Migraine

Key Points

• Migraine attacks are recurrent, often unilateral, throbbing headaches that can last 4 to 72 hours when untreated.
• Associated symptoms include nausea, vomiting, photophobia, and phonophobia.
• Classic migraine includes aura; common migraine occurs without aura, and some clients progress through prodrome-aura-attack-postdrome stages.
• Abortive therapy treats an active attack, whereas preventive therapy reduces attack frequency and functional burden over time.
• There is no cure, so management focuses on trigger avoidance plus acute and preventive therapy.
• Lifestyle optimization, medication strategy, and stress-response training are core care domains.

Pathophysiology

Migraine is linked to abnormal brain activity involving nerve pathways and neurochemical changes that influence cerebral and pericranial blood-flow dynamics. Exact mechanisms remain incompletely defined, and attacks are often precipitated by identifiable personal triggers.

Classification

• Classic migraine (with aura): Neurologic warning symptoms precede headache, such as visual disturbances.
• Common migraine (without aura): Migraine phenotype without prodromal neurologic aura pattern.
• Staged migraine pattern: Prodrome (often 24-48 hours preattack), aura, attack, and postdrome phases in variable combinations.

Nursing Assessment

NCLEX Focus

Differentiate aura findings, trigger history, and attack pattern to individualize prevention and rapid self-management.

• Assess headache pattern, duration, intensity, and associated nausea/vomiting or light/sound sensitivity.
• Assess aura features such as blind spots, flashing lights, zigzag lines, blurred vision, eye pain, or tunnel vision.
• Assess trigger profile: sleep disruption, missed meals, caffeine withdrawal, stress, hormonal shifts, flashing lights, motion sickness, smoke/tobacco exposure, potent odors, alcohol, and food triggers (for example aged cheeses, aspartame, and MSG-containing foods).
• Assess postdrome effects such as fatigue or confusion after attacks.
• Assess family history and functional impact on daily life.
• Screen for secondary-headache red flags (sudden worst headache, neck stiffness, seizure/confusion/LOC change, trauma-related onset, or new persistent headache in a previously headache-free patient) and escalate urgently when present.

Nursing Interventions

• Teach trigger-avoidance planning and symptom diary use.
• Reinforce lifestyle protection: regular sleep schedule, meal regularity, stress control, and weight optimization when indicated.
• Teach early-attack self-care: rest in dark quiet room, cool compress or ice pack, hydration, and early symptom-directed medication use.
• Reinforce triptan timing and limits: administer at migraine onset, repeat only as prescribed after 2 hours, and do not exceed ordered daily maximum dose.
• Escalate promptly for chest discomfort, angina-like symptoms, severe dizziness, arrhythmia cues, or hypersensitivity findings after triptan administration.
• Screen for ergot-alkaloid contraindications (for example CAD/PVD, hypertension, renal/hepatic dysfunction) and teach alcohol avoidance plus no abrupt overuse-withdrawal cycles.
• Review serotonergic interaction risk when triptans or lasmiditan are coadministered with SSRIs/SNRIs/TCAs and escalate serotonin-syndrome cues immediately.
• Reinforce post-dose safety for lasmiditan due to CNS depression and impaired-driving risk.
• Support escalation pathways for frequent attacks or functional decline requiring preventive therapy adjustment.
• Integrate biofeedback and relaxation training for stress-modulation support.

High-Frequency Attack Burden

Frequent migraine attacks can significantly impair function and may require preventive regimen reassessment.

Pharmacology

Drug Class	Examples	Key Nursing Considerations
Acute analgesic therapy	Ibuprofen, aspirin, acetaminophen; combination products with caffeine	Use early in attack for mild-moderate pain; monitor overuse risk.
Migraine-specific acute therapy: triptans	Sumatriptan	5-HT1B/1D receptor agonism with reduced neuropeptide release; administer at onset; may repeat once after 2 hours per order (common oral max 200 mg/day). Contraindicated with prior MI/CAD, stroke, uncontrolled hypertension, and PVD; monitor chest pain and arrhythmia cues.
Migraine-specific acute therapy: ergot alkaloids	Ergotamine	Cerebral vasoconstrictive effect for acute migraine. Avoid in CAD/PVD, hypertension, or renal/hepatic dysfunction; monitor nausea, vomiting, and abdominal pain; avoid alcohol and dose overuse.
Migraine-specific acute therapy: ergot derivative	Dihydroergotamine	Can reduce severe refractory attack burden; monitor vasoconstrictive adverse effects and contraindication profile similar to ergot pathways.
Selective serotonin receptor agonist (5-HT1F)	Lasmiditan	Reduces neuropeptide/glutamate release without vasoconstriction focus; monitor drowsiness/CNS depression and impaired-driving risk; serotonin-syndrome risk rises with other serotonergic drugs.
CGRP receptor antagonist	Rimegepant, zavegepant nasal contexts	Calcitonin gene-related peptide blockade for acute migraine treatment; monitor nausea, hypersensitivity, and dyspnea risk.
Preventive therapy	Anticonvulsants, beta-blockers/calcium-channel blockers, antidepressants, CGRP agents, onabotulinumtoxinA	Daily prevention for frequent/severe migraine burden and functional impairment.
Symptom adjuncts	Antiemetic contexts	Useful when nausea-vomiting burden limits oral medication tolerance.
Adjunctive supplements	Riboflavin, magnesium	Can be used in prevention plans for selected patients.

Clinical Judgment Application

Clinical Scenario

A patient reports recurrent unilateral pulsating headaches with visual zigzags, nausea, and work absences despite intermittent OTC use.

• Recognize Cues: Classic migraine pattern with significant functional burden.
• Analyze Cues: Trigger control and medication strategy are insufficient.
• Prioritize Hypotheses: Reduce attack frequency and improve function with preventive optimization.
• Generate Solutions: Build trigger-management plan and reassess acute versus preventive medication balance.
• Take Action: Implement structured lifestyle and pharmacologic plan with follow-up.
• Evaluate Outcomes: Attack frequency, severity, and activity limitation decrease over time.

Related Concepts

• beta-blockers - Common preventive-option class for migraine prophylaxis.
• anticonvulsants - Preventive options that reduce neuronal excitability.
• antiemetics - Adjunctive nausea and vomiting management during attacks.
• seizures-and-epilepsy - Aura terminology overlap requires differential clarification.

Self-Check

1. Which findings distinguish classic migraine from common migraine?
2. Why are trigger diaries important in long-term migraine management?
3. When should preventive therapy be considered over acute-only treatment?