NR 603 Week 1 Study Guide
Migraine: Assessment
It is important that the patient characterize the headache by describing the duration, quality, and
location of the pain.
A medication profile is essential and should include medications that have been tried in the past for
headache control. If OTC medications are taken, the number used per month should be identified
A targeted physical examination is important in ruling out harmful secondary headache pathologies
and confirms any information given in the history.
The examination findings in primary headache disorders are usually within normal limits.
Key aspects of the physical examination include a cardiopulmonary and complete neurologic
assessment with a major focus on the following:
· • Funduscopic and pupillary assessment
· • Auscultation of the carotid and vertebral arteries
· • Mental status examination
· • Palpation of the head, neck, and temporal arteries
· • Evaluation for any neck stiffness, focal weakness, sensory loss and gait
· • Vital signs
Problem findings include:
· Onset of headache after the age of 50 years
· Asymmetry of pupillary responses
· Decreased deep tendon reflexes
· Headache described as “the worst ever experienced”
· Personality change
· Onset of a new or different headache
· Onset of a headache that progressively worsens
· Papilledema
· Painful temporal arteries
Diagnosis
· If the diagnosis is not clear or the history or physical findings are cause for concern, diagnostic
studies should be used to distinguish primary headache from a secondary condition.
· Blood tests are usually not indicated, may include a complete blood count (CBC) to exclude
anemia or an infectious process, (ESR) or (CRP) to help exclude temporal arteritis, and thyroid
function tests to identify thyroid dysfunction.
· Lyme titer or rheumatoid factors may also be indicated in some situations.
Practice guidelines
· Advocate three principles for diagnostic testing:
(1) testing should be avoided if it will not change the management of the patient,
(2) testing is not indicated if the patient is not significantly more likely than the general
public to have an abnormality
(3) testing may make sense in a patient who is excessively concerned that he or she has
a serious problem that is causing the headaches.
· Neuroimaging should be considered when any serious signs or symptoms are present but it is
not indicated if the patient has had these headaches for years, if there are no focal neurologic
signs, and if the headache improves without the use of analgesics.
Treatment
· Nonpharmacological measures
, behavior modification, biofeedback, acupressure, management of headache triggers, and
a wellness program.
· Preventive therapy is appropriate for patients if they are unable to deal with their attacks, they
experience more than four headaches a month, or the attacks are prolonged and refractory to
medicine.
Preventive therapy is given daily and will decrease headache intensity and frequency
A connection has been shown between epilepsy and migraine; therefore
anticonvulsants, such as divalproex sodium (Depakote), gabapentin (Neurontin), and
topiramate (Topamax), can be used
A patient with cold hands, Raynaud phenomenon, or hypertension may do well with
calcium channel blockers, such as diltiazem (Cardizem) and amlodipine (Norvasc),
which cause vasodilation and decrease blood pressure.
A beta blocker, such as propranolol (Inderal) or atenolol, may be chosen for the patient
with palpitations caused by mitral valve prolapse or panic disorders and should be
avoided in those with asthma.
If sleep is a problem or if chronic pain persists in the shoulders, a tricyclic
antidepressant, such as amitriptyline (Elavil).
The mechanism of action for both beta blockers and calcium channel blockers is
not fully understood.
Calcium channel blockers prevent calcium from entering the cells and therefore
decrease their excitability. This may in turn prevent vascular spasm and
headache.
Beta blockers affect the beta1-adrenergic receptors and inhibit the usual
adrenergic responses.
it has been theorized that either may have an effect on the serotonergic system
within the brain and the vascular system.
· Abortive therapy is used to treat the intensity and duration of pain during an attack and to
manage associated symptoms, such as nausea and vomiting
A patient with a severe migraine or cluster attack that peaks to full intensity within 15
minutes will most likely benefit from parenteral or nasal therapy rather than oral
medication
Simple analgesics, such as acetaminophen and aspirin, can represent first-line treatment
in the management of mild to moderate headaches.
Caffeine combinations (Excedrin, Anacin) can potentiate their absorption and
analgesia.
When simple analgesics are ineffective, combining them with a short-acting
barbiturate, such as butalbital (Fioricet, Fiorinal, Esgic), may be effective.
(NSAIDs) are helpful in treating an acute attack.
Naproxen sodium (Anaprox DS, Aleve) has a longer half-life and a better safety
profile than some of the other NSAIDs. The addition of metoclopramide will
facilitate their absorption and potentiate their effect.
Ergot derivatives are effective in the treatment of moderate to severe attacks that might
not have responded to simple or combination analgesics. Two forms are currently in
use: ergotamine tartrate (Cafergot) and dihydroergotamine.
Triptans, developed approximately 20 years ago, have given many migraine and
cluster headache patients’ relief within a short time.
Dementia: Assessment
The physical examination should focus on neurologic signs; blood pressure; carotid bruits; and the
assessment of cognition, mood, function, and behavior.
Migraine: Assessment
It is important that the patient characterize the headache by describing the duration, quality, and
location of the pain.
A medication profile is essential and should include medications that have been tried in the past for
headache control. If OTC medications are taken, the number used per month should be identified
A targeted physical examination is important in ruling out harmful secondary headache pathologies
and confirms any information given in the history.
The examination findings in primary headache disorders are usually within normal limits.
Key aspects of the physical examination include a cardiopulmonary and complete neurologic
assessment with a major focus on the following:
· • Funduscopic and pupillary assessment
· • Auscultation of the carotid and vertebral arteries
· • Mental status examination
· • Palpation of the head, neck, and temporal arteries
· • Evaluation for any neck stiffness, focal weakness, sensory loss and gait
· • Vital signs
Problem findings include:
· Onset of headache after the age of 50 years
· Asymmetry of pupillary responses
· Decreased deep tendon reflexes
· Headache described as “the worst ever experienced”
· Personality change
· Onset of a new or different headache
· Onset of a headache that progressively worsens
· Papilledema
· Painful temporal arteries
Diagnosis
· If the diagnosis is not clear or the history or physical findings are cause for concern, diagnostic
studies should be used to distinguish primary headache from a secondary condition.
· Blood tests are usually not indicated, may include a complete blood count (CBC) to exclude
anemia or an infectious process, (ESR) or (CRP) to help exclude temporal arteritis, and thyroid
function tests to identify thyroid dysfunction.
· Lyme titer or rheumatoid factors may also be indicated in some situations.
Practice guidelines
· Advocate three principles for diagnostic testing:
(1) testing should be avoided if it will not change the management of the patient,
(2) testing is not indicated if the patient is not significantly more likely than the general
public to have an abnormality
(3) testing may make sense in a patient who is excessively concerned that he or she has
a serious problem that is causing the headaches.
· Neuroimaging should be considered when any serious signs or symptoms are present but it is
not indicated if the patient has had these headaches for years, if there are no focal neurologic
signs, and if the headache improves without the use of analgesics.
Treatment
· Nonpharmacological measures
, behavior modification, biofeedback, acupressure, management of headache triggers, and
a wellness program.
· Preventive therapy is appropriate for patients if they are unable to deal with their attacks, they
experience more than four headaches a month, or the attacks are prolonged and refractory to
medicine.
Preventive therapy is given daily and will decrease headache intensity and frequency
A connection has been shown between epilepsy and migraine; therefore
anticonvulsants, such as divalproex sodium (Depakote), gabapentin (Neurontin), and
topiramate (Topamax), can be used
A patient with cold hands, Raynaud phenomenon, or hypertension may do well with
calcium channel blockers, such as diltiazem (Cardizem) and amlodipine (Norvasc),
which cause vasodilation and decrease blood pressure.
A beta blocker, such as propranolol (Inderal) or atenolol, may be chosen for the patient
with palpitations caused by mitral valve prolapse or panic disorders and should be
avoided in those with asthma.
If sleep is a problem or if chronic pain persists in the shoulders, a tricyclic
antidepressant, such as amitriptyline (Elavil).
The mechanism of action for both beta blockers and calcium channel blockers is
not fully understood.
Calcium channel blockers prevent calcium from entering the cells and therefore
decrease their excitability. This may in turn prevent vascular spasm and
headache.
Beta blockers affect the beta1-adrenergic receptors and inhibit the usual
adrenergic responses.
it has been theorized that either may have an effect on the serotonergic system
within the brain and the vascular system.
· Abortive therapy is used to treat the intensity and duration of pain during an attack and to
manage associated symptoms, such as nausea and vomiting
A patient with a severe migraine or cluster attack that peaks to full intensity within 15
minutes will most likely benefit from parenteral or nasal therapy rather than oral
medication
Simple analgesics, such as acetaminophen and aspirin, can represent first-line treatment
in the management of mild to moderate headaches.
Caffeine combinations (Excedrin, Anacin) can potentiate their absorption and
analgesia.
When simple analgesics are ineffective, combining them with a short-acting
barbiturate, such as butalbital (Fioricet, Fiorinal, Esgic), may be effective.
(NSAIDs) are helpful in treating an acute attack.
Naproxen sodium (Anaprox DS, Aleve) has a longer half-life and a better safety
profile than some of the other NSAIDs. The addition of metoclopramide will
facilitate their absorption and potentiate their effect.
Ergot derivatives are effective in the treatment of moderate to severe attacks that might
not have responded to simple or combination analgesics. Two forms are currently in
use: ergotamine tartrate (Cafergot) and dihydroergotamine.
Triptans, developed approximately 20 years ago, have given many migraine and
cluster headache patients’ relief within a short time.
Dementia: Assessment
The physical examination should focus on neurologic signs; blood pressure; carotid bruits; and the
assessment of cognition, mood, function, and behavior.
