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MIGRAINETREATMENT

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PRE/POSTTEST WITH EXPLANATIONS

QUESTION 1Two targets that have yielded effective migraine treatments are

a. Serotonin and substance P

b. CGRP and substance P

c. Serotonin and CGRP

d. Nitric oxide and substance P

EXPLANATION

Serotonin subreceptor agonists include triptans, ergots, and lasmiditan. Medications with anti-CGRP effects include gepants and monoclonal antibodies.

REFERENCES

Goadsby PJ, et al. N Engl J Med. 2002;346:257–270. Hargreaves RJ, Shepheard SL. Can J Neurol Sci. 1999;26 (suppl3):S12–S19.

QUESTION 2Propranolol, amitriptyline, and topiramate have failed to reduce frequency, duration, or severity of migraine days in a patient with an average of 8 days per month of disabling but episodic migraine. What therapeutic option with Level A evidence would you consider next for this patient?

a. Verapamil

b. Gabapentin

c. Ketamine

d. An anti-CGRP or anti-CGRP receptor monoclonal antibody

EXPLANATION

Verapamil and gabapentin have little or no evidence for migraine preventive effectiveness in the American Headache Society Preventive Guidelines. Ketamine does not even make the list—no evidence. Optimal selection of treatment for the patient for a monoclonal antibody is described in the American Headache Society Position Statement On Integrating New Migraine Treatments Into Clinical Practice.

REFERENCES

American Headache Society. Headache. 2019;59(1):1-18.

QUESTION 3Which acute migraine medications are under review or recently FDA-approved for patients with migraine and vascular disease?

a. Gepants and monoclonal antibodies

b. Lasmiditan and monoclonal antibodies

c. Gepants and lasmiditan

d. New formulations of triptans and DHE

EXPLANATION

Gepants block CGRP-induced vasodilation but do not vasoconstrict. Lasmiditan is a serotonin-1F agonist, without clinically significant serotonin-1B effect, so lasmiditan does not cause vasoconstriction. Both appear safe in patients with vascular disease or multiple vascular risk factors

REFERENCES

Kuca B, et al. Neurology. 2018;91(24):e2222-e2232. Tfelt-Hansen P. Headache. 2011;51:118-123.

MIGRAINE TREATMENT

QUESTION 4A patient with disabling high frequency episodic migraine has tried metoprolol, nortriptyline, and valproate without success. She is not in an area where behavioral treatments are an option, and she adamantly will not take monoclonal antibodies due to needle phobia that she does not wish to confront. What options for prevention and acute treatment might be reasonable?

a. Verapamil

b. Gabapentin

c. External trigeminal nerve stimulation or single pulse transcranial magnetic stimulation

d. DHE nasal spray

EXPLANATION

Verapamil and gabapentin have little or no evidence for effectiveness in the American Headache Society Preventive Guidelines. DHE nasal spray is an acute medication, not preventive. Both of the noninvasive neurostimulators listed are FDA approved for prevention of migraine. Optimal selection of patients for new treatments is described in the American Headache Society Position Statement On Integrating New Migraine Treatments Into Clinical Practice.

REFERENCES

American Headache Society. Headache. 2019;59(1):1-18. Silberstein et al. Neurology. 2012;78:1337-1345.

QUESTION 5What are the FDA approved medication treatments for chronic migraine?

a. Amitriptyline, propranolol, valproate, onabotulinumtoxinA

b. Amitriptyline, topiramate, valproate, onabotulinumtoxinA

c. Erenumab, fremanezumab, galcanezumab, onabotulinumtoxinA

d. Erenumab, fremanezumab, galcanezumab, eptinezumab

EXPLANATION

The three monoclonal antibodies are FDA approved for prevention of migraine, including both episodic and chronic. OnabotulinumtoxinA is FDA approved only for chronic migraine.

REFERENCES

https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/103000s5307lbl.pdf. Accessed January 15, 2019. Tepper SJ. Headache. 2018;58(suppl 3):238-275.

MIGRAINE TREATMENT