3-Question Quiz: Migraine Emergency; Prevention; Botox

Question 1: Migraine Emergency

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Answer B.Octreotide

According to 2016 guidelines by the American Academy of Neurology, about 1.2 million Americans present to the emergency department each year for acute migraine. Recommended therapy for these patients include intravenous metoclopramide, intravenous prochlorperazine, and subcutaneous sumatriptan. However, evidence suggests that subcutaneous and intravenous octreotide may be ineffective and is associated with increased local reactions and diarrhea. The AAN advises avoidance of octreotide in these patients.

See: Orr SL, Friedman BW, Christie S, et al. Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. Headache. 2016 Jun;56(6):911-40. doi: 10.1111/head.12835.

See: Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2013 Jul;33:629-808.

Question 2: Migraine Prevention

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Answer D. Metoprolol

According to 2012 guidelines by the AAN (reaffirmed in 2015), the following drugs have Level A evidence and should be offered for the prevention of episodic migraine in adults: divalproex sodium, sodium valproate, topiramate, metoprolol, propranolol, timolol, and frovatriptan for short-term menstrual-associated migraine prevention. Lamotrigine is established as ineffective and should not be considered for migraine prevention (Level A negative). Clomipramine is probably ineffective and should not be considered for migraine prevention (Level B negative). The following drugs have Level C negative evidence and should probably not be considered for migraine prevention: acebutolol, clonazepam, nabumetone, oxcarbazepine, and telmisartan.

See: Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012 Apr 24;78(17):1337-45. doi: 10.1212/WNL.0b013e3182535d20.

Question 3: Botox

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Answer A. Chronic migraine

According to 2016 guidelines from the AAN, Botox (OnabotulinumtoxinA, or OnaBoNT-A), strong Level A evidence supports the use of Botox in treating chronic migraine, and the drug should be offered to increase the number of headache-free days in these patients. Strong, Level A evidence suggests that Botox is not effective in episodic migraine, and should not be offered as a treatment. Moderate, Level B evidence suggests that botulinum toxin is probably ineffective in treating chronic tension-type headache.

See: Simpson DM, Hallett M1, Ashman EJ, et al. Practice guideline update summary: Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2016 May 10;86(19):1818-26. doi: 10.1212/WNL.0000000000002560.