What is therapeutic gain?
A. The improvement in quality of living gained by headache relief.
B. The percentage response for active treatment minus the percentage response for placebo.
C. The minimum response that can be reliably expected from treatment.
D. The percentage response with active treatment.
E. The consistent improvement seen each time treatment is compared to placebo.
The answer is B. Therapeutic gain is the percentage response for active treatment minus percentage response for placebo. Because the placebo rate is often high in clinical trials of headache patients, the therapeutic gain represents the presumed effect of the active treatment, independent of a placebo response. Placebo effects are more striking in studies involving children and adolescents with acute headache than in adults. (Loder, Goldstein, & Biondi, Cephalalgia 2005)
An obese woman with frequent migraine headaches had good relief of her headaches on Topiramate (Topamax). She was also pleased with weight loss on the medication; however, word-finding difficulty interfered with her job as a radio talk show host, so she asked if her medication could be switched. What would you suggest?
The answer is C. Zonisamide (Zonegran), like topiramate (Topamax), has properties of a carbonic anhydrase inhibitor and has been shown to decrease the frequency and severity of migraine headaches, although it has been less extensively studied than has topiramate. In a short-term study, zonisamide and a diet decreased weight more than diet alone. Zonisamide is less likely to cause cognitive side effects or word-finding difficulties than is topiramate. Divalproex sodium (Depakote), propranolol (fnderal), gabapentin (Neurontin), and amitriptyline (Elavil) do not have the weight loss or weight neutral properties of topiramate and zonisamide. Zonisamide should not be given to a patient with a true sulfa drug allergy. (Gadde, Franciscy, Wagner, et al., JAMA 2003)
Which geographic area has the lowest adjusted prevalence of migraine?
D. South and Central America
E. North America
The answer is A. Migraine is more common in Europe and the Americas as compared to Africa and Asia. In all geographic areas, migraine is more common in women than men, although the gender disparity is less in Africa as compared to North America. Migraine is less common in African Americans and Asians in the United States. This international variation is unexplained. (Silberstein, Lipton, & Dodick, Wolff’s Headache and Other Head Pain)
Headache accompanied by bilateral neck pain:
A. Indicates the diagnosis of cervicogenic headache.
B. Is consistent with the diagnosis with migraine.
C. Generally correlates with an anatomic neck lesion on radiological testing.
D. Has been proven to respond to radiofrequency radiolysis.
E. Is inconsistent with the diagnosis of tension-type headache (TTH).
The answer is B. Neck pain commonly accompanies the head pain of migraine or TTH, without any radiological correlate in the neck or cervical spine. The neck pain associated with migraine and tension-type headaches is generally bilateral. The diagnosis of cervicogenic headache is controversial, but the neck pain associated with cervicogenic headache has been described as unilateral, without side-shift. Radiofrequency radiolysis has had variable results, including lack of benefit in a randomized, placebo-controlled studies. (Da Silva & Bordini, Curr Pain Headache Rep 2006)