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Nursing Assessment and Treatment of Headaches in Children by mercy2beans111

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									                      Nursing Assessment and Treatment
                           of Headaches in Children
                                                          by Annette Lavalle, RN, MPS

    Presenter: Kathryn R. Kolar, RN, Ph D, CS-PNP
                  Associate Professor, University of Mississippi School of Nursing
                  Director and PNP, Johnson Elementary School Based Health Center


         eadache is defined as a single or repet-   varies so much that it does not offer much                  palsy, which may include reversible

  H      itive pain or discomfort about the
         head or face. It is a common problem
  of children as well as adults, with over 40%
                                                    help in diagnosis.

                                                    Migraine or Vascular Headaches                          ■
                                                                                                                one-sided blindness. These are rarely
                                                                                                                seen in school-age populations.
                                                                                                                Cluster migraines (these are really
  of 7-year-olds and 75% of fifteen-year-olds       Almost all school nurses have met a kid who                 vascular in origin) bring about
  reporting that they have had a headache.          suffers from migraine headaches; 5% of                      nasal dis-charge and/or congestion,
  Headaches are usually benign and transient        elementary-age children are affected (boys                  one-sided watery eye, but no nausea
  but can be serious and should be assessed         more than girls) and 17% of adolescents                     and vomiting.
  with that in mind.                                (girls more than boys). Many migraine
     Headaches do not originate from the            sufferers have a personal history of               The diagnosis of migraine varies. One par-
  brain tissue, since the brain is insensate,       childhood motion sickness or vertigo, and          ticular method requires that three of these
  but arise from stimulation of nerve end-          70% of adolescent sufferers have a positive        six groups of symptoms be present:
  ings in larger arteries or veins or from the      family history of migraine. There are several         1. An aura, scotoma, vertigo, numbness,
  periosteum, skin of the head, face or             types of migraine:                                       tingling, or paresthesia.
  neck, the mucosal linings of the airways             ■ Classic—migraine with aura. This                 2. Pain described as pounding, throbbing
  and sinuses, from the temporal-mandibular               variety may be either bilateral or unilat-         or pulsating
  joint, or from the teeth and gums.                      eral, it does not always affect the same        3. Localized pain—one sided
     There are several categories of headaches:           side, and by definition there is a motor        4. Gastrointestinal symptoms: nausea,
     ■ Sinus                                              or sensory disturbance.                            vomiting, abdominal discomfort
     ■ Migraine                                        ■ Common—migraine without aura.                    5. Relief of pain by sleep
     ■ Tension                                            This is a less sharp and less well-defined      6. A positive family history
     ■ Depression                                         headache and does not have attendant
     ■ Trauma                                             motor/sensory disturbance. This is           Tension Headaches
     ■ Pathological /Serious, Others                      the most common variety in children          This kind of headache is caused by muscular
                                                          and adolescents.                             contractions and usually has an onset at 8 to
  Sinus Headaches                                      ■ Complicated—focal neurological deficits       12 years of age. They are most common in
  Amazingly, only 15% of people with a                    may persist after the pain of migraine       overweight females. The headache is
  sinus condition complain of headache,                   has dissipated. These deficits may fall      preceded by stress especially as related
  but their histories are quite definitive for            into one of the following categories:        to relationships (student-teacher, among
  this variety of headache. The complaints                ■ Hemiplegic or Hemisensory—uni-             peers, etc.). They are lengthy, lasting from
  and history include pain in, around, above                 lateral motor weakness/sensory dis-       hours to days. The pain is described as
  or behind the eyes, in the maxillary area,                 turbances may last several hours          aching, dull, an annoyance, and tightness in
  and in face rather than head locations.                    after the headache is gone.               the scalp. It can involve the entire head bilat-
  The pain is reported as dull or throb-                  ■ Basilar migraine—the pain comes            erally or the occipital region alone. There are
  bing and is increased by changing to a                     from the basilar and posterior cere-      no prodromal symptoms, no nausea and
  reclining position. The pain is worse in                   bral arteries and gives rise to an        vomiting, and no positive family history.
  the morning or during the night and can                    occipital headache with diplopia,
  be associated with fever, rhinorrhea,                      tinnitus, or ataxia. This is usually      Depression Headaches
  allergies, cough, and postnasal drip/                      found in older adolescent females.        These headaches are fairly severe and can
  sore throat. The mucosa may be pale or                  ■ Ophthalmoplegic migraines give             last days or weeks. The personality of the
  boggy if allergies exist, but nasal discharge              rise to same-sided third cranial nerve    sufferer is compulsive, with the student

March 2004                                                                                                                        School Nurse News 31
  making excessive personal demands. These            ■   Setting—where were you when it               mosis (DIC, meningitis, child abuse), and
  children do not have a positive outlook                 started hurting, what were you doing?        vomiting without nausea. These all require
  on life; they are of the doom-and-gloom             ■   Associated manifestations—what hap-          immediate medical attention.
  type personality.                                       pened before it started (nausea, vomit-
                                                          ing, diplopia, etc.)?                        Nursing Interventions
  Headaches Associated with Head Trauma               ■   Aggravating and/or alleviating fac-          The interventions vary with assessment, but
  With closed head trauma the pain can be                 tors—what makes it worse? better?            consider reassurance, rest, and carbohydrate
  acute or chronic from the moment of the                                                              snack, relaxation techniques, massage, acu-
  incident and increasing within the first          History                                            pressure, or ice packs to occipital region. For
  hour. In the acute phase there can be nausea,     It is important to ask about recent or acute       the frequent sufferer, try keeping a headache
  vomiting, lethargy and seizures depending         history, such as recent illness or injury. Ques-   log. Sending a child home is a last resort;
  on the amount of intercranial pressure.           tions may include: Where is the student in         refer the child to the doctor if the headache
  Later, dizziness and personality changes can      her menstrual cycle? Is this associated with       requires the child to be sent home more
  appear and persist for days or weeks.             menarche? Is the student dieting? Has there        than once a semester.
                                                    been a change in appetite? Might the student
  Less Common and Pathological Causes               be on a fad diet and be suffering from hypo-       Pharmacological Interventions
    ■ Intracranial Masses                           glycemia or dehydration? Has the student’s         Non-migraine: acetaminophen or ibuprofen
      The pain is localized or generalized          weight changed? What has the student just          Migraine: acetaminophen, ibuprofen, nap-
      and increases with activities that increase   been doing? Is this a post gym class headache,     roxen. Physician orders may include
      the intracranial pressure (bending over,      with exposure to heat? Does the student see        beta-blockers, tricyclics, cyproheptadine,
      coughing, sneezing, etc.). The pain is        things, as in the past? Might there be vision      anticonvulsants, or calcium channel
      worse in the morning and the headache         or other sensory changes? Is the student           blockers. It is important to remember that if
      may include projectile vomiting, vomit-       sleeping well? Has there been a change in          medication is to be given, the sooner it is
      ing without nausea, and focal seizures.       medications? Has the student been crying?          given the better the result will be.
    ■ Benign Intracranial Hypertension                 Remote past information may also be of
      These are related to pseudo tumors            help, such as: Does the student have               Implications for School Practice
      and manifest symptoms similar to those        headaches often? Has the student been sick?        “The school nurse has a pivotal role in the
      of intracranial masses. This is called        Are the teeth in good condition? Has there         assessment and care of the child with a
      pseudo tumor cerebri. The condition can       been dental work recently? Does the student        headache. It is essential that the school
      also be caused by changes in medication.      abuse any substances? Does the student have        nurse is familiar with the various types and
    ■ Epilepsy                                      allergies? How heavy is the child’s backpack?      causes of headaches, and is able to recog-
      There may be headaches associated             Has there been exposure to noise or toxins?        nize and respond to the warning signs of
      with a postictal state or as part of the      Does the student get along well with peers,        potentially serious headaches. An appro-
      aura that precedes a seizure.                 siblings and teachers? What else does the          priate assessment of the child with a
    ■ Meningeal Irritation                          sufferer do; how does the student spend            headache is imperative for an accurate
      This may cause headache as a result of        spare time—computers, loud music? Does             interpretation of the cause of the problem
      an infection, inflammation, or hemor-         the student seem depressed? Is there a family      so that effective nursing interventions can
      rhage. The onset is acute with diffuse        history of headaches? How do family mem-           be implemented.”
      pain, nuchal rigidity and Level of            bers handle their headaches?                                                      Kathryn Kolar
      Consciousness (LOC) changes.
    ■ Aneurysms                                     Physical Signs                                             AUTHOR’S COMMENTS
      These cause throbbing headaches and           Vital signs, neurological assessment, assess         Dr. Kolar provided a wonderful, concise and
      alterations in LOC.                           muscle tone (right and left equal?) Inspect          quick review of all kinds of headaches. I tried
                                                    face and head, palpate for tenderness. Is visual     the web site headaches.org and found some
  Nursing Assessment                                acuity okay? Are the lymph nodes enlarged?           very valuable information for those who want
  These seven variables will assist in all nurs-                                                         to use headache logs. Just as I’m sure all
                                                                                                         school nurses do, I see children with
  ing assessments, but here are slanted toward      Warning Signs                                        headaches in my office every day. Her presen-
  the assessment of headaches:                      We all live in dread of the fulminating              tation was a thorough review and a validation
    ■ Location—point with one finger to             headache. Here are some of the warning signs         of my practice.
       where it hurts most                          of severe problems: sudden onset, increasing
    ■ Quality—what does the pain feel like:         severity, severe pain on awaking, seizures, his-
       pulsating, dull, stabbing, etc.?             tory of head trauma, fever, nuchal rigidity,       ABOUT THE AUTHOR
                                                                                                       Annette Lavalle, RN, MPS is a veteran school
    ■ Quantity—how much pain is there?              increasing blood pressure, irritability, change    nurse-teacher in the Kingston (NY) City Schools. Feel
    ■ Chronological—how has the pain                in behavior, lethargy, slurred speech,             free to contact her with your comments or questions
       changed since it started, more or less?      extremely specific pain, petechiae or ecchy-       at annie@lavalle.com.



32 School Nurse News                                                                                                                              March 2004

								
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