chamberlain college of nursing nr565 week 4 midterm exam study guide nr 565 week 4 midterm exam study guide v1 ch 152935 latest
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NR 565 (NR565)
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NR565 Week 4 Midterm Exam Study Guide
Chapter 35: Chronic Migraine and Cluster Headache
Chapter 29: Anxiety and Depression
Chapter 15: Drugs Affecting the Central Nervous System
Chapter 35: Chronic Migraine and Cluster Headache
Chronic daily headache headaches 15 or more days a month for longer than 3 months
Chronic daily headaches (CDH) can be divided into five subtypes:
o chronic tension-type headache
o chronic migraine
o hemicrania continua (Not in the study guide = not covered in depth)
rare disorder that responds completely to indomethacin and to nothing else. Indomethacin
(Indocin) 75 to 150 mg is given daily; doses up to 200 mg daily may be needed. Referral
to a neurologist is recommended.
o medication-overuse headache
o new daily persistent headache.
Use of drugs for acute headache treatment more than 9 days a month is associated with increased risk of
chronic daily headaches.
Medication-overuse is addressed later
Pathophysiology: Patho of CDH is often unclear and of mixed origin.
There is a clear difference between chronic migraine and hemicrania continua (Not in the study guide =
not covered).
The boundary between chronic tension-type headache and chronic migraine is less clear and may require
a neurology referral for treatment.
The term chronic migraine refers to CDH that starts as episodic migraine (less than 15 days a month) that
transforms into a chronic pattern of greater than 15 days a month of migraine headache
It was formerly called “transformed migraine.”
The initial migraines have the pathogenesis of migraine discussed earlier.
Chronic migraine is not well understood but is thought to be related to a combination of atypical pain
processing, cortical hyperexcitability, neurologic inflammation, and central sensitization.
Risk factors for chronic migraine include female gender, history of head or neck injury, life stress,
psychiatric disorders, and comorbid pain disorders
Goals of Treatment
The first goal of treatment for CDH is to break the pattern of daily headache. The patient is then stabilized on
prophylactic or preventive therapy.
Rational Drug Selection
Chronic Migraine
,In most patients with chronic migraine, the daily headache cycle can be broken by using repeated doses of IV
DHE (dihydroergotamine mesylate).
Approximately 70% to 80% of patients respond to DHE.
o The patient is given a test dose of 0.33 mL of DHE (1 mg/mL solution) with 5 mg of
metoclopramide or 10 mg of prochlorperazine (Compazine).
o Followed by 0.5 mL of DHE and one of the anti-nausea medications every 6 hours for 48 to 72
hours.
o This usually requires inpatient treatment.
o DHE is contraindicated in coronary and peripheral vascular disease.
Alternatives to DHE:
Chlorpromazine (Thorazine)
Prochlorperazine.
If the patient has medication-overuse headache due to misuse of analgesics, ergots, or combination
medications, the patient has to be detoxified (Discussed later)
Treatment of chronic migraine may require consultation with a neurologist.
Preventive pharmacotherapy can be started after the headache cycle is broken.
The patient usually responds to migraine-preventive medications such as propranolol, divalproex, or a
tricyclic antidepressant.
Amitriptyline is a good choice if the patient is also depressed.
The seizure medications topiramate or valproic acid may be used.
The patient is on preventive medication until the headache days are reduced by 50%, and then an
additional 3 to 4 weeks, for a total of 6 to 12 weeks.
The patient should also receive alternative therapy to treat CDH. Behavioral counseling, biofeedback therapy,
relaxation therapy, physical exercise, and acupuncture are all valid alternative therapies for treatment of CDH.
Monitoring
Monitoring of patients with CDH who are on preventive therapy requires the patient to keep a diary of headache
and medication use.
Patients’ blood pressure should be monitored if they are on a beta blocker
Liver function monitored if on divalproex, as per migraine therapy monitoring.
Ongoing monitoring of headache is necessary because 31% may have recurrence of headache in spite of
preventive medication.
Outcome Evaluation
Patients with CDH are difficult to treat. Treatment success is determined by how effective it has been in
breaking the cycle of daily headaches and how effective the preventive treatment is. The patient's headache
diary is key in the evaluation of the success of treatment.
Patient Education
,Should include a discussion of information related to the overall treatment plan as well as that specific to the
drug therapy, reasons for taking the drug, drugs as part of the total treatment plan, and adherence issues.
Patient education information specific to treating CDH should focus on the following principles:
1. Education about the nature of the disorder, particularly that it is biological in origin, with neurochemical
changes producing the headache.
2. Overuse of analgesics, leading to medication-overuse headache, must be emphasized.
3. The influence of stress, anxiety, depression, and inability to relax should be discussed, and the patient
encouraged to use nonpharmacological therapies to decrease headache.
CLUSTER HEADACHES: characterized by intense pain lasting for 15 minutes to 2 hours.
Occur in “clusters” of several weeks or months, with the headache subsiding for months at a time, often
to recur.
The patient can experience one to three attacks a day, usually at the same time of day. They occur most
frequently at night, awakening the patient from sleep.
Men are affected more than women, with onset in their late twenties.
The pain of a cluster headache is unique in that it occurs behind or around one eye, with tearing,
conjunctival injection, and drooping of the eyelid common symptoms.
There may be nasal congestion, facial flushing, and sweating. The pain is so severe that the patient is
unable to lie down or sit still, often pacing the floor in pain.
Pathophysiology
No clear etiology for cluster headaches.
They are most likely a neuronal disorder originating in the hypothalamus.
The clockwork-like timing of cluster headaches suggests that the circadian pacemaker or biological
“clock” is dysfunctional.
Goals of Treatment
Relieving the pain of an acute cluster headache and decreasing the length of time of the cluster are the goals of
cluster headache management.
Rational Drug Therapy
Most patients with cluster headaches require acute and preventive therapy.
The acute attacks are severe and last only a short time-intervention must be fast-acting. The patient usually
requires both acute and preventive medications to manage the headache.
Acute Therapy
Oxygen therapy administered via a 100% nonrebreather mask for 15 to 30 minutes often provides
immediate relief of cluster headache.
Sumatriptan, administered SC, or intranasal sumatriptan or zolmitriptan may provide relief of acute
cluster headaches
, Intranasal lidocaine is thought to be effective in treating cluster headache.
o The patient lies supine, hyperextends the head at 45 degrees, and rotates it 30 degrees to the side
of the headache.
o The lidocaine nasal solution is then dripped into the nostril on the affected side over 30 seconds.
o The onset is approximately 5 minutes.
Ergotamine derivatives are also effective for acute cluster headaches.
o Sublingual 2 mg tablets are administered at the beginning of the cluster headache.
o Ergotamine suppositories or DHE intranasally or IM may also be used
o Ergotamine may also be administered in a 2 mg dose given before bed if nocturnal attacks occur
frequently.
Preventive Therapy
Verapamil can prevent cluster headaches in some patients.
Calcium channel blockers are thought to prevent cluster headache by inhibiting vasospasm of the
cerebral arteries.
Cluster headaches appear to need dosing in the high range to achieve headache reduction.
Divalproex can be effective in preventing cluster headaches. The dosing is the same as for migraine
prophylaxis
Lithium appears to have some effect on cluster headaches in some patients, and a trial of lithium is
warranted if the patient does not respond to other preventive medications.
o The dose for cluster headache prevention is 300 mg daily to a maximum of 300 mg 3 times a
day.
o The patient needs careful monitoring for adverse effects, including electrocardiogram (ECG),
electrolytes, thyroid function, creatinine, and CBC studies.
Nonpharmacological therapies include avoidance of all alcohol during the clustering of headaches because
alcohol often precipitates a headache.
Patients often are able to drink alcohol between headache clusters without adverse effects.
Tobacco, stress, anger, and vigorous physical activity should be avoided.
The patient needs to maintain a normal sleep pattern, if possible.
Cluster headaches do not appear to respond to self-care measures such as massage and relaxation.
Monitoring
Cluster headaches can be severely disabling, and the intense pain and loss of sleep can significantly
affect the patient's quality of life.
The health-care provider needs to monitor the patient for suicidal thoughts during the headache.
The headache diary helps to monitor the effectiveness of acute and preventive medications.
A patient treated with lithium requires careful monitoring of ECG and chemistries throughout treatment.
Outcome Evaluation
Cluster headaches by definition are self-limiting and will eventually stop, regardless of treatment.
The focus of care is to provide measures that shorten or prevent cluster headaches during the cluster.
Evaluation of the effectiveness of acute and preventive therapy is accomplished by self-report with a
headache diary.
Modifications in pharmacological management of cluster headaches should be based on the headache
diary.
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