Education and Non-Pharmacologic Interventions For the Chronic Headache Sufferer

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Education and Non-Pharmacologic Interventions
For the Chronic Headache Sufferer

• Karen Lynn Frizelis, MSN, APN
• Nurse Practitioner

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Disclosure

• Karen Lynn Frizelis, MSN, APN has no commercial
  relationships that might influence the content of
  this presentation.

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The Headache Assessment

• Debbie Johnson (fictional patient)
• DOB 2/3/1979
• Headache History
• 1992 (age 13)
• Started with episodic headaches
• Currently has daily headaches (past 3 yrs)
• Headaches are moderate to severe intensity
• Pain is 3 to10 averages a 6 (on a 1-10 pain
  scale)
• MRI done June 2012-WNL

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Headache Assessment (contd)

• Daily Headaches
• Some level of headache always present
• Photophobia is constant
• Occasionally osmophobic
• When the headaches are severe, they are
• Primarily right sided
• Throbbing
• Nausea
• Vomiting only a few episodes of vomiting with
  severe headaches over the past 20 yrs

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The Headache Assessment (contd)

• Headache Medications
• Triptans orally about 4 days a week
• Butalbital/Aspirin/caffeine/codeine 2-4/day
• During works she uses OTC migraine pills with
  aspirin, caffeine and acetaminophen or plain
  acetaminophen 1000mg.
• States that these OTCs are in her purse and desk
  drawer. She takes a couple of pills several times
  during the workday - although they dont seem to
  help much.

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Headache Assessment (contd)

• Medical History
• GERD
• Child birth x2
• Insomnia but Forinal 3 helps her sleep
• Other Medications
• Nexium 40mg q day
• Multi-Vitamin one a day (no other supplements)
• No Birth Control meds (husband had vasectomy)

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Headache Assessment (contd)

• Family History
• Positive for migraines in mom, sister, aunt
• Social History
• Minimal Alcohol use (1-2 x month at a social
  event)
• Never smoked
• Married, 2 children ages 10 and 2
• Intermittently feels a little down/depressed
• Works at Kraft Foods full-time for 10yrs.
• Has used up all her sick days though as of July

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Education

• Headache Diet
• Headache Diaries
• Coaching the Headache sufferer in good
  communication with their provider

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Education-The Headache Diet

• Pro and cons of Debbie following a headache
  diet
• Common food/beverage triggers
• Teaching her about her personal headache
  thresholds

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Diet in Headache

• Encourage three meals a day-
• Debbie reports that she often skips meals.
• She knows her headache often worsens when she is
  hungry.
• Encourage healthy snacks in her purse desk drawer
  etc. when she has to skip meals due to work
  meetings, etc

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Diet - Caffeine

• Caffeine
• She currently consumes 2-3 caffeine beverages a
  day.
• Dont forget caffeine in medications
• Is moderation ok?/Is it necessary to
  decaffeinate?
• Caffeine withdrawal headaches
• Explore the role of caffeine and her insomnia

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Diet - Alcohol

• Alcohol
• Do her headaches changed after consuming alcohol
  at a social event?
• Debbie has found some alcohol more likely to
  trigger a worsening of her headache
• Red Wine Beer
• With new medications, it may be wise to avoid
  entirely.
• Debbie is fine with abstaining from alcohol at
  this time

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Diet - The Role of Tyramine

• Tyramine is a vasoactive amine that in some
  people and some periods in time can trigger
  headaches
• Aged, dried, air-dried, cured or fermented meats,
  fish and diary
• salami, bologna, pepperoni, sausages, bacon,
  corned beef
• lox, caviar, herring
• blue cheese, cheddar, cheese, feta, gouda,
  parmesan, etc

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Education - Headache Diaries

• Pros and Cons
• Can help the patient identify/limit triggers
• What to have patient record

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Common Headache Triggers

• Foods
• Alcohol
• Excessive caffeine and caffeine withdrawal
• Menstruation
• Visual stimuli / flashing lights
• Disturbed sleep pattern
• Weather changes

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Headache Diary-An example
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Headache Threshold

• As the headache sufferer experiences certain
  triggers it can ad up and tip the scale on
  their Headache Threshold.
• The goal is to decrease the number of triggers.

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Headache Diary/Identifying Triggers

• Debbie had some of her worst headaches after she
  and her husband went to movies with her 10y/o
  child.
• When keeping a headache diary she discovered
  additional triggers that she could control

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Headache Diary/Identifying Triggers

• She discovered that she has no problems going to
  the movies but avoids eating pepperoni pizza
  prior to the movies which was their usual movie
  night ritual
• When possible she also avoids having a movie
  night within few days of the start of her
  menstrual cycle.

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Education Communication with the Provider -
Appointments

• Prepare for the next headache providers
  appointment. Bring notes.
• When headaches are fewer, bringing the headache
  diary to the appt. can be helpful.
• Prepare List of meds needing a refill then less
  time needs to be spent on this.

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Education Communication with the Provider

• Encourage patient to become active in their
  headache management.
• When to call provider with headaches
• Status migrainosus
• Feels like headache control that the team has
  achieved is diminishing

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Non-Pharmacologic Interventions

• We already discussed some
• non-pharmacologic interventions such as
  teaching the patient the importance of
• Regular sleep patterns
• Eating three meals a day,
• Caffeine and alcohol in moderation
• Identifying personal headache triggers

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Additional Non-Pharmacologic Interventions

• Psychotherapy
• Biofeedback
• Relaxation exercises
• Meditation
• Regular exercise/Yoga
• Acupuncture
• Products/OTC remedies
• Resources

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Non-Pharmacologic Interventions

• Not Non-pharmacologic but
• Feverfew
• Ginger
• Butterbur
• Magnesium
• Vitamin B2 (riboflavin)
• Vitamin D
• ASK the patient specifically about
• usage of these products!

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Non-Pharmacologic interventions

• Ice/Warm packs
• Wrist Bands
• Music
• Aromatherapy
• When empowering the patient in their headache
  management warn them about internet products with
  bogus claims.

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Resources

• Educate and empower your patient by teaching them
  about available resources
• National Headache Foundation
• http//www.headaches.org/
• ACHE is an acronym for the American Headache
  Society (AHS) Committee for Headache Education
• http//www.achenet.org/

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THANK-YOU!