Migraine Meds: An 8-question Quiz

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Migraine is a neurologic disorder that is often disabling and frequently difficult to treat. A wide range of agents are used, both on and off label, to manage migraine headaches which can be episodic or chronic. Test your migraine knowledge with this 8-question quiz on the disorder and the drugs and devices used to treat it. 

Question 1 

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Answer: C. Metoprolol. Although commonly used for prevention of migraine, metoprolol does not have the FDA indication for episodic migraine prevention. 

Question 2

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Answer: C. Anti-dopaminergic medications. These include metoclopramide, promethazine, chlorpromazine, droperidol, and domperidone. Although commonly used to treat the nausea and vomiting of migraine, they are not typically dosed for prevention.

Question 3

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Answer: A. True. Onabotulinum toxin A has been FDA approved for chronic migraine in the US since 2010. It is approved for chronic migraine using 155 units in 31 fixed sites (each site receiving 5 units Botox) and is to be repeated every 12 weeks. Propanolol, timolol, divalproex sodium, and topiramate are only FDA-approved for the prevention of episodic migraine but are commonly used for prevention of chronic migraine.¹

Question 4

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Answer: D. 70% of migraine patients discontinue their first cycle of an oral preventive by 6 months.²

Question 5

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Answer: A. Lack of efficacy and E. Side-effects are listed as the two most common reasons for discontinuation of migraine preventive medication in a large multi-center international study. 

Question 6

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Answer: D. Occipital nerve stimulator. Placement of an occipital nerve stimulator for refractory migraine has fallen out of favor in recent years due to complications including lead migraine. The other neurostimulators have the advantage of being non-invasive. 

Question 7

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Answer: E. All treatments listed have shown efficacy in published clinical trials. 

Question 8

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Answer: D. CGRP. CGRP is a 37-amino acid peptide found in neurons and glial cells. There are receptors to CGRP throughout the trigeminal system and in multiple brain regions. The category of CGRP coming to market in 2018 is referred to as CGRP monoclonal antibodies and there are several pharmaceutical companies in a very tight race to win first FDA approval. They work by blocking either the receptor site or the CGRP ligand, effectively reducing the amount of free CGRP. In clinical trials, this category of medication for migraine prevention appears to be quite promising with a favorable side-effect profile and efficacy seen as early as 1 to 2 weeks after the first injection.^3-5

References:

1. Blumenfeld A, Ashkenazi A. OnabotulinumtoxinA for the treatment of headache. Headache. 2013;53:54-61. 
2. Hepp Z, Dodick DW, Varon SF, et al. Adherence to oral migraine-preventive medications among patients with chronic migraine. Cephalalgia. 2015;35:478-488. 
3. Edvinsson L, Goadsby PJ. Neuropeptides in headache. Eur J Neurol. 1998;5:329-341.
4. Russo AF. Calcitonin gene-related peptide (CGRP): a new target for migraine. Annu Rev Pharmacol Toxicol. 2015;55:533-552.
5. Raddant AC, Russo AF. Calcitonin gene-related peptide in migraine: intersection of peripheral inflammation and central modulation. Expert Rev Mol Med. 2011;13:e36.