20 Questions
Which of the following medications is contraindicated in patients with renal failure?
Migrinal
Which of the following medications has the highest maximum daily dose (MDD)?
Lasmiditan
Which of the following medications is a selective 5-HT1F agonist?
Lasmiditan
Which of the following medications should be avoided in patients with severe hepatic and renal disease?
Zavegepant
Which medication is recommended as rescue therapy for migraine treatment?
Dexamethasone
What is the maximum daily dose of Promethazine (Phenergan)?
100 mg
Which medication is a 5-HT3 antagonist?
Ondansetron
Which treatment approach for migraine involves the use of NSAIDs and combination products first, reserving other therapies?
Step-Up Care
Which triptan has the fastest onset of action?
Sumatriptan (Imitrex)
What is the maximum oral dose of sumatriptan for patients with hepatic impairment?
50 mg
Which triptan has the longest duration of action?
Eletriptan (Replax)
Which triptan should be avoided in patients with severe hepatic impairment?
Sumatriptan (Imitrex)
Which type of migraine is defined as having 15 or more monthly headache days for 3 months or more?
Chronic Migraine (CM)
What is the definition of aura in relation to migraines?
A complex of positive and negative focal neurologic symptoms that precedes or accompanies a migraine attack
Which of the following is NOT a risk factor for migraines?
Diet
What are the treatment options for migraines?
Behavioral/non-pharmacologic therapy, acute migraine treatment, and migraine prophylaxis
Which of the following medications should be avoided in patients with congestive heart failure (CHF)?
NSAIDs and corticosteroids
Which of the following medications should be avoided in patients with chronic kidney disease (CKD) and a creatinine clearance (CrCl) less than 15?
NSAIDs and Rimegepant
Which of the following medications should be avoided in patients with liver disease?
NSAIDs, ditans, gepants, and certain triptans
Which of the following medications should be avoided in patients with sulfa allergy?
Almotriptan
Study Notes
Migraine Prophylaxis and Rescue Therapy in Special Populations
- Pregnancy: Increased risk of pre-eclampsia and gestational hypertension. Acetaminophen, magnesium IV, NSAIDs (1st and 2nd trimester only), Metoclopramide IV, and certain triptans can be considered.
- Pediatrics: Devices are an option for children aged 12 and above. Acetaminophen, NSAIDs (ibuprofen, naproxen), and certain triptans can be used for children over 6 years old.
- CAD: Avoid triptans, ergot alkaloids, and potential drug-drug interactions with NSAIDs (anticoagulants, antiplatelets).
- CHF: Avoid NSAIDs and corticosteroids.
- PUD: Avoid NSAIDs and corticosteroids.
- Geriatrics: Avoid NSAIDs and ditans.
- CKD: Avoid NSAIDs and Rimegepant (CrCl < 15). Naratriptan requires dose adjustment and should be avoided in CrCl < 15.
- Liver Disease: Avoid NSAIDs, ditans, gepants, and certain triptans. Reduce the maximum daily dose of acetaminophen.
- Sulfa allergy: Avoid almotriptan.
- Serotonergic Agents: Avoid use with triptans and ditans due to potential interactions.
- QTc prolongation: Be cautious with medications that prolong QTc.
- Antiemetics: Consider CYP3A4 interactions with gepants, almotriptan, eletriptan, and ergot alkaloids. Use non-oral medications for nausea and vomiting.
Migraine Prophylaxis Considerations:
- Goals of therapy: Prevent headaches, improve quality of life, reduce severity and frequency, educate patients, and reduce headache-related distress.
- Indications for Migraine Prophylaxis: Patient preference, acute migraines that interfere with daily routines despite treatment, frequent attacks, overuse of acute treatments, headaches that reoccur in a predictable pattern, and uncommon migraine variants.
- Treatment timeline: Start with a low dose and titrate up. Some benefit may be seen after 1 month, but therapeutic trials must be 2-6 months long. Prophylaxis is continued for at least 6-12 months after headache frequency is diminished.
- FDA Approved Therapies for Prophylaxis: Propranolol, timolol, non-DHP CCBs, valproic acid, divalproex sodium, topiramate, amitriptyline, nortriptyline, venlafaxine, frovatriptan, naratriptan, zolmitriptan, rimegepant, atogepant, anti-CGRP antibodies (erenumab, fremanezumab, galcanez
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