Recognising and managing migraine
Intended for healthcare professionals
CPD    

Recognising and managing migraine

Lauren Elizabeth Palk Advanced nurse practitioner, neurology, Musgrove Park Hospital, Taunton, England

Why you should read this article:
  • To update your knowledge of the ‘red flag’ migraine symptoms that could indicate a more serious condition

  • To familiarise yourself with the non-pharmacological and pharmacological management strategies available to treat migraine

  • To contribute towards revalidation as part of your 35 hours of CPD (UK readers)

  • To contribute towards your professional development and local registration renewal requirements (non-UK readers)

Migraine is a common neurological disorder characterised by a severe, pulsating headache, sometimes accompanied with photophobia or phonophobia and nausea and/or vomiting. The symptoms of migraine can have a significant adverse effect on a person’s ability to undertake normal activities. Nurses have an important role in assisting patients in identifying migraine triggers and in supporting them to manage the symptoms of migraines through lifestyle changes and pharmacological treatments. This article describes different types of migraines and some differential diagnoses and ‘red flag’ symptoms that could indicate a more serious condition. The author also discusses non-pharmacological and pharmacological management strategies and treatments.

Nursing Standard. doi: 10.7748/ns.2023.e12059

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

Lauren.palk@somersetft.nhs.uk

Conflict of interest

None declared

Palk LE (2023) Recognising and managing migraine. Nursing Standard. doi: 10.7748/ns.2023.e12059

Published online: 23 November 2023

Aims and intended learning outcomes

The aims of this article are to enhance nurses’ understanding of migraine and their ability to recognise the signs and symptoms of common types of migraine and to increase their awareness of management and treatment options. After reading this article and completing the time out activities you should be able to:

  • Discuss the signs and symptoms of migraine without aura and migraine with aura.

  • Recognise some of the less common types of migraine.

  • Identify some health conditions that may mimic the symptoms of migraine, including other headache disorders.

  • Recognise ‘red flag’ symptoms associated with headache that require escalation.

  • Describe some common migraine triggers.

  • Discuss non-pharmacological and pharmacological management and treatment options for people who experience migraine.

Introduction

Migraine is a common neurological disorder that affects around 15% of the population (Al-Hassany et al 2020). It is three to four times more common in women than in men, a disparity believed to be partly mediated by fluctuations in oestrogen and progesterone levels, although the precise mechanisms are not fully understood (Al-Hassany et al 2020). Migraine is classified as a primary headache disorder meaning there is no underlying pathology, in contrast with a secondary headache which has an underlying cause, such as temporal arteritis (inflammation of the vessels that supply blood to the head) (British Association for the Study of Headache 2019).

Symptoms commonly associated with migraine include a unilateral and severe pulsating headache, sometimes accompanied by photophobia (aversion or extreme sensitivity to light) or phonophobia (aversion or extreme sensitivity to sound) and nausea and/or vomiting. These symptoms can adversely affect an individual’s ability to undertake normal activities and can be exacerbated by simple actions (International Headache Society 2018a).

The British Association for the Study of Headache (2019) and the National Institute for Health and Care Excellence (NICE) (2021) have published guidelines for the diagnosis and management of headaches, including migraines, but do not discuss the potential adverse effects of migraine on a person’s life. It is important that nurses understand the symptoms of migraine and consider their potentially debilitating effects on an individual so that they can offer patients appropriate advice on management, including recognising migraine triggers.

This article gives an overview of the signs and symptoms of common types of migraine, describes some differential diagnoses and ‘red flag’ symptoms and discusses migraine triggers. The author also describes some non-pharmacological and pharmacological approaches to management.

Time Out 1

Have you cared for a patient who experiences migraine or do you, or someone you know, experience migraine? Make a note of the signs and symptoms. Reflect on how these symptoms affect the person’s (or your own) life

Types of migraine

The two most common types of migraine are migraine without aura and migraine with aura. The most common of these is migraine without aura, with around 70-90% of people who experience migraine having this type (Dodick 2018, Stroke Association 2023). Migraine without aura is characterised by a unilateral, severe, pulsating pain in the head sometimes with associated symptoms such as photophobia or phonophobia and nausea and/or vomiting. This type of migraine can affect the individual’s ability to continue normal activities of daily living and the symptoms can be exacerbated by simple tasks or actions, such as walking up the stairs (International Headache Society 2018a). Diagnostic criteria for migraine without aura are shown in Box 1.

Box 1.

Diagnostic criteria for migraine without aura

  • A. At least five attacks fulfilling criteria B-D

  • B. Headache attack lasting 4-72 hours (untreated or unsuccessfully treated)

  • C. Headache has at least two of the following characteristics:

    • Unilateral

    • Pulsating quality

    • Moderate or severe pain intensity

    • Aggravated by, or causing avoidance of, routine physical activity (for example, walking or climbing the stairs)

  • D. During the headache, the individual experiences at least one of the following:

    • Nausea and/or vomiting

    • Photophobia/phonophobia

  • E. Symptoms cannot be more accurately accounted for by another diagnosis from the International Classification of Headache Disorders 3rd edition (International Headache Society 2018b)

(International Headache Society 2018a)

Migraine with aura is less common, with an estimated 10-30% of people who experience migraine having this type (Dodick 2018). This type of migraine involves sensory disturbances – referred to as aura – which often precede a headache and which progress over a short period of time (5-20 minutes) and tend to reduce in less than an hour (Greenberg et al 2020). These sensory disturbances commonly manifest as visual disturbances, for example flashing lights, blind spots, tunnel vision or wavy lines in the field of vision. Less common aura can include pins and needles, dizziness, numbness or tingling sensation or weakness on one side of the body (International Headache Society 2018c). Box 2 lists diagnostic criteria for migraine with aura.

Box 2.

Diagnostic criteria for migraine with aura

  • A. At least two attacks fulfilling criteria B and C

  • B. One or more of the following fully reversible aura symptoms:

    • Visual

    • Sensory

    • Speech and/or language

    • Motor

    • Brainstem

    • Retinal

  • C. At least three of the following characteristics:

    • At least one aura symptom spreads gradually over ≥5 minutes

    • Two or more aura symptoms occur in succession

    • Each individual aura symptom lasts 5-60 minutes*

    • At least one aura symptom is unilateral†

    • At least one aura symptom is positive‡

    • The aura is accompanied, or followed within 60 minutes, by headache

  • D. Symptoms cannot be more accurately accounted for by another diagnosis from the International Classification of Headache Disorders 3rd edition (International Headache Society 2018b)

*When for example three symptoms occur during an aura, the acceptable maximal duration is 3 × 60 minutes. Motor symptoms may last up to 72 hours Aphasia is always regarded as a unilateral symptom; dysarthria (slurred speech) may or may not be Scintillations and pins and needles are positive symptoms of aura

(International Headache Society 2018c)

Although migraine with and without aura are the most common types, other less common types of migraine can have symptoms that may be concerning to the person experiencing them. It is important that the nurse has an awareness of different types of migraine so that they can offer reassurance to the person. Some examples of less common migraine types in adults are shown in Table 1.

Table 1.

Examples of less common migraine types in adults

Migraine typeFeatures
Menstrual migraine
  • Migraine linked to menstruation and which generally occurs in the two days leading up to a period and during the first three days once bleeding commences

  • Symptoms tend to be more severe and can last longer than other migraine types and are less responsive to treatment

Hemiplegic migraine
  • A rare type of migraine where the individual experiences weakness on one side of the body during a migraine, which may be accompanied by:

    • Visual disturbances

    • Slurring of speech

    • Dizziness or vertigo

    • Hearing problems or ringing in the ears

    • Confusion

  • The weakness may last between one hour and several days but usually resolves within 24 hours

  • The person may experience a headache before or after the weakness or may not develop a headache at all

Migraine with brainstem aura
  • A rare type of migraine associated with at least two of the following neurological symptoms:

    • Dysarthria (slurred speech)

    • Vertigo

    • Tinnitus

    • Diplopia (double vision)

    • Ataxia (unsteady gait)

    • Syncope (temporary decreased consciousness)

    • Pins and needles and/or numbness in both arms and/or legs

    • Alterations in eyesight in both eyes, for example seeing patterns or flashing lights

(Adapted from Migraine Trust 2021a)

Differential diagnoses

As mentioned previously, migraine is a primary headache disorder with no underlying pathology. However, other health conditions – including non-migraine headache disorders – can mimic migraine symptoms, so it is vital that the nurse undertakes a comprehensive patient history and assessment to exclude or identify an underlying pathology (Japp et al 2018).

Table 2 shows examples of health conditions and headache disorders that may mimic the symptoms of migraine.

Table 2.

Examples of health conditions and headache disorders that may mimic the symptoms of migraine

ConditionCharacteristics
Transient ischaemic attack (TIA)
  • TIAs and migraine have similar symptoms, including headache and visual disturbances. However, a migraine headache usually develops gradually whereas a headache associated with TIA develops suddenly

Brain tumour
  • Very rare cause of headache

  • Characterised by a throbbing or dull headache that deteriorates over time and can be more painful in the morning

  • Occurs as a result of a build-up of pressure in the cranium, due to blocking of the flow of cerebrospinal fluid or the tumour pressing on nerves or other vessels

Temporal arteritis (giant cell arteritis)
  • Chronic vasculitis characterised by granulomatous inflammation in the walls of medium and large arteries

  • Symptoms include new-onset, unilateral headache in the temporal area alongside visual disturbances

  • Usually affects people aged >50 years

Subarachnoid haemorrhage
  • A sudden, severe, acute headache caused by cerebral bleeding

  • This may be accompanied by stroke-like symptoms, blurred vision and nausea and/or vomiting

Sinusitis
  • Caused by inflammation of the sinuses

  • The person may experience headache with pain around the eyes, across the forehead and over the cheeks

Medicine overuse headache (rebound headache)
  • A headache that occurs due to frequent use of analgesics, such as triptans, opioids, non-steroidal anti-inflammatories or paracetamol

  • Often develops in people with a primary headache disorder such as migraine or who have a family history of migraine

  • Headache usually occurs ≥15 days per month

Cluster headache
  • A primary headache disorder characterised by sudden onset of severe pain on one side of the head, often around the eye

  • Often occurs in cycles or clusters and is more common in men than in women

  • Can last between 15 minutes and three hours

  • Often develops during the night

While most headaches are benign, it is important that nurses can recognise ‘red flag’ symptoms so that they can escalate the patient’s care as appropriate. Red flag symptoms include (NICE 2022):

  • Headache with systemic signs and symptoms, such as rash, fatigue, neck stiffness – may indicate meningitis.

  • Headache with neurological signs and symptoms, such as loss of consciousness or focal neurological signs (that is, impairment of nerve, spinal cord or brain function that affects a specific part of the body) and which are not typical aura signs – may indicate transient ischaemic attack or stroke.

  • Sudden onset headache with maximal intensity occurring within seconds to minutes (also known as a thunderclap headache) – may indicate subarachnoid haemorrhage.

  • New headache in patients aged >50 years – may indicate temporal arteritis.

  • Headache with evidence of papilledema (swelling of the optic nerve) on fundoscopy – may indicate space occupying lesion.

  • Positional headache, particularly if symptoms deteriorate when sitting in the upright position – may indicate a cerebrospinal fluid leak and resulting intracranial hypotension.

  • Patients with secondary risk factors; for example, new onset headache in patients who are immunocompromised or following trauma – may indicate central nervous system infection or subarachnoid haemorrhage.

Time Out 2

Think about any patients you have cared for who presented with a migraine-type headache (with or without a previous diagnosis of migraine). How did you rule out other potential causes? Were there any red flag symptoms? What did you do if you identified red flag symptoms? If you have not cared for a patient with this presentation, imagine such a scenario and consider what information you would require from the patient to rule out other potential causes of the headache

Migraine triggers

The pathophysiology of migraine is complex and not fully understood. There are various emerging theories – for example, activation of the trigeminal nerve and possible inflammation of the meningeal vasculature causing a change in the way pain is processed by the brain (Grossman and Porth 2014) – that are beyond the scope of this article. Migraines are, however, understood to be caused by abnormal brain activity which affects the nerve signals, chemicals and blood vessels in the brain temporarily. It is also believed that genes may have a role because the condition is often familial (NHS Inform 2023).

More is understood about migraine triggers – the factors involved in activating a migraine. A trigger in this context has been described as something that happens to a person, or something that they do, that results in them experiencing a migraine (Migraine Trust 2021b). Common migraine triggers can be categorised as emotional, physical, dietary, environmental and medicine-related (Knott 2021, NHS Inform 2023).

Nurses can encourage people to keep a diary of their migraine experience to help to identify triggers. Box 3 shows some examples of migraine triggers.

Box 3.

Examples of migraine triggers

Emotional – stress, anxiety, tension, shock, depression, excitement

Physical – tiredness, inadequate sleep quality or amount, shift work, suboptimal posture, hypoglycaemia, strenuous exercise

Dietary – missed, delayed and/or irregular meals, dehydration, alcohol, caffeine, chocolate, citrus fruits, foods containing tyramine

Environmental – bright lights, flickering screens, smoking, loud noises, changes in climate, strong smells

Medicine-related – combined oral contraceptive pill, hormone replacement therapy

(Adapted from NHS Inform 2023)

Time Out 3

You have an appointment with a patient who has recently been experiencing two to three migraines every month. The patient is a 42-year-old married woman who has three children and works part time in an office. What questions might you ask the patient to help her identify possible triggers? Think about emotional, physical, dietary, environmental and medicine-related triggers

Management

Management to support people who experience migraines can be categorised as lifestyle and trigger management (non-pharmacological), acute treatment (medicines taken during migraine) and preventative treatment (medicines that aim to reduce the likelihood of developing a migraine) (Weatherall 2015). The overall aim of management is to reduce the frequency and severity of migraines and to avoid headaches related to medicine overuse. For most people who experience migraine, a combination of lifestyle and trigger management and pharmacological treatment is the most effective option (Manning et al 2007).

Management and treatment plans should be tailored to an individual’s needs, taking into account their lifestyle and the potential effect of any lifestyle changes on their quality of life, as well as the potential adverse effects and contraindications of any medicines. Non-pharmacological management approaches are particularly important for women who are pregnant or trying to conceive and for people who wish to avoid medicines for other reasons (Manning et al 2007).

Lifestyle and trigger management

Robblee and Starling (2019) proposed evidence-based lifestyle modifications based on the acronym ‘SEED’ – sleep, eat, exercise and diary – as a way of supporting people to modify migraine triggers and reduce the severity of symptoms.

Key points

  • Migraines may be caused by abnormal brain activity which affects the nerve signals, chemicals and blood vessels in the brain temporarily

  • While most headaches are benign, it is important that nurses can recognise ‘red flag’ symptoms so that they can escalate the patient’s care as appropriate

  • The overall aim of management is to reduce the frequency and severity of migraines and to avoid migraine triggers

Sleep

Inadequate sleep is a well-recognised migraine trigger (Kim et al 2017). Sleep apnoea and insomnia are associated with increased frequency of migraines, therefore this should be identified when taking the patient’s history (Robblee and Starling 2019, Agbétou and Adoukonou 2022). If inadequate sleep is identified during history taking, nurses can provide advice on sleep hygiene, for example establishing a bedtime routine, such as going to bed at the same time each night, avoiding stimulants such as nicotine or caffeine before bed and putting mobile phones on silent (Swann 2017).

Eat

There is no specific diet recommended for managing migraine, however some evidence suggests elimination diets and diets high in certain nutrients such as folates can reduce the severity of symptoms (Hindiyeh et al 2020). An elimination diet involves removing foods from the diet that are suspected migraine triggers; for example, removing caffeine, cheese, chocolate and milk from the diet has been found to reduce the frequency of migraines in some people (Hindiyeh et al 2020). Elimination diets are controversial, however, as removing foods can result in inadequate intake of protein, energy and micronutrients, resulting in undernutrition (Gazerani 2020).

If a patient decides to try to identify and eliminate certain foods, the nurse can encourage them to make a note of these foods and record whether this has reduced the frequency and/or severity of their migraine symptoms. However, it may be more realistic to encourage the person to maintain a regular eating pattern, explaining that missing meals or irregular eating can trigger migraine (Weatherall 2015). Another important principle of dietary management is maintaining optimal fluid intake, as dehydration is a recognised migraine trigger, and reducing caffeine intake (Migraine Trust 2021b).

Exercise

While the relationship between migraine frequency and obesity is not well understood, a case control study concluded that migraine is significantly associated with obesity (defined by the researchers as body mass index ≥30) and overweight (Adoukonou et al 2018). Although the effect of losing weight on the frequency and intensity of migraine is unknown, this modification is advised and should be encouraged by nurses where appropriate (Marmura 2018).

Diary

Keeping a headache diary can identify the number of days per month an individual experiences a migraine as well as the days they are migraine free (Agbétou and Adoukonou 2022). The main information that should be recorded is the date of the migraine, the severity of the pain and the type, dose and effectiveness or lack of effectiveness of any analgesia taken. This information can help to determine the severity of symptoms and support development of an individual treatment plan. Additionally, it may help to identify if the person is experiencing medicine overuse headaches (Dean 2020).

A headache diary can also be used to identify migraine triggers and/or patterns, for example by recording foods eaten, fluids taken, sleep pattern and menstrual cycle.

Time Out 4

Choose three triggers from the list of examples in Box 2. Thinking again about the patient in Time out 3, consider what lifestyle management advice you might offer, based on the acronym SEED (sleep, eat, exercise, diary), for each trigger

Acute treatment

The main goal of acute treatment is to identify a reliable and effective way of restoring an individual’s ability to function. NICE (2023a) recommends monotherapy with either aspirin, a non-steroidal anti-inflammatory (such as ibuprofen) or a 5HT1-receptor agonist (a triptan), which should be taken as soon as the person knows they are developing a migraine. In people with migraine with aura, NICE (2023a) recommends taking a 5HT1-receptor agonist at the start of the headache rather than at the start of the aura, unless they both start at the same time.

Opioids should not be prescribed for the acute management of migraine as these medicines are ineffective for this type of pain, may increase the risk of rebound headache (medicine overuse headache) and are associated with a risk of addiction. An oral anti-emetic should be considered in addition to acute treatment for migraine even in the absence of nausea and vomiting (NICE 2021); gut absorption slows down during a migraine attack, therefore taking an anti-emetic may improve absorption (Migraine Trust 2021c).

While acute treatments can be effective in reducing the severity of symptoms during a migraine attack, if they are taken too often (10-15 days or more per month, depending on the medicine) this can result in medicine overuse headache (Migraine Trust 2021d). Medicine overuse headache is one of the most common complications of primary headaches such as migraine (Gillies 2009). When a high level of an analgesic is taken on a regular basis, the pain returns as each dose wears off resulting in withdrawal symptoms, which the person then attempts to relieve by further use of the analgesic, resulting in a cycle of medicine overuse. Eventually, the analgesic stops relieving the original pain and starts to cause more pain (Migraine Trust 2021d).

Pregnant women should be advised to take paracetamol for the acute treatment of migraine. A non-steroidal anti-inflammatory or a triptan can be considered once the risks compared with the benefits of the use of these medicines during pregnancy have been discussed between the prescribing clinician and the patient (NICE 2021).

Preventative treatment

Preventative treatment is usually considered when the frequency and severity of migraines have significant adverse effects on the person’s daily life. Choice of treatment is dependent on patient preference, medicine interactions and comorbidities (NICE 2023a). The main medicines used as preventative treatments are beta blockers, such as propranolol hydrochloride, tricyclic antidepressants, such as amitriptyline hydrochloride, and anticonvulsants, for example topiramate or sodium valproate; sodium valproate must not be taken by pregnant women (NICE 2023a).

When discussing preventative treatment options with the person it is important that the nurse explains that the first-choice option may not work and that other medicines may need to be tried. NICE (2023a) recommends first-line treatment with propranolol or topiramate, both of which have contraindications and cautions. For example, propranolol is contraindicated in people with a known history of asthma or bronchospasm due to potential side-effects which can cause bronchospasm. Topiramate should be used with caution in women of childbearing age because there is a risk of fetal malformation, particularly when used in the first trimester. Women of childbearing age should therefore be advised to take effective contraception such as medroxyprogesterone acetate depot injection or to have an intrauterine device inserted if they decide to take migraine preventative medicines. If they are taking a contraceptive pill, this should be used along with a barrier method such as a condom (Joint Formulary Committee 2023).

Calcitonin gene-related peptide receptor agonists

Calcitonin gene-related peptides (CGRP) are a type of protein which have a role in pain transmission. A relatively new treatment for migraine is CGRP monoclonal antibodies (CGRP receptor agonists), which target CGRP proteins to prevent migraine developing by blocking or reducing the body’s absorption of CGRP to interrupt the process that leads to migraine symptoms (Ho et al 2010, Edvinsson 2017, Migraine Trust 2021e). These medicines are administered subcutaneously due to potential adverse effects on the digestive system (Berger 2022). Advantages of CGRP monoclonal antibodies medicines in the prevention of migraine include a long half-life (which can be weeks to months), limited toxicity and low risk of medicine interaction (Migraine Trust 2021e). However, CGRP monoclonal antibodies are not advised for use during pregnancy due to some reported incidences of toxicity, premature labour and spontaneous abortion (Migraine Trust 2021e).

At the time of writing, three CGRP monoclonal antibodies – erenumab, fremanezumab and galcanezumab – were available on NHS prescription (Weatherley 2022, Joint Formulary Committee 2023). In July 2023, NICE (2023b) published guidance recommending the use of rimegepant, a CGRP receptor antagonist, for the prevention of episodic migraine in adults who have at least four and fewer than 15 migraine attacks per month, only if at least three preventative treatments have not worked. Rimegepant does not constrict or tighten blood vessels, making it a potential option for people with cardiovascular related risks (Migraine Trust 2021f).

Headache clinics

Most people who experience headache are managed in primary care, usually by their GP or practice nurse. However, some patients may be referred to a headache clinic, which may be linked to a hospital neurology department and staffed by a multidisciplinary team, including a consultant neurologist, a headache nurse specialist and a pharmacist (Migraine Trust 2021g). The headache nurse specialist has a crucial role in providing patients with a diagnosed primary headache disorder such as migraine with support, education and management (Bhola and Ertem 2022).

Time Out 5

Is there a headache clinic in your locality? If so, what is the referral process? Could you meet with and/or shadow one of the multidisciplinary team members to enhance your practice in supporting patients with migraine? You could write a reflection of this experience. You can also access the NHS RightCare: Headache & Migraine Toolkit (www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2020/01/rightcare-headache-and-migraine-toolkit-v1.pdf) which aims to support healthcare services to improve headache and migraine care delivery

Conclusion

Migraine is a primary headache disorder, the symptoms of which can significantly disrupt people’s ability to function normally. Some health conditions, including headache disorders, can mimic the signs and symptoms of migraine, so it is important that the nurse can distinguish between these and can recognise red flags that may indicate that patients require escalation.

Nurses can support patients to identify migraine triggers, which may help to reduce the frequency and severity of migraine, and can offer advice regarding management and treatment, which generally consists of a combination of lifestyle changes and pharmacological treatments. Treatment plans should be individualised and take account of the patient’s lifestyle, the potential effect of any lifestyle changes to the person’s quality of life, and potential adverse effects and contraindications of medicines.

Time Out 6

Identify how recognising and managing migraine applies to your practice and the requirements of your regulatory body

Time Out 7

Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account

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