chapter 35 HEADACHE AND MIGRAINE

Question 1

Paige has a history of chronic migraines and would benefit from preventative medication. Education regarding migraine preventive medication includes:

1. Medication is taken at the beginning of the headache to prevent it from getting worse.
2. Medication alone is the best preventative against migraines occurring.
3. Medication should not be used more than four times a month.
4. The goal of treatment is to reduce migraine occurrence by 50%.

Answer 1

4. The goal of treatment is to reduce migraine occurrence by 50%.

Question 2

A first-line drug for abortive therapy in simple migraine is:

1. Sumatriptan (Imitrex)
2. Naproxen (Aleve)
3. Butorphanol nasal spray (Stadol NS)
4. Butalbital and acetaminophen (Fioricet)

Answer 2

2. Naproxen (Aleve)

Question 3

Vicky, age 56 years, comes to the clinic requesting a refill of her Fiorinal (aspirin and butalbital) that she takes for migraines. She has been taking this medication for over 2 years for migraines and states one dose usually works to abort her migraine. What is the best care for her?

1. Switch her to sumatriptan (Imitrex) to treat her migraines.
2. Assess how often she is using Fiorinal and refill her medication.
3. Switch her to a beta blocker such as propranolol to prevent her migraine.
4. Request she return to the original prescriber of Fiorinal as you do not prescribe butalbital for migraines.

Answer 3

2. Assess how often she is using Fiorinal and refill her medication.

Question 4

When prescribing ergotamine suppositories (Wigraine) to treat acute migraine, patient education would include:

1. Ergotamine will briefly make the migraine worse before the migraine resolves.
2. The patient may experience bradycardia and dizziness.
3. They may need premedication with an antinausea medication.
4. Ergotamine works best if the patient starts off with a full suppository to get the full effect.

Answer 4

3. They may need premedication with an antinausea medication.

Question 5

Migraines in pregnancy may be safely treated with:

1. Acetaminophen with codeine (Tylenol #3)
2. Sumatriptan (Imitrex)
3. Ergotamine tablets (Ergostat)
4. Dihydroergotamine (DHE)

Answer 5

1. Acetaminophen with codeine (Tylenol #3)

Question 6

Xi, a 54-year-old female, has a history of migraines that do not respond well to OTC migraine medication. She is asking to try Maxalt (rizatriptan) because it works well for her friend. Appropriate decision making would be:

1. Prescribe the Maxalt, but only give her four tablets with no refills to monitor the use.
2. Prescribe Maxalt and arrange to have her observed in the clinic or urgent care with the first dose.
3. Explain that rizatriptan is not used for postmenopausal migraines and recommend Fiorinal (aspirin and butalbital).
4. Prescribe sumatriptan (Imitrex) with the explanation that it is the most effective triptan.

Answer 6

2. Prescribe Maxalt and arrange to have her observed in the clinic or urgent care with the first dose.

Question 7

Kelly is a 14-year-old patient who presents to the clinic with a classic migraine. She says she is having a headache two to three times a month. The initial plan would be:

1. Prescribe NSAIDs as abortive therapy and have her keep a headache diary to identify her triggers.
2. Prescribe zolmitriptan (Zomig) as abortive therapy and recommend relaxation therapy to reduce her stress.
3. Prescribe acetaminophen with codeine (Tylenol #3) for her to take at the first onset of her migraine.
4. Prescribe sumatriptan (Imitrex) nasal spray and arrange for her to receive the first dose in the clinic.

Answer 7

1. Prescribe NSAIDs as abortive therapy and have her keep a headache diary to identify her triggers.

Question 8

Jayla is a 9-year-old patient who has been diagnosed with migraines for almost 2 years. She is missing up to a week of school each month. Her headache diary confirms she averages four or five migraines per month. Which of the following would be appropriate?

1. Prescribe amitriptyline (Elavil) daily, start at a low dose and increase dosage slowly every 2 weeks until it’s effective in eliminating migraines.
2. Encourage her mother to give her Excedrin Migraine (aspirin, acetaminophen, and caffeine) at the first sign of a headache to abort the headache.
3. Prescribe propranolol (Inderal) to be taken daily for at least 3 months.
4. Explain that it is rare for a 9-year-old child to get migraines and she needs an MRI to rule out a brain tumor.

Answer 8

3. Prescribe propranolol (Inderal) to be taken daily for at least 3 months.

Question 9

Amber is a 24-year-old patient who has had migraines for 10 years. She reports a migraine on average of once a month. The migraines are effectively aborted with naratriptan (Amerge). When refilling Amber’s naratriptan, education would include:

1. Naratriptan will interact with antidepressants, including selective serotonin reuptake inhibitors (SSRIs) and St John’s wort, and she should inform any providers she sees that she has migraines.
2. Continue to monitor her headaches, if the migraine is consistently happening around her menses there is preventive therapy available.
3. Pregnancy is contraindicated when taking a triptan.
4. All of the above

Answer 9

4. All of the above

Question 10

When prescribing for migraines, patient education includes:

1. Triptans are safe to be used as often as needed as long as the patient is healthy.
2. Use triptan before trying OTC meds such as acetaminophen or naproxen.
3. Stress reduction and regular sleep are integral to migraine treatment.
4. If migraines worsen they are to increase their medication.

Answer 10

3. Stress reduction and regular sleep are integral to migraine treatment.

Question 11

Juanita presents to the clinic with a complaint of headaches off and on for months. She reports they feel like someone is “squeezing” her head. She occasionally takes Tylenol for the pain, but usually just “toughs it out.” Initial treatment for tension headache includes asking her to keep a headache diary and a prescription for:

1. Sumatriptan (Imitrex)
2. Naproxen (Aleve)
3. Ergotamine (Ergostat)
4. Tylenol with codeine (Tylenol #3)

Answer 11

2. Naproxen (Aleve)

Question 12

Nonpharmacologic therapy for tension headaches includes:

1. Biofeedback
2. Stress management
3. Massage therapy
4. All of the above

Answer 12

4. All of the above

Question 13

James has been diagnosed with cluster headaches. Appropriate acute therapy would be:

1. Butalbital and aspirin (Fiorinal)
2. Meperidine IM (Demerol)
3. Oxygen 100% for 15 to 30 minutes
4. Indomethacin (Indocin)

Answer 13

3. Oxygen 100% for 15 to 30 minutes

Question 14

Preventative therapy for cluster headaches includes:

1. Massage or relaxation therapy
2. Ergotamine nightly before bed
3. Intranasal lidocaine four times a day during “clusters” of headaches
4. Propranolol (Inderal) daily

Answer 14

2. Ergotamine nightly before bed

Question 15

When prescribing any headache therapy, appropriate use of medications needs to be discussed to prevent medication-overuse headaches. A clinical characteristic of medication-overuse headaches is that they:

1. Are increasing in frequency
2. Are increasing in intensity
3. Recur when medication wears off
4. Begin to “cluster” into a pattern

Answer 15

3. Recur when medication wears off