Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

MKSAP: 30-year-old woman with episodic migraine

mksap
Conditions
October 18, 2014
Share
Tweet
Share

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 30-year-old woman is evaluated for episodic migraine without aura that first presented in high school and has persisted into the third trimester of her current pregnancy. The headache attacks occur two to four times monthly and last 12 to 24 hours. She experiences moderately severe pain, significant nausea, no vomiting, and pronounced photophobia with most of the attacks. Her only medication is prenatal vitamins.

Physical examination findings, including vital signs, are normal.

Which of the following is the most appropriate treatment?

A: Acetaminophen
B: Amitriptyline
C: Naproxen
D: Oxygen
E: Rizatriptan

MKSAP Answer and Critique

The correct answer is A: Acetaminophen.

This patient should be treated with acetaminophen. Although migraine often improves during pregnancy, many women continue to experience episodes throughout all three trimesters. Nonpharmacologic therapies are emphasized, with hydration, rest, and local application of ice all effective means of treating an acute attack. For pregnant women who require medical management, only medications with appropriate FDA and Teratogen Information System (TERIS) ratings for safety of use should be selected as treatment during pregnancy. The drug of choice for this patient is acetaminophen, one of the few acute migraine agents rated pregnancy category B (no evidence of risk in humans but no controlled human studies) by the FDA. This is often combined with metoclopramide or ondansetron, also both category B drugs, if nausea or vomiting is a significant migraine-related symptom during pregnancy.

Recent population-based studies have documented an increased risk of adverse pregnancy outcomes for women with migraine, including low-birth-weight, preterm deliveries, eclampsia, and placental abruption.

Amitriptyline is rated category C (risk to humans not ruled out) by the FDA. Although it is effective in migraine prevention, the low monthly migraine frequency in this patient does not warrant preventive pharmacotherapy.

Naproxen is rated category B by the FDA in the first two trimesters of pregnancy, but concerns of fetal patent ductus arteriosus and maternal bleeding at delivery render this option unsuitable for third trimester management of migraine.

Oxygen may be effective in the management of acute cluster headache, but no significant data support its use in acute migraine.

Rizatriptan carries an FDA pregnancy rating of category C and should be used in pregnant patients only after category B options have been exhausted.

Key Point

ADVERTISEMENT

  • Acetaminophen, combined with metoclopramide or ondansetron for relief of the nausea and vomiting that can accompany migraine, is appropriate for use in pregnant women with migraine because these agents are unlikely to have a negative effect on the fetus.

This content is excerpted from MKSAP 16 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

Prev

There is no excuse for physicians to take advantage of vulnerable patients

October 18, 2014 Kevin 47
…
Next

The Fault in Our Stars: Should thyroid cancer be renamed?

October 18, 2014 Kevin 2
…

Tagged as: Neurology, OB/GYN

Post navigation

< Previous Post
There is no excuse for physicians to take advantage of vulnerable patients
Next Post >
The Fault in Our Stars: Should thyroid cancer be renamed?

ADVERTISEMENT

More by mksap

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 26-year-old man with back pain

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 36-year-old man with abdominal cramping, diarrhea, malaise, and nausea

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 52-year-old woman with osteoarthritis of the right hip

    mksap

More in Conditions

  • Understanding depression beyond biology: the power of therapy and meaning

    Maire Daugharty, MD
  • Why medicine must stop worshipping burnout and start valuing humanity

    Sarah White, APRN
  • Why perinatal mental health is the top cause of maternal death in the U.S.

    Sheila Noon
  • A world without vaccines: What history teaches us about public health

    Drew Remignanti, MD, MPH
  • Unraveling the mystery behind one of the most dangerous pregnancy complications: preeclampsia

    Thomas McElrath, MD, PhD and Kara Rood, MD
  • How community paramedicine impacts Indigenous elders

    Noah Weinberg
  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How community paramedicine impacts Indigenous elders

      Noah Weinberg | Conditions
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • How fragmented records and poor tracking degrade patient outcomes

      Michael R. McGuire | Policy
  • Past 6 Months

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How medical culture hides burnout in plain sight

      Marco Benítez | Conditions
  • Recent Posts

    • How fragmented records and poor tracking degrade patient outcomes

      Michael R. McGuire | Policy
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • How I learned to stop worrying and love AI

      Rajeev Dutta | Education
    • Understanding depression beyond biology: the power of therapy and meaning

      Maire Daugharty, MD | Conditions
    • Why compassion—not credentials—defines great doctors

      Dr. Saad S. Alshohaib | Physician
    • Addressing U.S. vaccine inequities in vulnerable communities [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How community paramedicine impacts Indigenous elders

      Noah Weinberg | Conditions
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • How fragmented records and poor tracking degrade patient outcomes

      Michael R. McGuire | Policy
  • Past 6 Months

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How medical culture hides burnout in plain sight

      Marco Benítez | Conditions
  • Recent Posts

    • How fragmented records and poor tracking degrade patient outcomes

      Michael R. McGuire | Policy
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • How I learned to stop worrying and love AI

      Rajeev Dutta | Education
    • Understanding depression beyond biology: the power of therapy and meaning

      Maire Daugharty, MD | Conditions
    • Why compassion—not credentials—defines great doctors

      Dr. Saad S. Alshohaib | Physician
    • Addressing U.S. vaccine inequities in vulnerable communities [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...