headaches have no known organic cause and include migraine, tension headache, and cluster headache
This caution applies to treatment of any type of headache.
What is use of vasoactive meds to treat headache in cardiac patients?
For example:
Ergotamine should not be used with serotonin receptor agonists (triptans), such as naratriptan, rizatriptan, sumatriptan, or zolmitriptan. Combining these medications may have additive effects and cause excessive vasoconstriction.
Verapamil – Ca++ channel blocker – relaxes muscle and has a vasodilation effect.
Stress; rapid changes in blood glucose levels; foods such as aged cheese, nuts, chocolate, caffeine, oranges, tomatoes, onions, MSG, aspartame, or alcohol.
What are common triggers associated with onset of migraine headaches?
Other triggers may include menstruation, head trauma, physical exertion, fatigue, stress, missed meals, weather, drugs, and variation in sleep patterns.
This type of Focal seizure is localized to one part of the patient's brain and characteristically suffers no loss of consciousness.
What is a "Focal Aware" seizure?
Focal Aware (former "Simple") seizures may include hallucinations such as tingling, light flashes, buzzing sensation, and / or autonomic symptoms or signs: epigastric sensations, pallor, - sweating, flushing, piloerection (Goosebumps), and dilated pupils.
Did you say "Focal Impaired" (former "Complex")? Focal Impaired seizures do alter consciousness and are usually followed by an amnesic post- ictal period.
Both can evolve into a generalized seizure, and both can have an aura.
This activity can cause a potentially fatal cascade effect of ventilatory insufficiency, hypoxemia, cardiac arrhythmias, hyperthermia, and systemic acidosis
What is status epilepticus?
Status epilepticus is a state of constant seizure activity – a series of seizures
Generalized convulsive status epilepticus is defined as:
A generalized convulsion lasting 30 minutes or longer
Or
When successive convulsions occur so frequently over a 30 minute period that the patient does not have time to recover between them
No conscious episodes between seizure activity
Tonic-clonic activity prohibits respiratory muscle function
Cerebral anoxia – immediate treatment
Not self limiting – life threatening emergency
Not predictable – no aura (most episodes) associated with seizure activity
Short-acting Lorazepam & diazepam must be followed with long-acting drugs (phenytion).
Subarachnoid hemorrhage, brain tumor, trigeminal neuralgia, diseases of the eyes, nose and teeth, and systemic illness.
What are serious illnesses associated with secondary headaches?
These secondary headaches can occur with serious illnesses!
It is important for you, as the nurse, to remember that headache is a symptom of an underlying disorder rather than a diagnosis. The headache may be minor or represent a life-threatening situation; therefore, careful assessment is essential
This α-Adrenergic blocker is administered IM or IV, and has these safety concerns.
What is Dihydroergotamine (DHE)
Dihydroergotamine (DHE) is used with caution in patients with cardiac history, pregnancy, and / or currently taking "triptans"?
Dihydroergotamine (DHE) may cause or contribute to excessive drowsiness / dizziness.
This phenomenon precedes a migraine headache by hours or days and has neurologic, psychologic, or other manifestations.
What is a "Prodrome"?
The prodrome phase of a migraine can occur anywhere from a few hours to even days before the actual attack.
This is usually considered as a warning sign for migraine sufferers which alerts them of an impending migraine.
Around 30% of people experience the prodrome phase.
I bet you were tempted to say, "Aura"! An aura immediately precedes a migraine, lasts 5 - 60 minutes, and may include visual, auditory, olfactory, or motor symptoms.
These are the three main classifications of seizures according to the 2017 reclassification per the International League Against Epilepsy.
What are Focal, Generalized (Motor and Absence) and seizures of unknown etiology?
Focal may include;
Motor symptoms (tonic, clonic and / or atonic activity
Nonmotor symptoms - autonomic, behavioral, cognitive, emotional or sensory
Aware - no change in awareness while seizure activity occurs
Impaired awareness - change in awareness while seizure activity occurs
Generalized - "Motor"
Clonic - jerky and rhythmic muscle contraction
Tonic - stiffening muscle contraction
Epileptic - continuous / contiguous seizure activity < 30min
Generalized - "Absence"
Typical - "petit mal"
Atypical - gradual "slump", subtle myoclonic jerk
Myoclonic - jerkiness, no LOC
Eyelid myoclonia - brief and repeated myoclonic jerks of the eyelids
Unknown: etiology unknown, may display symptoms of any of the above.
This type of seizure episode increases up to 25% in pregnant women with epilepsy.
What are “eclamptic” seizure episodes?
Hypoxia that may occur during seizures places the woman and the fetus at risk of anoxia.
Many anticonvulsant drugs have teratogenic (cancer causing) properties - exercise caution!
Women (with h/o Seizure/Epilepsy) contemplating pregnancy are encouraged to discuss plans with their HCP.