How to treat a migraine

Nursing, Dec 2002 by McGuire, Lora

QUESTION: My patient came to the ED for severe migraine pain that hadn't been relieved by over-thecounter (OTC) medication. Why would she wait so long to get help?

ANSWER: Many patients try to cope on their own until they can't control the pain with OTC medications. They also can become weary of repeated episodes or start to worry about a serious disorder, such as a brain tumor. What most patients don't know is this: OTC medications may actually worsen migraine pain by causing a rebound headache. By teaching your patient to recognize early symptoms of a migraine and treat it appropriately, you can help her avoid another visit to the ED.

More than a headache

Migraine affects nearly 28 million Americans, mostly women. Less than one-half of these sufferers are properly treated. No medical test exists for diagnosing migraine, but you can assess the condition by asking your patient the following questions:

* What are the onset, location, duration, characteristics, aggravating factors, associated symptoms, relieving factors, and treatment to date of your headache?

* What other symptoms precede (such as an aura) and accompany your headache, such as phonophobia or photophobia?

* What is your medical history? Also, what is your cardiovascular history? (Some drugs used to treat migraines have serious cardiovascular adverse effects.)

What OTC medications are you taking? Are you using any herbs or alternative therapies?

What triggers your migraine attacks? For example, do,certain smells, foods, hunger, or your menstrual period trigger an attack?

After asking these questions, perform a physical assessment. Then compare your findings with the diagnostic criteria of a migraine (see How Do I Know It's a Migraine?).

Treating a migraine

Treatment with abortive and preventive medication depends on the level of disability associated with the headache episode.

An abortive medication works by alleviating inflammation and reducing the severity and duration of a migraine attack. Nonsteroidal anti-inflammatory drugs such as naproxen and ibuprofen are effective first-line drugs in some cases. Metoclopramide (Reglan) taken orally may speed drug absorption and also helps to relieve nausea.

Triptans are a class of drugs that have proven very effective for migraine pain. Five triptans are on the market: sumatriptan (Imitrex), rizatriptan (Maxalt), zolmitriptan (Zomig), naratriptan (Amerge), and almotriptan (Axert). These drugs, available in oral, parenteral, or nasal spray forms, are contraindicated in patients with a history of cardiovascular or peripheral vascular disease or severe hypertension. Their use should be limited to no more than two doses a day.

If a triptan is contraindicated or ineffective, the prescribes may order Midrin or the vasoconstrictor dihydroergotamine (Migranal) nasal spray. Midrin is a migraine-- specific combination drug that contains acetaminophen, a vasoconstrictor, and a sedative.

Second-line migraine abortive medications include the older group of ergotamine drugs such as Cafergot (ergotamine and caffeine), parenteral ketorolac (Toradol), butorphanol (Stadol) nasal spray, and dihydroergotamine IN. or LM. Teach your patient that overuse of any of the abortive medications can lead to rebound or chronic daily headache, which is a challenging syndrome to treat.

Preventive medications such as beta-blockers, calcium channel blockers, tricyclic antidepressants, selective serotonin reuptake inhibitors, and divalproex have been found effective in reducing the frequency of headache episodes. Women with hormonal headaches due to estrogen withdrawal may benefit from oral contraceptives to maintain estrogen levels.

Put your finger on the trigger

Help your patient identify what triggers her migraine attacks so she can try to reduce their frequency. Common culprits are stress, changes in weather, perimenstrual changes, skipped meals, bright or flickering lights, lack of sleep, certain foods (red wine, cheese), perfume and other strong odors, cigarette smoke, oversleeping, and exercise.

To track what triggers her migraines as well as which medications alleviate her pain, advise her to keep a diary. During each episode, she should write down what happened before the migraine as well as which medications alleviated her pain. For a copy of a migraine diary, which can be photocopied, go to JAMA's migraine information center at http://www. ama-assn.org(special/migraine/ support/educate/diary.htm.

To obtain copies of the International Headache Society's migraine guidelines, visit http://www.i-h-s.org or call Blackwell Science Society Membership at +44 (0) 1865 206180.

SELECTED REFERENCES

Adelman, J., and Adelman, R.: "Current Options for the Prevention and Treatment of Migraine," Clinical Therapeutics. 23(6):772-788, June 2001. Braunwald, E., et al.: Harrison's Principles of Internal Medicine. New York, N.Y., McGraw-Hill Co., Inc., 2001.

Goadsby, P., et al.: "Migraine-Current Understanding and Treatment," The New England Journal of Medicine. 346(4):257-270, January 24, 2002. Lipton, R., et al.: "Migraine Diagnosis and Treatment: Results from the American Migraine Study II," Headache. 41(7):638-645, July-August 2001.