Correct Answers to MODULE 3: The ABCs of Acute Medication in Primary Care
Pre-Post Test Questions (Correct Answer is Bold)
1. A 72-year-old male patient with a history of coronary disease and migraine presents to your office stating that his over the counter meds are not effective as abortive meds for acute treatment of his migraines. Which classes of abortive meds do not have a warning in the package insert for patients with cardiovascular disease?
a. NSAIDS and Gepants
b. NSAIDS and Triptans
c. Gepants and Ditans
d. Ditans alone
e. Ergots and NSAIDS
Explanation: The correct answer is c. Only the gepants and ditans do not have a warning in their package inserts for cardiovascular disease.
2. Which statement is most representative of the new class of medications called the gepants (eg. rimegepant, ubrogepant)? Please choose best answer.
a. They have no drug interactions that you need to be concerned about.
b. They should not be used on the same day with other abortive meds such as triptans or ergots.
c. Their side effects include paresthesias, chest pain, neck tightness and somnolence.
d. They have a low incidence of side effects and are thought to have a low likelihood of causing medication overuse headaches.
Explanation: The correct answer is d. The gepants have a drug interaction with CYP3A4 inhibitors such as erythromycin, clarithromycin, protease inhibitors, antifungals and verapamil. There is no contraindication to use them with triptans or ergots as they have a completely different mechanism of action. Side effects are nausea and somnolence. Paresthesias, chest pain/tightness or neck tightness are triptan side effects. The correct answer is d as gepants have a low incidence of side effects and a low likelihood of causing medication overuse headaches.
3. What is the best proven approach to improve efficacy of the triptans (eg. sumatriptan [Imitrex}, etc)? Choose best answer.
a. Take the triptan early in the attack when you are sure it is a migraine, and the pain severity is mild
b. Take the triptan at the start of the aura phase of the migraine attack
c. Take the triptan at the first hint of any nausea during the attack
d. Take the triptan prior to onset of the headache when the patient experiences prodromal symptoms of a migraine attack (yawning, neck pain, dizziness, photo/phonophobia or hyperphagia, etc).
e. Take the triptan with the first hint of any headache whether a migraine or tension headache
Explanation: The correct answer is a. You want to take the triptans at the first sign that the person is experiencing a migraine attack when the pain severity is mild. The reason for this is that sensitization of second and third order neurons of the trigeminal system may occur later in the migraine attack. Once sensitization occurs, the attack may be more difficult to treat. Treatment of migraines during the prodrome or aura phases of migraine have not been conclusively proven to treat acute migraine attacks.
4. Your patient has been prescribed an acute medication. What is a realistic goal to determine if the acute therapy is effective?
a. Is the pain severity reduced to a mild to moderate level at two hour post dosage?
b. Is the patient pain free or near pain free at two hours post dosage?
c. Is the patient pain free or near pain free at one hour post dosage?
d. Is the pain severity reduced to a mild to moderate level at one hour post dosage?
Explanation: The correct answer is b. The best question to ask your patients to access the efficacy of acute medications is whether they are pain free or near pain free at two hours. Another question might be to determine if they are missing work or social activities because of migraine attacks. If they are not pain free at 2 hours or are missing life events, then you may need to change their acute medication regimen.
5. Medication overuse headaches are headaches that occur because of the overuse of acute medication. How much medication overuse can lead to this type of headaches?
a. ≥ 1 day per week of abortive medication use for two weeks
b. ≥ 2 days per week of abortive medication use for several months
c. Daily abortive medication use for 2 weeks
d. 3-4 days per week of acute medication use for 2 weeks
Explanation: The correct answer is b. Medication overuse is defined as use of simple analgesics (eg. NSAIDs, ASA) more than 15 days per month or use of triptans, ergots or combination analgesics (eg. ASA/acetaminophen/caffeine) more than 10 days per month. A good rule of thumb is that if they are using their acute medications more than 2 days per week then they may be overusing their acute medications. Gepants are not thought to cause medication overuse. We don’t have much data on medication overuse headache in those on ditans.