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.
