Summative Cases

Summative Case #5

Nichole Lopez, DNP, RN, FNP-BC, PMGT-BC

Case Study

Patient Profile

Name: Marsha Kennedy

Age: 48 years old

Gender: female

Chief Complaint

“I cannot get rid of these headaches.”

Current Medications

  • Levocetirizine dihydrochloride (OTC) 5 mg 1 tablet by mouth daily
  • Olmesartan 10 mg 1 tablet by mouth daily
  • Ibuprofen (OTC) 200 mg 3 tablets by mouth three times daily as needed for headaches
  • Multivitamin (Women’s Centrum) 1 tablet by mouth daily
  • Denies other vitamins/minerals, herbals, or other supplements
  • Denies hormone replacement therapy

Current Problem List

Obesity, seasonal allergies, and hypertension

History of Present Illness

M.K. is a 48-year-old Caucasian woman who presents today with headaches that began approximately two months ago with a gradual onset and gradual worsening frequency. She describes the headaches as throbbing and pulsating and states that while they occur unilaterally, they happen on both the left and right sides of her head. When asked where she feels the pain, she points to her frontal temporal regions. She rates the headaches as a 6/10 on a 0-10 Numeric Analog Scale (NAS) but states that they have been almost always present lately. Currently, the headaches are occurring approximately 10 times per month and lasting anywhere from 48-72 hours. She states that the headaches generally begin during the day and gradually worsen as the day goes on. She also complains of nausea, vomiting, dizziness, photophobia, phonophobia, fatigue, and difficulty with sleep, generally a few nights prior to the start of her headaches. She denies visual changes, aura, weakness, and neck pain. She reports trying over-the-counter ibuprofen, but it has been ineffective thus far. The only thing that helps to alleviate her headaches is lying down in a dark room and “sleeping them off.” In fact, she reports missing approximately five days of work over the past two months. At this time, she cannot identify any triggers. She states that her last menstrual period (LMP) was two weeks ago and the headaches do not seem to worsen before or after her menstrual cycle. She checks her blood pressure at home and it has been running consistently around 120/70’s. She recalls having an issue with headaches when she was approximately 11-12 years old but was never formally diagnosed or treated.

Past Surgical History

Two Cesarean sections (19 and 21 years ago)

Family History

  • Mother: hypertension, migraine headaches
  • Father: lung cancer diagnosed at 60 years old, deceased
  • Maternal grandmother: hypertension
  • Maternal grandfather: hypertension
  • Paternal grandfather: unknown
  • Paternal grandmother: unknown

Social History

  • Administrative assistant at local university.
  • She states that she tries to take a walk two to three times per week, one to two miles.
  • She reports frequent takeout and fast food for lunches, otherwise well-balanced diet; 40 ounces of water per day; denies coffee/tea/soda.
  • Lives in a one-story home with her husband and two cats. Both daughters currently away in college.
  • Alcohol use: rare (approximately one to two glasses of wine every six months)
  • Tobacco smoke: prior use in college, nothing since.
  • Illicit drug use: denies

Review of Systems

  • Constitutional: Denies fever, chills. Endorses weight stable over the past two-three years.
  • HEENT: Endorses photophobia and phonophobia. Denies h/o head trauma, eye pain, postnasal drip, sinus pain/pressure, nasal discharge, dizziness, visual changes, and tinnitus.
  • Respiratory: Denies shortness of breath, cough, wheezing.
  • Cardiovascular: Denies chest pain/pressure and pedal edema.
  • Gastrointestinal: Reports decreased appetite, reports nausea and vomiting when headaches are present. Denies abdominal pain, tenderness, constipation, and diarrhea.
  • Dermatological: Denies lesions, rashes, and bruising.
  • Musculoskeletal: Denies neck and shoulder pain.
  • Neurological: Endorses headaches (see HPI). Denies weakness in extremities and aura.
  • Psychological: Denies anxiety, depression, and nervousness.

Physical Assessment

General appearance: Alert and oriented x’s 4, moderately obese female.

Vitals

  • Height: 5’3”
  • Weight: 196 lbs
  • BMI: 34.7
  • Blood pressure: 124/72 mm Hg
  • Heart rate:  78 bpm
  • Respiratory rate: 18 bpm
  • Temperature: 98.2°F
  • Oxygen saturation: 100% on room air

General Survey

  • HEENT: Moist mucous membranes, PERRLA (Pupils equal, round, reactive to light, accommodating). No tenderness, swelling, or masses upon palpation of head, no signs of temporal artery inflammation or tenderness. Extraocular movements and visual fields are intact. No signs of inflammation or discharge in eyes, papilledema, or retinal hemorrhages. Tympanic membranes are pearly grey, without bulging or retraction. No tenderness upon palpation of bilateral frontal and maxillary sinuses, nasal discharge, redness, and swelling. Oropharynx is pink and tonsils intact. No signs of inflammation or discharge.
  • Respiratory: Lungs clear to auscultation bilaterally throughout all lobes.
  • Cardiovascular: Normal rhythm without murmurs. Normal s1 and s2.
  • Gastrointestinal: Active bowel sounds in all 4 quadrants, no tenderness to palpation and no guarding.
  • Dermatological: No abrasions, ulcerations, rashes, or bruising.
  • Musculoskeletal: Range of motion to cervical spine is intact. No cervical spine abnormalities, tenderness, muscle spasms, or stiffness noted upon palpation.
  • Neurological: Gait steady. Good coordination and balance. Sensation is intact bilaterally to pain and light touch. Cranial nerves I-XII intact. 5/5 muscle strength in all four extremities, no focal deficits, hyperreflexia, signs of confusion, or cognitive impairment. Negative Kernig’s and Brudzinski’s signs.
  • Psychological: Normal mood and affect. No apparent anxiety noted.

🔍 Assessment Tip: SNOOP

The following acronym, “SNOOP,” can be used to detect red flags that, if present, would warrant neuroimaging (MRI/MRA):

  • S – Are there any signs or symptoms of Systemic or Secondary causes or risk factors?
  • N – Are there any signs or symptoms of Neurological issues upon completion of the patient’s history and physical exam? Associated visual changes, weakness, and altered mental status are all red flags.
  • O – What was the Onset of the headaches? Sudden and severe “thunderclap” presentation is a red flag.
  • O – Is the patient greater than 50 years Old at the time of new headache onset?
  • P – Has there been any changes to the prior headache Pattern? Is headache intensity dependent upon Position changes? Is there Papilledema on the patient’s physical exam? Are the headaches Precipitated by sneezing, coughing, exercise, or the Valsalva maneuver?

An electroencephalogram and/or cerebrospinal fluid analysis are not generally indicated unless either an infectious etiology or seizures need to be ruled out.

Diagnostic Testing

None indicated at this time.

Table 1. Assessment and Comparison of Different Types of Headaches
Types:  Tension  Cluster  Migraine 
Location:  Bilateral Unilateral: generally around or behind the eye Unilateral
Pain Intensity:  Mild to moderate Severe to extreme Mild to severe
Quality:  Pressure Pulsating, throbbing Sharp, “ice-pick”
Timing:  Hours to days Minutes to hours Hours to days
Associated Symptoms:  Mild nausea, photophobia/phonophobia might be present Red watery eyes or runny nose Nausea, vomiting, photophobia, phonophobia, & with aura or without aura

Most Likely Diagnosis

Migraine headaches without aura.

Least Likely Diagnosis

  • Tension type headaches
  • Cluster headaches
  • Cerebrovascular accident (CVA)—most lethal

Treatment Plan

  1. Requested Mrs. Kennedy keep a headache journal to identify frequency, duration, severity, and headache triggers.
  2. Initiate Propranolol 20 mg, one tablet by mouth twice daily for migraine prevention.
  3. Decrease ibuprofen to 400 mg by mouth three times daily as needed to prevent rebound headaches. Patient will continue to decrease as tolerated.
  4. Consider work concerns. Patient may need temporary disability forms completed.
  5. Patient education: Written patient materials provided regarding lifestyle modification, including identifying and modifying triggers (foods, stress, dehydration, and lack of or too much sleep).

Activity: Pathophysiology of Migraines

Fill in the blanks with the correct term: unilateral, photophobia, aura, followed, preceded, bilateral, vision loss

According to the Headache Classification Committee of the International Headache Society, migraines can be classified into different subtypes, two of which include a migraine without aura and a migraine with aura. For a migraine without aura, the recurrent headaches must last four to 72 hours. This headache is generally _________________, pulsating, and described as moderate to severe. A migraine without aura is generally worsened by physical activity and is associated with _________________, phonophobia, and nausea. In contrast, a migraine with ________________ generally results in recurrent, fully reversible attacks that last only a few minutes. A migraine with aura generally presents with one or more of the following symptoms that are unilateral: sensory, visual, speech and language, brainstem, motor, or retinal disturbances, often followed by other migraine symptoms or a headache (Pescador-Ruschel, & De Jesus, 2024).

🔍 Pathophysiology of Migraines

Other subtypes of migraines include chronic migraine, probable migraine, and episodic syndromes that may possibly be associated with migraines, such as gastrointestinal disturbances (abdominal pain or discomfort, nausea, and vomiting), benign paroxysmal vertigo, and benign paroxysmal torticollis (Pescador-Ruschel, & De Jesus, 2024).

Although the pathophysiology of migraine headaches is not fully understood, it is thought that the pathogenesis of these headaches involves multiple elements of both the central nervous system (CNS) and the peripheral nervous system (PNS). Prior biological theories centered on vascular changes, such as vasodilation, that would produce migraine headaches and vasoconstriction that would produce auras. However, the current biological theories of migraine headaches suggest that there are, in fact, multiple primary neuronal impairments that lead to a series of both extracranial and intracranial changes (Pescador-Ruschel & De Jesus, 2024). According to Matsuda et al. (2019), neuropeptide release, edema, and rapid plasma extravasation triggers inflammation of the nerves. This inflammation, which is localized to the central nervous system (CNS) and the peripheral nervous system (PNS), contributes to the pain associated with headaches. This reaction may also be responsible for the transition from episodic migraine headaches to chronic migraine headaches. (Su, & Yu 2018). Neuropeptides are also believed to play a role in the pathogenesis of migraine headaches and include CGRP, serotonin, and pituitary adenylate cyclase-activating polypeptide (Pescador-Ruschel, & De Jesus, 2024). Furthermore, migraine headaches have a strong genetic component. The risk of developing migraine headaches is three times or greater in those individuals who have relatives with a history of migraine headaches (Pescador-Ruschel, & De Jesus, 2024).

If left untreated, migraines can lead to the development of persistent aura without infarction, migrainous infarction, status migrainosus, and migraine aura-triggered seizures (Pescador-Ruschel, & De Jesus, 2024).

Activity: Recommended Pharmacological Management

Fill in the blanks with the correct term: acute, prophylactic, triptans, naproxen, 10, 24, beta-blockers, opioids, regular exercise

The treatment of migraine headaches takes a multifaceted approach to alleviate the patient’s symptoms, prevent attacks, and improve the patient’s quality of life. It takes a person-centered approach to lifestyle modification to address the patient’s triggers. There are also ________________ or abortive medications which aim to lessen the progression of the headache, and ________________ or preventative medications which aim to decrease the frequency, severity, and duration of the acute migraine attacks, thereby reducing disability (Pescador-Ruschel, & De Jesus, 2024).

According to Pescador-Ruschel & De Jesus (2024), recommended acute or abortive medications include:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs): Ibuprofen 400-600mgs Naproxen 275-825 mgs, Diclofenac 65 mgs, and Aspirin 900-1000 mgs
  • Acetaminophen: 1000 mgs
  • ________________: Sumatriptan (SQ injection: 6 mgs, Nasal Spray: 20-40 mgs, Nasal Powder: 10-30 mgs, or Oral: 50-100 mgs), Zolmitriptan (Nasal: 2.5-5 mgs or Oral: 2.5 mgs), Rizatriptan, Eletriptan, and Almotriptan

A combination of triptans and ________________ is often more effective than using each class of medications alone and may be needed to treat moderate to severe attacks. For example, sumatriptan 85 mgs may be used in combination with naproxen 500 mgs. If the patient’s insurance carrier allows, this is provided in a single tablet; however, it may also be prescribed separately. A patient-centered approach is necessary. Patients who have not responded to one triptan may benefit from a trial with a different triptan. It is important to limit the use of triptans to less than ________________ days per month to avoid rebound headaches from medication overuse. It is important to know that triptans are contraindicated in patients with ischemic stroke, poorly controlled hypertension, angina, ischemic heart disease, pregnancy, and basilar or hemiplegic migraine (Pescador-Ruschel, & De Jesus, 2024). An alternative for patients with these cardiovascular risk factors includes a medication known as lasmiditan. Lasmiditan (50 or 100 mgs) is a selective serotonin 1F receptor agonist that does not cause vasoconstriction. Patients should be cautioned not to drive or operate heavy machinery for eight hours after taking lasmiditan due to the adverse effect of dizziness (Pescador-Ruschel, & De Jesus, 2024). Lastly, patients taking selective serotonin reuptake inhibitors (SSRIs) or serotonin noradrenaline reuptake inhibitors (SNRIs) should be monitored closely due to the risk of developing serotonin syndrome (Pescador-Ruschel, & De Jesus, 2024).

🔍 Recommended Pharmacological Management

An alternative for patients with these cardiovascular risk factors includes a medication known as lasmiditan. Lasmiditan (50 or 100 mg) is a selective serotonin 1F receptor agonist that does not cause vasoconstriction. Patients should be cautioned not to drive or operate heavy machinery for eight hours after taking lasmiditan due to the adverse effect of dizziness (Pescador-Ruschel, & De Jesus, 2024). Lastly, patients taking selective serotonin reuptake inhibitors (SSRIs) or serotonin noradrenaline reuptake inhibitors (SNRIs) should be monitored closely due to the risk of developing serotonin syndrome (Pescador-Ruschel, & De Jesus, 2024).

Antiemetics such as chlorpromazine, prochlorperazine, or metoclopramide may be used along with NSAIDs or triptans to help alleviate the patient’s nausea and vomiting. Diphenhydramine may also be added to decrease the risk of dystonic reactions that are generally associated with metoclopramide. CGRP antagonists, such as rimegepant (75 mg in a single dose) or ubrogepant, may be prescribed for those patients who have not responded to the above treatments or those patients with coronary risk factors (Pescador-Ruschel, & De Jesus, 2024). Ergots may be administered via either the intravenous, intramuscular, subcutaneous, or intranasal use; however, they are used as a bridge therapy for status migrainosus or medication overuse headaches since their effectiveness is not well-established and they carry a significant risk of adverse effects such as cardiovascular, cerebrovascular, and peripheral ischemic complications (Pescador-Ruschel, & De Jesus, 2024). While dexamethasone has not been shown to provide immediate relief, it may decrease the recurrence of headaches. Some non-pharmacological therapies used for the abortive treatment of migraine headaches include the following: transcranial magnetic stimulation, transcranial magnetic stimulation, nonpainful remote electric neurostimulation, and peripheral nerve blocks. It is important to note that transcranial magnetic stimulation is contraindicated in patients with a history of epilepsy (Pescador-Ruschel, & De Jesus, 2024).

According to Pescador-Ruschel & De Jesus (2024), the following is a list of preventative medications:

  • Beta-blockers such as metoprolol and propranolol. These medications are helpful in patients who suffer from hypertension if they are nonsmokers.
  • Anticonvulsants such as valproate acid and topiramate. These medications are recommended for patients with a history of epilepsy or those who are overweight. Caution is given if the patient has a history of kidney stones. Patients must be educated to stay well hydrated.
  • Antidepressants such as amitriptyline and venlafaxine are beneficial for patients who suffer from anxiety, depression, and insomnia.
  • Calcium channel blockers such as verapamil and flunarizine are often recommended for women of childbearing age and for those patients who suffer from Raynaud’s phenomenon.
  • For adults, botulin toxin is recommended if the patient is experiencing frequent headaches lasting four or more hours per day and an average of 15 or more days per month.
  • CGRP antagonists such as erenumab, galcanezumab, and fremanezumab.

Regular exercise, relaxation training, biofeedback, cognitive behavioral therapy, and the reduction of triggers are a few of the therapies that can be incorporated into the patient’s treatment regimen. Lifestyle modifications play a crucial role in enhancing the patient’s mental well-being and promoting their active participation in care. This requires a strong social support and a strong commitment on behalf of the patient (Pescador-Ruschel, & De Jesus, 2024).

Review Questions

Click the arrow to expand the section and view the correct answers.

  1. A 44-year-old woman presents with unilateral, frontal/temporal headaches described as throbbing and pulsating. The headaches occur approximately 6-8 times per month and last anywhere from 4-72 hours. They are almost always accompanied by nausea, vomiting, photophobia, and phonophobia. Generally, the only thing that helps is to lay down in a dark, quiet room. She often misses work because of the headaches. What is the most likely diagnosis?
    1. Cluster headaches
    2. Tension headaches
    3. Migraine headaches
    4. Temporal arteritis
Answer:

C. Migraine headaches

Feedback: Migraine headaches are generally unilateral (one-sided). They are often described as throbbing or pulsating in quality and of moderate to severe in their intensity. Migraine headaches often interfere with daily activities, such as work or school. They are often aggravated by physical activity and many individuals seek a dark and quiet room. Other symptoms commonly associated with migraine headaches include nausea and/or vomiting, photophobia, or phonophobia.

  1. When interviewing your patient with headaches, which subjective symptom would warrant more urgent workup?
    1. Sudden, severe, and debilitating headaches
    2. New onset in older adults
    3. Headaches accompanied by fever, neck stiffness, neurological deficits, or vision changes
    4. All of the above
Answer:

D. All of the above

Feedback: Headaches accompanied by fever, neck stiffness, vision changes, or other neurological deficits indicate a potential secondary cause, not just a typical primary headache, and require urgent medical evaluation. Also, a secondary cause should be considered with all “Red flag” headache symptoms such as severe, sudden or rapid onset, and debilitation (also known as a “thunderclap” headache), headaches that worsen significantly, or are a new onset in the older adult (age greater than 50).

  1. Which of the following are migraine triggers?
    1. Wine
    2. Cheese
    3. Excessive sleep
    4. All of the above
Answer:

D. All of the above

Feedback: Wine, cheese, chocolate, caffeine, too little or too much sleep, stress, or environmental factors such as odors and noise, can all be triggers of migraine headaches.

  1. Which of the following medications should NOT be considered as first-line treatment by the nurse practitioner for migraine prophylaxis?
    1. Propranolol
    2. Topiramate
    3. Calcium channel blockers
    4. Divalproex
Answer:

C. Calcium channel blockers

Feedback: Calcium channel blockers have shown a weak efficacy for treatment of migraine headaches and therefore should be considered for second-line prophylactic treatment. Propranolol, topiramate, and divalproex are all considered first-line treatments based on established evidence of efficacy.

  1. A 38-year-old woman presents with gradual onset of unilateral, throbbing headaches that are accompanied by nausea without vomiting and photophobia. She has a history of migraine headaches. Which of the following medication classes would be most appropriate (first-line treatment) for the nurse practitioner to prescribe for the patient’s ACUTE migraine?
    1. Beta-blockers
    2. Triptans
    3. Antidepressants
    4. Anticonvulsants
Answer:

B. Triptans

Feedback: Migraine preventative treatment options include beta-blockers, antidepressants, anticonvulsants, and calcitonin gene-related peptide (CGRP). Triptans is the best choice of medication class that is used for acute migraine treatment. Although CGRP’s may be utilized as a migraine abortive, it is recommended specifically for patients who do not respond to the first-line treatments or for those patients with coronary artery disease.

  1. Which of the following is a contraindication for prescribing the triptan drug classification?
    1. Liver disease
    2. Kidney disease
    3. Ischemic heart disease
    4. Ulcers
Answer:

C. Ischemic heart disease

Feedback: It is important to know that triptans are contraindicated in patients with ischemic stroke, poorly controlled hypertension, angina, ischemic heart disease, pregnancy, and basilar or hemiplegic migraine (Pescador-Ruschel, & De Jesus, 2024).

  1. A 42-year-old woman presents with a chief concern of “being stressed out” at work. She has been experiencing almost daily headaches for the past 2-3 months and has been taking OTC ibuprofen 600mg three times per day. She describes her headaches as band-like and dull. She denies nausea, vomiting, photophobia, and phonophobia. She also experiences tight neck and shoulder muscles bilaterally. Which of the following is appropriate for the nurse practitioner to include in this patient’s management plan?
    1. Advise the patient to start taking Tylenol 1000mg twice a day.
    2. Start the patient on a triptan and discontinue the ibuprofen.
    3. Start the patient on a beta-blocker for migraine prevention.
    4. Decrease the patient’s ibuprofen to 400 mg twice a day and encourage stress reduction techniques, such as exercise and guided imagery or meditation, with a goal of tapering the patient off the ibuprofen.
Answer:

D. Decrease the patient’s ibuprofen to 400 mg twice a day and encourage stress reduction techniques, such as exercise and guided imagery or meditation, with a goal of tapering the patient off the ibuprofen.

Feedback: Reducing or discontinuing the patient’s ibuprofen is appropriate management. This patient is most likely experiencing tension type headaches and medication-overuse headaches. The most rescue medication should be used is twice per week or the patient runs the risk of experiencing medication-overuse (rebound) headaches. The initiation of stress reduction techniques is appropriate for this patient.

  1. A 58-year-old man with a history of hypertension presents to the office with a new onset of 10/10 (NAS) headache, which started yesterday. He is also experiencing nausea and vomiting. He denies photophobia or phonophobia. He denies a history of headaches and denies previous head injury. What is the appropriate next step for the nurse practitioner to take?
    1. Initiate ibuprofen 600 mg twice daily as needed and have the patient keep a headache diary.
    2. Escalate the patient’s care because he must have an MRI/MRA as soon as possible.
    3. Initiate sumatriptan 50 mg by mouth once per day as needed.
    4. Initiate a beta-blocker such as propranolol.
Answer:

B. Escalate the patient’s care because he must have an MRI/MRA as soon as possible.

Feedback: The nurse practitioner should escalate the patient’s care because the patient must have an MRI/MRA as soon as possible.

The following acronym “SNOOP” can be used to determine whether neuroimaging (MRI/MRA) is indicated:

  • S – Are there any signs or symptoms of Secondary causes or risk factors?
  • N – Are there any signs or symptoms of Neurological issues upon completion of the patient’s history and physical exam?
  • O – What was the Onset of the headaches?
  • O – Is the patient greater than 50 years Old at the time of onset?
  • P – Is the headache intensity dependent upon Position changes? Has there been any changes to the prior headache Pattern? Is there Papilledema on the patient’s physical exam? Are the headaches Precipitated by the Valsalva maneuver?
  1. A 32-year-old female presents to the office with a history of migraine headaches. She states that her headaches have become more and more frequent over the past month. The pattern and intensity of her headaches continues to be the same. Her headaches are always accompanied by nausea, vomiting, phonophobia, and photophobia. She discloses to the nurse practitioner that she has already used her entire month’s supply of sumatriptan 100mg per day in only two weeks. Her last dose of her sumatriptan was yesterday. She is tearful and says that she just doesn’t know what to do. Which of the following is the most appropriate next step for the nurse practitioner to take?
    1. Discontinue the patient’s sumatriptan and immediately initiate ergotamine in its place.
    2. Initiate propranolol and discontinue the patient’s sumatriptan medication.
    3. Initiate propranolol and immediately initiate ergotamine to replace the patient’s sumatriptan.
    4. Renew the patient’s sumatriptan and initiate propranolol.
Answer:

B. Initiate propranolol and discontinue the patient’s sumatriptan medication.

Feedback: Ergots should not be prescribed/given within 24 hours of a triptan. This patient is most likely experiencing medication rebound headaches. Discontinuing the patient’s sumatriptan is appropriate management. This patient is most likely experiencing medication-overuse headaches. The most rescue medication should be used is twice per week or the patient runs the risk of experiencing medication-overuse (rebound) headaches. Education regarding rebound headaches should also be provided. The initiation of stress reduction techniques is also appropriate for this patient.

  1. A 42-year-old male presents to the primary care office. He has a long history of headaches and has been experiencing rhinorrhea and a 10/10 (NAS) “ice-pick” headache behind his left eye since around 7 pm last night. He took sumatriptan 100 mg without any relief. He denies nausea and vomiting. He states that the only thing that has helped is to pace back and forth in his living room. Which type of headache is this patient experiencing?
    1. Migraine headaches
    2. Tension-type headaches
    3. Cluster headaches
    4. Medication rebound headaches
Answer:

C. Cluster headaches

Feedback: The patient’s most likely diagnosis is cluster headaches. The patient is experiencing rhinorrhea and a unilateral 10/10 (NAS) “ice-pick” headache, which describes a cluster headache.

References

Matsuda, M., Huh, Y., & Ji, R. (2023). Roles of inflammation, neurogenic inflammation, and neuroinflammation in pain. Journal of Anesthesia 33(1), 131-139. https://doi.org/10.1007/s00540-018-2579-4

Pescador-Ruschel, M.A., & De Jesus, O. (2024). Migraine Headache. National Library of Medicine-StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK560787/

Su, M., Yu S. (2018). Chronic migraine: A process of dysmodulation and sensitization. Molecular Pain. 14. https://doi.org/10.1177/1744806918767697 

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Be Prepared for Your Nurse Practitioner Clinical Readiness Exam Copyright © 2026 by Elizabeth Heavey, Renee Biedlingmaier, Colleen Burgoyne and Carnel C. Jackson is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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