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More than a headache: how migraine treatment often falls short

Even though migraine is common, there’s a lack of understanding of it, even among nurses
Picture shows a woman holding her head

Even though migraine is common, theres a lack of understanding of it, even among nurses

  • Migraine is mainly managed in primary care but nurses in other settings will care for affected patients too
  • There is a low level of understanding of treatment options across all areas of nursing including general practice
  • Care is variable, and nurses need to understand the risks of medication overuse. Plus tips if you are a nurse who gets migraine

Migraine is the most common neurological disorder in the UK, affecting one in seven people, according to the Migraine Trust .

That makes this debilitating condition more prevalent than diabetes, epilepsy and asthma combined.

Poor understanding and limited training for nurses on migraine

But despite the numbers affected and the

...

Even though migraine is common, there’s a lack of understanding of it, even among nurses

  • Migraine is mainly managed in primary care but nurses in other settings will care for affected patients too
  • There is a low level of understanding of treatment options across all areas of nursing – including general practice
  • Care is variable, and nurses need to understand the risks of medication overuse. Plus tips if you are a nurse who gets migraine
Picture shows a woman holding her head
Picture: iStock

Migraine is the most common neurological disorder in the UK, affecting one in seven people, according to the Migraine Trust

That makes this debilitating condition more prevalent than diabetes, epilepsy and asthma combined.

Poor understanding and limited training for nurses on migraine

But despite the numbers affected and the major impact it can have on quality of life, care for many people is well below the standard they should receive, according to charities and specialist nurses.

‘The impact of migraine on individuals is huge,’ says Ria Bhola, headache nurse specialist at the Migraine Trust. ‘It affects a large proportion of the population and is a burden for the individual. It affects many people’s ability to function and enjoy life.’

Ria Bhola, headache nurse specialist at the Migraine Trust
Ria Bhola: ‘The impact of migraine on
individuals is huge’

As millions of people are affected, and to varying degrees, the neurological condition is mainly managed in primary care. But nurses in care homes, emergency departments and many other settings will care for patients affected by it too.

Ms Bhola says there is a low level of understanding of migraine in primary care and elsewhere. Part of the problem is a lack of education – she does not know of a single course about migraine or headache management aimed at practice nurses, and there is little on the subject on preregistration nursing courses.

Even nurses training in neurology have only a single session on headache, she says. Specialist headache care, which is in short supply and difficult to access, should be reserved for the most complex cases. But this means better primary care support is needed.

‘People generally don’t understand how debilitating migraine can be’

York Teaching Hospital NHS Foundation Trust advanced nurse specialist in headache Jill Murphy says: ‘The problem is that people generally don’t understand what migraine is and how debilitating it can be. Patients get a very varied response from primary care.

‘Painkillers are not the answer when people have chronic migraine. I do appreciate the time limits that practice nurses and GPs have, but ten-minute appointments are not long enough to get a full picture of what is happening to a patient.’

Who does migraine affect?

  • Migraine affects three times as many women as men, with this higher rate likely to be hormonally driven
  • More than three quarters of people with migraine experience at least one attack each month, and more than half experience severe impairment during attacks
  • Migraine often starts in puberty but mostly affects people aged between 35 and 45
  • Much younger people, including children, can be affected – about 4% of boys and girls who have not yet reached puberty experience migraine, and as children get older there is a predominance among girls

Source: Migraine Trust

 

Getting the right diagnosis is a crucial first step

Migraine is a complex condition with a wide variety of symptoms. For many people, the main feature is a painful headache, but other symptoms include disturbed vision – also known as migraine aura – sensitivity to light, sound and smells, and nausea and vomiting. Attacks generally last between four and 72 hours and for many people, they are frightening.

While the causes are not fully understood, there is often a genetic element, with 80% of people with migraines having a family member who shares the condition.

The brain of someone affected by migraine is sensitive to change triggered by factors including stress, lack of food intake, alcohol consumption and lack of sleep. In women it can be triggered by hormone levels.

As with treatment and condition management generally, getting the right diagnosis is a crucial first step. At present it tends to take a lot of time before people get this, Ms Bhola says. ‘We know that care is very variable.’

Migraine in numbers

  • There are 190,000 migraine attacks every day in the UK
  • One in seven people experience migraine
  • Three times as many women are affected as men

Source: Migraine Trust

And if management is very variable now, studies over the past couple of decades suggest this may be a long-standing issue. One UK survey of 9,770 people who experienced migraine, for example, found most did not consult their GP because they did not believe they would understand or empathise with them.

Supporting people to self-manage is essential

And an Italian study suggested migraine remained undiagnosed and under-treated in at least 50% of patients, with fewer than half of individuals consulting a physician.

Supporting people to self-manage is an essential part of headache care, says Ms Bhola.

‘Suggest people keep a headache diary – this is a very useful first step,’ she advises nurses. ‘It doesn’t need to be a very detailed account of what someone has done each day, but a brief record in a calendar or diary format of when the person has a headache or migraine attack.

Keeping a diary should show a pattern of symptoms

‘Record the pain level on a scale of one to ten, and if the person took painkillers, what type and the dose. After keeping this diary for between one and three months it should show a pattern of symptoms and how severely the person is affected. This is good information to take to a GP appointment, which helps the patient get a correct diagnosis.’


Picture: iStock

The diary can also flag up if the patient has developed medication-overuse headaches, leading them to increase the risk of developing daily headaches. These are prompted by withdrawal or rebound from drugs, which patients then tend to treat with more painkillers.

Drugs associated with the development of headaches due to overuse of medication include caffeine, ergots, paracetamol, codeine and triptans, according to the Migraine Trust.

Risks from taking too much pain-relief medication

People are deemed to be at risk if they use acute pain-relief medicine more than two or three days a week or more than ten days in a month. The treatment is to stop this medication, although this will generally cause withdrawal symptoms and some patients may need extra support. 

Ms Bhola says it is essential that primary care staff know about these risks. ‘It is important that healthcare professionals stress the impact of overusing pain-relief medication, both over the counter and prescription,’ she says.

Picture shows partial shot of woman holding a glass of water in one hand and a tablet in the other
Picture: iStock

Ms Murphy agrees: ‘Medication overuse should be managed in primary care. People are becoming more knowledgeable about it, but while having the knowledge, primary care staff don’t necessarily have the skills to implement change.’

The three main approaches to migraine management

  • The first is lifestyle, including eating well and regularly, taking regular exercise and losing weight, if appropriate
  • Then there is acute treatment during an attack. The National Institute for Health and Care Excellence (NICE) recommends a combination of an oral triptan, a type of painkiller that is believed to reverse changes to blood vessels in the brain caused by migraine, with either non-steroidal anti-inflammatory drugs or paracetamol
  • Finally, there is prevention, where two main medicines are recommended. One is an epilepsy drug, topiramate, and the other propranolol, which was developed to treat high blood pressure and angina. Both have contraindications that need to be considered by the healthcare professional

 

For most people, lifestyle changes and the right medical approach will help them manage their condition well, Ms Murphy says. About 1-2% develop chronic migraine, when patients experience headache for 15 or more days a month.

These individuals need to be referred for specialist care to discuss other treatments. But access to specialist services is limited, with long waits to see specialist nurses and neurologists.

The All Party Parliamentary Group on primary headache disorders reported in 2014 that there were only around 12 trained headache specialist nurses for the whole of England.

The report, Headache Services in England, said: ‘Headache disorders are not prioritised in the NHS. Despite their prevalence and impact, headache disorders are at the “bottom of the pile” of neurological commissioning priorities. Headache needs to be better recognised as a long-term health condition.’

Migraine is ‘too long under-recognised and under-resourced’

Ms Bhola says the Migraine Trust would like to see major improvements to ensure everyone affected by migraine has access to the best possible information, support and care to ensure they receive an accurate and timely diagnosis and access to treatment.

As part of this, the charity plans to contribute to education in primary care settings. 

Ms Bhola says: ‘Migraine has too long been under-recognised and under-resourced, and it is time to acknowledge and meet the needs of this significant population.’

Nurses with migraine: how to cope at work

Coping with migraine at work, especially in fast-paced nursing environments, can be punishing.

The Migraine Trust advises people affected to tell their managers about their condition. Formal disclosure means it will be on your personnel file, should there be any changes to management in the future.

Keep your manager updated if the condition changes, and keep a record of all correspondence.

People with migraine are more likely to take short-term sickness absences because of their condition.


Migraine could cause you to have frequent short-term sickness absence, so it is important to talk to your manager about how it affects you  Picture: iStock 

Poor sleep, eating habits and general well-being are potential triggers

Nurses are advised to check their employer’s sickness policy and absence management procedure, which should outline the employer’s approach to managing sickness absence, how they will provide support and what to expect if there is a need to be absent from work.

Those who are concerned about how migraine-related sickness absence is managed are entitled to discuss it with their manager or human resources department.

The Migraine Trust recommends taking steps to manage stress at work. Stress can compromise sleep, eating habits and general well-being, all of which are potential trigger factors for migraine.

Source: The Migraine Trust


Erin Dean is a health journalist


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