Diagnosing Migraine in Primary Care
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Your friend, your aunt, your patient in your primary care office, medication commercials with celebrities - everyone seems to be talking about migraine. But is it a headache or is it a migraine? How do you know the difference?
As a new grad, it’s not unusual to feel like you have been thrown into the deep end when patients present with a migraine or a headache. It’s not a super black and white topic; there are not a lot of objective findings or tests that you can order to get evidence. On top of that, patients sometimes have a hard time describing their symptoms, adding to the challenge.
Diagnosing Migraine in Primary Care
This week, we’ll talk about what makes a migraine different from a headache, and how to approach your patient who just knows that their head hurts and they want relief.
✅ Differentiating headaches and migraines
✅ Migraine red flags
✅ Other diagnoses that can be mistaken for migraine
✅ A word about auras
✅ The importance of a headache diary for you and your patient
When you have a good handle on the red flags, and what makes a migraine different from a regular headache, managing migraines will get easier for both you and your patient. Check out the links below to learn more about triggers, criteria for auras, and a handy headache diary for your patient (and you).
Aura criteria:
At least three of the following six characteristics:
At least one aura symptom spreads gradually over ≥5 minutes
Two or more symptoms occur in succession
Each individual aura symptom lasts 5 to 60 minutes
At least one aura symptom is unilateral
At least one aura symptom is positive
The aura is accompanied, or followed within 60 minutes, by headache
Resources mentioned in this episode:
Link to food triggers: https://my.clevelandclinic.org/health/articles/9648-headaches-and-food
Link to headache diary: https://headaches.org/wp-content/uploads/2021/05/HEADACHE-DIARY.pdf
Link to migraine triggers: https://www.mayoclinic.org/diseases-conditions/migraine-headache/symptoms-causes/syc-20360201
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WEBVTT
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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Okay, so I want to talk to you about migraines.
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So when it comes to migraines, I feel like I think there's just so much to keep track
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of when you're a new grad.
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Like even if you learn about migraines in school, it's just there's something different
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about the way that people present.
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I don't know.
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I want to talk about migraines.
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Hopefully this is a helpful topic for you.
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One of the things that I would do and that I still do actually is that I have
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a quick text that I have in my HPI for a patient when they come in with a headache
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and I'm trying to figure out what type of headache we're talking about.
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So if you didn't catch the last episode that I did, it was about headache red flags.
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So definitely go back and check that one out if you haven't already, because that
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informs your assessment of migraines as well.
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But one of the things I do with migraines is I'm trying to make sure I'm asking all
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the assessment questions to figure out are we heading towards migraine versus another
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type of headache.
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And there are so many different types of headaches.
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So many different kinds.
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But hopefully this episode will help you differentiate what the criteria is for a migraine or not.
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So there is actual criteria for a migraine and that's based on the International Classification
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of Headache Disorders and there are specific criteria involved.
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Typically patients have a unilateral throbbing slash pulsatile headache, moderate to severe
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pain and it's aggravated by physical activity.
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It typically lasts four to 72 hours.
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There's a bit of a gradual onset and it tends to get better with resting in the dark.
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They also during the headache have at least one of the following, nausea and vomiting,
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photophobia, sensitivity to light, or phonophobia, sensitivity to sound.
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So part of the criteria is making sure that they have at least one of those last
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like three things that I mentioned, the sensitivity to light and sound and nausea.
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And the other part of the criteria is that there's been at least five attacks that
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generally speaking meet that criteria.
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The tricky part is if you have somebody with their first presentation of a migraine,
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you have to be watchful, right?
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The other part of the criteria is that you have to be careful that there's no
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other potential underlying criteria or sorry, underlying other diagnoses, right?
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So you want to do your due diligence and making sure like what is going on here.
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And also if they meet all that criteria and there's not anything else that's
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pulling you in another direction, it is likely going to be a migraine.
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These are clinical diagnosis.
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We don't need testing for them unless they are showing some signs of red flags.
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So we do want to be mindful of that.
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The other thing we want to consider, well, we definitely want to assess for
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is whether or not there's an aura.
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So everybody's aura is different.
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Not everybody has them.
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Typically it occurs with at least two attacks to be diagnostic for a migraine
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with aura, they can be all over the place.
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I mean, patients have variety of descriptions that they have for it,
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whether it's wavy lines that they see, or there's some sort of motor or
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speech changes, things like that.
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The main thing is that it's gradual onset and it's self-limited and it's
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not like associated with anything else that's going on.
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So when it comes to aura, there's actually, according to that classification,
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there's six different characteristics.
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And actually I can link to these down below.
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I kind of just look at them and reference them, but the moral of the
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story is that it's typically a gradual onset and that the headache is around
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the same time and that it's typically like a unilateral thing as well.
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Anyway, I will link to those down below.
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You can copy and paste that similar to those red flags that I mentioned in
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last week's episode, that you can just copy and paste those and put
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those into your HPI and make sure that you're asking about those things.
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All of the red flags that you want to watch out for for migraines are the
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same as general red flag headaches.
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So definitely go back and check out that episode if you haven't already.
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When it comes to managing patients with migraines, there is a whole
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host of things that we can do for patients.
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I think one thing I want to stress in this episode, though,
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is obtaining a headache diary.
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So many patients are resistant to this, but it really is quite helpful
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because it helps paint the picture of like why these are happening
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in the first place and it helps us avoid doing lots of medication.
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So, for example, a lot of people with migraines will have certain triggers.
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I usually give them a list of foods and I can link some resources
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down below the episode to look at what foods may be triggering.
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They just need to observe.
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When you see this person, you determine it's likely a migraine.
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Let's do some observation and do a close follow-up in like two weeks
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and see how they're doing in addition to treatment, right?
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So we want to do observation.
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What foods might be triggering it?
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Here's a list of foods.
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How consistent is diet?
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How consistent is their hydration status, their caffeine use, their sleep?
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What about hormones?
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What's going on with their hormonal cycles?
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And are there certain stressors or environmental changes?
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Like there's a whole list of things that they can keep track of to notice
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and get to know themselves better because the alternative is we just keep
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giving patients medications that may or may not work versus if we understand
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the underlying rationale for it, then we can go from there.
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So typically what I do is a lot of education with patients of like,
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here are all these things that you can do to empower yourself to manage this.
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We're going to do it together.
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Here's a template for a headache diary.
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Just write down when it happened, what else was going on.
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Hopefully we can start to unravel all of the things that are going on
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that are contributing to your migraines in the first place.
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So I do have a colleague who works in neurology in a headache clinic,
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and I'm trying to get her to come on the channel.
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So hopefully we can have a conversation more about headaches and migraines,
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but hopefully this is a helpful primer for your patients with migraines
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to differentiate one between the other and definitely check out
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the resources and the quick text that I have down below this episode.
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And yeah, if you haven't grabbed the ultimate resource guide for the new NP,
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head over to realworldnp.com slash guide.
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I really just don't share anywhere else.
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Thank you so much for tuning in.
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Hang in there and I'll talk to you soon.
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That's our episode for today.
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Thank you so much for listening.
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with notes from me, patient stories and extra bonuses.
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I really just don't share anywhere else.
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Thank you so much again for listening.
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Take care and talk soon.
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