Correct Answers to MODULE 4: The ABCs of Preventive Therapy in Primary Care
Pre-Post Test Questions (Correct Answer is Bold)
1. A migraine preventive medication should be initiated in which of the following situations? Choose the best answer.
a. Two or more migraine attacks per month
b. Three or more headache days per month
c. Four or more days per month with migraine
d. Three or more attacks with migraine
e. Only in patients with chronic migraine (those with 15 or more days per month with headache and 8 or more days per month with migraine)
Explanation: The correct answer is c. Current guidelines suggest that preventives should be considered in those with four or more migraine days per month.
2. You want to start an oral preventive (eg. amitriptyline [Elavil], propranolol [Inderal] or topiramate [Topiramate]) for your patient with migraine. He or she asks how long it will take before they start seeing an improvement in their migraines. Which of the following represents that best explanation to give to your patient?
a. It may take three to four months before we start to see a response to this preventive medication. So be patient….
b. You may start to see an improvement in 1-2 months after its start, but we may need to increase the dosage after 2 months, and we may not achieve maximal improvement until 3-4 months or longer after its start.
c. The medication will start to work immediately after we start it and we should know within one month if it is working or not
d. It can take up to 6 months after it start to see an effect
Explanation: The answer is a. The subcutaneous monoclonal antibodies can cause redness and swelling at the injection site and rare rash. Erenumab can cause constipation and rare hypertension. It should be mentioned that there is limited long term safety data with these medications. We also recommend that appropriate birth control be used to prevent pregnancy as the effects of these medications on pregnancy women is unknown.
3. It is not uncommon for a patient to have unrealistic expectations regarding preventive therapy for migraine. In other words, they think that the preventive is a “cure” for all migraine attacks!!! What would constitutive a realistic goal to access improvement with a migraine preventive?
a. 75% reduction in the frequency of monthly migraine days.
b. 50% reduction in the frequency and disability of migraine attacks.
c. It might not reduce the frequency of migraine attacks, but it should improve the responsive to medications and reduce the disability of attacks.
d. 50% reduction in the frequency of monthly migraine days.
e. 75% reduction in the frequency of monthly migraine attacks
Explanation: The answer is d. Current guidelines recommend a 50% reduction in the frequency of monthly migraine days as a reasonable goal to judge the efficacy of a migraine preventive. A “super response” would be encountered if patients experience a 75% reduction in the frequency of monthly migraine days. Remember to ask about the number of monthly migraine “days” as opposed to migraine “attacks” as migraine days are a more reflective measure of migraine burden.
4. Which classes of medications have level A evidence (eg. two positive randomized controlled studies) supporting their use as preventive medications for episodic migraine?
a. Antidepressants, anticonvulsants and CGRP Monoclonals
b. Calcium channel blockers, anticonvulsants and CGRP monoclonals
c. Beta blockers, anticonvulsants and CGRP monoclonals
d. Antidepressants, beta blockers and CGRP Monoclonals
Explanation: The correct answer is c. The beta blockers, anticonvulsants and CGRP monoclonals have level A evidence for use as preventives.