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 one of the subcutaneous monoclonal antibodies (eg. erenumab, galcanezumab , fremanazumab) as a preventive medication in a patient with migraine. The patients ask what are their common side effects? Please choose best answer.
a. All three can cause redness and swelling of the injection site and rare rash. Erenumab can also cause constipation and rare hypertension.
b. All three have been reported to cause nausea, constipation, paresthesias and diarrhea in patients.
c. All three can cause injection site reactions, constipation and depression.
d. All three can cause fatigue, constipation and somnolence as side effects.
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.