How Do Triage Nurses Evaluate If Headaches Are Serious?
By Marci Lawing, RN TriageLogic Nurse Manager
Headaches are incredibly common, so much so that people often dismiss the symptoms as a benign nuisance.
Common Headaches and Causes
According to World Health Organization (WHO), “1 adult in 20 has a headache every – or nearly every – day (2014).” Frequent headaches can be an indicator of a headache disorder and any persistent or recurrent headache should be evaluated by a physician. According to WHO tension headaches are among the most common types of headache disorders. Sufferers of tension headaches experience pain and tightness around the head and the neck muscles. Staying in one position for too long is a common trigger, making office workers, especially susceptible to tension headaches. Another cause of tension headaches for both adults and children is stress. An adult may have stress due to financial worries, while a child may feel pressure to earn better grades in school.
A painful but increasingly growing type of headache is a Migraine. These severe headaches effect 1 adult in every 7 in the world (WHO, 2014). They occur in all continents, but for reasons not yet known, they appear to be somewhat less common in the Far East. Women are 3 times more likely to get Migraines, most likely related to hormones. While persons of any age can suffer from Migraines, they are most common between the ages of 35-45, but are sometimes seen in younger people, including children.
Other common sources of headaches include viral illnesses such as the common cold and frontal sinusitis which is felt above the eyebrow. Interestingly, the frontal sinusitis headache is usually not seen until after age 10 because the frontal sinus is not fully developed until that age. Caffeine withdrawal and taking too much medication are other causes of headaches.
Headaches Due to Emergent Causes
While most headaches are temporary and are easily treated once the trigger is determined, one should always be aware that headaches can be a warning sign of a serious condition. Such conditions can include brain aneurysms (a bulge in an artery in your brain); encephalitis (brain inflammation); hematoma’s (blood vessel ruptures in the brain), and brain AVM (arteriovenous malformation). Symptoms of these conditions range from sudden, extreme headaches, vomiting, stiff neck, blurred or double vision, and neurologic symptoms such as weakness or numbness of the arms or legs, confusion, and loss of consciousness. Anyone with sudden and severe symptoms without a known cause should seek medical attention immediately.
Whenever a patient calls with a presenting complaint of a headache, the triage nurse must first rule out any emergent causes.
According to a study done in 2000 of pediatric patients that were triaged by a nurse and referred to the Emergency Room, 39% were diagnosed with a viral infection, 18% with Sinusitis and 18% with Migraine but 14% had serious diagnosis such as Meningitis, Blocked VP shunt, Brain tumor complications (Lewis, Headache 2000: 40:200-203).
The triage nurse uses specialized evidence-based protocols to assist her in making sure the patient reaches the right level of care at the right time. The triage nurse asks a series of questions to elicit responses from the patient. The nurse uses many tools, but her listening skills are most important, as the information provided by the patient, helps the nurse determine the severity of the headache. Questions asked might include:
- When did it start?
- Where does it hurt?
- Can you rate it for me
- What makes it better/worse?
- Have you ever had a headache like this before?
- What chronic illnesses do you have?
- What medications do you take daily and what have you taken for the headache so far?
Other concerns must be addressed also, such as “Is the patient difficult to awaken, confused or disoriented? Is their speech slurred?” Can the patient walk without assistance or is there any new onset of weakness to their arms or legs. Other emergent symptoms to rule out include having a stiff neck, purple or blood colored rash or complaining of a headache that is incapacitating (“the worst headache of the patients’ life”).
Once emergent symptoms are eliminated as the probable cause of the headache the nurse can offer the patient home care advice such as proper doses of Tylenol or Motrin, cool compresses to the forehead, making sure the patient has eaten (in case blood sugar is low) and resting in a dark quiet room. The nurse must also make sure the patient is aware of the symptoms that, should they develop, would need to be seen immediately.
For the vast majority of people suffering from headache, effective treatment requires no expensive equipment, tests or specialists. However, assessing headaches for a telephone triage nurse means ruling out emergent symptoms by listening carefully to the patient’s concerns and using protocols. The essential components of effective management are awareness of the problem, correct diagnosis, avoiding mismanagement of headaches, appropriate lifestyle modifications and informed use of cost-effective pharmaceutical remedies (http://www.who.int/features/qa/25/en/).
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