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Supplements New Approaches for the Management and Treatment of Migraine
Migraine in the Managed Care Environment
Gary M. Owens, MD
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CME/CE Quiz
Clinical Approaches to Migraine Prophylaxis
Andrew Blumenfeld, MD

CME/CE Quiz

Continuing Medical Education Accreditation The University of Cincinnati College of Medicine designates this educational activity for a maximum of 2 Category 1 credits toward the AMA Physician's Recognition Award. Each physician should claim only those hours that he/she actually spends in the educational activity.

The University of Cincinnati College of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor medical education for physicians.

Continuing Pharmacy Education Accreditation

Medical World Communications Office of Continuing Professional Education is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This program is approved for 2 contact hours (0.2 CEUs) under the ACPE universal program number of 290-999-05-005-H01.

Instructions

After reading "New Approaches for the Management and Treatment of Migraine," complete the program evaluation and select the 1 best answer to each of the following questions. A statement of continuing education hours will be mailed to those who successfully complete (with a minimum score of 70%) the examination at the conclusion of the program.

1. The largest factor in the cost of medical care for migraine patients is:

  1. Hospitalization
  2. Emergency department services
  3. Diagnostic testing and monitoring
  4. Medication

2. Which agents are currently approved for abortive treatment of acute migraine?

  1. Nonsteroidal anti-inflammatory agents and triptans
  2. Triptans and ergot alkaloids
  3. Ergot alkaloids and antiemetics
  4. Antiemetics and nonsteroidal anti-inflammatory agents

3. Certain agents of which classes are currently approved for migraine prophylaxis?

  1. Antidepressants and calcium channel blockers
  2. Calcium channel blockers and antiepileptics
  3. Antiepileptics and beta blockers
  4. Beta blockers and serotonin blockers

4. Triptans are generally considered to be:

  1. Cost effective despite high acquisition cost
  2. Cost effective because of low acquisition cost
  3. Not cost effective because of high acquisition cost
  4. Not cost effective despite low acquisition cost

5. In comparison with a stepped-care approach to migraine treatment, a stratified-care approach offers:

  1. Lower direct costs for medical care and indirect costs for lost productivity
  2. Lower direct costs but poorer clinical outcome
  3. Higher direct costs but superior outcome and lower overall costs
  4. Clinical equivalence, lower direct costs, and higher indirect costs

6. Onset of chest pain in patients with migraine has been associated with use of:

  1. Propranolol
  2. Verapamil
  3. Topiramate
  4. Sumatriptan

7. Migraine prophylaxis is cost effective if:

  1. The actual number of headaches per month exceeds the cost-equivalent number
  2. The cost-equivalent number exceeds the actual number of headaches per month
  3. Direct medical costs exceed indirect costs
  4. Indirect costs exceed direct medical costs

8. Defining criteria for chronic migraine include all of the following EXCEPT:

  1. Attacks on at least 15 days per month for more than 3 months
  2. Attacks must be accompanied by aura
  3. Attacks cannot be attributed to other conditions
  4. Attacks cannot be attributed to medication overuse

9. Risk factors for chronic migraine include all of the following EXCEPT:

  1. High frequency of episodic attacks
  2. Hypertension
  3. Hyperthyroidism
  4. Overconsumption of caffeine

10. Which agent used in migraine prophylaxis has been associated with weight gain?

  1. Propranolol
  2. Divalproex
  3. Topiramate
  4. Botulinum toxin

11. The mechanism by which botulinum toxin prevents migraine is thought to involve:

  1. Agonist activity at serotonin receptors
  2. Antagonist activity at serotonin receptors
  3. Regulation of dopamine activity in the brain
  4. Blockade of pain impulses and motor impulses in head and neck muscles

12. Measures to reduce acute migraine frequency include all of the following EXCEPT:

  1. Avoidance of alcohol
  2. Avoidance of glaring or flickering lights
  3. Avoidance of strongly aromatic substances
  4. Weight correction

13. Findings from clinical trials of botulinum toxin include all of the following EXCEPT:

  1. Meaningful reductions in headache frequency
  2. Absence of systemic effects
  3. Absence of problems related to compliance
  4. One-month duration of effectiveness

14. The mechanism by which antiepileptic drugs prevent migraine is thought to involve:

  1. Generalized depression of cerebral cortical activity
  2. Augmentation of gamma-aminobutyric acid
  3. Increases in carbonic anhydrase activity
  4. Blockade of serotonin receptors

15. In general, managed care plans regard the use of botulinum toxin in migraine prophylaxis as:

  1. A safe and effective measure that is routinely approved in most patients
  2. Automatically disallowed because it is not approved by the US Food and Drug Administration
  3. A secondary modality that may be considered in patients in whom conventional approaches have been ineffective or intolerable
  4. Permissible only in combination with an approved systemically acting agent

16. In most managed care plans:

  1. Triptans as a class are approved as first-line abortive treatment for migraine, but selection of a specific agent and dosing regimen is individualized
  2. Triptans are approved only after failure of ergot alkaloids, which are less costly
  3. Policies on migraine prophylaxis are more definitive and consistent than policies on abortive treatment
  4. Prophylaxis is approved only for patients who meet the criteria for chronic migraine

17. Triptans:

  1. Can be considered clinically interchangeable despite cost differences
  2. Produce an adequate clinical response within 2 hours in over 90% of patients
  3. Can be used as often as needed with no increased risk of conversion to chronicity
  4. Account for the greatest share of the cost of migraine medication in the United States

18. In migraine prophylaxis:

  1. Beta blockers are contraindicated in combination with divalproex
  2. Botulinum toxin is contraindicated in patients with hypertension
  3. It is not known whether the effectiveness of antidepressants is related to their mood-altering activity
  4. Selective serotonin reuptake inhibitors are more effective than tricyclic antidepressants

19. In which of the following patients would a typical managed care plan be most likely to approve the use of botulinum toxin for migraine prophylaxis?

  1. A treatment-naïve patient having an average of 6 headaches per month
  2. A patient who has 6 headaches per month despite trials of divalproex and topiramate
  3. A patient who has 6 headaches per month, all treated successfully with triptans
  4. A patient in whom prophylaxis with antidepressants is effective but has been causing weight gain

20. All of the following statements about migraine epidemiology are true EXCEPT:

  1. The prevalence is higher in women than in men
  2. The overall prevalence in the western nations is approximately 11% among adults
  3. Patients with frequent migraine are at increased risk for ischemic stroke
  4. Peak prevalence is in people aged 50 to 65 years



Figure

CE QUIZ

For Pharmacists

ANSWER CARD INSTRUCTIONS

Testing and Grading Procedures

1. Each participant achieving a passing grade of 70% or higher on any examination will receive an official computer form stating the number of CE credits earned. This form should be safeguarded and may be used as documentation of credits earned.

2. Participants receiving a failing grade on any exam will be notified and permitted to take 1 reexamination at no cost.

3. All answers should be recorded on the answer form. Please print clearly to ensure receipt of CE credit.

4. To receive credit certification electronically, please provide your e-mail address. Detach and mail completed exam form with your $10.00 payment to Pharmacy Times, 405 Glenn Drive, Suite 4, Sterling, VA 20164-4432; or fax to 703-404-1801.

5. Take the test online for FREE at www.pharmacytimes.com and receive immediate grading and CE credits, and download your CE statement of credit.

Please photocopy the test form for additional test takers.

Medical World Communications Office of Continuing Professional Education is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This program is approved for 2 contact hours (0.2 CEUs) under the ACPE universal program number of 290-999-05-005-H01. The program is available for CE credit through June 30, 2006.

Answer card and evaluation form for Pharmacists follow on page S76.

Figure

New Approaches for the Management and Treatment of Migraine

GOAL

To provide participants with current information about new approaches to the management and treatment of migraine.

TARGET AUDIENCE

This activity is intended for physicians, medical directors, pharmacists, pharmacy directors, primary care physicians, and specialists in neurology.

EDUCATIONAL OBJECTIVES

After completing this continuing education activity, the participant should be able to:

-Discuss the complications that often occur when treating chronic or intractable migraine and the new therapies such as botulinum toxin that may provide effective treatment.

-Explain and compare the costs associated with treating migraine.

-Define the challenges managed care decision makers face when creating policy for migraine management and treatment.

CONTINUING MEDICAL EDUCATION ACCREDITATION

The University of Cincinnati College of Medicine designates this activity for a maximum of 2 Category 1 credits toward the AMA Physician's Recognition Award. Each physician should claim only those hours that he/she actually spends in the educational activity.

The University of Cincinnati College of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor medical education for physicians. Release Date: June 1, 2005. Expiration Date: June 30, 2006.

CONTINUING PHARMACY EDUCATION ACCREDITATION

 
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