Headache
Headache: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
The most common neurologic symptom, headaches may be localized or generalized, producing mild to severe pain. About 90% of all headaches are benign and can be described as vascular, muscle-contraction, or a combination of both. (See Comparing benign headaches.) Occasionally, though, 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 sinus disorder, tests, drugs, or other treatments.
Other causes of headache include fever, eyestrain, dehydration, and systemic febrile illnesses. 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
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? Try to identify precipitating factors, such as certain foods or exposure to bright lights. Ask what helps to relieve the headache. Is the patient under stress? Has he had trouble sleeping?
Take a drug and alcohol history, and ask about head trauma within the last 4 weeks. Has the patient recently experienced nausea, vomiting, photophobia, or visual changes? Does he feel drowsy, confused, or dizzy? Has he recently developed seizures, or does he have a history of seizures?
Physical assessment
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: widened pulse pressure, bradycardia, altered respiratory pattern, and increased blood pressure. Check pupil size and response to light, and note any neck stiffness.
Medical causes
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 brain tumor causes a localized headache near the tumor site; as the tumor grows, the headache eventually becomes generalized. The pain is usually intermittent, deep-seated, and dull, and most intense in the morning. It’s aggravated by coughing, stooping, Valsalva’s maneuver, and changes in head position, and it’s relieved by sitting and rest. Associated signs and symptoms include personality changes, altered LOC, motor and sensory dysfunction, and eventually signs of increased ICP, such as vomiting, increased systolic blood pressure, and 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; and other features.
Encephalitis
A severe, generalized headache is characteristic of encephalitis. Within 48 hours, the patient’s LOC typically deteriorates — perhaps from lethargy to coma. Associated signs and symptoms include 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 LOC. Other signs and symptoms include unilateral seizures, hemiparesis, hemiplegia, high fever, decreased pulse rate and bounding pulse, widened pulse pressure, increased blood pressure, a positive Babinski’s reflex, and decerebrate posture.
If the patient slips into 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)
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.
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 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.
Intracerebral hemorrhage
In some patients, intracerebral hemorrhage produces a severe generalized headache. Signs and symptoms vary with the size and location of the hemorrhage. A large hemorrhage may produce a rapid, steady decrease in LOC, perhaps resulting in coma. Other common findings include hemiplegia, hemiparesis, abnormal pupil size and response, aphasia, dizziness, nausea, vomiting, seizures, decreased sensation, irregular respirations, positive Babinski’s reflex, decorticate or decerebrate posture, and increased blood pressure.
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. Fever occurs early with meningitis and may be accompanied by chills. As ICP increases, vomiting and, occasionally, papilledema develop. Other features include altered LOC, seizures, ocular palsies, facial weakness, and hearing loss.
Plague
The pneumonic form of plague, caused by the bacterium Yersinia pestis, causes a sudden onset of headache, chills, fever, myalgias, productive cough, chest pain, tachypnea, dyspnea, hemoptysis, respiratory distress, and cardiopulmonary insufficiency.
Postconcussional syndrome
With 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, inability to concentrate, and noise and alcohol intolerance.
Signs and symptoms of this disease include severe headache, fever, chills, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last for up to 2 weeks, and in severe cases, the patient may develop hepatitis or pneumonia.
Severe acute respiratory syndrome
Severe acute respiratory syndrome (SARS) is an acute infectious disease of unknown etiology that generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms of SARS 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.
Sinusitis (acute)
Acute sinusitis is usually marked by a dull periorbital headache that’s usually aggravated by bending over or touching the face and is relieved by sinus drainage. Fever, sinus tenderness, nasal turbinate edema, sore throat, malaise, cough, and nasal discharge may accompany the headache.
Smallpox
Initial signs and symptoms of smallpox (variola major) include severe headache, backache, abdominal pain, 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 forms a crust and scab, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.
Subarachnoid hemorrhage
Subarachnoid hemorrhage commonly produces a sudden, violent headache along with nuchal rigidity, nausea and vomiting, seizures, dizziness, ipsilateral pupil dilation, and altered LOC that may rapidly progress to coma. The patient also exhibits positive Kernig’s and Brudzinski’s signs, photophobia, blurred vision and, possibly, 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, both acute and chronic subdural hematomas may cause 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 progressively worsening LOC. Late signs may include unilateral pupil dilation, sluggish pupil reaction to light, and ptosis.
Temporal arteritis
A throbbing unilateral headache in the temporal or frontotemporal region may be accompanied by vision loss, hearing loss, confusion, and fever. The temporal arteries are tender, swollen, nodular, and sometimes erythematous.
Tularemia
Signs and symptoms of tularemia (caused by inhalation of the bacterium Francisella tularensis) include abrupt onset of headache, fever, chills, generalized myalgias, nonproductive cough, dyspnea, pleuritic chest pain, and empyema.
Other causes
Diagnostic tests
A lumbar puncture or myelogram may produce a throbbing frontal headache that worsens on standing.
Drugs
A wide variety of 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.
Special considerations
Continue to monitor the patient’s vital signs and LOC. Watch for any 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. Explain the rationale of these interventions to the patient.
Prepare the patient for diagnostic tests, such as skull X-rays, computed tomography scan, lumbar puncture, or cerebral arteriography.
Pediatric pointers
If a child is too young to describe his symptoms, suspect a headache if you see him banging or holding his head. In an infant, a shrill cry or bulging fontanels may indicate increased ICP and headache. In a school-age child, ask the parents about the child’s recent scholastic performance and about any problems at home that may produce a tension headache.
Twice as many young boys have migraine headaches as girls. In children older than age 3, headache is the most common symptom of a brain tumor.
Patient counseling
Teach the patient and his family or caregiver how to recognize signs of reduced LOC and seizures. Discuss ways to maintain a safe, quiet environment and reduce environmental stress, if indicated. Discuss the use of analgesics to ease the headache.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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