NUR 7072 Module 3 Migraine Case Paper: Red Flags, Acute Treatment and When to Start Prevention Example

Six Days a Month: When Migraine Needs Prevention, Not Just Rescue

Student Name

M.S. in Nursing, Family Nurse Practitioner, Thomas Edison State University

NUR-7072: Adult Primary Care Part II

Mentor Name

Month Day, Year

Six Days a Month: When Migraine Needs Prevention, Not Just Rescue

The Patient

Erin Walsh, an invented 31-year-old paralegal, has had headaches since college, but over the past year they have come about six days a month. Each begins on one side, throbs, worsens with movement and brings nausea along with a strong dislike of light and noise, lasting most of a day. She has no visual or sensory symptoms before the headache. She takes ibuprofen 600 mg at onset, which helps partly, and has missed work three times in two months. Attacks cluster around her period and after poor sleep. Her mother has migraines. She uses an intrauterine device for contraception. Her blood pressure, neurologic examination and fundoscopic examination are normal.

Ruling Out Secondary Headache

Do et al. (2019) reviewed the evidence on warning features, organized under the mnemonic SNNOOP10, that suggest a headache has a secondary cause. They include fever and other systemic symptoms, prior cancer, deficits on neurologic examination, a sudden thunderclap start, a first headache after 50, a change in headache pattern or a new headache, positional headache, headache brought on by coughing, sneezing or exertion, papilledema, progressive or atypical presentations, pregnancy or the postpartum period, a painful eye with autonomic features, onset after trauma, immune suppression and overuse of pain medicine. The authors noted that the strength of evidence behind individual flags varies. Ms. Walsh had none: her pattern is long-standing, her examination is normal and her medication use is below overuse thresholds. Imaging was not needed.

Confirming Migraine

Her headaches meet the criteria for migraine without aura: attacks lasting hours, one-sided and pulsing, strong enough to stop her work, made worse by moving and joined by nausea and sensitivity to light and noise. The menstrual pattern and family history support the diagnosis.

How Often Prevention Is Missed

Lipton et al. (2007) surveyed a large national sample and found that about 12 percent of Americans had migraine in the past year, and that women had it roughly three times more often than men did. Many reported severe impairment during attacks. About a quarter of people with migraine had attack frequency or disability high enough that preventive treatment should be offered or considered, yet only a small fraction of them were using it. The study showed a gap between need and care that primary care is well placed to close.

Acute Treatment

Ailani et al. (2021) recommend nonsteroidal anti-inflammatory drugs and other simple analgesics for mild to moderate attacks and triptans for moderate to severe attacks or when analgesics fail. For patients who cannot take triptans because of cardiovascular disease, or who do not respond to at least two oral triptans, newer acute options include the gepants and lasmiditan. Treating early in the attack improves response. To avoid medication overuse headache, simple analgesics should be limited to fewer than 15 days a month and triptans to fewer than 10.

When to Start Prevention

The consensus statement advises offering prevention at six headache days a month regardless of disability, at four days when attacks cause some disability and at three when disability is severe, and considering it at somewhat lower counts. Established oral options include certain beta blockers, topiramate and divalproex, with amitriptyline and venlafaxine also considered. Medicines targeting calcitonin gene-related peptide can be started once two or more proven oral preventives have failed or caused intolerable side effects over an adequate trial. Ms. Walsh, with six headache days and missed work, meets the threshold to offer prevention.

Plan

Sumatriptan 50 mg was prescribed at the start of an attack, repeatable once after two hours, with naproxen as an option to combine for longer attacks. She has no cardiovascular disease, uncontrolled hypertension or hemiplegic migraine, so triptans are safe for her. For prevention, we discussed options. Topiramate can cause cognitive slowing, a concern in her detail-heavy job, and carries pregnancy risks, although her IUD provides reliable contraception. Amitriptyline can cause drowsiness and weight gain. She chose propranolol, starting at 20 mg twice daily and increasing as tolerated, since she has no asthma, low blood pressure or depression.

Lifestyle and Self-Management

A headache diary will track attacks, triggers, medication days and menstrual timing. We discussed regular sleep and meal times, hydration, limiting caffeine to a steady amount and regular aerobic exercise. Because her attacks cluster around her period, short-term prevention around menses could be added later if needed.

Work Accommodations

As a paralegal, Ms. Walsh spends long hours at a screen. We discussed regular breaks, reducing screen glare and keeping a quiet, dim place available at work to rest briefly when an attack begins, along with taking her triptan early rather than waiting to see whether the headache will build.

Contraception and Safety

Migraine with aura raises stroke risk with estrogen-containing contraceptives. Ms. Walsh has no aura and uses an IUD, so no change was needed, but she was told to report any new aura.

Follow-Up

Preventive drugs need two to three months at an effective dose to judge benefit, with a goal of at least a 50 percent reduction in headache days. She will return in six weeks to review her diary and adjust the propranolol dose, sooner if attacks change in character.

Limits

The prevalence study relied on self-reported symptoms. Many red flags have limited evidence for their predictive value. The patient is invented.

Conclusion

Do and colleagues' red flags ruled out a secondary headache, Lipton and colleagues showed how often people who need prevention go without it and Ailani and colleagues set the thresholds and options for acute and preventive therapy. A triptan for attacks, propranolol for prevention, a diary and limits on rescue medicine give Ms. Walsh a plan aimed at fewer headaches, not just faster relief.

References

Ailani, J., Burch, R. C., Robbins, M. S., & Board of Directors of the American Headache Society. (2021). The American Headache Society consensus statement: Update on integrating new migraine treatments into clinical practice. Headache, 61(7), 1021-1039. https://doi.org/10.1111/head.14153

Do, T. P., Remmers, A., Schytz, H. W., Schankin, C., Nelson, S. E., Obermann, M., Hansen, J. M., Sinclair, A. J., Gantenbein, A. R., & Schoonman, G. G. (2019). Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology, 92(3), 134-144. https://doi.org/10.1212/WNL.0000000000006697

Lipton, R. B., Bigal, M. E., Diamond, M., Freitag, F., Reed, M. L., & Stewart, W. F. (2007). Migraine prevalence, disease burden, and the need for preventive therapy. Neurology, 68(5), 343-349. https://doi.org/10.1212/01.wnl.0000252808.97649.21