NAPLEX Question of the Week: Mastering the Migraine

This week's question will take into account many patient specific factors toward the correct answer. Are you ready?
NAPLEX Question of the Week: Mastering the Migraine
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A 47 year old male presents to urgent care for management of his headaches which have been progressively worsening over the past several months and he currently has one. He is currently taking ibuprofen 800mg approximately twice weekly as needed for headaches as well as itraconazole 200mg once daily for treatment of onychomycosis. It is discovered through detailed history and physical examination that his headaches are more consistent with migraines. He wishes to take something immediately to treat his migraine so that he can go back directly to work where he controls heavy equipment related to moving large crates at a sea port. Which of the following would be most appropriate for treating our patient's acute migraine headache?

A. Ubrelvy

B. Lasmiditan

C. Qulipta

D. Nurtec ODT

E. Tosymra

Answer with rationale:

The correct answer is E. A renaissance has occurred in recent years in the management of migraine headaches, with a number of newly approved agents for both treatment and prophylaxis. There are several keys to answering this question. First, you have to be aware of generic and brand names to take the NAPLEX. Ubrelvy (ubrogepant), Qulipta (atogepant), and Nurtec ODT (rimegepant) are all calcitonin gene-related peptide (CGRP) antagonists that are approved for migraine headache management. Nurtec ODT is approved for both treatment and prophylaxis of migraine headaches while Ubrelvy is approved only for treatment and Qulipta is only approved for prophylaxis. Reyvow (lasmiditan) is a 5-HT1F receptor agonist FDA-approved for treatment of migraine with or without aura. Tosymra is a brand name for sumatriptan nasal spray.  Answers A and D would be incorrect as strong 3A4 inhibitors, such as itraconazole which our patient is taking, should not be given with these agents. Answer B is incorrect as our patient operates heavy machinery for a living and has to go back to work. Lasmiditan is only recommended if patient will not be driving or operating heavy machinery for at least 8 hours after the dose which would not be good for our patient's request. Answer C would be incorrect as this is only indicated for migraine prophylaxis, not treatment. This leaves answer E which is sumatriptan (Tosymra). Our patient does not have any listed significant cardiovascular history, such as ischemic stroke, and therefore can receive this therapy.

Have a great week as you continue to prepare for the exam!

Dr. B

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