Running head: HEADACHES 1

Teaching Plan: Headaches

Laurie Pomella

University of South Florida

February 13, 2012

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Teaching Plan: Headaches

According to Bastable (2008), a teaching plan is “a blueprint for action to achieve the

goal and the objectives that have been agreed upon by the educator and the learner” (p. 407). The

author continues by listing the primary construct sections that should be incorporated into a

teaching plan including a goal and objectives, purpose, content, methods and tools, timing, and

evaluation of instruction (Bastable, 2008). Furthermore, Bastable elucidates rationales for the

construction of teaching plans. She asserts that teaching plans organize and map lessons, clearly

define and communicate the contents of the lesson for both learner and colleagues, and that they

legally document implementations for individual plans and for institutional accreditation as well

(Bastable).

Purpose and Goals

The purpose and goal(s), according to Bastable (2008), are each one of the eight basic

elements of a teaching plan. The purpose of this teaching plan is to provide the student with

information necessary to differentiate headache types (tension, migraine, & cluster). The goal of

the teaching presentation is for the student to demonstrate the ability to identify the different

types of headaches including the etiology, clinical manifestations, collaborative care, and nursing

management. Internal consistency is insured when the purpose, goals, and objectives are all

derived from the same domain classification according to Bastable.

Course Objectives/Outcomes

Bastable (2008) stresses internal consistency is paramount when designing teaching plans

and that the number and types of course objectives should be made prior to the plan

development. The course objectives for this teaching plan is as follows: At the completion of

the 70-minute didactic presentation, the student will be able to

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compare the etiology, of tension-type, migraine, and cluster headaches; differentiate the clinical manifestations of tension-type, migraine, and cluster

headaches; discuss collaborative care for tension-type, migraine, and cluster headaches; and

implement the nursing management of tension-type, migraine, and cluster headaches.

Internal consistency is also identified through the complexity of each objective (Bastable). Since

this teaching plan is designed to instruct ADN level students, the objectives are complex

considering their readiness to learn, learning needs, and diverse learning styles.

Baccalaureate Essentials

Although the course being taught is at the Associate Degree level, several of the

“Baccalaureate Essentials” were identified in the lesson (American Association of Colleges for

Nursing, 2009). According to the American Association of Colleges for Nursing (AACN),

Essentials I through IX delineate the outcomes expected of graduates of baccalaureate

nursing programs. Achievement of these outcomes will enable graduates to practice

within complex healthcare systems and assume the roles: provider of care;

designer/manager/coordinator of care; and member of a profession. (p. 2)

Therefore, it is extremely important to ensure that all teaching plans include the Baccalaureate

Essentials. The Baccalaureate Essentials identified within this teaching plan came from

Essentials I, II, VII, and IX and are discussed in the following.

Baccalaureate Essentials I, Liberal Education for Baccalaureate Generalist Nursing

Practice, the “use collaborative learning projects to build communication and leadership skills” is

integrated within the teaching plan using the discussion-group based activity (AACN, 2009, p.

4). Another example of Essential I, to “provide direct experiences integrating artistic ways of

knowing such as the arts, cinema, poetry, literature, and music to enhance the practice of

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nursing,” is evidenced by the use of music and relaxation techniques during student breaks and

as therapeutic nursing implementation for the patient experiencing pain (AACN, p. 4). An

example of Essential II, Basic Organizational and Systems Leadership for Patient Safety and

Quality Care, is to “Role-play with nursing and medical students using Situation, Background,

Assessment, Recommendation (SBAR) communication” and is integrated into the discussion-

group based activity (AACN, p. 5). Essential VII, Clinical Prevention and Population Health for

Optimizing Health, is to “provide health counseling regarding smoking cessation, stress

management, exercise, and diet” and is evidenced by the diet and stress-relief measures the

patient is instructed to follow for prevention of headaches (AACN, p. 8). Lastly, an example of

Essential IX that is found within this teaching plan, the Baccalaureate Generalist Nursing

Practice, is to “use unfolding case study analysis to correlate a patient’s medical condition and

pathophysiology and design appropriate therapeutic interventions” and is demonstrated by the

discussion-group based activity (AACN, p. 10).

Content Outline

Summary of the Etiology and Pathophysiology of Tension-Type Headache, Migraine

Headache, and Cluster Headache

Tension-type- ♀more commono the most common type of headache lasting minutes to days and are often

described as a bilateral pressing/tightening around the location of the ‘hat-band’

o Once thought to be caused by muscular contractions,o etiology of abnormal neuronal sensitivity and pain facilitation . (Lewis,

Dirksen, Heitkemper, Bucher, & Camera, 2011). Migraine- ♀ 3x more than ♂

o recurring unilateral or bilateral throbbing pain associated with triggers most commonly food, odors, stress, fatigue, alcohol, or excessive caffeine;

o exact cause unknown- neuronal hyperexcitability with onset after puberty; o Associated abnormalities include seizures, Tourette’s, ischemic stroke,

anxiety, and depression;

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o 70% of migraine sufferers have a 1st generation relative who suffers from migraines (Lewis et al.).

Cluster- ♂ 6x more common than ♀o Rare (<0.1% pop.), sharp stabbing pain repeated same time of day for

weeks to months lasting minutes to 3 hours with periods of remission;o Etiology and pathophysiology not fully known, trigeminal nerve pain,

dysfunction of intracranial blood vessels = vasodilation, pain pathway, circadian rhythm = hypothalamus at night,

o Triggers include alcohol, odors, and napping (Lewis et al., 2011).

Summary of the Clinical Manifestations and Diagnostic Studies of Tension-Type, Migraine,

and Cluster Headache

That painful headache that won't go away...is it a migraine? Keep watching to find out. http://www.youtube.com/watch?v=CeWHTM7d_-k&feature=fvs

Lewis et al., 2011, p. 1486, Table 59-1 Tension-type-

o No aura, squeezing band, phonophobia, photophobia, no nausea/vomiting,o may have combo tension and migraine or tension-type between migraines,o Diagnostics- HISTORY, electromyography (EMG), may have increased

resistance to passive head movements and head/neck tenderness (Lewis et al.).

Migraine-o May have aura (10%) including sights, smells, or sounds prior to

headache, most do not;o Headache lasts 4-72 hours that is steady, throbbing pain, correlating with

the pulse, and person “hibernates” from all activity/stimulation;o Diagnostics- HISTORY, no testing specific for migraine but if atypical

then head computed tomography (CT) and magnetic resonance imaging (MRI) are recommended (Lewis et al.).

Cluster-o Most severe form of headache with intense stabbing pain up to eight times

per day cycles lasting two weeks to three months followed by remissions lasting months to years’

o Pain around the eye, radiating to the temple, forehead, cheek, nose, or gums and may include swelling around the eye, nasal congestion, lacrimation, pupil constriction, facial flushing or pallor;

o Diagnostics- HISTORY, headache diary, head CT, MRI, or magnetic resonance angiography (MRA) to rule out infection, tumor, or aneurysm (Lewis et al.).

Other-o Sinus infections, increased intracranial pressure, brain tumors,

hemorrhagic stroke, carbon monoxide poisoning, and subarachnoid hemorrhage can all present with complaints of headache and symptoms

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vary which makes clinical evaluation and history important diagnostic tools (Lewis et al.).

Discussion of the Abortive/Symptomatic Therapies and the Preventative/Prophylactic

Therapies Available for Tension-Type, Migraine, and Cluster Headache

Breakthroughs in preventive medications can now help many patients to significantly reduce, or even eliminate, their migraine headaches. http://www.youtube.com/watch?v=l4UOUQDM00I

Lewis et al., 2011, p. 1489, Table 59-3 Tension-type-

o Abortive/Symptomatic Non-opioids:

aspirin, ibuprofen, naproxen, acetaminophen non-steroidal anti-inflammatory drugs (NSAIDs) plus muscle

relaxers, sedatives, tranquilizer, and/or codeine: butalbital (barbiturate)/acetaminophen/caffeine = Fioricet, habit forming, liver damage, and can cause gastrointestinal

(GI) bleeding if contains aspirin muscle relaxants: flexiril, baclofen, Soma, Skelaxin

o Preventative/Prophylactic Tricyclic antidepressants

Elavil, Pamelor, Sinequan Selective serotonin reuptake inhibitors (SSRIs)

Prozac, Paxil β-Adrenergic blocker

Inderal, Toprolo May cause sedation- take at bedtime and increase

fluids Biofeedback Psychotherapy Muscle relaxation training

Migraine-o Abortive/Symptomatic

Mild to moderate- non-opioids NSAID or Tylenol

moderate to severe- Triptans = gold standard Imitrex, Maxalt, Zomig Potent vasoconstrictors- caution coronary artery disease

(CAD), cerebrovascular accident (CVA), peripheral arterial disease (PAD), and uncontrolled hypertension (HTN)

Imitrex (sumatriptan)- monitor first doses for chest tightness, take one at onset and may repeat in two hours

if > 3/month- preventative neededo Preventative/Prophylactic

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β-Adrenergic blocker Inderal, Toprol,

o May cause sedation- take at bedtime and increase fluids

Antidepressants Amitriptyline

Antiseizure Depakene, Topamax

Calcium channel blockers verapamil

Botulinum toxin (Botox) Biofeedback Relaxation therapy Cognitive-behavioral therapy

Cluster-o Abortive/Symptomatic

α-Adrenergic blocker ergotamine tartrate

oxygen 100% O2 at 6-8 L/min for 10 minutes, may repeat after five

minute rest Serotonin receptor agonists- Triptans

Imatrex, Maxalt, Zomigo Preventative/Prophylactic

α-Adrenergic blocker ergotamine tartrate

serotonin antagonist corticosteroid

prednisone Calcium channel blockers

Verapamil Lithium

o May cause sedation- take at bedtime and increase fluids

Biofeedback

Implementation of the Nursing Management of Tension-Type, Migraine, and Cluster Headache

Review of subjective and objective data needed from the patient with complaints of headache-

o Lewis et al., 2011, p. 1490, Table 59-4o Subjective

Past health history Recent fall or head trauma, seizures, relationship of headaches to

activity?

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Family history Nutrition/diet

o Triggers- nitrates, monosodium glutamate (MSG), alcohol What are associated signs and symptoms

Photophobia, phonophobia, N/V, location and description of pain Sleep/rest disturbances Lacrimation, nasal stuffiness

Medications Overuse of NSAIDs, caffeine, nasal sprays, over-the-counter

(OTC) medications, herbal remedies Surgeries

Sinus, cranial, facial, dental worko Objective

Anxiety, apprehension, Cluster: pallor, unilateral facial flushing with cheek edema, conjunctivitis Migraine: generalized edema, pallor, diaphoresis Horner’s syndrome: unilateral contraction of the pupil, ptosis (drooping)

of the eyelid, unilateral loss of facial sweating, and recession of the eyeball into the orbit (enopthalmos)

Head, neck, and shoulder muscle stiffness and resistance to passive motion

discussion of possible nursing diagnoses and planning, implementations, and expected outcomes for the patient with a headache

o What are the most common migraine triggers? http://www.youtube.com/watch?NR=1&feature=endscreen&v=7m9J6nmbIGM

o Lewis et al., 2011, p. 1491, Nursing Care Plan 59-1 Outcome- pain control Interventions- pain management Planning-

decrease or eliminate pain increase comfort, and decrease anxiety understanding of triggers and treatment strategies use positive coping strategies for those with chronic pain increased quality of life and decreased disability

Suggest- Daily exercise Relaxation Positive coping methods Headache diaries Avoid over-medication, rebound headache, and possible overdose Avoid food triggers Patient teaching Lewis et al., p. 1491, Table 59-5

Teaching Strategies

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Bastable (2008) advises that the teaching strategy implemented should complement the

materials being taught. For example, using lecture for imparting knowledge and return

demonstration for psychomotor skill teaching. As previously mentioned the information to be

delivered during this presentation is complex and is designed to instruct the ADN level student.

The primary delivery of this presentation is through didactic lecture that is supplemented with a

word puzzle, short video clips, a case study discussion, and a discussion-group based activity.

That being said, it is important to remember that the average attention span, according to the

Indiana University (IU) Teaching Handbook, is approximately 15-20 minutes long and university

classes last 50 to 75 minutes, therefore it will be important to use the other teaching strategies

throughout the presentation to maintain participant interest (Indiana University, 2011). This

concept is further substantiated in the IU Teaching Handbook by the following claim. “Many IU

instructors report that when they intersperse short lectures with active engagement for students

for as brief a time as two to five minutes, students seem to become re-energized for the next 15-

to 20-minute mini-lecture” (Indiana University, para. 3).

Resources

Resources utilized to deliver this data include an interactive PowerPoint presentation,

which has imbedded videos, diagrams, illustrations, and anatomical charts. The lecture is

intended to supplement the required textbook readings for the course found in the Nursing

Management: Chronic Neurologic Problems chapter of Lewis et al., (2011) “Medical-Surgical

Nursing: Assessment and Management of Clinical Problems.” There is a 30-minute case study

scenario and review that will follow the lecture where students will split into three groups of 15

and collaborate to discover the answers to given scenario questions. In addition, the students

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will be provided with a challenging crossword puzzled based upon the vocabulary, concepts, and

therapies of headaches.

During the scheduled breaks of this presentation, classical music will be played through

the speaker system. Those students who wish to participate may look up the prices of some of

the more popular medications used to abort or prevent on their smart phones or laptops and

share their findings with the class on the whiteboard. ‘Edutainment’ is provided through

humorous illustrations, current event factoids, and games.

Evaluation Methods

Student evaluation will be in the form of unit test questions and discussion of case study

reviews. The unit test questions will be multiple-choice style, true/false, and/or matching. Each

group will choose a representative to share their case study and the answers to the review

questions. It is believed that in doing so the entire class will glean the information gained

through each groups’ efforts.

Teaching Plan for Headache Lecture

The following is the teaching plan designed for a Associate Degree in Nursing (ADN)

70-minute didactic lecture on headaches based from the required student readings in Lewis et al.,

(2011), “Medical-Surgical Nursing: Assessment and Management of Clinical Problems”. This

lecture time does not include the two 10-minute breaks or the 30-minute small discussion-group

based activity that is planned to reinforce the materials presented.

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PURPOSE: To provide students with information necessary to differentiate headache types (tension, migraine, & cluster).GOAL: The student will demonstrate the ability to identify the different types of headaches including the etiology, clinical manifestations, collaborative care, and nursing management.Objectives & Subobjectives

Content Outline Method Time Resources Method of Evaluation

At the completion of the 70-minute didactic presentation, the student will be able to: 1. Compare

and contrast the etiology, of tension-type, migraine, and cluster headaches.

1. Summary of the etiology and pathophysiology of tension-type headache

*bilateral pressing/tightening around the location of the ‘hat-band’*abnormal neuronal sensitivity and pain facilitation*Once thought to be caused by muscular contractions

2. Summary of the etiology and pathophysiology of migraine headache

*exact cause unknown- neuronal hyperexcitability with onset after puberty*70% of migraine sufferers have a 1st

generation relative who suffers from migraines*recurring unilateral or bilateral throbbing pain associated with triggers most commonly food, odors, stress, fatigue, alcohol, or excessive caffeine

3. Summary of the etiology and pathophysiology of cluster headache

*Rare (<0.1% pop.), sharp stabbing pain repeated same time of day for weeks to months lasting minutes to 3 hours with periods of remission*trigeminal nerve pain, dysfunction of intracranial blood vessels = vasodilation, pain pathway, circadian rhythm = hypothalamus at night*Triggers include alcohol, odors, and napping

Lecture, case study, crossword

15 min.

PowerPoint presentation, Video, Written materials, anatomical charts, case study scenario review

Post-testing, Question and answer, Discussion of case study reviews

2. Differentiate the clinical manifestation

1. Summary of the clinical manifestations and diagnostic studies of tension-type headache

Lecture, case study,

15min.

PowerPoint presentation, Video,

Post-testing, Question

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of tension-type, migraine, and cluster headaches.

*No aura, squeezing band, phonophobia, photophobia, no nausea/vomiting *may have combo tension and migraine or tension-type between migraines,*Diagnostics- HISTORY, electromyography (EMG), may have increased resistance to passive head movements and head/neck tenderness

2. Summary of the clinical manifestations and diagnostic studies of migraine headache

*May have aura (10%) including sights, smells, or sounds prior to headache, most do not;*Headache lasts 4-72 hours that is steady, throbbing pain, correlating with the pulse, and person “hibernates” from all activity/stimulation;*Diagnostics- HISTORY, no testing specific for migraine but if atypical then head computed tomography (CT) and magnetic resonance imaging (MRI) are recommended

3. Summary of the clinical manifestations and diagnostic studies of cluster headache

*Most severe form of headache with intense stabbing pain up to eight times per day cycles lasting two weeks to three months followed by remissions lasting months to years’*Pain around the eye, radiating to the temple, forehead, cheek, nose, or gums and may include swelling around the eye, nasal congestion, lacrimation, pupil constriction, facial flushing or pallor;*Diagnostics- HISTORY, headache diary, head CT, MRI, or magnetic resonance angiography (MRA) to rule out infection, tumor, or aneurysm

crossword Written materials, anatomical charts, case study scenario review

and answer, Discussion of case study reviews

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3. Discuss collaborative care for tension-type, migraine, and cluster headaches.

1. Discussion of the Abortive/Symptomatic therapies available for tension-type, migraine, and cluster headachesTension-type

*Non-opioids*NSAIDs plus muscle relaxers, sedatives, tranquilizer, and/or codeine*muscle relaxantsMigraine*Mild to moderate- non-opioids*moderate to severe- Triptans = gold standardCluster*α-Adrenergic blocker*oxygen*Serotonin receptor agonists- Triptans

2. Discussion of the Preventative/Prophylactic therapies available for tension-type, migraine, and cluster headachesTension-type

*Tricyclic antidepressants*Selective serotonin reuptake inhibitors (SSRIs)*β-Adrenergic blocker *Biofeedback*Psychotherapy*Muscle relaxation training

Migraine*β-Adrenergic blocker *Antidepressants*Antiseizure*Calcium channel blockers*Botulinum toxin (Botox)*Biofeedback*Relaxation therapy*Cognitive-behavioral therapyCluster*α-Adrenergic blocker*serotonin antagonist*corticosteroid*Calcium channel blockers*Biofeedback

Lecture, case study, crossword

15min.

PowerPoint presentation, Video, Written materials, anatomical charts, case study scenario review

Post-testing, Question and answer, Discussion of case study reviews

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4. Implement the nursing management of tension-type, migraine, and cluster headaches.

1. Review of subjective and objective data needed from the patient with complaints of headacheSubjectivePast health history•Recent fall or head trauma, seizures, relationship of headaches to activity?•Family history•Nutrition/dietoTriggers- nitrates, monosodium glutamate (MSG), alcoholWhat are associated signs and symptoms•Photophobia, phonophobia, N/V, location and description of pain•Sleep/rest disturbances•Lacrimation, nasal stuffinessMedications•Overuse of NSAIDs, caffeine, nasal sprays, over-the-counter (OTC) medications, herbal remediesSurgeries•Sinus, cranial, facial, dental workObjectiveAnxiety, apprehension,Cluster: pallor, unilateral facial flushing with cheek edema, conjunctivitisMigraine: generalized edema, pallor, diaphoresisHorner’s syndrome: unilateral contraction of the pupil, ptosis (drooping) of the eyelid, unilateral loss of facial sweating, and recession of the eyeball into the orbit (enopthalmos) Head, neck, and shoulder muscle stiffness and resistance to passive motion

2. Discussion of possible nursing diagnoses and planning for the patient with a headache; discuss nursing implementations for the patient with a headache; confer the expected outcomes for the patient with headacheOutcome- pain control

Lecture, case study, crossword

15min.

PowerPoint presentation, Video, Written materials, case study scenario review anatomical charts

Post-testing, Question and answer, Discussion of case study reviews

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Interventions- pain managementPlanning- •decrease or eliminate pain•increase comfort, and decrease anxiety•understanding of triggers and treatment strategies•use positive coping strategies for those with chronic pain•increased quality of life and decreased disabilitySuggest-•Daily exercise•Relaxation•Positive coping methods•Headache diaries•Avoid over-medication, rebound headache, and possible overdose•Avoid food triggers

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References

American Association of Colleges for Nursing. (2009). Nurse faculty tool kit for the

implementation of the baccalaureate essentials. Retrieved from

http://www.aacn.nche.edu/publications/baccalaureate-toolkit

Bastable, S.B. (2008). Behavioral objectives: Development of teaching plans. In K. Sullivan, E.

Ekle, & A. Sibley (Eds.), Nurse as educator: Principles of teaching and learning for

nursing practice (3rd ed., pp. 383-427). Sudbury, MA: Jones and Bartlett Publishers,

LLC.

Illumistream (Producer). (2008). Is it a Migraine? (Migraine #1) [Video file]. Retrieved from

http://www.youtube.com/watch?feature=endscreen&v=CeWHTM7d_-k&NR=1

Illumistream (Producer). (2008). Migraine triggers (Migraine #3) [Video file]. Retrieved from

http://www.youtube.com/watch?NR=1&feature=endscreen&v=7m9J6nmbIGM

Illumistream (Producer). (2008). No More Migraines? (Migraine #5) [Video file]. Retrieved

from http://www.youtube.com/watch?v=l4UOUQDM00I

Indiana University (2011). Teaching methods: Lecturing. In the Center for Innovative Teaching

and Learning (Eds.), Indiana university teaching handbook (section 2). Retrieved from

http://www.teaching.iub.edu/handbook_toc.php

Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Camera, I.M. (2011). Nursing

management: Chronic neurologic problems. In K. Green & J. Horn (Eds.), Medical-

surgical nursing: Assessment and management of clinical problems (8th ed., pp. 1485-

1492). St. Louis, MO: Elsevier/Mosby.