Drugs for migraine

Treatment Guidelines from The Medical Letter® Published by The Medical Letter, Inc • 145 Huguenot Street, New Rochelle, NY 10801 • A Nonprofit Publication IN THIS ISSUE (starts on next page) Drugs for Migraine .p 107 Important Copyright Message The Medical Letter® publications are protected by US and international copyright laws Forwarding, copying or any distribution of this material is prohibited Sharing a password with a non-subscriber or otherwise making the contents of this site available to third parties is strictly prohibited By accessing and reading the attached content I agree to comply with US and international copyright laws and these terms and conditions of The Medical Letter, Inc For further information click: Subscriptions, Site Licenses, Reprints or call customer service at: 800-211-2769 FORWARDING OR COPYING IS A VIOLATION OF US AND INTERNATIONAL COPYRIGHT LAWS Treatment Guidelines from The Medical Letter® Published by The Medical Letter, Inc • 145 Huguenot Street, New Rochelle, NY 10801 • A Nonprofit Publication Volume 11 (Issue 136) December 2013 www.medicalletter.org Tables Triptans: Onset of Action Some Drugs for Treatment of Migraine Some Drugs for Prevention of Migraine Page 108 Page 109 Page 110 Drugs for Migraine Related article(s) since publication A nonopioid analgesic may be effective for treatment of mild-to-moderate migraine A triptan is the drug of choice for treatment of moderate-to-severe migraine The short-acting oral triptans sumatriptan, almotriptan, eletriptan, rizatriptan, and zolmitriptan are similar in their efficacy and speed of onset; naratriptan and frovatriptan have a slower onset and longer duration of action The nasal spray formulations of sumatriptan and zolmitriptan have a faster onset of action than oral triptans Subcutaneous sumatriptan is the fastest-acting and most effective triptan formulation Patients who not respond to one triptan may respond to another For prevention of migraine, topiramate, valproate, propranolol, timolol, or metoprolol is recommended TREATMENT OF MIGRAINE Treatment of migraine in the emergency department, which may involve use of intravenous drugs, is not discussed here ANALGESICS — Treatment with a nonopioid analgesic may be sufficient for mild-to-moderate episodes of migraine without nausea, disability, or need for bed rest Aspirin and acetaminophen1 alone have been shown to be effective Both are also available by prescription in widely used combinations with butalbital and caffeine (Fiorinal, Fioricet, and others) Butalbital has not been shown to be effective for treatment of migraine in controlled trials and has been associated with tolerance and dependence Oral combinations of aspirin or acetaminophen with an opioid are effective for relief of migraine pain, but they can cause the usual opioid adverse effects (such as nausea, drowsiness, and constipation), and their use can lead to tolerance, dependence, and addiction Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen sodium (Aleve, and others) and ibuprofen (Advil, Motrin, and generics) have been effective in relieving migraine pain.2,3 Naproxen has a longer halflife and may have a longer duration of action than ibuprofen Diclofenac is available as a powder for oral solution (Cambia) for treatment of migraine; it has a rapid onset of action, but is much more expensive than generic NSAIDs SEROTONIN (5-HT1B/1D) RECEPTOR AGONISTS (“TRIPTANS”) — A triptan is the drug of choice for treatment of moderate-to-severe migraine.4 Use of a triptan early in an attack when pain is still mild to moderate in intensity can improve outcomes Sumatriptan is available for subcutaneous (SC) selfinjection (with or without a needle),5 as a nasal spray, and for oral administration, and has been approved by the FDA as a transdermal patch formulation The injectable and possibly the nasal-spray formulations may be useful for patients with nausea and/or vomiting, and they have a more rapid onset of action than the oral tablets SC sumatriptan produces relief within hours in about 80% of patients with moderate-tosevere migraine Sumatriptan nasal spray has produced relief in about 60% of patients after hours, about the same as oral sumatriptan, which has been effective in about 50% to 60% of patients with acute migraine after hours and in about 70% after hours.6 The transdermal patch has not been compared to other formulations of sumatriptan, but it will likely have a slower onset of action than the nasal spray or injectable formulations It frequently causes application-site reactions.7 A fixed-dose combination tablet containing sumatriptan 85 mg and naproxen 500 mg (Treximet) provided better pain relief than either agent taken alone in patients with moderate or severe migraine.8 Federal copyright law prohibits unauthorized reproduction by any means and imposes severe fines 107 Drugs for Migraine Table Triptans: Onset of Action Onset of action Elimination half-life Almotriptan (Axert) 30-60 3-4 hrs Eletriptan (Relpax) 30-60 ~4 hrs Frovatriptan (Frova) ~2 hrs ~25 hrs Naratriptan (Amerge) 1-3 hrs ~6 hrs Rizatriptan (Maxalt) 30-60 Sumatriptan (Imitrex) tablets nasal spray SC injection Zolmitriptan (Zomig) tablets nasal spray 2-3 hrs ~2 hrs 30-60 10-15 ~10 2-3 hrs 30-60 10-15 The oral short-acting triptans almotriptan, eletriptan, rizatriptan and zolmitriptan are similar in efficacy to sumatriptan.9 Zolmitriptan, like sumatriptan, is also available as a nasal spray; compared to sumatriptan, fewer patients complain about its taste.10 Naratriptan and frovatriptan have longer half-lives and have a slower onset of action and lower initial response rate than other triptans.11 Recurrence – In patients with moderate-to-severe migraine, the rate of recurrence within 24 hours after treatment with a triptan is generally 20% to 40%; it may be slightly lower with naratriptan and frovatriptan Recurrences usually respond to a second dose of the triptan Adverse Effects – Tingling, flushing, dizziness, drowsiness, fatigue, and a feeling of heaviness, tightness, or pressure in the chest may occur with all triptans, but most commonly with injectable sumatriptan A burning sensation at the injection site is common with SC sumatriptan CNS symptoms such as somnolence and asthenia following triptan therapy may be part of the migraine attack, unmasked by the successful treatment of pain, rather than adverse effects of the drugs Angina, myocardial infarction, cardiac arrhythmia, stroke, and death have occurred rarely with triptans,12 which are contraindicated in patients with coronary, cerebrovascular or other arterial disease, or uncontrolled hypertension They should be used with caution in patients with other risk factors for vascular disease, particularly diabetes Drug Interactions – A triptan should generally not be used within 24 hours after another triptan or an ergotcontaining drug because vasoconstriction could be additive MAO inhibitors increase serum concentrations of rizatriptan, sumatriptan, and zolmitriptan; they should not be used within weeks of each other Propranolol increases serum concentrations of eletriptan, rizatriptan, and zolmitriptan Inhibitors of CYP3A4, including verapamil, can increase eletriptan 108 serum concentrations.13 Triptans are frequently taken together with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs); serotonin syndrome has been reported with concurrent use.14 ERGOTS — Ergotamine, a non-specific serotonin agonist and vasoconstrictor, has been used for many years for treatment of moderate-to-severe migraine headache It is available alone in sublingual tablets and in combination with caffeine in oral tablets and suppositories Comparative studies have shown that oral ergotamine plus caffeine is less effective than a triptan for acute treatment of migraine.15 Dihydroergotamine, which can be injected subcutaneously, intramuscularly, or intravenously, or sprayed intranasally, is also effective in acute migraine treatment It can be effective in some patients who not respond to triptans Dihydroergotamine nasal spray relieves migraine after hours in about 50% of patients with a 15% incidence of headache recurrence within 24 hours Adverse Effects – Dihydroergotamine is a weaker vasoconstrictor than ergotamine and causes fewer adverse effects Nausea and vomiting are fairly common with ergotamine, but can be prevented by pretreatment with or concurrent use of an antiemetic such as metoclopramide (Reglan, and generics) Serious adverse effects, such as vascular (including coronary) occlusion and gangrene, are rare and are usually associated with overdosage (>6 mg in 24 hours or 10 mg per week) Liver disease or fever can accelerate development of severe vasoconstriction Ergots are contraindicated in patients with arterial disease or uncontrolled hypertension Drug Interactions – The effects of ergots may be potentiated by triptans, beta blockers, dopamine, nicotine, or CYP3A4 inhibitors Ergots and triptans should not be taken within 24 hours of each other Use of ergots is contraindicated with strong CYP3A4 inhibitors such as clarithromycin (Biaxin, and generics) or itraconazole (Sporanox, and generics).13 MEDICATION OVERUSE HEADACHE Overuse of drugs for migraine, such as analgesics and triptans, but especially butalbital and opioids, can lead to chronic headache with structural and functional changes in the brain Treatment of medication overuse headache involves withdrawing the overused drug(s) Abrupt withdrawal may require hospitalization and bridge therapy with other drugs Preventive medications for migraine should be considered Future use of acute migraine treatments should be limited to 50% reduction in headache frequency with these drugs.23 In randomized double-blind studies, topiramate was at least as effective as propranolol for migraine prevention.24,25 Topiramate has also reduced the number of migraine headache days per month and improved associated symptoms in patients with chronic migraine (>15 headache days/month for >3 months) and medication overuse headache.26,27 Published results of clinical trials suggest that gabapentin (Neurontin, and others) may not be effective for migraine prophylaxis.28 110 Adverse effects of valproate include nausea, fatigue, tremor, weight gain, and hair loss Acute hepatic failure, pancreatitis, and hyperammonemia (in patients with urea cycle disorders) occur rarely Other effects include polycystic ovary syndrome, hyperinsulinemia, lipid abnormalities, hirsutism, and menstrual disturbances Topiramate commonly causes paresthesias; fatigue, language and cognitive impairment, taste perversion, and weight loss can also occur Topiramate can rarely cause secondary narrow-angle glaucoma, oligohydrosis, nephrolithiasis, and symptomatic metabolic acidosis ANTIDEPRESSANTS — Tricyclic antidepressants can prevent migraine in some patients and may be given concurrently with other prophylactic agents, but they often cause sedation, dry mouth, and weight gain Amitriptyline is the only tricyclic shown to be effective in clinical trials.29 Nortriptyline and imipramine (Tofranil, and generics), which may have fewer adverse effects than amitriptyline, are also frequently used Newer antidepressants such as the SNRI venlafaxine may also be effective in preventing migraine.30 Treatment Guidelines from The Medical Letter • Vol 11 ( Issue 136) • December 2013 Drugs for Migraine OTHERS — Pericranial injections of onabotulinumtoxinA (Botox) may be marginally effective for prophylaxis of headaches in adult patients with chronic migraine.31 Botulinum toxin is not recommended for prevention of episodic migraine in children whose mothers took the drug during pregnancy Women should avoid ACE inhibitors and ARBs if they become or are planning to become pregnant; drugs that act on the renin-angiotensin system can cause fetal and neonatal morbidity and death Calcium channel blockers are used for prevention of migraine, but evidence for their effectiveness is weak Verapamil (Calan, and generics) was somewhat more effective than placebo in some small studies.22 In small double-blind trials, the angiotensin-converting enzyme (ACE) inhibitor lisinopril (Prinivil, and others) and the angiotensin receptor blocker (ARB) candesartan (Atacand, and generics) have reduced migraine frequency by about 30-35%; they have not been compared to other, better-established prophylactic agents.32 Nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen and ibuprofen, have been used for short-term prevention of migraine, including menstrual migraine, and for aborting acute attacks.33 The dietary supplement petasites (butterbur; Petadolex) 100-150 mg per day reduced migraine attack frequency by 36-60% in randomized, placebo-controlled trials in about 300 patients.33,34 Riboflavin, magnesium citrate, coenzyme Q10, and feverfew have also been reported to be effective in preventing migraine in small, randomized, placebo-controlled trials.33,35-38 10 11 12 13 14 PREGNANCY Acetaminophen and/or opioids are commonly used for treatment of acute migraine attacks during pregnancy NSAIDs should not be used in the third trimester because they can cause premature closure of the ductus arteriosus Opioids should also be avoided late in the third trimester because of the risk of neonatal withdrawal The triptans are classified as category C (embryo/fetal toxicity in animals; no adequate studies in humans) for use during pregnancy, but sumatriptan, which has been used the longest, and possibly rizatriptan, eletriptan, and zolmitriptan, not appear to be associated with an increased risk of birth defects.39,40 All ergots are contraindicated (category X) during pregnancy Preventive therapy is generally not recommended during pregnancy Valproate sodium, valproic acid, and divalproex sodium are contraindicated (category X) for prevention of migraine in pregnant women; IQ scores were lower in the children of mothers who took these drugs during pregnancy.41 Topiramate has been reported to increase the risk of cleft lip and cleft palate 15 16 17 18 19 20 21 MJ Prior et al A randomized, placebo-controlled trial of acetaminophen for treatment of migraine headache Headache 2010; 50:819 CC Suthisisang et al Meta-analysis of the efficacy and safety of naproxen sodium in the acute treatment of migraine Headache 2010; 50:808 C Suthisisang et al Efficacy of low-dose ibuprofen in acute migraine treatment: systematic review and meta-analysis Ann Pharmacother 2007; 41:1782 EA MacGregor In the clinic Migraine Ann Intern Med 2013; 159:ITC5-1 A sumatriptan needle-free injector for migraine Med Lett Drugs Ther 2010; 52:50 SD Silberstein Migraine Lancet 2004; 363:381 A sumatriptan patch (Zecuity) for migraine Med Lett Drugs Ther 2013; in press RB Lipton et al Consistency of response to sumatriptan/naproxen sodium in a placebo-controlled crossover study Cephalalgia 2009; 29:826 MM Johnston and AM Rapoport Triptans for the management of migraine Drugs 2010; 70:1505 Zolmitriptan (Zomig) nasal spray for migraine Med Lett Drugs Ther 2004; 46:7 V Tullo et al Frovatriptan versus zolmitriptan for the acute treatment of migraine: a double-blind, randomized, multicenter, Italian study Neurol Sci 2010; 31:S51 G Roberto et al Triptans and serious adverse vascular events: data mining of the FDA Adverse Event Reporting System database Cephalalgia 2013; Aug (epub) Inhibitors and inducers of CYP enzymes and P-glycoprotein Med Lett Drugs Ther 2013; 55:e44 FDA Public Health Advisory Combined use of 5-hydroxytryptamine receptor agonists (triptans), selective serotonin reuptake inhibitors (SSRIs) or selective serotonin/norepinephrine reuptake inhibitors (SNRIs) may result in life-threatening serotonin syndrome 7/19/2006 Last updated August 16, 2013 Available at www.fda.gov/Drugs/ DrugSafety/PostmarketDrugSafetyInformationforPatientsandProvider s/DrugSafetyInformationforHeathcareProfessionals/PublicHealthAdv isories/ucm124349.htm Accessed November 12, 2013 MJ Láinez et al Crossover, double-blind clinical trial comparing almotriptan and ergotamine plus caffeine for acute migraine therapy Eur J Neurol 2007; 14:269 JR Saper and AN DaSilva Medication overuse headache: history, features, prevention and management strategies CNS Drugs 2013; 27:867 SJ Tepper Medication-overuse headache Continuum (Minneap Minn) 2012; 18:807 SD Silberstein et al Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society Neurology 2012; 78:1337 E Loder et al The 2012 AHS/AAN guidelines for prevention of episodic migraine: a summary and comparison with other recent clinical practice guidelines Headache 2012; 52:930 T Pringsheim et al Acute treatment and prevention of menstrually related migraine headache: evidence-based review Neurology 2008; 70:1555 EA MacGregor et al Safety and tolerability of frovatriptan in the acute treatment of migraine and prevention of menstrual migraine: results of a new analysis of data from five previously published studies Gend Med 2010; 7:88 Treatment Guidelines from The Medical Letter • Vol 11 ( Issue 136) • December 2013 111 Drugs for Migraine 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 V Limmroth and MC Michel The prevention of migraine: a critical review with special emphasis on beta-adrenoceptor blockers Br J Clin Pharmacol 2001; 52:237 V Shaygannejad et al Comparison of the effect of topiramate and sodium valporate in migraine prevention: a randomized blinded crossover study Headache 2006; 46:642 HC Diener et al Topiramate in migraine prophylaxis–results from a placebo-controlled trial with propranolol as an active control J Neurol 2004; 251:943 F Ashtari et al A double-blind, randomized trial of low-dose topiramate vs propranolol in migraine prophylaxis Acta Neurol Scand 2008; 118:301 S Silberstein et al Topiramate treatment of chronic migraine: a randomized, placebo-controlled trial of quality of life and other efficacy measures Headache 2009; 49:1153 HC Diener et al Topiramate reduces headache days in chronic migraine: a randomized, double-blind, placebo-controlled study Cephalalgia 2007; 27:814 M Linde et al Gabapentin or pregabalin for the prophylaxis of episodic migraine in adults Cochrane Database Syst Rev 2013; 6:CD010609 DW Dodick et al Topiramate versus amitriptyline in migraine prevention: a 26-week, multicenter, randomized, double-blind, doubledummy, parallel-group noninferiority trial in adult migraineurs Clin Ther 2009; 31:542 S Tarlaci Escitalopram and venlafaxine for the prophylaxis of migraine headache without mood disorders Clin Neuropharmacol 2009; 32:254 Botulinum toxin for chronic migraine Med Lett Drugs Ther 2011; 53:7 BJ Gales et al Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for the prevention of migraines Ann Pharmacother 2010; 44:360 S Holland et al Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society Neurology 2012; 78:1346 RB Lipton et al Petasites hybridus root (butterbur) is an effective preventive treatment for migraine Neurology 2004; 63:2240 J Schoenen et al Effectiveness of high-dose riboflavin in migraine prophylaxis A randomized controlled trial Neurology 1998; 50:466 A Peikert et al Prophylaxis of migraine with oral magnesium: results from a prospective, multi-center, placebo-controlled and double-blind randomized study Cephalalgia 1996; 16:257 PS Sándor et al Efficacy of coenzyme Q10 in migraine prophylaxis: a randomized controlled trial Neurology 2005; 64:713 HC Diener et al Efficacy and safety of 6.25 mg t.i.d feverfew CO2extract (MIG-99) in migraine prevention–a randomized, doubleblind, multicentre, placebo-controlled study Cephalalgia 2005; 25:1031 ML Hilaire et al Treatment of migraine headaches with sumatriptan in pregnancy Ann Pharmacother 2004; 38:1726 K Nezvalová-Henriksen et al Triptan safety during pregnancy: a Norwegian population registry study Eur J Epidemiol 2013; 28:759 In brief: warning against use of valproate for migraine prevention during pregnancy Med Lett Drugs Ther 2013; 55:45 Correction: Drugs for Epilepsy (Treat Guidel Med Lett 2013; 11:9) The dosage of topiramate in Table on page 11 has been changed from 200-400 mg/day in doses to 100-400 mg/day in doses The dosage recommendation in the labeling for monotherapy is 400 mg per day, but Medical Letter consultants have pointed out that in clinical practice, the usual dose of topiramate for monotherapy is 100-200 mg per day Higher doses may be needed for adjunctive use 112 Coming Soon in Treatment Guidelines: Drugs for Lipids – January 2014 Drugs for HIV Infection – February 2014 Follow us on Twitter @MedicalLetter Treatment Guidelines ® from The Medical Letter EDITOR IN CHIEF: Mark Abramowicz, M.D EXECUTIVE EDITOR: Gianna Zuccotti, M.D., M.P.H., F.A.C.P., Harvard Medical School EDITOR: Jean-Marie Pflomm, Pharm.D ASSISTANT EDITORS, DRUG INFORMATION: Susan M Daron, Pharm.D., Corinne Z Morrison, Pharm.D., Michael P Viscusi, Pharm.D CONSULTING EDITORS: Brinda M Shah, Pharm.D., F Peter Swanson, M.D CONTRIBUTING EDITORS: Carl W Bazil, M.D., Ph.D., Columbia University College of Physicians and Surgeons Vanessa K Dalton, M.D., M.P.H., University of Michigan Medical School Eric J Epstein, M.D., Albert Einstein College of Medicine Jane P Gagliardi, M.D., M.H.S., F.A.C.P., Duke University School of Medicine Jules Hirsch, M.D., Rockefeller University David N Juurlink, BPhm, M.D., PhD, Sunnybrook Health Sciences Centre Richard B Kim, M.D., University of Western Ontario Hans Meinertz, M.D., University Hospital, Copenhagen Sandip K Mukherjee, M.D., F.A.C.C., Yale School of Medicine Dan M Roden, M.D., Vanderbilt University School of Medicine Esperance A K Schaefer, M.D., M.P.H., Harvard Medical School F Estelle R Simons, M.D., University of Manitoba Neal H Steigbigel, M.D., New York University School of Medicine Arthur M.F Yee, M.D., Ph.D., F.A.C.R, Weill Medical College of Cornell University SENIOR ASSOCIATE EDITOR: Amy Faucard EDITORIAL FELLOW: Jennifer Y Lin, M.D., Harvard Medical School MANAGING EDITOR: Susie Wong ASSISTANT MANAGING EDITOR: Liz Donohue PRODUCTION COORDINATOR: Cheryl Brown EXECUTIVE DIRECTOR OF SALES: Gene Carbona FULFILLMENT AND SYSTEMS MANAGER: Cristine Romatowski DIRECTOR OF MARKETING COMMUNICATIONS: Joanne F Valentino VICE PRESIDENT AND PUBLISHER: Yosef Wissner-Levy Founded in 1959 by Arthur Kallet and Harold Aaron, M.D Copyright and Disclaimer: The Medical Letter is an independent nonprofit organization that provides healthcare professionals with unbiased drug prescribing recommendations The editorial process used for its publications relies on a review of published and unpublished literature, with an emphasis on controlled clinical trials, and on the opinions of its consultants The Medical Letter is supported solely by subscription fees and accepts no advertising, grants or donations No part of the material may be reproduced or transmitted by any process in whole or in part without prior permission in writing The editors not warrant that all the material in this publication is accurate and complete in every respect The editors shall not be held responsible for any damage resulting from any error, inaccuracy or omission Subscription Services Subscriptions (US): Mailing Address: The Medical Letter, Inc 145 Huguenot Street, Ste 312 New Rochelle, NY 10801-7537 Customer Service: Call: 800-211-2769 or 914-235-0500 Fax: 914-632-1733 Web Site: www.medicalletter.org E-mail: custserv@medicalletter.org Permissions: To reproduce any portion of this issue, please e-mail your request to: permissions@medicalletter.org Subscriptions (US): - $189; year - $98; years years - $189; year years- -$98; $279 $49/yr for students, years residents - $279 $49/yr for students, interns, and fellows in the interns, US and residents Canada and fellows in the US and Canada E-mail site license inquiries to: E-mail site license inquiries info@medicalletter.org or call to: info@medicalletter.org 800-211-2769 x315 or call 800-211-2769 x315 Special fees for bulk subscriptions Special for bulk subscriptions Special fees classroom rates are availSpecial classroom rates areeach available Back issues are $12 able Back issues are $12 each Major credit cards accepted Major credit cards accepted Copyright 2013 ISSN 1541-2792 Treatment Guidelines from The Medical Letter • Vol 11 ( Issue 136) • December 2013 Treatment Guidelines: Online Continuing Medical Education Up to 24 credits included with your subscription medicalletter.org/cme Choose CME from Treatment Guidelines from The Medical Letter and earn up to 24 Category Credits per year: Free Individual Exams - Free to active subscribers of Treatment Guidelines from The Medical Letter Answer 12 questions per issue and submit answers online Earn up to credits/exam Paid Individual Exams - Available to non-subscribers Answer 12 questions per issue and submit answers online Earn up to credits/exam $12/exam ACCREDITATION INFORMATION: ACCME: The Medical Letter is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians The Medical Letter Inc designates this enduring material for a maximum of AMA PRA Category Credit(s)™ Physicians should claim only the credit commensurate with the extent of their participation in the activity This CME activity was planned and produced in accordance with the ACCME Essentials and Policies AAFP: This enduring material activity, Treatment Guidelines from the Medical Letter Continuing Medical Education Program, has been reviewed and is acceptable for up to 15 Prescribed credits by the American Academy of Family Physicians AAFP certification begins January 1, 2013 Term of approval is for one year from this date Each issue is approved for 1.25 Prescribed credits Credit may be claimed for one year from the date of each issue Physicians should claim only the credit commensurate with the extent of their participation in the activity ACPE: The Medical Letter is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education This exam is acceptable for 2.0 hour(s) of knowledge-based continuing education credit (0.2 CEU) ® AANP and AAPA: The American Academy of Nurse Practitioners (AANP) and the American Academy of Physician Assistants (AAPA) accept AMA Category Credit for the Physician’s Recognition Award from organizations accredited by the ACCME AOA: This activity, being ACCME (AMA) approved, is acceptable for Category 2-B credit by the American Osteopathic Association (AOA) Physician Assistants: The National Commission on Certification of Physician Assistants (NCCPA) accepts AMA PRA Category Credit(s)™ from organizations accredited by ACCME NCCPA also accepts AAFP Prescribed credits for recertification Treatment Guidelines is accredited by both ACCME and AAFP Physicians in Canada: Members of The College of Family Physicians of Canada residing in the US are eligible to receive Mainpro-M1 credits (equivalent to AAFP Prescribed credits), and members residing in Canada are eligible to receive Mainpro-M2 credits due to a reciprocal agreement with the American Academy of Family Physicians Treatment Guidelines CME activities are eligible for either Section or Section (when creating a personal learning project) in the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada (RCPSC) Physicians, nurse practitioners, pharmacists and physician assistants may earn credits with this exam MISSION: The mission of The Medical Letter's Continuing Medical Education Program is to support the professional development of healthcare professionals including physicians, nurse practitioners, pharmacists and physician assistants by providing independent, unbiased drug information and prescribing recommendations that are free of industry influence The program content includes current information and unbiased reviews of FDA-approved and off-label uses of drugs, their mechanisms of action, clinical trials, dosage and administration, adverse effects and drug interactions The Medical Letter delivers educational content in the form of self-study material The expected outcome of the CME Program is to increase the participant’s ability to know, or apply knowledge into practice after assimilating, information presented in materials contained in Treatment Guidelines The Medical Letter will strive to continually improve the CME program through periodic assessment of the program and activities The Medical Letter aims to be a leader in supporting the professional development of healthcare professionals through Core Competencies by providing continuing medical education that is unbiased and free of industry influence The Medical Letter is supported solely by subscription fees and accepts no advertising, grants or donations GOAL: Through this program, The Medical Letter expects to provide the healthcare community with unbiased, reliable and timely educational content that they will use to make independent and informed therapeutic choices in their practice LEARNING OBJECTIVES: The objective of this activity is to meet the need of healthcare professionals for unbiased, reliable and timely information on treatment of major diseases The Medical Letter expects to provide the healthcare community with educational content that they will use to make independent and informed therapeutic choices in their practice Participants will be able to select and prescribe, or confirm the appropriateness of the prescribed usage of the drugs and other therapeutic modalities discussed in Treatment Guidelines with specific attention to clinical evidence of effectiveness, adverse effects and patient management Upon completion of this activity, the participant will be able to: Explain the current approach to the management of migraine Discuss the pharmacologic options available for treatment and prevention of migraine and compare them based on their efficacy, dosage and administration, potential adverse effects and drug interactions Determine the most appropriate therapy given the clinical presentation of an individual patient Privacy and Confidentiality: The Medical Letter guarantees our firm commitment to your privacy We not sell any of your information Secure server software (SSL) is used for commerce transactions through VeriSign, Inc No credit card information is stored IT Requirements: Windows 98/NT/2000/XP/Vista/7/8, Pentium+ processor, Mac OS X+ w/ compatible processor; Microsoft IE 6.0+, Mozilla Firefox 2.0+ or any other compatible Web browser Dial-up/high-speed connection Have any questions? Call us at 800-211-2769 or 914-235-0500 or e-mail us at: custserv@medicalletter.org Questions start on next page Treatment Guidelines from The Medical Letter • Vol 11 ( Issue 136) • December 2013 DO NOT FAX OR MAIL THIS EXAM To take CME exams and earn credit, go to: medicalletter.org/CMEstatus Issue 136 Questions Which of the following is least likely to cause medication overuse headache in patients with migraine? a a triptan b acetaminophen c an opioid d an NSAID The drug of choice for treatment of moderate-to-severe migraine is: a butalbital b an NSAID c a triptan d an ergot Subcutaneous injection of sumatriptan produces relief within hours in about what percentage of patients with moderate-tosevere migraine? a 40% b 60% c 80% d 100% A 42-year old woman with episodic migraine has been taking oral sumatriptan to treat her attacks, but often vomits after taking it You could tell her that: a sumatriptan nasal spray is about equally effective b vomiting does not reduce the effectiveness of the oral drug c oral sumatriptan has a faster onset of action than the nasal spray d all of the above The sumatriptan formulation with the fastest onset of action is the: a oral tablet b transdermal patch c nasal spray d SC injection The rate of recurrence of migraine within 24 hours after treatment with a triptan is about: a