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Clinical: Identifying and supporting patients with migraine

Key learning points

 

  • Migraines should be differentiated from other types of headache, including cluster headaches and tension headaches
  • There are many treatments for migraine, ranging from medication to non-drug approaches
  • Patients should know that any medication they are taking for migraine will need time to work, but should stop taking a drug if it is making their symptoms worse

Primary headache disorders are extremely disabling and highly prevalent. They place a significant demand on NHS resources and are an enormous financial cost to the UK economy.[1]

Migraine is a chronic disorder affecting 18% of women and 6% of men.[2] Migraine is not just a simple headache; some patients don’t have headache pain at all but more debilitating and frightening symptoms such as light and sound sensitivity, nausea, vomiting, loss of sensation in hands and face, confusion and speech disturbance.

Hormones are thought to play an influence, with more women than men experiencing migraines. More than 50% of women migraineurs report an association between migraine and menstruation.[3]

In the World Health Organization’s list of diseases 2011, [4] migraine was ranked as the seventh most disabling global disease. The list was updated in 2015 and reviewed by the Lancet [5] in 2016.

Migraine ranked just behind asthma. Furthermore, 80% of migraine sufferers have disabling attacks that interfere with life at work, home and socialisation.[6] Despite this, many sufferers do not consult their GP even though migraine may be disrupting their lives. 

Nurses are well placed to identify patients who are experiencing migraines. The International Headache Society (IHS) [7] has produced clear guidelines on diagnosing migraine and other headache conditions.

It is important to establish a clear diagnosis so the most appropriate treatment can be attempted. Other types of headaches, such as tension or cluster headaches require different treatments. It is also important to rule out underlying neurological disease and refer patients if in doubt. 

Diagnosing migraine: advice for nurses in primary care

Nurses should take a clear and careful history when diagnosing a patient with possible migraine. To establish the frequency and patterns of the attacks, nurses should ask the patient the following:

  • The age of onset.
  • Description of the severity of pain and whether it is best described as a dull ache, throbbing or stabbing.
  • Location of the pain and whether it is worse on exertion.
  • Associated features, such as sensitivity to light, sound and or smells.
  • Any nausea or vomiting.
  • How the patient feels between attacks.
  • Whether all attacks are the same.
  • Whether the attacks affect everyday life.
  • Any visual or sensory disturbances. These might be difficulty in speech, pins and needles or tingling in the hands and face.
  • Family history of migraines and headaches.

A headache diary or migraine apps can be useful tools to collect this information. 

It is important to look at other medical history too. Has the patient identified any triggers? These can include lack of or too much sleep, missed meals, stress or eating certain foods. 

In my experience, the best and quickest approach is usually to ask the patients these questions directly rather than letting them lead the consultation. It is also a good idea to ask the patient to bring a pre-prepared statement to this effect.

Distinguish between migraine, chronic migraines and headache types

Migraine

Most people can describe having a headache (there are several types, including migraine, tension headaches and cluster headaches) at some point in their lives but there are distinct differences between migraine and headaches. 

Migraine attacks typically last between four and 72 hours untreated. They are moderate to severe, usually with unilateral pain (throbbing that gets worse on exertion). There might be associated symptoms of nausea, vomiting and light and sound sensitivity. 

One in 10 sufferers will experience an aura prior to the headache pain and this can last anywhere from five to 60 minutes. An aura typically presents itself as a visual disturbance, such as flashing lights, zig-zag lines or a loss of part of the vision. Other aura symptoms can include sensory or motor symptoms. It is possible to have aura without headache and for some patients this can be just as disabling. Migraine is an intermittent condition and sufferers should be pain free between attacks.

Although everybody’s migraine is different, there are five basic stages: [8]

1 The warning (prodrome) stage Some people (about 40%) are able to recognise this over time. Symptoms can include yawning, being very tired, very energetic or cravings for sweet food. 

2 The aura stage Common aura symptoms are visual disturbances such as flashing lights, blurred vision or blind spots. About 10% of patients report aura with each attack (30% with some attacks).  There are also less common symptoms that include pins and needles, confusion and speech difficulties. This phase of an attack can be very frightening, especially the first time it happens. 

3 The headache phase This is the main stage where the patient will have a headache and or abdominal pain and other symptoms such as sensitivity to light, sounds and smells. It is unlikely that sufferers will be able to continue with normal activities and they may want to sleep. 

4 The postdrome stage At this stage, the pain is getting better but the sufferer may feel tired and run down.

5 The recovery stage It can take about 48 hours to fully recover and feel back to normal, although some patients recover more quickly.

Chronic migraine

Chronic migraine, by contrast, is not intermittent and is a more chronic condition. While it shares many of the symptoms of a migraine, it is more debilitating because of the greater frequency of days affected. Sufferers describe near daily symptoms – some days a background headache and some days a migraine.

It is medically defined as headaches occurring more than 15 days a month, with at least eight migraine days. This condition can have a huge burden on quality of life, including both work and family commitments. There is a greater need to assess what medications are being used acutely and a good preventive regime should be considered. 

Tension headache

Tension headaches are usually described as bilateral and like having a tight band around the head. They tend to be mild to moderate in nature and can be short or more prolonged but don’t usually have associated symptoms. 

Cluster headache

Cluster headache is more rare and tends to be experienced more by men than by women. It is characterised by episodes of acute severe pain, sometimes called suicide headache because the pain is so severe.

This comes daily and sometimes more than once a day for periods of six to eight weeks but can become more chronic in about one-third of sufferers. It is usually unilateral, accompanied by a red and watery eye on the side affected, with nasal congestion. Sufferers can be woken from sleep and can become agitated from lying in a darkened room. It has a huge impact on a sufferer’s quality of life.

Treatments

Treatments for migraine can be regarded in two broad ways: acute medications when the attack starts and preventive medications to be used every day to try to reduce the frequency of the attacks. 

Acute treatments 

Acute treatments include over-the-counter painkillers, such as aspirin, paracetamol and ibuprofen, anti-emetics and longer lasting NSAIDs such as naproxen. The only migraine-specific medications are the triptans. There are seven in the family: sumatriptan, zolmitriptan, naratriptan, rizatriptan, eletriptan, almotriptan and frovatriptan. Sumatriptan is currently available over the counter but the others remain only available on prescription. 

Triptans should be taken as early as possible but not before the onset of headache phase of the attack. They are also known as 5HT1 agonists. They come as tablets (both to be swallowed and in dispersible form), injection and nasal spray preparations. No triptan is better than another but patients who tend to vomit may need to consider a nasal spray such as zolmitriptan, which avoids the GI tract and is absorbed within the nasal spaces. 

It is important to be alert to the possibility of a medication overuse headache. This can occur in patients who are over-using NSAIDs or other over-the-counter painkillers such as opiates or triptans for more than 10 days a month.

If medication overuse is identified, it is important to explain to the patient the long-term impact this can have on their migraines but also to be sympathetic, as reducing painkillers can be very hard to do. They will need extra support to achieve this.

Preventive medications 

For any patient with more than four attacks a month, it is important to consider a preventive medication to try to reduce the frequency of their attacks. The options to be considered include:

  • Vitamins and mineral supplements Patients can administer these themselves – magnesium, vitamin B2, co-enzyme Q10. Dolovent is a new mixed product that contains all three ingredients. 
  • Medications on prescription These include ß-blockers such as propanolol, neuromodulators (topiramate, gabapentin), antidepressants (amitriptyline) and angiotensin receptor blockers (candesartan), which seems to be better tolerated than propanolol in terms of side-effects. 
  • Injectables These include Botox (licensed for chronic migraine or steroid and local anaesthetic occipital nerve injections. 
  • Neurostimulators These include Cefaly, vagal nerve stimulator (VNS) and transmagnetic stimulator (TMS). These devices have been around for about four years and some patients report success, while others have found no benefit. They should not be ruled out as they offer another option that is a non-drug approach. They are currently not available on the NHS but may become so in the future if they prove to be cost effective. 
  • Daith piercing This is a fairly new option of a piercing on the pressure point at the innermost fold of cartilage on the ear. Some patients have found success with this, but there is currently only limited long-term evidence. However, it is an inexpensive non-drug approach.
  • Physical therapies (physiotherapy, osteopathy and chiropractic treatments). There is conflicting evidence on the use of these treatments, but in the author’s clinic, they have been found to offer good adjunctive therapy and therefore a more holistic approach.

Treatment guidelines

According to the National Institute for Health and Care Excellence (NICE) guidelines [9] on headache management, propanolol and topiramate are to be considered as the first drugs of choice. Topiramate, however, can be a very difficult drug for patients to tolerate and propanolol can cause increased aura symptoms.

Many of these medications have the possibility of side-effects and this should be explained to the patient prior to use. There needs to be a balance of benefits and side-effects. 

The patient needs to know that they must give medication a chance to work and discontinue any drug that is making their symptoms worse. No one drug will suit everybody. Finding the right medication or combination can be a lengthy process.

This is where the nurse is in a unique position during this process of trial and error by offering support and reassurance that things will improve and to ascertain that the patient is using the medication at the correct dosage and for the correct length of time.

Patients with headache will also require reviews to assess the efficacy of treatments, tolerance to medications, advice and support. 

It is also important to recognise when a patient needs more specialist input. 

Nurses’ supportive and educational role

A report by the All-Party Parliamentary Group on Primary Headache states that the biggest opportunities to address the burden of headache exist with primary care and that the provision of good quality headache care is poor. 

Specialist nurses could provide a cost-effective service to help relieve this burden.

The nurse’s role in supporting migraine patients should not be underestimated. As a nurse on the helpline for the charity Migraine Action, I frequently speak to patients who value being able to talk to someone who understands their fears and concerns and provides reassurance that they are not alone.

In addition to the debilitating symptoms of migraine, sufferers who work also face additional stress from unsympathetic employers. Many employers do not fully understand the debilitating impact that migraine has and are not always willing to sign off on all the, sometimes considerable, sick days that are medically needed by their employees. 

I have spoken to patients who have even lost jobs or felt under pressure to resign because of this misunderstanding by employers. Migraine Action has produced literature to guide sufferers through these difficult issues.

Outside of work, many patients feel that they can’t plan anything in advance for fear of having an attack and letting people down. This results in them missing family commitments. 

They may feel happier to discuss these non-medical concerns with a nurse rather than a GP. Nurses often have more time to listen to these concerns and provide this supportive role. 

Charities and patient groups can play a key role in promoting awareness and supporting sufferers. Migraine Action provides patient education days across the country to educate patients on how best to manage their own condition and where to seek help with management. 

Conclusion

Primary care nurses potentially have many opportunities to diagnose migraine – for example, when patients present for smear checks or blood pressure checks. Nurses can help pinpoint the nature of the headache, offer therapeutic options, signpost patients to useful groups and offer support for some of the wider problems encountered by people with this condition. No patient should have to suffer in silence any more.

Useful groups

References

1 House of Commons. A Report of the All-Party Parliamentary Group on Primary Headache Disorders 2014. 

2 Lipton RB, Stewart WF. Migraine in the United States: A review of epidemiology and healthcare use. Neurology 1993;43:56-510.

3 MacGregor EA, Igarashi H, Wilkinson M. Headache and hormones: Subjective versus objective assessment. Headache Quarterly 1997;8:126-36.

4 Atlas of headache disorders and resources in the world. World Health Organization. 2011.

5 GBD 2015 research group. Disease and Injury Incidence and Prevalence Collaborators. Lancet 2016;388:1545-602.

6 Steiner TJ. Lifting the burden: the global campaign to reduce the burden of headache worldwide. The Journal of Headache Pain 2005;6:373-77.

7 Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013;33:629-808.

8 Blau JN. Migraine: theories of pathogenesis. Lancet 1992;339:1202-7. 

9 National Institute for Health and Care Excellence (NICE) CG150. Headaches in the over-12s: diagnosis and management. 2012 nice.org.uk/guidance/cg150