Grand rounds Headache nr508 Kim Roberts 2-11-18
HEADACHE
Brain tissue does not experience sensations of pain.
Pain occurs in several locations:
The tissues covering the brain
The attaching structures at the base of the brain
Muscles and blood vessels around the scalp, face, and neck
The source of a headache is normally caused by muscle tension, or vascular problems.
The International Headache Society diagnostic criteria for classification of headache:
Primary classifications: Tension-type, Migraine, Cluster
Bilateral, band-like feeling of pressure around the head with a constant, squeezing and tightness
Most common type of headache is the Tension Headache
Classified into four types:
Frequent episodic tension-type headache
Infrequent episodic tension-type headache
Chronic tension-type headache
Probable tension-type headache
(ICHD-3 The International Classification of Headache Disorders 3rd edition, n.d.).
Tension Headaches
According to research, tension headaches occur because of pain sensitivity, perception, and neurotransmitters.
Genetics are thought to be involved in chronic tension headache.
Environmental factors (stress) are involved in the physiologic processes experienced with episodic tension headache.
Abnormalities in the central nervous system, cause sensitivity to pain experienced in tension headaches.
Connective tissue and muscles in the neck and shoulders cause a tension headache by forming knots in the muscles.
Neurotransmitters cause the brain to experience pain when stimulated such as serotonin and nitric oxide.
Medication and Substance abuse cause about one third of all headaches.
Causes: Poor Posture, Work Conditions, Fatigue, Eyestrain, Physical Activity, Food, Stress Pharmacologic agents, Dental Problems, Physical Trauma, Hormonal Changes.
Symptoms of a tension headache: Constant, dull pain above the eyes and across the back of the head
Head pain that gets worse as the day progresses
Pain that may spread over your entire head and to your shoulders and neck
Muscles that are tight in the neck or shoulder area
Head pain that is made worse by bright lights or loud noises
(ICHD-3 The International Classification of Headache Disorders 3rd edition, n.d.).
Pathophysiology
78% of headache patients in population-based studies are from tension type headaches, it is the least distinct of all headache types. A clinical diagnosis is made mainly by on negative symptoms (Barbanti, Egeo, Aurilia, & Fofi, 2014).
3
Tension headache
Frequent episodic tension-type headache- ≥12 and <180 days per year, last from 30 minutes to 7 days, bilateral location, pressing/tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity, no nausea or vomiting, either photophobia or phonophobia, not caused by another disorder.
Infrequent episodic tension-type headache- <12 days per year, last from 30 minutes to 7 days, bilateral location, pressing/tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity, no nausea or vomiting, either photophobia or phonophobia, not caused by another disorder.
Chronic tension-type headache- ≥180 days per year, last from 30 minutes to 7 days, bilateral location, pressing/tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity, no nausea or vomiting, either photophobia or phonophobia, not caused by another disorder.
Probable tension-type headache- Do not fulfill some of the above criteria.
(ICHD-3 The International Classification of Headache Disorders 3rd edition, n.d.).
DIAGNOSTIC CRITERIA
4
Tension headache
Questions
1. What is the most common side effect when taking NSAIDs, Acetaminophen and Aspirin?
A. Heartburn
B. Hypertension
C. Nausea
D. Insomnia
2. What is an indicator to do further testing in a patient with headaches?
A. Nausea and Vomiting
B. Blurred Vision
C. Recent head trauma
D. All of the above
3. What is the primary cause of a rebound headache?
A. Overuse of medication
B. Underuse of medication
C. Insomnia
D. All of the above
4. If a tension headache lasts ≥180 days per year, last from 30 minutes to 7 days what is the headache classification?
A. Frequent episodic tension-type headache
B. Infrequent episodic tension-type headache
C. Chronic tension-type headache
D. Probable tension-type headache
5. How long must preventive type drug that treats tension-type headaches be taken before the beginning to work?
A. Several weeks
B. Thirty minutes
C. Two days
D. None of the above
Answers: 1:C, 2:D, 3:A, 4:C, 5:A
Medical providers will perform physical and neurological exams to discover the type and cause of an individuals chronic or recurrent headaches. Pain characteristics: What type of pain pulsating, dull, sharp, or stabbing.
Pain intensity: Does the pain interfere with your average daily living?
Pain location: Where is the pain felt in your head?
Do you feel pain all over your head, one side of your head, or do you feel it in the forehead area or behind your eyes?
5
Tension headaches
Ibuprophen (Advil, Motrin, A-G Profen, Addaprin, Bufen, Genpril, Caldolor, Haltran), Analgesic NSAIDs
Dose-200 to 400 mg ORALLY every 4 to 6 hours as needed; MAX dose, 1200 mg in 24 hours
Side Effects-Heartburn, Nausea, Dizziness, Cardiac arrest, CHF, HTN, Hyperkalemia, GI bleeding.
MOA-a nonsteroidal anti-inflammatory drug (NSAID) that exhibits analgesic and antipyretic activities by inhibiting prostaglandin synthesis.
Contraindications-Asthma, urticaria, or other allergic-type reaction following aspirin or other NSAID administration, In the setting of coronary artery bypass graft (CABG) surgery, •Hypersensitivity to ibuprofen (Micromedex, n.d.a).
Aspirin (Ecotrin, Bayer, Ascriptin, Aspergum, Aspirtab, Easprin, Ecpirin, Entercote), Analgesic
Dose-500 mg to 1000 mg ORALLY every 4 to 6 hours; MAX: 4 g/24 hours.
Side Effects-GI ulcer, Hemorrhage, Exudative age-related macular degeneration, Tinnitus, Bronchospasm, Angioedema, Reye's syndrome.
MOA-inhibitor of prostaglandin synthesis and platelet aggregation which irreversibly inactivates cyclooxygenase via acetylation which prevents the conversion of arachidonic acid to thromboxane A(2).
Contraindications-Hypersensitivity to NSAIDs, Syndrome of asthma, rhinitis, urticaria, angioedema, or bronchospas(Micromedex, n.d.b).
Over The Counter (OTC) Medications
There are many medications on the market that will treat a tension headache and reduce an individuals pain. Over the counter (OTC) medications for headaches are considered the first line of treatment such as aspirin, ibuprofen, and naproxen (Barbanti, Egeo, Aurilia, & Fofi, 2014).
6
Tension Headache OTC MEDICATIONS
Acetaminophen (Tylenol, Genapap, Feverall, Actamin Maximum Strength, Altenol, Aminofen, Ofirmev, Anacin Aspirin Free),
Dose-Adults: 650 to 1000 mg orally every 4 to 6 hours as needed (maximum 4 g/day)
Side effects-Constipation, Nausea, Vomiting, Headache, Insomnia,
Agitation, increased the risk of hepatic injury if taken with alcohol, Liver failure.
MOA-centrally acting analgesic and antipyretic with minimal anti-inflammatory properties and reduces fever by inhibiting the formulation and release of prostaglandins in the CNS and by inhibition endogenous pyrogens in the hypothalamic.
Contraindications-hepatic disease, allergy to acetaminophen or any other components of the product (Micromedex, n.d.c).
Naproxen (EC Naprosyn, Naprosyn)
Dose-500 mg orally initial dose, then 250 mg orally every 6 to 8 hours as needed or 500 mg orally every 12 hours as needed (maximum initial dose, 1250 mg/day, then 1000 mg/day)
Side effects-Abdominal pain, Constipation, Heartburn, Nausea, Dizziness Headache, Dyspnea, Body fluid retention, Congestive heart failure, Hypertension, Myocardial infarction, Hyperkalemia
MOA- a propionic acid derivative NSAID with analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action is unknown but involves inhibition of cyclooxygenase (COX-1 and COX-2), which reduces prostaglandin synthesis.
Contraindications-Asthma, urticaria, or allergic-type reaction following aspirin or other NSAID administration, Use in the setting of CABG surgery (Micromedex, n.d.d).
7
Headaches
Preventive medications
Amitriptyline (Elavil, Vanatrip) is an antidepressant agent that helps prevent tension headaches.
Dose-30–75 mg orally, may increase to MAX, 150 mg/day
Side Effects-Weight gain, Constipation, Dizziness, Headache, Somnolence, Blurred vision, Depression, and Hepatotoxicity
MOA-Amitriptyline hydrochloride is a tricyclic antidepressant (TCA) that has a sedative property. It promotes neuronal activity by blocking the membrane pump mechanism so that the absorption of serotonin and norepinephrine in serotonergic and adrenergic neurons does not occur.
Contraindications-Coadministration with cisapride; may cause QT interval prolongation and increase the risk of arrhythmia, Coadministration with an MAOI or use within 14 days of discontinuing an MAOI; may cause a hyperpyretic crisis, severe convulsions, death, and MI (Micromedex, n.d.g).
***Preventive medications must be taken for several weeks before there effects will be therapeutic to the individual..
***Overuse of OTC pain relievers may interfere with the effects of the preventive drugs.
Education about Medications
Over-the-counter (OTC) drugs have many side effects and contraindications with other medications and diseases that may cause serious harm.
According to the Beers Criteria, elderly patients should avoid chronic use of NSAIDS, Acetaminophen, and Aspirin (Micromedex, n.d.g).
Try not to take over-the-counter drugs more than 3 times a week, because you may get rebound headaches. Continually taking OTC medications for headache pain will cause a rebound headache to occur when you stop taking the medicine
According to Dreischulte & Guthrie (2012), the quality measures of drug prescribing include avoiding inappropriate medications by checking contraindications before prescribing or taking a medication. Use medications in proper dosage and purpose. Check for drug to drug interactions. Monitoring for side effects and drug levels.
Case Study
Jake, a 25-year-old male comes to the clinic for reoccurring headaches. He states that his symptoms started four days ago, and he gets no relief from Ibuprofen. He has previously been healthy. He does not smoke, but drinks 2-3 beers socially on weekends. He works out daily lifting weights and doing 30 minutes of cardio. He is currently taking a pharmacology class in college. He has no history of drug abuse. On physical examination, his blood pressure is 110/67 mm Hg, heart rate is 66/min, and he is afebrile. He describes the headache as dull and progressively get worse throughout the day, the pain ranges from 2 to 6 on scale of 1-10 (10 being worst pain). He has no previous medical history of headaches. When asked where it hurts Jake states; “it hurts over my entire head and to my shoulders and neck ”. He denies vomiting and nausea. He states that “sometimes light makes it worse”. He denies blurred vision, diplopia, tearing, rhinorrhea, numbness, or sensitivity to noise. He has taken Ibuprofen “a each day and at first it worked and now it will get a little better but then comes back”. When asked how much Ibuprofen he takes a day he states “I take eight a day trying to get rid of the pain”. When asked if working out makes it worse Jake states “no”. When asked if he feels like he is under stress he states “money and my pharmacology class both stress me out a lot, but that is why I work out daily”.
Surgeries; None
Hospitalizations; None
Current prescribed medications; None
Current Vitamins and supplements; Protein shake 2 x day, Multivitamin daily
Hours of sleep a day; 4-6
Meals a day; 2 (skips breakfast)
Poor Posture while working, fatigue from sleeping improperly, and eyestrain can all cause tension headaches. Intense physical activity or lack of activity can cause a tension headache, but the pain is not intensified by physical activity. Dental problems that cause a person to clench their jaw while sleeping may cause pain in the ear, cheek, temples, neck, or shoulders which lead to a tension headache. Physical trauma from a head or neck injury and hormonal changes may cause or increase the occurrence of tension headaches. Stress from writing a grand rounds presentation can also lead to a tension headache (Jensen, 2017)
10
Diagnosis
Jake has Infrequent episodic tension-type headache as evident by, bilateral dull mild to moderate pain that travels to his neck and shoulders and feels like a tight band around his head that last from 30 minutes to 7 days. He is able to continue his usual daily activities with the headaches and has no associated symptoms of nausea, vomiting, or phonophobia, although he does have some photophonia. He may also be having rebound headaches which are associated with frequent use of any analgesic medication being overused. Improvement of rebound headaches will not occur until the medication is discontinued. She should be screened for depression and anxiety as psychiatric co-morbidity is common in patients with tension type headaches.
DIFFERENTIAL DIAGNOSIS
Conditions that may cause symptoms similar to tension headaches include but are not limited to:
Brain tumor Dental/oral disease Caffeine dependency Encephalitis
Cluster Headache Cervical spine disease Chronic sinusitis Glaucoma
(Jensen, 2017).
After a complete assessment of the patient if the history or physical is unusual for an intracranial issue than a head CT or MRI scan may be indicated. Blood tests can include a complete blood count (CBC), and a complete chemistry panel. The spinal fluid analysis is needed only on rare occasions. Test that may be indicated by clinical findings may include an x-ray of the cervical spine (Jensen, 2017)
11
Barriers to effective care
The primary clinical barrier is due to the lack of knowledge of health-care providers. Medical education that focuses on headache disorders are usually given four hours in undergraduate school. Many people that have headache disorders are not diagnosed and treated: 40% of people with migraine or TTH are professionally diagnosed.
The public does not view headache disorders as a serious health issue because they are mainly episodic, are not contagious, and death does not occur. Many of the individuals that suffer from headaches are not aware that effective treatments exist. 50% of all individuals with headache disorders are self-treating.
Due to health-care costs constraints, governments do not acknowledge the profound burden of headaches on the public. The government may not be considering the loss of working days that individuals miss because of headaches compared to he small cost of treating headaches.
Infrequent episodic tension-type headache usually become chronic when life stressors or posture are not corrected. Most tension-type headaches are episodic or intermittent, allowing the individual to continue to work and live a normal life. Episodic tension-type headaches usually improve over time.
(Leonardi, 2015).
Treatment Plan
Treatment of a tension headache must start with lifestyle modifications. Jake needs adequate sleep (at least 8-10 hours per night), no caffeine, drink plenty of water, and do not skip meals. I will encourage Jake to include relaxation and stress relieving techniques in his daily activities. Non-pharmacological ways to reduce stress include massages, acupuncture, biofeedback and behavioral therapies. I will educated Jake of the importance of avoiding any identified triggers that may cause his tension headaches (ihs.org, 2013). OTC medications such as NSAIDs are first-line treatment for tension headaches, however, Jake reports that Ibuprofen does not relieve his headache anymore. At this time labs are not indicated. I will have Jake stop taking the Ibuprophen. I will inform him it may take 2 to 10 days for his sign and symptoms from the rebound headaches to be relieved. I will have him make an appointment for one week from now to evaluate his need for a preventive drug for the treatment of his tension headaches, such as Venlafaxine hydrochloride, Amitriptyline, or Mirtazapine.
According to Dreischulte & Guthrie (2012), the quality measures of drug prescribing include avoiding inappropriate medications by checking contraindications before prescribing or taking a medication. Use medications in proper dosage and purpose. Check for drug to drug interactions. Monitoring for side effects and drug levels (Dreischulte & Guthrie, 2012)
I will educate Jake about the signs and symptoms of using OTC medications and to try not to take over-the-counter drugs more than 3 times a week, because you may get rebound headaches. Continually taking OTC will cause a rebound headache to occur when you stop taking the medicine prompting you to take more of the medication (Barbanti, Egeo, Aurilia, & Fofi, 2014).
13
Reference
Barbanti, P., Egeo, G., Aurilia, C., & Fofi, L. (2014). Treatment of tension-type headache: from old myths to modern concepts. Neurological Sciences, 3517-21. doi:10.1007/s10072-014-1735-3
Jensen, R. H. (2017), Tension-Type Headache – The Normal and Most Prevalent Headache. Headache: The Journal of Head and Face Pain. doi:10.1111/head.13067
Micromedex. (n.d.a). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/56E151/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/A4B146/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Ibuprofen&fromInterSaltBase=true&false=null&=null#
Micromedex. (n.d.b). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/E4A67E/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/E91CDB/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=asa&UserSearchTerm=asa&SearchFilter=filterNone&navitem=searchGlobal#
Reference
Barbanti, P., Egeo, G., Aurilia, C., & Fofi, L. (2014). Treatment of tension-type headache: from old myths to modern concepts. Neurological Sciences, 3517-21. doi:10.1007/s10072-014-1735-3
Dreischulte, T., & Guthrie, B. (2012). High-risk prescribing and monitoring in primary care: how common is it, and how can it be improved? Therapeutic Advances in Drug Safety, 3(4), 175–184. http://doi.org/10.1177/2042098612444867
Jensen, R. H. (2017), Tension-type headache – The normal and most prevalent headache. Headache: The Journal of Head and Face Pain. doi:10.1111/head.13067
Leonardi, M. (2015). Burden of migraine: what should we say more?. Neurological Sciences, 361-3. doi:10.1007/s10072-015-2188-z
ICHD-3 The International Classification of Headache Disorders 3rd edition. (n.d.). Retrieved from https://www.ichd-3.org/
Micromedex. (n.d.a). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/56E151/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/A4B146/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Ibuprofen&fromInterSaltBase=true&false=null&=null#
Reference Continued
Micromedex. (n.d.b). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/E4A67E/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/E91CDB/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=asa&UserSearchTerm=asa&SearchFilter=filterNone&navitem=searchGlobal#
Micromedex. (n.d.c). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/74FE35/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/20B80A/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Acetaminophen&UserSearchTerm=Acetaminophen&SearchFilter=filterNone&navitem=searchGlobal#
Micromedex. (n.d.d). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/8F54A3/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/03B8AF/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Naproxen&fromInterSaltBase=true&false=null&=null#
Reference Continued
Micromedex. (n.d.e). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/98DD5B/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/CAC700/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFAction/evidencexpert.DoIntegratedSearch?SearchTerm=Mirtazapine&UserSearchTerm=Mirtazapine&SearchFilter=filterNone&navitem=searchALL#
Micromedex. (n.d.f). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/EE6205/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/6DE827/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Venlafaxine hydrochloride &UserSearchTerm=Venlafaxine hydrochloride &SearchFilter=filterNone&navitem=searchALL#
Micromedex. (n.d.g). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/DAEAF8/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/E63695/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Amitriptyline&UserSearchTerm=Amitriptyline&SearchFilter=filterNone&navitem=searchGlobal#
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Reference Continued
Micromedex. (n.d.f). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/EE6205/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/6DE827/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Venlafaxine hydrochloride &UserSearchTerm=Venlafaxine hydrochloride &SearchFilter=filterNone&navitem=searchALL#
Micromedex. (n.d.g). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/DAEAF8/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/E63695/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Amitriptyline&UserSearchTerm=Amitriptyline&SearchFilter=filterNone&navitem=searchGlobal#
Micromedex. ( n.d.h). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/441CEC/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/33BB65/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.IntermediateToDocumentLink?docId=1172&contentSetId=50&title=Beers%2BCriteria%2B-%2BA%2BSummary%2Bof%2BPotentially%2BInappropriate%2BMedication%2BUse%2BAmong%2Bthe%2BElderly&servicesTitle=Beers%2BCriteria%2B-%2BA%2BSummary%2Bof%2BPotentially%2BInappropriate%2BMedication%2BUse%2BAmong%2Bthe%2BElderly
Society, I. (2006, January 25). ICHD-II Full Text Search. Retrieved from http://www.ihs-klassifikation.de/en/02_klassifikation/02_teil1/02.00.00_tension.html
The International Classification of Headache Disorders, 3rd edition (2013). Cephalalgia,
33(9), 629–808. doi:10.1177/0333102413485658
17
Grand rounds Headache nr508 Kim Roberts 2-11-18
HEADACHE
Brain tissue does not experience sensations of pain.
Pain occurs in several locations:
The tissues covering the brain
The attaching structures at the base of the brain
Muscles and blood vessels around the scalp, face, and neck
The source of a headache is normally caused by muscle tension, or vascular problems.
The International Headache Society diagnostic criteria for classification of headache:
Primary classifications: Tension-type, Migraine, Cluster
Bilateral, band-like feeling of pressure around the head with a constant, squeezing and tightness
Most common type of headache is the Tension Headache
Classified into four types:
Frequent episodic tension-type headache
Infrequent episodic tension-type headache
Chronic tension-type headache
Probable tension-type headache
(ICHD-3 The International Classification of Headache Disorders 3rd edition, n.d.).
Tension Headaches
According to research, tension headaches occur because of pain sensitivity, perception, and neurotransmitters.
Genetics are thought to be involved in chronic tension headache.
Environmental factors (stress) are involved in the physiologic processes experienced with episodic tension headache.
Abnormalities in the central nervous system, cause sensitivity to pain experienced in tension headaches.
Connective tissue and muscles in the neck and shoulders cause a tension headache by forming knots in the muscles.
Neurotransmitters cause the brain to experience pain when stimulated such as serotonin and nitric oxide.
Medication and Substance abuse cause about one third of all headaches.
Causes: Poor Posture, Work Conditions, Fatigue, Eyestrain, Physical Activity, Food, Stress Pharmacologic agents, Dental Problems, Physical Trauma, Hormonal Changes.
Symptoms of a tension headache: Constant, dull pain above the eyes and across the back of the head
Head pain that gets worse as the day progresses
Pain that may spread over your entire head and to your shoulders and neck
Muscles that are tight in the neck or shoulder area
Head pain that is made worse by bright lights or loud noises
(ICHD-3 The International Classification of Headache Disorders 3rd edition, n.d.).
Pathophysiology
78% of headache patients in population-based studies are from tension type headaches, it is the least distinct of all headache types. A clinical diagnosis is made mainly by on negative symptoms (Barbanti, Egeo, Aurilia, & Fofi, 2014).
3
Tension headache
Frequent episodic tension-type headache- ≥12 and <180 days per year, last from 30 minutes to 7 days, bilateral location, pressing/tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity, no nausea or vomiting, either photophobia or phonophobia, not caused by another disorder.
Infrequent episodic tension-type headache- <12 days per year, last from 30 minutes to 7 days, bilateral location, pressing/tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity, no nausea or vomiting, either photophobia or phonophobia, not caused by another disorder.
Chronic tension-type headache- ≥180 days per year, last from 30 minutes to 7 days, bilateral location, pressing/tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity, no nausea or vomiting, either photophobia or phonophobia, not caused by another disorder.
Probable tension-type headache- Do not fulfill some of the above criteria.
(ICHD-3 The International Classification of Headache Disorders 3rd edition, n.d.).
DIAGNOSTIC CRITERIA
4
Tension headache
Questions
1. What is the most common side effect when taking NSAIDs, Acetaminophen and Aspirin?
A. Heartburn
B. Hypertension
C. Nausea
D. Insomnia
2. What is an indicator to do further testing in a patient with headaches?
A. Nausea and Vomiting
B. Blurred Vision
C. Recent head trauma
D. All of the above
3. What is the primary cause of a rebound headache?
A. Overuse of medication
B. Underuse of medication
C. Insomnia
D. All of the above
4. If a tension headache lasts ≥180 days per year, last from 30 minutes to 7 days what is the headache classification?
A. Frequent episodic tension-type headache
B. Infrequent episodic tension-type headache
C. Chronic tension-type headache
D. Probable tension-type headache
5. How long must preventive type drug that treats tension-type headaches be taken before the beginning to work?
A. Several weeks
B. Thirty minutes
C. Two days
D. None of the above
Answers: 1:C, 2:D, 3:A, 4:C, 5:A
Medical providers will perform physical and neurological exams to discover the type and cause of an individuals chronic or recurrent headaches. Pain characteristics: What type of pain pulsating, dull, sharp, or stabbing.
Pain intensity: Does the pain interfere with your average daily living?
Pain location: Where is the pain felt in your head?
Do you feel pain all over your head, one side of your head, or do you feel it in the forehead area or behind your eyes?
5
Tension headaches
Ibuprophen (Advil, Motrin, A-G Profen, Addaprin, Bufen, Genpril, Caldolor, Haltran), Analgesic NSAIDs
Dose-200 to 400 mg ORALLY every 4 to 6 hours as needed; MAX dose, 1200 mg in 24 hours
Side Effects-Heartburn, Nausea, Dizziness, Cardiac arrest, CHF, HTN, Hyperkalemia, GI bleeding.
MOA-a nonsteroidal anti-inflammatory drug (NSAID) that exhibits analgesic and antipyretic activities by inhibiting prostaglandin synthesis.
Contraindications-Asthma, urticaria, or other allergic-type reaction following aspirin or other NSAID administration, In the setting of coronary artery bypass graft (CABG) surgery, •Hypersensitivity to ibuprofen (Micromedex, n.d.a).
Aspirin (Ecotrin, Bayer, Ascriptin, Aspergum, Aspirtab, Easprin, Ecpirin, Entercote), Analgesic
Dose-500 mg to 1000 mg ORALLY every 4 to 6 hours; MAX: 4 g/24 hours.
Side Effects-GI ulcer, Hemorrhage, Exudative age-related macular degeneration, Tinnitus, Bronchospasm, Angioedema, Reye's syndrome.
MOA-inhibitor of prostaglandin synthesis and platelet aggregation which irreversibly inactivates cyclooxygenase via acetylation which prevents the conversion of arachidonic acid to thromboxane A(2).
Contraindications-Hypersensitivity to NSAIDs, Syndrome of asthma, rhinitis, urticaria, angioedema, or bronchospas(Micromedex, n.d.b).
Over The Counter (OTC) Medications
There are many medications on the market that will treat a tension headache and reduce an individuals pain. Over the counter (OTC) medications for headaches are considered the first line of treatment such as aspirin, ibuprofen, and naproxen (Barbanti, Egeo, Aurilia, & Fofi, 2014).
6
Tension Headache OTC MEDICATIONS
Acetaminophen (Tylenol, Genapap, Feverall, Actamin Maximum Strength, Altenol, Aminofen, Ofirmev, Anacin Aspirin Free),
Dose-Adults: 650 to 1000 mg orally every 4 to 6 hours as needed (maximum 4 g/day)
Side effects-Constipation, Nausea, Vomiting, Headache, Insomnia,
Agitation, increased the risk of hepatic injury if taken with alcohol, Liver failure.
MOA-centrally acting analgesic and antipyretic with minimal anti-inflammatory properties and reduces fever by inhibiting the formulation and release of prostaglandins in the CNS and by inhibition endogenous pyrogens in the hypothalamic.
Contraindications-hepatic disease, allergy to acetaminophen or any other components of the product (Micromedex, n.d.c).
Naproxen (EC Naprosyn, Naprosyn)
Dose-500 mg orally initial dose, then 250 mg orally every 6 to 8 hours as needed or 500 mg orally every 12 hours as needed (maximum initial dose, 1250 mg/day, then 1000 mg/day)
Side effects-Abdominal pain, Constipation, Heartburn, Nausea, Dizziness Headache, Dyspnea, Body fluid retention, Congestive heart failure, Hypertension, Myocardial infarction, Hyperkalemia
MOA- a propionic acid derivative NSAID with analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action is unknown but involves inhibition of cyclooxygenase (COX-1 and COX-2), which reduces prostaglandin synthesis.
Contraindications-Asthma, urticaria, or allergic-type reaction following aspirin or other NSAID administration, Use in the setting of CABG surgery (Micromedex, n.d.d).
7
Headaches
Preventive medications
Amitriptyline (Elavil, Vanatrip) is an antidepressant agent that helps prevent tension headaches.
Dose-30–75 mg orally, may increase to MAX, 150 mg/day
Side Effects-Weight gain, Constipation, Dizziness, Headache, Somnolence, Blurred vision, Depression, and Hepatotoxicity
MOA-Amitriptyline hydrochloride is a tricyclic antidepressant (TCA) that has a sedative property. It promotes neuronal activity by blocking the membrane pump mechanism so that the absorption of serotonin and norepinephrine in serotonergic and adrenergic neurons does not occur.
Contraindications-Coadministration with cisapride; may cause QT interval prolongation and increase the risk of arrhythmia, Coadministration with an MAOI or use within 14 days of discontinuing an MAOI; may cause a hyperpyretic crisis, severe convulsions, death, and MI (Micromedex, n.d.g).
***Preventive medications must be taken for several weeks before there effects will be therapeutic to the individual..
***Overuse of OTC pain relievers may interfere with the effects of the preventive drugs.
Education about Medications
Over-the-counter (OTC) drugs have many side effects and contraindications with other medications and diseases that may cause serious harm.
According to the Beers Criteria, elderly patients should avoid chronic use of NSAIDS, Acetaminophen, and Aspirin (Micromedex, n.d.g).
Try not to take over-the-counter drugs more than 3 times a week, because you may get rebound headaches. Continually taking OTC medications for headache pain will cause a rebound headache to occur when you stop taking the medicine
According to Dreischulte & Guthrie (2012), the quality measures of drug prescribing include avoiding inappropriate medications by checking contraindications before prescribing or taking a medication. Use medications in proper dosage and purpose. Check for drug to drug interactions. Monitoring for side effects and drug levels.
Case Study
Jake, a 25-year-old male comes to the clinic for reoccurring headaches. He states that his symptoms started four days ago, and he gets no relief from Ibuprofen. He has previously been healthy. He does not smoke, but drinks 2-3 beers socially on weekends. He works out daily lifting weights and doing 30 minutes of cardio. He is currently taking a pharmacology class in college. He has no history of drug abuse. On physical examination, his blood pressure is 110/67 mm Hg, heart rate is 66/min, and he is afebrile. He describes the headache as dull and progressively get worse throughout the day, the pain ranges from 2 to 6 on scale of 1-10 (10 being worst pain). He has no previous medical history of headaches. When asked where it hurts Jake states; “it hurts over my entire head and to my shoulders and neck ”. He denies vomiting and nausea. He states that “sometimes light makes it worse”. He denies blurred vision, diplopia, tearing, rhinorrhea, numbness, or sensitivity to noise. He has taken Ibuprofen “a each day and at first it worked and now it will get a little better but then comes back”. When asked how much Ibuprofen he takes a day he states “I take eight a day trying to get rid of the pain”. When asked if working out makes it worse Jake states “no”. When asked if he feels like he is under stress he states “money and my pharmacology class both stress me out a lot, but that is why I work out daily”.
Surgeries; None
Hospitalizations; None
Current prescribed medications; None
Current Vitamins and supplements; Protein shake 2 x day, Multivitamin daily
Hours of sleep a day; 4-6
Meals a day; 2 (skips breakfast)
Poor Posture while working, fatigue from sleeping improperly, and eyestrain can all cause tension headaches. Intense physical activity or lack of activity can cause a tension headache, but the pain is not intensified by physical activity. Dental problems that cause a person to clench their jaw while sleeping may cause pain in the ear, cheek, temples, neck, or shoulders which lead to a tension headache. Physical trauma from a head or neck injury and hormonal changes may cause or increase the occurrence of tension headaches. Stress from writing a grand rounds presentation can also lead to a tension headache (Jensen, 2017)
10
Diagnosis
Jake has Infrequent episodic tension-type headache as evident by, bilateral dull mild to moderate pain that travels to his neck and shoulders and feels like a tight band around his head that last from 30 minutes to 7 days. He is able to continue his usual daily activities with the headaches and has no associated symptoms of nausea, vomiting, or phonophobia, although he does have some photophonia. He may also be having rebound headaches which are associated with frequent use of any analgesic medication being overused. Improvement of rebound headaches will not occur until the medication is discontinued. She should be screened for depression and anxiety as psychiatric co-morbidity is common in patients with tension type headaches.
DIFFERENTIAL DIAGNOSIS
Conditions that may cause symptoms similar to tension headaches include but are not limited to:
Brain tumor Dental/oral disease Caffeine dependency Encephalitis
Cluster Headache Cervical spine disease Chronic sinusitis Glaucoma
(Jensen, 2017).
After a complete assessment of the patient if the history or physical is unusual for an intracranial issue than a head CT or MRI scan may be indicated. Blood tests can include a complete blood count (CBC), and a complete chemistry panel. The spinal fluid analysis is needed only on rare occasions. Test that may be indicated by clinical findings may include an x-ray of the cervical spine (Jensen, 2017)
11
Barriers to effective care
The primary clinical barrier is due to the lack of knowledge of health-care providers. Medical education that focuses on headache disorders are usually given four hours in undergraduate school. Many people that have headache disorders are not diagnosed and treated: 40% of people with migraine or TTH are professionally diagnosed.
The public does not view headache disorders as a serious health issue because they are mainly episodic, are not contagious, and death does not occur. Many of the individuals that suffer from headaches are not aware that effective treatments exist. 50% of all individuals with headache disorders are self-treating.
Due to health-care costs constraints, governments do not acknowledge the profound burden of headaches on the public. The government may not be considering the loss of working days that individuals miss because of headaches compared to he small cost of treating headaches.
Infrequent episodic tension-type headache usually become chronic when life stressors or posture are not corrected. Most tension-type headaches are episodic or intermittent, allowing the individual to continue to work and live a normal life. Episodic tension-type headaches usually improve over time.
(Leonardi, 2015).
Treatment Plan
Treatment of a tension headache must start with lifestyle modifications. Jake needs adequate sleep (at least 8-10 hours per night), no caffeine, drink plenty of water, and do not skip meals. I will encourage Jake to include relaxation and stress relieving techniques in his daily activities. Non-pharmacological ways to reduce stress include massages, acupuncture, biofeedback and behavioral therapies. I will educated Jake of the importance of avoiding any identified triggers that may cause his tension headaches (ihs.org, 2013). OTC medications such as NSAIDs are first-line treatment for tension headaches, however, Jake reports that Ibuprofen does not relieve his headache anymore. At this time labs are not indicated. I will have Jake stop taking the Ibuprophen. I will inform him it may take 2 to 10 days for his sign and symptoms from the rebound headaches to be relieved. I will have him make an appointment for one week from now to evaluate his need for a preventive drug for the treatment of his tension headaches, such as Venlafaxine hydrochloride, Amitriptyline, or Mirtazapine.
According to Dreischulte & Guthrie (2012), the quality measures of drug prescribing include avoiding inappropriate medications by checking contraindications before prescribing or taking a medication. Use medications in proper dosage and purpose. Check for drug to drug interactions. Monitoring for side effects and drug levels (Dreischulte & Guthrie, 2012)
I will educate Jake about the signs and symptoms of using OTC medications and to try not to take over-the-counter drugs more than 3 times a week, because you may get rebound headaches. Continually taking OTC will cause a rebound headache to occur when you stop taking the medicine prompting you to take more of the medication (Barbanti, Egeo, Aurilia, & Fofi, 2014).
13
Reference
Barbanti, P., Egeo, G., Aurilia, C., & Fofi, L. (2014). Treatment of tension-type headache: from old myths to modern concepts. Neurological Sciences, 3517-21. doi:10.1007/s10072-014-1735-3
Jensen, R. H. (2017), Tension-Type Headache – The Normal and Most Prevalent Headache. Headache: The Journal of Head and Face Pain. doi:10.1111/head.13067
Micromedex. (n.d.a). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/56E151/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/A4B146/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Ibuprofen&fromInterSaltBase=true&false=null&=null#
Micromedex. (n.d.b). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/E4A67E/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/E91CDB/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=asa&UserSearchTerm=asa&SearchFilter=filterNone&navitem=searchGlobal#
Reference
Barbanti, P., Egeo, G., Aurilia, C., & Fofi, L. (2014). Treatment of tension-type headache: from old myths to modern concepts. Neurological Sciences, 3517-21. doi:10.1007/s10072-014-1735-3
Dreischulte, T., & Guthrie, B. (2012). High-risk prescribing and monitoring in primary care: how common is it, and how can it be improved? Therapeutic Advances in Drug Safety, 3(4), 175–184. http://doi.org/10.1177/2042098612444867
Jensen, R. H. (2017), Tension-type headache – The normal and most prevalent headache. Headache: The Journal of Head and Face Pain. doi:10.1111/head.13067
Leonardi, M. (2015). Burden of migraine: what should we say more?. Neurological Sciences, 361-3. doi:10.1007/s10072-015-2188-z
ICHD-3 The International Classification of Headache Disorders 3rd edition. (n.d.). Retrieved from https://www.ichd-3.org/
Micromedex. (n.d.a). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/56E151/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/A4B146/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Ibuprofen&fromInterSaltBase=true&false=null&=null#
Reference Continued
Micromedex. (n.d.b). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/E4A67E/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/E91CDB/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=asa&UserSearchTerm=asa&SearchFilter=filterNone&navitem=searchGlobal#
Micromedex. (n.d.c). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/74FE35/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/20B80A/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Acetaminophen&UserSearchTerm=Acetaminophen&SearchFilter=filterNone&navitem=searchGlobal#
Micromedex. (n.d.d). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/8F54A3/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/03B8AF/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Naproxen&fromInterSaltBase=true&false=null&=null#
Reference Continued
Micromedex. (n.d.e). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/98DD5B/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/CAC700/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFAction/evidencexpert.DoIntegratedSearch?SearchTerm=Mirtazapine&UserSearchTerm=Mirtazapine&SearchFilter=filterNone&navitem=searchALL#
Micromedex. (n.d.f). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/EE6205/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/6DE827/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Venlafaxine hydrochloride &UserSearchTerm=Venlafaxine hydrochloride &SearchFilter=filterNone&navitem=searchALL#
Micromedex. (n.d.g). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/DAEAF8/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/E63695/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Amitriptyline&UserSearchTerm=Amitriptyline&SearchFilter=filterNone&navitem=searchGlobal#
16
Reference Continued
Micromedex. (n.d.f). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/EE6205/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/6DE827/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Venlafaxine hydrochloride &UserSearchTerm=Venlafaxine hydrochloride &SearchFilter=filterNone&navitem=searchALL#
Micromedex. (n.d.g). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/DAEAF8/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/E63695/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Amitriptyline&UserSearchTerm=Amitriptyline&SearchFilter=filterNone&navitem=searchGlobal#
Micromedex. ( n.d.h). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/441CEC/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/33BB65/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.IntermediateToDocumentLink?docId=1172&contentSetId=50&title=Beers%2BCriteria%2B-%2BA%2BSummary%2Bof%2BPotentially%2BInappropriate%2BMedication%2BUse%2BAmong%2Bthe%2BElderly&servicesTitle=Beers%2BCriteria%2B-%2BA%2BSummary%2Bof%2BPotentially%2BInappropriate%2BMedication%2BUse%2BAmong%2Bthe%2BElderly
Society, I. (2006, January 25). ICHD-II Full Text Search. Retrieved from http://www.ihs-klassifikation.de/en/02_klassifikation/02_teil1/02.00.00_tension.html
The International Classification of Headache Disorders, 3rd edition (2013). Cephalalgia,
33(9), 629–808. doi:10.1177/0333102413485658
17
Grand rounds Headache nr508 Kim Roberts 2-11-18
HEADACHE
Brain tissue does not experience sensations of pain.
Pain occurs in several locations:
The tissues covering the brain
The attaching structures at the base of the brain
Muscles and blood vessels around the scalp, face, and neck
The source of a headache is normally caused by muscle tension, or vascular problems.
The International Headache Society diagnostic criteria for classification of headache:
Primary classifications: Tension-type, Migraine, Cluster
Bilateral, band-like feeling of pressure around the head with a constant, squeezing and tightness
Most common type of headache is the Tension Headache
Classified into four types:
Frequent episodic tension-type headache
Infrequent episodic tension-type headache
Chronic tension-type headache
Probable tension-type headache
(ICHD-3 The International Classification of Headache Disorders 3rd edition, n.d.).
Tension Headaches
According to research, tension headaches occur because of pain sensitivity, perception, and neurotransmitters.
Genetics are thought to be involved in chronic tension headache.
Environmental factors (stress) are involved in the physiologic processes experienced with episodic tension headache.
Abnormalities in the central nervous system, cause sensitivity to pain experienced in tension headaches.
Connective tissue and muscles in the neck and shoulders cause a tension headache by forming knots in the muscles.
Neurotransmitters cause the brain to experience pain when stimulated such as serotonin and nitric oxide.
Medication and Substance abuse cause about one third of all headaches.
Causes: Poor Posture, Work Conditions, Fatigue, Eyestrain, Physical Activity, Food, Stress Pharmacologic agents, Dental Problems, Physical Trauma, Hormonal Changes.
Symptoms of a tension headache: Constant, dull pain above the eyes and across the back of the head
Head pain that gets worse as the day progresses
Pain that may spread over your entire head and to your shoulders and neck
Muscles that are tight in the neck or shoulder area
Head pain that is made worse by bright lights or loud noises
(ICHD-3 The International Classification of Headache Disorders 3rd edition, n.d.).
Pathophysiology
78% of headache patients in population-based studies are from tension type headaches, it is the least distinct of all headache types. A clinical diagnosis is made mainly by on negative symptoms (Barbanti, Egeo, Aurilia, & Fofi, 2014).
3
Tension headache
Frequent episodic tension-type headache- ≥12 and <180 days per year, last from 30 minutes to 7 days, bilateral location, pressing/tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity, no nausea or vomiting, either photophobia or phonophobia, not caused by another disorder.
Infrequent episodic tension-type headache- <12 days per year, last from 30 minutes to 7 days, bilateral location, pressing/tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity, no nausea or vomiting, either photophobia or phonophobia, not caused by another disorder.
Chronic tension-type headache- ≥180 days per year, last from 30 minutes to 7 days, bilateral location, pressing/tightening (non-pulsating) quality, mild or moderate intensity, not aggravated by routine physical activity, no nausea or vomiting, either photophobia or phonophobia, not caused by another disorder.
Probable tension-type headache- Do not fulfill some of the above criteria.
(ICHD-3 The International Classification of Headache Disorders 3rd edition, n.d.).
DIAGNOSTIC CRITERIA
4
Tension headache
Questions
1. What is the most common side effect when taking NSAIDs, Acetaminophen and Aspirin?
A. Heartburn
B. Hypertension
C. Nausea
D. Insomnia
2. What is an indicator to do further testing in a patient with headaches?
A. Nausea and Vomiting
B. Blurred Vision
C. Recent head trauma
D. All of the above
3. What is the primary cause of a rebound headache?
A. Overuse of medication
B. Underuse of medication
C. Insomnia
D. All of the above
4. If a tension headache lasts ≥180 days per year, last from 30 minutes to 7 days what is the headache classification?
A. Frequent episodic tension-type headache
B. Infrequent episodic tension-type headache
C. Chronic tension-type headache
D. Probable tension-type headache
5. How long must preventive type drug that treats tension-type headaches be taken before the beginning to work?
A. Several weeks
B. Thirty minutes
C. Two days
D. None of the above
Answers: 1:C, 2:D, 3:A, 4:C, 5:A
Medical providers will perform physical and neurological exams to discover the type and cause of an individuals chronic or recurrent headaches. Pain characteristics: What type of pain pulsating, dull, sharp, or stabbing.
Pain intensity: Does the pain interfere with your average daily living?
Pain location: Where is the pain felt in your head?
Do you feel pain all over your head, one side of your head, or do you feel it in the forehead area or behind your eyes?
5
Tension headaches
Ibuprophen (Advil, Motrin, A-G Profen, Addaprin, Bufen, Genpril, Caldolor, Haltran), Analgesic NSAIDs
Dose-200 to 400 mg ORALLY every 4 to 6 hours as needed; MAX dose, 1200 mg in 24 hours
Side Effects-Heartburn, Nausea, Dizziness, Cardiac arrest, CHF, HTN, Hyperkalemia, GI bleeding.
MOA-a nonsteroidal anti-inflammatory drug (NSAID) that exhibits analgesic and antipyretic activities by inhibiting prostaglandin synthesis.
Contraindications-Asthma, urticaria, or other allergic-type reaction following aspirin or other NSAID administration, In the setting of coronary artery bypass graft (CABG) surgery, •Hypersensitivity to ibuprofen (Micromedex, n.d.a).
Aspirin (Ecotrin, Bayer, Ascriptin, Aspergum, Aspirtab, Easprin, Ecpirin, Entercote), Analgesic
Dose-500 mg to 1000 mg ORALLY every 4 to 6 hours; MAX: 4 g/24 hours.
Side Effects-GI ulcer, Hemorrhage, Exudative age-related macular degeneration, Tinnitus, Bronchospasm, Angioedema, Reye's syndrome.
MOA-inhibitor of prostaglandin synthesis and platelet aggregation which irreversibly inactivates cyclooxygenase via acetylation which prevents the conversion of arachidonic acid to thromboxane A(2).
Contraindications-Hypersensitivity to NSAIDs, Syndrome of asthma, rhinitis, urticaria, angioedema, or bronchospas(Micromedex, n.d.b).
Over The Counter (OTC) Medications
There are many medications on the market that will treat a tension headache and reduce an individuals pain. Over the counter (OTC) medications for headaches are considered the first line of treatment such as aspirin, ibuprofen, and naproxen (Barbanti, Egeo, Aurilia, & Fofi, 2014).
6
Tension Headache OTC MEDICATIONS
Acetaminophen (Tylenol, Genapap, Feverall, Actamin Maximum Strength, Altenol, Aminofen, Ofirmev, Anacin Aspirin Free),
Dose-Adults: 650 to 1000 mg orally every 4 to 6 hours as needed (maximum 4 g/day)
Side effects-Constipation, Nausea, Vomiting, Headache, Insomnia,
Agitation, increased the risk of hepatic injury if taken with alcohol, Liver failure.
MOA-centrally acting analgesic and antipyretic with minimal anti-inflammatory properties and reduces fever by inhibiting the formulation and release of prostaglandins in the CNS and by inhibition endogenous pyrogens in the hypothalamic.
Contraindications-hepatic disease, allergy to acetaminophen or any other components of the product (Micromedex, n.d.c).
Naproxen (EC Naprosyn, Naprosyn)
Dose-500 mg orally initial dose, then 250 mg orally every 6 to 8 hours as needed or 500 mg orally every 12 hours as needed (maximum initial dose, 1250 mg/day, then 1000 mg/day)
Side effects-Abdominal pain, Constipation, Heartburn, Nausea, Dizziness Headache, Dyspnea, Body fluid retention, Congestive heart failure, Hypertension, Myocardial infarction, Hyperkalemia
MOA- a propionic acid derivative NSAID with analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action is unknown but involves inhibition of cyclooxygenase (COX-1 and COX-2), which reduces prostaglandin synthesis.
Contraindications-Asthma, urticaria, or allergic-type reaction following aspirin or other NSAID administration, Use in the setting of CABG surgery (Micromedex, n.d.d).
7
Headaches
Preventive medications
Amitriptyline (Elavil, Vanatrip) is an antidepressant agent that helps prevent tension headaches.
Dose-30–75 mg orally, may increase to MAX, 150 mg/day
Side Effects-Weight gain, Constipation, Dizziness, Headache, Somnolence, Blurred vision, Depression, and Hepatotoxicity
MOA-Amitriptyline hydrochloride is a tricyclic antidepressant (TCA) that has a sedative property. It promotes neuronal activity by blocking the membrane pump mechanism so that the absorption of serotonin and norepinephrine in serotonergic and adrenergic neurons does not occur.
Contraindications-Coadministration with cisapride; may cause QT interval prolongation and increase the risk of arrhythmia, Coadministration with an MAOI or use within 14 days of discontinuing an MAOI; may cause a hyperpyretic crisis, severe convulsions, death, and MI (Micromedex, n.d.g).
***Preventive medications must be taken for several weeks before there effects will be therapeutic to the individual..
***Overuse of OTC pain relievers may interfere with the effects of the preventive drugs.
Education about Medications
Over-the-counter (OTC) drugs have many side effects and contraindications with other medications and diseases that may cause serious harm.
According to the Beers Criteria, elderly patients should avoid chronic use of NSAIDS, Acetaminophen, and Aspirin (Micromedex, n.d.g).
Try not to take over-the-counter drugs more than 3 times a week, because you may get rebound headaches. Continually taking OTC medications for headache pain will cause a rebound headache to occur when you stop taking the medicine
According to Dreischulte & Guthrie (2012), the quality measures of drug prescribing include avoiding inappropriate medications by checking contraindications before prescribing or taking a medication. Use medications in proper dosage and purpose. Check for drug to drug interactions. Monitoring for side effects and drug levels.
Case Study
Jake, a 25-year-old male comes to the clinic for reoccurring headaches. He states that his symptoms started four days ago, and he gets no relief from Ibuprofen. He has previously been healthy. He does not smoke, but drinks 2-3 beers socially on weekends. He works out daily lifting weights and doing 30 minutes of cardio. He is currently taking a pharmacology class in college. He has no history of drug abuse. On physical examination, his blood pressure is 110/67 mm Hg, heart rate is 66/min, and he is afebrile. He describes the headache as dull and progressively get worse throughout the day, the pain ranges from 2 to 6 on scale of 1-10 (10 being worst pain). He has no previous medical history of headaches. When asked where it hurts Jake states; “it hurts over my entire head and to my shoulders and neck ”. He denies vomiting and nausea. He states that “sometimes light makes it worse”. He denies blurred vision, diplopia, tearing, rhinorrhea, numbness, or sensitivity to noise. He has taken Ibuprofen “a each day and at first it worked and now it will get a little better but then comes back”. When asked how much Ibuprofen he takes a day he states “I take eight a day trying to get rid of the pain”. When asked if working out makes it worse Jake states “no”. When asked if he feels like he is under stress he states “money and my pharmacology class both stress me out a lot, but that is why I work out daily”.
Surgeries; None
Hospitalizations; None
Current prescribed medications; None
Current Vitamins and supplements; Protein shake 2 x day, Multivitamin daily
Hours of sleep a day; 4-6
Meals a day; 2 (skips breakfast)
Poor Posture while working, fatigue from sleeping improperly, and eyestrain can all cause tension headaches. Intense physical activity or lack of activity can cause a tension headache, but the pain is not intensified by physical activity. Dental problems that cause a person to clench their jaw while sleeping may cause pain in the ear, cheek, temples, neck, or shoulders which lead to a tension headache. Physical trauma from a head or neck injury and hormonal changes may cause or increase the occurrence of tension headaches. Stress from writing a grand rounds presentation can also lead to a tension headache (Jensen, 2017)
10
Diagnosis
Jake has Infrequent episodic tension-type headache as evident by, bilateral dull mild to moderate pain that travels to his neck and shoulders and feels like a tight band around his head that last from 30 minutes to 7 days. He is able to continue his usual daily activities with the headaches and has no associated symptoms of nausea, vomiting, or phonophobia, although he does have some photophonia. He may also be having rebound headaches which are associated with frequent use of any analgesic medication being overused. Improvement of rebound headaches will not occur until the medication is discontinued. She should be screened for depression and anxiety as psychiatric co-morbidity is common in patients with tension type headaches.
DIFFERENTIAL DIAGNOSIS
Conditions that may cause symptoms similar to tension headaches include but are not limited to:
Brain tumor Dental/oral disease Caffeine dependency Encephalitis
Cluster Headache Cervical spine disease Chronic sinusitis Glaucoma
(Jensen, 2017).
After a complete assessment of the patient if the history or physical is unusual for an intracranial issue than a head CT or MRI scan may be indicated. Blood tests can include a complete blood count (CBC), and a complete chemistry panel. The spinal fluid analysis is needed only on rare occasions. Test that may be indicated by clinical findings may include an x-ray of the cervical spine (Jensen, 2017)
11
Barriers to effective care
The primary clinical barrier is due to the lack of knowledge of health-care providers. Medical education that focuses on headache disorders are usually given four hours in undergraduate school. Many people that have headache disorders are not diagnosed and treated: 40% of people with migraine or TTH are professionally diagnosed.
The public does not view headache disorders as a serious health issue because they are mainly episodic, are not contagious, and death does not occur. Many of the individuals that suffer from headaches are not aware that effective treatments exist. 50% of all individuals with headache disorders are self-treating.
Due to health-care costs constraints, governments do not acknowledge the profound burden of headaches on the public. The government may not be considering the loss of working days that individuals miss because of headaches compared to he small cost of treating headaches.
Infrequent episodic tension-type headache usually become chronic when life stressors or posture are not corrected. Most tension-type headaches are episodic or intermittent, allowing the individual to continue to work and live a normal life. Episodic tension-type headaches usually improve over time.
(Leonardi, 2015).
Treatment Plan
Treatment of a tension headache must start with lifestyle modifications. Jake needs adequate sleep (at least 8-10 hours per night), no caffeine, drink plenty of water, and do not skip meals. I will encourage Jake to include relaxation and stress relieving techniques in his daily activities. Non-pharmacological ways to reduce stress include massages, acupuncture, biofeedback and behavioral therapies. I will educated Jake of the importance of avoiding any identified triggers that may cause his tension headaches (ihs.org, 2013). OTC medications such as NSAIDs are first-line treatment for tension headaches, however, Jake reports that Ibuprofen does not relieve his headache anymore. At this time labs are not indicated. I will have Jake stop taking the Ibuprophen. I will inform him it may take 2 to 10 days for his sign and symptoms from the rebound headaches to be relieved. I will have him make an appointment for one week from now to evaluate his need for a preventive drug for the treatment of his tension headaches, such as Venlafaxine hydrochloride, Amitriptyline, or Mirtazapine.
According to Dreischulte & Guthrie (2012), the quality measures of drug prescribing include avoiding inappropriate medications by checking contraindications before prescribing or taking a medication. Use medications in proper dosage and purpose. Check for drug to drug interactions. Monitoring for side effects and drug levels (Dreischulte & Guthrie, 2012)
I will educate Jake about the signs and symptoms of using OTC medications and to try not to take over-the-counter drugs more than 3 times a week, because you may get rebound headaches. Continually taking OTC will cause a rebound headache to occur when you stop taking the medicine prompting you to take more of the medication (Barbanti, Egeo, Aurilia, & Fofi, 2014).
13
Reference
Barbanti, P., Egeo, G., Aurilia, C., & Fofi, L. (2014). Treatment of tension-type headache: from old myths to modern concepts. Neurological Sciences, 3517-21. doi:10.1007/s10072-014-1735-3
Jensen, R. H. (2017), Tension-Type Headache – The Normal and Most Prevalent Headache. Headache: The Journal of Head and Face Pain. doi:10.1111/head.13067
Micromedex. (n.d.a). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/56E151/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/A4B146/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Ibuprofen&fromInterSaltBase=true&false=null&=null#
Micromedex. (n.d.b). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/E4A67E/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/E91CDB/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=asa&UserSearchTerm=asa&SearchFilter=filterNone&navitem=searchGlobal#
Reference
Barbanti, P., Egeo, G., Aurilia, C., & Fofi, L. (2014). Treatment of tension-type headache: from old myths to modern concepts. Neurological Sciences, 3517-21. doi:10.1007/s10072-014-1735-3
Dreischulte, T., & Guthrie, B. (2012). High-risk prescribing and monitoring in primary care: how common is it, and how can it be improved? Therapeutic Advances in Drug Safety, 3(4), 175–184. http://doi.org/10.1177/2042098612444867
Jensen, R. H. (2017), Tension-type headache – The normal and most prevalent headache. Headache: The Journal of Head and Face Pain. doi:10.1111/head.13067
Leonardi, M. (2015). Burden of migraine: what should we say more?. Neurological Sciences, 361-3. doi:10.1007/s10072-015-2188-z
ICHD-3 The International Classification of Headache Disorders 3rd edition. (n.d.). Retrieved from https://www.ichd-3.org/
Micromedex. (n.d.a). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/56E151/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/A4B146/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Ibuprofen&fromInterSaltBase=true&false=null&=null#
Reference Continued
Micromedex. (n.d.b). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/E4A67E/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/E91CDB/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=asa&UserSearchTerm=asa&SearchFilter=filterNone&navitem=searchGlobal#
Micromedex. (n.d.c). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/74FE35/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/20B80A/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Acetaminophen&UserSearchTerm=Acetaminophen&SearchFilter=filterNone&navitem=searchGlobal#
Micromedex. (n.d.d). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/8F54A3/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/03B8AF/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Naproxen&fromInterSaltBase=true&false=null&=null#
Reference Continued
Micromedex. (n.d.e). Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/98DD5B/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/CAC700/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFAction/evidencexpert.DoIntegratedSearch?SearchTerm=Mirtazapine&UserSearchTerm=Mirtazapine&SearchFilter=filterNone&navitem=searchALL#
Micromedex. (n.d.f). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/EE6205/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/6DE827/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Venlafaxine hydrochloride &UserSearchTerm=Venlafaxine hydrochloride &SearchFilter=filterNone&navitem=searchALL#
Micromedex. (n.d.g). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/DAEAF8/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/E63695/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Amitriptyline&UserSearchTerm=Amitriptyline&SearchFilter=filterNone&navitem=searchGlobal#
16
Reference Continued
Micromedex. (n.d.f). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/EE6205/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/6DE827/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Venlafaxine hydrochloride &UserSearchTerm=Venlafaxine hydrochloride &SearchFilter=filterNone&navitem=searchALL#
Micromedex. (n.d.g). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/DAEAF8/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/E63695/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Amitriptyline&UserSearchTerm=Amitriptyline&SearchFilter=filterNone&navitem=searchGlobal#
Micromedex. ( n.d.h). Retrieved from http://www.micromedexsolutions.com.chamberlainuniversity.idm.oclc.org/micromedex2/librarian/CS/441CEC/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/33BB65/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.IntermediateToDocumentLink?docId=1172&contentSetId=50&title=Beers%2BCriteria%2B-%2BA%2BSummary%2Bof%2BPotentially%2BInappropriate%2BMedication%2BUse%2BAmong%2Bthe%2BElderly&servicesTitle=Beers%2BCriteria%2B-%2BA%2BSummary%2Bof%2BPotentially%2BInappropriate%2BMedication%2BUse%2BAmong%2Bthe%2BElderly
Society, I. (2006, January 25). ICHD-II Full Text Search. Retrieved from http://www.ihs-klassifikation.de/en/02_klassifikation/02_teil1/02.00.00_tension.html
The International Classification of Headache Disorders, 3rd edition (2013). Cephalalgia,
33(9), 629–808. doi:10.1177/0333102413485658
17
Chamberlain College of Nursing
Grand Rounds
Guidelines with Scoring Rubric
Purpose
The purpose of this assignment is to enhance the student’s clinical reasoning, confidence and learning of multiple pharmacological agents through facilitated discussion.
Description
In Week 6, you will create a PowerPoint Grand Rounds presentation on the topic assigned to you by the faculty member. In Week 7, you will lead a discussion based on your presentation as well as interact with peers in discussions related to their Grand Rounds presentations.
Course Outcomes
Through this assignment, the student will demonstrate the ability to:
1. Describe the most commonly prescribed drugs use in primary care for the chose condition.
2. Utilize clinical guidelines, research articles or other materials to support your findings.
3. Identify any practice barriers, issues, or problems (including cultural diversity and healthcare literacy).
4. Discuss best practices for optimal outcomes.
Due Dates: Week 6: Grand Rounds PowerPoint Presentation due by Sunday 11:59 p.m. MT at the end of Week 6.
Total Points Possible: Week 6 PowerPoint- 75 points
Week 7 Discussion- 75 points
Requirements:
In Week 6, create a PowerPoint presentation related to a common condition in primary care. Your professor will assign you the condition that you are to present.
In a PowerPoint presentation of 15 slides or less, describe the most commonly prescribed drugs for your assigned condition. Provide evidence by sharing clinical guidelines, research articles, or other scholarly materials to support your findings. You will identify barriers to practice or additional issues related to the condition and the use of pharmacologic treatment, including potential issues related to cultural diversity and healthcare literacy.
Read the following article and incorporate evidence from it as a part of your presentation: Dreischulte, T., & Guthrie, B. (2012). High-risk prescribing and monitoring in primary care: how common is it, and how can it be improved?. Therapeutic advances in drug safety, 3(4), 175-184. The article can be found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4110851/
Finally, you will describe the expected outcomes for medication management, including expectations for follow up care. Citations should be provided at the bottom of slides, and a full reference list should be included in APA format on the final slide. You will create five (5) multiple choice or true-false questions created from your presentation content. Provide the answers to the questions you have created. The PowerPoint presentation and questions are due by Sunday 11:59 p.m. MT at the end of Week 6.
In Week 7, you will post the PowerPoint presentation you have created to the discussion area, but first remove the answers to the questions you have created. Please post the presentation including five (5) questions to the discussion area by Sunday 11:59 p.m. MT at the end of Week 6 to facilitate a robust discussion.
Participating in the Discussion: You will be required to respond to at least three other students, who have no responses to their posting.** In your post, you will discuss a drug that could be prescribed for the condition DIFFERENT than those presented. Come up with a different treatment plan from the Walmart or Target $4 RX list, and offer reasons for the change or if the drug is not on the list, why? Use references to support your responses. You should also answer the presenter’s five questions.
Three responses to a peer’s presentations are due by Thursday 11:59 p.m. MT of Week 7 so that the presenting student can interact with you.
**If all students have a response, then choose the student with the least responses to their posting.
Leading the Discussion: You must respond to any student who posts to you by THURSDAY regarding your case with a substantial response, either answering their questions or noting their response and acting as leader. You also must respond to any faculty responses to your initial posting if posted by THURSDAY. Use references to support your responses. All FINAL responses to your initial posts must be completed by Sunday, 11:59 p.m. MT.
Preparing the power point presentation
Grand Rounds PowerPoint Week 6
|
Category |
Points |
% |
Description |
|
Case Study Presentation |
15 |
|
Presents a case using a fictional patient who presents to clinic with assigned medical condition. Provides detailed description of patient, including signs and symptoms of condition |
|
Medication Management |
20 |
|
Describes, in detail, the most commonly prescribed drugs for condition, including trade and generic names, typical dosages, mechanism of action, adverse effects, and major contraindications and interactions. Describes alternate therapies. |
|
Evidence Based Support |
10 |
|
Provides evidence from clinical guidelines, research-based articles, or other appropriate provider-level resources. Includes evidence from Dreischulte & Guthrie (2012) article. |
|
Barriers to Practice |
5 |
|
Describes potential barriers, issues, or problems related to disease process and prescribing, including potential issues related to cultural or socioeconomic diversity and healthcare literacy |
|
Identifying Outcomes |
5 |
|
Describe optimal outcomes after treatment with suggested medication |
|
Test Questions |
15 |
|
Includes five (5) knowledge-based questions related to presentation materials |
|
Formatting |
5 |
|
Slides are clear and easy to read. No more than 15 slides (excluding test question and reference slides) are submitted. References use APA format. |
|
Total |
75 |
100 |
A quality assignment will meet or exceed all of the above requirements. |
Grading Rubric PowerPoint Presentation- Week 6
|
Criterion |
Exceptional Outstanding or highest level of performance
|
Exceeds Very good or high level of performance
|
Meets Satisfactory level of performance
|
Needs Improvement Poor or failing level of performance
|
Developing Unsatisfactory level of performance |
|
Content Possible Points = 70 |
|
|
|
|
|
|
Case Study Presentation |
15 Points |
13 Points |
12 Points |
6 Points |
0 Points |
|
|
Presents a case using a fictional patient who presents to clinic with assigned medical condition. Provides detailed description of patient, including signs and symptoms of condition. |
Presents a case using a fictional patient who presents to clinic with assigned medical condition. Provides detailed description of patient, but omits some signs and symptoms of condition. |
Presents a case using a fictional patient who presents to clinic with assigned medical condition. Provides vague description of patient and omits some signs and symptoms of condition. |
Presents a case using a fictional patient who presents to clinic with assigned medical condition, but does not provide description of patient, including signs and symptoms of condition. |
Does not present a case study. |
|
Medication Management |
20 Points |
18 Points |
16 Points |
8 Points |
0 Points |
|
|
Describes, in detail, the first line prescribed drugs for condition, including trade and generic names, typical dosages, mechanism of action, adverse effects, and major contraindications and interactions. Describes alternate therapies. |
Generally describes the first line prescribed drugs for condition, omitting one of the following: trade and generic names, typical dosages, mechanism of action, adverse effects, and major contraindications and interactions, and alternate therapies. |
Generally describes the first line prescribed drugs for condition, omitting 2-3 of the following: trade and generic names, typical dosages, mechanism of action, adverse effects, and major contraindications and interactions, and alternate therapies. |
Generally describes the first line prescribed drugs for condition, or incorrectly identifies first line drug, omitting 4 or more of the following: trade and generic names, typical dosages, mechanism of action, adverse effects, and major contraindications and interactions, and alternate therapies. |
Does not describe medications for condition.
|
|
Evidence-Based Support |
10 Points |
9 Points |
8 Points |
4 Points |
0 Points |
|
|
Provides evidence from clinical guidelines, research-based articles, or other appropriate provider-level resources. Includes evidence from Dreischulte & Guthrie (2012) article.
|
Provides evidence from clinical guidelines, research-based articles, or other appropriate provider-level resources. Does not include evidence from Dreischulte & Guthrie (2012) article.
|
Provides evidence from sources other than clinical guidelines, research-based articles, or other appropriate provider-level resources. Includes evidence from Dreischulte & Guthrie (2012) article.
|
Provides evidence from sources other than clinical guidelines, research-based articles, or other appropriate provider-level resources. Does not include evidence from Dreischulte & Guthrie (2012) article.
|
Does not provide evidence to support.
|
|
Barriers to Practice |
5 Points |
4 Points |
3 Points |
1 Point |
0 Points |
|
|
Describes potential barriers, issues, or problems related to disease process and prescribing, including potential issues related to cultural or socioeconomic diversity and healthcare literacy. |
Describes potential barriers, issues, or problems related to disease process and prescribing, but omits potential issues related to either cultural, socioeconomic diversity, or healthcare literacy. |
Describes potential barriers, issues, or problems related to disease process and prescribing, but omits potential issues related to two of the following: cultural, socioeconomic diversity, or healthcare literacy. |
Describes potential barriers, issues, or problems related to disease process and prescribing, but omits potential issues related to cultural, socioeconomic diversity, AND healthcare literacy. |
Does not describe potential barriers.
|
|
Identifying Outcomes |
5 Points |
4 Points |
3 Points |
1 Point |
0 Points |
|
|
Describe optimal outcomes after treatment with suggested medication, including expected follow up care. |
Describe optimal outcomes after treatment with suggested medication, does not include expected follow up care. |
Incorrectly identifies optimal outcomes after treatment with suggested medication, including expected follow up care. |
Incorrectly identifies optimal outcomes after treatment with suggested medication, does not include expected follow up care. |
Does not address outcomes. |
|
|
15 Points |
13 Points |
12 Points |
6 Points |
0 Points |
|
Test Questions |
Includes five (5) knowledge-based questions with correct responses related to presentation materials. |
Includes four (4) knowledge-based questions with correct responses related to presentation materials. |
Includes two-three (2-3) knowledge-based questions related to presentation materials OR Includes five (5) questions but does not include correct responses. |
Includes one (1) knowledge-based question related to presentation materials. |
Does not include questions. |
|
Content Subtotal |
of 70 points |
||||
|
Format Possible Points = 5 Points |
|
|
|
|
|
|
Grammar, APA Formatting, Syntax, Spelling, & Punctuation
|
5 Points |
4 Points |
3 Points |
1 Point |
0 Points |
|
|
APA format, grammar, spelling, and/or punctuation are accurate, or with zero to one errors. |
Two to four errors in APA format, grammar, spelling, and syntax noted |
Five to seven errors in APA format, grammar, spelling, and syntax noted. |
More than 7 errors in APA format, grammar, spelling, and syntax noted |
Post contains ten or more errors in APA format, grammar, spelling, and/or punctuation or repeatedly makes the same errors after faculty feedback |
|
Format Subtotal |
of 75 points |
||||
|
Total Points |
of 75 points |
Grand Rounds Discussion Week 7
|
Category |
Points |
% |
Description |
|
|
Leading the Discussion |
25 |
|
Posts PowerPoint presentation by Sunday 11:59 p.m. at the end of Week 6. Responds substantively to all peers who interact with PowerPoint presentation, and answers any faculty questions posted to discussion by Sunday 11:59 p.m. MT at the end of Week 7. |
|
|
Participating in the Discussion |
10 |
|
Responds substantively to at least three different peer presentations by Thursday 11:59 p.m. MT of Week 7. |
|
|
Identifying best practices |
20 |
|
In participation responses to presentations, discusses a drug that could be prescribed for the condition DIFFERENT than those presented. Presents an alternate treatment plan from the Walmart or Target $4 RX list, and offers reasons for the change or if the drug is not on the list, why? Uses scholarly, evidenced based references to support responses. |
|
|
Responding to questions |
15 |
|
Answers five (5) questions for three different presentations for a total of 15 questions. |
|
|
Format |
5 |
|
Compose the posts in clear, concise, and organized manner using proper APA format, grammar and syntax. |
|
|
Total |
75 |
|
|
|
Grading Rubric Grand Rounds Discussion- Week 7
|
Criterion |
Exceptional Outstanding or highest level of performance
|
Exceeds Very good or high level of performance
|
Meets Satisfactory level of performance
|
Needs Improvement Poor or failing level of performance
|
Developing Unsatisfactory level of performance |
|
Content Possible Points = 70 |
|
|
|
|
|
|
Leading the Discussion |
25 Points |
22 Points |
21 Points |
10 Points |
0 Points |
|
|
Posts PowerPoint presentation by Sunday 11:59 p.m. MT of the end of Week 6. Responds substantively to all peers who interact with PowerPoint presentation, and answers any faculty questions posted to discussion by Sunday 11:59 p.m. MT at the end of Week 7.
|
Posts PowerPoint presentation by Sunday 11:59 p.m. MT of the end of Week 6. Responds substantively to some peers who interact with PowerPoint presentation, and answers any faculty questions by Sunday 11:59 p.m. MT at the end of Week 7.
|
Posts PowerPoint presentation by Sunday 11:59 p.m. MT of the end of Week 6. Responds with limited substance to some peers who interact with PowerPoint presentation, but does not answer faculty questions by Sunday 11:59 p.m. MT at the end of Week 7.
|
Posts PowerPoint presentation by Sunday 11:59 p.m. MT of the end of Week 6. Responds to faculty questions, but does not respond to peers in own presentation discussion.
|
Does not post PowerPoint presentation in the discussion.
|
|
|
10 Points |
9 Points |
8 Points |
4 Points |
0 Points |
|
Participating in the Discussion |
Student responds substantively to at least three different peer presentations by Thursday 11:59 p.m. MT.
|
Student responds substantively to at least two different peer presentations by Thursday 11:59 p.m. MT.
|
Student responds substantively to at least three different peer presentations by Sunday 11:59 p.m. MT.
|
Student responds substantively to one peer presentation by Thursday 11:59 p.m. MT.
|
Student does not participate; or, student responds to less than three peer presentations by after Thursday 11:59 p.m. MT. |
|
Identifying Best Practices (Participant) |
20 Points |
18 Points |
16 Points |
8 Points |
0 Points |
|
|
In participation responses to presentations, discusses a drug that could be prescribed for the condition DIFFERENT than those presented. Presents an alternate treatment plan from the Walmart or Target $4 RX list, and offers reasons for the change or if the drug is not on the list, why? Uses scholarly, evidenced based references to support responses in ALL responses to presentations. |
In participation responses to presentations, discusses a drug that could be prescribed for the condition DIFFERENT than those presented. Presents an alternate treatment plan from the Walmart or Target $4 RX list, but does not provide reasons for the change or why the drug is not on the list. Uses scholarly, evidenced based references to support responses in at least 2 responses to presentations. |
In participation responses to presentations, discusses a drug that could be prescribed for the condition DIFFERENT than those presented. Does not present alternate treatment. Uses scholarly, evidenced based references to support responses in at least 2 responses to presentations. |
In participation responses to presentations, discusses a drug that could be prescribed for the condition DIFFERENT than those presented. Does not present alternate treatment. Does not provide scholarly, evidence based references. |
Does not provide substantive responses to peer presentations. Does not include different drugs nor provide scholarly resources.
|
|
Responding to questions (Participant) |
15 Points |
13 Points |
12 Points |
6 Points |
0 Points |
|
|
Answers five questions for three different presentations for a total of fifteen questions. |
Answers three-four questions for three different presentations for a total of nine-twelve questions. |
Answers three-five questions for two different presentations for a total of six-ten questions. |
Answers three-five questions for one presentation. |
Does not answer presentation questions. |
|
Content Subtotal |
_____of 70 points |
||||
|
Format Possible Points = 5 Points |
|
|
|
|
|
|
Grammar, APA Formatting, Syntax, Spelling, & Punctuation
|
5 Points |
4 Points |
3 Points |
1 Point |
0 Points |
|
|
APA format, grammar, spelling, and/or punctuation are accurate, or with zero to one errors. |
Two to four errors in APA format, grammar, spelling, and syntax noted. |
Five to seven errors in APA format, grammar, spelling, and syntax noted. |
More than 7 errors in APA format, grammar, spelling, and syntax noted. |
Post contains ten or more errors in APA format, grammar, spelling, and/or punctuation or repeatedly makes the same errors after faculty feedback. |
|
Format Subtotal |
of 5 points |
||||
|
Total Points |
of 75 points |
|
NR508 Directions & Rubric.docx |
3 |
416 - Current Event: Grading Rubric
Name: Section:
Current Event Notes Points Earned
Points Possible
Data Research Use 3 or more sources to gather information about the story and the coverage from various media sources.
5
Media Comparison Breakdown Clearly discusses the purpose, form/structure, the event/story, and the facts presented by the media. Dissects the information and analyzes the coverage of the event. What are the descriptives?
10
Position (opinion) Discusses the coverage of event as they are presented by the medium(s), while constructing a strong representation of one's own perspective of media by asking AND answering strong questions. What are your reasons?
10
Question(s)/Discussion Present an interesting assortment of questions that help generate a meaningful discussion/dialogue on the issues presented.
5
Written Response Reflects on the event coverage with presenting strong detail and rationale on the individual’s analysis of the media’s coverage of the story, explanation for the reason and answers to the questions asked by the student, and comparison of individual’s view to the classes discussion.
10
Errors Answers are thorough and without mistake.
(-5)
TOTAL 40
36-40 = A
Exceeds expectations! Displays a strong analysis and identification of purpose, form/structure, and presentation by media through this medium. Uses clear terminology and solid opinions when discussing the particular event/article.
32-35.9 = B Above average. Exhibits a good recognition of the media’s coverage on the event/story analyzed. Interprets decent coverage of event/article with understanding of media and explaining opinions.
28-31.9 = C Average. Demonstrates basic understanding of media’s purpose, form/structure, and presentation. Basic coverage of article.
24-27.9 = D Below Average. Shows a low understanding of media through this medium with low identification with weak analysis on event/article.
0-23.9 = F Failure. Presents no clear understanding of the event through this medium.
Current Event:
With sharing a current event, make sure to present more than just what you saw/read with one source. To be aware of media you must find an event/story from one main source of media (ex., CNN, NBC, BBC) and 2 other sources that help either verify the facts presented or to counteract the discussion. Be prepared to:
Key points: remember 3 sources is the minimum. Highly recommend finding more to help present a clearer coverage of information. Also, a variety of sources, such as, contrasting sources or outside coverage (like the BBC or other worldwide coverage) helps.
Written Response:
Your written response should contain your:
(1) event/story you decided to cover and why [including the sources]
(2) the facts you analyzed from each source and perspectives of the media [descriptives - give details and depth]
(4) the classes response and perspective [questions asked and response from class]
(5) if your viewpoint/perspective changed.
Think of this as a reflection piece. The written response should be between 4-5 pages.
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