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Migraine Management FNP Approach

Abstract

Migraine is a devastating neurological disease that disproportionally impacts Black women in United States resulting in significant under diagnosis and under treatment. The focus of this paper is on comprehensive migraine management among Black women in the Plainfield community of Illinois between 18 and 50 years. The Shuler Nurse Practitioner Practice Model is used as a framework to examine social determinants of health, cultural and ethnic diversity, and the family nurse practitioner (FNP's) multifaceted role. This discussion covers primary and secondary prevention strategies, pathophysiology and epidemiology of migraine, diagnostic criteria and differential diagnoses, evaluation and pharmacological management, inter-professional collaboration, and patient education. The goal of this integrative approach is to promote health outcomes and mitigate migraine care disparities among this underserved population.

Keywords: migraine, Black women, social determinants of health, family nurse practitioner, Shuler Model

MIGRAINE MANAGEMENT FNP APPROACH

Migraine is a chronic neurological disorder that affects millions of people in the United States. However, among these individuals, Black women aged 18 through 50 face unique challenges that compound existing disparities in diagnosis, treatment and overall quality of life. These women are often living in diverse communities where there is a combination of biological, cultural and social factors that can make caring for them complicated. Effective and culturally sensitive management of migraines is important because they can cause severe impairment of daily functioning, professional productivity, and emotional well-being. While research and treatment options for migraines have advanced, many Black women continue to be underdiagnosed and undertreated largely because of systemic barriers in healthcare systems. Moreover, lack of trust, limited access to specialists, insufficient provider education on cultural differences further widens this gap in health outcome. Family nurse practitioners (FNPs) are in a unique position to help close the gap on these disparities through comprehensive, evidence based and patient centered care. This paper takes a holistic approach to migraine management for Black women living in Plainfield, IL, discussing pathophysiology, epidemiology, diagnosis, prevention, pharmacology, patient education, and interdisciplinary collaboration. To enhance and promote equitable and effective migraine care, it will be necessary to incorporate culturally competent strategies as well as advanced nursing models.

Social Determinants of Health and Cultural/Ethnic Diversity

Social determinants of health (SDOH) are important determinants of the burden of migraine among Black women. It is also a result of factors like racial bias in clinical settings, socioeconomic instability and educational inequities that all conspire to cause under diagnosis and ineffective management (Kiarashi et al., 2021). Black women suffer disproportionate systemic delays of care and access to poor quality care if received. There is a large literature demonstrating consequences of delayed care, poor outcomes, and mortality resulting from systemic racism and structural inequities for Black patients with a migraine (VanderPluym et al., 2022). Further, lack of insurance coverage or underinsurance leads to missed early intervention and prevention opportunities.

Additionally, beliefs about where there are limits to pain tolerance, the healthcare system not being trusted, and social stigma regarding neurological care continue to perpetuate these inequities (Burch et al., 2021). Today, mistrust in healthcare exists to some extent because of historical injustices such as unethical medical experimentation on Black populations. The barrier to timely intervention is further obscured by the demographic heterogeneity of the Plainfield, Illinois community and limited access to specialty care. It is critical to address these issues and achieve equitable access to migraine management resources through culturally competent care which includes the building of trust, transportation improvements, and expansion of community health programs.

Pathophysiology of Migraine

Migraine is a pathophysiologic process with multiple neurovascular and biochemical pathophysiologic processes. A key feature of migraine development is cortical spreading depression (CSD), characterized as a wave of neuronal and glial depolarization and suppression of brain activity (Puledda et al., 2023). Initiation of this phenomenon leads to a downstream cascade of effect, in which, trigeminovascular system is activated, and cerebrovascular vasodilation is caused together with the release of inflammatory neuropeptides such as calcitonin gene related peptide (CGRP), substance P and neurokinin A (Khan et al. 2021). Together, these processes account for the pain and accompanying neurological symptoms of migraine headaches.

Also, the pathogenesis of migraine can be contributed by genetic predisposition. People with familial hemiplegic migraine or another form of inherited migraine have certain ion channel mutations along with neurotransmitter pathways and vascular function (Khan et al., 2021). This genetic susceptibility is triggered by environmental factors such as hormonal fluctuations, stress, some foods, and sleep disturbances leaving the migraine having a lower threshold to initiate. The understanding of the biological basis of migraine has provided a framework to develop target specific therapies directed to the underlying mechanisms. For example, CGRP antagonists and monoclonal antibodies have fundamentally changed the migraine prevention landscape and are recommended for first line use in patients who suffer from frequent or severe attacks (Ailani et al. 2021).

Epidemiology

Migraine affects about 39 million Americans with women being 3 times more likely to have a migraine than men (Dong et al., 2025). The gender disparity is even more pronounced within the Black female population with prevalence rates indicating that up to 20% could report chronic migraine symptoms (Burch et al., 2021). Migraine remains underdiagnosed and undertreated, however, in the face of the burden of disease, these inequities in systemic healthcare, coupled with cultural factors that impact access and health seeking behavior, contribute to this barrier. Similarly, epidemiological patterns indicate that social determinants of health impact the frequency, severity, impact and treatment outcomes of migraine in Black women (Kiarashi et al., 2021).

Cultural stigma about expressing pain and historical mistrust of medical institutions within the Black community compound accurate reporting and diagnosis. Additionally, other studies have shown consistently that Black women with migraine less often receive a formal diagnosis or effective pharmacologic therapy than White women with migraine (Kiarashi et al., 2021). This highlights the importance of early screening efforts, as well as culturally sensitive and patient centered approaches to migraine management for family nurse practitioner (FNP) practice settings.

Diagnostic Process

In most of the cases migraine is diagnosed by clinical grounds in accordance with ICHD 3 (Overeem et al., 2025). According to Overeem (2025), to meet diagnostic threshold, headache must recur for 4–72 hours and have the following characteristics: unilateral location, pounding quality, moderate to severe intensity, and exacerbation by nonphysical maneuvers including walking or climbing stairs. Other important symptoms like nausea, vomiting, photophobia, and phonophobia also support the diagnosis and distinguish migraine headaches from other types of headaches.

A complete patient history, including headache features, trigger pattern, family history of migraines, and other neurologic symptoms, should be undertaken as diagnostic measures. A comprehensive neurological evaluation is also important to mitigate the possibility of signs of secondary headache disorders (Cook et al., 2025). Although migraine is a clinical diagnosis, MRI or CT scans should be performed if the headache is atypical, in the presence of abnormal neurologic findings or if there is a sudden change in headache pattern. In the absence of systemic symptoms such as fever, weight loss, or evidence of metabolic dysfunction, laboratory tests are usually not required.

Family nurse practitioners must apply standardized diagnostic protocols in the same way to maintain accuracy and address disparities in the diagnosis of racial and ethnic groups (Overeem et al., 2025). Avoiding implicit biases and prioritizing culturally informed communication strategies during diagnostic equity in migraine care will be productive with the use of validated assessment tools.

Differential Diagnoses

Accurate treatment planning and preventing the progression of symptoms is important when evaluating patients for migraine and must be done while considering differential diagnoses. One relevant differential is Tension Type Headache (ICD-10 G44.2), which often manifests as a bilateral, pressing, or tightening headache that is mild to moderate in intensity. In contrast to migraines, these headaches are generally not accompanied by nausea or vomiting and rarely worsen with routine physical activity (Puledda et al., 2023).

Cluster Headache (ICD 10 G44.0) is another very important differential diagnosis. Cluster headache is characterized by unilateral pain that is very severe and typically around the orbital or temporal region. Autonomic symptoms such as lacrimation, nasal congestion, or edema of the eyelid (Ailani et al., 2021) are usually present. Cluster headaches differ significantly in timing and periodicity from migraine attacks, occurring in clusters over weeks, followed by remission occurrences.

Medication Overuse Headache (ICD-10 G44.4) is the third differential to consider. The frequent use of acute headache medications (e.g., analgesics, triptans, or ergotamine), results in a pattern of chronic daily headaches (Cook et al., 2025). Medication overuse needs to be identified and addressed because it will severely complicate the clinical course of most primary headache disorders. Effective, patient centered migraine management strategies are supported by careful, systematic approach to differential diagnosis.

Primary and Secondary Prevention

Primary prevention of migraine targets reducing risk factors and promoting lifestyle behaviors to prevent migraine attacks. Family nurse practitioners have an important role in leading patients away from pharmacologic treatment, for instance toward setting out a schedule to follow, practicing stress management techniques like cognitive behavioral therapy, and altering their diet to avoid established triggers of migraine (Callen et al., 2024). Black women can particularly benefit from stress reduction strategies, such as mindfulness, biofeedback, and physical activity, as they may have higher stress burdens due to constant discrimination and socioeconomic challenges. An important part of a comprehensive prevention plan also includes addressing environmental triggers, such as bright lights, strong odors or weather changes.

Secondary prevention is early identification and intervention of migraines to prevent progression from episodic to chronic migraine. Given the high disability associated with Migraine, early pharmacological intervention with triptans, CGRP antagonists, and newer monoclonal antibodies is being recommended in patients who present with a clinical criterion of diagnosis for Migraine (Ailani et al. 2021; Cook et al. 2025). Other acute treatments include non-pharmacologic such as neuromodulation devices, which have gained popularity since some patients have contraindications for standard therapies.

Family nurse practitioners should take responsibility to identify modifiable risk factors of obesity, hypertension, depression and medication overuse, all of which can lead to migraine chronification (VanderPluym et al., 2022). Prevention strategies must be culturally appropriate for an individual patient’s context, taking into consideration barriers including limited access to healthy food sources, safe spaces for exercise, and affordable healthcare resources. FNPs may help reduce the disproportionate burden of migraine among Black women by embedding culturally competent primary and secondary prevention strategies into clinical practice and improve long term outcomes.

Evaluation, Management, and Pharmacology

Black women in the Plainfield community need an individualized, holistic approach to effective migraine management. Management strategies include the pharmacologic and non-pharmacologic interventions aimed at acute attacks and their prevention. Acute treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, and newer medications targeting specific neural pathways in migraine pathophysiology (Ailani et al., 2021). Preventive pharmacologic options, however, are effective for patients with frequent or disabling migraines and include beta blockers, antiepileptic medication such as topiramate, antidepressants, and monoclonal antibodies against calcitonin gene related peptide (CGRP) or its receptor (Puledda et al., 2023).

FNP’s are uniquely suited to select therapies that are specifically tailored to each patient’s needs. Treatment selection must evaluate migraine frequency and severity, comorbid conditions (such as hypertension or depression), patient preference, and the patient’s cultural context (Callen et al., 2024). For example, some patients may first opt for non-pharmacologic because they are concerned about medication side effects or have had previous bad experiences with the healthcare system. However, pharmacologic management must be integrated with behavioral interventions. Other treatment modalities besides non-drug includes cognitive behavioral therapy (CBT), which has been found to reduce migraine frequency and help with coping mechanisms, and mindfulness-based stress reduction or biofeedback (Cook et al., 2025).

FNP also continuously monitors treatment efficacy and side effects, promote medication adherence and adjust management plans accordingly. Education related to correct medication use, particularly not allowing acute medication to use very frequently to prevent medication overuse headache is necessary. FNPs can provide comprehensive and sustainable migraine management plans for their patients by incorporating pharmacologic therapies with lifestyle modifications and behavioral strategies.

Interprofessional Collaboration and Referral

Migraine disorders are typically complex, and effective management often entails collaboration among several healthcare disciplines. Neurologists offer specialized diagnostic tools and advanced treatment options for refractory and atypical migraine cases (VanderPluym, et al. 2022). For patients with chronic or debilitating migraines, pain management specialists can provide alternative interventions, including nerve blocks, infusion therapies and neuromodulation. Collaboration with mental health providers is critical when psychological conditions, including depression, anxiety, or post-traumatic stress disorder, are present because these factors can influence the extent to which migraine burden arises from psychological factors.

When first line treatments are ineffective or diagnostic uncertainty remains after a thorough evaluation, referral to specialized care is indicated or when red flag symptoms suggest secondary causes of headache (Kiarashi et al., 2021). Referral within a reasonable time interval improves patient outcomes by improving the accuracy and management of diagnosis as well as the availability of advanced therapeutic choices. Rehabilitative therapies directed by physical therapists may supplement pharmacological treatments and take place when migraines are associated with musculoskeletal tension or cervical spine disorders in particular.

Overcoming systemic barriers to care for Black women experiencing migraines requires building strong inter-professional care teams. For example, these teams should be trained in culturally competent care, knowing that historical trauma, lack of trust in healthcare systems, and social determinants such as housing instability or transportation barriers impact migraine management (Callen et al., 2024). Within a supportive healthcare environment and in light of efforts to advance value in healthcare quality, the FNPs must take a leadership role in coordinating inter-professional collaboration, advocating for patient centered care models, and ensuring that each patient receives equitable, high-quality treatment.

Patient Education

Patient education holds a central role in the effective management of migraine, and in the culturally diverse population such as Black women in Plainfield, Illinois. This comprehensive education provides patients with an understanding of their diagnosis, available treatment options, correct medication use, and necessary lifestyle adjustment (Cook et al., 2025). On the one hand, education should just supply information, but, more importantly, education should incorporate a feeling of empowerment and active participation in care. Recognizing and addressing historical mistrust in healthcare systems, family nurse practitioners (FNPs) must employ culturally competent communication strategies to validate the patients’ experiences and concerns (VanderPluym et al., 2022).

It is important to teach patients to recognize early warning signs of an impending migraine. Prodromal symptoms such as mood changes, food cravings, or neck stiffness can help patients recognize when to use abortive therapeutics, which can help reduce the severity and duration of an attack. Minimizing the risk of medication overuse headaches while also improving treatment effectiveness, educating patients on how to use acute medications, like triptans or NSAIDs, prevents them from overusing their acute medications. The use of headache diaries encourages patients to track migraine patterns, identify migraine triggers and track responses to interventions allowing it for better patient self-management and more effective interaction with healthcare providers (Callen et al., 2024).

To optimize understanding, adherence and communication, FNPs must tailor their educational interventions to each patient's literacy level, cultural background, and personal preferences. However, further support for patient centered education initiatives includes providing written materials, including digital resources, and involving family members in a teaching session.

Integration of the Shuler Nurse Practitioner Model

The Shuler Nurse Practitioner Model is a sophisticated blueprint for the provision of whole and patient centered care. The model is rooted in health promotion, disease prevention, and empowerment, promoting the addressing of patients' multifaceted needs—including biological, psychological, social, and spiritual dimensions (Shuler & Davis, 2020). For FNP’s to deal with migraine, it reaches beyond symptom control and must understand what causes emotional dysfunction in patients, poor interpersonal relationships, lost productivity, and poor quality of life.

To guarantee that care is provided based on individual values, preferences and cultural contexts, the Shuler Model is applied to the management of migraine. For example, FNPs are more capable of formulating a more empathetic and culturally relevant care plans because they understand that systemic racism may contribute to Black women's unique stressors due to economic inequity. Stress reduction techniques, getting access to mental health service, and interventions to improve sleep hygiene and nutrition could be considered for health promotion strategies.

The Shuler Model also supports the advocacy role of the nurse practitioner. As stated by VanderPluym et al. (2022), Black women are faced with systemic biases that lead to under-diagnosis and under treatment of migraines. Promoting diversity in clinical research, supporting community-based health education programs, using their various resources to train cultural competence among providers in their systems are among advocacy efforts. Practicing full integration of the Shuler Model will enable FNPs to greatly enhance health equity and patient empowerment.

Conclusion

Black women bear the brunt of a severe public health crisis in migraines, unresolved social determinants of health, and the systemic burden of inequities in care. By leveraging the use of evidence based diagnostic and treatment strategies, culturally sensitive communication, and holistic models such as the Shuler Nurse Practitioner Model, family nurse practitioners are well positioned to address these disparities. FNPs have the ability to focus on patient education, inter-professional collaboration and advocacy which forms relationships with the patient, engages the patient to self-manage and improve outcomes in the marginalized population. Sustained efforts are needed to address clinical and social factors that influence health, and that all patients receive comprehensive, respectful and effective care to ensure equity in migraine care.

References

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Burch, R., Rizzoli, P., & Loder, E. (2021). The prevalence and impact of migraine and severe headache in the United States: updated age, sex, and socioeconomic‐specific estimates from government health surveys.  Headache: The Journal of Head and Face Pain,  61(1), 60-68. https://doi.org/10.1111/head.14024

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