The emergency department is a place where people seek immediate medical attention for acute and severe health problems. However, many living with migraine the emergency department can often be an unwelcoming and challenging environment.
The bustling atmosphere, noise, bright lights, and lack of sensory considerations can further exacerbate their symptoms. This can leave them feeling even worse due to this sensory overload. Compounded by the stigma surrounding migraine, the severity of this neurological condition is often downplayed or dismissed.
Due to these factors, if someone with migraine chooses to go to the emergency department, it signifies that they have endured prolonged suffering, may have experienced a drastic change in symptoms, or are encountering their first-ever migraine attack.
In this blog, I want to delve into issues faces by those living with migraine, how to recognize and differentiate migraine in the emergency department, and discuss how we can possibly manage someone living with migraine in this setting.
Migraine Disorder and Its Impact on Patients
Migraine is a neurological condition characterized by recurring episodes of severe headache, often accompanied by other debilitating symptoms. It affects a large portion of the world population, making it one of the most prevalent and impactful disorders worldwide.
Migraine disorder affects over 1 billion people across the world. According to the Global Burden of Disease study in 2016, migraine was the 2nd leading cause of years lived with disability behind only Low Back Pain.
Although the exact cause of migraine remains unclear, genetic and environmental factors are known to contribute to its presentation. It can affect people of all ages, from children to the elderly, but is most common between the ages of 25 and 55, with a high prevalence among women.
Migraine disorder, despite its significant global prevalence and debilitating symptoms, has unfortunately been subject to stigmatization even within the healthcare community. This stigma often manifests as a lack of understanding and empathy towards someone living with migraine.
First we must be sure not to confuse migraine cause and migraine triggers as this can further stigmatize those living with migraine.
This results in suboptimal care and treatment outcomes. Many healthcare providers may dismiss migraine as “just a headache” or trivialize the impact this disease has on a patient’s life.
This dismissive attitude can leave patients feeling invalidated and discouraged from seeking necessary medical care or discussing their symptoms openly.
Additionally, the episodic and invisible nature of migraine can further contribute to the stigmatization. This often leads to symptoms being mistaken for excuses or lack of resilience.
To overcome this stigma in the emergency department it’s our role as physical therapists to foster a supportive and understanding environment. Physical therapists can ensure that migraine patients receive the care, validation, and treatment they deserve.
Migraine Diagnosis and Other Symptoms
Diagnosing migraine can be challenging as there are no specific tests to confirm its presence. Healthcare professionals should rely on a patient’s medical history, symptoms presentation, and ruling out other possible causes of secondary headache.
Migraine without aura diagnostic criteria are defined by Headache Duration, Headache characteristics, and non-headache symptoms.
Beware that migraine can present in other ways as well. For example, Schrieber et al found that 88% of those with self-reported or physician-diagnosed with sinus headache actually had migraine-like headache. Also note that aura is present in about 30% of those living with migraine.
Impact on Quality of Life
Living with migraine can significantly impact one’s quality of life, both physically and emotionally. The frequency, duration, and severity of migraine attacks vary greatly from person to person, but they often result in the inability to perform daily activities, attend work or school, and participate in social functions.
The pain and associated symptoms can be so severe that individuals may have to isolate themselves in a quiet and dark space until the attack subsides in order to reduce symptom exacerbation.
The episodic and chronic nature of migraine also poses a challenge to those with migraine. The fear of experiencing a sudden migraine attack can lead to anxiety and affect their ability to make plans or commitments.
Furthermore, the unpredictable nature of migraine can cause frustration, emotional distress, and feelings of helplessness. The impact on mental health is significant, showing higher rates of depression and anxiety.
It’s important not to blame depression and anxiety on migraine. Neither cause migraine disease. Treatment of anxiety and depression is important and necessary in migraine. However, this does not mean that treatment will stop their attacks or cure migraine.
Additionally, the economic burden of migraine should not be overlooked. The direct costs of medical appointments, medications, and testing, along with indirect costs like lost workdays and reduced productivity can accumulate quickly and place immense financial strain on the patient and their family.
Differential Diagnosis and Ruling out Serious Pathology
When it comes to diagnosing and managing migraine in the emergency department, it is essential to differentiate it from other causes of headache, participate secondary headaches that may be indicative of more serious pathology.
One effective tool that should be used in all settings when evaluating headache is the acronym SNNOOP10, which can help in performing a thorough differential diagnosis.
(Do TP, Remmers A, Schytz HW, Schankin C, Nelson SE, Obermann M, Hansen JM, Sinclair AJ, Gantenbein AR,
Schoonman GG. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology.
2019 Jan 15;92(3):134-144.)
If a headache presents with one or more the the SNNOOP10 criteria, further investigation is warranted. This may include imaging studies, such as MRI or CT scan, blood tests, or consultation a neurologists in the emergency department. These tests help rule out secondary causes of headache, and ensure accurate diagnosis and appropriate management.
It is important to note that the absence of SNNOOP10 does not confirm a diagnosis of migraine. Migraine diagnosis still relies on a comprehensive evaluation of symptoms, history, and exclusion of other primary headaches.
Another diagnostic tool like the ID-Migraine questionnaire can further aid in migraine diagnosis. This questionnaire is a simple and reliable screening (sensitivity 0.81, specificity 0.75).
ID-Migraine uses 3 easy questions:
- Has a headache limited your activities for a day or more in the last three months?
- Are you nauseated or sick to your stomach when you have a headache?
- Does light bother you when you have a headache?
The SNNOOP10, ID-Migraine, and comprehensive evaluation are necessary in the differential diagnosis of migraine and ruling out serious pathology. Recognition of red flags can help identify secondary headaches that may require further investigation and emergent medical care.
By carefully evaluating these criteria, PTs in the ED can ensure accurate diagnosis, referral to appropriate services, and provide appropriate management strategies to patients experiencing migraine or other types of headache.
Physical Therapy for Migraine in the Emergency Department
While traditional medical intervention, such as medications, are commonly administered in the ED, there is emerging recognition of potential benefits of physical therapy interventions for migraine management.
Here I want to explore the role of a physical therapist in the ED, focusing on the assessment of the upper cervical spine, acute treatment strategies (modalities and manual interventions), and the importance of education.
Assessment of the Cervical Spine
Once serious secondary pathology of headache has been ruled out a physical therapist can start with a physical examination of the cervical spine. Neck pain is one of the most common complaints associated with a migraine attack, and dysfunction in this region has been observed. But it is also common with tension-type headache and cervicogenic headache.
Evaluation of the cervical spine can help to identify potential contributing factors or musculoskeletal abnormalities that may exacerbate or trigger migraine attacks, and differentiate tension-type headache and cervicogenic headache from migraine.
In a study by Luedtke et al in 2017 found 6 physical examination tests had significant differences between those with migraine and headache-free subjections. These tests were the craniocervical flexion test, trigger points (of the SCM, masseters, temporalis, suboccipitals, and upper traps), flexion-rotation test, PAIVMs of C0-3, Thoracic Screening, and symptom reproduction and resolution (manual pressure technique applied to C0-3).
Musculoskeletal dysfunction found with these examination tests cannot be solely due to migraine. Identification of musculoskeletal dysfunctions that may be a modifiable migraine trigger may serve as a potential treatment pathway to reduce attack frequency.
Treatment Options Available in the Emergency Department
Before I continue, I think it’s important to acknowledge that research on physical therapy interventions for migraine is still relatively limited, and the available studies often have small sample sizes.
Additional, there is a risk of bias in many of these, which may affect the generalizability of the finding. Due to these limitations, it is crucial to interpret the results with caution and consider them as preliminary evidence rather than definitive treatments.
Despite these limitations, the emerging evidence suggests that interventions, such as manual therapy techniques, application of transcutaneous electrical nerve stimulation (TENS), and cryotherapy have the potential to provide relief and complement traditional medical management for migraine in the emergency department.
Use of Manual Therapy
Manual therapy techniques, such as mobilization and manipulation of the cervical spine, have shown promise in alleviating acute migraine symptoms and have potential in reducing attack frequency.
There are a variety of manual techniques with aims to improve joint mobility, reduce muscle tension, and modulate nociceptive pathways. By employing skilled hands-on techniques, a physical therapist can provide immediate relief in the ED setting, and potentially short the duration or intensity of the migraine attack.
TENS Application in the ED
Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique that involves the application of electrical currents to the skin. Several studies have shown the efficacy for TENS in migraine for reducing pain intensity, aborting migraine in the ED, and providing a long-term treatment option.
Here is one study that used TENS in the emergency department:
Treatment of migraine attacks by transcutaneous electrical nerve stimulation in
emergency department: A randomize controlled trial
The settings of the device used in this study were:
● Frequency of 50 Hz
● Pulse width of 125μs
● Time: 20 minutes
● Location: Forehead, over supratrochlear nerve bilaterally.
Use of Cryotherapy
Cold therapy, such as application of ice packs or compresses the the head and neck, have been reported to help reduce pain and mitigate a migraine attack. There are only a handful of studies looking at cryotherapy in migraine.
Two small studies using application of cold have been performed that can be used by physical therapists. One study looked at applying an adjustable wrap around the neck to target the carotid arteries.
The other looked at a head cap (similar to https://theheadachehat.com/) which is a gel ice pack that encapsulates the head. This also provides sustained pressure around the head, which some with migraine benefit and others do not.
In both studies, participants showed reduction in pain scores related to headache.
Lifestyle Education and Headache Diary
Physical therapists in the ED play a role in educating patients about lifestyle modifications that can help prevent future migraine attacks. We can provide guidance on factors such as stress management, sleep hygiene, diet, and regular exercise.
A good summary of these benefits can be found here:
Additionally, we can emphasize the importance of maintaining a headache diary to track triggers, symptoms, and response to treatments. This can be a valuable tool for long term management by both the patient and their healthcare providers. It can help to identify patterns, and personalize treatment approaches.
Incorporating physical therapy interventions within the ED setting can offer a multi-modal non-pharmacological treatment approach to migraine. Assessment of musculoskeletal dysfunction, use of manual therapy, modalities, and education can
provide immediate symptom relief, empower patient in self-management, and help with long-term treatment.
After The Emergency Department
After seeking care in the emergency department for migraine, it’s crucial to help continue the journey towards comprehensive migraine management. Beyond the immediate relief provided in the ED, there are additional steps to take that can enhance the long-term well-being of a patient, and minimize the impact of migraine.
It is highly recommended to provide referral to a neurologist, preferably a Headache Specialist. These specialists have fellowship training in diagnosing and managing headache disorders. A Headache Specialist possesses the specialized knowledge necessary to optimize migraine treatment.
Migraine is not just a physical burden; it can impact one’s mental health too. The experience of chronic pain, the limitations it imposes, and the uncertainty of when migraine may occur can lead to increased anxiety and depression. Providing referral mental health services, such as therapy or counseling, can provide valuable support in managing the emotional toll of migraine. Mental health professionals can help develop coping strategies, and address any underlying
psychological factors that may exacerbate migraine.
If you identified musculoskeletal dysfunction as a contributing factor, a referral to outpatient PT services would be beneficial. Continued PT interventions can help lead to better migraine management.
If you tried an application of TENS with your patient and it was found beneficial it can be helpful to provide parameter settings, and information on how to obtain a personal device for home management. Further follow up can also be performed by the outpatient PT.
Conclusion
In conclusion, the emergency department can be a challenging and overwhelming environment for individuals seeking help for migraine attacks. The stigma surrounding migraine, coupled with the lack of understanding and empathy, can make it difficult for patients to receive the care and validation they deserve.
As physical therapists, it is our responsibility to create a supportive and understanding environment for migraine patients in the ED.
While traditional medical interventions are commonly administered in the ED, physical therapy interventions have shown potential in providing relief and complementing medical management for migraine.
By recognizing the unique challenges faced by migraine patients in the emergency department, physical therapists can play a vital role in providing comprehensive care, improving patient outcomes, and minimizing the impact of migraine on their lives. Together, we can create a more supportive and understanding healthcare environment for those living with migraine.
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