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12 Cards in this Set

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Refer to case (c):

Which of the following best describes this patients headache type?
a. primary headache --> migraine with aura
b. secondary headache --> migraine with aura
c. primary headache --> tension type headache
d. secondary headache --> tension type headache
a. primary headache --> migraine with aura
Refer to case (c):

Which of the following medications would be most appropriate for RT’s moderate to severe headaches?
a. Sumatriptan 5mg orally at the onset of the aura
b. Ibuprofen 200mg orally at the onset of the aura
c. Rizatriptan 30mg orally at the onset of the aura
d. Frovatriptan 7.5mg orally at the onset of the aura
c. Rizatriptan 30mg orally at the onset of the aura
20. RT presents to a follow-up appointment after keeping a headache diary for 3 months. When reviewing the diary you decide that RT is a candidate for preventative treatment. Which of the following is the best recommendation for this patient?
a. Verapamil 240mg daily orally
b. Propranolol 40mg bid orally
c. Valproic acid 250mg daily orally
d. Ibuprofen 400mg daily orally
e. Topiramate 100mg bid orally
b. Propranolol 40mg bid orally (beta-blockers are 1st line)

(Verapamil is the preferred CCB as a 2nd or 3rd line)
Refer to case (d):

Which of the following statements is most correct regarding prophylactic migraine
therapy in PM?
a. PM is already on an effective prophylactic agent
b. PM has not used more than 3 tablets of sumatriptan per week and is therefore not a candidate for prophylactic treatment
c. PM should be on prophylactic therapy because her hypertension is a
contraindication for using triptans
d. PM is at high risk for rebound headaches due to excessive triptan use
e. PM is a candidate for prophylactic treatment due to her increasing frequency and severity of attacks
e.
PM is a candidate for prophylactic treatment since her migraines are
occurring more than 2 times per month, and there is a trend toward more frequent,
severe attacks causing disruption of her daily routine. A is incorrect because if the
nifedipine was effective, her migraines would not be getting worse. Her HTN is
controlled, so C is incorrect. B and D are both incorrect because they do not accurately assess her use.
18. Which medication (if needed
Refer to case (d):
Which medication (if needed) would be the BEST CHOICE for prophylactic treatment of migraine with aura in PM?
a. Birth Control Pills
b. Topiramate
c. Propranolol
d. Divalproex sodium
e. PM is already on an effective prophylactic agent
b.
Topiramate is the best choice here. Although propranolol would be an excellent
choice in most patients, PM also suffers from asthma. Beta blockers, especially nonselective
beta-blockers, can cause airway reactivity and prevent rescue inhalers from
working effectively. Divalproex sodium would also be a good option, but the patient
11
is already obese, and this agent often causes weight gain. Birth control pills would
be an option if her migraines were related to her menstrual cycle; however, since she
is having severe migraines every couple of weeks (rather than clustered around one
week during the month) this is unlikely. E is incorrect because if the nifedipine was
effective, her migraines would not be getting worse.
RP is a 35 year old African American female who is 20 weeks pregnant. Her past medical history is significant for mild depression and hyperlipidemia. She comes to your office today with complaints of recent onset of mild to moderate intensity headaches. She describes the pain as pressing in quality, bilateral in location, and claims she experiences
extreme phonophobia during the attacks. She is experiencing these headaches roughly two times per week. She has not treated these headaches yet because she is very concerned about taking any medications that might harm her fetus and requests your expert opinion.

What type of headache is RP most likely experiencing and how would you advise
her?
a. Tension headache; advise her to take APAP 1 gram prn headache and adopt non-pharmacologic measures for prevention.
b. Migraine headache; advise her to take APAP 1 gram prn headache and adopt non-pharmacologic measures for prevention.
c. Tension headache; advise her not to take any medications since they will
adversely affect her fetus.
d. Migraine headache; advise her not to take any medications since they will
adversely affect her fetus.
e. Tension headache; advise her to call her physician and ask for a prescription for an opioid since APAP will be ineffective.
a.
Tension headache; advise her to take APAP 1 gram prn headache and adopt nonpharmacologic
measures for prevention. The description of her headaches is consistent with tension headache. APAP is the safest analgesic medication for her and her unborn child. It would be prudent to attempt this medication before escalating to stronger
medications such as opioids.
JH is a 20 year old white male who suffers from chronic migraine (other past medical
history is non-contributory). His migraines began about one year ago, and he has been
well controlled on his current regimen until recently (which he attributes to stress from
tougher college courses). He feels the prophylaxis medication he is on is still working well since his attacks have been reduced to approximately one migraine per week. When he does experience a migraine attack, however, he states his current triptan doesn’t seem to work as effectively as it once did. Furthermore, he would like to try another medication since he has read that there are several agents in the same class as the drug he is already taking and they may work even if his current drug is not.
Medications:
Sumatriptan (Imitrex) 100 mg po prn migraine
Propranolol (Inderal LA) 160 mg po qdaily

Which of the following would be the MOST APPROPRIATE choice for JH at this
time?
a. Zolmitriptan 25 mg po prn migraine
b. Eletriptan 80 mg po prn migraine
c. Almotriptan 12.5 mg po prn migraine
d. Frovatriptan 10 mg po prn migraine
e. Rizatriptan 30 mg po prn migraine
c.
Almotriptan (Axert) 12.5 mg is the most appropriate choice based on dosing and
current evidence. Answers A, B, and D are incorrect because almotriptan is a better
answer based on current evidence and the doses exceed the max daily dose for each medication or are incorrect based on current FDA recommendations (remember in lecture, I stated the 80 mg tablet of ELE is not approved in the U.S. as a single dose). E is incorrect because the max daily dose should be 15 mg since he is also taking propranolol for prophylaxis.
LD is an obese 35 yo WF with a past medical history of migraine with aura, controlled
hypertension, and hypothyroidism. She is currently experiencing about 2-3 migraines per week. She reports that “extremely severe” episodes occur once every couple of weeks, often causing her to miss work. Normally, LD fills her sumatriptan (Imitrex) on the
same day every month, and she receives 9 tablets with each refill. She comes in today
asking if she can get a refill (one week early) on her migraine prescription because her headaches seem to be occurring more frequently.
Medications:
Sumatriptan (Imitrex) 100 mg prn migraine
Lisinopril (Prinivil/Zestril) 10 mg qdaily (an ACE inhibitor)
Levothyroxine (Synthroid) 0.075 mg qam

Which of the following statements is most true regarding prophylactic migraine
therapy in LD?
a. LD is already on an effective prophylactic agent
b. LD is a candidate for prophylactic treatment due to her increasing frequency
and severity of attacks
c. LD should be on prophylactic therapy because her HTN is a contraindication for using triptans
d. LD can now be classified as having medication overuse headaches due to
excessive triptan use and needs to be started on prophylactic treatment
e. LD has not used more than 3 tablets of sumatriptan
b.
LD is a candidate for prophylactic treatment since her migraines are occurring more than 2 times per month, and there is a trend toward
more frequent, severe attacks causing disruption of her daily routine. a is incorrect
because if the lisinopril was effective, her migraines would not be getting worse.
Her HTN is controlled, so c is incorrect. d and e are both incorrect because they
do not accurately assess her use. Medication overuse headache requires HA > 15
days per month.
Which of the following would be a good option for prophalactic treatment of migraines, but not good in a patient that is already obese, because it often causes weight
gain?
a. Propranolol
b. Dihydroergotamine
c. Divalproex sodium
d. Birth Control Pills
e. LD is already on an effective prophylactic agent
c.
MS is a 30 yo BF who has a past medical history significant for migraine without aura (with significant nausea and vomiting during attacks), mild depression, and hyperlipidemia. She comes to your office today complaining that the Imitrex (sumatriptan) previously prescribed to her is no longer that effective in treating her
migraines. She is experiencing approximately one migraine per month and is also on
propranolol for prophylaxis.
Medications:
Sumatriptan (Imitrex) 100 mg prn migraine
Propranolol (Inderal) 60 mg qdaily for migraine prophylaxis
Ezetimibe (Zetia) 10 mg qdaily for cholesterol

Which medication would be the most appropriate choice to change to for acute
treatment of her migraines?
a. Maximum dose Frovatriptan (Frova)
b. Maximum dose Intranasal Dihydroergotamine (Migranal)
c. Maximum dose Naratriptan (Amerge)
d. Maximum dose Rizatriptan (Maxalt)
e. Maximum dose Almotriptan (Axert)
e.
Almotriptan (Axert) 12.5 mg is the most appropriate choice
based on dosing and current evidence. Answers a and c are incorrect because
almotriptan is a better answer based on current evidence and the doses exceed the
max daily dose for each medication. b is incorrect because she already experiences significant nausea and vomiting with her migraines (and there is a much better
option). d is incorrect because the max daily dose should be 15 mg since she is also
taking propranolol.
MS is a 30 yo BF who has a past medical history significant for migraine without aura (with significant nausea and vomiting during attacks), mild depression, and
hyperlipidemia. She comes to your office today complaining that the Imitrex (sumatriptan) previously prescribed to her is no longer that effective in treating her migraines. She is experiencing approximately one migraine per month and is also on propranolol for prophylaxis.
Medications:
Sumatriptan (Imitrex®) 100 mg prn migraine
Propranolol (Inderal) 60 mg qdaily for migraine prophylaxis
Ezetimibe (Zetia) 10 mg qdaily for cholesterol

Three months later, MS returns to the clinic and says she is pregnant. What changes would be most appropriate to make with respect to her migraine medications?
a. Continue propranolol for prophylaxis; switch acute medication back to
sumatriptan
b. Discontinue both propranolol and acute medication; advise her to take
acetaminophen 1g prn migraine
c. Discontinue both propranolol and acute medication; advise her to take Advil 400mg prn migraine
d. Discontinue both propranolol and acute treatment and advise the use of ergotamine prn migraine
b.
Discontinuing her medications and advising her to take
acetaminophen is the best option for her. NSAIDS and ergotamine can cause fetal
harm, and non-pharmacologic prophylactic treatment is recommended for pregnant
women (propranolol is pregnancy category C).
TL is a 38 YO African-Amer. female who presents with a 6-month history of recurring headaches. She has a past medical history significant for allergic rhinitis and “mild” depression. She experiences ~2 headaches every 2 weeks. She describes the pain as left-sided, throbbing, and very severe, with attacks lasting ~4 hours. The pain comes on suddenly with no warning, gets worse when she walks up or down stairs, and is accompanied by mild nausea with no vomiting. She is not currently getting any relief from her headache medicine. Her family history is significant for father with migraines (deceased - age 72 secondary to colon cancer); mother alive and well; she has 2 siblings, both also have migraines.

TL’s current medications include:
Paxil (paroxetine) 20mg PO QD x 6 months
Flonase (fluticasone) 2 sprays in each nostril once daily x 2 years
Excedrin (aspirin, acetaminophen and caffeine) as needed for migraine headaches (uses 5 tabs ~4 days/week) x 4 months

Pertinent labs/vitals include:
Scr 0.9, AST/ALT – within normal limits, BP 102/66, Pulse - 68

14. Which of the following would be the BEST therapeutic option for acute treatment of RJ’s headaches?
a. Discontinue Excedrin. Begin Amerge (naratriptan) PRN for at least 2 months to ensure an adequate trial of this medication.
b. Discontinue Excedrin. Begin Axert (almotriptan) 6.25mg PO at onset of migraine.
c. Increase Excedrin use to 2 tabs daily to prevent rebound headache.
d. Discontinue Excedrin. Begin Midrin (isometheptene, acetaminophen, dichloralphenazone) as needed for acute treatment of headache.
b.