58 l Nursing2014 l January
www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Preventing By Yvonne D’Arcy, MS, CRNP, CNS
SHAUNL /iSTOCK
HEADACHES ARE ONE OF THE MOST COMMON pain complaints that healthcare providers encounter in outpatient settings and EDs. Among all types of headache, migraines are the most difficult to manage. Treating migraine pain in an ED or outpatient setting can be especially challenging when nausea and vomiting, which often accompany migraine pain, compromise the oral route for medications. This article discusses how nurses can educate adult patients about potential migraine triggers and the use of medications and techniques to help prevent them. Managing migraine attacks is beyond the scope of this article and will be addressed in a future article.
www.Nursing2014.com
Most debilitating The International Headache Society classifies primary headaches in four categories, each with specific diagnostic criteria.1 • migraine: the two main types are migraine without aura and migraine with aura. Aura, defined as the early symptoms of a migraine attack, is caused by focal cerebral dysfunction and usually lasts 20 to 30 minutes. Visual aura is most common, followed by sensory disturbances such as paresthesias. • tension-type headache: includes infrequent and frequent episodic tension-type headaches, as well as chronic and probable tension-type headaches. • trigeminal autonomic cephalalgias: includes cluster headache and paroxysmal hemicrania among other types.
headache in adults
MIGRAINE
January l Nursing2014 l 59
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
• other primary headache disorders, such as primary cough headache, primary exercise headache, and primary thunderclap headache. Migraine, the most debilitating primary headache disorder, is defined as a neurovascular disorder characterized by headache, autonomic system dysfunction, and gastrointestinal symptoms. Migraine is considered chronic when headache is experienced for 15 or more days per month for more than 3 months, with the features of migraine headache experienced at least 8 days per month.1 The sudden and often unpredictable onset of severe migraine headache and associated symptoms can disrupt a patient’s life, creating anxiety and fear of the unexpected. This may prevent patients from making social commitments or participating in leisure activities and increase absenteeism in the workplace. Who gets migraines? In the general population, the prevalence of migraines is 18% for women and 6% in men.2 (See A bigger headache for women for more on women’s susceptibility to headaches.) About one-third of all patients experience an aura before migraine headache.3 An estimated 80% of migraineurs have a positive family history of
A bigger headache for women2,10 The occurrence of headache is similar in both sexes until puberty, when women experience twice as many headaches as men. Here are some of the major differences in the headaches that women experience. • Women experience greater disability with headaches causing more missed days of work, restricted activity, and a more negative effect on family responsibilities. • More women than men seek healthcare for headache pain; 68% of women are headache sufferers. • Women are 40% more likely to receive a prescription medication to treat headache pain.
60 l Nursing2014 l January
migraine.4 Although the pathophysiology isn’t well understood, a genetic cause is suspected and new research supports this view.3 Signs, symptoms, and triggers Besides severe headache pain, patients with migraines experience symptoms such as nausea, vomiting, photophobia (sensitivity to light), phonophobia (sensitivity to sound), and osmophobia (sensitivity to odors).1 Nurses caring for a patient experiencing a migraine headache know that managing all these symptoms can be daunting. They may get one symptom under control but be unable to control others. Migraines have many potential triggers, including certain foods, alcohol, and emotional stress or anxiety. (See What can trigger a migraine?) In women, migraines may be associated with menses and can be classified as menstrually related migraine (MRM). Options for prophylaxis Although there’s no cure for migraines, the evidence supports use of certain medications for prophylaxis. Published in 2012, updated guidelines from the American Academy of Neurology (AAN) and the American Headache Society (AHS) indicate that while 38% of American migraine sufferers would benefit from a preventive medication, only 3% to 13% are taking one.5 Prophylactic therapy is indicated for patients whose headaches are frequent (once a week or more frequently), long-lasting, or the cause of significant disability.6 Given the high level of disability with migraines, using medication once or twice a day to prevent headaches or minimize the intensity of headaches if they occur would seem a good strategy for migraineurs. The updated guidelines address pharmacologic treatment for episodic migraine prevention in adults. The authors analyzed information from 29 studies published between 1999 and 2009 to determine which treatments for migraine prevention are supported by the evidence. They
What can trigger a migraine?4,10 Identifying migraine triggers helps patients prevent migraines. The following is a partial list of common triggers experienced by migraine sufferers. Many ingested substances can serve as migraine triggers; for example • certain foods, such as pickled, preserved, or fermented foods (aged cheese, salami, or freshly baked breads), fruits, nuts, and chocolate • alcohol • caffeine withdrawal. Physical triggers, which are more diverse and individualized, include • lack of sleep or too much sleep • illness or emotional stress • strong odors • weather and seasonal changes.
rated medications for efficacy and ranked them as follows.5 • Level A, established efficacy. Antiepileptic drugs: divalproex sodium, sodium valproate, topiramate. Betablockers: metoprolol, propranolol, timolol. For MRM: the triptan frovatriptan for short-term prophylaxis. • Level B, probably effective: Antidepressants: amitriptyline, venlafaxine. Beta-blockers: atenolol, nadolol. For MRM: naratriptan and zolmitriptan for short-term prophylaxis. • Level C, possibly effective: angiotensin-converting enzyme inhibitor: lisinopril. Angiotensin receptor blocker: candesartan. Alpha-agonists: clonidine, guanfacine. Antiepileptic drug: carbamazepine. Beta-blockers: nebivolol, pindolol. Antihistamine: cyproheptadine. Level U preventive therapies include medications with inadequate or conflicting data to support or refute medication use, such as antithrombotics. The other category includes medications that are established as possibly or probably ineffective, such as the antiepileptic drug lamotrigine. The 2012 AHS/AAN Guidelines for Prevention of Episodic Migraine: A Summary and Comparison With Other www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Recent Clinical Practice Guidelines discusses nonsteroidal anti-inflammatory drugs (NSAIDs) and complementary and alternative medicine therapies to prevent or reduce the number of headaches. It presents some interesting findings.7 • Level A, established as effective: An extract of Petasites hybridus (butterbur) root can reduce the frequency of migraine attack by 26% to 60% at recommended dosages. However, its safety for long-term use hasn’t been established. Warn patients who try this option that the Petasites plant contains potentially carcinogenic alkaloids that are removed from commercial preparations. They shouldn’t consume any part of the plant itself, only commercial butterbur preparations.8 • Level B, probably effective: NSAIDs: fenoprofen, ibuprofen, ketoprofen, naproxen. Herbal therapies: riboflavin, magnesium, feverfew. At the other end of the spectrum, drugs and treatments that aren’t supported by sufficient evidence or are ineffective include aspirin, indomethacin, omega-3, montelukast, and hyperbaric oxygen therapy. Applying the guidelines Each patient who has migraine headaches needs an individualized preventive plan that fits his or her lifestyle and values. Trying to develop a plan of care with therapies that the patient can’t or won’t follow will only lead to frustration. Patients who need migraine prophylaxis should discuss the options with their healthcare provider to decide which therapy or combination of therapies will work best. Important factors that patients and healthcare providers should consider include costs, patient lifestyle, coexisting medical conditions, personal preferences, and age. For older adults, the recommendation for NSAIDs can be difficult to apply. The American Geriatric Society Updated Beers Criteria recommends that NSAIDs be used only for the shortest period of time at the www.Nursing2014.com
lowest dose in older adults because of the increased risk of gastrointestinal bleeding and other adverse drug reactions. Amitriptyline must also be used with caution in older adults because it can cause hypotension, increasing the risk of falls.9 Considering coexisting conditions can help clinicians determine which drug or treatment might work best. For patients who have underlying depression related to their headaches, using an antidepressant may help both conditions. For obese patients, a medication such as topiramate may be an appealing choice because weight loss is a possible side effect. Similarly, topiramate or another antiepileptic drug such as divalproex might be a good choice for patients with epilepsy. No matter which medication or treatment is selected, the patient will need to commit to an adequate trial to determine if the chosen option is effective and suits his or her treatment goals. Keeping a clear head To help patients prevent migraines, nurses and other healthcare professionals must develop a trusting collaboration with them to encourage them to actively engage in identifying migraine triggers and report the effectiveness of therapies. Give patients this advice: • Identify triggers for your migraines by trying to remember what was happening just before it started. Keep a headache diary to track what you were doing, where you were, the time of day, and what you ate before the headache began. (For a sample form, visit the National Headache Foundation at http://www.headaches.org/ For_Professionals/Headache_Diary.) • Take prophylactic medications as prescribed and promptly report any adverse drug reactions to your healthcare provider. • Try to reduce your stress levels and explore nonpharmacologic approaches to migraine prevention. The AAN’s practice parameters recommend considering relaxation
training, thermal biofeedback combined with relaxation training, electromyographic biofeedback, and cognitive-behavioral therapy.6 Reassure patients that many therapeutic options are available to help them prevent or minimize migraine headaches. By keeping a migraine diary and collaborating with the healthcare provider, they can develop an individualized plan that works for them. ■ REFERENCES 1. Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd ed (beta version). Cephalalgia. 2013;33(9):629-808. 2. Estemalik E, Tepper S. Preventive treatment in migraine and the new US guidelines. Neuropsychiatr Dis Treat. 2013;9:709-720. 3. National Institute of Neurological Disorders and Stroke. NINDS Migraine Information Page. 2013. http://ninds.nih.gov/disorders/migraine/migraine. htm. 4. Kolb-Lucas K. Strategies for treating migraines. Nursing. 2008;35(5):32-36. 5. Holland S, Silberstein SD, Freitag F, Dodick DW, Argoff C, Ashman E. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012;78(17):1346-1353. 6. Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55(6):754-762. 7. Loder E, Burch R, Rizzoli P. The 2012 AHS/AAN guidelines for prevention of episodic migraine: a summary and comparison with other recent clinical practice guidelines. Headache. 2012;52(6):930-945. 8. Bajwa ZH, Sabahat A. Preventive treatment of migraine in adults. UpToDate. 2013. http://www. uptodate.com. 9. American Geriatrics Society. Pharmacologic management of persistent pain in the older patient. J Am Geriatr Society. 2009;57:1331-1346. 10. D’Arcy Y. A Compact Clinical Guide to Women’s Pain. New York, NY: Springer Publishing; 2013. RESOURCE Holland S, Silberstein SD, Freitag F, Dodick DW, Argoff C, Ashman E. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012;78(17):1346-1353. Yvonne D’Arcy is a pain management and palliative care nurse practitioner at Surburban Hospital-Johns Hopkins Medicine in Bethesda, Md., and a member of the Nursing2014 editorial board. The author has disclosed that she has no financial relationships related to this article.
DOI-10.1097/01.NURSE.0000438711.20345.a9
January l Nursing2014 l 61
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Preventing By Yvonne D’Arcy, MS, CRNP, CNS
SHAUNL /iSTOCK
HEADACHES ARE ONE OF THE MOST COMMON pain complaints that healthcare providers encounter in outpatient settings and EDs. Among all types of headache, migraines are the most difficult to manage. Treating migraine pain in an ED or outpatient setting can be especially challenging when nausea and vomiting, which often accompany migraine pain, compromise the oral route for medications. This article discusses how nurses can educate adult patients about potential migraine triggers and the use of medications and techniques to help prevent them. Managing migraine attacks is beyond the scope of this article and will be addressed in a future article.
www.Nursing2014.com
Most debilitating The International Headache Society classifies primary headaches in four categories, each with specific diagnostic criteria.1 • migraine: the two main types are migraine without aura and migraine with aura. Aura, defined as the early symptoms of a migraine attack, is caused by focal cerebral dysfunction and usually lasts 20 to 30 minutes. Visual aura is most common, followed by sensory disturbances such as paresthesias. • tension-type headache: includes infrequent and frequent episodic tension-type headaches, as well as chronic and probable tension-type headaches. • trigeminal autonomic cephalalgias: includes cluster headache and paroxysmal hemicrania among other types.
headache in adults
MIGRAINE
January l Nursing2014 l 59
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
• other primary headache disorders, such as primary cough headache, primary exercise headache, and primary thunderclap headache. Migraine, the most debilitating primary headache disorder, is defined as a neurovascular disorder characterized by headache, autonomic system dysfunction, and gastrointestinal symptoms. Migraine is considered chronic when headache is experienced for 15 or more days per month for more than 3 months, with the features of migraine headache experienced at least 8 days per month.1 The sudden and often unpredictable onset of severe migraine headache and associated symptoms can disrupt a patient’s life, creating anxiety and fear of the unexpected. This may prevent patients from making social commitments or participating in leisure activities and increase absenteeism in the workplace. Who gets migraines? In the general population, the prevalence of migraines is 18% for women and 6% in men.2 (See A bigger headache for women for more on women’s susceptibility to headaches.) About one-third of all patients experience an aura before migraine headache.3 An estimated 80% of migraineurs have a positive family history of
A bigger headache for women2,10 The occurrence of headache is similar in both sexes until puberty, when women experience twice as many headaches as men. Here are some of the major differences in the headaches that women experience. • Women experience greater disability with headaches causing more missed days of work, restricted activity, and a more negative effect on family responsibilities. • More women than men seek healthcare for headache pain; 68% of women are headache sufferers. • Women are 40% more likely to receive a prescription medication to treat headache pain.
60 l Nursing2014 l January
migraine.4 Although the pathophysiology isn’t well understood, a genetic cause is suspected and new research supports this view.3 Signs, symptoms, and triggers Besides severe headache pain, patients with migraines experience symptoms such as nausea, vomiting, photophobia (sensitivity to light), phonophobia (sensitivity to sound), and osmophobia (sensitivity to odors).1 Nurses caring for a patient experiencing a migraine headache know that managing all these symptoms can be daunting. They may get one symptom under control but be unable to control others. Migraines have many potential triggers, including certain foods, alcohol, and emotional stress or anxiety. (See What can trigger a migraine?) In women, migraines may be associated with menses and can be classified as menstrually related migraine (MRM). Options for prophylaxis Although there’s no cure for migraines, the evidence supports use of certain medications for prophylaxis. Published in 2012, updated guidelines from the American Academy of Neurology (AAN) and the American Headache Society (AHS) indicate that while 38% of American migraine sufferers would benefit from a preventive medication, only 3% to 13% are taking one.5 Prophylactic therapy is indicated for patients whose headaches are frequent (once a week or more frequently), long-lasting, or the cause of significant disability.6 Given the high level of disability with migraines, using medication once or twice a day to prevent headaches or minimize the intensity of headaches if they occur would seem a good strategy for migraineurs. The updated guidelines address pharmacologic treatment for episodic migraine prevention in adults. The authors analyzed information from 29 studies published between 1999 and 2009 to determine which treatments for migraine prevention are supported by the evidence. They
What can trigger a migraine?4,10 Identifying migraine triggers helps patients prevent migraines. The following is a partial list of common triggers experienced by migraine sufferers. Many ingested substances can serve as migraine triggers; for example • certain foods, such as pickled, preserved, or fermented foods (aged cheese, salami, or freshly baked breads), fruits, nuts, and chocolate • alcohol • caffeine withdrawal. Physical triggers, which are more diverse and individualized, include • lack of sleep or too much sleep • illness or emotional stress • strong odors • weather and seasonal changes.
rated medications for efficacy and ranked them as follows.5 • Level A, established efficacy. Antiepileptic drugs: divalproex sodium, sodium valproate, topiramate. Betablockers: metoprolol, propranolol, timolol. For MRM: the triptan frovatriptan for short-term prophylaxis. • Level B, probably effective: Antidepressants: amitriptyline, venlafaxine. Beta-blockers: atenolol, nadolol. For MRM: naratriptan and zolmitriptan for short-term prophylaxis. • Level C, possibly effective: angiotensin-converting enzyme inhibitor: lisinopril. Angiotensin receptor blocker: candesartan. Alpha-agonists: clonidine, guanfacine. Antiepileptic drug: carbamazepine. Beta-blockers: nebivolol, pindolol. Antihistamine: cyproheptadine. Level U preventive therapies include medications with inadequate or conflicting data to support or refute medication use, such as antithrombotics. The other category includes medications that are established as possibly or probably ineffective, such as the antiepileptic drug lamotrigine. The 2012 AHS/AAN Guidelines for Prevention of Episodic Migraine: A Summary and Comparison With Other www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Recent Clinical Practice Guidelines discusses nonsteroidal anti-inflammatory drugs (NSAIDs) and complementary and alternative medicine therapies to prevent or reduce the number of headaches. It presents some interesting findings.7 • Level A, established as effective: An extract of Petasites hybridus (butterbur) root can reduce the frequency of migraine attack by 26% to 60% at recommended dosages. However, its safety for long-term use hasn’t been established. Warn patients who try this option that the Petasites plant contains potentially carcinogenic alkaloids that are removed from commercial preparations. They shouldn’t consume any part of the plant itself, only commercial butterbur preparations.8 • Level B, probably effective: NSAIDs: fenoprofen, ibuprofen, ketoprofen, naproxen. Herbal therapies: riboflavin, magnesium, feverfew. At the other end of the spectrum, drugs and treatments that aren’t supported by sufficient evidence or are ineffective include aspirin, indomethacin, omega-3, montelukast, and hyperbaric oxygen therapy. Applying the guidelines Each patient who has migraine headaches needs an individualized preventive plan that fits his or her lifestyle and values. Trying to develop a plan of care with therapies that the patient can’t or won’t follow will only lead to frustration. Patients who need migraine prophylaxis should discuss the options with their healthcare provider to decide which therapy or combination of therapies will work best. Important factors that patients and healthcare providers should consider include costs, patient lifestyle, coexisting medical conditions, personal preferences, and age. For older adults, the recommendation for NSAIDs can be difficult to apply. The American Geriatric Society Updated Beers Criteria recommends that NSAIDs be used only for the shortest period of time at the www.Nursing2014.com
lowest dose in older adults because of the increased risk of gastrointestinal bleeding and other adverse drug reactions. Amitriptyline must also be used with caution in older adults because it can cause hypotension, increasing the risk of falls.9 Considering coexisting conditions can help clinicians determine which drug or treatment might work best. For patients who have underlying depression related to their headaches, using an antidepressant may help both conditions. For obese patients, a medication such as topiramate may be an appealing choice because weight loss is a possible side effect. Similarly, topiramate or another antiepileptic drug such as divalproex might be a good choice for patients with epilepsy. No matter which medication or treatment is selected, the patient will need to commit to an adequate trial to determine if the chosen option is effective and suits his or her treatment goals. Keeping a clear head To help patients prevent migraines, nurses and other healthcare professionals must develop a trusting collaboration with them to encourage them to actively engage in identifying migraine triggers and report the effectiveness of therapies. Give patients this advice: • Identify triggers for your migraines by trying to remember what was happening just before it started. Keep a headache diary to track what you were doing, where you were, the time of day, and what you ate before the headache began. (For a sample form, visit the National Headache Foundation at http://www.headaches.org/ For_Professionals/Headache_Diary.) • Take prophylactic medications as prescribed and promptly report any adverse drug reactions to your healthcare provider. • Try to reduce your stress levels and explore nonpharmacologic approaches to migraine prevention. The AAN’s practice parameters recommend considering relaxation
training, thermal biofeedback combined with relaxation training, electromyographic biofeedback, and cognitive-behavioral therapy.6 Reassure patients that many therapeutic options are available to help them prevent or minimize migraine headaches. By keeping a migraine diary and collaborating with the healthcare provider, they can develop an individualized plan that works for them. ■ REFERENCES 1. Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd ed (beta version). Cephalalgia. 2013;33(9):629-808. 2. Estemalik E, Tepper S. Preventive treatment in migraine and the new US guidelines. Neuropsychiatr Dis Treat. 2013;9:709-720. 3. National Institute of Neurological Disorders and Stroke. NINDS Migraine Information Page. 2013. http://ninds.nih.gov/disorders/migraine/migraine. htm. 4. Kolb-Lucas K. Strategies for treating migraines. Nursing. 2008;35(5):32-36. 5. Holland S, Silberstein SD, Freitag F, Dodick DW, Argoff C, Ashman E. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012;78(17):1346-1353. 6. Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55(6):754-762. 7. Loder E, Burch R, Rizzoli P. The 2012 AHS/AAN guidelines for prevention of episodic migraine: a summary and comparison with other recent clinical practice guidelines. Headache. 2012;52(6):930-945. 8. Bajwa ZH, Sabahat A. Preventive treatment of migraine in adults. UpToDate. 2013. http://www. uptodate.com. 9. American Geriatrics Society. Pharmacologic management of persistent pain in the older patient. J Am Geriatr Society. 2009;57:1331-1346. 10. D’Arcy Y. A Compact Clinical Guide to Women’s Pain. New York, NY: Springer Publishing; 2013. RESOURCE Holland S, Silberstein SD, Freitag F, Dodick DW, Argoff C, Ashman E. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012;78(17):1346-1353. Yvonne D’Arcy is a pain management and palliative care nurse practitioner at Surburban Hospital-Johns Hopkins Medicine in Bethesda, Md., and a member of the Nursing2014 editorial board. The author has disclosed that she has no financial relationships related to this article.
DOI-10.1097/01.NURSE.0000438711.20345.a9
January l Nursing2014 l 61
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
