chronic tension headache
TRANSCRIPT
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OBJECTIVES
General Objective
As nursing students, we deal with patients of different diseases during our exposure in
different hospitals. As we learn, it is our duty and responsibility to improve ourselves in
dealing with patients having disease. This case study aims to identify the defining
characteristics of chronic tension type headache, and its signs and symptoms in order to
gain knowledge about the disease and provide quality nursing care to the patients
inflicted by it.
Specific Objectives
To identify risk factors why this type of disease arises and also to identify risk
areas and situations that is prone to chronic tension type headache
To promote awareness to the public regarding the incidence of chronic tension
type headache
To have an idea of specific programs that we can suggest to the authorities to
lessen the events of chronic tension type headache cases, and therefore improvethe quality of life.
To know specific management and immediate interventions that we can apply
whenever we encountered this type of disease.
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INTRODUCTION
Case Definition
Tension headaches are the most common type of primary headaches among adults. They
are commonly referred to as stress headaches. Tension headachesare similar to migraine in
many respects, although the location of the headache may be somewhat different and the cause is
more obvious. Prolonged nervous tension often seems to produce a spasm of the muscles in the
back of the neck, particularly in certain people. This muscles spasm draws the tissues over the
surface of the cranium very tight, so the pain is felt not only in the back of the neck, but also over
the top and front of the head as well. This is a steady, aching type of pain. Usually there is
no nausea, vomiting, orflashing lights, for the problem does not appear to affect the brain but is
due to external causes.
Tension-type headaches account for nearly 90% of all headaches. Approximately 3% of
the population has chronic tension-type headaches.
A tension headache may appear periodically ("episodic," less than 15 days per month) or
daily ("chronic," more than 15 days per month). An episodic tension headache may be described
as a mild to moderate constant band-like pain, tightness, or pressure around the forehead or back
of the head and neck.
These headaches may last from 30 minutes to several days. Episodic tension headaches
usually begin gradually, and often occur in the middle of the day.
The "severity" of a tension headache increases significantly with its frequency. Chronic
tension headaches come and go over a prolonged period of time. The pain is usually throbbing
and affects the front, top, or sides of the head. Although the pain may vary in intensity
throughout the day, the pain is almost always present. Chronic tension headaches do not affect
vision, balance, or strength.
Tension headaches usually don't keep a person from performing daily tasks.
http://www.medicinenet.com/script/main/art.asp?articlekey=20628http://www.modernguidetohealth.com/conditions-diseases/tension-headache-relief.htmlhttp://www.modernguidetohealth.com/conditions-diseases/tension-headache-relief.htmlhttp://www.modernguidetohealth.com/conditions-diseases/tension-headache-relief.htmlhttp://www.medicinenet.com/script/main/art.asp?articlekey=20628 -
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Incidence
Headache is a painful and common symptom. A number of primary headache disorders
have been characterized, including tension-type headache, migraine and cluster headache, and
overall these disorders account for approximately 95% of all headache complaints. Where
studied, primary headache disorders have a lifetime prevalence of 90% . Migraine on its own
ranks among the top 20 causes of years of life lived with disability. Tension-type headache
afflicts more on women than of men living in developed countries. The epidemiology and
experiences of patients with headache disorders in the developing world are uncertain, because
the majority of research on headache disorders comes from a limited number of high-income
countries. Where sought, regional variation in the incidence, prevalence and economic burden of
headache disorders has been found. Social, financial and cultural factors can all influence the
experience of the individual headache sufferer, and patients in resource-poor settings could
presumably experience an even greater impact of these influences. Yet the contribution of low-
and middle-income countries to the understanding of headache disorders has not been
characterized.
Little wonder, then, that tension headaches are the most common kind of all headaches.
They have recently been renamed "tension-type headaches" because of the possible role
researchers now believe that the chemistry in the brain may play in their origin. TTH can occur
at any age, but onset during adolescence or young adulthood is common. It can begin in
childhood.
About 30%-80% of the adult population suffers from occasional tension headaches;
approximately 3% suffer from chronic daily tension headaches. Women are twice as likely to
suffer from tension-type headaches as men. One study found that almost 90 percent of women
and about 70 percent of men experience tension headaches are estimated to suffer from the dull
pressure and aches caused by tension-type headaches at some time in their lives. The symptom is
also frequently described as feeling like a rubber band tightly gripping one's head.
Tension headaches can occur at any age, but they generally strike during adolescence or
adulthood. This sort of headache occurs most often in people between 20 and 50 years of age.
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Most people with episodic tension headaches have them no more than once or twice a
month, but the headaches can occur more frequently.
Chronic tension headaches tend to be more common in females. Many people with
chronic tension headaches have usually had the headaches for more than 60-90 days.
Etiology
The exact cause or causes of tension headache are unknown. Experts used to think that
the pain of tension headache stemmed from muscle contraction in the face, neck and scalp,
perhaps as a result of heightened emotions, tension or stress. But research suggests that there
doesn't appear to be a significant increase in muscle tension in people diagnosed with tension
headache.
The most common theories support interference or "mixed signals" involving nerve
pathways to the brain, which is demonstrated by a heightened sensitivity to pain in people who
have tension headaches. Increased muscle tenderness, a common symptom of tension headache,
may be the result of overactive pain receptors.
There is no single cause for tension headaches. This type of headache is not an inherited
trait that runs in families. In some people, tension headaches are caused by tightened muscles inthe back of the neck and scalp. This muscle tension may be caused by:
Inadequate rest
Poor posture
Emotional or mental stress, including depression
Anxiety
Fatigue
Hunger
Overexertion
In others, tightened muscles are not part of tension headaches, and the cause is unknown.
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Tension headaches are usually triggered by some type of environmental or internal stress. The
most common sources of stress include family, social relationships, friends, work, and school.
Examples of stressors include:
Having problems at home/difficult family life
Having a new child
Having no close friends
Returning to school or training; preparing for tests or exams
Going on a vacation
Starting a new job
Losing a job
Being overweight
Deadlines at work
Competing in sports or other activities
Being a perfectionist
Not getting enough sleep
Being over-extended (involved in too many activities/organizations)
Episodic tension headaches are usually triggered by an isolated stressful situation or a build-
up of stress. Daily stress can lead to chronic tension headaches.
Medication-overuse headache is caused by taking painkillers (or triptan medicines) too often
for tension-type headaches or migraine attacks. For example, you may take a lot of painkillers
for a bad spell of headaches. You may end up taking painkillers every day, or on most days.
Your body then becomes used to painkillers. A withdrawal headache then develops if you do not
take painkillers each day. You think this is just another tension-type headache, and so you take a
further dose of painkiller. When the effect of each dose of painkiller wears off, a furtherwithdrawal headache develops, and so on. This is how medication-overuse headache develops. It
is a common cause of headaches that occur daily, or on most days.
Until recently it was believed that tension headaches were caused by muscle tension around
the head and neck. One of the theories says that the main cause for tension type headaches and
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migraine is teeth clenching which causes a chronic contraction of the temporal muscle. Although
muscle tension may be involved, many researchers now question this idea, and recent research
has shown that tension headache patients do not have increased muscle tension
Another theory is that the pain may be caused by a malfunctioning pain filter which is
located in the brain stem. The view is that the brain misinterprets information, for example from
the temporal muscle or other muscles, and interprets this signal as pain. One of the main
neurotransmitters which are probably involved is serotonin. Evidence for this theory comes from
the fact that chronic tension-type headaches may be successfully treated with certain
antidepressants such as amitriptyline. However, the analgesic effect of amitriptyline in chronic
tension-type headache is not solely due to serotonin reuptake inhibition, and likely other
mechanisms are involved. Patients with chronic tension-type headache have increased muscle
and skin pain sensitivity, demonstrated by low mechanical, thermal and electrical pain
thresholds. Hyperexcitability of central nociceptive neurons (in trigeminal spinal nucleus,
thalamus, and cerebral cortex) is believed to be involved in the pathophysiology of chronic
tension-type headache. Recent evidence for generalized increased pain sensitivity or
hyperalgesia in CTTH strongly suggests that pain processing in the
central nervous system is abnormal in this primary headache disorder. Moreover, a dysfunction
in pain inhibitory systems may also play a role in the pathophysiology of chronic tension-type
headache
General Signs and Symptoms
Signs of tension headaches include:
A headache that is constant, not throbbing, Pain or pressure on both sides of head.
Pressure that makes feel like head is in a vise.
Aching pain at temples or the back of head and neck.
Steady, constant feeling of pressure that usually begins in the forehead, or the back of the
neck.
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Tension headaches tend to come back, especially when under stress. They can last from
30 minutes to several days.
Tightness around forehead that may feel like a vise grip
Mild to moderate pain or pressure affecting the front, top or sides of the head Headache occurring later in the day
Difficulty falling asleep and staying asleep
Chronic fatigue
Irritability
Disturbed concentration
Mild sensitivity to light or noise
General muscle aching
Other signs and symptoms
Can be described as a weight on top of my head
Steady, constant feeling of pressure usually begins in the forehead, temple, or back of the
neck.
Excruciating pain localized to the eye and orbit and radiating to the facial and temporal
regions.
The pain is accompanied by watering of the eye and nasal congestion.
Cranial arteritis often begins with fatigue, malaise, weight loss, and fever.
Clnical manifestations associated with inflammation (heat, redness, swelling, tenderness,
or pain over the involved artery) usually present.
Usually, pain from a tension headache is not severe and does not get in the way of your work or
social life. But for some people the pain is very bad or lasts a long time. You have chronic
tension headaches if they occur at least 15 days a month
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PATIENTS PROFILE
Patients data
RN is a 42 year old female, Married, Roman Catholic, Filipino citizen, born on February
28, 1969, and presently residing at Manila. She consulted in ADU Hospital last July 29, 2011
with a diagnosis of Chronic Tension Headache. Vicente Falcon M.D as his admitting
physician.
Nursing History
Chief complaint
Headache for 15 days.
Present History
2 weeks prior to consultation patient has been suffering a constant, daily
headache. The headache is making her tired and it is difficult for her to concentrate at
work. She has seen her Doctor in Marians Hospital about this complaint. The Doctor
diagnosed stress and recommended paracetamol three times a day. The treatment was
not effective, headache still persisted, which prompted her to have a consultation in ADU
Hospital.
Past History
No previous injuries and serious illness reported.
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Personal and social history
RN is a 42 year old female, a Filipino citizen who resides at Manila. She was born on
February 28, 1969 in Pampanga, her religious affiliation is Roman Catholic and she is married to
MSN. She is a Highschool Teacher. She usually works for 10 hours a day around 7:30 am to
5:30 pm. She always sleeps around 11 in the evening and wakes up at 5 in the morning. Her
husband is a jeepney driver bound in Baclaran-Monumento route, and also the president of their
jeepneys association. RN has 2 children. Her only day-offs is Saturdays and Sundays but uses
these days working in the house and taking care of her 2 children.
Family Health and Illness History
According to RN, the familial disease she knows that they have in their family was
hypertension that is on her fathers side. Her father died because of heart attack and her mother
died of senility.
Feeding History
She usually eats 3 meals and 1 snack (in the afternoon). She eats 1rice per meal. She is
also fond of eating vegetables and fatty and spicy foods. She drinks 1 liter of water a day.
Immunization History
She was able to receive all childhood immunizations and complete Tetanus Toxoid.
OB History
She had her first menses when she was 12 years old. She has 2 children, both NSD.
G2P2.
Gordons Functional Health Pattern
Health Perception Pattern
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The patient says Kung may sakit ako, kumukunsulta ako kaagad sa doctor, magastos
magpakunsulta pero mas magastos kung lumala.
Nutrition Metabolic Pattern
She usually eats 3 meals and 1 snack (in the afternoon). She eats 1rice per meal.
She is also fond of eating vegetables and fatty and spicy foods. She drinks 1 liter of water a day.
Elimination Pattern
The patient usually defecates every other day. The stool is usually brownish in color. She
urinates 3 to 4 times a day, yellowish in color. She has no complained of any pain when voiding
and defecating.
Activity and Exercise Pattern
The patient is a highschool teacher. She usually works for 10 hours a day around
7:30 am to 5:30 pm, Mondays to Fridays. She considers doing household chores every weekend
as her exercise. The patient says these past two weeks I cannot concentrate well on my work
and even at home because of this headache.
Sleep and Rest Pattern
She usually has 5 hours of sleep. She always sleeps around 11 in the evening and
wakes up at 4 in the morning.The patient says nito ngang nakaraang dalawang lingo hirap
akong makatulog dahil sumasakit ang ulo ko.
Cognitive Perceptual Pattern
She didnt have any difficulty in understanding, following instructions and formulating
sentences. She answers the questions appropriately. It is evident that she is bothered and irritated
due to her headache.
Role relationship Pattern
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The patient is happily living with her family.
Self perception/concept Pattern
The patient said ok naman ako eh, but for the past two weeks hindi na dahil dito sa
headache ko. She maintains an eye to eye contact during the interview.
Coping/ Stress Pattern
When she has problems, she tells it to her husband and prays.
Values/Belief Pattern
The patient is a Roman Catholic and she has faith in God. She usually goes to mass every
Sunday with her husband and children. According to her she always prays.
Review of systems
SYSTEMS ACTUAL FINDINGSIntegumentary Fair complexion
Turgor returns 1-2 seconds.
Hair is black and equally distributed. Hair is coarse and no parasites;
pink nails- round and firm.
Respiratory (-) DOB, (-) SOB
Cardiovascular No murmur
BP of 120/90
Neurologic Presence of weakness
Headache
Cooperative
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Gastrointestinal No loss of appetite
Musculoskeletal Equal ROM (range of motion)
Hematologic No incidence of bleeding or hemorrhage
Endocrine No heat and cold intolerance
No loss of appetite
Immunologic No fever
Urinary Has no history of Urinary tract infection
Has no changes in elimination pattern
Physical Assessment
Vital Signs:
T- 36.7 CP- 68 bpm
RR- 15 cpm
BP- 120/90
HEAD:
(+) Headache with a pain scale of 7/10
Afebrile
AREAS TO ASSESS ACTUAL FINDINGS NORMAL FINDINGS
SKULL Normal - Generally round, with
prominences in the frontal and
occipital area.
(Normocephalic).
- No tenderness noted upon
palpation.Scalp Normal -Lighter in color than the
complexion.
- Can be moist or oily.
- No scars noted.
- Free from lice, nits and
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dandruff.
- No lesions should be noted.
- No tenderness nor masses on
palpation.
Hair Normal -Can be black, brown or
burgundy depending on the
race.
-Evenly distributed covers the
whole scalp (No evidences of
Alopecia)
-Maybe thick or thin, coarse or
smooth.-Neither brittle nor dry.
Face Normal -palpebral fissure (distance
between the eye lids) equal in
both eyes.
-bilateral Nasolabial fold
(creases extending from the
angle of the corner of the
mouth). Slight asymmetry in
the fold is normal.
Eyes Normal Eyebrows
Symmetrical and in line
with each other.
Maybe black, brown or
blond depending on race.
Evenly distributed.
Eyes
Evenly placed and inline
with each other.
Non protruding.
Equal palpebral fissure.
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Eyelashes
Color dependent on race.
Evenly distributed.
Turned outward.
Eyelids
Upper eyelids cover the small
portion of the iris, cornea, and
sclera when eyes are open.
No PTOSIS noted. (drooping
of upper eyelids).
Meets completely when eyes
are closed.
Symmetrical.
Lacrimal Apparatus
Lacrimal gland is normally
non palpable.
No tenderness on palpation. No regurgitation from the
nasolacrimal duct.
Conjunctiva
Both conjunctivae are
pinkish or red in color.
With presence of many
minutes capillaries.
Moist
No ulcers
No foreign objects
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Sclerae
Sclerae is white in color
(anicteric sclera)
No yellowish discoloration
(icteric sclera).
Some capillaries maybe
visible.
Some people may have
pigmented positions.
Cornea
There should be no
irregularities on the surface.
Looks smooth.
The cornea is clear or
transparent. The features of
the iris should be fully visible
through the cornea.
There is a positive cornealreflex.
Anterior chamber and Iris
The anterior chamber is
transparent.
No noted any visible
materials.
Color of the iris depends on
the persons race (black, blue,
brown or green).
From the side view, the iris
should appear flat and should
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not be bulging forward. There
should be NO crescent shadow
casted on the other side when
illuminated from one side.
Pupils
Pupillary size ranges from
3 7 mm, and are equal in
size.
Equally round.
Constrict briskly/sluggishly
when light is directed to the
eye, both directly and
consensual.
Pupils dilate when looking
at distant objects, and constrict
when looking at nearer
objects.
EARS Normal The ear lobes are bean
shaped, parallel, and
symmetrical.
The upper connection of the
ear lobe is parallel with the
outer canthus of the eye.
Skin is same in color as in
the complexion.
No lesions noted on
inspection.
The auricles are has a firm
cartilage on palpation.
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The pinna recoils when
folded.
There is no pain or
tenderness on the palpation of
the auricles and mastoid
process.
The ear canal has normally
some cerumen of inspection.
No discharges or lesions
noted at the ear canal.
On otoscopic examination
the tympanic membrane
appears flat, translucent and
pearly gray in color.
NOSE and PARANASAL
SINUSES
Normal -Nose in the midline
- No Discharges.
- No flaring alae nasi.
- Both nares are patent.
- No bone and cartilage
deviation noted on palpation.
- No tenderness noted on
palpation.
- Nasal septum in the mid line
and not perforated.
- The nasal mucosa is pinkish
to red in color. (Increased
redness turbinates are typical
of allergy).
- No tenderness noted on
palpation of the paranasal
sinuses.
NECK Normal -May not be palpable. Maybe
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normally palpable in thin
clients.
-Non tender if palpable.
-Firm with smooth rounded
surface.
-Slightly movable.
-About less than 1 cm in size.
-The thyroid is initially
observed by standing in front
of the client and asking the
client to swallow. Palpation of
the thyroid can be done either
by posterior or anterior
approach.
THORAX Normal -The shape of the thorax in a
normal adult is elliptical; the
anteroposterior diameter is
less than the transverse
diameter at approximately a
ratio of 1:2.
-Moves symmetrically on
breathing with no obvious
masses.
-No fail chest which is
suggestive of rib fracture.
-No chest retractions must be
noted as this may suggest
difficulty in breathing.
-No bulging at the ICS must
be noted as this may
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obstruction on expiration,
abnormal masses, or
cardiomegaly.
-The spine should be straight,
with slightly curvature in the
thoracic area.
-There should be no scoliosis,
kyphosis, or lordosis.
-Breathing maybe
diaphragmatically of costally.
-Expiration is usually longer
the inspiration.ABDOMEN Normal -Skin color is uniform, no
lesions.
-Some clients may have striae
or scar.
-No venous engorgement.
-Contour may be flat, rounded
or scapoid
-Thin clients may have visible
peristalsis.
-Aortic pulsation maybe
visible on thin clients.
EXTREMITIES Normal -Both extremities are equal in
size.
-Have the same contour withprominences of joints.
-No involuntary movements.
-No edema
-Color is even.
-Temperature is warm and
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even.
-Has equal contraction and
even.
-Can perform complete range
of motion.
-No crepitus must be noted on
joints.
-Can counter act gravity and
resistance on RO
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Assessment Diagnosis Planning Interventions Rationale Evaluation
SUBJECTIVE
CUES:
The patient
verbalized I feel
like my head is being
crumpled from the
inside and banged on
a hard surface
repetitively.
OBJECTIVECUES:
Rated pain
as 9 out of10
Facialgrimace
Gurading
behavior
(clutches
head and
assumes
fetal
position)
Palmar and
Acute Pain r/t
decreased cerebral
blood flow secondaryto migraine as
manifested byguarding behavior,
facial grimace and
pallor
After 4 hours of
nursing
interventions, the
patient will be able
to:
Become relieved of
signs and symptoms
of pain experienced
as
evidenced by:
Verbalize pain is
relieved (rate pain
from 0-4 out of 10)
Demonstrate use of
diversional
activities such as
relaxing and/orsleeping
Assess
contributingfactors to pain
such as bright
lights and strongfumes
Reviewmedication
regimen
Provide comfortmeasures such as
repositioning theclient in a
comfortable
position andproviding a hot
or cold compress
Providecalm and quietenvironment
Instruct use of
relaxation techniques
such as deepbreathing
To determine
underlying causeof pain and treat
accordingly.
Certain drugs
may cause fatigueand drowsiness.
To allow nonpharmocological
pain relief andpromote good
circulation to thebrain and
decrease
vasoconstriction
To decrease
environmental
factors whichcontribute toheadache and
promote rest
To distract
attention from pain anddecrease tension
After 4 hours of
nursing interventions
the patient:
Verbalized feeling ofrelief of pain and feel
better
Pain scale 0 out of 10
Was able to use
relaxation techniquessuch as deep breathing
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facialpallor
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DISCHARGE PLANNING
M (MEDICATION)
Take the entire course of any prescribed medications.
E (EXERCISE & ACTIVITY)
Have adequate rest and assisted exercises to maintain muscle tonicity and also avoid
engaging in extraneous activities to avoid tension headache.
T (TREATMENT)
Undergo necessary procedure as needed. Observe self for any suspicious condition and
notify to your doctor.
H (HOME TEACHING)
Encourage nutrition supplements to prevent weight loss. Observe safety measure at home
to prevent for injuries. Provide quiet, comfortable and peace environment. Proper preparation offood and water to have adequate nutrition and hydration.
O (OUT PATIENT FOLLOW UP)
Return to the doctor as frequent as possible to monitor your present condition. Keep all of
follow-up appointments. Even though you feel better, there are some complications that may stilloccur. Its important to have the doctor monitor his progress.
D (DIET)
Planning meal and having regular family meals can help ensure that you gets enough
calories, protein and other necessary nutrients; these can also become ways to engage yourself in
nutritional health care.
S (SPIRITUALITY)
Keeping faith in God and believing in Him can uplift some distress in the whole family.
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NURSING IMPLICATIONS
Nursing Research
This case study is important to nursing research because it opens new opportunity to
conduct another research in relation to the disorder even though there are many existing
researches with regards to this disorder. Even if we know that chronic tension headache is stillcommon nowadays, research will still be a key to discover a better treatment for it. As a part of
medical team, and as a nursing student, it is very vital for us to be aware for the new researches
because we are the primary care giver for our client. We are the one who is always in contact
with our client. Nursing research is our way to have a new knowledge and understanding aboutthe disease that we can use to render the best quality of care for our client.
Nursing Education
In Nursing Education, it is an advantage for us to have this case study because it gives usadditional and new knowledge about the disorder. As a nursing student, it is important to know
everything about a certain disease. When we have the knowledge about the disease, we can be
able to give the best quality of care when we encounter a patient with the same disorder. This
case study does have nursing care management. We, student nurses are also an educator to ourclient. It is important that we teach accurate details to our client because they believe on what we
say. Even a single mistake about the information that we give to our client can take away their
life. As an educator, we should be responsible enough to spread the knowledge about this certaindisease to prevent acquiring the disease. Prevention will always be better than cure.
Nursing practice
Through the help of this study we can acquire more informations and knowledge aboutchronic tension headache. Knowing that chronic tension headache can be acquired in several
ways, we can also prevent ourselves in acquiring such disease. We are very prone to acquire this
disease because we are always in contact with many clients and due to a tiring job. This case
study will be an essential tool to render the best quality of care that we can render to our client.