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Migraine Headaches

Definition, Pathophysiology Incidence, and Prevalence

Migraine headaches are a particular type of recurrent headache that can be debilitating for the affected individual. They can occur with or without preceding focal neurologic symptoms or have an atypical presentation (Ferri, 2018). The classification of headaches is as follows: vascular (migraine and cluster), muscle contraction (tension), mixed headaches (vascular and muscle), traction, or inflammatory headaches (Warren, 2017). Migraine headaches are typically severe and throbbing and last from 4 to 72 hours, accompanied by either or both nausea or vomiting and photophobia or phonophobia (Warren, 2017). The pain from migraines may occur all over the head but typically is localized to a hemisphere; migraine pain is throbbing in character, of moderate or severe intensity, and made worse by exercise (Ferri, 2018). Migraine incidence increases from infancy, peaks during the 30’s and typically decreases over time; peak ages are between 18 and 49 years of age (Ferri, 2018). There is a 3:1 female (18% of females) to male (6% of males) ratio of migraine sufferers and more than 50% of migraine sufferers have an affected family member (Ferri, 2018). Migraines are often hereditary and so acquiring a thorough family history is important in order to determine a diagnosis for the headache sufferer. The pathophysiology of migraines is not clear; however, there is evidence supporting that a primary neuronal event can result in trigeminovascular reflex which causes neurogenic inflammation (Migraine, 2017; Ferri, 2018).

Physical Assessment and Examination

Migraine sufferers appear normal between migraine headache episodes. Migraines are generally unilateral, individuals can be photosensitive and sound sensitive, the pain can last for days, nausea and vomiting may occur, and some migraines may cause visual disturbances called an aura (McCance & Huether, 2014). The diagnosis of migraine without aura should include at least five migraine headache attacks that fulfill criteria; headache lasting 4 to 72 hours; and two of the following unilateral location, pulsating quality, moderate or severe pain, and aggravation or avoidance of routine physical activity (Ferri, 2018). Nausea and/or vomiting and photophobia and phonophobia generally consist of a migraine headache episode. Migraine with aura usually involves visual disturbances, such as flashes of light or wavy, zigzag vision. Sometimes migraine sufferers with auras may consist of touching sensations (sensory), movement (motor) or speech (verbal) disturbances, or muscular weakness (Migraine, 2017). The diagnosis of migraine with aura includes at least two migraine attacks, symptoms of aura is fully reversible,  Diagnostic tests such as computed tomography (CT) scan or a magnetic resonance image (MRI) with or without contrast is recommended if the individual with headaches has noticed a change in the frequency, severity, has begun having seizures with their headache, has developed personality changes, or shows any abnormal neurological findings (Dunphy, Winland-Brown, Porter, & Thomas, 2015, p. 128).

Treatment and Management Plan

Patients should be encouraged to keep a headache diary that records the number of headaches, severity, alleviating factors, and precipitating factors (stress, foods, alcohol, environmental factors, etc.). The patient should try to avoid known triggers that precipitate migraine headaches, such as alcohol, smoking tobacco, caffeine, and dietary factors; reducing stress, relaxation training, and minimizing sleep, meal, and exercise disturbances may help prevent migraine headaches. The patient’s account of headache symptoms is important to determine if the headache symptoms may be life-threatening. For example, symptoms of a subarachnoid hemorrhage may include an intense sudden onset of head pain and this can be a life-threatening condition if not treated appropriately as soon as possible (Warren, 2017). Other urgent headache causes are transient ischemia attacks or cerebral vascular attacks. Pharmacologic therapy for mild migraines includes: aspirin; ibuprofen; acetaminophen; the combination of acetaminophen, aspirin, and caffeine (Excedrin Migraine) may ease moderate migraine pain (Ferri, 2018). Moderate to severe migraine therapy includes triptans, and if necessary for additional relief, intravenous antiemetics (Ferri, 2018). Prophylaxis for migraine headaches includes the avoidance of triggers, beta-blocker medication, tricyclic antidepressants, the antiepileptic medication topiramate, valporic acid, and Botox injections. Patients should be seen by their primary monthly to follow-up on migraine therapy. A referral to neurology should be initiated if the affected individual if treatment is not effective. As a chronic migraine sufferer, it has been quite the road to determine effective prophylaxis. I would encourage patients suffering from migraines that they may benefit from combination therapies such as triptans, NSAIDs, massage, aromatherapy, topical numbing substances, and others. I have been using Botox for the past six months, it has not effectively prevented all of my migraines but the frequency has reduced! As providers, we must follow clinical recommendations but we are also always learning from others about potential effective off-label methods for migraine relief.

References

Dunphy, L., Winland-Brown, J., Porter, B., & Thomas, D. (2015). Primary care: The art and science of advanced practice nursing (4th ed.). Philadelphia, PA: F.A. Davis Company.

Ferri, F. (2018). Ferri’s clinical advisor 2018. Philadelphia, PA: Elsevier Inc.

McCance, K., & Huether, S. (2014). Pathophysiology: The Biologic Basis for Disease in Adults and Children, 7th Edition. St Louis: Mosby.

Migraine. (2017, April 26). Mayo Clinic. Retrieved March 3, 2018, from https://www.mayoclinic.org/diseases-conditions/migraine-headache/symptoms-causes/syc-20360201

Warren, E. (2017). Neurological Symptoms in primary care Part 3: Headache. Practice Nurse, 47(3), 16-19.

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