Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations for migraines and fibromyalgia
- Describe the diagnostics and laboratory values for migraines and fibromyalgia
- Apply nursing concepts and plan associated nursing care for the patient with migraines and fibromyalgia
- Evaluate the efficacy of nursing care for the patient with migraines and fibromyalgia
- Describe the medical therapies that apply to the care of migraines and fibromyalgia
Any type of pain, such as a headache or lower back pain, that is ongoing and continues for longer than three months is known as chronic pain. This section reviews migraines, which include severe headaches, and fibromyalgia, which causes musculoskeletal pain that is widespread throughout the body.
Migraines
Migraines are typically thought of as severe headaches. But a migraine is actually a serious neurological disease characterized by a severe, throbbing pain or pulsing sensation that may affect one or both sides of the head. The pain from a migraine is so severe that it disrupts routine activities. If untreated, a migraine attack can last for several days. According to the American Migraine Foundation (2021), migraines affect at least 39 million Americans.
Pathophysiology
The causes of migraines are not fully determined, but genetics may be a factor for some patients because migraines sometimes run in families. Migraines also tend to be triggered by factors such as stress, anxiety, tobacco, alcohol, certain foods such as cheese, food additives such as monosodium glutamate (MSG), low blood sugar, weather changes, bright flashing lights, loud sounds, and irregular sleep patterns. Concussions, hormonal changes, and chemical imbalances in the brain also cause migraines in some patients.
Clinical Manifestations
For some patients, migraines progress through four stages—prodrome, aura, attack, and postdrome. Other patients may only experience some of the stages (Mayo Clinic, 2023e; NIH, 2023). Generally, the symptoms of the four stages include the following:
- prodrome—This stage occurs twenty-four to forty-eight hours before a migraine. During this stage, premonitory symptoms occur, which may include the following:
- mood changes with euphoria or depression
- cravings for certain foods
- uncontrollable yawning
- increased need to urinate
- fluid retention
- constipation
- stiff neck
- aura—This stage occurs in the minutes immediately before the migraine begins. Symptoms during this stage include the following:
- muscle weakness and/or numbness
- visions with flashing lights
- loss of eyesight
- speaking difficulties
- sensations of pins and needles in the arm or leg
- attack—In this stage, the headache begins and gradually worsens. Symptoms during this stage include the following:
- throbbing or pulsating pain on one or both sides of the head
- sensitivity to sound, light, touch, and/or smell
- nausea, which may lead to vomiting
- postdrome—This stage, which may last up to twenty-four hours, occurs after the headache is over. The symptoms during this stage include the following:
- exhaustion
- confusion
- elation
Generally, migraines are incurable unless caused by an underlying condition, such as head trauma that can be cured. But migraines can be treated, and nursing care can help patients learn to live with migraines.
Assessment and Diagnostics
To assess and diagnose migraines, patients must undergo a physical examination that includes a review of their family background, medical history, and symptoms.
For patients with migraines, a physical examination may reveal a family history of migraines. It may also reveal factors, such as tobacco and alcohol use, irregular sleep patterns, and stress that are risk factors for migraines. The physical examination should provide details about patients’ headaches, including frequency, duration, and severity, that can help identify if the headaches are migraines. Other details, such as going through prodrome, aura, and/or postdrome in addition to having a headache, can help determine if a patient has migraines.
Diagnostics and Laboratory Values
Tests, such as blood tests, cannot confirm a migraine diagnosis. However, blood tests and imaging, such as MRI and CT scans, can help rule out conditions, such as low blood sugar, infections, brain tumors, and strokes, which may be causing migraines. MRI and CT scans may find problems such as brain tumors and strokes that can cause migraines.
If test results do not reveal health problems that cause migraines, providers may diagnose migraines based on patients’ symptoms, including the frequency, location, and duration of headaches. A family history of migraines as well as known triggers, such as certain foods and bright lights, can help confirm a migraine diagnosis.
Nursing Care of the Patient with Migraines
If a patient’s migraines cannot be relieved by addressing an underlying cause, the patient should receive nursing care that helps them learn techniques to prevent migraines and manage them when they do occur. This includes identifying migraine triggers, such as sleep deprivation and loud noises, and teaching patients to avoid those triggers. This also includes teaching patients how to deal with the symptoms of migraines, such as pain and nausea.
Nursing care for patients with migraines should focus on treating underlying causes to eliminate migraines if possible. For example, if a patient has an infection or a brain tumor that is causing migraines, nursing care should focus on resolving this problem. If other factors, such as smoking or irregular sleep patterns, are causing migraines, patients should receive help to overcome these problems.
Recognizing Cues and Analyzing Cues
The cues for migraines will be found in the patient’s physical examination. Nurses should be alert for cues such as a family history of migraines and risk factors such as stress, tobacco and alcohol use, and irregular sleep patterns. Primary cues will come from information patients provide verbally about their experiences with migraines, including the frequency, duration, and intensity of headaches, as well as whether patients experience the symptoms found in prodrome, aura, and/or postdrome stages of migraines. Additional cues may be found in test results. Although these tests cannot diagnose migraines, they can reveal if patients have problems such as infections and brain tumors that can cause migraines.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Migraine symptoms should be prioritized on the basis of their severity. Severe migraine pain that disables patients and leaves them unable to function should be prioritized over milder migraine pain. Although migraines generally are not life-threatening, they can severely disrupt patients’ lives, making it challenging for them to handle their daily routines. Solutions should include eradicating underlying causes of migraines if possible. If migraines cannot be relieved, solutions should focus on helping patients learn to manage and cope with migraines. The nursing interventions appropriate for patients with migraines may include those in Table 17.18.
| Nursing Care | Rationale |
|---|---|
| Complete focused neurological assessments. | Patients may have headaches and other issues such as mood changes, food cravings, muscle weakness, speaking difficulties, and other symptoms that might indicate a migraine is forthcoming. |
| Monitor vital signs. | Changes in the patient’s vital signs such as heart rate and blood pressure may indicate health issues. |
| Provide a peaceful environment. | Patients with migraines need a quiet room with dim lights. They may also need a cool cloth or ice pack to help with pain. |
| Administer medications for immediate relief. | Patients with migraines may need medications such as the following during a headache:
|
| Administer medications to prevent migraines, as ordered. | Patients with migraines may need medications such as the following to prevent a migraine:
|
| Assist with mental health support. | Patients with migraines who are unable to get relief may need consultation with a mental health professional to help them cope with the challenges of living with migraines. Some patients may need prescription medications to help with issues such as anxiety and depression. |
Evaluation of Nursing Care for the Patient with Migraines
The desired outcome for patients with migraines is to stop migraine headaches and their symptoms, as well as prevent attacks in the future. For patients whose migraines cannot be stopped, nursing care should help them learn to manage the factors that trigger migraines, limiting the frequency and severity of migraines. To evaluate patients with migraines, nurses should consider vital signs, such as the patient’s temperature and heart rate. They should also examine the patient’s neck and head, noting if the patient has areas of tenderness or swelling. The patient’s behavior should also be evaluated, focused on whether the patient appears to be restless, grimaces in pain, or moves into certain positions in an effort to alleviate pain.
Medical Therapies and Related Care
The medical therapies for patients with migraines may include medications to prevent migraines, as well as medications to provide relief after a migraine occurs. For example, some patients may benefit by taking triptans, which change the way the brain circulates blood and processes pain signals. Other patients with migraines, especially those who experience nausea, may get relief by taking antiemetics, which interfere with the neurotransmitter receptors that trigger nausea and vomiting. For many patients with migraines, the most effective medications are simply anti-inflammatories, such as aspirin and ibuprofen. Some patients with migraines also find alternative medical treatments helpful, such as yoga and massage therapy.
Fibromyalgia
A chronic condition that affects soft tissues and muscles throughout the body, causing musculoskeletal pain and tenderness, is called fibromyalgia. The condition has no cure and affects at least one in twenty-five people in the United States. Most patients with fibromyalgia are middle-aged females, although anyone can experience it, including children. The condition often runs in families, although it also occurs in patients without a family history of the condition (Johns Hopkins Medicine, 2024b; NIAMSD, 2021).
Pathophysiology
The cause of fibromyalgia is unknown, although medical experts suspect the condition is linked to stress and sleep disorders. Other causes may include endocrine, biochemical, and immune disorders. Patients who have conditions and diseases such as migraines, lupus, rheumatoid arthritis, osteoarthritis, chronic back pain, irritable bowel syndrome, anxiety, and/or depression also tend to be more likely to develop fibromyalgia. In some cases, the condition appears to be triggered by an infection, such as HIV, Lyme disease, and both hepatitis B and C (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2021). Although fibromyalgia is a chronic condition without a cure and the pain can be severe enough to disrupt patients’ daily routines, it does not damage the body’s muscles or bones.
Clinical Manifestations
Fibromyalgia affects patients in varied ways, and pain can affect any part of the body. Often, the pain is worse in tendons and ligaments, where the muscles attach to the body’s bones. For some patients with fibromyalgia, the pain is mild, whereas others experience more severe pain. The pain may present as stiffness, soreness, aching, or a burning sensation. Other common symptoms of fibromyalgia include the following:
- fatigue
- headaches, including migraines
- restless legs
- stiff joints
- numbness and/or tingling in the legs and arms
- sensitivity to touch
- sensitivity to noise, light, and temperature
- lack of exercise endurance
- cognitive difficulties referred to as fibro fog. Fibro fog may include the following issues (Arthritis Foundation, n.d.):
- difficulty concentrating
- lack of alertness
- forgetfulness
- reduction in thinking skills, including inefficient and slow thinking abilities
- difficulty retrieving information stored in the brain
- sleep disorders
- anxiety and depression
- constipation and/or bladder disorders, such as interstitial cystitis
- excessive pain during menstrual periods
Assessment and Diagnostics
Typically, fibromyalgia is diagnosed by ruling out other conditions and diseases that cause similar pain, such as rheumatoid arthritis. Patients undergo a physical examination and generally must experience ongoing pain for at least three months in at least four body areas before their condition is considered to be fibromyalgia. The body areas include the jaw, neck, shoulders, arms, legs, back, chest, and buttocks. To rule out other conditions that cause similar pain, doctors usually order blood tests. Other symptoms experienced by patients may include sleep disorders, fatigue, restless legs, headaches, stiff joints, cognitive difficulties, and issues such as constipation or bladder dysfunctions. Patients may also have anxiety and/or depression.
Diagnostics and Laboratory Values
If blood tests show results such as rheumatoid factor, thyroid dysfunction, vitamin D deficiency, a high erythrocyte sedimentation rate, or antinuclear antibodies, doctors may determine that the patient has another condition, such as lupus or rheumatoid arthritis, rather than fibromyalgia. If blood tests have normal results and offer no explanation for the patient’s pain, fibromyalgia is a likely diagnosis.
Nursing Care of the Patient with Fibromyalgia
Nursing care for patients with fibromyalgia should focus on controlling symptoms and helping patients learn how to manage their condition. For some patients, this may require lifestyle changes as well as treatment for conditions such as anxiety and depression that contribute to fibromyalgia.
Recognizing Cues and Analyzing Cues
The cues of fibromyalgia will be found in the patient’s physical examination, particularly the locations and duration of the pain. Nurses will find other cues in patient symptoms such as fatigue, stiff joints, restless legs, and sensitivity to touch. By talking to the patient, nurses can learn about other cues, such as sleep disorders, anxiety, and depression. Finally, cues will be found in the patient’s blood test results. If tests do not identify another cause for the patient’s pain, such as rheumatoid arthritis, it is reasonable to make a fibromyalgia diagnosis.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Fibromyalgia should be prioritized based on the severity of symptoms. For example, symptoms that cause severe, widespread pain and sleep deprivation should be prioritized over milder symptoms that cause fewer disruptions to a patient’s daily routine. Solutions should be generated that help patients learn to manage the pain and discomfort caused by fibromyalgia, while also learning to cope and function. The nursing interventions appropriate for patients with fibromyalgia may include those in Table 17.19.
| Nursing Care | Rationale |
|---|---|
| Complete focused physical examination. | Patients with fibromyalgia will experience pain and likely other symptoms, such as headaches, restless legs, stiff joints, anxiety, and depression. They may also have difficulty sleeping and may experience fibro fog or other problems, such as constipation and/or bladder issues. |
| Monitor vital signs. | Changes in the patient’s vital signs such as heart rate and blood pressure may indicate health issues. |
| Administer medications for pain. | Although fibromyalgia cannot be cured, patients can be helped with medications. Pain relievers such as acetaminophen and ibuprofen may be beneficial, and patients who need stronger medications may find pain relief by taking antiseizure drugs, such as pregabalin and gabapentin. Some patients may be helped with antidepressants, such as milnacipran and duloxetine, which can treat patients’ pain, as well as anxiety and depression. |
| Administer medications for other symptoms. | Other medication may include laxatives, sedatives, and other drugs appropriate to treat issues such as constipation and sleep disorders. |
| Coordinate with physical therapist. | Physical therapy can help patients with fibromyalgia learn exercises and techniques to strengthen their muscles, improving their flexibility and strength. |
| Coordinate with occupational therapist. | Occupational therapy can help patients with fibromyalgia learn how to organize their home and work areas to make it easier to accomplish tasks without stressing the body. |
| Assist with mental health support. | Patients with fibromyalgia and their families may need consultation with a mental health professional to help them cope with the challenges of living with fibromyalgia. Some patients may need prescription medications to help with issues such as anxiety and depression, which may also help with pain. |
Evaluation of Nursing Care for the Patient with Fibromyalgia
The desired outcome for patients with fibromyalgia is symptom relief, including relief from pain as well as other problems such as restless legs, stiff joints, and anxiety. If patients’ symptoms cannot be completely relieved, nursing care should help them learn to control and manage their symptoms, improving their quality of life. This goal is met if patients are able to function despite their pain and do so without experiencing problems such as anxiety and depression. This can be evaluated with tools such as serial assessments of patients’ pain levels, screening for depression, and assessment of patients’ ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
Medical Therapies and Related Care
The medical therapies used to treat fibromyalgia may include medications for pain, as well as medications for other symptoms such as constipation and insomnia. For example, as noted previously, some patients may benefit by taking triptans or antiemetics, whereas others may do well with anti-inflammatories such as aspirin and ibuprofen. Some patients may find relief from antiseizure drugs, such as pregabalin and gabapentin, which can also be used to fight pain. For constipation and insomnia, medications such as laxatives and sedatives may be beneficial. Physical and/or occupational therapy may also be helpful.