American Board of Internal Medicine (ABIM) Certification Practice Exam

What treatment is particularly useful for patients with migraine without aura who have not responded to NSAIDs or oral triptans, particularly those experiencing vomiting?

1. Topiramate

2. Self-administered subcutaneous sumatriptan

3. Propranolol

4. Ergotamine

The correct answer is: Self-administered subcutaneous sumatriptan

The treatment particularly useful for patients with migraine without aura who have not responded to NSAIDs or oral triptans, especially those experiencing vomiting, is self-administered subcutaneous sumatriptan. When patients have migraines accompanied by significant nausea and vomiting, oral medications may not be effective due to poor absorption. Subcutaneous sumatriptan bypasses the gastrointestinal tract, allowing for rapid and reliable relief from migraine symptoms. The pharmacological action of sumatriptan as a triptan makes it effective for treating migraines by constricting dilated cranial blood vessels and inhibiting the release of pro-inflammatory neuropeptides. While other treatments, like Topiramate and Propranolol, can be used for migraine prevention, they are not designed for acute treatment or rescue therapy in an ongoing migraine attack. Ergotamine can also be effective for treating migraines, but its use has declined due to side effects and contraindications. Additionally, it can exacerbate nausea and vomiting, making it less ideal for patients experiencing these symptoms. Thus, subcutaneous sumatriptan emerges as a viable option in this clinical scenario.