head ache and head injury.DEEPILALINGAM.R

HEADACHE AND HEAD INJURY

1. HEADACHE AND HEAD INJURY PRESENTED BY DEEPIKA.R M.SC N II YEAR COLLEGE OF NURSING MADRAS MEDICAL COLLEGE

2. INTRODUCTION Headache, or cephalalgia , is one of the most common of all human physical complaints. Headache is a symptom rather than a disease It may indicate organic disease (neurologic or other disease), a stress response, vasodilation (migraine), skeletal muscle tension (tension headache), or a combination of factors

3. MAJOR TYPES: PRIMARY HEADACHE OR IDIOPATHIC HEADACHE SECONDARY HEADACHE A primary headache is one for which no organic cause can be identified. This type of headache includes Migraine, Tension-type, and Cluster headaches

4. CAUSES Cranial arteritis is a cause of headache in the older population, Reaching its greatest incidence in those older than 70 years of age . Inflammation of the cranial arteries is characterized by a severe headache localized in the region of the temporal arteries. The inflammation may be generalized

5. COMMON HEADACHES

6. secondary headache A secondary headache is a symptom associated with other causes, such as a brain tumor, an aneurysm, or lumbar puncture Serious disorders related to headache=include, subarachnoid hemorrhage, stroke, severe hypertension, meningitis, and head injuries

7. International Headache Society Classification of Headache A classification of headaches was issued first by the Headache Classification Committee of the International Headache Society in 1988. The International Headache Society revised the headache classification in 2013

8. International Headache Society Classification of Headache Migraine Tension-type headache Trigeminal autonomic cephalalgias Other primary disorders Headache attributed to trauma or injury to the head and/or neck Headache attributed to cranial or cervical vascular disorder Headache attributed to nonvascular intracranial disorder Headache attributed to a substance or its withdrawal

9. International Headache Society Classification of Headache Headache attributed to infection Headache attributed to disorder of homeostasis Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures Headache attributed to psychiatric disorder Painful cranial neuropathies and other facial pains Other headache disorders

10. Migraine Migraine is a complex of symptoms characterized by periodic and recurrent attacks of severe headache lasting from hours to days in adults CAUSES Primarily a vascular disturbance that has a strong familial tendency Typical time of onset is at puberty , The incidence is higher in women than men

11. MIGRAINE SUBTYPES Migraine with and without aura. Most patients have migraine without an aura

12. Pathophysiology Hyperexcitable brain that is susceptible to a phenomenon known as cortical spreading depression , Wave of depolarization over the cerebral cortex, cerebellum, and hippocampus. Activates inflammatory neuropeptides and other neurotransmitters (including serotonin), resulting in the stimulation of meningeal nociceptors. Vascular changes, inflammation, and a continuation of pain signal stimulation occur

13. Pathophysiology Initial phase of this process is known as the premonitory phase and may include light, sound, and smell sensitivity If treatment is initiated at this point, the migraine may be fully terminated. As the attack progresses, central sensitization occurs, and the migraine becomes much harder to treat

14. Clinical Manifestations- Migraine Four phases : Premonitory, Aura, The headache, and Recovery

15. Premonitory Phase Experienced by more than 80% of adult migraine sufferers, with symptoms that occur hours to days before a migraine headache Depression, Irritability, Feeling cold, Food cravings, Anorexia, Change in activity level, Increased urination, Diarrhea, or Constipation involve the neurotransmitter dopamine

16. Aura Phase Focal neurologic symptoms. Visual disturbances Hemianopia Other symptoms Numbness and tingling of the lips, face, or hands; mild confusion; slight weakness of an extremity; drowsiness; and dizziness Cerebral blood flow studies performed

17. Headache Phase Migraine headache is severe and incapacitating and is often associated with Photophobia (light sensitivity), Phonophobia (sound sensitivity), or Allodynia (abnormal perception of innocuous stimuli)

18. Postdrome Phase The pain gradually subsides, but patients may experience tiredness, weakness, cognitive difficulties, and mood changes for hours to days Muscle contraction in the neck and scalp is common Muscle ache and localized tenderness Patients may sleep for extended periods

19. Tension type headaches Tension type headaches tend to be chronic and less severe and are probably the most common type of headache Trigeminal autonomic cephalalgias Include cluster headaches and paroxysmal hemicrania. Cluster headaches are relatively uncommon and seen more frequently in men than in women

20. Causes of tension headache Hormonal changes associated with menstrual cycles, bright lights, stress, depression, sleep deprivation, fatigue, or odors . Certain foods containing tyramine Monosodium glutamate, and chocolate may be food triggers The use of oral contraceptives may be associated with increased frequency and severity of attacks in some women Emotional or physical stress may cause contraction of the muscles in the neck and scalp

21. Causes of tension headache One theory is that it is caused by dilation of orbital and nearby extracranial arteries Cranial arteritis is thought to represent an immune vasculitis in which immune complexes are deposited within the walls of affected blood vessels, producing vascular injury and inflammation

22. Other types-clinical manifestation Tension-type headache Steady, constant feeling of pressure that usually begins in the forehead, temple, or back of the neck. “A weight on top of my head.”

23. Cluster headaches Unilateral and come in clusters of one to eight daily, Excruciating pain localized to the eye and orbit and radiating to the facial and temporal regions. Watering of the eye and nasal congestion. Each attack lasts 15 minutes to 3 hours and may have a crescendo–decrescendo pattern.

24. clinical manifestation

25. Assessment and Diagnostic Findings Detailed history, A physical assessment of the head and neck, and a complete neurologic examination. CT scan, Cerebral angiography, or MRI scan may be used to detect underlying causes, such as tumor or aneurysm.

26. Assessment and Diagnostic Findings Electromyography (EMG) may reveal a sustained contraction of the neck, scalp, or facial muscles. Laboratory tests may include Complete blood count, Erythrocyte sedimentation rate, Electrolytes, glucose, creatinine, and thyroid hormone levels

27. Medical Management Migraine headache is divided into abortive (symptomatic) and Preventive approaches The triptans, which are serotonin receptor agonists, are the most specific antimigraine agents available The five triptans in routine clinical use include sumatriptan ( imitrex ), naratriptan ( amerge ), rizatriptan ( maxalt ), zolmitriptan ( zomig ), and almotriptan ( axert ) β-Blockers have been effective in migraine prevention

28. Medical Management variety of formulations, such as nasal sprays, inhalers, conventional tablet, disintegrating tablet, suppositories, or injections. The nasal sprays are useful for patients experiencing nausea and vomiting Ergotamine preparations (taken orally, sublingually, subcutaneously, intramuscularly, by rectum, or by inhalation) may be effective in aborting the headache

29. Cluster Headache-management Triptans are the standard of treatment High-flow 100% O2 by non-rebreather mask is well-tolerated, safe, and effective as an alternative treatment. 6 to 8 L/min for 10 minutes may relieve headache High-dose verapamil is the first-choice drug.

30. Nonpharmacologic therapies Regular sleep, meals, exercise, relaxation, and avoidance of dietary triggers Stress reduction techniques, such as Biofeedback, Exercise programs, and Meditation, are examples of nonpharmacologic therapies that may prove helpful.

31. Prevention Avoid specific triggers Alcohol, Nitrites, Vasodilators, and histamines may precipitate cluster headaches. Elimination of these factors helps prevent the headaches

32. Nursing Management To treat the acute event of the headache To prevent recurrent episodes Patient education regarding precipitating factors, possible lifestyle or habit changes that may be helpful, and pharmacologic measures

33. Head Injuries Head injury includes any injury or trauma to the scalp, skull, or brain. A serious form of head injury is traumatic brain injury (TBI).

34. INCIDENCE Men are twice as likely to sustain a TBI as women. Deaths from head trauma occur at 3 points after injury : Immediately after the injury, Within 2 hours after injury, and About 3 weeks after injury, Most deaths occur immediately after the injury , either from the direct head trauma or from massive hemorrhage and shock.

35. common causes of head injury Deaths occurring within a few hours of the trauma are caused by progressive worsening of the brain injury or internal bleeding Deaths occurring 3 weeks or more after the injury result from multisystem failure

36. Common causes of head injury Falls and motor vehicle accidents. Other causes of head injury include Firearms, Assaults, Sports-related trauma, Recreational injuries, and War-related injuries.

37. Types of Head Injuries 1.Scalp Lacerations 2.Skull Fractures (1) linear or depressed; (2) simple, comminuted, or compound; and (3) closed or open 3.Head Trauma Diffuse (generalized) or focal (localized). In a diffuse injury (e.g., Concussion, diffuse axonal injury) In a focal injury (e.g., Contusion, hematoma),

38. 1.Scalp laceration Type of external head trauma. Because the scalp contains many blood vessels with poor constrictive abilities Associated with profuse bleeding Complication Blood loss and Infection.

39. 2.Skull Fractures Skull Fractures (1) linear or depressed; (2) simple, comminuted, or compound; and (3) closed or open. Depend on the velocity, Momentum, Direction, and Shape (blunt or sharp) of the injuring agent and Site of impact .

40. Types of skull fracture

41. Fracture location and manifestation

42. Signs of head injury

43. 3.Head Trauma A . Generalized B . Focal(localized) In a diffuse injury (e.g., Concussion, diffuse axonal injury), damage to the brain is not localized to one area. In a focal injury (e.g., Contusion, hematoma), damage is localized to a specific area of the brain. Brain injury can be classified as Minor ( GCS 13 to 15 ), Moderate ( GCS 9 to 12 ), or Severe ( GCS 3 to 8 ).

44. A . Diffuse Injury- Generalized CONCUSSION, A sudden transient mechanical head injury with disruption of neural activity and a change in the LOC , is considered a minor diffuse head injury. The patient may or may not lose total consciousness with this injury. Concussion is generally considered benign and usually resolves spontaneously SIGNS AND SYMPTOMS Loc(5mts), Amnesia about the event (retrograde amnesia), and Headache.

45. Post concussion syndrome Post concussion syndrome may develop in some patients, usually from 2 weeks to 2 months after the injury. Manifestations include Persistent headache, Lethargy, personality and Behavioral changes, Shortened attention span, Decreased short-term memory, and Changes in intellectual ability

46. Diffuse axonal injury Diffuse axonal injury (DAI) is widespread axonal damage occurring after a Mild, Moderate, or Severe TBI. The damage occurs primarily around axons in the subcortical white matter of the cerebral hemispheres, basal ganglia, thalamus, and brainstem

47. CONT,…--Diffuse axonal injury The trauma changes the function of the axon, resulting in axon swelling and disconnection. This process takes 12 to 24 hours to develop and may persist longer. CLINICAL MANIFESTATION Decreased LOC, Increased ICP, Decortication or Decerebration, and Global cerebral edema

48. B . Focal injury Focal injury can be minor to severe and Localized to an area of injury. Focal injury consists of lacerations, contusions, hematomas, and cranial nerve injuries. Lacerations involve actual tearing of the brain tissue.

49. Focal injury=C/M With major head trauma, many delayed responses can occur. These include Hemorrhage, Hematoma formation, Seizures, and cerebral edema. Intracerebral hemorrhage.

50. Focal injury=C/M Unconsciousness, Hemiplegia on the contralateral side, and A dilated pupil on the ipsilateral side Subarachnoid hemorrhage and Intraventricular hemorrhage can occur from head trauma

51. CONTUSION A contusion is bruising of the brain tissue within a focal area. It is usually associated with a closed head injury and often occurs at a fracture site. A contusion may have areas of hemorrhage, infarction, necrosis, and edema. coup-contrecoup injury

52. CONTUSION=Coup-contrecoup injury Contusions or lacerations occur both at the site of the direct impact of the brain on the skull (coup) and at a second area of damage on the opposite side away from injury (contrecoup), leading to multiple contused areas. Contrecoup injuries tend to be more severe

53. Complications Epidural Hematoma Subdural Hematoma Intracerebral Hematoma

54. Epidural hematoma An epidural hematoma results from bleeding between the dura and inner surface of the skull An epidural hematoma is a neurologic emergency. It is usually associated with a linear fracture crossing a major artery in the dura, causing a tear. Headache, nausea and vomiting, or focal findings. Rapid surgical intervention to evacuate the hematoma and prevent cerebral herniation,

55. Subdural hematoma A subdural hematoma occurs from bleeding between the dura mater and arachnoid layer of the meninges SUBTYPES Acute (24 to 48 hrs), Decreasing LOC and Headache The ipsilateral pupil dilates and becomes fixed if ICP is significantly increased

56. SUBTYPES-Subdural hematoma Subacute( 2 to 14 days of the injury.) Enlargement of hematoma Chronic( over weeks or months) Atrophy. Increased ICP Other C/M : somnolence , confusion, lethargy, and memory loss

57. Intracerebral hematoma Intracerebral hematoma occurs from bleeding within the brain tissue. Frontal and temporal lobes. Involved

58. Diagnostic Studies Increased ICP CT MRI PET , and Evoked potential studies may be used to diagnose head injuries. Transcranial doppler studies allow for the measurement of cerebral blood flow (CBF) velocity. A cervical spine x-ray series, CT scan, or MRI of the spine may be done since cervical spine trauma often occurs at the same time as a head injury.

59. Pupillary check for size and response

60. ICP monitoring

61. Management The principal treatment of head injuries is Prompt diagnosis and surgery (if needed), in addition, Measures to prevent secondary injury by treating cerebral edema and Managing increased ICP Treatment of skull fractures is usually conservative.

62. CRANIOTOMY INDICATION Depressed fractures and fractures with loose fragments, A craniotomy is done to elevate the depressed bone and remove the free fragments. Cranioplasty will be needed later

63. CRANIOTOMY Large acute subdural and epidural hematomas- surgical evacuation Burr-hole openings may be used in an extreme emergency for a more rapid decompression , followed by a craniotomy . A drain may be placed after surgery for several days to prevent blood from reaccumulating

64. Craniectomy Craniectomy may be done, Removing a piece of skull to reduce the pressure inside the cranial vault. It reduces the risk for herniation.

65. NURSING MANAGEMENT Nursing Assessment Emergency care Acute Care Ambulatory Care

66. Nursing Assessment Assessing and monitoring the neurologic status, by using GCS Determining whether a CSF leak has occurred , Subjective Data Important Health Information- Past health history : Mechanism of injury : motor vehicle collision, sports injury, industrial incident, assault, falls Medications: Anticoagulant drugs Functional Health Patterns Alcohol or recreational drugs. Risk-taking behaviors Headache, mood or behavioral change, mentation changes, aphasia, dysphasia, impaired judgment

67. Nursing Assessment Objective Data General: Altered mental status Neurologic : Altered level of consciousness, seizure activity, pupil dysfunction, cranial nerve deficit(s) Musculoskeletal: Motor deficit/impairment, weakness, palmar drift, paralysis, spasticity, decorticate or decerebrate posturing, muscular rigidity or increased tone, flaccidity, ataxia

68. Glasgow coma scale

69. Maintaining the airway To establish and maintain an adequate airway Optimal oxygenation to preserve cerebral function. Facilitates drainage of oral secretions Head of the bed elevated about 30 degrees to decrease intracranial venous pressure Establishing effective suctioning procedures Closely monitoring arterial blood gas

70. Monitoring neurologic function close assessment and monitoring Level of Consciousness. cardiac monitoring, pulse oximetry, invasive arterial blood pressure monitoring, end-tidal CO2, and temperature monitoring

71. Other Neurologic Signs. The size and equality of the pupils Anosmia (lack of sense of smell), Eye movement abnormalities, Aphasia, memory deficits, and Posttraumatic seizures or epilepsy Psychological deficits (impulsiveness; emotional lability; or uninhibited, aggressive behaviors)

72. Monitoring fluid and electrolyte balance Syndrome of inappropriate antidiuretic hormone (SIADH) due to osmotic diuretics Hyponatremia is common after head injury due to shifts in extracellular fluid, electrolytes, and volume Monitoring serum electrolytes, blood glucose values, and intake and output Urine is tested regularly for acetone.

73. Pr omoting adequate nutrition Metabolic changes that Increase calorie consumption and nitrogen excretion. Protein demand increases Parenteral nutrition via a central line or Enteral feedings given via a nasogastric or Nasojejunal feeding tube

74. Other nursing management Preventing injury Maintaining body temperature-occur due to damage to the hypothalamus, cerebral irritation from hemorrhage, or infection Maintaining skin integrity Monitoring and managing potential complications Maintenance of adequate CPP is important to prevent serious complications of head injury( Adequate CPP>50mm hg)

75. Nursing Diagnosis-Actual Diagnosis Ineffective airway clearance and impaired gas exchange related to brain injury ineffective cerebral tissue perfusion related to increased ICP, decreased CPP, and possible seizures Deficient fluid volume related to decreased LOC and hormonal dysfunction Imbalanced nutrition: less than body requirements related to increased metabolic demands, fluid restriction, and inadequate intake Disturbed sleep pattern related to brain injury and frequent neurologic checks Deficient knowledge about brain injury, recovery, and the rehabilitation process

76. Potential nursing diagnosis Risk for injury (self-directed and directed at others) related to seizures, disorientation, restlessness, or brain damage Risk for impaired skin integrity related to bed rest, hemiparesis, hemiplegia, immobility, or restlessness Risk for imbalanced body temperature related to damaged temperature-regulating mechanisms in the brain