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Identifying, Diagnosing, and Managing Patients with Chronic Migraine in Primary Care Everett Schlam, MD Assistant Director Mountainside Hospital Family.

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Presentation on theme: "Identifying, Diagnosing, and Managing Patients with Chronic Migraine in Primary Care Everett Schlam, MD Assistant Director Mountainside Hospital Family."— Presentation transcript:

1 Identifying, Diagnosing, and Managing Patients with Chronic Migraine in Primary Care Everett Schlam, MD Assistant Director Mountainside Hospital Family Medicine Residency Program Verona, NJ

2 Best Practices Pearls Communication is the only diagnostic tool available for migraine and successful communication requires participation of the healthcare provider and patient Open-ended questions that allow the patients to “tell their story” provides better alignment and understanding Warning signs and comfort features can help separate primary and secondary headache disorders Chronic migraine is a diagnosis defined by 15 or more days per month of headache for at least 3 months in an individual with migraine

3 Making a Diagnosis Primary vs. secondary headache Warning signs Comfort signs Migraine vs. non-migraine Symptoms Duration of attacks Changes over time Disability Lipton RB, et al. Managing migraine: A healthcare professional’s guide to collaborative migraine care. Hamilton, Ontario: Baxter Publishing Inc; 2008.

4 Evaluating the Patient with the Complaint of Headache Warning signs Age - 50 yrs New onset or recent change Neurological symptoms or signs Underlying diseases Systemic symptoms Fever, hypertension, weight loss Comfort features Established pattern of HA 6 months Menstrual association Variable locations of HA Complete resolution between attacks Positive family history HA, headache

5 Worrisome Headache “Red Flags” ‘SNOOP4’ – When in doubt, investigate the atypical! Systemic symptoms (fever, weight loss); or S econdary risk factors – underlying disease (HIV, systemic cancer) N eurologic symptoms or abnormal signs (confusion, impaired alertness, or consciousness) O nset: Sudden, abrupt, or split-second (first, worst) O lder: New onset and progressive headache, especially in middle age >50 (giant cell arteritis) P attern change: First headache or different, change in type of headache Postural aggravation Papilledema Dodick D. Semin Neurol. 2010;30: Sadovsky D, et al. Am J Med. 2005:118(Suppl 1):11S-17S.

6 Secondary Headaches Vascular Infectious Inflammatory/Neoplastic Primary Headaches What to Listen For: Patterns Minutes Hours/Days Weeks/Months Months/Years Cady RK, et al. Headache. 2002;42:

7 Profiling Headache Pattern Recognition Primary Headaches Migraine Tension-type Cluster Miscellaneous headaches unassociated with structural lesions Secondary Headaches Post-traumatic Vascular disorders Stroke, hemorrhage Nonvascular intracranial disorder Neoplasm, meningitis, low or high CSF pressures Substances/withdrawal Systemic infection or metabolic disorder Cranial, extracerebral lesions Intl Classification of Headache Disorders: 2 nd ed. Cephalalgia. 2004;24(Suppl 1):7. CSF, cerebral spinal fluid

8 Migraine – The Most Common Headache Seen in Clinical Practice Patients seen in primary care IHS diagnosis based on diary review Tepper SJ, et al. Headache. 2004;44: N = 377 IHS, International Headache Society

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10 Pre-test ARS Question Diagnostic Criteria for Chronic Migraine includes which of the following 1.Headache ≥10 days per month for greater than 6 months 2.Headache ≥ 15 days per month for greater than 6 months 3.Headache ≥ 10 days per month for greater than 3 months 4.Headache ≥ 15 days per month for greater than 3 months 5.Unsure

11 Pre-test ARS Question Collaborative Care in the Management of Migraine is characterized by all of the following except 1.Effective communication between the provider and patient 2.Patient responsibility including keeping a headache diary 3.Patient reporting all headaches to the provider to get advice on how to treat each attack 4.Development of a “migraine tool box” 5.Unsure

12 Migraine in Primary Care A harbinger of a patient population at high risk of decades medical need Chronic migraine (>15 HA days/mo) has annual prevalence of 3% (1.1%-5.1%) but a lifetime prevalence is much higher 14% transform to chronic annually 26% resolve; 40% transition; 34% persist Most remain with very frequent episodic or chronic migraine Katsarava Z, et al. Neurology. 2004;62: Manack A, et al. Neurology. 2011;76:

13 A Model of Migraine Progression Severe Impairment Cady RK, et al. Headache. 2004;44: Normal Neurological Function Mild Impairment Moderate Impairment Stage 4 Chronic Migraine Stage 3 Transforming Migraine Stage 1&2 Episodic Migraine

14 Creating a Clinical Model for Successful Management of Chronic Migraine Patients

15 IHS Criteria for Episodic Migraine (without Aura) At least 5 attacks Headache attacks lasting 4-72 hours Headache with at least 2 of the following: Unilateral location Pulsating quality Moderate to severe pain Aggravation or avoidance of physical activity During headache at least one of the following: Nausea and/or vomiting Photophobia and phonophobia Not attributed to another disorder The International Classification of Headache Disorders. 2 nd ed. Cephalalgia. 2004;24(suppl 1):24-25.

16 Classification of Migraine Episodic Migraine <15 headache days per month X 3 months = EM Without aura With aura Chronic Migraine ≥15 headache days per month X 3 months = CM HA day = 4 or more hours of moderate-to-severe HA or response to migraine-specific medications EM, episodic migraine CM, chronic migraine Intl Classification of Headache Disorders: 2 nd ed. Cephalalgia. 2004;24(Suppl 1): Olesen J, et al. Cephalalgia. 2006;26:

17 Chronic Migraine Headache (tension-type, probable migraine, and/or migraine) on ≥15 days per month for ≥3 months Occurring in a patient who has had at least 5 lifetime IHS 1.1 migraine attacks On ≥8 or more days per month headache has fulfilled IHS criteria for migraine Treated and relieved by triptan/ergot before the expected development of symptoms fulfilling IHS migraine criteria No MOH as defined by IHS 8.2 Describes patient not headache attack Olesen J, et al. Cephalalgia. 2006;26: MOH, medication overuse headache

18 Criteria Accepted by FDA: Chronic Migraine A.Headache ≥15 days per month for greater than 3 months B.Headache duration, if untreated, of ≥4 hours C.(Established History of Migraine) Olesen J, et al. Cephalalgia. 2006;26: Dodick DW, et al. Headache. 2010;50: Botox product information:

19 The Migraine Process Headache Post - headache Pre-headache Mild Moderate Severe Time © 2012 Primary Care Network Aura

20 Headache Days in Chronic Migraine Pre-headache phase Headache phase Migraine Evolution Time (hours) PremonitoryAura w/o Headache Mild Headache (tension-type) Migrainous Headache Migraine Headache Diagnosis if Process Terminates at Different Stages Cady RK, et al. Headache. 2002;42: Neurochemical Disruption Electrical Disinhibition Physiological Phases of Migraine Trigeminal Disinhibition Neurovascular Activation Central Sensitization

21 Understanding the Journey from Episodic to Chronic Migraine

22 Relationship of Episodic to Chronic Migraine Episodic migraine precedes chronic migraine Chronic migraine can be considered a complication of episodic migraine

23 Chronic Migraine Risk Factors Modifiable Attack frequency Obesity Snoring/obstructive sleep apnea Stressful life events Medication overuse Caffeine overuse Not modifiable Age Female gender Low education or socioeconomic status Genetic factors Head injury Ashina S, et al. Curr Treat Options Neurol. 2008;10:36-43.

24 Stage 1: Infrequent Episodic Migraine Impact During Attack Frequency Severity Infrequent Episodic Migraine Headache Complete Recovery between attacks Incapacity Normal Lipton RB, et al. Managing migraine: A healthcare professional’s guide to collaborative migraine care. Hamilton, Ontario: Baxter Publishing Inc; 2008:25.

25 Stage 2: Frequent Episodic Migraine Impact During Attack Frequency Severity Frequent Episodic Migraine Headache Time to Recover Incapacity Normal Lipton RB, et al. Managing migraine: A healthcare professional’s guide to collaborative migraine care. Hamilton, Ontario: Baxter Publishing Inc; 2008:26.

26 Stage 2 Migraine 3 or less migraine attacks per month or 8 HA days Full recovery between migraine episodes MIDAS generally 10 or less Lipton RB, et al. Managing migraine: A healthcare professional’s guide to collaborative migraine care. Hamilton, Ontario: Baxter Publishing Inc; 2008:26. MIDAS, The Migraine Disability Assessment

27 Stage 3: Transforming Migraine Functional Status Frequency Severity Transforming Migraine Migraine Poor Recovery Time Incapacity Normal Lipton RB, et al. Managing migraine: A healthcare professional’s guide to collaborative migraine care. Hamilton, Ontario: Baxter Publishing Inc; 2008:26.

28 Transforming Migraine Attacks less distinct: 8-14 days of HA per month Return to baseline function does not always occur between migraine attacks Evidence of physiological and/or psychological dysfunction often present MIDAS Lipton RB, et al. Managing migraine: A healthcare professional’s guide to collaborative migraine care. Hamilton, Ontario: Baxter Publishing Inc; 2008:26.

29 Stage 4: Chronic Migraine Incapacity Normal Frequency Severity Chronic Migraine Headache Disease Impact Incomplete Recovery Lipton RB, et al. Managing migraine: A healthcare professional’s guide to collaborative migraine care. Hamilton, Ontario: Baxter Publishing Inc; 2008:27.

30 Chronic Migraine Greater than 15 days of HA/month for greater than 3 months (HA>4h) Little or no return to normal baseline function Low-grade HA or feeling as if on the edge of next migraine Comorbidity frequent MIDAS Buse DC, et al. J Neurol Neurosurg Psychiatry. 2010;81: Cady R, et al. Curr Pain Headache Rep. 2005;9: Blumenfeld AM, et al. Cephalalgia. 2011;31:

31 Chronic Migraine CM is not just “more” episodic migraine Greater severity of headache and associated symptoms Greater impact and healthcare cost It can be reversed Delayed diagnosis and management may result in end organ damage Buse DC, et al. J Neurol Neurosurg Psychiatry. 2010;81: Welch KMA, et al. Headache. 2001;41:

32 End Organ Damage Possibly Associated With Chronic Migraine Welch KMA, et al. Headache. 2001;41: ; Kurth T, et al. BMJ. 2011;342:c7357; McWilliams L, et al. Pain. 2004; 111:77-83; O’Bryant SE, et al. Headache. 2006;46: ; Bigal ME, et al. Headache. 2006;46: ; Breslau N, et al. Neurology. 2003;60:

33 Comorbidities of CM and EM ComorbidityChronic migraineEpisodic migraine Psychiatric disorders Depression Anxiety 46.3% n= % n=2347 Non-headache pain Fibromyalgia Chronic fatigue syndrome 41.7% n= % n=2739 Vascular disease events Hypertension Stroke 8.2 n=41 3.3% n=275 Survey of 8726 migraine sufferers CM (N=499) EM (N=8227) Buse DC, et al. J Neurol Neurosurg Psychiatry. 2010;81: Bagley CL, et al. Headache. 2012;52:

34 Evolution of Chronic Migraine Episodic Migraine Chronic Migraine Medication overuse Mood and anxiety disorders Sleep disorders and IBS Normal Mild Impairment Moderate Impairment Severe Impairment Cady R, et al. Curr Pain Headache Rep. 2005;9:47-52.

35 Migraine “Plus” As migraine chronifies it becomes More debilitating Associated with greater comorbidity More difficult to manage Possible for end-organ damage It becomes Migraine “Plus” Welch KMA, et al. Headache. 2001;41: Kurth T, et al. BMJ. 2011;342:c7357. Olesen J, Goadsby PJ, Ramadan NM, Tfelt-Hansen P, Welch KMA, eds. The Headaches. 3 rd ed. Philadelphia, PA: Lippincott Williams & Wilkins;2006.

36 How is Staging Useful? Acute and preventive care can be based on stage of migraine Documentation of treatment benefit Assessment of change over time Increase awareness to comorbidities, consultations, and referrals Cady RK, et al. Headache 2004;44:

37 Establishing the Diagnosis of Chronic Migraine

38 Early Diagnosis The most important tool to prevent chronic migraine is effective control of episodic migraine Early diagnosis Meaningful education Effective acute treatment Regularly scheduled follow-up visits Lipton RB, et al. Managing migraine: A healthcare professional’s guide to collaborative migraine care. Hamilton, Ontario: Baxter Publishing Inc; 2008.

39 Migraine Can and Often Will be a Medical Problem That Last Decades Healthcare interventions span decades Scores of visits to PCP Numerous diagnostic studies Multiple medications Comorbidities It’s best to get it “right” sooner rather than later Diamond ML, et al. Practicing Physician's Approach to Headache. 6 th ed. Phila;PA: WB Saunders;1999:

40 Patient-centered/HCP-monitored Management of Acute Migraine: Developing, Not Discovering, Patients Collaborative care dynamic 2 experts in the room Why is collaborative care important? Migraine is a chronic disease Treatment needs change and evolve over time Patient will ultimately determine treatment decisions Consequences: Stitch in time saves nine Primary care specialists will be left managing poorly treated patients Lipton RB, et al. Managing migraine: A healthcare professional’s guide to collaborative migraine care. Hamilton, Ontario: Baxter Publishing Inc; 2008.

41 Collaborative Care Model Patient Expertise Self-observation/ HA diary Treatment need Awareness of what works Awareness of lifestyle Awareness of triggers Clinician Expert Knowledge of evidence Knowledge of the disease Effective communication Tools for migraine tool box Pharmacology Lipton RB, et al. Managing migraine: A healthcare professional’s guide to collaborative migraine care. Hamilton, Ontario: Baxter Publishing Inc; 2008.

42 The 5 “Ps” for Effective Migraine Communication Pattern PPPPP PhenotypePersonPharmacologyPrecipitants Pattern over time Phenotype of dominant headache(s) Person between or at baseline headache Pharmacology Weather Lifestyle Diet Reproduced with permission © 2011 Primary Care Education

43 Patterns of Headache “Can you explain to me the pattern of your headaches?” Migraine Episodic Transforming Chronic Nonmigraine New onset persistent daily headache Short duration P 1 P 1 Reproduced with permission © 2011 Primary Care Education

44 Headache Phenotype: Critical Question to Ask Tell me what you experience when your headache is at its worst Often need to evaluate more than one headache phenotype Migraine can have many different phenotypes 22 PP 2 2

45 Headache Phenotypes “Tell me what your worst headaches feel like.” Migraine Probable Migraine (Migrainous) Tension-type Other Wheeler SD. Neurologist. 2009;15: P 2 P 2

46 P Patient “What do you feel like between episodes of severe headache?” A look between headaches Normal Episodic physiological disruptions Comorbid diseases Buse DC, et al. J Neurol Neurosurg Psychiatry. 2010;81: Cady R, et al. Curr Pain Headache Rep. 2005;9: P 3 P 3

47 Pharmacology “How do you treat your headaches?” Assessment for excessive or inappropriate medication usage Silberstein SD, Lipton RB. Chronic daily headache, including transformed migraine, chronic tension-type headache, and medication overuse. In: Silberstein SD, et al, eds. Wolff’s Headache and Other Head Pain. 7 th ed. New York: Oxford University Press; 2001: I take hydrocodone… it’s the only thing that works, but… I only take it when I need it Well… I take my triptan… …but only as a last resort! P 4 P 4

48 Medication overuse (MO) Consensus defined limits on specific drugs associated with medication overuse headache 10 days a month X 3 months Opioids Butalbital Caffeine combinations Triptans/Ergotamines 15 days per month X 3 months NSAIDs Other OTCs

49 Medication Overuse Headache Clinic diagnosis based on escalating or worsening of headache pattern with increasing use of acute treatment medication Generally considered over 3 month period of time

50 Lifestyle Recommendations “Natural” measures of brain restoration Schedule regulation Sleep Meals Exercise Hydration School/work attendance Keep a Diary Eliminate or restrict stimulants Avoid “triggers” I can’t sleep… I have no energy… I just don’t understand why doctors can’t help me "Are you aware of events or other things that put you at risk of having a migraine?" P 5 P 5 Reproduced with permission © 2011 Primary Care Education

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52 Pre-test ARS Question Evidence-based efficacious acute migraine treatment strategies include all of the following except 1.Oral triptan taken early in the attack 2.DHE (Dihydroergotamine) non-oral delivery 3.Injectable sumatriptan 4.Opioids such as hydrocodone 5.Unsure

53 Management of Chronic Migraine

54 Building a Unique Migraine Tool Box

55 Preventive Strategies Education Lifestyle/behavior Pharmacologic Nonpharmacologic

56 Nonpharmacologic Biofeedback Cognitive behavioral therapy Useful at all stages of migraine! Never too young to start Nicholson RA, et al. Curr Treat Options Neurol. 2011;13:28-40.

57 Preventive Drugs for Frequent Episodic Migraine Level A Divalproex sodium* Oral 125 – 1000 mg Sodium valproate* Oral 125 – 1000 mg Topiramate* Oral 50 – 200 mg Metoprolol Oral 100 – 200 mg Propranolol* Oral 80 – 240 mg Timolol* Oral 20 – 60 mg Frovatriptan (MRM) Oral 2.5 mg Butterbur Oral 75 mg bid Level B Amitriptyline Oral 30 – 150 mg Venlafaxine Oral 12.5 – 75 mg Atenolol Oral 50 – 100 mg Nadolol Oral 40 – 320 mg Naratriptan (MRM) Oral 1, 2.5 mg Zolmitriptan (MRM) Oral 2.5, 5 mg ODT 2.5, 5 mg Nasal 5 mg Silberstein SD, et al. Neurology. 2012;78; * FDA approved

58 Risks of Preventive Medications AEDs Divalproate Weight gain Hair loss Tremor Pancreatitis (rare) Topiramate Paresthesias Cognitive changes Kidney stones Decrease effectiveness of oral contraceptives Beta Blockers Lethargy/fatigue Heart block Asthma Cold hands and feet See Package Insert on specific drugs for complete descriptions of adverse events

59 Risks of Preventative Medications Tricyclic Antidepressants Weight gain Cardiac arrhythmias Anticholinergic symptoms Sedation Seizures SNRI - Venlafaxine Dry mouth Nausea Nervousness Insomnia Somnolence Abnormal ejaculation Withdrawal syndrome See Package Insert on specific drugs for complete descriptions of adverse events

60 Looking to the Patient to Define Preventive Prophylactic Needs (Not really trial and error) Obese topiramate Depressed tricyclic or venlafaxine Bipolar divalproex sodium Performance anxiety propranolol Hypertension propranolol Menstrual migraine frovatriptan

61 Preventative Medications in Chronic Migraine

62 OnabotulinumtoxinA Only FDA approved intervention Preempt studies: Large placebo controlled (saline injection) studies of subject with CM. Efficacy at 24 weeks minus 8.4 – 9.0 days per month vs. placebo of 6.7 days per month Very low drop out rates (3.8%) and excellent tolerability with only neck pain (9%) and headache (5%) being reported greater than 5% Significant improvement in QOL Dodick DW, et al. Headache 2010;50: Diener HC, et al. Cephalalgia –814.

63 Adverse Reactions Reported by 2% of Patients Treated With BOTOX  (More Frequent Than Placebo) in Two Chronic Migraine Double-Blind, Placebo- Controlled Clinical Trials *Dodick et al 2010 reported n=39 (5.5%);15 of the 39 incidences of muscular weakness were facial paresis. BOTOX ® (onabotulinumtoxinA) Prescribing Information. Allergan, Inc., Dodick DW et al. Headache. 2010;50: Severe worsening of migraine requiring hospitalization occurred in approximately 1% of patients treated with BOTOX ® in Study 1 and Study 2, usually within the first week after treatment, compared to 0.3% of placebo-treated patients.

64 Topiramate in Chronic Migraine Double-blind, placebo-controlled, randomized study of 306 patients with CM Reduction of HA days Topiramate 5.8 days Placebo 4.7 days Statistically significant improvement in QOL and symptom severity Silberstein S, et al. Headache. 2009,49:

65 Acute Treatment in Chronic Migraine (no acute treatment has been studied or approved in chronic migraine)

66 Factors That Influence Acute Therapy Outcomes Choice of acute medication Delivery method Treatment times Patient adherence Different presentations of migraine Medication limits Bigal M, et al. Headache. 2009;49:

67 Triptans Sumatriptan Oral – 25, 50, 100 mg Nasal – 5, 20 mg Auto-injector – 4 or 6 mg Needle-free injector – 6 mg Zolmitriptan Oral – 2.5, 5 mg ODT – 2.5, 5 mg Nasal – 5 mg Naratriptan Oral – 1, 2.5 mg Rizatriptan Oral – 5, 10 mg ODT – 5, 10 mg Almotriptan Oral – 6.25, 12.5 mg Frovatriptan Oral – 2.5 mg Eletriptan Oral – 20, 40 mg Sumatriptan/Naproxen Oral – 85 mg/500 mg ODT, orally disintegrating tablet Physicians' Desk Reference, th ed. Montvale, NJ: PDR Network, LLC; 2010.

68 Oral Therapies Non-triptan NSAIDS Diclofenac potassium solution* Combinations Acetaminophen/aspirin/caffeine Analgesics Antiemetics Triptans Ergotamines Matchar DB, et al. Evidence-based guidelines for migraine headache. AAN. US Headache Consortium. 2000:1-58. * FDA approved

69 Parenteral Therapies Triptans Subcutaneous Nasal Ergotamines/DHE 1 IM/SC IN Phenothiazines 2 Rectal IM Ketorolac IV, IM, IN DHE, dihydroergotamine IM, intramuscular IN, intranasal IV, intravenous 1 Physicians' Desk Reference, th ed. Montvale, NJ: PDR Network, LLC; Kelly AM, et al. Headache. 2009;49:

70 Rescue Therapies Triptans Subcutaneous DHE NSAIDs IM/IV Rectal Antihistamines Steroids Other Kelley NE, et al. Headache. 2012;52: Kelley NE, et al. Headache. 2012;52: Kelley NE, et al. Headache. 2012;52:

71 Dihydroergotamine Used by headache specialist for chronic or intractable migraine for decades Can be delivered IV, IM, SC, or oral inhalation Anti-emetics often used with IV and IM but not necessarily with oral inhalation Works anytime during attack Low risk for MOH

72 Medication Overuse and Medication Overuse Headache

73 Risks of Acute Medications Triptans MOH Triptan sensations Rare cardiac events Rare serotonin syndrome? Dihydroergotamine Nausea Muscle pain Vasoconstriction Non-Steroidal Medications GI events including bleeding Liver and renal toxicity Rare CV events See Package Insert on specific drugs for complete descriptions of adverse events

74 Therapeutic Hierarchy in Management of CM

75 Management of CM Accurate diagnosis Emphasis of collaborative management Preventive therapy Acute therapy Frequent follow up QOL and reduction in overuse of medical resources

76 Points to Consider Don’t repeat failures Think of synergy Triptan and NSAID DHE and antiemetic Pharmacology Initiate preventives, including behavioral therapies, early Blumenfeld A, et al. Headache. 2012;52:

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78 Pre-test ARS Question Treatment options for chronic migraine include all of the following, except 1.ß-blockers 2.OnabotulinumtoxinA 3.Long-acting Oxycodone 4.Topiramate 5.Unsure

79 Best Practices Pearls Communication is the only diagnostic tool available for migraine and successful communication requires participation of the healthcare provider and patient Open-ended questions that allow the patients to “tell their story” provides better alignment and understanding Warning signs and comfort features can help separate primary and secondary headache disorders Chronic migraine is a diagnosis defined by 15 or more days per month of headache for at least 3 months in an individual with migraine

80 Thank you for attending!

81

82 Post-test ARS Question Diagnostic Criteria for Chronic Migraine includes which of the following: 1.Headache ≥10 days per month for greater than 6 months 2.Headache ≥ 15 days per month for greater than 6 months 3.Headache ≥ 10 days per month for greater than 3 months 4.Headache ≥ 15 days per month for greater than 3 months 5.Unsure

83 Post-test ARS Question Collaborative Care in the Management of Migraine is characterized by all of the following except: 1.Effective communication between the provider and patient 2.Patient responsibility including keeping a headache diary 3.Patient reporting all headaches to the provider to get advice on how to treat each attack 4.Development of a “migraine tool box” 5.Unsure

84 Post-test ARS Question Evidence-based efficacious acute migraine treatment strategies include all of the following except: 1.Oral triptan taken early in the attack 2.DHE (Dihydroergotamine) non-oral delivery 3.Injectable sumatriptan 4.Opioids such as hydrocodone 5.Unsure

85 Post-test ARS Question Treatment options for chronic migraine include all of the following, except: 1.ß-blockers 2.OnabotulinumtoxinA 3.Long-acting Oxycodone 4.Topiramate 5.Unsure

86 Everett Schlam, MD


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