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.