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ASSESSMENT OF MIGRAINE HEADACHE: A PROTOCOL FOR ADVANCED
PRACTICE NURSES IN PRIMARY CARE

By

Terry Scharf

A SCHOLARLY PROJECT
Submitted to
Michigan State University
In partial fulfillment of the requirements
for the degree of
MASTER OF SCIENCE IN NURSING
College of Nursing
1 998

Chairperson: Laura Struble

ABSTRACT

ASSESSNIENT OF MIGRAINE HEADACHE: A PROTOCOL FOR ADVANCED
PRACTICE NURSES IN PRIMARY CARE

By

Terry Scharf
Migraine headache is a disorder fiequently encountered in the family practice population.
Most migraine headache sufferers have never been correctly diagnosed or effectively
treated for the disorder. Several barriers have been identified that reduce the likelihood of
correct diagnosis and effective treatment of migraine headache disorder. The Health
Belief Model provides a theoretical framework for demonstrating how these barriers
reduce effective treatment of migraine headaches. The Health Belief Model is modified
to illustrate specific migraine barriers and interventions. A Protocol is provided using the
International Headache Society criteria for diagnosis of headache disorders for use by
advanced practice nurses in family practice. Use of the protocol can improve the

effective diagnosis and treatment of migraine headache disorder.

ACKNOWLEDGEMENT
To my mother, Carol Garrett, who always loved me unconditionally, and

remained as proud of me when I failed as when I succeeded.

iii

TABLE OF CONTENTS

LIST OF TABLES
LIST OF FIGURES
INTRODUCTION

THE ADVAN- IPRACI'ICE NURSE IN MIGRAINE DIAGNOSIS AND TREATMENT

 

 

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BACKGROUND OF THE PROBLEM
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STATEMENT OF THE PROBLEM l4
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iv

Migraine with aura ....... . - - ......... 4O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other migraine variants .................................................. -- .41
Phases ofmigraine ....... - ....... -- 43
Migraine triggers -- . ............................................ - ...... -- 44
Pharmacologic treatments .................................................................................................................... 44
Non-pharmacologic treatments .............................. . ........................ 45
Diet interventions ................................................................................................................................. 45
Lifestyle interventions -- . -- -- -- ................................................ 46
Vitamins and herbs ............................................................................................... 46
WW ..................................................................................................................... 47
WW .................................................................................................. 47
Win ...................... - .. . ................... 48
W .. 43
History ................................................. - 49
W - -- ...................... ........................ 53
MW ............................................................................................................. 55
Cl" and MRI ......................................................................................................................................... 56
Blood tests ..................... -- - .. - ................................................... 57
Cerebral angiography ....... - .............................................. 58
Radionuclide scans, Spect and Pet scans, and Evoked potentials .............................. .- -- - - 59
Cranial X-rays .............. - -. ............................................................................ 59
Electroencephalography ................................................ - .................... 59
Thermography ..................................................................................................................................... 60
Transcranial doppler ................................................................................. .. 60
Lumbar puncture .................................................................................................................................. 60

' ................................................................................................................................... 61

Head and neck ......................................................................................... 62
Sensory systems ................................................................................................................................... 65
The motor system ................................................................................................................................ 65
Cerebellar examination ........................................................................................................................ 65
Reflexes ................. . . - ....................................................................................... 66
Mental status .......................... -- -- - .......................................................... 66
W .......................................................................... 66
WW ................................................................. 67
IHS Classification of headache ............. - ...................................................................... 67
IHS criteria for migraine without aura.. .................................................................... 71
IHS criteria for migraine with aura ............................................................ 72
IHS Criteria for tension headache ........................................................................................................ 73
IHS Criteria for cluster headache ......................................................................................................... 75
MW ........................................................................................................... 77
WW ............................................................................................................. 77
W ................................................................................................................................ 81
W ................................................................................................................................... 82
WW ............................................................................................................................ 82
WW .............................................................................................................. 84
CONCLUSION ............................................................................................................................................ 84
APPENDICES .............................................................................................................................................. 85
APPENDIX A: General Medical Informatiohn .................................................................................. 86
APPENDIX B: Headache Questionnaire ............................................................................................ 89
APPENDIX C: Headache Diary ......................................................................................................... 94
APPENDIX D: Migraine Headache Assessment ............................................................................... 96

REFERENCES ............................................................................................................................................. 98

Table 1:

Table 2:

Table 3:

Table 4:

Table 5:

LIST OF TABLES

New International Headache Society Classification of Headache ................................. 68
Diagnostic Criteria for Migraine Without Aura ............................................................ 71
Diagnostic Criteria for Migraine With Aura .................................................................. 72
Diagnostic Criteria for Tension-Type Headache ........................................................... 74
Diagnostic Criteria for Cluster Headache ...................................................................... 76

vi

LIST OF FIGURES

Figure 1: Health Belief Model ..................................................................................................... 26
Figure 2: Migraine Headache Health Belief Model ..................................................................... 31
Figure 3: Migraine Headache Interventional Health BeliefModel .......... 34

vii

INTRODUCTION

Migraine headache is a disorder frequently encountered by the primary care
practitioner. The migraine patient population is of special concern to Advanced Practice
Nurses (APNs) because all age groups are affected and the disorder is one of the leading
reasons for primary care consultations. According to Schiffinan, Haley, Baker and
Lindgren (1994) headache is one of the ten most common presenting symptoms in
general medical practices. Headache is the second most common chronic pain complaint
and the seventh leading presenting complaint for ambulatory care encounters in America
accounting for 18.3 million outpatient visits per year (Barrett, 1996).

Migraine Headache has been defined as paroxysmal headache separated by
headache fi'ee intervals and accompanied by two of the following four features; focal
cerebral symptoms, nausea, unilaterally, and positive family history (V ahlquist, 1955).
Migraine is the manifestation of a hereditary sensitivity of neurovascular reactions to
certain stimuli, or to cyclic changes in the central nervous system (Lance, 1993).

Despite the high rate of disabling migraine headache in the family practice
population, most patients have never been diagnosed by a practitioner or treated with
prescription medications (Saper, 1997). Many patient, provider, and sociodemographic
variables exist which act as barriers to appropriate migraine headache diagnosis and
treatment. Stang, Osterhaus and Celentano (1994), assert that identifying and eliminating
barriers to effective care of migraine patients can reduce the overall impact of the

disorder.

THE ADVANCED PRACTICE NURSE IN MIGRAINE DIAGNOSIS

AND TREATMENT

The Masters prepared APN has educational preparation and clinical training
beyond the basic preparation required to become a registered nurse. APNs conduct
comprehensive health assessments and possess advanced skills in the diagnosis and
treatment of complex responses of individuals, families, and communities to health
problems such as migraine headache disorder. APNs formulate clinical decisions to
manage acute and chronic illness and promote wellness. Patient education, research,
management, leadership, and consultation are incorporated into their clinical role (Snyder
& Mirr, 1995). Studies have shown that APNs can provide better care for the chronically
ill than other health care providers (Weiss, 1993). The APN’s emphasis on patient
counseling and education and firm orientation in the healing, helping, and caring domain,
making them excellent practitioners for patients suffering chronic migraine headaches.

WW

APNs are trained to be excellent patient educators specializing in knowledge
transmission as a means of empowering patients in their own self care (Snyder & Mirr,
1995). APNs consider patient education to be a communication of facts designed to
provide a knowledge base for health activities. These health activities are aimed at
increasing the ability of patients to make informed decisions affecting personal well
being.

The successful treatment of migraine headache disorder is centered upon lifestyle

changes involving diet, exercise, and behavioral modifications. Patient education is the

major focus of nursing intervention in the management of migraine headaches.
Information related to general prevention, medication use, side effects, treatment plans,
stress management, relaxation techniques, diet, and exercise is essential to client
satisfaction and success (Kennedy & Barter, 1994). Health education and counseling by
the APN facilitate behavioral change. Patient counseling assists the patient to understand
the illness, cope with symptoms, and prevent complications. APNs emphasize
counseling as an effective mechanism in helping migraine headache patients manage their
disorder.

A trusting one-to-one relationship with the patient, encouraging the verbalization
of feelings and conveying a sense of hope and acceptance, is the most helpful to the
migraine headache patient (Kennedy & Barter, 1994). APNs are more flexible in their
roles with patients than other practitioners and their interactions tend to be more subtle
and complex (Pierson, 1997). Differences in practitioner style, make APNs adept at
working with the chronically ill migraine patient, and can be attributed to the APN’s
culture as a nurse and to the APN’s orientation in the healing, helping, and caring
domain.

Care is the highest form of commitment toward patients (Lewis & Brykczynski,
1994). APNs care for people with and without illness and are not necessarily oriented
toward curing. They ofien go beyond the call of duty and are committed beyond the
circumscribed realm of their jobs. It is the nursing culture of caring that differentiates

APNs from other practitioners.

The healing domain of the APN involves several competencies under the
categories of creating, valuing, attending, and providing. The specific skills involved in
these competencies are: creating a healing climate, maintaining self care, giving support,
contributing self, protecting dignity, maintaining confidentiality, providing sensitive
humor, providing sense of presence, detecting feelings and concerns, monitoring own
emotions, risk taking, aiding decision making, communicating through touch, providing
emotional and informational support, and preserving personhood and comfort of the
patient (Lewis & Brykczynski, 1994). These activities of the healing domain
communicate caring and helping between the APN and the patient and aid in building a
therapeutic relationship necessary for successful treatment of migraine headache disorder.

APNs have continued the nursing tradition of placing particular emphasis on
patient education and counseling (Snyder & Mirr, 1995). This focus on patient
empowerment through education, along with the APN’s competency in the healing,
helping, and caring domain make the APN an excellent practitioner for the migraine
headache patient.

BACKGROUND OF THE PROBLEM

H' . 1E .

Throughout history, migraine headaches have been a problem to patients and
physicians. References to migraine in the literature (“megrim” or “sick headache”) can
be found as far back as 3000 BC (Lipton, Silberstein, & Stewart, 1994). Archaeologists
believe that ancient cultures attempted as early as 7000 BC to cure headaches by a

method known as trepanning. Trepanning involved drilling holes into the skulls of

headache sufferers to release evil spirits and was presumably done using stone knives
without anesthesia.

Sumerains in 4000 BC believed that headaches were a curse from the gods. They
performed ceremonies and incantations to cure it, as did Egyptians from about the year
1200 BC. Headaches were treated by Galen around 130 to 200 AD by bloodletting and
purging. This method may have worked by reducing blood pressure, as did taking an
extract from the Ruta plant prescribed by Dioscoride in 77 AD. Various other treatments,
such as applying an electric eel to the head to shock away the headache, and taking
concoctions made of vulture heads, cow brains and goat dung were tried over the next
thousand years. Between the 8th and 3rd centuries BC the Chinese began using
acupuncture to treat headaches (Cady & Everett, 1994).

In the 17th century, Sir Thomas Willis theorized that headaches were caused by
distention of nerves and vessels in the brain (vascular theory). Eighteenth century
physicians suggested a relationship between headaches and diet. In the 19th century,
physicians suggested that lifestyle was a factor in headaches and denounced the
bloodletting treatments. Bromides, hemp and the forerunners of aspirin and
acetaminophen were used with some success (Cady & Everett, 1994). In the late 19th
century, Liveing and Gowers formulated the theory that headache resulted from a
disturbance in the central nervous system. This became the basis for the neurogenic
theory of migraine (Rapoport & Shefiell, 1996). Ergot derivatives were used by the 20';h

century and became the preferred medical treatment of migraine (Cady & Everett, 1994).

21].] [11"

Headache and its causative factors remain enigmatic for researchers and
physicians. Some researchers contend that an intracerebral, meningeal, or extracranial
vascular component is associated with release of hurnoral agents that mediate
biochemical changes resulting in headache. Others believe that all clinical aspects of
migraine, including the headache, are the result of central processes occurring in the brain
and the brain stem (Rapoport & Shefiell, 1996). Some of the more important
explanations that account for the headache of migraine are included below; however, a
comprehensive study of the pathophysiology of migraine is beyond the scope of this
project.

Painful stimuli in the periphery of the body cause activation of impulses that
travel along small myelinated and unmyelinated fibers that end in the dorsal horn of the
spinal column. These nerve fibers synapse with secondary neurons that ascend to the
thalamus by way of the spinothalarnic pathways. The pain signals are modulated in the
dorsal horn by intemeurons that contain GABA (enkephalin and gamma-aminobutyric
acid). The descending monoaminergic pathways, the serotonergic pathway, and the
noradrenergic tract influence the inhibitory neurons. A deficiency in the descending
monoaminergic elements can open the pain control gates and allow head and neck pain to
occur. Other pain modulating pathways in the brain influence the quality and emotional

content of the head and neck pain (Rapoport & Shefiell, 1996).

ZZZC'H""II1

Migraine is a brain response with a threshold that, when exceeded,
initiates an attack. Spreading oligemia and spreading cortical depression of Leao account
for the neurological symptoms of migraine with aura. During nrigrainous aura a burst of
neuronal activity is followed by neuronal depolarization that spreads slowly into
contiguous brain regions. Brain blood flow may become hyper-oxygenated during the
first few minutes of neuronal activation, followed afterward by hyperemia. It is doubtful
that ischemia and vasospasm account for the neurologic symptoms (Welch, 1997).

H l C l . . I . . . I l I

The trigeminovascular system, which arises in the meninges at the interface of the
ends of the primary afferent small caliber C fibers of the fifth cranial nerve, is important
in the modulation of headache pain (Rapoport & Shefiell, 1996). Irnpulses travel along
the fifth nerve to the ganglion along the brain stem, into the pons, and down into the
trigeminal nucleus caudalis. Pain is registered after the impulses reach the thalamus and
then the cortex.

According to Welch (1997), migraine headaches have been attributed to activation
of the trigeminovascular system by as yet undetermined mechanisms. It is thought that
during a migraine headache, peptides may be released fi'om trigeminal sensory axons,
producing neurogenic inflammation and local vasodilatation. A calcitonin gene-related
peptide is released into jugular venous blood during a migraine attack, causing a

neuropeptide mediated inflammatory response resulting in head pain (Welch, 1997).

The platelets of migraine patients are often hyperaggregable. Much of the
serotonin in the human body is stored in the platelets. Shortly before a migraine
headache begins, platelet serotonin increases and then decreases during the attack. The
result is increased excretion of the main metabolite of serotonin, S-hydroxyindoleacetic
acid 5-HIAA in the urine following the migraine attack. There is also evidence of a
platelet release reaction in migraine and an increase in Beta-thromboglobulin during
migraine headache, suggesting platelet activation. After serotonin is released from the
platelets it acts (with other chemicals and neuropeptides) as a potent vasoconstrictor.

So far, seven 5-HT receptors have been identified. These receptors are found in
the meninges, the cortex, in brain stem nucleii, and in deeper structures of the brain.
There are two important serotonin receptors involved in migraine headache: 5-HT1
receptors can terminate attacks of headache, and 5-HT2 receptors can prevent attacks.
This information is helpful in explaining why both serotonin agonists and serotonin
antagonists are helpful in treating migraine and are often prescribed for headache
sufferers (Rapoport & Sheftell, 1996).

Migraine is a complex and common familial disorder that exhibits no clear-cut
mode of inheritance. Migraine is more common in females and is more frequently
transmitted on the maternal side; however, this difference has yet to be explained by
transmissible genetic factors. Thirty to fifty percent of the variance in migraine can be
attributed to genetic factors, which suggests that non-transmissible factors explain at least

half of the variance as well. The specific factors that may be inherited in migraine are not

known (Merikangas, 1990). Recent studies of migraine heritability confirm that migraine
is present more frequently in first degree relatives of migraineurs than in first-degree
relatives of non-migraineurs. These studies also show that the mother of a given
migraine sufferer is more likely to be affected than the father of the migraineur,
suggesting maternal inheritance. In addition, genetic influence in migraine with aura
seems to be stronger than in migraine without aura (Joost, Terwindt, & F erarri, 1997).

Many researchers have investigated the mode of inheritance in migraine, and
many possibilities have been considered including: dominant in women and recessive in
men, dominant in both sexes with 100% penetrance in women and 40% penetrance in
men, recessive with varying degrees of penetrance, and finally polygenic. It seems clear
that there is a strong component of heredity involved in migraine, but researchers have
yet to clearly define it (Couch, 1994). Studies have been hampered in the past by the lack
of a valid definition of migraine, the lack of a standardized method for determining
symptom criteria, the high prevalence of migraine in the population, and unpredictable
patterns of age and sex expression (Merikangas, 1990).

The term comorbidity refers to the presence of coexisting illnesses or syndromes
in a patient with a specifically identified disease such as migraine headache disorder. The
main reason comorbid disorders are investigated is to discern if both conditions emanate
from the same underlying causal factors. Investigation of migraine and other disorders
may reveal risk factors and underlying pathophysiology that are common to both

disorders and may shed new light on the primary disorder (Merikangas & Stevens, 1997).

10

Migraine comorbidity, according to Stang and Osterhaus (1994), can increase disability,
health care utilization, or a patient’s risk of adverse outcomes.

Psychiatric cormorbidities are commonly associated with migraine. Merikangas
and Stevens (1997) report that depression and anxiety disorders are clearly more common
among migraineurs. In addition, longitudinal studies have demonstrated that the onset of
these disorders in the same person follows a predictable course: anxiety in childhood,
followed by migraine headache disorder in adolescence, and then the onset of depression
in later years. Rapoport and Sheftell (1996) believe a possible cause of this phenomenon
may be a disorder of the biogenic amines and neuropeptides that regulate mood and play
a role in the primary headache disorders. Specifically, serotonin is thought to be a critical
factor in anxiety, depression, migraine headache disorder, eating disorders, obsessive
compulsive disorders, and vasospasm. In the case of migraine and psychiatric disorders
it may be that each disorder increases the risk of onset of the others; shared
neurobiological or psychobiological mechanisms may underlie both.

Physical conditions thought to be comorbid with migraine include ischemic
stroke, cardiovascular disease, hypertension, gastrointestinal disorders, allergies, asthma,
seizure and other neurologic disorders, and preeclampsia. Migraine headache patients are
twice as likely to suffer from chest pain than their cohorts matched for age, smoking, and
asthma history (Stang, Stemfield, & Sidney, 1994). A recent study showed that children
with migraine have a high incidence of hypercholesterolenria. These children often come
fiom families with a history of myocardial infarctions and cerebrovascular accidents as
well as migraine headache disorder (Joost, Terwindt, & Ferarri, 1997). The studies

concerning migraine and coronary heart disease have revealed increased rates of

ll

myocardial infarction among the parents and other relatives of migraineurs. After
controlling for smoking there is no significant increase in the rate of heart disease in the
migraine patients themselves. There is however, a correlation between migraine
headache and higher systolic blood pressure readings in patients over forty. Age matched
controls without migraine have lower systolic blood pressure readings (Merikangas &
Fenton, 1994).

Several studies have demonstrated an association between migraine and
subsequent stroke. Buring and associates (1995) report a significantly increased risk of
stroke in physicians with a self-reported history of migraine headaches. Others have
found the relationship between migraine and subsequent stroke to be stronger in patients
with a history of migraine with aura (Merikangas & Fenton, 1994) and in young female
patients with migraine history. Merikangas, F enton, Cheng, Stolar, and Risch (1997)
have recently reported that there is a non-random association of history of severe
headache, migraine headache, and subsequent stroke, particularly in young women (under
45) with a history of migraine. These researchers advise that severe headache and
migraine history should be considered as risk factors for the development of stroke,
particularly in the absence of other established risk factors.

Merikangas, F enton, Cheng, Stolar, and Risch (1997) hypothesize that
mechanisms for the association between migraine and stroke include irregularities in
blood flow, vascular hyperactivity or structure, cardiac abnormalities such as rnitral valve
prolapse, immunologic factors, and abnormal production or function of vasoactive
substances, including prostaglandins, noradrenergic and cholinergic transmitters and

receptors, nitric oxide, and histamines. Buring and associates (1995) postulate that

12

abnormalities in platelet aggregability and secondary changes in blood flow may
predispose to cerebral infarction.

This information is useful to primary care practitioners treating migraine headache
patients. Treatment of migraine is likely to be much more successful if coexisting anxiety
and depressive disorders are treated as well (Rapoport & Shefiell, 1996). In addition,
young women with migraine may need screening for potential risk factors for stroke such
as smoking and oral contraceptive use, particularly in light of recent evidence linking
migraine to subsequent stroke in young women. All migraine headache patients may
benefit fi'om lifestyle interventions known to reduce the risks of stroke, hypertension, and
coronary heart disease.

The modes of inheritance, pathophysiology, and comorbidities of migraine
headache disorder still require much investigation before they will be clearly defined and
well understood by researchers. Ongoing research in these areas will hopefully contribute
to a knowledge base that can enable practitioners to better treat the painful headache of
migraine as well as identify risk factors for conditions known to be comorbid with
migraine.

SIGNIFICANCE OF THE PROBLEM

Prudence

Migraine is a common and disabling headache disorder with a large
socioeconomic impact and significant adverse effects on quality of life. Approximately
23 million Americans suffer fiom migraine headache, and 11 million of these experience

significant levels of headache related disability (Lipton & Stewart, 1994). Migraine

13

headache affects 17.6 percent of females and 6 percent of males between the ages of 12
and 80 according to Lipton and Stewart (1993) causing significant suffering and
disability. According to Solomon (1994), as many as 18 percent of women and 6 percent
of men experience migraine and more than half of them report significant disability with
migraine attacks. Commonly affected by the disorder are those between the ages of 25 to
44, which are the years of greatest earning potential, resulting in great societal costs in
lost productivity (Stang & Osterhaus, 1993).

I To further complicate an already challenging set of problems, it appears that the
prevalence of migraine may be increasing. According to Lipton and Stewart (1997)
prevalence of migraine increased 60 percent from 1981 to 1989. Some of this increase
may be due to greater public awareness, or increased consultation and diagnosis rates;
however, recent studies suggest an actual increase in the prevalence of migraine. Lipton
and Stewart assert that an explanation for these findings is required (1997).

Disability is defined as the extent to which headaches interfere with a person’s
ability to engage in his or her usual activities (Lipton & Stewart, 1993). As many as 26%
of undiagnosed and 50% of diagnosed migraineurs suffer with severe disability.
Disability is likely to be increased with moderate to severe pain, nausea, vomiting,
numbness, and tingling. Intractable nausea or vomiting may be as disabling as the pain.
Migraine aura produces disability by impairing vision or disrupting motor or
somatosensory function. Photophobia and phonophobia may lead to restricted activity
and limited social interaction. Confused thinking, which is common with migraine,

effects efficiency and competency on the job and at home (Lipton & Stewart, 1994).

14

E. '1 1E .11 E11. . Sfifl

The financial impact of migraine for society and individuals is staggering, with
estimates of up to 17 billion dollars in lost productivity per year (Saper, 1997).
Migraineurs in the United States have been reported to spend more than 3 million days
each month incapacitated and bedridden by headache and associated symptoms. In
addition, employed male migraineurs average 2.7 million, and employed female
migraineurs spend 18.8 million days per year with activities restricted by migraine
attacks. The average male migraine sufferer costs $6,684 per year in lost productivity
and the average female migraineur costs $3,600 (Rapoport, 1994). Stang and Osterhaus,
(1992) reported that housewives experienced an estimated 38 million days per year of
restricted activity due to migraine attacks. Twenty five percent of the estimated 23
million migraineurs in America experience frequent attacks (4 or more per month).
Thirty five percent have one to three attacks per month, and 40% experience one or fewer
attacks per month (Lipton & Stewart, 1997).

Migraine is an increasingly prevalent and disabling headache disorder with
enormous effects on quality of life for sufferers and socioeconomic impact on society.
Continued research is needed in the area of migraine headache identification and
treatment to ameliorate the effects of this disorder.

STATEMENT OF THE PROBLEM

Migraine headache is a commonly encountered problem that is underdiagnosed
and undertreated in primary care practices, with resulting enormous personal and
economic losses for patients and society. APNs must overcome several barriers that

prevent correct diagnosis and treatment of migraine headache resulting in poor

15

management of migraine headache patients. The International Headache Society
Diagnostic Criteria For Headache Disorders, and the Health Belief Model, which
emphasizes the role of barriers in the decisions patients make about seeking health care,
are helpful in guiding the APN in making correct diagnoses and reducing barriers to
migraine treatment.
PURPOSE OF THE PROJECT

The purpose of this project is to provide APNs in primary care with a clinical
protocol using the International Headache Society Criteria For Headache Disorders,
guided by the Health Belief Model, for the accurate assessment and diagnosis of migraine
headaches. Use of the protocol will aid in improving accurate diagnosis and treatment of
migraine patients. The barriers to seeking consultation for and complying with migraine
treatment will be examined within the context of the Health Belief Model.
Understanding patient and practitioner characteristics that have been identified as barriers
to effective diagnosis, and use of the IHS criteria will assist the nurse practitioner in
forming an accurate headache diagnosis and ensuring patient compliance.

LITERATURE REVIEW

This literature review will focus on several points that are critical to the APN in
understanding the problems with treatment of migraine headache in primary care. There
are many sources that elaborate upon these points and provide essential information for
family practitioners treating migraine patients. This information is helpful for primary

care providers seeking to eliminate barriers to migraine diagnosis and treatment.

 

Headache, a common complaint among adult outpatients, is the most fi'equent
pain complaint confronted by primary care physicians, and is the seventh to tenth leading
presenting complaint for ambulatory care encounters in the United States (Barrett, 1996;
Capobianco, Cheshire, & Campbell, 1996, Kumar & Joos, 1996; Lipton, Silberstein, &
Stewart, 1994; Schiffinan, Haley, Baker, & Lindgren, 1994; Stang & Osterhaus, 1994).
At least 40 million Americans seek medical help each year for headache disorders, 23
million of whom are specifically diagnosed as migraine (Saper, 1997; Weiss, 1993).

In the United States, migraine headache is a highly prevalent condition occurring
in 18% of females and 6% of males greater than 12 years of age (Capobianco, Cheshire,
& Campbell, 1996; Lipton & Stewart, 1994; Rapoport & Sheftell, 1996; Saper, 1997;
Solomon, 1994; Stang & VonKorff, 1994; Stewart, Shechter, & Rasmussen, 1994;
Welch, 1997). Migraine sufferers who consult physicians most often seek help from their
primary care practitioner first, making migraine headache disorder of principle
importance to primary care providers (Capobianco, Cheshire, and Campbell, 1996;
Kumar & Joos, 1995; Lipton, & Stewart, 1994; Rapoport & Sheftell, 1996; Saper, 1997;
Stang, Stemfield, & Sydney, 1995).

U'Jfit'l'd- t‘.00'-l a! m UO-uum-u tO‘I.-'JI|'vJ

In spite of the reported high prevalence of migraine headache disorder in the
general population, physicians often fail to diagnose the condition, or misdiagnose
migraine headache disorder (Cady, 1994; Campbell, 1990; Capobianco, Cheshire, &
Campbell, 1997; Saper, 1997; Stang, Stemfield, & Sydney, 1995; Stang & VonKorff,

1994; Silberstein, 1994; Solomon, 1994). Only 30 to 51% of migraineurs who seek care

l7

and fulfill IHS criteria for migraine receive the correct diagnosis (Gobel, 1994; Stang,
Osterhaus, & Celentano, 1994). High rates of headache-related disability have been
documented yet most people with migraine have never been diagnosed by a physician nor
treated with prescription medications (Lipton & Stewart, 1993).

11"Hll°DflIll l

Migraine headache is not only misdiagnosed, but ineffectively treated as well.
Even among migraineurs who receive the correct diagnosis, undertreatrnent is common,
resulting in unnecessary pain and disability (Capobianco, Cheshire, & Campbell, 1996;
Lipton & Stewart, 1993; Lipton, Stewart, & VonKorff, 1994; Rapoport & Shefiell, 1996;
Saper, 1997; Silberstein, 1994; Solomon, 1994; Stang, Osterhaus, & Celentano, 1994).

I 1° . H l l . C l

The cost of migraine headache to patients in terms of lost income from work and
inability to firlfill family and social obligations is enormous. Employers, and society in
general, experience economic losses in terms of reduced productivity of people suffering
from migraine headache disorder (Lipton & Stewart, 1994; Lipton, Stewart, & VonKorff,
1994; Lissovoy & Lazarus, 1994; Rapoport, 1994; Rasmussen, Jensen, & Olesen, 1994;
Saper, 1997; Solomon, 1997; Stang & Osterhaus, 1992; Stang, Osterhaus, & Celantano,
1994; Welch, 1997;).

Migraine results in a significant number of missed days of school or work, or
otherwise restricted activity, for headache sufferers. F ifiy-two percent of migraineurs
report that headaches disrupt their daily activities and two thirds missed work due to
migraine or worked an average of five days per month with migraine. These migraineurs

who work while ill estimated their headaches reduced their effectiveness on the job to an

18

average of about 57% of their normal performance (Stang, & Osterhaus, 1992).
According to Welch (1997) 8% of males and 14% of females miss all or part of a day of
school or work in any one month, and Barrett (1996) asserts that migraineurs miss 150
million work days annually.

The annual cost to employers in terms of lost productivity varies widely but has
been estimated as 1.4 to 1.9 billion dollars (Stang & Osterhaus, 1992), 3 billion (Barrett,
1996; Solomon, 1994), 1.2 billion to 17.2 billion (Capobianco, Cheshire, & Campbell,
1996; Lipton & Stewart, 1994; Rapoport, 1994; Saper, 1997;We1ch, 1997) and 57 billion
dollars in annual cost to business, with 4 billion dollars spent on over the counter
analgesics (Weeks & Baskin, 1994). The cost of reduced productivity for homemakers in
terms of household maintenance and childcare is very difficult to quantify (Stang &
Osterhaus, 1992).

The direct costs of migraine headache disorder to patients can be measured not
only in lost income fiom work absenteeism but in medical expenses as well. Direct costs
include diagnosis, treatment, medication, and sometimes hospitalization and
rehabilitation (Lissovoy & Lazarus, 1994). Stang and Osterhaus (1992) reported that
648 migraineurs spent $529,000 per year in migraine related health costs, an average of
$817 per person. Rapoport (1994) estimated itemized migraine related medical costs to
range from $53 to $64 for a physician office visit, $111 to $201 for a hospital clinic or
emergency room visit, and for medical supplies, including prescription medications to
range from $2.75 (prescription co-pay) to $50. The average cost of diagnostic procedures
ranged from $300 for lumbar puncture to $700, $1000, $225, and $2,800 for CT scan,

MRI, EEG, and arteriography, respectively.

19

E' 11"E' '11

Several barriers have been identified that function to reduce the likelihood of not
only diagnosis but also effective treatment of migraine. Several authors assert that in
order to improve the diagnosis and treatment of migraine headache disorder, barriers to
treatment must be eliminated (Lipton, Amatrriek, Ferrari, & Gross, 1994; Lipton &
Stewart, 1993; Rapoport, 1994; Saper, 1997; Silberstein, 1994; Spierings & Miree, 1993;
Stang & Osterhaus, 1992; Stewart & Lipton, 1994). Identifying and eliminating barriers
to effective care of migraine headache patients can reduce the overall impact and direct
costs of the disease (Stang, Osterhaus, & Celentano, 1994).

According to Lipton, Amatniek, Ferrari, and Gross (1994) barriers to effective
treatment for migraine exist on three levels: 1. Many migraine sufferers do not consult
medical providers. Several patient characteristics have been identified which may be
associated with reluctance to seek medical care for headache disorders. 2. Those who
consult may not receive the correct diagnosis. Lack of familiarity with headache
disorders, lack of valid case definition, and physician bias may explain why practitioners
often fail to recognize migraine headache disorder. 3. Those who consult often do not
receive effective treatment. Practitioners often fail to adequately treat migraine
symptoms, or fail to establish a satisfactory relationship with the patient; both situations
frequently result in patient noncompliance or discontinuation of treatment (Spierings &
Miree, 1993).

E . I . . l .

Recent epidemiological studies screening for migraine sufferers in the general

population have provided insight into the prevalence and distribution of migraine.

20

Migraine headache seems to be an enormous problem for patients, yet many sufferers
may have never consulted a physician for the problem (Lipton, Silberstein, & Stewart,
1994). Certain personal characteristics of migraine sufferers may create barriers to
migraine diagnosis and treatment. According to Rapoport (1994), characteristics that
make migraine diagnosis less likely include: male gender, low- income status, symptom
profile (excluding visual aura, nausea, vomiting, or disability), and patient use of over-
the-counter medications. According to Lipton and Stewart (1993), low-income
individuals have the highest prevalence of migraine and the lowest rate of diagnosis.
Stang and Von Korff (1994) report that the presence of chronic headache, emotional
distress, and the absence of disability reduce the likelihood of a migraine diagnosis. Most
physician-diagnosed cases of migraine are in women, because they are more likely to
consult physicians. In addition, older people who have had the disease for a longer
period of time, and those in higher income brackets with greater access to health care are
more accurately diagnosed with migraine headache disorder. Males, younger patients,
those without disturbing or extremely uncomfortable symptoms, and patients who obtain
varying levels of relief with over the counter medications are less likely to consult
physicians for headache symptoms (Silberstein, 1994). The patient's lack of knowledge
about symptoms that differentiate migraine headaches from other headache syndromes is
also an important barrier preventing them from seeking medical consultation. According
to Saper (1997), many who experience headaches have not consulted a physician, and
only 50 percent of undiagnosed migraineurs correctly identify their headaches as

migraine.

21

E l‘ . l'

Many patients who consult physicians for headache disorders do not receive the
correct diagnosis for their problem. This practitioner-related barrier to migraine
diagnosis and treatment represents a great impediment to effective migraine symptom
control. Migraine headaches are consistently misdiagnosed and undertreated according to
Stang, Osterhaus, and Celentano (1994). They report that among migraineurs who seek
care, clinicians recognize only 45 to 51 percent as migraineurs.

Another practitioner-related barrier to accurate migraine diagnosis is physician
bias. Many primary care physicians feel uncomfortable managing migraine patients
because they lack formal training in the diagnosis and management of headache.
Physicians often perceive that managing headache patients is time consuming and that
patient psychosocial issues will complicate treatment. In addition, chronic headache
patients are viewed as analgesic abusers and physicians are reluctant to assume
responsibility for their care (Kumar & Joos, 1995). This sort of physician bias can
constitute a very real barrier to migraine treatment.

A major problem in accurately diagnosing migraine headaches in the past has
been the lack of a reliable and valid case definition (Merikangas, 1990). The IHS in 1988
published a set of guidelines for the classification of headaches, which has greatly
facilitated the definition of migraine in the context of other forms of headache. It has also
enabled studies on migraine to be conducted on a more comparable basis (Olesen, 1994).
Until the introduction of the IHS diagnostic criteria, diagnosis of migraine in primary
practice was often much more difficult than it had to be, resulting in poor management of

migraine patients.

22

E 1? . l .

Migraineurs often do not receive effective treatment for their condition, even
when the correct diagnosis is made. A recent study revealed that 25% of migraineurs,
when consulting a physician for headaches, were not asked about nausea and vomiting
(Saper, 1997). Nausea and vomiting are critical features of migraine diagnosis and
migraineurs with nausea are twice as likely to be disabled by their headache symptoms.
The practitioner’s failure to recognize and treat these symptoms causes even accurately
diagnosed migraineurs to sufler unnecessarily.

A major determinant in whether or not the patient receives effective treatment
may be the patient's degree of compliance with the treatment plan. Many migraine
patients do not comply with treatment plans and follow-up schedules once they have
received a correct diagnosis. Stang, Osterhaus, and Celentano (1994) state that slightly
more than half of migraineurs who do not return for follow up care report dissatisfaction
with the physician or problems with the medication regimen.

Spierings and Miree (1993) agree that the main reason for lack of compliance and
follow-up is patient/practitioner relationship. They fiuther assert that quality of
communication, time spent with the patient, perceived friendliness, empathy, and interest
of the practitioner are key factors in patient compliance. Studies have shown that if the
practitioner spends more time with the patient, shows concern, fiiendliness, and interest,
and tries to address the patient's expectations and concerns, patients will feel more
satisfied with clinical interactions. As a result, the patient will be more likely to comply

with treatment (Spierings & Miree, 1993).

23

 

In 1988 the International Headache Society, (II-IS), published a new classification
and diagnostic criteria for all headache disorders, cranial neuralgias, and facial pain. This
comprehensive system reflects the consensus of an international panel of experts on
headache disorders. The IHS system divides headaches into 13 major types, which
include 129 headache subtypes. The first 4 items in the IHS classification comprise the
primary headache disorders, which represent 90% of all headaches. The remaining items
are the secondary headache disorders.

Many headache specialists endorse the IHS criteria for use in research and clinical
settings. The new IHS criteria are a comprehensive classification system and provide an
important step in standardizing headache diagnosis with specific, unambiguous
diagnostic criteria. This will allow clinicians to diagnose headache disorders more
uniformly than before (Barrett, 1996; Cady, 1994a; Couch, 1994; Delessio, 1994; Olesen,
1994; Olesen & Lipton, 1994; Rasmussen, Jensen, & Olesen, 1994; Saper, 1997;
Solomon, 1997; Whitney, 1990).

The IHS classification has been found by many researchers to have high
reliability, (substantial at both the one and two digit levels), and validity, and to have
good sensitivity and specificity, making them useful not only in the clinic but in research
studies of migraine as well (Granella et al., 1994; Iversen, Langemark, Andersson,
Hansen, & Olesen, 1994; Merikangas, Dartigues, Whitaker & Angst, 1994; Saper, 1997;
Solomon, 1997; Stewart, Shechter, & Rasmussen, 1994). The IHS criteria have been
reported to have good interobserver agreement on headache diagnosis as well (D’Amico,

Leone, Fillipini, & Bussone, 1994).

24

’1'.“MANHHVJHH. “.2 . ‘ *‘ U..w.'_ -.m-.

Headache specialists agree that the most important aspect of effective treatment of
migraine headache disorder is a good patient-practitioner relationship. Individualization
of therapy is essential and patient priorities must be taken into account (Saper, 1997).
The relationship must be characterized by effective communication with an emphasis on
teamwork (Capobianco, Cheshire, & Campbell, 1996; Welch, 1997). The practitioner
must show compassion, empathy, and understanding as they counsel and educate the
migraine patient (Cady, 1994; Kennedy & Barter, 1994; Spierings & Miree, 1993;
Rapoport & Shefiell, 1996; Smith, 1994; Weeks & Baskin, 1994; Weiss, 1993; Welch,
I997).

Migraine headache is a disorder that is fiequently encountered in primary care and
is often misdiagnosed and undertreated by practitioners. Migraine headache has financial
and social costs for individuals and society. Treatment of migraine headache is impeded
by patient characteristics, problems with diagnosis, and ineffective treatment, which
function as barriers to migraine care. Improvement of patient/practitioner relationships
and use of the IHS criteria for headache diagnosis can result in better quality of care for
migraine patients.

THEORETICAL FRAMEWORK

IheHealthBeliefMQdcl

The Health Belief Model was developed by Hochbaurn, Kegeles, Leventhal, and
Rosenstock in the early 1950’s in response to a need by the Public Health Service to
convince individuals to embrace the concept of preventive health care. According to

Rosenstock (1974), the theory focuses on the current dynamics confronting the

25

individual, rather than on the historical perspective of his/her prior experiences. The
model was initially proposed to explain preventive health behavior. It was later adapted
to explain illness and sick role behavior, such as compliance or lack of compliance with
treatment plans.

The model proposes that an individual’s subjective state of readiness to take
action and engage in health related behaviors is a function of several factors. In order for
an individual to take action to avoid a disease, the person needs to believe that: (l) he or
she is personally susceptible to the disease, (2) the event of contracting the disease would
have at least a moderately severe effect on some component of the individual’s life, and
(3) taking a particular action would be beneficial by reducing susceptibility to, or severity
of, the disease. According to the model, the perceived barriers in taking health related
action, such as cost, convenience, embarrassment, and pain, must be outweighed by the
benefits of taking action, such as reduction of the risk of occurrence or severity of the
disease (Rosenstock, 1974). A cue to take action, such as a perception of a bodily state,
(internal cue), must occur to trigger the appropriate health behavior. Various
demographic, personal, social, and structural factors are viewed as modifying variables
that can influence an individual's health-related perceptions but are not considered to be
direct causes of health action.

As shown in Figure l, the individual’s perceptions of susceptibility are altered by
variables such as age, sex, and social class. Cues to action interact with these variables to
represent a perceived threat of disease. The likelihood that the individual will take health
related action becomes a function of his/her perceptions of the benefits of the action

minus the barriers to taking the action (Rosenstock, 1974).

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27

The Health Belief Model has been useful in predicting both health behavior before
illness, such as willingness to undergo cancer screening, and health behavior during
illness, such as compliance with medical regimens or prescribed therapies. It provides a
useful framework for intervention, especially in understanding and reducing barriers to
care (Becker, 1974; Rosenstock, 1974; Feuerstein, Labbe, & Kuczrnierczyk, 1986;
Steptoe & Mathews, 1984; Stroebe & Stroebe, 1995). According to Rosenstock (1974),
practitioners can increase patient response in the following ways: (1) minimizing the
barriers to action, (2) increasing the opportunities to act, which will increase perceived
benefits, and (3) provide cues to trigger responses. By assessing the barriers to
compliance, the practitioner can individualize interventions to suit the particular needs of

the patient (Becker, 1974; Feuerstein, Labbe, & Kuczrnierczyk, 1986).

on, u 3' ' UH‘ Lu'a uh Ir ii. truer .m Dir. H. o
Scekflm

An examination of the role of illness behavior using the Health Belief Model is
helpful in understanding how four specific barriers to migraine diagnosis and treatment,
(gender, socioeconomic status, over the counter medication use, and practitioner/patient
relationship), effect the patient’s decision to seek or comply with care. According to
Kirscht (1974), behavioral decisions are made to avoid negatively valued outcomes. In
other words the health care action to be taken must reduce the threat of pain and disability
in the migraine patient. The personal threat inherent in an illness is weighed against the

threat of role loss that may occur if the illness is actually found to be present. In health

28

belief terms, the cost of a course of action to reduce a threat becomes important when
evaluating a given symptom, in this case, headache.

Male gender acts as a barrier to migraine headache diagnosis and treatment in the
Health Belief Model, because having a headache disorder, (or any other illness), may be
perceived as a threat to the integrity of the male role. According to Kirscht (1974), the
threat of an illness is weighed against the threat of role loss, and in childhood boys clearly
learn to appear unafraid and to deny symptoms. This may make them less likely to
present to the APN for headache treatment.

The patient’s use of over the counter medications to treat headache firnctions as a
barrier to migraine diagnosis and treatment in the Health Belief Model. Decisions to self-
treat are complicated, but it seems these decisions are based on beliefs about symptoms,
the possibility of future conditions, and the perceived efficacy of the action. When faced
with threatening symptoms, (such as headache), the patient’s belief in the efficacy of a
wide range of actions increases (Kirscht, 1974). Self-treatment of headache influences
the practitioner’s decision to treat the patient's symptoms and actually functions as a
barrier to correct diagnosis and treatment of migraine. In addition, if the patient uses over
the counter medications and obtains some measure of relief he/she will be less likely to
believe it is a migraine headache and will be less likely to present to the practitioner for
treatment. Unfortunately, the use of over the counter medications alone is often
inadequate for treatment of migraine headaches. Use of the same over the counter
medications; however, supplemented with anti-emetics and counseling and teaching
about diet, exercise, and lifestyle changes can constitute very adequate treatment for

many nrigraineurs. The patient may never have the benefit of these additional therapies if

29

they do not present for treatment, or if the practitioner fails to diagnose them or under-
treats them because they are using over the counter medications.

Low income status of patients flmctions as a barrier in the Health Belief Model by
reducing the perceived value of possible benefits of treatment. Kirsch (1974) asserts that
it may be that situational barriers that become chronic, such as poverty, lack of
transportation, family problems, and negative experiences with agencies and providers,
lead to pessimistic beliefs and low motivation. Situational factors such as low income
may create negative orientations that serve as rationalizations for failure to seek care.
These situational factors enter into health care decisions and need to be incorporated into
the psychological benefits and barriers to seeking care (Kirsch, 1974).

An unsatisfactory practitioner/patient relationship acts as a barrier to migraine
diagnosis and treatment in the Health Belief Model, with the indirect result manifested in
the patient’s failure to comply with treatment regimens. According to Becker (1974), in
circumstances where the practitioner is formal, rejecting, controlling, disagrees with the
patient, or interviews the patient at length without subsequent feedback, patient non-
compliance often results. When patients perceive lack of warmth in the
practitioner/patient relationship and fail to receive an explanation of the illness, non-
compliance is high. When the patient is satisfied with the initial contact, perceives the
practitioner as fiiendly, and feels that the practitioner understands the complaint,
compliance is better (Becker, 1974).

“mun“ '_ r. ':- . U”_ . ‘..._ .r . UHWV -:.'-.,._

The Health Belief Model’s emphasis on barriers to taking health related action is

very helpful to the APN in understanding the reluctance of migraine patients to seek care

30

and their frequent non-compliance after initiating medical consultation. Becker (1974),
asserts that the elements of the Health Belief Model associated with individual’s
decisions in the areas of seeking preventative health care also apply to compliance with
prescribed regimens in persons already diagnosed with an illness. The Health Belief
Model can be modified to facilitate the APN’s understanding and care planning for
migraine patients by expanding upon or focusing on the patient’s perceived barriers to
treatment. Other elements of the health belief model, such as cues to action, and
perceived benefits of taking health related action, can also be remodeled by the
practitioner for the requirements of individual patients (Becker, 1974).

The following paragraphs detail the modification of the original Health Belief
Model to facilitate understanding and care planning for migraine headache patients. The
Migraine Headache Health Belief Model illustrates variables specific to migraine patients
and elucidates barriers to treatment. The Migraine Headache Interventional Health Belief
Model is a further adaptation of the Migraine Health Belief Model demonstrating the
migraine patient’s internalization of the APN’s migraine teaching. In addition the
interventional model incorporates interventions designed to reduce the patient’s barriers
to treatment.

The Migraine Headache Health Belief Model starts with the headache patient’s
perception of susceptibility to migraine headache disorder, which may be reduced due to

lack of familiarity with migraine headache as a possible personal diagnosis (see figure 2.)

31

 

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32

The headache patient is aware that they have headaches but fail to realize they
may be sufl‘ering from migraine headaches. According to Solomon (1994), the results of
a questionnaire using the IHS criteria for migraine completed by a random sample of
20,000 people throughout the United States, indicated that only 29 percent of men and 41
percent of women who suffer with headaches, know they have migraine disorder. The
majority who had migraine (as judged by their answers) did not recognize that they were
suffering migraine headaches. Many migraine headache sufferers may never perceive
personal susceptibility to or severity of migraine headache disorder and therefore fail to
recognize cues to action, thus precluding the possibility of diagnosis and treatment. In
the opinion of this author, the patient’s lack of knowledge about personal susceptibility,
severity of, and threat of the disease constitutes a barrier to treatment that can be better
understood using the Migraine Headache Health Belief Model.

The modifying factors which are thought to influence an individual’s health
related perceptions but are not direct causes of health related action, are also related to
possible barriers of health care seeking in migraine patients in the Migraine Headache
Health Belief Model. Some demographic variables of the migraine population are: age,
sex, socio-economic status, personality type, and ethnicity.

Cues to action such as media campaigns or magazine articles that prompt patients
to seek care are lacking in migraine headache disorder. This can be attributed partly to
the lack of public education programs, physician education programs, and clinic and
population based screening programs, recommended by Lipton and Stewart (1993) to

reduce the number of untreated migraine sufferers. The Migraine Headache Health Belief

33

Model identifies specific cues to action that could be helpful in initiating care for
migraine patients and in helping to educate practitioners.

The likelihood that a migraine sufferer will seek medical treatment according to
the Migraine Headache Health Belief Model depends upon the perceived benefits of
seeking medical consultation for headaches minus the barriers, (actual and perceived), to
seeking treatment. The model identifies several barriers to migraine diagnosis and
treatment, which can be grouped into three categories: patient characteristics, incorrect
diagnosis, and ineffective treatment. Patients will be more likely to seek care if these

barriers are eliminated.

 

Figure 3 illustrates the Migraine Headache Interventional Health Belief Model.
The interventional model illustrates the concepts of the original Health Belief Model and
the Migraine Headache Health Belief Model and suggests interventions at each stage of
the model to improve diagnosis and treatment of migraine. This model begins with the
patient’s perception of suffering from a legitimate and treatable headache disorder. This
is the result of the APN’s intervention of screening patients for migraine and educating
about the disorder. In addition, the patient perceives the threat of migraine as increased
personal disability in work and social roles. Therefore the failure to consult and receive
treatment for migraine headaches would be perceived by the patient to result in increased
disability. The modifying variables of age, gender, ethnicity, personality type,
socioeconomic status, and prior knowledge of migraine remain unchanged from the

previous model.

 

 

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35

Specific APN interventions to formulate effective cues to action are provided in
the Migraine Headache Interventional Health Belief Model. Increasing patient and
practitioner education, generation of research, informative articles, and active screening
of clinical and community populations are suggested as means to provide the impetus to
act upon improving migraine diagnosis and treatment.

The perceived benefits of seeking treatment for migraine headaches in the
interventional model are reduction in pain and disability from migraine headache. These
benefits are obtained after subtracting the costs of the three levels of barriers. APN
interventions for reduction of barriers are detailed for each of the three levels of barriers.
To reduce patient characteristics as barriers to treatment, practitioners are advised to
recognize young age, male gender, chronic headache, over the counter medication use,
emotional distress of the patient, and patient lack of knowledge about migraine as
possible markers of migraine headache. The possibility of migraine should be included
in the differential diagnosis when encountering these patient characteristics in the health
history.

To reduce incorrect diagnosis as a barrier to migraine headache treatment the
APN should use the IHS criteria for migraine headache to establish or rule out migraine
as a diagnosis. In addition, APNs should educate other practitioners about the legitimacy
of headache complaints, as well as comorbidities, and disability experienced by headache
patients.

Ineffective treatment as a barrier can be reduced by recognizing the importance of
the patient/practitioner relationship to successful migraine treatment. The APN should

stress communication, mutuality, and commitment to the treatment regimen and should

36

emphasize this to patients. Patients should be educated about the chronic but benign
nature of migraine, and that successful treatment depends upon compliance with the
medication and treatment regimen.
PROTOCOL FOR ASSESSMENT OF MIGRAINE HEADACHE

Introduction

The protocol for the accurate assessment of migraine headache includes the IHS
diagnostic criteria for headache disorders, general information on migraine headache
disorder, brief descriptions of selected interventions, a headache diary, 3 general medical
information form, and a questionnaire instrument for evaluation of headache and
associated symptoms. In addition, the protocol provides information on eliciting a
detailed headache history and provides specific instructions for the physical examination,
including guidelines for diagnostic and laboratory tests and specification of which
patients need physician or specialist referrals. Patient counseling and teaching, goals of
treatment, and outcome measurement will be included.

The protocol will recommend APN teaching and counseling about diet and
lifestyle interventions and will briefly address pharmcologic and non-pharmcologic
treatments; however, treatment of migraine headaches with specific medications is not in

the scope of this project and will not be addressed.

 

The APN in family practice will see all age groups of patients in varying states of
health. It is important for APN’s to recognize which patients are appropriate for
assessment and treatment, which patients require referral to physicians or physician

specialists, and which patients require immediate physician attention.

37

All patients who present with a chief complaint of headache should be screened
using the Protocol for Assessment of Migraine Headache. The APN should use the
headache history, health history, and physical examination to establish a headache
diagnosis. Patients whose health history and review of systems suggest headache
disorder and possible barriers to headache treatment should be screened as well. The
headache history, health history, and physical exam will begin to differentiate the patients
with primary headache disorders such as migraine, tension, and cluster headache fiom the
patients suffering from secondary headache disorders caused by a structural lesion.

APNs working in specialized headache clinics are adept at treating all of the
primary headache disorders with pharmcologic and non-pharmcologic treatments.
Family practice APNs can treat young healthy adult patients with clear-cut histories
suggestive of migraine or tension headache using selected pharmcologic interventions,
such as simple analgesics and anti-emetics. Family practice APNs should feel
comfortable using all non-pharmcologic interventions such as diet, counseling, education,
stress reduction, and other lifestyle interventions. The APN should consult with a
physician when considering referrals for interventions such as acupuncture, physical
therapy, chiropractic therapy, nerve blocks, trigger point injections, and transcutaneous
electrical nerve stimulation therapies.

Patients under the age of 16, or patients with the onset of a new headache after age
40, should be referred to a physician. Patients with the onset of a new or different
headache type, onset of subacute headache that progressively worsens over time, onset of
headache with sexual activity, coughing, straining or exertion also should be referred to a

physician. In addition, patients with chronic malaise, myalgia and arthralgia require

38

physician referral. Patients who present to the APN with a complaint of sudden onset of
‘Wvorst headache of my life,” or headache associated with either focal neurological deficit
or change in mental status should be referred to an emergency room for immediate work
up. Patients with severe headache plus fever and nuchal rigidity, or headache and severe
hypertension or papilledema should be seen immediately by a physician or referred to an
emergency room. These symptoms suggest secondary headache that may rapidly
progress to a life-threatening situation. (See Headache Danger Signs for more
information.)

3 I I E . E] H I l 1:. l

The APN will need to be educated about headache disorders in general to be able
to make specific headache diagnoses. The following information is an overview of
primary and secondary headache disorders with a specific focus on migraine headache.

E . l l 2

Primary headaches are formally divided into 3 types: migraine, cluster, and
tension headaches. They have characteristic features which distinguish them from
secondary headaches, most notably lack of an organic disorder or structural lesion to
explain the disorder (Olesen, 1994). Although primary headache is the most common
form of headache, the etiology of this disorder remains poorly understood.

Semadambeadache

Secondary headaches are attributed to an underlying structural lesion or can be
traced to an organic cause. Secondary headaches lack in characteristic features, and exact
mechanisms whereby organic causes produce headache are often unknown. Secondary

headaches fall into the following ten categories:

9.

39

. Headache associated with head trauma

Miscellaneous headaches not associated with structural lesions (idiopathic stabbing
headache, exertional headache, and headache associated with sexual activity)
Vascular disorders and associated headache (ischemic stroke, hemorrhage, and
arteritis)

Headache associated with non-vascular intracranial disorders such as neoplasm or
space occupying lesion

Headache associated with the use of substances or their withdrawal

Headache associated with noncephalic infection (diffuse viral or bacterial infection)
Headache associated with metabolic disorders, such as hypoxia and hypoglycemia
Headache associated with facial pain and disorder of the cranium, neck, eyes, ears,
nose, sinuses, teeth, mouth, and other facial or cranial structures, such as TMJ
dysfunction, sinusitis, and glaucoma

Cranial neuralgia

10. Non-classifiable headache (Rapoport & Sheftell, 1996).

M' .

Migraine is a common headache disorder characterized by combinations of

neurologic, gastrointestinal, and autonomic symptoms (Silberstein, 1994). Migraine is

characterized by episodic head pain, nausea and vomiting, which can be severe and

debilitating. Migraine episodes have five phases: the prodrome, aura, headache, headache

termination, and postdrome (Saper, 1997). Not all five phases are present in every

migraine sufferer, and presence of some or all of the phases varies from headache to

headache for some sufferers. Migraine attacks commonly last flour 4 to 72 hours. The

40

most common forms of migraine fall into two classifications: migraine with aura, and
migraine without aura. Migraine occurs more often in women than in men.

The headache of migraine is the most uncomfortable phase of migraine headache
syndrome, according to Rapoport and Sheflell (1996), who report that migraine has been
called “angina of the soul”, and “a biological repriman ” for those whose headaches are
precipitated by overextending ones self. Migraine headaches are often unilateral, but can
be bilateral. The pain is usually throbbing or pulsating in nature, but can be perceived as
steady and squeezing as well. The pain can move around to different locations during the
attack, or from one attack to another. The pain from migraine ranges from mild to very
severe, and can vary during the attack or from one attack to another. Many nrigraineurs
have the headache in the same location for every attack (Blau, 1990).

The headache tends to develop slowly, often taking several hours to reach peak
intensity, and lasts from 4 to 72 hours. Migraine headaches tend to be worsened with
normal activity such as moving the head or eyes, bending over, and climbing stairs.
Migraine headache is frequently accompanied by photophobia, phonophobia, nausea and
vomiting, constipation, or diarrhea Some mi graineurs cannot stand to be touched during
an attack, (haptophobia). Migraine patients are often very pale during attacks, with
characteristic coolness of the extremities, and may have dark circles around the eyes or
sunken appearing eyes (Blau, 1990).

l H . . l

Migraine with aura differs from migraine without aura only in the presence of

focal visual, motor, or sensory neurological symptoms that warn the patient that a

41

headache is about to occur. Migrainous aura is experienced by only 20% of migraine
patients. The aura evolves over a 5 to 20 nrinute time period but can last as long as an
hour. The headache usually follows the aura within 5 to 20 minutes but can take up to an
hour to begin. Occasionally the aura and the headache occur at the same time, or the
patient may experience the aura and then no headache at all.

Visual auras are described as: scotomas (formed or unformed figures),
fortification scotomas (zigzagging or scintillating figures that resemble the jagged barrier
around a fort), photopsia (unformed flashes of light, and distorted perception of the shape
and size of objects). The visual aura migrates slowly across the visual field, and finally
disappears. Motor manifestations of auras include hemiparesis and aphasia and are
attributed to brainstem disturbances. Other aura symptoms attributed to the brainstem
include ataxia, reduced level of consciousness, diplopia, tinnitus, hearing loss, vertigo,
and dysartln'ia. Sensory auras are perceived as hypersensitivity to feel and touch,
parasthesias such as tingling ascending fi'om the hand, up the arm, to the face, and
reduced sensation, numbness or hypoesthesia (Saper, 1997).

Q l . . .

The practitioner may occasionally encounter migraine headache disorders that do
not fulfill the IHS criteria for migraine or rrrigraine with aura. These headache syndromes
follow migraine with and without aura on the IHS Classification of Headache and are as
follows: ophthalmoplegic migraine, retinal migraine, childhood periodic syndromes that
might be precursors of migraine, complications of migraine, and nrigrainous disorder not
fulfilling the above criteria. It is the recommendation of this author that any of these

nrigraine variants encountered by the primary care practitioner be referred to a physician

42

specialist for a complete neurological workup. Some of these migraine variants may
difficult to differentiate from secondary headache disorders and further diagnostic testing
may be necessary.

Ophthalmoplegic migraine presents with a paralysis of the third, fourth, or sixth
cranial nerve. Most commonly the third cranial nerve is affected and manifests as a third
nerve paresis with a dilated pupil on one side, ptosis, and difficulty moving the eye up,
medially, or down. Retinal migraine is a rare disorder that presents as sudden reversible
monocular scotoma or blindness lasting less than one hour. This condition may be a true
emergency, as prolonged spasm of the retinal artery can lead to ischemia and blindness,
especially if the episodes are frequent or prolonged. Complications of migraine involve
stroke-like symptoms such as hemisensory and hemimotor defects. These neurological
symptoms persist beyond the occurrence of headache and may last days to weeks
(Rapporort & Sheftell, 1996).

Childhood periodic syndromes that might be precursors of migraine- Children
may have any of the specific symptoms of migraine with and without aura,
opthalmoplegic migraine, retinal migraine and basilar migraine. Children may also
exhibit abdominal pain, nausea, and vomiting associated with headache and called
abdominal migraine (Prensky, 1987). Children may also have symptoms of facial pallor,
confusion, dizziness, and vertigo with migraine. Infrequently, children will present with
hemiplegia or hemisensory deficits. This form of childhood migraine is often familial
and difficult to control (Solomon, 1994). This author recommends that children with
suspected migraine syndromes be referred to a pediatrician or neurologist for firrther

evaluation.

43

Migrainous disorder not fulfilling above criteria describes any unusual headache
presentation. Basilar migraine, according to Rapoport and Shefiell (1996), is a headache
preceded by aura symptoms that originate either from the brain stem or both occipital
lobes. Basilar auras typically consist of bilateral visual symptoms, dysarthria, tinnitis,
vertigo, ataxia, diplopia, and decreased level of consciousness. Patients with these
symptoms should be referred to a physician specialist for further evaluation.

E! E . .

Prodrome -- Forewarrring that a headache will occur. This may begin hours to
days before the headache and include photophobia, phonophobia, osmophobia, mental
and mood changes, peripheral vasoconstriction, fatigue and sluggishness, increased
urinary frequency, anorexia, constipation, diarrhea, fluid retention, food cravings, or
sometimes just a vague feeling that a headache is about to occur.

Aura -- Focal visual, motor, or sensory neurologic symptoms that evolve over a
period of 5-20 minutes and last less than an hour.

Headache-- Migraine head pain is typically unilateral and throbbing in nature but
the features can vary. Headache occurs most often in the morning, or is present upon
awakening, but can start at any time. Pain tends to develop gradually and plateaus at the
moderate to severe level. Headache is frequently accompanied by nausea and vomiting.
Pain lasts from 2-72 hours and is exacerbated by activity.

Headache Termination-- During headache termination, pain tapers gradually and
eventually disappears.

Postdrome-- After the headache of migraine has resolved, the migraine sufferer

often experiences general fatigue, tiredness, listlessness, and a washed-out feeling. Scalp

44

tenderness, aching muscles, food craving, or anorexia may occur. Mood alterations such
as euphoria or depression may sometimes occur (Saper, 1997).

Migraine headache sufferers have a biologically determined migraine threshold,
which may be exceeded by a myriad of internal and external environmental factors called
triggers. When the headache threshold is exceeded, migraine and the associated
manifestations develop. Rapoport and Shefiell (1996) liken triggers to a stick of
dynamite with detonators. The stick of dynamite represents the inherited physiological
dysfunction that produces biological vulnerability. The detonators are the triggers, any
one of which, singly or in combination with others, can set off the explosion.

Common migraine triggers include: hormonal fluctuation, menopause, certain
foods, beverages such as tea or alcohol, food additives and preservatives such as MSG
and nitrates, caffeine, change in external environment, (weather changes, moving,
vacation), changes in internal environment such as infection or metabolic changes, stress
or stressful events, sensory stimuli such as bright or flickering lights, odors of perfumes,
exhaust or cleaning chemicals, physical exertion, and certain medications.

W

The pharmacologic treatment of migraine generally follows three strategies: (1)
preventive or prophylactic, (2) abortive, and symptomatic and, (3) rescue or symptomatic
relief, which is the last option when the first two strategies fail. Pharmacologic agents
include simple analgesics, combination analgesics, anti-emetics, NSAIDs, ergot
derivatives, DHE, sumatriptin, phenotlriazines, corticosteroids, narcotic analgesics, Q-

blockers, calcium channel blockers, tricylic anti-depressants, anticonvulsants, serotonin

45

antagonists, beta blockers, and MAO inhibitors. Unless the APN specializes in neuro-
science and headache treatment, he/she should refer patients who require pharmacologic
treatment beyond simple analgesics and anti-emetics to a physician for further treatment.

WWW:

Several non-pharmacologic interventions are used with and without
pharmacologic agents in the treatment of migraine. Treatments include: heat application,
ice application, biofeedback therapy, yoga, myofascial release therapy, cognitive therapy,
exercise, nutritional counseling, stress management techniques, acupuncture, physical
therapy, chiropractic therapy, osteopathic manipulative therapy, massage therapy, and
occasionally nerve blocks, trigger point injections, and transcutaneus electrical nerve
stimulation.

Stress management, exercise, and nutritional counseling are very effective
interventions that are helpful to most migraine patients and can be easily incorporated
into APN teaching and counseling protocols. Many patients have found biofeedback
therapy and yoga to be helpful in reducing number and severity of headaches. Treatments
such as nerve blocks, trigger point injections, and transcutaneous electrical nerve
stimulation are more controversial and referrals for their use should only be provided by
headache specialists and neurologists.

D' . .

There are several diets used by migraine sufferers with varying levels of success.
Most of these stress avoiding certain foods known to precipitate headache in migraine
sufferers. Migraineurs are advised to avoid cheese, dairy products, wheat products, corn,

eggs, soybeans, chocolate, alcoholic beverages, especially red wine, and caffeinated

46

beverages such as coffee, tea and cola (Kennedy & Barter, 1994). Many of these foods
contain vasoactive substances such as phenylethylamine, and various nitrates that can
precipitate migraine in some patients. Rapoport and Shefiell (1996) state that this type of
elimination diet will not help the majority of migraineurs; however, a substantial number
of patients have valid food triggers, so they still use diet interventions in their treatment
of migraine.

[.2 l . .

A balanced lifestyle promoting good health and wellness is ofien helpful for
migraine headache sufferers. Migraineurs should reduce stress in their home, work, and
social lives as much as possible. Kennedy and Barter (1994) recommend adequate rest,
relaxation, laughter, a nourishing diet, and socialization with fiiends and family to
ameliorate migraine headache fi’equency and severity. Other helpful interventions
include: regular exercise, cessation of smoking, and avoidance of irregular sleep and meal
patterns.

Zitamr’nmriihezbs

Several studies have indicated that deficiencies of B-vitamins, calcium, vitamin D
and magnesium may contribute to migraine frequency and severity. Thys-Jacobs (1994)
suggested that deficiencies of vitamin D and calcium in women may trigger the
vasomotor instability and vasospasm clinically manifested as migraine, and that
supplementing these may bring about symptomatic relief. Other researchers have
documented low levels of magnesium in brain tissues of migraine sufferers during an
attack and believe that magnesium could be the link between the physiological threshold

for migraine attack and the mechanisms of the attack itself (Ramadan & associates,

47

1989). Rapoport and Sheflell (1996) believe the use of vitamin B-6, B-2 (riboflavin), and
vitamin E are helpful for some patients.

In addition, various herbal remedies are thought to have a positive effect on
migraine treatment. Feverfew, garlic, ginger, and ginseng have been reported to be
helpful in treating migraine; although scientific studies of the effectiveness of herbal
remedies are needed (Rapoport & Sheftell, 1996).

W

The patient requesting an appointment for consultation for headaches should be
informed that a proper evaluation for headache will require approximately one hour for
the examination and interview. It is time saving to ask the patient to arrive 15 minutes
prior to the appointment to fill out the General Medical Information Form and the
Headache Questionnaire.

The General Medical Information Form, Headache Questionnaire, and Headache
Diary used in this protocol were written by, and used with permission from, Dr. Edmund
Messina, a neurologist and headache specialist in Lansing, Michigan. Dr. Messina and
the nurse practitioner in his practice use these forms to screen headache patients for pre-
existing medical problems and conditions Comorbid with headache disorders, to aid in
establishing a headache diagnosis, and to help patients track their own headaches.

I] E l I I l' l I E . E

The General Medical Information Form gathers information about the patient’s
age, marital status, occupation, and right or left handedness. The form specifically elicits
a chief complaint and date of onset of symptoms. The form inquires about accidents,

seatbelt use, and whether or not the patient has been seen in the Emergency Room for the

48

problem. The form also requires a medical and surgical history and contains a review of
systems. Family history and habit history are reviewed as well as diet and sleep patterns.
The form inquires about previous CT scans, MRI studies, EEG and EMG studies,
myelograms, other x-rays and recent blood work (see Appendix A, General Medical
Information Form).

IheHeadashLQnestionnaire

The Headache Questionnaire asks specifically how many headache types the
patient has. Many patients with headaches have more than one type. The patient is asked
to describe each type of headache in detail and apply a subjective rating of intensity of
pain for each. The pain scale used starts at level one, a low level pain of which the
patient is aware but not requiring treatment, and ends at level five, intense pain rendering
the patient unable to firnction at all (see Appendix B, Headache Questionnaire).

The Headache Questionnaire elicits location on the patient’s head and times the
headache is present. Women are asked to supply information about their headaches in
relation to their menstrual cycle and headache triggers are reviewed. The questionnaire
asks what makes the headaches worse or better and inquires about symptoms associated
with the headache. In addition a family headache history, a brief disability rating, patient
support systems, and previous headache medication use are reviewed.

W

The headache diary is for patients to use in tracking their headache patterns. This
form has the date, duration in hours, pain intensity rating using the previously mentioned
one through five pain scale, triggers, relieving factors, and relationship to menses. The

form is useful in helping practitioners and patients identify triggers, provide information

49

about other factors in the patient’s headache, and revise the treatrrrent plan (see Appendix
C, Headache Diary).

Him

A complete and accurate history is the most important element of the headache
consultation. The practitioner should take advantage of this opportunity to screen the
headache patient for barriers to treatment such as specific patient related barriers, past
practitioner-related barriers and previous incorrect diagnosis and ineffective treatment
barriers. A thorough headache is the cornerstone of headache diagnosis. A good family
history is very helpful since approximately 70% of migraine headache patients have a
family history positive for headache disorder as well as depression, sleep disturbances,
alcoholism, and other illnesses associated with serotonin metabolism (Cady, 1994). A
thorough headache history should elicit the following information:
1. Age of onset and description of early headaches
2. Frequency of previous and current headaches, gradual or sudden onset
3. Location of pain
4. Description of the pain
5. Duration of the pain
6. Description of the prodrome
7. Description of the aura, if any
8. Associated symptoms
9. Types of behavior during the headache
lO. Headache triggers

11. Past headache medications, prescription, and over the counter medications

50

12. Current medications (for both headache and any other conditions)

13. Allergies to medications

14. Past medical history

15. Past surgical history

16. Family history (including headache)

l7. Habit history, sleep, alcohol, drugs, caffeine, cigarette smoking

18. Age at menarche, menopause, reproductive history, contraceptive or estrogen use

19. Psychosocial history (Rapoport & Sheftell, 1996).

20. Headache treatment barriers

a.

b.

F

1.

male gender,

low income status

chronic headache

young age

over-the-counter medication use

emotional distress

lack of knowledge about migraine headache disorder
previous incorrect headache diagnosis

previous practitioner bias

previous practitioner failure to treat all migraine symptoms
problems with previous practitioner-patient relationship

patient difficulty with treatment regimen or follow-up schedule

51

In addition to the above aspects of the history, the following pain assessment
questions should be usefirl in generating a very thorough description of the patient’s
headaches.

1. How long have you had this pain?

2. How often does this pain occur?

3. Where does the pain begin?

4. Does the pain move around?

5. Is the pain a deep pain, like an ache, or near the surface?

6. What brings on the attacks?

7. What increases the pain or makes it worse?

8. What relieves the pain?

9. What is the pain like?

10. How bad is the pain in terms of affecting daily activities? (Blau, 1990)

The practitioner should obtain a complete review of systems and inquire about
history of previous practitioner consultations for treatment of headaches. Medical records
including the dates and results of previous neuroirnaging studies should be obtained. It is
always helpful to ask why the patient is seeking medical attention. Some patients simply
want reassurance that they do not have a serious cause for their headaches, such as brain
tumor or aneurysm (Capobianco, Cheshire, & Campbell, 1996). In addition the
expectations of the patient regarding the consultation can be disclosed, aiding the APN in

providing care that meets with the patient’s satisfaction.

52

Information from the history and review of systems is invaluable in establishing a
diagnosis. Particular attention should be paid to the following areas of Rapoport and
Sheftell’s (1996) headache history when the APN suspects migraine headache.

The age of onset is important in the diagnosis of migraine because it establishes
whether the headaches are of recent origin, have been present for years, or have changed
in quality, intensity or location. These are often clues to the presence of organic
pathology. Migraine onset is usually between ages 6 and 25. Migraine prevalence is
equal among females and males until puberty, when it becomes 3 times more common in
females. Headaches that have been present for years are likely to be benign primary
headaches such as migraine, which have no underlying pathology. Headaches that begin
abruptly after age 40 or 50 may be caused by underlying disease or dangerous pathology
(see Headache Warning Signs, below).

The location of pain in migraine is variable but often occurs in or behind the eye
or in the frontoternporal area. The pain can be unilateral or bilateral or may be
holocranial. Many migraine patients have pain that switches fi'om one side to the other,
from one episode to the next. Migraine pain is usually described as throbbing or
pounding, often in cadence with the pulse. Migraine pain can be experienced as an
intense squeezing or pressure inside the head. Migraine headaches typically last from 4
to 72 hours. Patients suffering migraine with aura typically experience headaches that
last fewer than 12 hours.

Symptoms associated with migraine include: nausea, vomiting, diarrhea,
dizziness, cold and pale extremities, sensitivity to light and sound, slightly confused

thinking, and worsening of pain with activity. Because any activity tends to exacerbate

53

the pain and nausea of migraine headache, patients experiencing attacks usually retreat to
a quiet, dark room and try to sleep. Inquiring about what the patient does during
headache attacks provides important clues in diagnosing migraine.

The habit history is important in the migraine patient because smoking, alcohol,
and excess caffeine can exacerbate headaches. The menstrual and hormonal history is
important in female migraineurs because headaches often occur in specific stages of the
menstrual cycle. In perimenopausal and postmenopausal, women the type and manner of
estrogen replacement can effect headaches. The patient’s psychosocial history can reveal
the presence of comorbid anxiety and depressive disorders which must be taken into
account when planning therapy for the migraine patient (Rapoport & Sheffiell, 1996).

The APN should be alert for specific characteristics of patients that have been
identified as barriers to treatment, such as male gender, young age, low income status,
symptom profile, and use of over the counter medications. The patient should be
questioned about past headache diagnoses and treatments as these have been shown to
constitute barriers to effective diagnosis and treatment of migraine. Awareness of these
barriers can enable the APN to provide more effective treatment and increase patient
compliance.

WW

Headache can occasionally herald a catastrophic or life threatening illness such as
meningitis or subarachnoid hemorrhage from a leaking aneurysm. It is essential that the
practitioner exercise appropriate care in evaluating headache patients. No single sign or

symptom differentiates benign headache disorders from serious illness involving

54

headache as a symptom. If the practitioner encounters any of the following danger signs,

referral to a physician or specialist and diagnostic studies are necessary (Cady, 1994a).

Patients complaining of sudden onset of “worst headache of my life”, headache

associated with change in neurological status or positive findings on a neurological exam,

or headache associated with fever or neck pain should be referred to an Emergency

Room. Patients with headache and elevated blood pressure should be seen immediately

by a physician and possibly referred to an Emergency Room for treatment.

1.

2.

3.

4.

5.

6.
A.
B.
C.
D.

response

7.

Onset of (headache after age 40.

Onset of new or different headache

“Worst headache of my life”

Onset of subacute headache that progressively worsens over time

Onset of headache with exertion, sexual activity, coughing, or straining

Headache associated with change in neurological status such as:

Drowsiness, confusion, memory impairment
Weakness, ataxia, loss of coordination
Sensory loss associated with headache

Unequal pupils, asymmetrical deep tendon response, or Babinski

E. Signs of meningeal irritation (neck pain and stiffiress, photophobia)

F. Visual changes

Abnormal medical evaluation

A.

B.

Fever

Hypertension

55

C. Chronic malaise, myalgia, arthralgia
D. Weight loss

E. Tender, poorly pulsatile temporal arteries
F. Papilledema (Cady, 1994).

Rapoport and Sheftell (1996) further advise that headaches accompanied by
generalized illness, nausea and fever, or headache accompanied by personality changes or
decrease in higher intellectual functioning constitute ‘red flags’ in the history that
necessitate careful evaluation to rule out sinister causes. If headache pain is severe,
escalates rapidly, and reaches a peak within five minutes it is more likely to be due to a
more serious organic cause than benign primary headaches such as migraine. Any of
these symptoms require an immediate physician or specialist consult.

13' . l I l I

Young, healthy patients with a clear-cut history suggestive of migraine may not
need further work-up according to Rapoport and Sheftell (1996); however, a first attack
of what appears to be migraine should probably be investigated. Patients with migraine
with aura, complicated migraine, tension type headache, slowly worsening headache
symptoms, unilateral headache associated with neurologic symptoms, unusual headaches,
basilar artery migraine, or other significant neurological history should have further
work-up. Patients with any of the Headache Danger Signs or changing headaches should
have a work-up.

Commonly performed diagnostic studies for headache evaluation are computed
tomography (CT scan), magnetic resonance imaging (MRI), magnetic resonance

angiogram (MRA), and blood tests. Less commonly used are cerebral angiography,

56

cranial x-rays, radionuclide slides, thermography, electroencephalography (EEG), lumbar
puncture, trans cranial doppler and evoked potentials.

CLaniMRI

Neuroimaging is usually urmecessary in the routine work-up of typical migraine
(Capobianco, Cheshire, & Campbell, 1996). However, if the patient presents with signs
and symptoms of increased intracranial pressure or acute neurological deficits CT or MRI
may be necessary. CT scans are useful in detecting subarachnoid hemorrhage, subdural
hemorrhage, or lesions large enough to produce increased intracranial pressure, and
hydrocephalus. CT scan using contrast can reveal arterio-venous malformations, tumors
and other lesions (Rapoport & Shefftell, 1996). MRI provides much better soft tissue
contrast than CT and can be used to diagnose smaller lesions of the brain stem and
cerebellum. MRI can be performed in conjunction with MR angiogram if vascular
lesions such as aneurysm are suspected (Smith, 1994).

CT scans are especially useful in the emergency evaluation of subarachnoid,
subdural, or other focal hemorrhage. MRI is better for evaluation of chronic headache
conditions and suspected posterior fossa lesions (Rapoport & Shefiell, 1996). CT and
MRI are very expensive, and the primary care practitioner must be prepared to order them
only when necessary, but to always know when they are necessary. The following
information is useful in ascertaining the need for CT or MRI in the primary care setting
(Smith, 1994).

CT or MRI is indicated when any of the following are present:

1. Unaccountable abnormality in vital signs

2. Decreased alertness or cognition

57

3. Onset with exertion

4. Worsening under observation

5. Nuchal rigidity

6. Focal neurological signs

7. First headache in patient over 50 years

8. “Worst headache of my life”

9. Initial evaluation of patient with suspected migraine with aura or basilar
migraine

CT or MRI is not indicated when all of the following are present:

1. Previous identical headache

2. Normal vital signs

3. Alertness and cognition intact

4. Supple neck

5. No neurological signs

6. Improvement in headache without analgesic or abortive medications
(Smith, 1994).

Richelieu:

A complete blood count, general chemistry profile, erythrocyte sedimentation
rate, thyroid stimulating hormone, and Lyme disease titer are all indicated in the work-up
of the headache patient. The CBC can reveal blood dyscrasias fi'om medications,
infectious disease, and more serious hematological conditions that may account for

headache. Chronic anemia may be associated with underlying malignancy, collagen

58

vascular disease, blood loss from medication usage, or other chronic illness and requires
investigation (Cady, 1994a).

The chemistry profile can reveal serious reactions to medications evident in
alterations in liver enzymes and other values. In addition, hidden medical conditions
such as hepatitis and renal dysfunction can be discovered. The ESR can be used to help
rule out temporal or giant cell arteritis and other vasculopathies and inflammatory
conditions. The ESR may be elevated by systemic infections, inflammatory conditions,
collagen vascular disease, occult malignancies, and multiple myeloma (Cady, 1994a). A
TSH should be done to rule out thyroid dysfunction as a cause of headache, and a Lyme
titer should be drawn in areas where the disease occurs (Rapoport & Sheftell, 1996).

Cemlszanziazmnbx

Cerebral angiography should be considered when attempting to rule out vascular
abnormalities such as aneurysms, cerebral arteritis, carotid artery stenosis, dissections or
occlusions, and arteriovenous malformations. Cerebral angiography is not indicated in
the routine work-up of migraine patients. Patients with migraine should not have direct
carotid artery punctures for angiography because intra-arterial injections of contrast
material into the blood vessels that lead to the migraine patient’s brain could cause
vasospasm and transient ischemic attack (Rapoport & Sheftell, 1996). Embolic or
ischerrric stroke is a rare but possible side effect of cerebral angiography and it should be
used only when absolutely necessary. Magnetic resonance angiography, although not as
accurate as cerebral angiography, is very effective in ruling out most vascular

abnormalities if needed in the migraine patient.

 

Radionuclide scans are rarely performed today because MRI can readily provide
more accurate information. SPECT, (single photon emission computed tomography), and
PET, (positron emission tomography), scans are still experimental in the evaluation of
migraine. Evoked potentials are useful in detecting a number of neurologic conditions
such as multiple sclerosis. Evoked potentials can be abnormal in migraine patients
suggesting excitability of the cortex. Evoked potentials are not useful in the routine
work-up of migraine unless other neurological conditions are suspected (Rapoport &
Sheftell, 1996).

Cranialezm

Skull x-rays are rarely helpful in the work-up of migraine headaches. Sinus x-
rays can be usefirl in differentiating migraine fi'om facial pain due to sinusitis. Cervical
spine x-rays are helpful in diagnosing arthritis and fracture which may cause cervicogenic
headache, but they are not useful in diagnosing disc disease (Rapoport & Sheftell, 1996).

Electmenmhalagmnbx

According to Capobianco, Cheshire, and Campbell (1996)
electroencephalography or EEG has no place in the routine work-up of migraine
headache. Many abnormalities have been discovered in the EEG readings of migraine
patients in the past but neurologists rarely find the information helpful or agree on the
interpretations of the findings. EEG should be ordered for migraine patients only if there

is a history or suspidbn of seizures, head trauma, loss of consciousness, or presyncope.

60

Why

The use of thermography in the evaluation of migraine headache has
demonstrated significant abnormalities in the temperature patterns of the heads and faces
of migraine patients. These results are interesting fiom a research point of view but do
little more than establish a temperature pattern consistent with migraine headaches.
According to Rapoport & Sheftell (1996), the thermograms provide graphic evidence of
altered physiology and help mi graineurs to realize that the headaches are not all in their
minds. It is the opinion of this author that thermography is not cost effective or useful in
the work-up of migraine headaches.

W

Transcrarrial doppler studies have demonstrated abnormal findings in migraine
patients. They are useful in the work-up of intracranial vascular conditions such as
vasospasm associated with ruptured aneurysm, but are not useful or cost effective in the
work-up of routine migraine.

W

Lumbar puncture is not performed in the routine work-up of migraine headache.
In cases of suspected subarachnoid hemorrhage, whether visible on CT scan or not,
lumbar puncture can establish the presence of blood in the cerebro-spinal-fluid, and
measure elevations in the opening pressure, indicating possible subarachnoid hemorrhage
or hydrocephalus. This may indicate the need for cerebral angiography, MRI, MRA, or
other diagnostic testing (Capobianco, Cheshire, & Campbell, 1996). Lumbar puncture
establishes the diagnosis of meningitis or other central nervous system infection as well.

Spinal fluid should be analyzed for cells, protein, glucose, VDRL, and antigens. Cultures

61

of the spinal fluid should be started. Lumbar puncture is contraindicated in the presence
of papilledema.

Wm

A complete physical and neurological exam including vital signs should be
performed on the headache patient to rule out the possibility of secondary headache,
(headache from an underlying pathological condition), and to ascertain the general health
status of the individual. The general physical exam is important in ruling out comorbid
conditions or factors that may contribute to headache such as hypertension, thyroid
dysfunction, pulmonary disease, cardiovascular disease, or gastrointestinal disturbance.

Medications taken for headache by migraine patients can be associated with
systemic effects and the practitioner should be alert for evidence of this. Beta-blockers
may cause wheezing or bradycardia, and overuse of ergotamines may cause decreased
pulses, myalgia, stomach pain, and nausea. Migraineurs who overuse narcotics or
butalbitol products may exhibit cerebellar ataxia, impaired concentration, sedation, and
depression. Patients withdrawing from benzodiazapines or barbiturates may have
increased irritability, dilated pupils, hyperreflexia, tremors, and piloerection.

The physical exam begins with the general presentation. The practitioner should
note an appearance of pain, fatigue, sadness, anxiety, pressured speech, or restlessness.
Also important is the patient’s response to the practitioner. Does the patient make eye
contact? Does the patient’s affect appear appropriate? Is the patient defensive or open to
inquiries? Along with a complete general physical examination the practitioner should

perform the following examinations (Rapoport & Sheftell, 1996).

62

W

Cranium- Observe shape, size, deformities, lumps, bumps, and scars. Palpate for
pericrarrial tenderness and excessive tightening of muscles.

Eyes- Check for ptosis, exophthalmos, conjunctiva] injection, and strabismus.
Apply gentle pressure to the orbits to check for increased intraocular pressure and
tenderness associated with glaucoma. Auscultate the orbits with the bell of the
stethoscope for bnrits.

Musculature- Check for tenderness in the area of the greater and lesser occipital
nerves, as well as the musculature of the head, stemocleidomastoid, suprascapular, and
infrascapular muscles. Check for range of motion of the neck in all directions. Inability
to flex the neck, with stiffiress, pain, and fever may be a sign of meningitis or
hemorrhage.

Jaws- Palpate and auscultate the temporomandibular joint. Deviation of the jaw
on opening, noise in the joint, tenderness on palpation, reduced range of motion, pain
with clenching or opening widely, and spasm of the internal pterygoid may indicate
temporomandibular joint dysfunction.

Temporal arteries- Observe for prominence and palpate for adequate pulsation,
tenderness, and rigidity to rule out temporal arteritis.

Sinuses- Evaluate for sinusitis by palpating the frontal and maxillary sinuses for
tenderness and swelling. Use a penlight or otoscope to transilluminate the fiontal and
maxillary sinuses for cloudiness. Observe for purulent nasal discharge, fever, and redness

and swelling of the mucous membranes. Chronic sinusitis only rarely causes chronic

63

headache but it must be included in the differential diagnosis of patients with any of the
above findings.

Carotid, vertebral and subclavian arteries- Palpate and auscultate the extracranial
carotid arterial tree, including the external carotid and vertebral arteries, for irregularities,
bruits, and rigidity. Auscultate over the temporal bone under the angle of the jaw for the
carotid arteries, and at the base of the neck for the subclavian and vertebral arteries. The
presence of bruits may indicate arteriovenous malformation, vascular tumor, or vessel
disease.

Thyroid- Palpate for thyroid swelling or nodules. Observe for symmetrical or
asymmetrical enlargement.

Lymph Nodes- Check for lymphadenopathy which may indicate infection or
underlying malignancy.

Cranial nerves- the cranial nerves should be fully and carefully evaluated in the
workup of the migraine patient with particular emphasis on the following:

Second cranial nerve- Examination of the cranial nerves, including fundoscopy, is
imperative in the work-up of the migraine headache patient. The frmdoscopic exam can
reveal papilledema and retinal changes from hypertension and diabetes, or may reveal
papilledema secondary to increased intracranial pressure from a tumor or other lesion.
Check for pupil reaction to light and accommodation.

Third and fourth cranial nerves- Check for visual field deficits and diplopia using
frnger counting with double simultaneous stimulation, (putting fingers in both fields at

once while the patient concentrates on your nose), and check all 6 cardinal gazes.

64

Deficits in visual field may be present in demyelinating disease, structural pathology, or
meningitis.

Fifth cranial nerve- Examine all three sensory divisions of the trigeminal nerve on
each side. Check the first division by testing corneal reflex and using light touch and pin
prick on the forehead. The second and third divisions are tested by with light touch and
pin prick on the jaw and cheek. Check for voluntary and involuntary movement of the
muscles supplied by the motor division of the trigenrinal nerve by feeling the masseter
bulk on clenching.

Seventh cranial nerve- Problems with the seventh (or facial) nerve may present as
Bell’s Palsy, (paralysis of one entire side of the face). Patients with central lesions
involving the face can still smile spontaneously, unlike those with peripheral lesions of
the seventh nerve.

Eighth cranial nerve- Check the patient’s hearing with light finger rubbing, and by
checking both Weber and Rinne responses with a tuning fork.

Ninth cranial nerve- Check the glossopharyngeal nerve by determining if light
touch sensation on both sides of the back of the throat is intact. Neuralagia of the ninth
nerve is evidenced by pain in the tonsillar area radiating to the ear.

Tenth cranial nerve- Check the gag reflex and note the character of the voice. If
the reflex is intact the palate and uvula should rise symmetrically. Difficulties such as
hoarseness in the patient’s voice may be a result of tenth cranial nerve damage.

Eleventh cranial nerve- weak stemocleidomastoid or trapezius muscles result
when the spinal accessory nerve is impaired. Shoulder shrugging and lateral head turning

may be affected.

65

Twelfth cranial nerve- Impairment of the hypogossal nerve may be evidenced by
deviation of the tongue, (which points to the side of the lesion). Atrophy or fasiculations
of the tongue also suggest twelfth cranial nerve damage.

Swarm

Test all modalities using light touch, hot and cold, and vibratory sensation.
Compare right to left and distal to proximal. Migraine headache patients’ sensations are
usually normal upon evaluation. Many migraineurs do demonstrate coolness of the
extremities, which is probably due to excessive vasomotor tone resulting in decreased
blood flow. Migraineurs may therefore complain of decreased perception of cold distally.
During a migraine attack patients often report that their head feels hot and that their hands
and feet are ice cold. This is probably because increased blood flow to the extracranial
vasculature results in enhanced heat, and decreased flow to the extremities causes
coolness.

W

All muscle groups should be checked for tone and strength. Check proximal and
distal power in the arms and legs. Evaluate for the presence of tremor at rest, and with
action, (intentional tremor). Look for cogwheel rigidity, (stiffness), suggesting
Parkinson’s disease. Tremors may be signs of medication side effects, demyelinating
disease, hyperthyroidism, and anxiety. Tremors may also be benign.

E l L! . .

Evaluate the migraine patient’s gait and coordination. Perform finger to nose,

heel to shin, tandem walking, and Romberg’s test. Even without formal testing, simple

66

observation of the patient’s gait and coordination can provide very accurate information
about the patient’s cerebellar integrity.

Reflexes

Check the deep tendon reflexes including the biceps, brachioradialis, triceps,
quadriceps, and Achilles. Check for pathological Babinski’s reflexes. Check the
pupillary, corneal, and gag reflexes with the cranial nerve exam. Check for Kemig’s and
Brudzinski’s sign, or stiffness of the neck, to rule out meningitis.

MentaLstatur

The history should be helpful in providing clues to the existence of depression or
anxiety. Be alert for blunted, sad or inappropriate affect in migraine patients. Check
ability to concentrate and recent and remote memory. Evaluate the migraine patient for
evidence of rumination or obsessional personality style (Rapoport & Sheftell, 1996).

WWW:

If the practitioner has only a limited time to spend with the headache patient, the
following examination falls within the scope of primary care practice and can be carried
out within the time usually allotted for a routine visit (Smith, 1994). It is the
recommendation of this author that a complete physical be scheduled within the next
week or so to more thoroughly examine the patient and review the health history.

Cognitive Status- An alert, coherent patient who is behaving reasonably seldom
has impaired cognition. This can be observed easily at the beginning of the examination.

Vital Signs- Take the blood pressure, temperature, pulse and respiratory rate. Any
abnormalities in the vital signs require further investigation and the practitioner must

consider the possible relationship to the headache complaint.

67

Neck- Check for nuchal rigidity, as positive Kernig and Brudzinski signs may
indicate meningitis. Patients with subarachnoid hemorrhage often complain of neck
stiffness and pain.

Cranial Nerves- Examine pupil size and light and accommodation reflexes.
Examine fundi and check for nystagrnus. Evaluate facial symmetry. Examination of the
cranial nerves will help screen for headache related intracranial lesion.

Power- Check deltoids, handgrip, hip movement, flexor and ankle dorsiflection
for motor power. Biceps tendon reflexes, knee jerks, and flexor responses should be
tested. The finger-nose test should be performed. Observe the patient walking to test gait
abnormality. Observe fine and gross motor skills and coordination. Abnormalities in any
of the following merit investigation (Smith, 1994).

II" 'II'II °lHllS'C"

After a careful review of the physical exam and entire headache and medical
history a diagnosis using The IHS criteria can be made. When reviewing the IHS criteria
for the primary headache disorders it should be clear that the information necessary to
make the diagnosis has been included in the history-taking format, (used in this protocol).
Table 1 shows the IHS diagnostic criteria for classification of headache.

EELS Z! .2 . Cl 1 l

The IHS Classification of Headache summarizes all the primary and secondary
headache disorders on a single table. As shown in Table 1, the first three groups are the

primary headaches, groups five through thirteen are the secondary headaches.

68

Table l . New International Headache Society Classification of Headache

1.1
1.2
1.3
1.4
1.5
1.6
1.7

2.1
2.2
2.3

3.1
3.2
3.3

4.1
4.2
4.3
4.4
4.5
4.6

5.1
5.2

6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9

Migraine
Migraine without aura
Migraine with aura
Opthalmoplegic migraine
Retinal migraine
Childhood periodic syndromes that may be precursors to or
Complications of migraine
Migranous disorder not fulfilling above criteria
Tension-type headache
Episodic tension-type headache
Chronic tension-type headache
Tension-type headache not fulfilling the above criteria
Cluster headache not associated with structural lesion
Cluster headache
Chronic paroxysmal henricrania
Cluster headache-like disorder not fulfilling the above criteria
Miscellaneous headaches not associated with structural lesion
Idiopathic stabbing headache
External compression headache
Cold stimulus headache
Benign cough headache
Benign exertional headache
Headache associated with sexual activity
Headache associated with head trauma
Acute posttraumatic headache
Chronic posttraumatic headache
Headache associated with vascular disorders
Acute ischemic cerebrovasculor disorder
Intracrarrial hematoma
Subarachnoid hemorrhage
Unruptured vascular malformation
Arteritis
Carotid or vertebral artery pain
Venous thrombosis
Arterial hypertension
Headache associated with other vascular disease

69

Table 1 continued

7. Headache associated with nonvascular intracranial disorder
7.1 High CSF pressure

7.2 Low CSF pressure

7.3 Intracranial infection

7.4 Intracranial sarcoidosis and other noninfectious inflammatory
7.5 Headache related to intrathecal injections

7.6 Intracranial neoplasm

7.7 Headache associated with intracranial disorder

8. Headache associated with substances or their withdrawal
8.1 Headache induced by acute substance use or exposure

8.2 Headache induced by chronic substance use or exposure

8.3 Headache from substance withdrawal (acute use)

8.4 Headache from substance withdrawal (chronic use)

8.5 Headache associated with substances but with uncertain mechanism
9. Headache associated with noncephalic infection

9.1 Viral infection

9.2 Bacterial infection

9.3 Headache related to other infection

10. Headache associated with metabolic disorder

10.1 Hypoxia

10.2 Hypercapnia

10.3 Mixed hypoxia and hypercapnia

10.4 Hypoglycemia

10.5 Dialysis

10.6 Headache related to other metabolic abnormality

11. Headache or facial pain associated with disorder of cranium,
neck, eyes, ears, nose, teeth,

mouth or other facial or cranial structures

11.1 Cranial bone

11.2 Neck

11.3 Eyes

11.4 Ears

11.5 Nose and sinuses

11.6 Teeth, jaws and related structures

11.7 Temporomandibular joint disease

70

Table 1 continued

12. Cranial neuralgias, nerve trunk pain, and deafferentation pain
12.1 Persistent (in contrast to tic-like) pain of cranial nerve origin

12.2 Trigeminal neuralgia

12.3 Glossopharyngral neuralgia

12.4 Nervus intermedius neuralgia

12.5 Superior laryngeal neuralgia

12.6 Occipital neuralgia

12.7 Central causes of head and facial pain other than tic douloureux
12.8 Facial pain not fulfilling the above criteria

13. Headache not classifiable

71

LELS"E" 'l

The IHS diagnostic criteria for migraine without aura have very specific inclusive
and exclusive criteria that must be met for the diagnosis to be made (see table 2). The
IHS criteria specify that a diagnosis of migraine without aura requires at least five attacks
of headache lasting four to seventy two hours with at least two of the following: unilateral
location, pulsating quality, moderate or severe intensity, and aggravation by routine
physical activity. In addition to the above, at least one of the following two is necessary
for the diagnosis: nausea and/or vomiting, and photophobia or phonophobia. The IHS
criteria also specify that for the diagnosis to be applied there must be no evidence of

associated organic or systemic metabolic disease as a cause of the headache.

Table 2. Diagnostic Criteria for Migraine Without Aura

A. At least 5 attacks firlfilling B-D.
B. Headache attacks last 4-72 hours (untreated or successfully treated).
C. Headache has at least two of the following characteristics:
1. Unilateral location
2. Pulsating quality
3. Moderate or severe intensity (inhibits or prohibits daily activities)
4. Aggravation by walking stairs or similar routine physical activity
D. During headache at least one of the following:

1. Nausea and/or vomiting

72

2. Photophobia and/or phonophobia
E. At least one of the following:

1. History and physical and neurological examinations do not suggest one
of the disorders listed in groups 5-11 (see above International Headache Society
Criteria)

2. History and/or physical and/or neurological examinations do suggest
such disorder, but it is ruled out by appropriate investigations
LE LS . . 2 . . . 1
According to the IHS criteria for diagnosis of migraine with aura at least two

attacks fulfilling three of the following four characteristics must be met: one or more fully
reversible aura symptoms indicating focal cerebral cortical and/or brain stem dysfunction,
at least one aura symptom develops gradually over more than four minutes or two or
more symptoms occur in succession, no aura symptom lasts more than one hour, and the
headache follows the aura with a free interval of less than one hour. The exclusion
criteria for migraine with aura also specify that no organic or systemic metabolic disease

may be present which account for the symptoms (see table 3).
Table 3. Diagnostic Criteria for Migraine With Aura

A. At least 2 attacks fulfilling B.
B. At least 3 of the following 4 characteristics:
1. One or more fully reversible aura symptoms indicating focal, cerebral

cortical and/or brain stem firnction.

73

2. At least one aura symptom develops gradually over more than 4
nrinutes or 2 or more symptoms occur in succession.
3. No aura symptom lasts more than 60 nrinutes. If more than one aura
symptom is present, accepted duration is proportionally increased.
4. Headache follows aura with a free interval of less than 60 minutes (it
may begin before or simultaneously with the aura).
C. At least one of the following:
1. History and physical and neurological examinations do not suggest one
of the disorders listed in groups 5-11.
2. History and/or physical and/or neurological examinations do suggest
such disorder, but it is ruled out by appropriate investigations.
3. Such disorder is present, but migraine attacks do not occur for the first
time in close temporal relation to the disorder.
EELS C . . 2 . l 1 l
Tension headache is the most common of all of the primary headache disorders.
It is more common in women than in men, and can occasionally be severe and disabling.
The patient usually reports a long history of headaches associated with fatigue and stress.
Depression, anxiety, sleep disturbances, low energy levels, sadness, guilt, difficulty
concentrating, irritability, and nervousness are frequently reported by tension headache
sufferers.
Patients complain of pain that is usually bilateral, but the pain can be unilateral.
The pain is described as a steady, aching pressure, like a band tightening around the

patient’s head. The pain is experienced in the occipital and upper neck region, as well in

74

as the frontal and temporal areas. The pain of tension headache varies from mild to
moderate and is often progressive, lasting 30 minutes to 7 days. The pain is not
aggravated by physical activity, and is not associated with nausea or vomiting. Tension
headache pain may produce anorexia (Weiss, 1993). The IHS criteria are helpful in

differentiating tension headache from the other primary headache disorders.
Table 4. Diagnostic Criteria for Tension-Type Headache

At least two of the following pain characteristics:

1. Pressing/tightening (nonpulsating) quality

2. Mild or moderate intensity may inhibit but does not prohibit activities)

3. Bilateral location

4. No aggravation by walking stairs or routine physical activity
Both of the following;

1. No nausea or vomiting (anorexia may occur)

2. Photophobia and phonophobia are absent, or one but not the other are
present
At least one of the following:

1. History, physical, and neurologic examinations do not suggest
headache associated with trauma, vascular or nonvascular disorders, substance use
or withdrawal, noncephalic infection, metabolic disorder and disorders of the
facial structures

2. History and/or physical and/or neurologic examinations suggest such

disorder, but it is ruled out

75

3. Such disorder is present but tension type headaches do not occur for
the first time in close temporal relation to disorder
WWW
According to Rapoport and Sheftell (1996), cluster headache is among the most

painfirl of all human experiences. Cluster headache has been called suicide headache,
because patients with this disorder have been known to consider suicide when treatment
measures fail. Cluster headache is four times more common in men than in women.

Rapoport and Sheftell (1996) offer an interesting patient profile commonly
observed in cluster patients. The typical cluster patient is a middle-aged male with a busy
schedule and much responsibility. Cluster headache patients are often social people,
described as “macho” types, who enjoy hunting, fishing, and other sports. They tend to
be heavy smokers and often drink alcohol to excess. Cluster men tend to be slightly taller
and thinner than average. They are more likely to have hazel eyes with chiseled features,
deeply furrowed foreheads, and prominent naso-labial folds. They often present with
peau d’orange, (orange peel skin), and telangiectasia of the nose and checks. They often
have a weather-beaten, lion-like facial appearance called leonine facies, (Rapoport &
Sheftell, 1996).

Cluster patients describe episodes of excruciating unilateral pain located behind or
around the eye. The pain may radiate to the jaw, nose, check, or temple. Cluster
headaches last 15 to 180 minutes, and occur in clusters lasting 3 to 16 weeks. They then
disappear for a year or more. Clusters are often nocturnal and tend to occur on the same
side. Lacrimation, unilatoral rhinorrea, miosis, ptosis, flushing, and edema of the affected

side are common.

76
Table 5. Diagnostic Criteria for Cluster Headache

A. At least 5 attacks firlfilling B-D.

B. Severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to
180 minutes untreated.

C. Headache is associated with at least one of the following signs that have to

be present on the pain side.

1 Conjunctival injection
2. Lacrimation
3. Nasal congestion

4. Rhinorrhea
5. Forehead and facial sweating
6. Miosis
7. Ptosis
8. Eyelid edema
D. Frequency of attacks: fi'om 1 every other day to 8 per day.
E. At least one of the following:
1. History and physical and neurological examinations do not suggest
one of the disorders listed in groups 5-11.
2. History and/or physical and/or neurological examinations do suggest
such disorder, but it is ruled out by appropriate investigations.
3. Such disorder is present, but cluster headache does not occur for the

first time in close temporal relation to the disorder.

77

The headache history, a review of neurologic symptoms, a headache treatment
barrier assessment, neurological exam, headache danger signs, and the IHS criteria for
diagnosis of migraine, tension-type, and cluster headaches have been incorporated into a
one page migraine headache assessment document by this author for facilitation of
headache diagnosis (see Appendix D). A pocket protocol card with the migraine
headache assessment is also included with this manuscript.

Migraine is a highly prevalent, underdiagnosed, and undertreated disease that
causes decades of suffering and disability for many patients. It is, according to Cady
(1994b), a chronic disease. Management models applied with success to other chronic
disease states suggest that early identification and treatment can reduce long-term
morbidity. Management of migraine should be divided into five basic components: (1)
education, (2) acute treatment strategies, (3) prophylactic strategies, (4)
nonpharmacological therapies, and (5) long term follow up. As with all chronic diseases
and disorders, education is the cornerstone of management (Cady, 1994b).

Migraine patients and their practitioners must form a collaborative partnership
characterized by open communication and mutual respect. Effective management of
headache demands that practitioners reach beyond traditional standards of therapy and
understand the medical, psychological, and social issues confi'onting the patient (Cady,
1994b)

The necessity of a strong patient/practitioner relationship for the successful

treatment of migraine cannot be stressed enough. After secondary causes of headache

78

have been ruled out, and the diagnosis of migraine is made, the majority of the further
treatment is directed at: (1) teaching the migraine patient to manage and control
symptoms, using nonpharmacologic therapies and strategies, and (2) counseling the
patient to assist him/her in making the necessary lifestyle changes and maximizing
coping behavior. Counseling and teaching are the key elements in the successful
treatment of rrrigraine patients. The remainder of the treatment will consist of
establishing a medication regimen for prophylactic and symptomatic control, making
modifications as needed, and following up on new or changing headache symptoms.

Headache patients tend to be fiequent callers, usually requesting pain
medications or acute headache treatment. According to Kennedy and Barter (1994), a
quiet, soothing tone and empathetic, informative, open-ended responses are often the
most effective interventions when counseling migraineurs. Patients must be believed
when they talk about the subjective complaints of migraine. Practitioner skepticism as to
the validity of the patient’s complaints or descriptions of disability is counterproductive
and may produce compliance problems. Educating patients about diagnosis,
pathophysiology, and treatment alternatives will maximize compliance (Rapoport &
Sheftell, 1996). The following are the major points to be covered when counseling and
educating rrrigraine patients (Kennedy & Barter, 1994).

1. Explain that the mechanism of migraine headache is not well understood.
Explain to the patient what we do know about the pathophysiology of nrigraine. Many
patients would like a precise answer about the underlying cause of headache, but this

remains a mystery. The physiological disturbance may involve a chemical alteration,

79

vascular changes, or a disturbance in nerve cells, but as yet researchers remain uncertain
as to the exact cause.

2. Reinforce to the patient that the goal of therapy is to reduce the severity,
frequency, and duration of headaches. In most cases it is not possible to eliminate the
headaches completely, but most headache patients can experience significant relief fi'om
pain and reduction in disability. It is important that the patient have realistic expectations
of medical treatment of migraine headaches.

3. Teach the patient to use the headache calendar so that a more objective
assessment of treatment response can be determined. The client should be educated to
record each headache, medications used, and their success or their lack of, food
consumed before the headache, activities performed before and during the headache, a
pain intensity estimate, and length of time for the headache to subside. In addition, the
patient should record any other factors, such as life stressors and relationship to menses,
that may be related. The headache calendar is helpful in visualizing progress and
improvement of the headache disorder.

4. Teach patients that overuse of ergotamines and pain medications may
actually exacerbate the headache problems. Patients who overuse analgesics often
experience a greatly increased frequency and severity of headaches, with headache pain
becoming refiactory to pain medication. Patients whose headaches have become
refi'actory to analgesics and ergotamines require a washout period of abstinence from
these medications to regulate the nocioceptive system.

5. Encourage the patient to continue preventive medications for several

weeks before making an assessment of the drug efficacy. The therapeutic effect of many

80

prophylactic medications for migraine often takes several weeks to become apparent.
Reinforce that patience and hope are important psychological variables in effective
migraine treatment.

6. Strongly recommend a balanced lifestyle for good health and wellness.
Patients can often control their levels of rest, relaxation, laughter, nourishing diet,
socialization with fiiends and family, work, and exercise patterns. Teach patients that
positive changes in any of these areas greatly enhance physical and mental well being,
and thereby greatly ameliorate migraine headache disorder.

7. After the workup for migraine reveals no abnormal findings, reassure the
patient that the headache is not due to a sinister cause, such as aneurysm or brain tumor
(Capobianco, Cheshire & Campbell, 1996). Explain to the patient that they were born
with a sensitive neurovascular system that overreacts to internal changes and external
stimuli, and that migraine is thought to be an inherited or genetic condition. Explain the
pathophysiology of primary headache disorders to patients.

8. Teach the patient about the role of triggers in migraine headache. Advise
patients that irregular sleep patterns, missed meals, smoking, certain foods, alcohol use,
prolonged overexertion, glare, noise, and odors act as triggers to many migraine patients
and should be avoided Capobionco, Cheshire, & Campbell, 1996). Advise the patient to
use a headache diary and food diary to discover his or her own particular triggers.

9. Educate the patient about what medications to take when, and why they
have been prescribed. Explain how the medications work and their potential side effects.
Patients should leave with simple and explicit written instructions and should be

encouraged to call with questions or problems (Rapoport & Sheftell, 1996).

81

10. If laboratory or diagnostic tests are required for the patient, be sure to
explain how the results will help you to manage their headaches more efficiently.
Describe the testing environment and any preparations required. Patients who are
claustrophobic may require small doses of benzodiazapines for MRI studies (Rapoport &
Sheftell, 1996).

ll. Educate female patients about the role of hormones in migraine headache
disorder. Inform patients that migraine often presents at puberty, disappears with
pregnancy and may worsen in the pen-menopausal years. Teach that migraine can be
exacerbated with hormone replacement or oral contraceptives (Rapoport & Sheftell,
1996)

12. Explain the role of stress and psychological factors. Advise the patient to
reduce stress in their personal lives as much as possible and to learn positive strategies for
managing unavoidable stress. Patients should be aware that rrrigraine headache is much
more likely to occur after stressful times and during letdown times, such as the first few
days of vacation and weekends. Some patients with overwhehning problems and
responsibilities may require ongoing counseling by the practitioner to learn to manage
stress more effectively (Rapoport & Sheftell, 1996).

W

The migraine patient should be scheduled to return for follow-up as soon as
possible after the completion of the history and physical examination and any diagnostic
workup. The practitioner should schedule up to an hour to explain the diagnosis and
begin teaching about pharmacologic and non-pharmacologic interventions and lifestyle

modifications that the patient will need to undertake. The patient should be encouraged

82

to call the practitioner if they have questions or concerns. The patient should return for a
thirty-minute visit in two weeks to evaluate progress with the medical regimen and
continue counseling and education.

Depending upon the extent .of headache related disability and success of the
treatment plan, the patient should be rescheduled to return at bi-weekly or monthly
intervals. Patients who are doing well may not need to be seen for three or six months.
All patients will need to return at least every six months for evaluation of possible side
effects of medication. Some migraine medications can produce hepatic or renal problems
or cause blood dyscrasias. As always, patients should be encouraged to call the
practitioner with problems or concerns.

Gnalsnflteannem

The goals of treatment in migraine are greater control of headaches, decreased
frequency of headaches, and enhanced quality of life (Rapoport & Sheftell, 1996).
Reduced pain and disability are the results of successful treatment. It is important that
the patient and practitioner have mutual goals in the treatment of migraine headache
disorder.

Measurement

The effectiveness of treatment in migraine headache management is likely to take
weeks to months to appreciate. An important tool for evaluating outcomes is the patient’s
headache diary, which should be reviewed at each visit to evaluate effectiveness of
individual interventions in diet, exercise, stress reduction, and pharmacologic and

nonpharmocologic therapies. Outcomes can be measured in reduction of headache

83

frequency, severity, and duration. Reduction in occurrence of associated symptoms such
as aura and nausea and vomiting are important parameters as well.

The practitioner should keep detailed notes on the telephone and office counseling
sessions to evaluate outcomes. Patients’ subjective estimates of the progress of their
headache treatments are helpful in appreciating improvement or worsening of their
conditions. Document the patient’s comments such as “I had only two headaches this
month instead of the two headaches each week I usually get.”

Another measure of outcomes is the patient’s use of medications. Patients who
are improving as a result of lifestyle interventions, counseling, and nonpharmocologic
therapies will require fewer prescription and over the counter medications. Again, careful
documentation on the part of the practitioner concerning medication use is of paramount
importance in measuring outcomes.

Ask the patient about disability measured in sick days at work, or at home for
homemakers. Inquire at each visit about the effects of the patient’s migraine headaches
on social and family obligations. Ask direct questions such as “Have you missed work
because of your migraine headaches in the past month?” and “Have you had any
problems fulfilling your family obligations because of headaches in the past month?”
Record the patient’s observations and compare them with previous visits to ascertain
improvement in migraine associated disability.

Measures of outcomes using the Protocol for Migraine Headache Assessment are
not in the scope of this study however, suggestions for further research using the protocol

are included.

84

Waugh

The Protocol for Migraine Headache Assessment requires evaluation for validity
and usefulness in the family practice setting. This can be accomplished by testing the
protocol with APNs in family practice or community health clinics. The APNs can test
the protocol by assessing and diagnosing headache patients using the Protocol for
Migraine Headache Assessment, and then having the patient diagnosed by a neurologist
specializing in headache treatment, functioning as co-investi gator. The two diagnoses
should then be compared to assess accuracy in identifying rrrigraine headache disorder.

APN’s working in family practice can further the study of headache diagnosis
using the IHS criteria by keeping statistics on the use of the protocol. Useful information
to be collected for retrospective research would be numbers of patients diagnosed with
migraine, tension, and cluster headaches in the clinic, and subjective rating of success of
treatment. Data on patient compliance with treatment regimen and follow up schedules

would also be useful.

CONCLUSION
It is appropriate and cost-effective for APNs in family practice to diagnose and
treat migraine headaches. Identification and elimination of barriers to migraine diagnosis
and treatment and use of the International Headache Society criteria will enable the APN
in family practice to more effectively treat migraine headaches. In addition to decreasing
pain and disability of migraine sufferers, APNs can have a substantial impact on the

tremendous personal and financial burden of migraine in this country.

85

APPENDICES

86

APPENDIX A

General Medical Information

87

GBSBIIAL DIBIDICAI‘ ISFOIIMA'I‘IOS

 

 

 

 

Name Date

Age _ Occupation

Referred by (Circle one) right handed left handed ambidextrous
(Circle one) female male

Primary Physician (Circle one) married single divorced widowed other

 

 

 

INSTRUCTIONS: Please fill out each item and remember to bring it with you to the first visit.

 

 

FOR WHAT PROBLEM ARE YOU COMING TO SEE US?

 

 

 

 

 

 

WHEN DID SYMPTOMS BEGIN?
DID SOMETHING CAUSE THIS?
IF A MOTOR VEHICLE ACCIDENT, PLEASE ANSWER THE FOLLOWING:
DATE OF ACCIDENT , WERE YOU THE DRIVER? yes no

WERE YOU WEARING A SEATBELT? yes no WERE YOU SEEN IN THE ER? yes no
IF A WORK RELATED INCIDENT , PLEASE ANSWER THE FOLLOWING?

DATE OF INJURY . ARE YOU ON WORKMAN'S COMP? yes no
ARE YOU OFF WORK BECAUSE OF THIS INCIDENT? yes no DATE LAST WORKED
IS THERE A LAWSUIT PENDING? yes no

WE NEED TO KNOW ABOUT YOUR GENERAL HEALTH FIRST. PLEASE CIRCLE THE FOLLOWING
CONDITIONS THAT YOU AWARE OF HAWNG IN THE PAST OR PRESENT TIME, INCLUDING SURGERY.

high blood pressure (hypertension) diabetes emphysema

asthma heart problems thyroid disorder

glaucoma cancer ulcers

seizures head injury neck problems

low back pain headaches stroke

nerve injury of any type mental illness substance abuse problems
eye problems fractures skin diseases

AIDS other:

00 YOU EXPERIENCE ANY OF THE FOLLOWING SYMPTOMS? PLEASE CIRCLE ALL THAT APPLY.
shortness of breath chest pain sleep difficulties
depression sexual difficulties passing out

numbness _ weakness of arms or legs muscle cramping

muscle twitching clumsiness handwriting change
walking problems incontinence vision difficulties

hearing loss ringing in the ears speaking problems
memory loss change in behavior fatigue

other.

FAMILY HISTORY: (please circle all that apply to illness that run in the family)

unknown stroke migraine
diabetes high blood pressure heart disease
crippling muscle diseases dementia or memory loss epilepsy

Parkinson's disease tremors mental illness

 

88

PLEASE TELL US ABOUT THE FOLLOWING HABITS: (Circle all that apply)

CIGARETTES I never smoked I smoke_ packslday l qu‘t __ yrs ago.

OTHER pipe cigars chewing/snuff

COFFEE none or decaf only less than 5 cups/day more than S cups/day

SOFT DRINKS

WITH CAFFEINE 1 or less per day 2-5 glasses per day more than 5 glasses per day
ALCOHOL never. a few fimeslyear. a few per month, more than once per week. daily

NUTRITION: WHAT TYPE OF DIET DO YOU FOLLOW?
no special diet low fat diabetic vegetarian heart diet Wilts

ANY ADDITIONAL VITAMNS OR FOOD SUPPLEMENTS? Please list here.

 

 

MEALTIMES breakfast lunch supper

SLEEP: (circle all that apply)

no problem sleeping trouble getting to sleep trouble staying asleep

snoring . nightmares excessive daytime drowsiness

need daytime naps falling asleep accidentally not refreshed after sleeping

use sleeping pills use coffee to stay awake use meds to stay awake
PRIOR MEDICAL CARE:

CIRCLE PAST TESTS AND FILL OUT AS WELL AS POSSIBLE:
TEST WHERE IT WAS PERFORMED WHEN DONE RESULT

CT scan brain

CT scan neck

CT scan low back
MRI brain

MRI neck

'MRI low back
Carotid duplex
EEG (brainwaves)
EMG (needle exam
Myelogram

other X-rays
recent blood tests

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE NAME ALL OTHER PHYSICIANS YOU HAVE SEEN FOR THE PROBLEM YOU ARE SEEING US
ABOUT, AS WELL AS OTHER PHYSICIANS IN YOUR CARE.

89

APPENDIX B

Headache Questionnaire

90

Edmund Messina MD

120 West Exchange Street. Ownsso, MI 48867

IIBAIDACIIB QUESTIOSSAIIIB

NAME DATE

 

 

INSTRUCTIONS: Please fill out each item. Please remember to bring this with you to the first visit

 

 

1 HOW MANY DIFFERENT TYPES OF HEADACHE DO YOU GET?

 

2 ON THE FOLLOIMNG UNES. BRIEFLY DESCRIBE THE TYPE OF PAIN EXPERIENCED WITH EACH TYPE

OF HEADACHE YOU GET. WE WILL ASK MORE DETAILED QUESTIONS LATER. EACH HEADACHE IS
DESCRIBED BY A LETTER. A. B. C ETC. USE- ADDITIONAL PAGES IF~ NEEDED. BE SURE TO INCLUDE NECK
PAIN.

A)

 

B)
C)
D)

3 FOR EACH HEADACHE TYPE, PLEASE CIRCLE THE NATURE OF THE PAIN
HEADACHE "A" -Throbbing. pouring -Sharp ~Burring -Dull. pressure
HEADACHE ”B" -Throbbing. pomding ' -Sharp Baring -Dtll. pressu'e
HEADACHE ”C" -Throbung, pomdlng -Sharp Baring -DLII. pressue
HEADACHE "D" -‘l'hrobbing, pouring -Sharp firming -Ddl. pressure

4 FOR EACH HEADACHE TYPE, WRITE THE LOWEST, AVERAGE AND WORST INTENSITY

 

Scoring the Intensity of your headaches
19161.11 Low level. aware of It but does not requ're treatment.
easy to ignore
IQLQLZ: Hadtoignore.sfiil maynotlead youtotreatit. does not
keep you from working
EELS: Unable to work unless meds are used. uncomfortable
and mable to ignore
MA: Severe, hard to concentrate, not able to perform
mentally demanding jobs
m: Intense. unable to function at all

 

 

 

HEADACHE ”A”
HEADACHE “B"
HEADACHE ”C"
HEADACHE ”D"
NOTE: This helps us decide which of the different headache types are the most troublesome.

 

 

91

5 PLEASE SHADE IN THE PARTS OF YOUR HEAD THAT ARE PAINFUL. YOU MAY WISH TO LABEL EACH
HEADACHE TYPE. USE DIFFERENT COLORS IF YOU WISH.

.. "/—\\
/" ’ \ \.
I 4 a l
‘ H: ; (VI Q Q [In] 3
i . \
/
/

6 WHAT TNES OF DAY ARE YOU MOST LIKELY TO GET A HEADACHE? PLEASE CIRCLE THE ONES THAT APPLY.

3)

K

midrighfI234567891011noon1234567891011 NOPAT'TERN

7 WHAT DAYIS) OF THE WEEK ARE YOU MOST UKELY TO GET A HEADACHE? PLEASE CIRCLE.

Monday Tuesday Wednesday Thusday Friday Saturday Sunday NO PATTERN

8 WOMEN: WHEN IN YOUR MENSTRUAL CYCLE ARE YOU MOST LIKELY TO GET A HEADACHE? PLEASE CIRCLE.

midcycle (ovulation) before periods during periods after periods no pattern NOT APPUCABLE

9 HAVE YOU NOTICED ANYTHING THAT CAN TRIGGER OR START UP YOUR HEADACHES? CIRCLE THE
EXAMPLES BELOW AND ADD ANY OTHERS THAT YOU HAVE NOTICED.

too much sleep not enough sleep irregdar sleep schedule weekends

when relaxing when stressed after a stressful time weather changes
bright lights exertion . odors certa'n seasons
alcohol cigarette smoke missed meals loud noises

sex . certa'n foods:

 

 

1 O WHICH OF THE FOLLOWING WILL WORSEN THE HEADACHE DISCOMFORT?

movement of head bending. stooping stra'ning light noise

01% MiehiganHeadaeheTredmertNdworlkandEdmundMessinaMD

92

1 1 WHICH OF THE FOLLOWING WILL HELP RELIEVE SOME OF THE HEADACHE PAIN?

medications a dark room sleep heating pad ice pack
exercise pacing keeping busy resfing qu'etly - meditation

1 2 WHICH OF THE FOLLOWING FEEUNGS OCCUR WITH THE HEADACHES?
GI nausea vomiting cramping diarrhea constipation hunger
SENSORY tender scalp tingling scalp neck pa'n numbness burning stabbing

SENSATIONS ringing ears ”dizziness" odors

VISUAL blurring double vision spots flashes of light zigzags colors

EMOTIONS confusion irritability depression restlessness ”hyper" feelings

MOTOR slurred speech no speech Weak arm weak leg droopy face

GENERAL chills flushing , paleness cold hands and feet runny nose
droopy eyelid fluttering heart confusion fdnting anxiety tiredness

OTHER

 

1 3 DOES YOUR IMMEDIATE FAMILY SUFFER FROM HEADACHES? IF YES, CIRCLE THE ONES THAT APPLY

UNKNOWN SISTER BROTHER
MOTHER MOTHER'S PARENTS MOTHER’S BROTHERS OR SISTERS

FATHER FATHER’S PARENTS FATHER’S BROTHERS OR SISTERS

14 DID YOU REGULARLY EXPERIENCE ANY OF THE FOLLOWING AS A CHILD? PLEASE CIRCLE

MOTION SICKNESS GI UPSET WHEN EXCITED COUCKY INFANT

1 5 WOMEN: CIRCLE ANY OF THE FOLLOWING CHANGES IN HEADACHES ASSOCIATED WITH PREGNANCY:

WORSENING WITH EARLY PREGNANCY IMPROVED NONE DURING PREGNANCY
MORE AFTER PREGNANCY NO CHANGE NOT APPUCABLE

OVERALL WORSE DURING PREGNANCY STARTED VIflTI-I PREGNANCY

1 6 IMPACT OF HEADACHE ON DAILY LIFE, PLEASE CIRCLE ITEMS AND COMMENT BELOW.

CANNOT MAKE PLANS MISSING WORK MISSING SCHOOL
CANNOT FUNCTION HURTING RELATIONSHIPS MAKING ME DEPRESSED
VERY FRUSTRATING USING TOO MANY MEDS MAKES ME IRRITABLE

I AM NO FUN ANYMORE LIFE IS A BURDEN I WISH I WOULD DIE
COMMENTS:

1 7 WHO DO YOU DEPEND ON FOR SUPPORT DURING THESE TRYING TIMES? CIRCLE ONE OR MORE.

SPOUSE SIGNIFICANT OTHER PARENT SIBUNG
FRIEND CLERGY COUNSELLOR PHYSICIAN
OTHER

 

e 1% Michioan Headache Trainers Network and Edmund .‘ka MD

93

PREVIOUS HEADACHE MEDICATIONS

PLEASE REVIEW THIS UST CAREFULLY AND CIRCLE ALL MEDS TRIED FOR HEADACHE RELIEF OR PREVENTIOh
MARK ANY COWENTS NEX'TTO THE MED. OR BELOW. WE NEED TO SEE WHAT WORKED, WHAT MADE YOU WORS
AND WHAT YOU DID NOT TOLERATE WELL

ADAPIN INDOCIN SKELAXIN
ADVIL ISOPTIN SOMA
ALEVE KLONOPIN ST ADOL SPRAY
ALKA SELTZER IBUPROFEN SUDAFED
ANACIN IMITREX SURMONTIL
ANAPROX UBRAX TALWIN
ATIVAN LIBRIUM TEGRETOL
ANTIVERT IJMBITROL TENORMN
ASENDIN UORISAL THORAZINE
ASPIRIN UTHIUM TIGAN
AXOTAL LOPRESSOR TIMOLOL
AVENTYL LUDIOMIL TOFRANIL
BELLERGAL MARPLAN TOLECTIN
BLOCADREN MECLOMEN TORECAN .
BUFFERIN MEDROL TORADOL
BUSPAR METHADONE TRANXENE
CAFERGOT TABS MEXITIL TRIAVIL
CAFERGOT SUPPOS. MICRAININ TYLENOL
CALAN MIDOL TYLENOL #3
CARDIZEM MIDRIN TYLOX
CENTRAX MORPHINE VALIUM
CLINORIL MY SOLINE VANQUISH
CODEINE NALFON VERAPAMIL
COMPAZINE NAPROSYN VICODIN
CONTAC NAPROXIN VISTARIL
CORGARD NARDIL VIVACTYL
DARVOCET NORFLEX WIGRAINE SUPPOS.
DARVON NORGESIC \MGRAINE TABS
DECADRON NORPRAMN XANAX
DEMEROL NUPRIN ZOLOFT
DEPAKENE PAMELOR

DEPAKOTE PARAFON FORTE OTHER MEDS TRIED:
DESYREL PARNATE

DHE PAXIL

DILANTIN PERCOCET

DISALCID PERCODAN

DOLOBID PERIACTIN

DRISTAN PHENERGAN

DURAGESIC PHENOBARBITAL

EFFEXOR PHRENAUN

ELAVIL PONSTEL

ENDEP PREDNISONE

ENTEX PROCARDIA

EOUAGESIC PROPRANOLOL

ERGOMAR PROZAC

ESGIC RESTORIL

EXCEDRIN ROBAXIN COMMENTS:
FELDENE ROBAXISAL

FIORICET SANSERT

F IORI NAL SERAX

FIORINAL #3 SINE-AID

F LEXARIL SINEQUAN

HALCION SINUTABS

E? 1% Michigan Headache TreatTIICIIi NMHK and Edmund Messina MD

 

 

 

 

 

 

 

 

 

94

APPENDIX C

Headache Diary

95

 

« MICHIGAN HEADACHE

‘ TnaATMENT NETWORK MOO")

LANSING - Dwosso

 

. Duration Grade Relieved by Menses
Dole BegIn In hrs 1-5 Triggered by med. etc. Stort‘stop

 

 

 

 

 

mwa~

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

‘O‘OCDVOU‘IBDOM—‘OOCDNO‘

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Copyright E Messmo MD H.397

96

APPENDIX D

Migraine Headache Assessment

MIGRATNE HEADACHE ASSESSMENT

HISTORY

Chief Headache Complaint

Headache History

age of onset

location of pain

description of pain

duration of pain

description of prodrome

description of euro

associated systems

behavior during headache

headache triggers

pest headache medications

past and present O.T.C. use

headache frequency

gradual or sudden increase

menstrual history

mental health history

3. Review of Neurologlc Systems

mental or memory changes

nausea and/or vomiting

dininess. unsteadinese. clumsiness

weakness or paralysis of the annuities

numbness. finding. loss of aeration

Shirred speech. difficulty swelowlng

word finding difficulties

bluned or distorted vision

double vision or blindness

ringing or buzzing In ears

seizures or syncope

head trauma. accidents

alcohol or other substance abuse

history of stroke (hernorrhadc. bchenlc)

change in bowel or bladder control

4. Headache Treatment Barrier Assessment

a. patient characteristics-male. low-income.
chronic headache. O.T.C. use. young age.
emotional distress. lack of knowledge
about migraine headache

b. incorrect diagnosis-practitioner falue
to correctly diagnose. practitioner bias.
lack of valid case defrrrltion

c ineffective treatment-practitioner failure
to treat all migraine symptoms. patient
difficulty with treatment and follow-up
regimens. patient/practitioner relationship
problem. patient non-compliance

P9

9?3'F*’?9”999?P

PPsPrrnapnPPPPP

a revrew of systems
b past rnedicallsurdcel history
c current medications
d .
e hmlly history
f social history
PHYSICAL EXAMINATION

1. General Physical Examination
ncludingbutnotirnltedto:cranium.eyee. shrines.
thyroid. lymph nodes. heart. lungs. circulation

2. Neurological Examination

a. mental status: language. orienbtion.
level of consciousness. memory.
concentration

b. cranial nerves: l-ernell. ll acuity. fundi.
pupils. visual fields. III. IV.& Vl-extra
ocular movements. double vision. pupils.
V-corneal reflex. masseter 8. temporalls
strengthmensory portion. VII-facial motor.
VIII-hearing. Ix. x-gag reflex. palate position.
swallowing. XI-etemocleidomastoid and
trapezius strength. XII-tongue movement.

C $1.11” fone-epasticity. rigidity. power- pronetor
direct muscle testing. hemi or paraparoeis.
proximal-distal weakness. mess. atrophy

d. coordination: finger to nose. heel to shin. rapid
alternating movements. gait-heel walldng. toe
walking. tandem. (steady? broad based?) Romberg

 

reflexes: DTRs-biceps. triceps. knee.
brachioradialis. snide. pathologic reflexes-Babinski.
sucking. grasp. palmer-mental. Kernig. Bruda‘naki
sensory pin prick. light touch. vibratory sense.
temperature. graphesthesia. steroognosis.
9096000950"

vascular carotid. subclavian. vertebral. temporal
arteries

3. Headache Danger Signs

P-P 57.9

onset of headache after age 40

onset of new or different headache

'Worat headache of my life'

onset of subacute headache that progressively

worsens
tnedadremsetwlmexerfiomeemelactivlty.
000m

headacheassociatedwithcl'lengeinneurologlcal
status:
I . . ll.

problems.
weakness. ataxia. loss of coordination. sensory

loss. unequal pupils. asymmetric deep tendon
response. Babinski response. signs of meningeal
irritation. visual changes. abnormal medical exam.
fever. hypertension. chronic malaise. W.
arti'raldaweightloesJenderandpoorlyprleetlle
temporal arteries. papilledema

IHSCRITERIA
i'erfollowlngcriterieehouldbeueedonlyaffereecondary
headechehasbeenruledout.

‘I. :IigraineWIthoutAur-a

b.
C.

at least 5 attacks fulfilling b-d

headache lasts 4-72 hours

headache has 2 of the folowlng:

1. unilateral location

2. pulsating quality

3. moderate or severe htensity (inhblte or
prevents activities)

4. aggregation by routine physical activities

dining the headache at least 1 of the followhg:

1. nausea end/or vomiting

2. photophobia andlor phonophobia

2. Migraine With Aura

a.
b.

atleeetZattecksfulflllingb

at least 30fthe following:

1. oneormorefullyreverslbleeurasyn'pbms

2. atleasttaurasymptomdevelopegradualy
(4ormoremin.)

3. noaurasymptomlastsmorethanoOmimtes

4. heedechefollawsaurawlthefreelntervalof
lessthanGOmin.

3. Tension-Type Headache

b.

atlasetZotfhefollowingpdncharaderistice

1. pressingltightening (nonpulsating quality)

a mild or moderate intensity. inhibits not
prohibits activities

3. blateral location

4. no aggravation by routine activity

both of the following:

1. no nausea or vomiting

2 photophobiaorphonophobiaabsentoronlyt
present

4. Cluster Headache

8.
b.

C.

at least 5 attacks fulfilling b-d

severe unilateral orbital. supraorbital. and/or
temporal pain lasting 15 to 180 minutes
headacheassociatedwlthatleasttofthefolmvlng
(on pain side)

conjunctival injection
lacrimation

nasal congestion

rhinorrhea

forehead and facial sweating
mlosis

ptosis

eyelid edema

esenswwe

frequencyofattacks: fromteveryotherdaytoo
PWWY

98

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99

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