Headache

Headache: Excerpt from Nursing: Interpreting Signs and Symptoms

The most common neurologic symptom, headaches may be localized or generalized, producing mild to severe pain. About 90% of headaches are benign and can be described as vascular, muscle-contraction, or a combination of both. (See Clinical features of headache, page 298.) Occasionally, however, headaches indicate a severe neurologic disorder associated with intracranial inflammation, increased intracranial pressure (ICP), or meningeal irritation. They may also result from an ocular or a sinus disorder, tests, drugs, or other treatments.

Other causes of headache include a fever, eyestrain, dehydration, systemic febrile illnesses, and stress. Headaches may occur in certain metabolic disturbances—such as hypoxemia, hypercapnia, hyperglycemia, and hypoglycemia—but they aren't a diagnostic or prominent symptom. Some individuals get headaches after seizures or from coughing, sneezing, heavy lifting, or stooping.

History and physical examination

If the patient reports a headache, ask him to describe its characteristics and location. How often does he get a headache? How long does a typical headache last? Does he have a history of high blood pressure? Try to identify precipitating factors, such as certain foods or exposure to bright lights. Ask what helps to relieve the headache. Does he experience stress at work or at home? Has he had trouble sleeping?

Take a drug and alcohol history, and ask about head trauma within the past 4 weeks. Has the patient recently experienced nausea, vomiting, photophobia, or vision changes? Does he feel drowsy, confused, or dizzy? Has he recently developed seizures or does he have a history of seizures?

Begin the physical examination by evaluating the patient's level of consciousness (LOC). Then check his vital signs. Be alert for signs of increased ICP—a widened pulse pressure, bradycardia, an altered respiratory pattern, and increased blood pressure. Check pupil size and response to light, and note any neck stiffness.

Medical causes

Anthrax (cutaneous).Along with a macular papular lesion that develops into a vesicle and finally a painless ulcer with anthrax, headache, lymphadenopathy, fever, and malaise may also occur.

Arteriovenous malformations.Less common than cerebral aneurysms, vascular malformations usually result from developmental defects of the cerebral veins and arteries. Although many are present from birth, they manifest in adulthood with a triad of symptoms: headache, hemorrhage, and seizures.

Brain abscess.With brain abscess, the headache is localized to the abscess site. Usually, it intensifies over a few days and is aggravated by straining. Accompanying the headache may be nausea, vomiting, and focal or generalized seizures. The patient's LOC varies from drowsiness to deep stupor. Depending on the abscess site, associated signs and symptoms may include aphasia, impaired visual acuity, hemiparesis, ataxia, tremors, and personality changes. Signs of infection, such as fever and pallor, usually develop late; however, if the abscess remains encapsulated, these signs may not appear.

Brain tumor.Initially, a tumor causes a localized headache near the tumor site; as the tumor grows, the headache becomes generalized. The pain is usually intermittent, deep seated, dull, and most intense in the morning. It's aggravated by coughing, stooping, Valsalva's maneuver, and changes in head position and relieved by sitting and rest. Associated signs and symptoms include personality changes, an altered LOC, motor and sensory dysfunction and, eventually, signs of increased ICP, such as vomiting, increased systolic blood pressure, and a widened pulse pressure.

Cerebral aneurysm (ruptured).Ruptured cerebral aneurysm is a life-threatening disorder that's characterized by a sudden, excruciating headache, which may be unilateral and usually peaks within minutes of the rupture. The patient may lose consciousness immediately or display a variably altered LOC. Depending on the severity and location of the bleeding, he may also exhibit nausea and vomiting; signs and symptoms of meningeal irritation, such as nuchal rigidity and blurred vision; hemiparesis; seizure activity; and other features.

Ebola virus.With ebola virus, headache is usually abrupt in onset, commonly occurring on the fifth day of illness. Additionally, the patient has a history of malaise, myalgia, a high fever, diarrhea, abdominal pain, dehydration, and lethargy. A maculopapular skin rash develops between the fifth and seventh days of the illness. Other possible findings include pleuritic chest pain; a dry, hacking cough; pronounced pharyngitis; hematemesis; melena; and bleeding from the nose, gums, and vagina. Death usually occurs in the second week of the illness, preceded by severe blood loss and shock.

Encephalitis.A severe, generalized headache is characteristic with encephalitis. Within 48 hours, the patient's LOC typically deteriorates—perhaps from lethargy to coma. Associated signs and symptoms include a fever, nuchal rigidity, irritability, seizures, nausea and vomiting, photophobia, cranial nerve palsies such as ptosis, and focal neurologic deficits, such as hemiparesis and hemiplegia.

Epidural hemorrhage (acute).Head trauma and a sudden, brief loss of consciousness usually precede acute epidural hemorrhage, which causes a progressively severe headache that's accompanied by nausea and vomiting, bladder distention, confusion, and then a rapid decrease in the patient's LOC. Other signs and symptoms include unilateral seizures, hemiparesis, hemiplegia, a high fever, a decreased pulse rate and bounding pulse, a widened pulse pressure, increased blood pressure, a positive Babinski's reflex, and decerebrate posture.

If the patient slips into a coma, his respirations deepen and become stertorous, then shallow and irregular, and eventually they cease. Pupil dilation may occur on the same side as the hemorrhage.

Glaucoma (acute angle-closure).Glaucoma is an ophthalmic emergency that may cause an excruciating headache as well as acute eye pain, blurred vision, halo vision, nausea, and vomiting. Assessment reveals conjunctival injection, a cloudy cornea, and a moderately dilated, fixed pupil.

Hantavirus pulmonary syndrome.Noncardiogenic pulmonary edema distinguishes hantavirus pulmonary syndrome. Common reasons for seeking treatment include flulike signs and symptoms—headache, myalgia, fever, nausea, vomiting, and a cough—followed by respiratory distress. Fever, hypoxia, and (in some patients) serious hypotension typify the hospital course. Other signs and symptoms include a rising respiratory rate (28 breaths/minute or more) and an increased heart rate (120 beats/minute or more).

Hypertension.Hypertension may cause a slightly throbbing occipital headache on awakening that decreases in severity during the day. However, if the patient's diastolic blood pressure exceeds 120 mm Hg, the headache remains constant. Associated signs and symptoms include an atrial gallop, restlessness, confusion, nausea and vomiting, blurred vision, seizures, and an altered LOC.

Influenza.A severe generalized or frontal headache usually begins suddenly with the flu. Accompanying signs and symptoms may last for 3 to 5 days and include stabbing retro-orbital pain, weakness, diffuse myalgia, fever, chills, coughing, rhinorrhea and, occasionally, hoarseness.

Listeriosis.Signs and symptoms of listeriosis include fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, meningitis may develop. These signs and symptoms include headache, nuchal rigidity, fever, and a change in the patient's LOC.

Meningitis.Meningitis is marked by the sudden onset of a severe, constant, generalized headache that worsens with movement. Associated signs include nuchal rigidity, positive Kernig's and Brudzinski's signs, hyperreflexia and, possibly, opisthotonos. A fever occurs early with meningitis and may be accompanied by chills. As ICP increases, vomiting and, occasionally, papilledema develop. Other features include an altered LOC, seizures, ocular palsies, facial weakness, and hearing loss.

Plague (Yersinia pestis).The pneumonic form of the plague causes a sudden onset of a headache, chills, fever, myalgia, a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, respiratory distress, and cardiopulmonary insufficiency.

Postconcussional syndrome.A generalized or localized headache may develop 1 to 30 days after head trauma and last for 2 to 3 weeks. This characteristic symptom may be described as an aching, pounding, pressing, stabbing, or throbbing pain. The patient's neurologic examination is normal, but he may experience giddiness or dizziness, blurred vision, fatigue, insomnia, an inability to concentrate, and noise and alcohol intolerance.

Q Fever.Signs and symptoms of Q fever include severe headaches, fever, chills, malaise, chest pain, nausea, vomiting, and diarrhea. Fever may last for up to 2 weeks, and in severe cases, the patient may develop hepatitis or pneumonia.

Severe acute respiratory syndrome (SARS).SARS generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include headache; malaise; a dry, nonproductive cough; and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

Smallpox (variola major).Initial signs and symptoms of smallpox include a severe headache, backache, abdominal pain, a high fever, malaise, prostration, and a maculopapular rash on the mucosa of the mouth, pharynx, face, and forearms, and then the trunk and legs. The rash becomes vesicular, then pustular, and finally crusts and scabs, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Subarachnoid hemorrhage.Subarachnoid hemorrhage commonly produces a sudden, severe headache along with nuchal rigidity, nausea and vomiting, seizures, dizziness, ipsilateral pupil dilation, and an altered LOC that may rapidly progress to coma. The patient also exhibits positive Kernig's and Brudzinski's signs, photophobia, blurred vision and, possibly, a fever. Focal signs and symptoms (such as hemiparesis, hemiplegia, sensory or vision disturbances, and aphasia) and signs of elevated ICP (such as bradycardia and increased blood pressure) may also occur.

Subdural hematoma.Typically associated with head trauma, acute and chronic subdural hematomas may cause a headache and decreased LOC. With acute subdural hematoma, head trauma also produces drowsiness, confusion, and agitation that may progress to coma. Later findings include signs of increased ICP and focal neurologic deficits such as hemiparesis.

Chronic subdural hematoma produces a dull, pounding headache that fluctuates in severity and is located over the hematoma. Weeks or months after the initial head trauma, the patient may experience giddiness, personality changes, confusion, seizures, and a progressively worsening LOC. Late signs may include unilateral pupil dilation, sluggish pupil reaction to light, and ptosis.

Tularemia.Signs and symptoms following inhalation of the bacterium Francisella tularensis include an abrupt onset of a headache, a fever, chills, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Typhus.Initial symptoms of typhus include a headache, myalgia, arthralgia, and malaise followed by an abrupt onset of chills, a fever, nausea, and vomiting. A maculopapular rash may be present in some cases.

West Nile encephalitis.Signs and symptoms of West Nile encephalitis include a fever, a headache, and body aches, commonly with a skin rash and swollen lymph glands. More severe infection is marked by a high fever, a headache, neck stiffness, stupor, disorientation, coma, tremors, occasional seizures, paralysis and, rarely, death.

Other causes

Diagnostic tests.A lumbar puncture, myelogram, or epidural or spinal procedure may produce a throbbing frontal headache that worsens on standing.

Drugs.Many drugs can cause headaches. For example, indomethacin produces headaches—usually in the morning—in many patients. Vasodilators and drugs with a vasodilating effect, such as nitrates, typically cause a throbbing headache. Headaches may also follow withdrawal from vasopressors, such as caffeine, ergotamine, and sympathomimetics.

Traction.Cervical traction with pins commonly causes a headache, which may be generalized or localized to pin insertion sites.

Nursing considerations

▪ Monitor the patient's vital signs and LOC.

▪ Watch for a change in the headache's severity or location.

▪ To help ease the headache, administer an analgesic, darken the patient's room, and minimize other stimuli.

▪ Prepare the patient for diagnostic tests, such as skull X-rays, a computed to-mography scan, lumbar puncture, or cerebral arteriography.

Patient teaching

▪ Explain all procedures and treatments to the patient.

▪ Discuss the signs of reduced LOC and seizures that the patient or his caregivers should report.

▪ Explain ways to maintain a safe, quiet environment and reduce environmental stress.

▪ Discuss the proper use of analgesics.

Pictures

Book Source Details

• Book Title: Nursing: Interpreting Signs and Symptoms
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Nursing: Interpreting Signs and Symptoms Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-668-7

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