MCQ Quiz: Management of Migraine

Effective management of migraine, a complex neurological disorder, is a key topic in the Patient Care VII: Brain and Behavior curriculum. It requires pharmacists to be adept at differentiating between acute and preventive treatment strategies and tailoring therapy to improve a patient’s quality of life. This quiz will test your knowledge on the evidence-based management of migraine, including the use of abortive therapies like triptans, prophylactic medications like CGRP antagonists, and crucial non-pharmacological counseling points.

1. The management of migraine is typically divided into which two main strategies?

  • A. Palliative and curative treatment
  • B. Acute (abortive) and prophylactic (preventive) treatment
  • C. Stimulating and sedating treatment
  • D. Surgical and non-surgical treatment

Answer: B. Acute (abortive) and prophylactic (preventive) treatment

2. For mild-to-moderate acute migraine attacks, what is a recommended first-line treatment?

  • A. An oral triptan
  • B. An intravenous opioid
  • C. A simple analgesic like an NSAID or acetaminophen
  • D. A CGRP monoclonal antibody

Answer: C. A simple analgesic like an NSAID or acetaminophen

3. Triptans (e.g., sumatriptan) are first-line therapy for moderate-to-severe acute migraine attacks. When should a patient be counseled to take this medication for best results?

  • A. On a daily scheduled basis
  • B. After the headache has become severe and incapacitating
  • C. At the first sign of a migraine attack
  • D. Only during the aura phase

Answer: C. At the first sign of a migraine attack

4. To prevent the development of medication-overuse headache (MOH), patients should be counseled to limit the use of acute migraine medications like triptans to fewer than:

  • A. 20 days per month
  • B. 15 days per month
  • C. 10 days per month
  • D. 5 days per month

Answer: C. 10 days per month

5. Prophylactic (preventive) therapy for migraine should be considered for a patient who:

  • A. Has one mild migraine per year.
  • B. Experiences frequent or disabling headaches that impact their quality of life.
  • C. Prefers to only use acute medications.
  • D. Has their first migraine ever.

Answer: B. Experiences frequent or disabling headaches that impact their quality of life.

6. Which of the following is a first-line medication class for migraine prophylaxis?

  • A. Opioids
  • B. Benzodiazepines
  • C. Beta-blockers (e.g., propranolol)
  • D. Stimulants

Answer: C. Beta-blockers (e.g., propranolol)

7. The newer CGRP monoclonal antibodies (e.g., erenumab, fremanezumab) are used for what purpose in migraine management?

  • A. The acute treatment of a migraine attack
  • B. The prophylactic (preventive) treatment of migraine
  • C. The treatment of tension-type headaches
  • D. The reversal of triptan side effects

Answer: B. The prophylactic (preventive) treatment of migraine

8. A patient has a history of uncontrolled hypertension and coronary artery disease. Which class of acute migraine medication is contraindicated?

  • A. NSAIDs
  • B. Triptans
  • C. Gepants
  • D. Acetaminophen

Answer: B. Triptans

9. The “gepants” (e.g., ubrogepant) are a class of oral medications for the acute treatment of migraine. What is their mechanism of action?

  • A. Serotonin 5-HT1B/1D agonism
  • B. CGRP receptor antagonism
  • C. Dopamine agonism
  • D. Beta-adrenergic blockade

Answer: B. CGRP receptor antagonism

10. A key non-pharmacological tool in the management of migraine is:

  • A. Avoiding all physical activity.
  • B. Increasing caffeine intake.
  • C. Keeping a headache diary to identify and manage triggers.
  • D. A low-carbohydrate diet.

Answer: C. Keeping a headache diary to identify and manage triggers.

11. Which anti-seizure medication is also commonly used for migraine prophylaxis but requires a slow titration due to cognitive side effects?

  • A. Phenytoin
  • B. Carbamazepine
  • C. Topiramate
  • D. Levetiracetam

Answer: C. Topiramate

12. The “Management of Migraine” lecture is a core part of which Patient Care course module?

  • A. Module 5: Anxiety and Sleep-Wake Disorders
  • B. Module 6: Epilepsy
  • C. Module 7: Other Neuropsychiatric Disorders
  • D. Module 2: Neurodegenerative Disorders

Answer: C. Module 7: Other Neuropsychiatric Disorders

13. A patient reports that their sumatriptan tablet is not working quickly enough. Which dosage form of sumatriptan has a faster onset of action?

  • A. The enteric-coated tablet
  • B. The extended-release tablet
  • C. The nasal spray or subcutaneous injection
  • D. There are no other dosage forms.

Answer: C. The nasal spray or subcutaneous injection

14. A patient with severe migraine-associated nausea and vomiting may benefit from the addition of which type of medication to their acute treatment regimen?

  • A. A proton pump inhibitor
  • B. An antiemetic like prochlorperazine or metoclopramide
  • C. A stool softener
  • D. An antibiotic

Answer: B. An antiemetic like prochlorperazine or metoclopramide

15. How long should an adequate trial of a new prophylactic migraine medication be before its efficacy is assessed?

  • A. One week
  • B. Two weeks
  • C. At least 2-3 months at a therapeutic dose
  • D. One year

Answer: C. At least 2-3 months at a therapeutic dose

16. Butalbital-containing analgesics are generally not recommended for migraine management due to:

  • A. Their high cost.
  • B. A high risk of medication-overuse headache and dependence.
  • C. Their lack of efficacy.
  • D. A lack of oral formulations.

Answer: B. A high risk of medication-overuse headache and dependence.

17. The “Plan” step of the Pharmacists’ Patient Care Process (PPCP) for a migraine patient would involve:

  • A. Collecting a headache history.
  • B. Assessing for medication overuse.
  • C. Establishing patient-centered goals and selecting an appropriate therapy.
  • D. Dispensing an acute medication.

Answer: C. Establishing patient-centered goals and selecting an appropriate therapy.

18. Lasmiditan is a newer acute migraine medication that is more selective than triptans because it does not cause:

  • A. Pain relief
  • B. Vasoconstriction
  • C. Nausea
  • D. Dizziness

Answer: B. Vasoconstriction

19. Which class of antidepressants is also used for migraine prophylaxis?

  • A. SSRIs
  • B. MAOIs
  • C. Tricyclic antidepressants (e.g., amitriptyline)
  • D. All of the above

Answer: C. Tricyclic antidepressants (e.g., amitriptyline)

20. A primary goal for a patient on migraine prophylaxis, as measured by Patient-Reported Outcomes (PROs), would be:

  • A. A 100% elimination of all headaches.
  • B. A 50% or greater reduction in the number of headache days per month.
  • C. The ability to use acute medications more than 15 days per month.
  • D. A complete cure of the underlying disease.

Answer: B. A 50% or greater reduction in the number of headache days per month.

21. A patient should be counseled not to use a triptan if they have used an ergotamine derivative within the last:

  • A. 2 hours
  • B. 6 hours
  • C. 12 hours
  • D. 24 hours

Answer: D. 24 hours

22. The management of menstrual migraine can involve:

  • A. Daily use of a triptan.
  • B. Short-term “mini-prophylaxis” with an NSAID or triptan around the time of menses.
  • C. Discontinuing all medications during menses.
  • D. An opioid analgesic.

Answer: B. Short-term “mini-prophylaxis” with an NSAID or triptan around the time of menses.

23. The “Assess” step of the PPCP for a patient complaining of frequent headaches involves:

  • A. Immediately recommending an OTC product.
  • B. Collecting information on headache frequency, duration, and characteristics to identify potential medication-overuse or need for prophylaxis.
  • C. Recommending the most expensive triptan.
  • D. Only checking their blood pressure.

Answer: B. Collecting information on headache frequency, duration, and characteristics to identify potential medication-overuse or need for prophylaxis.

24. Which of the following is a common side effect of topiramate that requires patient counseling?

  • A. Weight gain
  • B. Sedation
  • C. Paresthesias (tingling in hands/feet) and cognitive slowing
  • D. Hypertension

Answer: C. Paresthesias (tingling in hands/feet) and cognitive slowing

25. A patient who fails a trial of one triptan for acute migraine management should be counseled to:

  • A. Assume all triptans will fail.
  • B. Try a different triptan, as response can be individualized.
  • C. Use only opioids from now on.
  • D. Stop all migraine treatment.

Answer: B. Try a different triptan, as response can be individualized.

26. The “Follow-up: Monitor and Evaluate” step of the PPCP is crucial in migraine management to:

  • A. Ensure the pharmacy inventory is correct.
  • B. Assess the efficacy and tolerability of the chosen treatment and make adjustments as needed.
  • C. Only check if the patient paid for the prescription.
  • D. Never speak to the patient again.

Answer: B. Assess the efficacy and tolerability of the chosen treatment and make adjustments as needed.

27. The use of a simple analgesic like an NSAID for acute migraine is most effective when:

  • A. Taken after the headache is severe.
  • B. Taken with a triptan.
  • C. Taken at the onset of the headache at an adequate dose.
  • D. Taken on an empty stomach.

Answer: C. Taken at the onset of the headache at an adequate dose.

28. What is the primary difference in the management approach for a patient with episodic migraine versus chronic migraine?

  • A. There is no difference.
  • B. Chronic migraine is less likely to require prophylactic therapy.
  • C. Chronic migraine (≥15 headache days/month) almost always requires prophylactic therapy to reduce headache frequency.
  • D. Acute medications are not used for chronic migraine.

Answer: C. Chronic migraine (≥15 headache days/month) almost always requires prophylactic therapy to reduce headache frequency.

29. The management of migraine with aura is pharmacologically _________ the management of migraine without aura.

  • A. completely different from
  • B. essentially the same as
  • C. much simpler than
  • D. focused on surgical options unlike

Answer: B. essentially the same as

30. The “Implementation” step of the PPCP for migraine management includes:

  • A. Assessing headache triggers.
  • B. Creating a problem list.
  • C. Counseling the patient on how and when to use their acute and/or prophylactic medications.
  • D. Following up in one month.

Answer: C. Counseling the patient on how and when to use their acute and/or prophylactic medications.

31. A patient should be advised that a potential side effect of triptans is “triptan sensations,” which can include:

  • A. A feeling of euphoria.
  • B. Tingling, flushing, or a feeling of pressure in the chest or neck.
  • C. Severe abdominal pain.
  • D. Significant weight gain.

Answer: B. Tingling, flushing, or a feeling of pressure in the chest or neck.

32. The primary goal of treating medication-overuse headache is to:

  • A. Increase the dose of the overused medication.
  • B. Discontinue the overused acute medication and bridge the patient with a different therapy.
  • C. Add another acute medication.
  • D. Do nothing.

Answer: B. Discontinue the overused acute medication and bridge the patient with a different therapy.

33. The management of migraine is covered in the curriculum alongside ADHD, indicating a focus on common __________ disorders.

  • A. cardiovascular
  • B. gastrointestinal
  • C. infectious
  • D. neuropsychiatric

Answer: D. neuropsychiatric

34. Which of the following is an appropriate goal of an acute migraine treatment?

  • A. To be pain-free within 2 hours.
  • B. To have a sustained response without recurrence.
  • C. To improve functional ability.
  • D. All of the above.

Answer: D. All of the above.

35. A key part of non-pharmacological management is identifying and avoiding triggers. Which of the following is a common migraine trigger?

  • A. Regular sleep
  • B. Consistent meals
  • C. Stress and hormonal changes
  • D. Moderate exercise

Answer: C. Stress and hormonal changes

36. Combining a triptan with an SSRI or SNRI requires counseling on the theoretical risk of:

  • A. Hypertensive crisis
  • B. Serotonin Syndrome
  • C. Liver failure
  • D. Kidney stones

Answer: B. Serotonin Syndrome

37. When choosing a prophylactic agent, the selection is often guided by:

  • A. The medication’s color.
  • B. The patient’s comorbidities and the medication’s side effect profile.
  • C. The pharmacy’s profit margin.
  • D. Using the newest agent available.

Answer: B. The patient’s comorbidities and the medication’s side effect profile.

38. For example, a patient with migraine and hypertension might be a good candidate for which prophylactic agent?

  • A. Amitriptyline
  • B. Topiramate
  • C. Propranolol
  • D. Valproic acid

Answer: C. Propranolol

39. A patient with migraine and depression might be a good candidate for which prophylactic agent?

  • A. A beta-blocker
  • B. A tricyclic antidepressant like amitriptyline or an SNRI like venlafaxine
  • C. A triptan
  • D. An NSAID

Answer: B. A tricyclic antidepressant like amitriptyline or an SNRI like venlafaxine

40. The pharmacist’s role in managing migraine involves:

  • A. Only dispensing medications.
  • B. Educating on triggers, counseling on acute and preventive therapies, and monitoring for efficacy and safety.
  • C. Diagnosing the type of headache.
  • D. Performing neurological exams.

Answer: B. Educating on triggers, counseling on acute and preventive therapies, and monitoring for efficacy and safety.

41. How are CGRP monoclonal antibodies administered?

  • A. As a daily oral tablet
  • B. As a monthly or quarterly subcutaneous injection
  • C. As an inhaled powder
  • D. As a transdermal patch

Answer: B. As a monthly or quarterly subcutaneous injection

42. A patient experiences aura with their migraines. What is the most appropriate management?

  • A. The management is completely different and requires specialized drugs.
  • B. The acute and prophylactic treatment options are generally the same as for migraine without aura.
  • C. Triptans are contraindicated.
  • D. Only opioids can be used.

Answer: B. The acute and prophylactic treatment options are generally the same as for migraine without aura.

43. A key counseling point for all acute migraine medications is the risk of ________ if used too frequently.

  • A. tolerance
  • B. dependence
  • C. medication-overuse headache
  • D. addiction

Answer: C. medication-overuse headache

44. “Stratified care” in migraine management refers to:

  • A. Using the same medication for every patient.
  • B. Choosing an initial treatment based on the patient’s attack severity and level of disability.
  • C. Layering multiple prophylactic medications at once.
  • D. Only using over-the-counter products.

Answer: B. Choosing an initial treatment based on the patient’s attack severity and level of disability.

45. Which of the following is a non-pharmacological strategy that has some evidence for migraine prevention?

  • A. A high-tyramine diet
  • B. Sleep deprivation
  • C. Regular exercise, acupuncture, and biofeedback
  • D. Bright, flashing lights

Answer: C. Regular exercise, acupuncture, and biofeedback

46. A patient who fails one oral triptan may be a candidate for:

  • A. Another oral triptan.
  • B. A different dosage form of a triptan (e.g., nasal spray).
  • C. A combination product (e.g., sumatriptan/naproxen).
  • D. All of the above.

Answer: D. All of the above.

47. The “Implementation” step of the PPCP for migraine management involves not only dispensing the drug but also:

  • A. Assessing the patient’s headache type.
  • B. Providing education on how to use the medication correctly.
  • C. Creating a problem list.
  • D. Deciding on the therapeutic goals.

Answer: B. Providing education on how to use the medication correctly.

48. Why are opioids and butalbital-containing products not recommended for routine migraine management?

  • A. They are not effective for pain.
  • B. They have a high risk for dependence and medication-overuse headache.
  • C. They are not available in oral formulations.
  • D. They are first-line agents.

Answer: B. They have a high risk for dependence and medication-overuse headache.

49. The overall goal of migraine management is to:

  • A. Restore the patient’s ability to function normally.
  • B. Reduce headache frequency and severity.
  • C. Minimize disability.
  • D. All of the above.

Answer: D. All of the above.

50. An understanding of migraine management is a core competency for pharmacists because:

  • A. Migraine is a rare condition.
  • B. Migraine is a common and disabling condition, and pharmacists are highly accessible healthcare professionals who can provide crucial counseling and care.
  • C. Only neurologists can treat migraine.
  • D. There are no effective treatments available.

Answer: B. Migraine is a common and disabling condition, and pharmacists are highly accessible healthcare professionals who can provide crucial counseling and care.

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