VOL: 96, ISSUE: 44, PAGE NO: 37
Frances Gibson, SRN, is a practice nurse in Suffolk
Migraine is a common complaint, thought to affect around 15%-18% of the female population and 6% of men. Many sufferers will never consult their GP, even though migraine may be disrupting their lives.
Since migraine can have a major impact on the quality of life for some individuals it needs to be taken seriously by health professionals (Bates et al, 1997). It is estimated that 18 million working days are lost to migraine each year, with the associated costs to industry and the economy. Giving the appropriate advice and treatment to patients not only transforms their lives, it also saves money for the nation as a whole.
As a result of the low consultation rates for migraine, most patients rely on self-medication and never receive advice about trigger factors or other treatments (Bates et al, 1997). Nurses are in a prime position to offer advice to patients with migraine, who may not wish to ‘bother the doctor’. Nurses can educate patients about diet and lifestyle, such as the importance of having regular meals, an adequate intake of water, less caffeine and regular sleep patterns.
Migraine is not just a simple headache. The pain can be severe and may be accompanied by other debilitating and even frightening symptoms. It is important to establish a clear diagnosis: other types of headache, such as a tension headache or chronic daily headache, require different treatments. Nurses should also be aware of the warning signs of underlying neurological disease and refer patients immediately if in any doubt (see Box 1).
Taking a careful history is the most important aspect of diagnosing migraine. The patient should be asked about the pattern and frequency of attacks. This should include duration, age at onset and whether there is a family history of migraine. Determine the severity and type of pain - whether it is a dull ache, throbbing or stabbing pain, the location of the pain and whether it is worse on moving around.
Does the patient feel well between attacks? Do they experience any other symptoms before, during or after an attack, and are all the attacks the same or are there different types? Find out if any trigger factors have been identified.
Migraine attacks typically last between four and 72 hours. The headache is moderate to severe, usually unilateral and throbbing, and is made worse by movement. Sufferers experience other symptoms including photophobia, phonophobia, nausea and sometimes vomiting. In between attacks they are completely well (Bates et al, 1997).
About one in 10 migraine sufferers will experience an aura (Blau, 1991). This is typically in the form of a visual disturbance, but can include other sensory or occasionally motor symptoms. These usually precede the headache and may last for five to 60 minutes. Some patients will experience aura symptoms without the onset of headache, which, if a change in pattern, may indicate underlying pathology (Ferrari, 1998).
Most migraine sufferers have fewer than 20 attacks a year, with the majority suffering 13-15 attacks a year. A few individuals will have frequent attacks and may benefit from prophylactic treatment for their migraine.
Other types of headache
It is important to recognise that there are many other causes of headache, not least as the symptom of underlying disease or infection. Few people have never experienced a headache at any time in their lives, perhaps as the result of a flu-like illness or from drinking alcohol. Headache may also be caused by stress and tension. Remember that individuals may suffer from different types of headache at different times and that treatment needs to be varied accordingly.
A tension headache is commonly bilateral, often being described as like a band around the head or a pressure on the head. The pain is mild to moderate and may persist for long periods of time although it can also be quite brief. Headaches that occur daily or on more than 15 days each month are unlikely to be migraine alone. This pattern of headache represents chronic daily headache syndrome.
Chronic daily headache (CDH) typically features episodic migraines superimposed on a background of constant headache. This condition may be induced by overuse of analgesics - particularly compounds which include codeine - triptans and ergot preparations. These patients will only improve if the drugs are discontinued, which may take up to eight weeks and require the use of other non-addictive medication to help with pain. Some patients may need referral to a specialist in order to come off these drugs.
Nurses need to be aware of this condition and ascertain what and how many analgesics patients are consuming - a medication history should always be taken. Many patients are unaware that they are overusing medication and have a perception that over-the-counter products are not going to be harmful, even when consumed in frequent and high doses.
A cluster headache is rare, affecting only 0.1 per cent of the population (Goadsby and Olesen, 1996). It predominately occurs in men and is characterised by episodes of acute and agonising headaches for periods of typically six to eight weeks. Pain is very severe, unilateral, often accompanied by red and watery eye, rhinorrhoea, nasal congestion, ptosis (droopy eyelids) and sweating. Attacks usually last 15-45 minutes but may be longer. Sufferers may be woken from sleep with the intense pain, and there can be a significant impact on a sufferer’s quality of life due to sleep disturbance.
The goal of migraine treatment should be to minimise the effects of the condition on the individual’s life (Hackett et al, 1994). For acute treatment there is a choice between simple soluble analgesics (sometimes in high doses) with antiemetics and the migraine-specific drugs.
Before consulting a doctor or nurse, many sufferers will have tried a range of analgesics bought over the counter. For some patients administration of soluble aspirin or paracetamol in the early stages of an attack will work very well; the addition of an antiemetic, to reverse gastric stasis and aid analgesic absorption as well as helping those with nausea or vomiting, should be considered.
Taking 2mg of ergotamine 1 at the onset of an attack may also be effective. However, ergotamine is associated with some unpleasant side-effects including nausea, colic, cold extremities and intermittent claudication. If used frequently (more than once a week) it may cause CDH or ergot-dependency (Lance, 1992).
The triptans are a migraine-specific class of drug for acute treatment of the condition. Triptans are 5-HT1 agonists and they work effectively at relieving both the headache and other migraine symptoms. Currently there are four triptans available on prescription: sumatriptan (Imigran), zolmitriptan (Zomig), naratriptan (Naramig), and rizatriptan (Maxalt). Sumatriptan is available as a nasal spray and a self-administering injection; rizatriptan is available as an oral melt preparation.
These preparations should be used at the onset of the migraine headache (they are not effective at preventing the aura if this occurs). They should not be used as prophylactic agents.
The introduction of these drugs has made a significant difference to the management of patients with migraine and has transformed the lives of many sufferers. They are fast and effective at relieving symptoms with relatively few side-effects. Relief is felt often after only half-an-hour after oral dosing; some patients may require a second dose if symptoms recur. Sumatriptan may cause an unpleasant feeling of heaviness or tightness, especially around the chest or throat. Other side-effects related to triptans include drowsiness, and transient nausea, vomiting and tingling.
Triptans should not be used:
- If a patient has ischaemic heart disease;
- In the case of a previous myocardial infarction or uncontrolled hypertension;
- In conjunction with ergotamine, lithium or monoamine-oxidase inhibitors.
If migraine attacks are frequent, prophylactic agents may be used as a short-term strategy in combination with acute treatments. Treatment should be reviewed after 3-6 months and then withdrawn to see if attacks return with the same frequency (Bates et al, 1997).
Commonly prescribed prophylactic agents are pizotifen, the beta-blocker propanolol and amitriptyline and sodium valproate. All these drugs are associated with unpleasant side-effects and response to treatment may be poor (attacks are reduced by 50% in about 50% of cases).
The British Association for the Study of Headache and Migraine in Primary Care Advisers have both produced treatment guidelines.
Trigger factors may be important for some individual migraine patients and, by urging patients to keep detailed headache diaries, patterns and associations can become apparent.
Common triggers are certain foods and drink (especially red wine), although the first stage of an attack can involve a craving for a certain food, which is then mistakenly blamed as a trigger. Other common triggers include female hormones, stress, tiredness and skipped meals. Anything can trigger an attack. Often a combination of triggers is needed rather than an individual event or food in isolation. If patients can identify trigger factors and avoid them or minimise them, migraine frequency can be significantly reduced for certain individuals.
Nurses can play a significant role in migraine management by identifying patients and offering them support, empathy and advice. Many patients will benefit from information about the correct use of over-the-counter products, trigger factors or use of other migraine-specific treatments.
In the past migraine has often been disregarded by the medical profession as being of little significance, but with new treatments available patients need no longer suffer in silence.