Running head: HEADACHES
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Teaching Plan: Headaches
Laurie Pomella
University of South Florida
February 13, 2012
HEADACHES
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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 discussiongroup 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
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Tension-type- ♀more common
o the most common type of headache lasting minutes to days and are often
described as a bilateral pressing/tightening around the location of the ‘hatband’
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
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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-typeo 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.).
Migraineo 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.).
Clustero 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.).
Othero 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
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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-typeo 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, Toprol
o May cause sedation- take at bedtime and increase
fluids
 Biofeedback
 Psychotherapy
 Muscle relaxation training
Migraineo 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 needed
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o Preventative/Prophylactic
 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
Clustero 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, Zomig
o 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
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Review of subjective and objective data needed from the patient with complaints of
headacheo Lewis et al., 2011, p. 1490, Table 59-4
o Subjective
 Past health history
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Recent fall or head trauma, seizures, relationship of headaches to
activity?
 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 work
o 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
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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
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Teaching Strategies
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 15to 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 &
Content Outline
Method
Time Resources Method of
Subobjectives
Evaluation
At the
1. Summary of the etiology and
Lecture,
15
PowerPoint Postcompletion of
pathophysiology of tension-type
case
min. presentation testing,
the 70-minute
headache
study,
, Video,
Question
didactic
*bilateral pressing/tightening around
crossword
Written
and
presentation,
the location of the ‘hat-band’
materials,
answer,
the student will
*abnormal neuronal sensitivity and
anatomical
Discussion
be able to:
pain facilitation
charts, case of case
1. Compare
*Once thought to be caused by
study
study
and contrast
muscular contractions
scenario
reviews
the etiology,
2. Summary of the etiology and
review
of tensionpathophysiology of migraine headache
type,
*exact cause unknown- neuronal
migraine, and
hyperexcitability with onset after
cluster
puberty
headaches.
*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
2. Differentiate
the clinical
manifestation
1. Summary of the clinical
manifestations and diagnostic studies
of tension-type headache
Lecture,
case
study,
15
min.
PowerPoint
presentation
, Video,
Posttesting,
Question
HEADACHES
of tensiontype,
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
12
crossword
Written
materials,
anatomical
charts, case
study
scenario
review
and
answer,
Discussion
of case
study
reviews
HEADACHES
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 headaches
Tension-type
*Non-opioids
*NSAIDs plus muscle relaxers,
sedatives, tranquilizer, and/or codeine
*muscle relaxants
Migraine
*Mild to moderate- non-opioids
*moderate to severe- Triptans = gold
standard
Cluster
*α-Adrenergic blocker
*oxygen
*Serotonin receptor agonists- Triptans
2. Discussion of the
Preventative/Prophylactic therapies
available for tension-type, migraine,
and cluster headaches
Tension-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 therapy
Cluster
*α-Adrenergic blocker
*serotonin antagonist
*corticosteroid
*Calcium channel blockers
*Biofeedback
13
Lecture,
case
study,
crossword
15
min.
PowerPoint
presentation
, Video,
Written
materials,
anatomical
charts, case
study
scenario
review
Posttesting,
Question
and
answer,
Discussion
of case
study
reviews
HEADACHES
4. Implement
the nursing
management
of tensiontype,
migraine, and
cluster
headaches.
1. Review of subjective and objective
data needed from the patient with
complaints of headache
Subjective
Past health history
•Recent fall or head trauma, seizures,
relationship of headaches to activity?
•Family history
•Nutrition/diet
oTriggers- 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 work
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
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 headache
Outcome- pain control
14
Lecture,
case
study,
crossword
15
min.
PowerPoint
presentation
, Video,
Written
materials,
case study
scenario
review
anatomical
charts
Posttesting,
Question
and
answer,
Discussion
of case
study
reviews
HEADACHES
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
15
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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.), Medicalsurgical nursing: Assessment and management of clinical problems (8th ed., pp. 14851492). St. Louis, MO: Elsevier/Mosby.