NAPLEX - Headache McGraw Hill

A physician you work with at your ambulatory care practice site asks your advice. He would like to know which serotonin receptor agonist migraine medication(s) is available as a nasal spray. You respond with which of the following? Select all that apply.

A

Sumatriptan

B

Rizatriptan

C

Zolmitriptan

D

Naratriptan

AC

Sumatriptan is available as Imitrex nasal spray.

Answers b is incorrect.Rizatriptan is available as Maxalt tablets and Maxalt MLT rapidly disintegrating tablets.

Answer c is correct.Zolmitriptan is available as Zomig nasal spray.

Answer d is incorrect.Naratriptan is available as Amerge oral tablets.

Which of the following represent a severe adverse effect that may result from taking ergotamine tartrate?

A

Purple toe syndrome

B

Ergotism

C

Pruritus

D

Nausea

B

Ergotism is intense ischemia that results in peripheral vascular ischemia and possible gangrene.

Answer a is incorrect. Purple toe syndrome is most commonly associated with warfarin therapy.

Answer c is incorrect. Pruritus is a side effect that can result from ergotamine; however, it is not commonly severe.

Answer d is incorrect. Nausea can be a side effect but is not recognized as severe.

AB is a 25-year-old college student who has been having headaches three to four times a month that last for 12 to 24 hours for the past couple of months. He describes them as having a gripping quality with pressure on both sides of his head, as if someone is squeezing his head with a rubber band. He does not experience nausea or vomiting. His headaches do not stop him from going to class, but sometimes he finds himself having to turn off his radio when studying since he just can't handle any noise. Light does not bother him during his headaches. Which of the following abortive treatment options would be appropriate recommendations for AB's headache?

A

Nonsteroidal anti-inflammatory drugs (NSAIDs)

B

Imitrex (sumatriptan)

C

Amitriptyline

D

Metoclopramide

A

NSAIDs and combination analgesic products are a primary abortive treatment for patients with tension headache. The patient presents with common symptoms of tension headache based on the International Headache Society Diagnostic Criteria for tension headache:

Headache lasts for 30 minutes to 7 days

At least two of the following characteristics:

Pressing/tightening quality

Mild intensity

Bilateral location

Not aggravated by routine physical activity

No nausea/vomiting

Photophobia/phonophobia absent or one but not the other is present

Other nonpharmacologic agents effective for treatment of tension headache include stress management, relaxation therapy, biofeedback, physical therapy.

Answer b is incorrect. The triptan class of medications has no documentation of efficacy in treatment of tension headache.

Answer c is incorrect.Amitriptyline is a prophylactic treatment option for migraine and tension headache. It would not have benefit as an abortive treatment.

Answer d is incorrect.Metoclopramide may be used as an adjunctive therapy for migraines that present with nausea and vomiting but would not be appropriate therapy to treat AB's tension headache.

MM presents to the emergency room (ER) with a severe migraine headache and nausea and vomiting. He has taken one dose of zolmitriptan 5 mg orally within the past 6 hours, but vomited within 10 minutes. Which of the following would be the most appropriate next step for treatment?

A

Metoclopramide 10 mg IV

B

Biofeedback

C

Three days of inpatient dihydroergotamine IV

D

Acetaminophen 650 mg per rectum (PR)

A

A single dose of antiemetic therapy administered 15 to 30 minutes prior to taking an abortive migraine medication may assist with nausea and vomiting. Prochlorperazine and metoclopramide are commonly used. Metoclopramide may also be useful for the gastroparesis, is often associated with migraine, and improves medication absorption.

Answer b is incorrect. Biofeedback is a common nonpharmacologic treatment used for management of headache. Two types are available: electrophysiologic and thermal biofeedback. Although this may assist the patient in relaxation and minimize headache symptoms, this would not be appropriate as a primary strategy for a severe headache.

Answer c is incorrect. This patient has only had one dose of zolmitriptan and vomited after a short time. Following administration of an antiemetic agent and assuming the patient has had success in the past with serotonin receptor agonist treatment, a second dose of a triptan could be administered, either oral or subcutaneous. For intractable, severe migraine, inpatient treatment with dihydroergotamine may be an option, administered 0.5 to 1 mg every 8 hours for 3 days.

Answer d is incorrect.Acetaminophen has been found to be an ineffective sole treatment option for migraine. Treatment with acetaminophen for severe migraine is not an appropriate option.

Select the brand name for eletriptan.

A

Maxalt

B

Zomig

C

Ergomar

D

Relpax

D

Relpax is the brand name for eletriptan.

Answer a is incorrect. Maxalt is the brand name for rizatriptan.

Answer b is incorrect. Zomig is the brand name for zolmitriptan.

Answer c is incorrect. Ergomar is the brand name for ergotamine tartrate.

Which of the following medications are matched correctly to their respective mechanism? Select all that apply.

A

Aimovig (erenumab-aooe): Selectively target and block calcitonin gene-related peptide receptor (CGRP-R).

B

Maxalt (rizatriptan): Inhibits cyclooxygenase-1 and 2 which results in decreased formation of prostaglandin precursors.

C

Nardil (phenelzine): Increases endogenous neurotransmitters by inhibiting monoamine oxidase (MAO).

D

Ajovy (fremanezumab-vfrm): Human monoclonal antibody that binds to CGRP and stimulates additional binding to the receptor.

AC

Aimovig is a CGRP-R antagonist.

Answer b is incorrect. Maxalt is a selective serotonin receptor agonist which leads to vasoconstriction and reduces inflammation.

Answer c is correct. Nardil is a MAO inhibitor.

Answer d is incorrect. Ajovy is CGRP-R antagonist and would block the binding to the receptor.

JB is a 55-year-old woman who has suffered from migraines for many years. Her zolmitriptan 5 mg works well to abort her headaches when they occur. Over the past few months, her headaches have increased in frequency to one every 2 weeks. She also complains of difficulty sleeping. Her vital signs today upon physical examination are height 5 feet 6 inches, weight 140 pounds, blood pressure 120/80 mm Hg, and heart rate (HR) 60 bpm. Her physician would like to start her on prophylactic drug therapy. Which of the following drug therapy would be a best next step for prophylaxis for this patient? Select all that apply.

A

Propranolol

B

Botulinum toxin type A

C

Amitriptyline

D

Phenelzine

BC Not sure if I agree w/B

It is always best to treat comorbid conditions whenever possible. This patient complains of difficulty sleeping and amitriptyline is a medication that has an adverse effect of drowsiness. Amitriptyline is well established in the literature for effective prophylactic therapy. It is useful in patients with comorbid depression or insomnia. Nortriptyline would be a tricyclic antidepressant that would cause less drowsiness. Caution should be used with these medications in the elderly due to the side effects.

Answer b is correct. Botulinum toxin type A (Botox) is approved for migraine treatment and prophylaxis.

Answer a is incorrect. The patient has a HR of 60 bpm and propranolol is a β-blocker which will slow the heart rate further.

Answer d is incorrect.Phenelzine (Nardil) is a monoamine oxidase inhibitor (MAOI). Significant lifestyle modifications regarding tyramine-containing foods are necessary to avoid hypertensive crisis. This would not be an appropriate first choice for prophylactic medication for this reason.

A patient presents to pick up a new prescription for sumatriptan tablets. When verifying the prescription, the computer alerts you to a potential drug interaction with a current prescription: Paxil 20 mg. Which of the following is the reason for concern with this potential drug interaction?

A

Stevens-Johnson syndrome.

B

Serotonin syndrome.

C

Neuroleptic malignant syndrome.

D

Computer error—there is no drug interaction present.

B

There is a potential increased risk of serotonin syndrome with administration of sumatriptan and paroxetine (Paxil).

Answer a is incorrect. There is no documentation of occurrence of these conditions with the concurrent administration of these agents.

Answer c is incorrect. There is no documentation of occurrence of these conditions with the concurrent administration of these agents.

Answer d is incorrect. There is a potential drug interaction present.

JJ is a 49-year-old man who experiences headache cycles two times a year, usually in the spring and fall. The headaches occur for about 3 to 4 weeks and he may have up to 5 headaches daily. The headaches are an unbearable type of pain that comes suddenly, located in his left eye, and stops within 1 to 2 hours. He experiences severe ocular and nasal symptoms, such as nasal stuffiness or rhinorrhea, ocular lacrimation, and ptosis. He tells you that in order to attempt to stop the pain, he sometimes rubs the areas of pain or even beats his head against objects. Which of the following are appropriate abortive treatment options for this patient's headache?

A

Oxygen

B

Fremanezumab-vfrm (Ajovy)

C

Amitriptyline

D

Topiramate

A

.Oxygen administered at 5 to 10 L/min by nonrebreather facemask for approximately 15 minutes is a first-line abortive treatment for cluster headache. This patient exhibits primary symptoms of cluster headache as per the International Headache Society Diagnostic Criteria for Migraine:

Headache is unilateral, orbital in location, lasting for 15 to 180 minutes.

Nasal congestion, rhinorrhea, ocular lacrimation, and ptosis are present.

Frequency of headaches lasts from 7 days to 1 year.

Answer b is incorrect.Calcitonin gene-related peptide (CGRP) antagonists are used in the management of migraine.

Answers c and d are incorrect.Amitriptyline and topiramate are prophylactic options for migraine and tension headache. There are no data to support its use as an abortive for cluster headache.

Which of the following are important notes regarding the storage and administration of Fremanezumab-vfrm (Ajovy)? Select all that apply.

A

Keep refrigerated.

B

Discard if left at room temperature for more than 24 hours.

C

Allow syringe to be at room temperature for 30 minutes prior to use.

D

May freeze for up to 1 month.

ABC

All of the calcitonin gene-related peptide (CGRP) antagonists must be refrigerated prior to use.

Answer b is correct. Fremanezumab-vfrm (Ajovy) must be discarded if stored at room temperature for more than 24 hours. Other CGRP antagonists must also be used or discarded if out of refrigeration for too long.

Answer c is correct. Prefilled syringes may be removed from the fridge 30 minutes prior to administering in order for the medication to reach room temperature.

Answer d is incorrect. None of the CGRP antagonists may be frozen.

Which of the following herbal medications has evidence of support for the treatment of migraine?

A

Glucosamine

B

Black cohosh

C

Feverfew

D

Saw palmetto

C

Feverfew is used for fever, headaches, prevention of migraines, and menstrual irregularities. Clinical studies have used 50 to 100 mg of feverfew extract daily for migraine prophylaxis.

Answer a is incorrect. Glucosamine is commonly used for osteoarthritis, joint pain, back pain, and glaucoma.

Answer b is incorrect. Black cohosh has many uses, but it is most commonly used for symptoms of menopause, premenstrual syndrome, and dysmenorrhea. There is no claim regarding the use for treatment of migraine.

Answer d is incorrect. Saw palmetto is used in benign prostatic hypertrophy (although it is not recommended for routine use by the Urology guidelines).

Which of the following are correct repeat dose instructions for the migraine medication?

A

Zomig tablets: take one tablet now; may repeat in 2 hours

B

Imitrex subcutaneous injection: use one injection now; may repeat in 30 minutes

C

Amerge tablets: take one tablet now; may repeat in 2 hours

D

Imitrex subcutaneous injection: use one injection now; may repeat in 30 minutes and then again at hour 2.

A

Zomig (zolmitriptan) tablets may be repeated in 2 hours if needed, not to exceed two doses in 24 hours.

Answers b and d are incorrect. Imitrex (sumatriptan) subcutaneous injection can be repeated in 1 hour if the headache has not resolved, not to exceed two injections in 24 hours.

Answer c is incorrect. Amerge (naratriptan) tablets may be repeated in 4 hours if needed, not to exceed two doses in 24 hours.

CJ is a 30-year-old patient admitted to the hospital with an unremitting migraine headache. She has tried two doses of naratriptan in the past 12 hours. She also takes lisinopril 10 mg once daily for her blood pressure and terbinafine for her onychomycosis. Her vital signs are BP 132/88 mm Hg, heart rate 70 bpm, height 5 feet 5 inches, and weight 130 lb. The physician plans to administer dihydroergotamine. Which of the following are contraindications for CJ receiving this treatment?

A

Uncontrolled hypertension

B

Elevated heart rate

C

Terbinafine

D

Naratriptan

D

Administration of serotonin agonists within 24 hours of ergotamine medications should be avoided due to risk of increased vasoconstriction.

Answer a is incorrect. Although uncontrolled hypertension would be a contraindication, this patient's BP is <140/90 mm Hg and would be defined as controlled.

Answer b is incorrect. Heart rate is not currently elevated for this patient at 70 bpm.

Answer c is incorrect.Ergotamine medications are contraindicated for use with potent inhibitors of CYP 3A4. Azole antifungals would be contraindicated. Terbinafine is a synthetic allylamine derivative used for treatment of onychomycosis of the toenail or fingernail. It is only a minor substrate of CYP 3A4. It has strong inhibition action on CYP 2D6 substrates.

A patient presents to your community pharmacy complaining of a headache. She rates the headache as a 7 on a scale of 1 to 10, and the pulsating worsens as the headache progresses. She experiences nausea and sensitivity to light until the headache dissipates after about 12 hours. She is unable to function during the headache. Which of the following headache types is this patient experiencing?

A

Migraine

B

Tension

C

Cluster

D

Caffeine

A

The International Headache Society diagnostic criteria for migraine include:

Headache lasts for 4 to 72 hours and

At least two of the following characteristics:

Unilateral location, pulsating, moderate to severe intensity, aggravated by routine physical activity

At least one of the following: Nausea and/or vomiting, photophobia, and phonophobia.

Answer b is incorrect. Tension headache would have a gripping/tightening quality, not aggravated by activity, no nausea or vomiting, photo- and phonophobia are absent, or one but not the other is present.

Answer c is incorrect. Cluster headache would last for no longer than 180 minutes and exhibits signs/symptoms of conjunctival injection, lacrimation, nasal congestion, rhinorrhea, sweating, miosis, ptosis, or eyelid edema.

Answer d is incorrect.Caffeine is a trigger for headaches, not a type of headache.

Select the brand name for Galcanequmab-gnlm.

A

Ajovy

B

Reyvow

C

Emgality

D

Aimovig

C

Emgality is the brand name for Galcanequmab-gnlm.

Answer a is incorrect. Ajovy is the brand name for Fremanezumab-vfrm.

Answer b is incorrect. Reyvow is the brand name for Lasmiditan.

Answer d is incorrect. Aimovig is the brand name for Erenumab-aooe.

Which of the following signs/symptoms are classified as red flags, indicating need for physician referral and diagnostic evaluation? Select all that apply.

A

"Worst headache of my life"

B

Acute headache that occurs after coughing/sneezing

C

Headache onset age ≥40 years

D

Blood pressure of 150/80 mm Hg

ABC

Headache associated with subarachnoid hemorrhage is often described by the patient as the "worst" headache.

Answer b is correct. Headache after coughing or sneezing could be benign. However, it can also be a sign of cranial mass lesion with cerebrospinal fluid path obstruction.

Answer c is correct. Headache at age ≥40 can be indicative of a new organic cause. Although it can also be benign, it requires physician evaluation.

Answer d is incorrect. A blood pressure reading of 150/80 mm Hg is not a red flag condition that would require physician referral for headache.

Which of the following would be an absolute contraindication for receiving a selective 5-HT1 receptor agonist (triptan)?

A

Diabetes

B

Ischemic heart disease

C

Anemia

D

Controlled hypertension

B

These medications are selective agonists for serotonin in the cranial arteries to cause vasoconstriction. Due to this constrictive nature, patients with ischemic heart disease or signs or symptoms of ischemic heart disease (including Prinzmetal angina, angina pectoris, myocardial infarction, or silent ischemia) should not take these medications.

Answer a is incorrect. There is no documentation of effect on blood glucose with these agents.

Answer c is incorrect. There is a 1% reported incidence of hemolytic anemia as an adverse effect. A diagnosis of anemia would not be a contraindication.

Answer d is incorrect. Uncontrolled hypertension, due to the information stated above, would be a contraindication. However, a patient with controlled hypertension would not be contraindicated if using for infrequent abortive treatment.

RS is a 60-year-old woman who has frequent migraines. She uses naratriptan (Amerge) and acetaminophen for acute migraine therapy and lithium for prevention. She has no other medical conditions. Over the weekend she was outside gardening for most of the day despite very hot summer weather. She was thirsty and sore on Sunday evening so she took a dose of ibuprofen before her family noticed she was tremulous, confused, and complaining of dizziness. Upon arrival at the emergency room (ER), her lithium level was checked. What would you anticipate with regard to her lithium level?

A

It is likely unchanged.

B

It is likely low from getting dehydrated.

C

It is likely high from getting dehydrated.

D

It is likely low due to an interaction with ibuprofen.

C

Lithium levels are likely to increase as a result of dehydration. Early signs of lithium toxicity may include tremor, nausea, diarrhea, blurred vision, vertigo, confusion, and decreased deep tendon reflexes. Her symptoms are consistent with lithium toxicity.

Answer a is incorrect. Her symptoms are consistent with lithium toxicity. Lithium levels could be anticipated to increase as a result of dehydration.

Answer b is incorrect. Dehydration would likely increase, not decrease, levels.

Answer d is incorrect. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen could increase lithium levels, not decrease levels.

A patient who currently takes oral sumatriptan often experiences headache recurrence, where the headache comes back within 24 hours after a positive response to the medication. Her physician would like a recommendation of a selective 5-HT1 receptor agonist (triptan) with a longer half-life. Which of the following would you recommend?

A

Frovatriptan

B

Rizatriptan

C

Zolmitriptan

D

Almotriptan

A

Her current medication, sumatriptan (Imitrex) has an elimination half-life of 2.5 hours. Frovatriptan (Frova) has an elimination half-life of 26 hours. The longer half-life products may benefit a patient who is responsive to triptans but requires a longer-acting medication to last the duration of the headache.

Answer b is incorrect.Rizatriptan (Maxalt) has a similar elimination half-life of 2 to 3 hours.

Answer c is incorrect.Zolmitriptan (Zomig) has a similar elimination half-life of 3 hours.

Answer d is incorrect.Almotriptan (Axert) has a similar elimination half-life of 3 hours.

A patient has a history of chronic constipation and irritable bowel syndrome. Which of the following medications would be recommended to avoid due to its side-effect profile?

A

Sumatriptan (Onzetra Xsail)

B

Galcanequmab-gnlm (Emgality)

C

Erenumab-aooe (Aimovig)

D

Onabotulinumtoxin A (Botox)

C

Erenumab-aooe (Aimovig) has had reports of constipation with serious complications, including the need for hospitalization and surgery. The onset of constipation was reported after the first dose in a majority of reported cases. Based on this side effect risk, it would not be a good option for a patient with a history of chronic constipation or irritable bowel syndrome.

Answers a, b, and d are incorrect.Sumatriptan (Onzetra Xsail), Galcanequmab-gnlm (Emgality), and Onabotulinumtoxin A (Botox) do NOT have any warnings or adverse effects related to constipation or other gastrointestinal side effects.

Which of the following are prophylactic treatment options for migraine headache? Select all that apply.

A

Verapamil

B

Topiramate

C

Valproic acid

D

Ergotamine

ABC

Verapamil is a calcium-channel blocker that is used for migraine prophylaxis. It would be useful for patients who cannot tolerate β-blockers or for patients with comorbid hypertension or angina.

Answer b is correct.Topiramate is an antiepileptic medication that was approved for use in migraines in 2004. It is dosed twice daily for migraine prevention. It would be useful for a patient with comorbid seizure disorder. It does have some more prominent cognitive side effects with >10% incidence, including memory difficulties, difficulty in concentrating, confusion, and speech difficulties.

Answer c is correct. Valproic acid is an antiepileptic medication also approved for migraine prophylaxis. It would be useful for those patients with comorbid seizure disorder or manic depressive illness.

Answer d is incorrect.Ergotamine is a medication that is only used for acute migraine treatment and should not be used for prophylaxis.

Which of the following is the brand name for rizatriptan?

A

Imitrex

B

Maxalt

C

Amerge

D

Frova

B

The generic name for Maxalt is rizatriptan.

Answer a is incorrect. The generic name of Imitrex is sumatriptan.

Answer c is incorrect. The generic name for Amerge is naratriptan.

Answer d is incorrect. The generic name for Frova is frovatriptan.

AH is a 24-year-old woman who has difficulty swallowing tablets following an accident affecting her jaw. She is a frequent migraine sufferer and is concerned about not having an abortive agent on hand. Her migraines have been successfully treated with sumatriptan tablets in the past. Which of the following might you suggest to her provider? Select all that apply.

A

Sumatriptan (Onzetra-Xsail)

B

Sumatriptan/naproxen (Treximet)

C

Sumatriptan (Imitrex Stat Dose)

D

Rizatriptan (Maxalt MLT)

ACD

Onzetra-Xsail is a nasal powder. Patient had success with sumatriptan oral.

Answer c is correct. Imitrex Stat Dose is an injection. Patient had success with sumatriptan oral.

Answer d is correct.Rizatriptan oral disintegrating tablet (ODT) may be appropriate as patient has had past success with another triptan product.

Answer B is incorrect. Treximet is only available in an oral tablet.

Which of the following plays a role in migraine pathogenesis? Select all that apply.

A

Norepinephrine

B

Serotonin

C

Dopamine

D

Substance P

BD

Serotonin is a vasoactive neurotransmitter that is released by the brainstem nuclei of the trigeminovascular system. Plasma levels of serotonin are found to be deficient during a migraine attack. Drugs that affect serotonin are often effective in treatment of migraines. Other agents discussed as playing an active role within the trigeminovascular system are the following neuropeptides: calcitonin gene-related peptide, substance P, and neurokinin A.

Answer a is incorrect. There are no data that support involvement of norepinephrine with the pathophysiology of migraine.

Answer c is incorrect.Dopamine may also play a role in migraine headaches as dopamine receptor antagonists are effective treatments administered as monotherapy or with other antimigraine medications; however, there is a lack of clinical data to support this theory.

A patient is picking up a prescription for Migranal (dihydroergotamine) at your community pharmacy counter. She has not used this medication before. Which of the following is an important counseling point to provide?

A

Remove the foil wrapper before inserting PR.

B

Once prepared, use within 8 hours.

C

Wear latex-free gloves to apply.

D

Take with a full glass of water.

B

Migranal is a dihydroergotamine nasal spray. Once the spray applicator has been prepared, use within 8 hours and discard any remaining solution.

Answers a, c, and d are incorrect. It is not available as a suppository, topical product, or oral formulation.

Treximet is a combination headache medication made up of which of the following?

A

Sumatriptan and naproxen

B

Acetaminophen, aspirin, and caffeine

C

Acetaminophen, isometheptene mucate, and dichloralphenazone

D

Acetaminophen, butalbital, and caffeine

A

Treximet contains sumatriptan and naproxen.

Answer b is incorrect.Acetaminophen, aspirin, and caffeine are Excedrin Migraine.

Answer c is incorrect.Acetaminophen, isometheptene mucate, and dichloralphenazone are Midrin.

Answer d is incorrect.Acetaminophen, butalbital, and caffeine are Fioricet.

DT is a 31-year-old woman who is 36 weeks pregnant. She currently has a headache with presentation most like a tension-type headache. She is requesting a recommendation for treatment. Which of the following is the best recommendation?

A

Naproxen

B

Ergotamine

C

Acetaminophen

D

Ibuprofen

C

.Acetaminophen is a pregnancy category B. Although it does cross the placenta, it is believed to be safe for use during pregnancy at therapeutic doses for a short period of time. The patient may also find benefit in psychophysiologic therapy, such as stress management, relaxation therapy, and biofeedback, as well as physical therapy.

Answers a and d are incorrect. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided late in the third trimester to prevent prostaglandin alterations that could lead to premature ductus arteriosus closure.

Answer b is incorrect.Ergotamine is a pregnancy category X. It may precipitate uterine contractions and ischemia leading to hypoxemia in the fetus.

Which of the following are applicable to the use of calcitonin gene-related peptide (CGRP) antagonist medications for migraine?

A

Inject daily, first thing in the morning, to attain optimal benefit.

B

Use at onset of migraine headache to see effect within 2 hours.

C

The deltoid is the appropriate administration site.

D

Initial administration is subcutaneously every month.

D

CGRP medications are initially administered as a monthly injection.

Answer b is incorrect. CGRP medications are used as prophylactic medications for migraine. Peak concentration is not attained for multiple days and maximal effect observed after weeks/months.

Answer c is incorrect. All CGRP medications are administered subcutaneously.

Answer d is correct. All CGRP medications have initial administration as subcutaneously every month.

LK suffers from chronic migraines and is currently experiencing an acute attack. She calls your community pharmacy and asks your professional advice. In talking with her you learn that she stopped drinking regular coffee, joined a gym, and started a monophasic oral contraceptive in the past 2 weeks. She attended a wine and cheese party last night with friends she met at the gym. Which recommendation would be best to provide that may help prevent migraines in the future?

A

Avoid intake of wine and cheese.

B

She should resume drinking regular coffee.

C

She may benefit from switching to a triphasic oral contraceptive.

D

She should avoid physical activity.

A

Wine and cheese are tyramine-containing foods which are known to be headache triggers. Other potential food triggers include alcohol, chocolate, citrus fruits, dairy, fermented foods, and foods containing additives such as monosodium glutamate, nitrites, saccharin, sulfites, or yeast. When trying to determine a trigger of a patient's headache, it is recommended that the patient eliminate all causative agents and then gradually add back in one item at a time.

Answer b is incorrect.Caffeine intake or withdrawal can be a trigger and so her recent discontinuation may have been a trigger for her current headache. However, since she has already cut regular coffee from her diet and future caffeine consumption could trigger additional migraines, it would be best for her to continue to limit regular coffee from her diet.

Answer c is incorrect. Estrogen or oral contraceptives are known triggers of migraine. A monophasic oral contraceptive would be preferred over a triphasic formulation because it provides a more consistent hormone level. It would not be appropriate to recommend changing to a triphasic contraceptive as this may trigger additional migraines.

Answer d is incorrect. Physical activity can be a trigger for some patients so it may be appropriate for LK to diary her headaches and physical activity to see if there is any correlation. Physical activity is very important for health, however, and it would not be appropriate to limit all physical activity.

While counseling a patient on Zolmitriptan (Zomig ZMT), it is important to educatethe patient on the following tips. Select all that apply.

A

Recommend that patient does not consume fluids for 5 minutes before or after using medication.

B

Dissolve medication in an 8-oz glass of water.

C

Store oral disintegrating tablet (ODT) medication in original package and do not remove until medication is needed.

D

Allow tablet to dissolve, do not chew or split tablets.

ACD

Avoiding fluids 5 minutes before and after will optimize absorption.

Answer b is incorrect. Allow tablet to slowly dissolve on the tongue. Do not dissolve tablet in a glass of water.

Answer c is correct. Keep tablet in original packet to prevent a decrease in the effectiveness of the medication. Take immediately after removed from package.

Answer d is correct. It is not recommended to chew or split tablets.

A patient is taking Zomig ZMT. Which of the following is true regarding this medication? Select all that apply.

A

It is a subcutaneous injection.

B

Liquid is not required for administration.

C

It is an orally disintegrating tablet.

D

It is a transdermal patch.

BC

Zomig ZMT is the orally disintegrating tablet dosage form of zolmitriptan. It does not require water for administration (answer b); this may be beneficial to those patients without access to water, requiring discrete administration, or who experience nausea with their headaches, where intake of large amounts of liquid with administration may aggravate this symptom. This medication is also available as a nasal spray solution and tablet.

Answer a is incorrect.Sumatriptan (Imitrex) is a selective serotonin agonist that is available as a subcutaneous injection. Zolmitriptan does not come in an injectable formulation.

Answer d is incorrect.Sumatriptan (Alsuma) is a selective serotonin agonist that is available as a transdermal patch. Zolmitriptan does not come as a transdermal patch.

A patient has Migranal (Dihydroergotamine nasal) and Frova (frovatripant) tablets on hand for abortive options. The patient has taken two tablets of Frova in the past 5 hours. She would like to know if she can take her Migranal now since the headache is not gone. Which of the following are appropriate responses? Select all that apply.

A

This sounds like a great idea and with differing mechanisms will have better benefit.

B

Taking a triptan within 24 hours is contraindicated due to increased risk of vasoconstriction.

C

Both agents are selective agonists for serotonin on intracranial blood vessels.

D

Since administration route is different, taking the Migranal now would be acceptable.

BC Disagree with C, DHE is nonsel serotonin agonist

.Dihydroergotamine and frovatriptan have very similar mechanisms with focus on agonist activity on 5HT-1D receptors.

Answer b is correct. Both agents have vasoconstrictive effects and should not be used together within 24 hours.

Answer c is correct. Both medications do have activity on serotonin.

Answer d is incorrect. Although Migranal is intranasal and Frova is a tablet, they both have similar mechanisms and it is the mechanism, not the absorption, which leads to this contraindication of use within the same 24 hours.