Sample Synoptic Self-Assessment · PGCert tier

Migraine Synoptic Self-Assessment

A 20-item postgraduate-tier synoptic on migraine — diagnosis, stratified acute care, preventive ladder, CGRP-pathway agents and special populations. Pitched deliberately above MRCGP-AKT difficulty. Anchored to NICE NG150 / CG150, ICHD-3, the 2025 IHS-Italian Society pharmacological guidelines (Ornello, Cephalalgia 2025), the IHS Global Practice Recommendations (Puledda 2024), and the contemporary NICE TA portfolio. Five items are flagged ★ Professor / Superspecialist tier.

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~30 minutes · 20 items · 5 Professor-level · CPD certificate · Independent & non-promotional

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01 · About this synoptic

Four-quadrant blueprint

Q1–Q5 · Diagnosis & ICHD-3

Migraine without / with aura · chronic migraine · hemiplegic · vestibular · ICHD-3 thresholds.

Q6–Q10 · Acute stratified care

NICE NG150 stratified care · UK triptan portfolio · gepants · ditans · triptan contraindications.

Q11–Q15 · Preventive ladder

Beta-blockers · candesartan · topiramate · amitriptyline · sodium valproate (PPP) · botulinum TA260.

Q16–Q20 · CGRP-era + special pops

CGRP mAbs · gepants · switching mechanisms · MOH · pregnancy · perimenopausal aura · PFO.

How it works. Select your answer for each item. Your selection is recorded but not marked. When all twenty are answered, click Mark my answers at the foot of the quiz. The results panel reveals the correct answer for each item plus a 60–120-word rationale focused on why the correct answer is correct, with one hyperlinked guideline reference per item. The certificate at the foot auto-populates with your name, date, score, quadrant breakdown, and personal reflection.

Progress 0 / 20 answered

Q1 · ICHD-3 migraine without aura Diagnosis

A 38-year-old woman has 6 episodes/month, each 18–24 hours, of unilateral pulsating moderate-severe headache with photo- and phonophobia, nausea, and aggravation by movement. Family history of migraine. Most likely diagnosis?

AMigraine without aura (ICHD-3 §1.1) BTension-type headache (§2) CCluster headache (§3.1) DHemicrania continua (§4.10) EMedication overuse headache (§8.2)

Q2 · ICHD-3 chronic migraine Diagnosis

A 45-year-old has headache for ≥ 15 days/month for the past 6 months, of which 9 days/month meet migraine criteria. Diagnosis?

AEpisodic migraine BChronic migraine (ICHD-3 §1.3) CNew daily persistent headache DMedication overuse headache ETension-type headache

Q3 · Aura definition Diagnosis

A 31-year-old has reproducible 20–30-minute episodes of zigzag scintillating visual disturbance starting centrally and spreading to a hemifield, followed within 1 hour by a unilateral pulsating headache. Diagnosis?

ATransient ischaemic attack BMigraine without aura CMigraine with typical visual aura (ICHD-3 §1.2) DHemiplegic migraine EOccipital epilepsy

Q4 · ★ Professor-level Hemiplegic migraine acute therapy Diagnosis

A 28-year-old man has 3 episodes over 2 years of unilateral motor weakness lasting 30–60 minutes followed by classical migraine. Father had similar attacks. Genetic testing reveals a CACNA1A mutation. He attends with a fresh attack — weakness on the left and severe right-sided headache. BP 134/80. ECG sinus rhythm. Most appropriate acute therapy?

ASumatriptan 100 mg orally BSumatriptan 6 mg subcutaneously CErgotamine DRimegepant 75 mg orodispersible — gepants are non-vasoconstrictive and contemporary IHS guidance favours them in hemiplegic migraine over triptans ECo-codamol 30/500

Q5 · Vestibular migraine Diagnosis

A 42-year-old woman has 6 episodes over 12 months of vertigo lasting hours, with photophobia and movement-aggravated head discomfort. No tinnitus or hearing loss. Migraine without aura previously diagnosed. Most likely diagnosis?

AMénière’s disease BBenign paroxysmal positional vertigo CVestibular neuritis DPosterior circulation TIA EVestibular migraine (ICHD-3 §1.6.6 / Bárány Society 2012)

Q6 · Severe vomiting at onset — route of triptan Acute

A 28-year-old triptan-naive woman has 4 severe migraine attacks/month, each 12–18 h, with severe vomiting from onset. No CVD, no aura, BMI 24, BP 116/74. Most appropriate triptan choice and route?

ASumatriptan 6 mg subcutaneously, or zolmitriptan 5 mg intranasally BFrovatriptan 2.5 mg orally CNaratriptan 2.5 mg orally DCo-codamol 30/500 two tablets EPethidine 50 mg IM

Q7 · Triptan contraindication after MI Acute

A 36-year-old woman with migraine without aura had an unprovoked NSTEMI 4 months ago (presumed coronary spasm). On aspirin, ticagrelor, atorvastatin, ramipril, bisoprolol. Migraine attacks 2–3/month, 24–36 h, severe with vomiting. NSAIDs partially effective. BP 122/76. ECG normal. Most appropriate acute therapy?

ASumatriptan 50 mg orally BRimegepant 75 mg orodispersible CSumatriptan 6 mg SC DCo-codamol 30/500 EErgotamine 1 mg orally

Q8 · Triptan switching Acute

A 32-year-old woman has used sumatriptan 100 mg orally for 2 years for migraine without aura — initially effective, now “not working”. NSAIDs + paracetamol pre-dose tried. BP normal, no CVD. Most appropriate next step?

AStop triptans entirely; offer SSRI BRefer to neurology for botulinum toxin CTrial a different triptan from a different sub-class (e.g. rizatriptan, zolmitriptan, eletriptan); ensure dosing at onset of pain; check for MOH; combine with NSAID DAdd codeine EStop all therapy and reassess in 6 months

Q9 · Gepant choice — preference for oral once-daily Acute

A 44-year-old woman with infrequent severe migraine attacks (about 2/month). Triptans previously — modest efficacy with chest tightness side effect. No CVD on workup. She prefers oral therapy and finds tablets easier than nasal sprays. Most appropriate gepant?

AZavegepant intranasal BAtogepant 60 mg daily CErenumab 70 mg SC monthly DRimegepant 75 mg orodispersible as needed (NICE TA919) — also licensed preventive at 75 mg every other day if needed in future EGalcanezumab 120 mg SC monthly

Q10 · ★ Professor-level MOH detoxification Acute

A 51-year-old woman has 22 headache days/month for 9 months. Started as 6 days/month 5 y ago. Sumatriptan 50 mg on 14 d/m + paracetamol/ibuprofen almost daily. Failed amitriptyline (sedation), propranolol (bradycardia). Headache pattern “dull background with overlying spikes”. Most appropriate next step?

AAdd a CGRP-pathway preventive without addressing acute medications BStop sumatriptan abruptly; continue paracetamol + ibuprofen daily CContinue current regimen; refer to neurology DAdd codeine for additional acute coverage EDiagnose MOH; abrupt withdrawal of sumatriptan and simple analgesics with steroid-tapering bridge; initiate CGRP-pathway preventive concurrently per DELIVER 2024 evidence

Q11 · First-line preventive in childbearing-potential woman Preventive

A 28-year-old woman has 7 migraine days/month, no contraception, long-term partner, undecided about pregnancy. BMI 22, BP 116/74. Most appropriate first-line preventive per NICE NG150?

APropranolol 40 mg twice daily increasing to 80 mg twice daily over 4 weeks BTopiramate 25 mg nightly increasing to 50 mg twice daily CSodium valproate 200 mg twice daily DAtogepant 60 mg daily EErenumab 70 mg SC monthly

Q12 · Candesartan as preventive Preventive

A 41-year-old woman has 7 migraine days/month and untreated hypertension (BP 152/92, eGFR 78). No CVD, BMI 26, no asthma, no diabetes. No previous preventive trialed. Most appropriate first-line preventive?

AAtogepant 60 mg daily BCandesartan 8 mg daily titrating to 16 mg as tolerated CTopiramate 25 mg titrating to 50 mg twice daily DSodium valproate 200 mg twice daily EErenumab 70 mg SC monthly

Q13 · Topiramate counselling Preventive

A 35-year-old woman with episodic migraine is starting topiramate 25 mg titrating to 50 mg twice daily. She uses Microgynon 30 (COC) for contraception. Which counselling point is essential?

ATopiramate has no effect on contraception BTopiramate is safe in pregnancy CTopiramate at doses ≥ 200 mg/day reduces COC efficacy (CYP enzyme induction); switch to a non-hormonal or progestogen-only method, or use additional barrier protection; additionally, topiramate is teratogenic (cleft lip/palate, hypospadias) so reliable contraception is essential DTopiramate causes weight gain ETopiramate requires monthly liver function tests

Q14 · Botulinum toxin NICE TA260 Preventive

A 38-year-old woman has chronic migraine (18 headache days/month, 11 of which migrainous, for 6 months). Failed propranolol, topiramate, amitriptyline at adequate doses. Currently sumatriptan 8 days/month. Per NICE TA260, which therapy is licensed?

AErenumab — first-line CGRP for episodic and chronic BVerapamil CIndomethacin DOnabotulinumtoxin A — PREEMPT protocol (155–195 units across 31 sites) every 12 weeks; for chronic migraine after 3 traditional preventive failures EGalcanezumab

Q15 · ★ Professor-level Refractory chronic migraine — CGRP selection by lifestyle fit Preventive

A 47-year-old woman with chronic migraine refractory to propranolol, topiramate, amitriptyline, and onabotulinumtoxin A (two PREEMPT cycles, 25% response). Works as paediatric anaesthetist with irregular shift pattern; needle-fearful but copes; values long dosing intervals. eGFR 80, no constipation history. Which CGRP-pathway agent is best matched to her preferences?

AErenumab 140 mg SC monthly BGalcanezumab 240 mg loading then 120 mg SC monthly CAtogepant 60 mg daily orally DRimegepant 75 mg every other day orally EFremanezumab 675 mg SC quarterly

Q16 · CGRP mAb mechanism switching CGRP & special pops

A 42-year-old woman with chronic migraine refractory to multiple preventives + onabotulinumtoxin A is on month 4 of erenumab 140 mg monthly with only 15% reduction in monthly headache days — does not meet the NICE 30% chronic-migraine continuation rule. Most appropriate next step?

ASwitch to a ligand-binding CGRP mAb (fremanezumab, galcanezumab, or eptinezumab) — different mechanism BContinue erenumab; reassess after a further 6 months CIncrease erenumab to 280 mg monthly DStop all preventive therapy ERestart topiramate

Q17 · Acute migraine in pregnancy CGRP & special pops

A 31-year-old woman, 18 weeks pregnant with second child, presents with severe migraine without aura — typical of her pre-pregnancy pattern. Paracetamol 1 g + cyclizine 50 mg has not aborted at 4 hours. Most appropriate next step?

ANaproxen 500 mg twice daily orally BSumatriptan 6 mg SC; document risk-benefit discussion CCo-codamol 30/500 two tablets every 4 hours DTopiramate 50 mg orally EErenumab 140 mg SC

Q18 · Perimenopausal migraine + aura on COC CGRP & special pops

A 47-year-old woman with longstanding migraine with aura attends with worsening symptoms. On Microgynon 30 for 12 years. Aura frequency increased from 1–2/y to 3 in last month. BMI 24, BP 122/76. Last period 5 weeks ago. Most appropriate management?

AContinue COC; add propranolol BSwitch COC to oral oestradiol-based HRT CStop COC immediately (FSRH UKMEC 4); switch to a progestogen-only method (POP, LNG-IUS, or Nexplanon); offer transdermal HRT for vasomotor symptoms if relevant DReduce ethinyl-oestradiol to 20 microgram EContinue COC; add aspirin 75 mg

Q19 · CGRP mAb pregnancy washout CGRP & special pops

A 33-year-old woman on galcanezumab 120 mg SC monthly for chronic migraine (well-controlled at 4 days/month) is engaged and would like to conceive within 12 months. How should galcanezumab be managed pre-conception?

AContinue galcanezumab through conception and pregnancy BStop galcanezumab on day of conception attempt CSwitch directly to topiramate DStop galcanezumab at least 5 months pre-conception (5 half-lives, t½ ~ 27 days); switch to a pregnancy-compatible preventive (propranolol or amitriptyline) ESwitch to atogepant

Q20 · ★ Professor-level PFO closure for migraine with aura CGRP & special pops

A 32-year-old woman with refractory migraine with aura has had a bubble study showing moderate-grade right-to-left shunt; cardiology have confirmed a 6 mm patent foramen ovale on TOE. She has failed amitriptyline, propranolol, topiramate, and is on month 4 of fremanezumab with 30% improvement. She has read about PFO closure online and asks whether she should pursue it. Most evidence-based response?

ARefer for PFO closure — standard of care for refractory migraine with aura BRecommend immediate PFO closure to prevent stroke CDecline any further intervention DOffer aspirin 75 mg as alternative to closure EExplain that randomised trials (PRIMA, PREMIUM, MIST) did not meet primary endpoints; PFO closure is not currently NICE-positive for migraine; observational signals exist in selected aura subgroups; consider trial enrolment if available; continue optimising preventive therapy

Personal reflection — for your CPD portfolio

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CPD certificate of completion

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Migraine Synoptic Self-Assessment — 20 single-best-answer items at PGCert tier

Personal reflection

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Authored by Prof Rajesh Varma · MD Acumen Ltd · mdacumen.com
Curriculum-aligned with NICE NG150 / CG150; ICHD-3; 2025 IHS-Italian Society pharmacological guidelines (Ornello, Cephalalgia 2025); IHS Global Practice Recommendations (Puledda 2024); contemporary CGRP-era NICE TA portfolio.

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Independence statement. Authored by Prof Rajesh Varma · MD Acumen Ltd. Independent of pharmaceutical sponsorship. All UK-licensed agents in any class are presented even-handedly per their NICE technology appraisals.

Educational disclaimer. CPD for qualified UK healthcare professionals. Check current BNF and NICE before prescribing.

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