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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Women's Health Update: Special Considerations in Patients with Menstrually Related Migraine


GOAL
To provide neurologists, obstetricians/gynecologists, primary care physicians, physician
assistants, and nurse practitioners up-to-date information on the diagnosis and treatment opportunities for menstrually related migraine, as well as highlight this condition's impact on healthcare.

TARGET AUDIENCE
This activity is designed for neurologists, obstetricians/gynecologists, primary care physicians, physician assistants, and nurse practitioners.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, participants should be able to:

  • Examine the prevalence and impact of menstrually related migraine in the United States
  • Discuss current understanding of the pathophysiology of menstrually related migraine
  • Identify the optimal treatments for menstrually related migraine, including concomitant contraceptive prescription
  • Review the many special opportunities to improve outcomes in counseling and managing women with migraine

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School 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 credits that he/she actually spent in the activity. The estimated time to complete this educational activity: 2 hours.

Release date: October 15, 2005.
Expiration date: October 15, 2007.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Endo Pharmaceuticals.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Directors and Participating Faculty reported the following:

PROGRAM DIRECTORS

Brian E. Mondell, MD
Medical Director
Baltimore Headache Institute
Assistant Professor of Neurology
Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Mondell reports having no financial or advisory relationship with corporate organizations related to this activity.

Stephen D. Silberstein, MD, FACP
Director, Jefferson Headache Center
Thomas Jefferson University Hospital
Professor of Neurology
Thomas Jefferson University
Philadelphia, Pennsylvania
Dr Silberstein reports receiving grants/research support from Abbott Laboratories, Allergan Inc, AstraZeneca LP, Eli Lilly and Company, GlaxoSmithKline, Johnson & Johnson, Medtronics, Merck & Co, NPS Pharmaceuticals, Pfizer Inc, Pozen Inc, UCB Pharma, and X-Cel Pharmaceuticals; and is on the advisory panel, speakers' bureau, and serves as a consultant to Abbott Laboratories, AstraZeneca LP, Eli Lilly and Company, GlaxoSmithKline, Johnson & Johnson, Merck & Co, Metis, NPS Pharmaceuticals, Ortho-McNeil Pharmaceutical, Pfizer Inc, Pozen Inc, UCB Pharma, and X-Cel Pharmaceuticals.

PARTICIPATING FACULTY

Jan Lewis Brandes, MD, MS
Director, Nashville Neuroscience Group;
Clinical Instructor
Department of Neurology
Vanderbilt University School of Medicine
Nashville, Tennessee
Dr Brandes reports receiving grants/research support from Allergan Inc, AstraZeneca LP, Bristol-Myers Squibb, Elan Pharmaceutical, Forest Laboratories, GlaxoSmithKline, Johnson & Johnson, Merck & Co, Novartis, Ortho-McNeil Pharmaceutical, Pfizer Inc, Pozen Inc, Sanofi-Synthelabo, UCB Pharma, Vernalis, Winston Labs; has received an educational grant from GlaxoSmithKline; has received honoraria from Allergan Inc, AstraZeneca LP, Endo Pharmaceuticals, GlaxoSmithKline, MedPointe Pharmaceuticals, Merck & Co, Ortho-McNeil Pharmaceutical, Pfizer Inc, Pharmacia, and UCB Pharma; and has served as a consultant to Allergan Inc, Aradigm Corp, AstraZeneca LP, GlaxoSmithKline, Merck & Co, Ortho-McNeil Pharmaceutical, and Pfizer Inc.

Roger K. Cady, MD
Medical Director
Headache Care Center and Primary Care Network, Inc.
Springfield, Missouri
Dr Cady reports receiving grants/research support from Abbott Laboratories, Allergan Inc, Alexa, Aradigm Corp, CAPNIA, Cipher, Eisai, Endo Pharmaceuticals, GelStat, GlaxoSmithKline, Johnson & Johnson, Matrixx, Merck & Co, Novartis, Ortho-McNeil Pharmaceuticals, Pfizer Inc, Pozen Inc, and Vernalis; has served as a consultant to Aradigm Corp; and has served on the advisory boards of Allergan Inc, Atrix Labs, CAPNIA, Endo Pharmaceuticals, GlaxoSmithKline, Johnson & Johnson, MedPointe, Merck & Co, Ortho-McNeil Pharmaceutical, and Winston Labs.

Frederick G. Freitag, DO
Associate Director 
Diamond Headache Clinic
Chicago, Illinois
Clinical Associate Professor
Department of Family Medicine
Rosalind Franklin University of Medicine & Science
Chicago Medical School
North Chicago, Illinois
Dr Freitag reports receiving grants and/or has conducted research for Abbott Laboratories, Allergan Inc, AstraZeneca LP, CAPNIA, Elan Pharmaceutical, GlaxoSmithKline, Merck & Co, Novartis, NPS Pharmaceuticals, Ortho-McNeil Pharmaceuticals, and Pozen Inc; has served as a consultant to Allergan Inc, CAPNIA, GlaxoSmithKline, Interpharm Pharmaceuticals, Medpointe Pharmaceuticals, Ortho-McNeil Pharmaceuticals, X-cel Pharmaceuticals, and Vendanta Research; and has served on the speakersÕ bureau of GlaxoSmithKline, MedPointe Pharmaceuticals, Ortho-McNeil Pharmaceuticals, Pfizer Inc, and X-cel Pharmaceuticals.

Richard B. Lipton, MD
Professor and Vice Chair
Department of Neurology
Professor of Epidemiology and Population Health
Albert Einstein College of Medicine
Director, Montefiore Headache Unit
Montefiore Medical Center
Bronx, New York
Dr Lipton reports receiving research/educational grants and serving on the advisory panel and speakers' bureaus of Allergan Inc, AstraZeneca LP, Boehringer-Ingelheim, Bristol-Myers Squibb, GlaxoSmithKline, Johnson & Johnson, Merck & Co, Ortho-McNeil Pharmaceutcal, Pozen Inc, and Pfizer Inc.

Gretchen E. Tietjen, MD
Professor and Chair
Division of Neurology
Director
Headache Treatment and Research Program, and Stroke Program
Medical University of Ohio
Toledo, Ohio
Dr Tietjan reports having no financial or advisory relationship with corporate organizations related to this activity.

Howard A. Zacur, MD, PhD 
Theodore and Ingrid Baramki Professor
Director of the Division of Reproductive Endocrinology and Infertility
Department of Gynecology and Obstetrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Zacur reports having no financial or advisory relationship with corporate organizations related to this activity.

Notice: The audience is advised that articles in this CME activity contain reference(s) to unlabeled or unapproved uses of drugs or devices.

Dr Brandes—Hormone therapy, including oral estrogen, patches, continuous oral contraceptives, and intermittent or short-term prophylaxis
Dr Cady—Naratriptan and frovatriptan as short-term prophylaxis for menstrually related migraine
Dr Silberstein—Intermittent or short-term prophylaxis

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Women's Health Update: Special Considerations In Patients With Menstrually Related Migraine
Brian E. Mondell, MD*; Stephen D. Silberstein, MD, FACP 

Migraine of all types, which affects 28 million men and women in the United States,1 is a disabling primary headache disorder that has considerable impact on activities of daily living, family and social activities, and productivity on the job and in school.1-4 It is most prevalent in men and women between the ages of 25 and 55, a span that roughly coincides with the average adult's peak years in the workplace and much of the average woman's reproductive years.1

However, migraine has an uneven gender distribution, striking women 33 more often than men.1 An estimated 60% of women with migraine report that their headaches occur only during the perimenstrual period or during this period and at other times of the month.3-5 By this reckoning, as many as 12 million women in the United States suffer from menstrually related migraine (MRM). Because many of these women also have menstrually related symptoms such as dysmenorrhea and menorrhagia, they deal not only with the burden of migraine, but also with the burden of menstruation.

This issue of Advanced Studies in Medicine acknowledges the increased prevalence and impact of migraine in women by presenting the proceedings of a roundtable symposium held in New York City on May 14, 2005.

The roundtable, Women's Health Update: Special Considerations in Patients With Menstrually Related Migraine, featured a distinguished faculty of headache specialists and a reproductive endocrinologist to explore the complex relationship between migraine headache and the menstrual cycle and elucidate why MRM can be more difficult to treat than can other types of migraine.

The issue begins with an overview of MRM and its diagnosis jointly authored by Dr Jan Lewis Brandes, a neurologist and headache specialist; Dr Frederick G. Freitag, an osteopathic physician and headache specialist; and Dr Howard A. Zacur, a reproductive endocrinologist.

The article presents a review of the hormonal changes that occur during the menstrual cycle and various stages in a woman's lifetime. These hormonal fluctuations play a major role in the pathogenesis of MRM, as well as informing the diagnosis and choice of therapy. To follow is a discussion of the epidemiology, classification, clinical characteristics, and pathophysiology of MRM, and in closing, an overview of the diagnosis of MRM and other hormone-related headaches, as well as the comorbid conditions that frequently accompany migraine and MRM.

Dr Roger K. Cady addresses acute treatment of MRM, focusing on approaches that recognize the contributions of the menstrual cycle and the migraine headache process, treatment dynamics, and phase-based therapy. He also reviews the treatment of migraine during pregnancy and lactation.

Dr Stephen D. Silberstein (co-chair of this roundtable) discusses preventive treatment, which is initiated when acute therapies for MRM fail to provide a satisfactory headache outcome. In particular, his review focuses on preemptive treatment directed at known migraine triggers, short-term prophylaxis with triptans, and hormonal manipulation for long-term prophylaxis.

Dr Gretchen E. Tietjen addresses the personal impact of MRM, noting that there is surprisingly little information in the literature on this condition. She describes several methods a woman can use to predict her next migraine attack, and explains why a multidisciplinary approach to MRM management is essential.

In the closing presentation, Dr Richard B. Lipton discusses in some detail the economic implications of migraine and MRM for employers and managed care health plans. He also presents strategies to provide cost-effective medical interventions in the workplace and explains why MRM is an attractive target for treatment in this regard.

This issue of Advanced Studies in Medicine also features a headache diary/calendar that is specific to MRM. It is available as a PDF at the Advanced Studies in Medicine web site, www.jhasim.com, where it can be downloaded as often as necessary and distributed to all women with migraine, MRM, or migraine-like headaches.  Click here to view the online content.

REFERENCES
1. Lipton RB, Diamond S, Reed M, Diamond ML, Stewart WF. Migraine diagnosis and treatment: results from the American Migraine Study II. Headache. 2001;47:638-645.
2. MacGregor EA, Hackshaw A. Prevalence of migraine on each day of the natural menstrual cycle. Neurology. 2004;63:351-353.
3. Couturier EG, Bornhof M, Neven AK, van Duijn NP. Menstrual migraine in a representative Dutch population sample: prevalence, disability and treatment. Cephalalgia. 2003;23:302-308.
4. Hu XH, Markson LE, Lipton RB, Stewart WF, Berger ML. Burden of migraine in the United States: disability and economic costs. Arch Intern Med. 1999;159:813-818.
5. Mannix LK, Calhoun AH. Menstrual migraine. Curr Treat Options Neurol. 2004;6:489-498.

*Medical Director, Baltimore Headache Institute; Assistant Professor of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
 Professor of Neurology and Director, Jefferson Headache Center, Thomas Jefferson University, Philadelphia, Pennsylvania.
Address correspondence to: Brian E. Mondell, MD, Johns Hopkins Hospital, Administration 324, 600 N Wolfe St, Baltimore, MD 21287. E-mail:
bmondell@jhmi.edu.





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