Headaches are a common nuisance that many people experience at one time or another, often due to stress, poor sleep, illness, or other causes. Headache disorders affect approximately 40% of the global population and are under-recognized and under-treated.
In this article:
- Types of Headaches
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Deficient Knowledge
- Impaired Comfort
- Ineffective Sleep Pattern
- Nausea
Types of Headaches
There are over 150 different types of headaches. Headaches can be broadly classified as either primary or secondary.
Primary headaches have no known cause and include migraine, tension, and cluster headaches.
Secondary headaches are caused by other health conditions like a neck injury, brain tumor, or sinus infection.
The most common types of primary headaches include tension headaches, cluster headaches, or migraine headaches.
Tension-type Headache
The most common type of headache is a stress headache or tension-type headache (TTH). This condition is described as mild to moderate pressing pain on the forehead in a band-like pattern that can last from several minutes to several days.
Cluster Headache
A cluster headache is considered the most painful form of primary headache. It is relatively rare and affects more men than women. Pain is unilateral and accompanied by nasal drainage or stuffiness and eye tearing. This condition is characterized by repeated headaches occurring in ‘cluster’ patterns for days or weeks, followed by periods of remission.
Migraine Headache
Migraine headaches are a recurring type of headache described as unilateral throbbing pain. These commonly occur in females between the ages of 25 and 50. Migraines may occur with an aura or, more commonly, without an aura (75% of cases). Chronic migraines are diagnosed when experienced at least 15 days a month for at least three months.
Nursing Process
Headaches range from mild to severe and can be debilitating for the patient. It is essential to identify the type of headache the patient is experiencing for effective treatment.
Interventions may include medications, botox injections, self-care activities, lifestyle modifications, and alternative therapies. The nurse supports the patient and their treatment regimen through education and follow-up.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to headaches or migraines.
Review of Health History
1. Ask the patient to describe the headache.
It is important to have the patient describe the frequency, intensity, and characteristics of the headache. Also, note any factors that aggravate or alleviate the pain. Ask the patient about other symptoms of their headaches, such as unilateral eye tearing, congestion, rhinorrhea, or ptosis.
2. Identify migraine headaches.
Migraines are characterized by a pounding headache on one side. Usually, symptoms last for 4-72 hours. Clinical manifestations of migraine headaches include:
- Unilateral throbbing that is synchronous with the person’s pulse
- Nausea and vomiting
- Sweating or chills
- Fatigue
- Dizziness
- Vision changes
- Sensitivity to light, sound, and odors
3. Review the patient’s medical history.
Note any comorbidities, including hypertension, diabetes, untreated/unmanaged dental conditions, fibromyalgia, depression, anxiety, bipolar disorder, epilepsy, multiple sclerosis, hormonal changes, and injuries to the face or head that may contribute to headaches.
4. Determine the patient’s risk factors.
Additional risk factors for headache disorders include:
- Stress
- Poor sleep
- Substance abuse
- Overconsumption of caffeine
- Alcohol
- Muscle tension
5. Track the family history.
Migraines tend to run in families. Children who suffer from migraines usually have at least one biological parent who has them.
6. Assess the patient’s environmental triggers.
Common environmental factors that cause headaches include:
- Environmental allergens
- Certain foods
- Secondhand smoke
- Exposure to strong chemical or perfume odors
7. Perform medication reconciliation.
Identify the patient’s prescribed medications and any over-the-counter medications. Patients with primary headache disorders may overuse medication and experience overuse headaches. Overuse headache features include headaches in the morning, headaches when a medication dose is delayed, and relief when medication is administered.
Physical Assessment
1. Perform a thorough head and neck assessment.
Assess the patient for trigger points and points of tenderness (using palpation), pain in the mouth (dental pain), or jaw clicks. Perform a cranial nerve assessment.
2. Assess the neurological status.
Central nervous system disorders may result in headaches. Note the following neurological findings:
- Change in the level of consciousness
- Balance issues
- Frequent falls
- Vision concerns (blurry vision, double vision, blind spots)
- Confusion
- Changes in personality
- Seizures
- Dizziness
3. Assess the HEENT system thoroughly.
A nasal exam should look for purulent drainage, inflammation, trauma, or a tumor in the nasal cavity. The ears should be checked for otitis media. The vision exam should include assessing the visual fields and for signs of intracranial pressure (papilledema) and nystagmus. An oral exam assesses for lesions or dental decay.
4. Use SNOOPP screening criteria.
SNOOPP is one screening mnemonic that identifies life-threatening signs of a secondary headache. It stands for:
- S: Systemic illness (fever, weight loss)
- N: Neurologic changes
- O: Onset is new or sudden
- O: Older age (over 60)
- P: Previous headache that worsens
- P: Positional headache, Precipitated by sneezing, coughing, or exercise (bending/jumping), and Papilledema
Diagnostic Procedures
Headache disorders are typically diagnosed based on a physical and neurological exam. Tests may be performed to rule out specific causes.
1. Conduct lab tests.
The following laboratory tests are considered for these conditions:
- With headaches, altered mentation, or focal neurologic deficits
- Serum glucose level
- Suspected giant cell arteritis (GCA)
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- Suspected cerebral venous thrombosis (CVT)
- Coagulation profile
- D-dimer
- Infection or inflammatory disease
- White blood cell count
- Suspected carbon monoxide poisoning
- Carboxyhemoglobin level
2. Anticipate imaging scans.
Diagnostic imaging is recommended for patients experiencing headaches with a new pattern or neurologic findings, HIV-positive patients experiencing a new type of headache, new and sudden-onset severe headaches, headaches with a fever, and anyone age 50 or above having a new headache.
Anticipate the following imaging scans:
- Head CT (recommended screening test)
- Cerebral CT Angiography (CTA)
- Magnetic Resonance Imaging (MRI)
- Magnetic Resonance Venography (MRV)
3. Consider a lumbar puncture.
Consider a lumbar puncture (LP) and cerebrospinal fluid testing for the following:
- Worst headache of the patient’s life
- Severe, rapid-onset headache
- Progressive headache
- Unresponsive and intractable headache
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with a headache or migraine.
1. Treat the primary headache.
Reducing symptoms and offering supportive care should be the main goals of treatment for primary headaches. Advise the patient to follow up with a neurologist or primary care physician for both preventive and therapeutic measures.
2. Attempt to reduce symptoms.
In the acute care setting, attempt to reduce environmental triggers. Avoid bright lights and keep the patient in a darkened room. Reduce noise and encourage rest. Offer cool compresses and eliminate odors.
3. Set the patient’s expectations.
Managing patient expectations should be part of the treatment plan. Recurring headaches are common. Migraines cannot be cured and may not be completely eliminated.
4. Anticipate the need for hydration.
IV hydration may be necessary for patients experiencing nausea and vomiting due to headaches. Dehydration is known to not only cause headaches but intensify the pain response.
5. Administer medications as ordered.
Migraine treatment often requires a combination of abortive (acute) and preventative therapy.
Migraine Treatment:
- Abortive treatment:
- NSAIDS
- Treatment for mild-moderate migraine attacks
- Triptans
- The first-line treatment used to abort and prevent migraine headaches
- For moderate-to-severe migraines
- Side effects are vascular and include flushing, chest pain, and shortness of breath
- Routes include oral, intranasal, subcutaneous, and intramuscular
- Examples include: Sumatriptan, Zolmitriptan, Eletriptan, Rizatriptan, and Almotriptan
- Opioid analgesics
- Only administered for severe migraine pain when no other treatment is effective but not advised for long-term use due to the incidence of addiction
- Calcitonin gene-related peptide (CGRP) antagonists (also preventative)
- Examples include Nurtec ODT and Ubrelvy
- NSAIDS
- Preventative (prophylactic) treatment:
- Calcium channel blockers
- Beta-blockers
- Tricyclic antidepressants
- Antiepileptics
- Botulinum toxin injections
Headache Treatment:
Treatment depends on the type and severity of the headache.
- Acetaminophen
- Adequate short-term pain relief, but a high recurrence rate.
- NSAIDs
- Extremely successful pain relief with good tolerability.
- Risk for nephrotoxicity and GI irritation/bleeding if used long-term or overused
- Examples include ibuprofen, ketorolac, naproxen, and diclofenac
- Oxygen
- The use of high-flow oxygen is beneficial for cluster headaches
Other medications include:
- Antidopaminergic agents (for analgesic and antiemetic effects)
- Corticosteroids
6. Discuss nonpharmacologic options.
Nonpharmacologic interventions can be used along with medications and include:
- Biofeedback
- Cognitive-behavioral therapy
- Massage
- Acupressure/Acupuncture
- Transcranial magnetic stimulation devices
7. Manage stress.
Patients can learn to manage stress and tension with solutions such as:
- Deep breathing exercises
- Muscle relaxation
- Visualization techniques
- Music therapy
- Yoga
- Regular exercise
8. Instruct on triggers.
Educate the patient on triggers of headaches and migraines, such as:
- Bright lights
- Certain odors
- Poor sleep
- Hormone fluctuations (menstruation)
- Foods (chocolate, cheese, wine)
9. Treat the underlying cause.
Finding and treating the underlying cause is essential to managing a secondary headache. This may include taking an antibiotic for an infection, receiving chiropractic care or physiotherapy for an injury, or managing a comorbidity.
10. Discuss medication changes.
Hormonal oral contraceptives contribute to headaches. Discuss switching to another form of birth control. Hormone replacement therapy may require a reduced dosage or discontinuation.
11. Educate on medication overuse.
Medication-overuse headaches (also known as rebound headaches) occur from excessive use of medications to treat headache pain and are the most common type of secondary headache. A detoxification approach is used while receiving other preventative therapy to reduce withdrawal symptoms.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for a migraine or headache, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for a migraine or headache.
Acute Pain
Pain is subjective and may be experienced differently from one patient to another. Pain felt in migraine and other types of headaches can range from mild to severe, and can be recurring and disabling.
Nursing Diagnosis: Acute Pain
Related to:
- Pressure, throbbing, or aching to the temples, eyes, sinuses, or base of the skull
- Migraine episode
As evidenced by:
- Guarding or protective behavior
- Restlessness
- Positioning to ease pain
- Increased heart rate
- Facial grimace
- Reports of pain
- Flat affect
- Loss of appetite
Expected outcomes:
- Patient will report a reduction in pain using the numeric pain scale.
- Patient will be able to complete daily tasks without disruption due to pain.
Assessment:
1. Assess the patient’s pain experience.
Pain is subjective and must be assessed meticulously based on its characteristics, onset, frequency, intensity, and quality. A detailed pain assessment can help determine the type of headache and develop the most appropriate treatment regimen.
2. Assess and monitor vital signs.
Vital signs may be altered during a patient’s pain episode. Fluctuations can indicate whether the patient’s condition is improving or worsening.
Interventions:
1. Administer pain medications as indicated.
OTC medications specific to migraines are available. Prescription-strength medication such as Fioricet may be required. Pain medications should be administered before the onset of the pain or during the prodrome phase when symptoms such as irritability or difficulty concentrating begin.
2. Teach patients non-pharmacologic pain management.
Nonpharmacologic pain management techniques like relaxation, cool compresses, darkness, and massage can help with pain relief. Moreover, these do not have any side effects or risk of dependence.
3. Schedule activities during the peak effects of pain relievers.
Headache pain can be debilitating and prevent the patient from working, caring for family, and ADLs. Schedule nursing tasks and patient care when pain is most controlled.
4. Identify precipitating factors.
Migraine headaches can have triggers such as stress, missed meals, too much caffeine or caffeine withdrawal, weather changes, exhaustion, exposure to smoke or strong odors, and more. Helping the patient identify specific instances of migraine occurrences can decrease episodes.
Deficient Knowledge
Patient education is an integral part of any treatment regimen to ensure compliance, prevent complications, and restore patients’ health. Inaccurate information can lead to poor adherence and unnecessary anxiety and expenses.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Inadequate access to resources
- Inadequate awareness of resources
- Lack of information
- Inadequate participation in care planning
- Lack of interest/motivation
- Misinformation
As evidenced by:
- Inaccurate follow-through of instructions
- Inaccurate statements about a topic
- Poor control of symptoms
Expected outcomes:
- Patient will verbalize understanding their disease process by exhibiting adherence to the treatment regimen.
- Patient will seek information on adjunctive treatment and lifestyle changes to improve health.
Assessment:
1. Assess the patient’s ability to learn.
Assess the patient’s ability to learn and determine possible barriers to learning to formulate an appropriate teaching plan.
2. Assess the patient’s willingness to learn.
Learning readiness is essential to patient education as it will determine how likely a person will seek out knowledge and participate in the learning process.
3. Acknowledge any cultural differences.
Acknowledging any cultural differences will establish rapport with the patient and improve therapeutic communication with the patient.
Interventions:
1. Educate on different treatment options.
Migraine treatments continue to improve. Other than analgesics, antidepressants, anti-seizure drugs, blood pressure medications, vitamins, and even Botox injections are used to treat migraines.
2. Provide accurate information and dispel myths.
There is still much to learn about headaches and migraines. Provide accurate information from reputable sources that the patient is able to understand.
3. Encourage a headache diary.
Have the patient keep a diary surrounding headaches and migraine episodes. This information can help with understanding possible triggers and changes to make in diet or lifestyle.
4. Consider resources.
Headaches and migraines can feel isolating. If the patient does not already see a neurologist, this specialist can offer expert treatment. Support groups may also help with feeling understood by others by sharing similar experiences.
Impaired Comfort
Patients suffering from migraines and other types of headaches often experience impaired comfort. Impaired comfort refers to an apparent lack of relief and peace in relation to a person’s physiological, environmental, spiritual, intellectual, and social patterns.
Nursing Diagnosis: Impaired Comfort
Related to:
- Headache and migraine pain
- Anxiety and worry
- Inadequate sleep
- Lack of support systems
- Associated symptoms such as nausea/vomiting, dizziness, etc.
As evidenced by:
- Expressed pain, anxiety, or worry
- Lack of sleep or restlessness
- Fatigue
- Difficulty relaxing
- Irritability
Expected outcomes:
- Patient will verbalize an improved sense of emotional relief and comfort.
- Patient will participate in strategies and interventions to improve spiritual and psychological comfort.
Assessment:
1. Assess the effect of impaired comfort on lifestyle.
Assess how the patient’s impaired comfort affects their ability to form relationships, maintain a career, and reach goals. This can direct interventions.
2. Assess current coping strategies.
Determine what the patient currently does to increase comfort. Does the patient have a support system, religious beliefs, or even negative coping behaviors? The patient may need redirection or additional resources.
3. Assess the patient’s goals for comfort.
Before interventions can be implemented and evaluated, the nurse must determine what the patient’s comfort goals are and what is important to their daily level of functioning.
Interventions:
1. Administer medications as indicated.
Pain medications can initially assist with pain that is causing impaired comfort. Additional medications such as antiemetics to help with nausea or antihistamines for dizziness and sleep aids can all improve comfort.
2. Establish a reliable and trusting relationship with the patient.
A trusting relationship encourages open and honest communication. Building a rapport can increase adherence to the treatment plan.
3. Minimize noise and stimuli.
Dim lighting in a cool and quiet room can induce comfort. Speak calmly and quietly to the patient when required.
4. Consider therapy consults.
Outward stress and personal issues can trigger headaches and prevent feelings of comfort. Encourage or provide opportunities to work with a counselor that may be able to develop coping strategies to control emotional stress.
Ineffective Sleep Pattern
Poor sleep is a trigger for headaches and migraines but may also result from headache and migraine pain and symptoms.
Nursing Diagnosis: Ineffective sleep pattern
Related to:
- Headache and migraine pain
- Anxiety and worry
- Impaired comfort
- Inadequate quality of sleep
- Fatigue
- Nausea and vomiting
- Sensitivity to light, sound, and odors
- Ineffective sleeping habits
- Irregular sleeping time
As evidenced by:
- Expressed headache or migraine, especially upon waking
- Verbal reports of difficulty falling or staying asleep
- Restlessness
- Fatigue
- Difficulty relaxing
- Irritability
- Decrease in health status
- Impaired quality of life
- Inability to perform activities of daily living
- Changes in mood
- Decreased energy
- Reduced cognitive performance
- Changes in appearance
Expected outcomes:
- Patient will verbalize an enhanced quality of sleep and sleeping time.
- Patient will maintain a regular sleep-wake routine.
- Patient will verbalize an improvement in energy, mood, and ability to complete daily tasks.
Assessment:
1. Assess sleeping habits and patterns.
Patients who experience frequent headaches and migraines report insomnia and poor sleep quality. Sleep deprivation, oversleeping, and irregularities in sleep all contribute to migraine attacks. Inadequate restorative sleep can cause headache and migraine symptoms due to a disruption of chemicals in the brain. Lack of sleep may disturb the descending pain inhibitory control system, increasing the patient’s sensitivity to migraine pain.
2. Identity sleep disorders.
Inquire about sleep disorders such as sleep apnea or narcolepsy, which may complicate the patient’s sleep patterns and contribute to headaches and migraines.
3. Review the patient’s medication list.
The following medications may affect sleep, contributing to headaches or migraines:
- Antidepressants
- Anticonvulsants
- Beta-blockers
- Antihistamines
- Corticosteroids
- Diuretics
Interventions:
1. Keep a sleep journal.
Ask the patient to record their sleep and wake patterns in a journal. They can also include related factors that affect sleep, such as foods eaten, alcohol or caffeine consumed, or a change in the sleeping environment. This information can help the nurse and care team develop interventions.
2. Suggest consistent sleeping habits.
A consistent routine is crucial to restorative sleep. Suggest the following sleeping habits:
- Go to bed and wake up at the same time each day
- Avoid using screens before bed
- Establish a relaxing bedtime ritual
- Refrain from strenuous activities at night
- Aim for 7-9 hours of sleep per night
3. Provide an environment conducive to sleeping.
Whether in the inpatient setting or at home, attempt to create an environment conducive to sleep, such as:
- Darkening the room
- Decreasing strong smells
- Lowering the room temperature
- Limiting noise
- Promoting relaxation techniques such as deep breathing or guided imagery
- Using a supportive pillow to prevent muscle tension
4. Consider a referral to a sleep specialist.
Consider a referral to a sleep specialist or sleep clinic if sleep continues to affect the patient’s health status. A sleep study may be able to identify underlying issues contributing to headaches or migraines.
Nausea
Migraines can activate changes within the brain that trigger nausea and vomiting.
Nursing Diagnosis: Nausea
Related to:
- Pain
- Stress
- Dehydration
- Noxious stimuli
- Overstimulation of brain structures responsible for nausea and vomiting
As evidenced by:
- Gagging sensation
- Food aversion
- Increased salivation
- Sour taste
- Increased swallowing
Expected outcomes:
- Patient will verbalize relief of nausea.
- Patient will demonstrate interventions that reduce nausea and vomiting.
Assessment:
1. Assess the onset and duration of the nausea.
Nausea can occur during any phase of a migraine attack but mainly during the prodrome phase before the headache actually begins. Nausea may last for several hours.
2. Evaluate for fluid and electrolyte imbalance.
Severe nausea and vomiting can result in fluid and electrolyte imbalances. Early identification of nutritional and fluid deficits can ensure prompt treatment and prevent further complications.
Interventions:
1. Administer antiemetics and pain medications as indicated.
Antiemetics address and manage nausea and vomiting in patients suffering from headaches or migraines. Pain may also trigger nausea, so alleviating the patient’s pain can dramatically reduce nausea and vomiting symptoms.
2. Encourage bland foods or ice chips when feeling nauseous.
Dry, bland foods like crackers improve nausea while ice chips promote hydration and significantly lessen the discomfort associated with the nauseous feeling. An empty stomach is more likely to exacerbate nausea. Educate to avoid spicy, greasy, or processed foods.
3. Encourage slow breathing.
Slow, controlled breathing in through the nose and out through the mouth can reduce the severity of nausea.
4. Instruct the patient to avoid triggers of migraines.
Since nausea is often linked to the start of a migraine attack, patients should be instructed to avoid migraine triggers like drinking alcohol, bright lights, sleep deprivation, and stress.
5. Manipulate the environment.
Reduce noise, dim lighting, and remove noxious odors. A fan blowing on the patient or a cool compress on the back of the neck may also help relieve nausea.
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