by Cory Wilbanks, DNP, APRN, AGACNP-BC, FNP-C, CNL, CNE
Assistant Professor, UTHSC College of Nursing
As a chronic migraine sufferer and healthcare provider, it is my personal goal to improve both awareness of migraine as a public health burden and its management. Chronic migraine is a disease, and headache is only one feature of the disorder—a fact that most people are unaware of. Chronic migraine is a disabling headache disorder that inflicts a burden upon more than 2% of the world’s population. Migraine affects more than 39 million women, men, and children in the U.S. and more than one billion people globally. The World Health Organization (WHO) deemed migraine as the 3rd most prevalent and 6th most disabling disorder in the world. It is estimated to be more prevalent than asthma, diabetes, and epilepsy combined.
According to the Migraine Research Foundation, migraine is a public health concern that presents with multiple social and economic costs. Chronic migraine is well noted to be misdiagnosed and undertreated—a statistic that has resulted in insufficient management of the disorder and undesirable patient experiences. The purpose of this article is to provide a brief description of chronic migraine, general diagnosis and management, its impact on the quality of life and resulting public health burden, and the role nurse practitioners (NPs) can play in mitigating this issue
The Picture of Migrain: What Is It?
The pathophysiology of migraine is not fully understood, and multiple complex theories exist; however, the current neurovascular theory describes a series of events that serve as the root cause of the pain. Migraine headaches are three times more common in women, and those who are white with a familial predisposition are at an increased risk. Common modifiable risk factors include sleep deprivation, stress, fatigue, changes in weather, menstruation, skipping or missing meals, potent odors, loud noises, flickering lights, oral contraceptives, vasodilators, alcohol consumption, caffeine, and assorted food triggers. No matter the cause, patients present with debilitating and oppressive pain.
While there are several subtypes and classifications of migraine, common complaints of migraine sufferers include a moderate to severe unilateral headache lasting four to 72 hours with or without a pulsating quality, associated nausea and/or vomiting, and aversion to light and/or sound. Patients may also experience visual effects such as flashing or flickering lights and spots, transient vision loss, paresthesia, paralysis, speech symptoms including dysarthria and aphasia, double vision, tinnitus, and vertigo. General fatigue and neck pain only compound the disabling nature of this disorder. When these patients report the presence of these headaches for at least 15 days per month for more than three months, the patient is said to have chronic migraine.
Diagnosis and Management
Properly diagnosing chronic migraine greatly relies on accurate and thorough client history and neurological examination. Typically, laboratory tests and neuroimaging are not required unless inexplicable exam findings call for investigation. Patient recall of the number of headache days per month, timing and duration, headache characteristics, alleviating and aggravating factors, and associated symptoms provide vital information. Because migraine is heavily under and misdiagnosed, it is particularly important to collect a detailed history and perform an attentively focused exam.
Once diagnosed, the goal of management is twofold: lessen the severity and duration of migraine episodes while reducing the extent of disability. The mainstay of managing chronic migraine is comprised of stepwise prophylactic therapy—an approach regrettably required by most insurance companies before novel approaches can be covered and used, lifestyle changes and active trigger avoidance, and attempting to curb the use of acute or abortive medications, which often cause rebound or medication-overuse headaches. Common preventative medications include beta-blockers, angiotensin receptor blockers, tricyclic antidepressants, and anticonvulsants. Injectable medications including onabotulinumtoxinA (Botox®), calcitonin generelated peptide (CGRP) antagonists like Emgality®, Aimovig®, and AJOVY®, alone or in combination with oral medications, are becoming increasingly popular. Alternative therapies are also used and include acupuncture, yoga, biofeedback, and herbal supplements. Despite its underutilization, the American Headache Society recommends at least a 2-3-month trial of prophylactic medications before it is considered a failed therapy; this management approach is observed in only 12% of patients in which preventative therapy is indicated.
For acute attacks, therapies range from NSAIDs, acetaminophen alone, or in combination with aspirin and caffeine, triptans, ergotamine, and various antiemetics. Novel therapies like ubrogepant (Ubrelvy™) and rimegepant (Nurtec™ ODT) are gaining popularity due to fewer side effects compared to their triptan predecessor. Lasmiditan (REYVOW®), the first serotonin receptor agonist approved for acute migraine treatment, is also becoming popular; however, the fear of abuse may deter prescribing because it is a schedule V controlled substance. Acute medications are “lifesavers” but overuse only contributes to the recurrence and burden of chronic migraine.
Public Health Burden
The 2016 Global Burden of Disease Study revealed that 45.1 million years of life lived with disability (YLDs) were attributed to migraine, and during 2015 the cost of treating chronic migraine was greater than 5.4 billion dollars. Additionally, healthcare costs associated with migraine, including lost productivity, are estimated to total as much as 36 billion dollars annually. Frequent migraine episodes harm family and social life as well as employment. Annually in the U.S., more than 157 million workdays are lost due to migraine, further negatively impacting the quality of life. According to the WHO, the long-term coping associated with chronic migraine may also predispose patients to other ailments such as depression and anxiety, with sufferers spending over 41 billion dollars treating all of their illnesses.
Role of the Nurse Practioner
Nurse practitioners, representatives of the most trusted profession for the 18th year in a row according to the U.S. Gallup poll, have the knowledge, skills, and patient trust to positively impact the burden of chronic migraine. While it is noted that one-third of all consultations for neurological complaints were for headache, many patients do not receive efficient care and rely on over-the-counter medications. Aligned with the previously discussed troubling statistics, more than 50% of all patients with migraine are under- or misdiagnosed. NPs must use their knowledge and skillset to perform pristine health histories and physical exams to properly diagnose. It is important to maintain up-to-date knowledge of classic and novel therapies as well as alternative therapies for management using a tailored, patient-specific approach. Patient awareness of the importance of adherence to treatment and management expectations is invaluable, and they must be informed that complete pain relief may not be attainable. Counseling should be utilized at every visit and include lifestyle modifications that include trigger avoidance, updates on needed medication changes, instruction on abstaining from medication overuse, and education on the importance of patient-self-recording of migraine events. NPs must not work in silos and should readily collaborate with neurologists/headache specialists, pain specialists, psychiatric/mental health providers, and alternative medicine practitioners. It is also important to detect socioeconomic factors that may impede treatment such as the cost of novel medications. Many pharmaceutical companies offer patient-savings programs, and NPs must be aware of these resources. Without question, NPs offer great expertise and are well suited to help alleviate the burden of chronic migraine.
Dr. Cory Wilbanks is an acute care and family nurse practitioner and Assistant Professor in the College of Nursing at the University of Tennessee Health Science Center in Memphis, TN. While he teaches future baccalaureate and doctoral nursing students full-time, he maintains clinical practice with a focus on general wellness and headache management.
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