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Questions and Answers
Which of the following factors is MOST crucial when prescribing triptans for migraine treatment?
Which of the following factors is MOST crucial when prescribing triptans for migraine treatment?
- Ensuring the patient has not used ergotamine derivatives within the past 24 hours, to avoid excessive vasoconstriction. (correct)
- Monitoring the patient's blood glucose levels for potential hyperglycemic effects.
- Determining the patient's creatinine clearance to adjust for renal excretion.
- Assessing the patient's liver function, due to the risk of drug-induced hepatitis.
A patient with a history of which condition would be LEAST suitable for treatment with ergot alkaloids?
A patient with a history of which condition would be LEAST suitable for treatment with ergot alkaloids?
- Well-controlled hypertension.
- Migraine headaches refractory to triptans.
- Raynaud's phenomenon. (correct)
- Chronic stable angina.
Which of the following medication classes is LEAST likely to be considered as a first-line option for preventive migraine therapy?
Which of the following medication classes is LEAST likely to be considered as a first-line option for preventive migraine therapy?
- Beta-blockers.
- Calcium channel blockers. (correct)
- Tricyclic antidepressants.
- Antiepileptic drugs.
A patient presents with severe, unilateral headaches occurring in clusters, accompanied by rhinorrhea and ptosis. Which acute treatment option is MOST appropriate?
A patient presents with severe, unilateral headaches occurring in clusters, accompanied by rhinorrhea and ptosis. Which acute treatment option is MOST appropriate?
What is the primary mechanism of action of CGRP inhibitors in migraine prevention?
What is the primary mechanism of action of CGRP inhibitors in migraine prevention?
Which characteristic is LEAST likely to be associated with cluster headaches?
Which characteristic is LEAST likely to be associated with cluster headaches?
A patient who reports using over-the-counter analgesics more than 15 days per month for the past 3 months is MOST at risk of developing which type of headache?
A patient who reports using over-the-counter analgesics more than 15 days per month for the past 3 months is MOST at risk of developing which type of headache?
Which of the following statements BEST differentiates migraines from tension-type headaches?
Which of the following statements BEST differentiates migraines from tension-type headaches?
Which of the following statements best describes the mechanism by which cortical spreading depression (CSD) is theorized to contribute to migraine pathophysiology?
Which of the following statements best describes the mechanism by which cortical spreading depression (CSD) is theorized to contribute to migraine pathophysiology?
A patient with frequent migraines is being considered for preventive therapy. Which factor would be most important in guiding the choice of a prophylactic medication?
A patient with frequent migraines is being considered for preventive therapy. Which factor would be most important in guiding the choice of a prophylactic medication?
A patient who uses abortive migraine medications more than twice a week is at risk of developing which complication?
A patient who uses abortive migraine medications more than twice a week is at risk of developing which complication?
Which statement accurately differentiates migraines from cluster headaches?
Which statement accurately differentiates migraines from cluster headaches?
Why is acetaminophen often combined with other drugs for abortive migraine treatment?
Why is acetaminophen often combined with other drugs for abortive migraine treatment?
Which of the following distinguishes cluster headaches from migraines?
Which of the following distinguishes cluster headaches from migraines?
A patient with a history of coronary artery disease should avoid which class of migraine abortive medications due to potential vasoconstrictive effects?
A patient with a history of coronary artery disease should avoid which class of migraine abortive medications due to potential vasoconstrictive effects?
Which migraine preventive medication requires cautious use or is contraindicated in patients with peripheral vascular disease due to its mechanism of action?
Which migraine preventive medication requires cautious use or is contraindicated in patients with peripheral vascular disease due to its mechanism of action?
A patient experiencing frequent cluster headaches has not responded well to first-line treatments. Which of the following second-line prophylactic medication options would be most appropriate, considering potential comorbidities and contraindications?
A patient experiencing frequent cluster headaches has not responded well to first-line treatments. Which of the following second-line prophylactic medication options would be most appropriate, considering potential comorbidities and contraindications?
What is the MOST appropriate acute treatment for a patient experiencing a cluster headache attack?
What is the MOST appropriate acute treatment for a patient experiencing a cluster headache attack?
Metoclopramide and prochlorperazine are indicated in migraine treatment primarily for what purpose?
Metoclopramide and prochlorperazine are indicated in migraine treatment primarily for what purpose?
A patient who frequently uses over-the-counter analgesics for tension-type headaches now reports daily headaches. After discontinuing the analgesics, how long should the patient expect headache improvement?
A patient who frequently uses over-the-counter analgesics for tension-type headaches now reports daily headaches. After discontinuing the analgesics, how long should the patient expect headache improvement?
A patient with frequent migraine attacks is being considered for prophylactic therapy. Beyond pharmacological options, which non-drug measure should be emphasized as part of their comprehensive treatment plan?
A patient with frequent migraine attacks is being considered for prophylactic therapy. Beyond pharmacological options, which non-drug measure should be emphasized as part of their comprehensive treatment plan?
Which of the following is the MOST significant adverse effect associated with divalproex (Depakote ER) that necessitates careful monitoring and patient education?
Which of the following is the MOST significant adverse effect associated with divalproex (Depakote ER) that necessitates careful monitoring and patient education?
A patient with a history of migraines is considering starting topiramate for migraine prevention but is concerned about cognitive side effects. Which of the following strategies would be MOST appropriate to mitigate these effects?
A patient with a history of migraines is considering starting topiramate for migraine prevention but is concerned about cognitive side effects. Which of the following strategies would be MOST appropriate to mitigate these effects?
Which drug class, when used for the prophylactic treatment of migraine headaches, is MOST likely to cause hypotension and anticholinergic side effects?
Which drug class, when used for the prophylactic treatment of migraine headaches, is MOST likely to cause hypotension and anticholinergic side effects?
A 35-year-old female reports predictable migraines occurring two days before the onset of menses. Besides perimenstrual triptans, which of the following is an appropriate treatment approach targeting the underlying cause of these menstrually associated migraines?
A 35-year-old female reports predictable migraines occurring two days before the onset of menses. Besides perimenstrual triptans, which of the following is an appropriate treatment approach targeting the underlying cause of these menstrually associated migraines?
Which of the following best describes the mechanism of action of rimegepant (Nurtec ODT) in the preventive treatment of migraines?
Which of the following best describes the mechanism of action of rimegepant (Nurtec ODT) in the preventive treatment of migraines?
A patient is considering botulinum toxin injections for chronic migraine prevention. What should the patient be counseled regarding the expected frequency of injections?
A patient is considering botulinum toxin injections for chronic migraine prevention. What should the patient be counseled regarding the expected frequency of injections?
A patient who has been prescribed propranolol for migraine prophylaxis reports experiencing persistent fatigue and exercise intolerance. What would be the MOST appropriate course of action?
A patient who has been prescribed propranolol for migraine prophylaxis reports experiencing persistent fatigue and exercise intolerance. What would be the MOST appropriate course of action?
A patient with a history of migraines is started on amitriptyline for migraine prevention. Which potential side effect requires careful consideration, especially in elderly male patients?
A patient with a history of migraines is started on amitriptyline for migraine prevention. Which potential side effect requires careful consideration, especially in elderly male patients?
Why are triptans contraindicated for patients with a history of ischemic heart disease?
Why are triptans contraindicated for patients with a history of ischemic heart disease?
A 45-year-old male with well-controlled hypertension and a history of smoking presents with frequent migraine headaches. Which abortive treatment option should be avoided?
A 45-year-old male with well-controlled hypertension and a history of smoking presents with frequent migraine headaches. Which abortive treatment option should be avoided?
Which statement accurately describes the mechanism by which triptans abort migraine attacks?
Which statement accurately describes the mechanism by which triptans abort migraine attacks?
A patient reports experiencing 'heavy arms' and 'chest pressure' after taking a triptan for migraine. Which of the following is the MOST appropriate course of action?
A patient reports experiencing 'heavy arms' and 'chest pressure' after taking a triptan for migraine. Which of the following is the MOST appropriate course of action?
What is thought to be the underlying mechanism for the reported chest symptoms (heavy arms or chest pressure) experienced by some patients taking Triptans?
What is thought to be the underlying mechanism for the reported chest symptoms (heavy arms or chest pressure) experienced by some patients taking Triptans?
Why does the route of administration of a triptan affect its efficacy in treating migraines?
Why does the route of administration of a triptan affect its efficacy in treating migraines?
How does aspirin, particularly when combined with metoclopramide, offer a therapeutic benefit in the acute treatment of migraines?
How does aspirin, particularly when combined with metoclopramide, offer a therapeutic benefit in the acute treatment of migraines?
A patient with migraines is using sumatriptan for acute attacks but finds that headaches recur within 24 hours in a significant number of instances. What is the MOST likely reason for this?
A patient with migraines is using sumatriptan for acute attacks but finds that headaches recur within 24 hours in a significant number of instances. What is the MOST likely reason for this?
Why is combining triptans and ergot alkaloids generally contraindicated?
Why is combining triptans and ergot alkaloids generally contraindicated?
Which of the following best describes the mechanism of action of ergotamine in treating migraines?
Which of the following best describes the mechanism of action of ergotamine in treating migraines?
What is a crucial consideration regarding the administration of ergotamine for migraine relief, given its pharmacokinetic properties?
What is a crucial consideration regarding the administration of ergotamine for migraine relief, given its pharmacokinetic properties?
What should patients taking ergotamine be advised regarding potential adverse effects and their management?
What should patients taking ergotamine be advised regarding potential adverse effects and their management?
Why is ergotamine contraindicated in patients with peripheral vascular disease or those taking potent CYP3A4 inhibitors?
Why is ergotamine contraindicated in patients with peripheral vascular disease or those taking potent CYP3A4 inhibitors?
What distinguishes dihydroergotamine (DHE) from ergotamine in terms of its adverse effect profile and administration?
What distinguishes dihydroergotamine (DHE) from ergotamine in terms of its adverse effect profile and administration?
What is the primary rationale for initiating preventive migraine therapy, and what are the typical expectations for its effectiveness?
What is the primary rationale for initiating preventive migraine therapy, and what are the typical expectations for its effectiveness?
In which of the following clinical scenarios would preventive migraine therapy be MOST appropriate, according to established guidelines?
In which of the following clinical scenarios would preventive migraine therapy be MOST appropriate, according to established guidelines?
Which of these findings are commonly associated with migraines? (Select all that apply)
Which of these findings are commonly associated with migraines? (Select all that apply)
Cluster headaches are typically found in what location?
Cluster headaches are typically found in what location?
What disorder is defined as a neurovascular disorder that involves dilation and inflammation of intracranial blood vessels?
What disorder is defined as a neurovascular disorder that involves dilation and inflammation of intracranial blood vessels?
Which two antimigraine medications are indicated for migraine treatment?
Which two antimigraine medications are indicated for migraine treatment?
What is the mechanism of action (MOA) of Aspirin?
What is the mechanism of action (MOA) of Aspirin?
What is considered the first line for abortive treatment of migraines?
What is considered the first line for abortive treatment of migraines?
What is the mechanism of action (MOA) of Triptans?
What is the mechanism of action (MOA) of Triptans?
A patient complains of heavy arms and chest pressure. What is the most likely headache medication cause?
A patient complains of heavy arms and chest pressure. What is the most likely headache medication cause?
Triptans are contraindicated in patients with which of the following conditions? (Select all that apply)
Triptans are contraindicated in patients with which of the following conditions? (Select all that apply)
What migraine drug's bioavailability is increased by a high fat meal?
What migraine drug's bioavailability is increased by a high fat meal?
What is the mechanism of action of Ergot Alkaloids?
What is the mechanism of action of Ergot Alkaloids?
Ergotism is defined as?
Ergotism is defined as?
A patient comes with cold, pale, numb extremities, muscle pain, gangrene, and sepsis. What is the most likely cause?
A patient comes with cold, pale, numb extremities, muscle pain, gangrene, and sepsis. What is the most likely cause?
What is Dihydro-ergotamine's most common adverse effect?
What is Dihydro-ergotamine's most common adverse effect?
A patient wants a medication to prevent migraines, what is the first line treatment for prevention?
A patient wants a medication to prevent migraines, what is the first line treatment for prevention?
What is the black box warning for divalproex?
What is the black box warning for divalproex?
A pregnant patient would like a preventative medication for migraines. Which of the following medications would not be prescribed?
A pregnant patient would like a preventative medication for migraines. Which of the following medications would not be prescribed?
Menstrually Associated Migraine is defined by?
Menstrually Associated Migraine is defined by?
What is the mechanism of action (MOA) of Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists?
What is the mechanism of action (MOA) of Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists?
Cluster headaches are defined as?
Cluster headaches are defined as?
What is the first line prophylaxis for cluster headaches?
What is the first line prophylaxis for cluster headaches?
Which of the following are methods for cluster headache abortive treatment? (Select all that apply)
Which of the following are methods for cluster headache abortive treatment? (Select all that apply)
Flashcards
Abortive Therapy Frequency
Abortive Therapy Frequency
Limit use to 1-2 days/week to avoid medication overuse headache (MOH).
Preventive Migraine Meds
Preventive Migraine Meds
Beta-blockers, antiepileptic drugs (topiramate), tricyclic antidepressants, CGRP inhibitors, botulinum toxin injections.
Migraine Pathophysiology
Migraine Pathophysiology
Dilation and inflammation of intracranial blood vessels, triggered by neural events.
Trigeminal Vascular System
Trigeminal Vascular System
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Migraine Triggers
Migraine Triggers
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Cortical Spreading Depression (CSD)
Cortical Spreading Depression (CSD)
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CSD Consequence
CSD Consequence
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Antiemetics for Migraine
Antiemetics for Migraine
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Migraine Characteristics
Migraine Characteristics
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Cluster Headache Characteristics
Cluster Headache Characteristics
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Tension Headache Characteristics
Tension Headache Characteristics
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Abortive Treatments for Migraines
Abortive Treatments for Migraines
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Abortive Treatments for Cluster Headaches
Abortive Treatments for Cluster Headaches
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Treatments for Tension Headaches
Treatments for Tension Headaches
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Migraine Headache
Migraine Headache
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Cluster Headache
Cluster Headache
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Aspirin (ASA) MOA
Aspirin (ASA) MOA
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Triptans: Mechanism of Action
Triptans: Mechanism of Action
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Triptans: Onset of Action
Triptans: Onset of Action
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Triptans: Headache Recurrence
Triptans: Headache Recurrence
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Triptans: Metabolism
Triptans: Metabolism
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Triptans: Adverse Effects
Triptans: Adverse Effects
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Triptans: CAD Risk Factors
Triptans: CAD Risk Factors
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Triptans: Contraindications
Triptans: Contraindications
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Triptans & Ergot Interactions
Triptans & Ergot Interactions
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Triptans & MAOIs
Triptans & MAOIs
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Triptans & SSRI/SNRIs
Triptans & SSRI/SNRIs
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Ergotamine MOA
Ergotamine MOA
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Ergotamine Adverse Effects
Ergotamine Adverse Effects
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Ergotamine Contraindications
Ergotamine Contraindications
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Preventive Migraine Therapy: Indications
Preventive Migraine Therapy: Indications
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Preventive Migraine Therapy: Drug Classes
Preventive Migraine Therapy: Drug Classes
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Cluster headache associated symptoms
Cluster headache associated symptoms
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Causes of Medication Overuse Headache (MOH)
Causes of Medication Overuse Headache (MOH)
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Preventing Medication Overuse Headache
Preventing Medication Overuse Headache
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Beta-blockers for Migraines
Beta-blockers for Migraines
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Divalproex (Depakote ER)
Divalproex (Depakote ER)
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Topiramate (Topamax)
Topiramate (Topamax)
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Tricyclic Antidepressants
Tricyclic Antidepressants
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Menstrually Associated Migraine
Menstrually Associated Migraine
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Treatment for Menstrual Migraines
Treatment for Menstrual Migraines
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CGRP Receptor Antagonists
CGRP Receptor Antagonists
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Botulinum Toxin for Migraines
Botulinum Toxin for Migraines
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Study Notes
Serotonin Receptor Agonists (Triptans) - Prescribing Key Considerations:
- Triptans selectively activate 5-HT1B and 5-HT1D receptors, causing vasoconstriction in intracranial blood vessels and suppressing CGRP release from trigeminal nerves.
- After subQ or intranasal dosing onset happens in 15 minutes for complete relief in 2 hours; after PO it is 30-60 minutes with complete relief in 4 hours.
- Approximately 40% of patients experience a headache recurrence within 24 hours.
- Triptans are metabolized in the liver (MAO) and excreted in urine, with a half-life of about 2.5 hours.
- Triptans can cause unpleasant—but not dangerous—chest symptoms, "heavy arms" or "chest pressure" rather than pain, unrelated to ischemic heart disease.
- Risk factors for coronary vasospasm should be ruled out before prescribing triptans; contraindicated if history of ischemic heart disease, MI, uncontrolled hypertension, or other heart disease is present.
- Should be avoided in pregnancy.
- Triptans should not be taken with ergots or other triptans within 24 hours due to vasoconstriction.
- Use with MAOs can cause increased levels and with SSRI/SNRIs can cause the development of serotonin syndrome.
Ergot Alkaloids - Prescribing Key Considerations:
- Ergotamine alters transmission at serotonergic and dopaminergic junctions, blocks inflammation associated with the trigeminal vascular system by blocking CGRP release.
- Ergotamine stimulates the chemoreceptor trigger zone, causing nausea and vomiting in about 10% of patients.
- Metoclopramide or prochlorperazine can help with nausea and vomiting.
- The ergots weakness in the legs, myalgia, numbness, and tingling in the fingers and toes, angina-like pain, and tachycardia.
- Serious toxicity with ergotamine/dihydroergotamine overdose is referred to as ergotism.
- Ergotism constriction of peripheral arteries and arterioles the extremities become cold, pale, and numb and can cause muscle pain and gangrene.
- Avoid in vascular disease and renal or hepatic impairment.
- Black Box Warning: Potent inhibitors of CYP3A4 can raise ergotamine to dangerous levels, thus posing a risk for intense vasospasm.
Preventive Migraine Therapy
- Migraine therapy reduces the frequency, intensity, and duration of migraine attacks and improves response to abortive drugs.
- Prevention is indicated for three or more migraines a month, if attacks are severe, or the response is do not respond adequately to abortive agents.
- Preferred drugs take 2 to 6 weeks to work like propranolol, divalproex, and amitriptyline.
Preventive Migraine Therapy - Drug Classes:
- Beta-blockers: Propranolol is most commonly used; metoprolol, timolol, atenolol, and nadolol are also effective.
- Antiepileptics: Divalproex and topiramate; divalproex reduces the incidence of attacks by 50% in 30% to 50% of patients.
- Tricyclic Antidepressants: Can work for both migraine and tension-type headaches through theorized inhibition of serotonin reuptake; amitriptyline is used most commonly.
- CGRP Receptor Antagonists: Rimegepant and ubrogepant; administered once monthly, with a long half-life of about 28 days.
- Other: Botulinum toxin, multiple injections into the scalp, neck, and upper back; patients experience about two fewer headache days a month, lasting from 6 to 12 weeks.
Migraines vs. Cluster Headaches - Presentation:
- Migraine: Recurrent moderate to severe headaches, sometimes with aura; may have neurological signs during attacks, photophobia, phonophobia, nausea, vomiting; triggered by specific causes.
- Cluster: Recurrent severe, unilateral headaches, often waking patients from sleep; associated with autonomic symptoms (rhinorrhea, lacrimation, ptosis, miosis); restlessness; episodic pattern.
Migraines vs. Cluster Headaches - Treatment:
- Migraine: Abortive - Triptans, NSAIDs; Preventive - beta-blockers, antiepileptic drugs, antidepressants, CGRP inhibitors.
- Cluster: Abortive - high-flow oxygen, sumatriptan nasal spray, intranasal lidocaine; Preventive - verapamil, lithium carbonate, prednisone, topiramate.
General Approach to Headache Treatment:
- Migraine: Identifying and avoiding triggers, abortive medications for acute attacks, preventive medications for frequent or severe attacks.
- Cluster: Acute treatment to rapidly relieve severe pain, preventive therapy to reduce cluster frequency. Tension: Pain relievers, stress management techniques.
Pathophysiology of Headaches
- Migraine: A neurovascular disorder characterized by dilation and inflammation of intracranial blood vessels. Neural events trigger vasodilation, leading to pain and further neural activation. Neurons of the trigeminal vascular system are key; Precipitating factors - anxiety, fatigue, stress, menstruation, alcohol, weather changes, and tyramine-containing foods.
- Cluster: Unknown pathophysiology, episodic patterns; associated with autonomic symptoms; severe, unilateral pain.
- Tension: Usually episodic, can become chronic; typically normal exam findings; NSAIDs, acetaminophen, muscle relaxants, biofeedback, and cognitive-behavioral therapy.
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Description
This quiz covers key aspects of migraine and headache management, including acute and preventive treatments. It addresses the selection of appropriate medications like triptans and CGRP inhibitors, and identifies contraindications for certain therapies. It also reviews the diagnosis and treatment of different headache types.
