This topic pulls together problems that cut across many neurologic diseases: headache, altered level of consciousness (LOC) and the unconscious client, and the day-to-day nursing of clients with motor, sensory, and swallowing deficits. It also reviews high-risk drug and safety points that appear throughout the unit.

Headache

• Primary headaches (no underlying disease): migraine, tension-type, and cluster headache.
• Secondary headaches result from another condition — subarachnoid hemorrhage, meningitis, mass lesion, increased ICP, giant cell arteritis, medication overuse.

Altered consciousness results from either widespread dysfunction of both cerebral hemispheres or dysfunction of the reticular activating system in the brainstem. Causes are structural (stroke, hemorrhage, tumor, trauma) or metabolic/toxic (hypoglycemia, hypoxia, hypercapnia, sodium disorders, uremia, hepatic encephalopathy, sepsis, drugs, alcohol, seizures). Metabolic causes are common and often reversible.

Related states

• Delirium: acute, fluctuating disturbance of attention — always look for a cause.
• Persistent vegetative state (unresponsive wakefulness): sleep–wake cycles and eye opening without awareness.
• Locked-in syndrome: awake and aware but paralyzed except vertical eye movements (ventral pons lesion).
• Brain death: permanent loss of all brain function including the brainstem — coma, absent brainstem reflexes, and apnea; declared according to national or institutional criteria.

Headache red flags (secondary cause) — sudden "thunderclap" or worst-ever headache; fever and neck stiffness; new neurologic deficit, confusion, or seizure; new headache after age 50; headache with cancer, immunosuppression, or pregnancy; worse with coughing or lying down; papilledema; jaw claudication or scalp tenderness in older adults (giant cell arteritis). Meningeal irritation: Kernig sign (hip and knee flexed to 90°, then extending the knee causes pain) and Brudzinski sign.

Unconscious client

• Airway patency, breathing pattern, SpO₂, gag and cough reflexes.
• GCS, pupils, motor response, posturing, brainstem reflexes (corneal, oculocephalic).
• Vital signs, temperature, glucose.
• Skin, mouth, and eyes (corneal dryness); hydration; bladder distension; bowel pattern.

Clients with neurologic deficits

• Standing and sitting balance, trunk control, strength, sensation, coordination, spasticity, visual field loss, neglect, cognition, and swallowing.
• Fall risk score; pressure-injury risk.

Migraine

• Acute: NSAIDs or acetaminophen for mild attacks; triptans (sumatriptan, rizatriptan) for moderate to severe. Triptans cause chest tightness, tingling, flushing; contraindicated in coronary artery disease, prior stroke, uncontrolled hypertension, and hemiplegic or brainstem aura; risk of serotonin syndrome with SSRIs/SNRIs is low but should be taught. Do not give within 24 hours of an ergotamine; sumatriptan and rizatriptan are avoided with MAO-A inhibitors; reduce the rizatriptan dose with propranolol. Newer options: gepants (ubrogepant, rimegepant) and lasmiditan (dizziness, sedation — no driving for 8 hours). Antiemetics (metoclopramide, prochlorperazine — watch for akathisia and dystonia).
• Limit acute treatment to fewer than about 10 days per month (triptans) or 15 days (simple analgesics) to avoid medication overuse headache.
• Prevention for frequent attacks: beta blockers (propranolol — avoid in asthma), topiramate (teratogenic, kidney stones, cognitive slowing), amitriptyline, candesartan, CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab — constipation, hypertension with erenumab), onabotulinumtoxinA for chronic migraine. Ergotamines are contraindicated in pregnancy and CAD and must not be used within 24 hours of a triptan. Valproate is avoided in people who could become pregnant.

Cluster headache: 100% oxygen at 12–15 L/min by non-rebreather mask for about 15 minutes (caution in COPD with CO₂ retention), subcutaneous or nasal triptan; preventive verapamil (ECG monitoring for heart block).

Coma management: secure the airway (intubation if GCS ≤ 8 or no protective reflexes), oxygenation, circulation, glucose (and thiamine before dextrose in malnourished or alcohol-using clients), naloxone for suspected opioid toxicity, treat seizures, ICP management, and treat the cause.

Rehabilitation team: physical therapy (gait, balance), occupational therapy (ADLs, adaptive devices), speech-language pathology (swallowing, communication), and dietitian.

Listed in priority order.

1. Airway, breathing, and aspiration prevention (unconscious or dysphagic client)
   • Side-lying (lateral) or semi-prone position if not contraindicated, head of bed elevated about 30°; suction oral secretions; oxygen as ordered.
   • Nothing by mouth until swallowing is assessed; enteral feeding with head of bed at least 30° and placement and residual checks per policy.
   • Oral care every 2–4 hours with suction available (reduces pneumonia).
2. Neurologic monitoring and ICP safety
   • Serial GCS, pupils, vital signs; report declines.
   • For clients at risk of increased ICP: avoid activities that trigger the Valsalva maneuver (straining at stool, coughing, pushing up in bed), keep the head midline, and space care.
3. Medication safety — high-risk neurologic drugs
   • Nimodipine (aneurysmal SAH): check BP before each dose; monitor for hypotension; oral or tube only.
   • Thrombolysis for ischemic stroke: eligibility is within 4.5 hours of last known well (extended with imaging); tenecteplase 0.25 mg/kg has a maximum of 25 mg; strict BP and neuro checks.
   • Levodopa: give on time; dyskinesia (involuntary writhing) occurs at peak drug effect, whereas wearing-off (stiffness, slowness) occurs before the next dose — report the timing pattern.
   • MG crisis: the first priority is respiratory failure from weak respiratory muscles.
4. Safe mobility after hemiplegia
   • Before gait training, confirm sitting and standing balance and posture stability; check orthostatic BP; use a gait belt, nonslip footwear, and assistive devices; stand on the client's affected side.
   • Progress: dangle → stand → pivot transfer → walk with support.
5. Skin and musculoskeletal integrity
   • Turn at least every 2 hours; pressure-redistributing mattress; heel off-loading.
   • Range-of-motion exercises, splints, and positioning to prevent contractures and foot drop; support a flaccid arm to prevent shoulder subluxation.
6. Eye care (unconscious client) — absent blink reflex causes corneal drying and abrasion: lubricating drops or ointment, keep lids closed (tape or moisture chambers as ordered).
7. Elimination — assess for bladder distension (bladder scanner), intermittent catheterization preferred to indwelling; bowel program to prevent constipation and straining.
8. Temperature — treat fever promptly (increases cerebral metabolic demand).
9. Communication and family support
   • Speak to the unconscious client and explain care — hearing may be preserved. Orient; involve family.
10. Respiratory muscle weakness (ALS, MG, GBS) — teach breathing exercises (diaphragmatic breathing, incentive spirometry) and assisted-cough techniques to support an effective cough; monitor vital capacity.

Headache

• Keep a headache diary (timing, food, sleep, menstrual cycle, stress, drugs used).
• Identify and avoid triggers: irregular sleep, skipped meals, dehydration, alcohol, certain foods, stress, bright light.
• Take acute medication early in the attack; limit acute medication days to prevent medication overuse headache.
• Seek emergency care for a sudden worst-ever headache, headache with fever and stiff neck, or headache with weakness, confusion, vision loss, or speech change.

Families of clients with neurologic deficits

• Fall prevention at home, safe transfers, skin checks, swallowing precautions, and signs of aspiration.
• Peripheral sensory loss: inspect feet daily using a mirror and by touch; test water temperature with a thermometer; wear protective footwear.
• Recognize stroke warning signs (BE FAST) and call emergency services immediately.
• Caregiver rest, respite, and community resources.

• Thunderclap or worst-ever headache, fever with neck stiffness, or new deficit = secondary headache red flag.
• Kernig sign: hip and knee flexed to 90°, extending the knee causes pain.
• Triptans: contraindicated in CAD, prior stroke, uncontrolled hypertension; limit use to avoid medication overuse headache.
• Cluster headache: 100% oxygen 12–15 L/min by non-rebreather; verapamil prevention.
• Altered LOC: check glucose first; airway if GCS ≤ 8.
• Unconscious client: side-lying, oral care, eye protection, turning, ROM, bladder and bowel care.
• ICP risk: avoid Valsalva, head midline, HOB 30°.
• Before gait training after hemiplegia: confirm balance and standing stability.
• Nimodipine → monitor for hypotension.
• Thrombolysis within 4.5 hours of last known well.
• Levodopa dyskinesia = peak-dose effect.
• MG crisis priority = respiratory failure; ALS: breathing exercises and assisted cough.
• Neuropathy: daily foot inspection with a mirror.