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


Finding A Fit: New Strategies For Chronic Daily Headache Prophylaxis


GOAL
To provide neurologists with up-to-date information on the treatment and management of patients with chronic daily headache.

TARGET AUDIENCE
This activity is designed for neurologists. No prerequisites required.

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, the participant should be able to:

  • Recognize the impact of chronic daily headache (CDH) in the United States.
  • Outline diagnostic approaches for CDH.
  • Identify useful pharmacologic and nonpharmacologic prophylactic options for CDH.
  • Recognize psychiatric comorbidities associated with CDH and treat accordingly.

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 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The estimated time to complete this educational activity: 2 hours.

Release date: April 15, 2006.
Expiration date: April 15, 2008.

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 Allergan, Inc.

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 Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

Brian E. Mondell, MD
Assistant Professor of Neurology
The Johns Hopkins University School of Medicine
The Johns Hopkins Hospital
Baltimore, Maryland
Dr Mondell reports having no significant financial or advisory relationships with corporate organizations related to this activity.

PARTICIPATING FACULTY

David W. Dodick, MD, FRCP(C), FACP
Professor of Neurology
Mayo Clinic College of Medicine
Mayo Clinic
Scottsdale, Arizona
Dr Dodick reports receiving research support from Advanced Bionics, Allergan, Inc, Medtronic, and St Jude; and serving as a consultant for Allergan, Inc, AstraZeneca, Endo Pharmaceuticals, GlaxoSmithKline, Medtronic, Merck & Co., Inc, Pfizer, Inc, and Ortho-McNeil.

Arthur H. Elkind, MD
Director, Elkind Headache Center
Mount Vernon, New York
President, National Headache Foundation
Clinical Associate Professor of Medicine
New York Medical College
Valhalla, New York.
Dr Elkind reports receiving research support from Abbott Laboratories and Allergan, Inc; and serving as a consultant for and receiving honoraria from Allergan, Inc.

Grace I. Forde, MD
Assistant Professor
Department of Neurology
New York University School of Medicine
Director of Neurological Services
North Shore Pain Service
Valley Stream, New York
Dr Forde reports receiving research support from GlaxoSmithKline and Pfizer, Inc; and serving as a consultant for GlaxoSmithKline.

Constance J. Johnson, MD
Director, Headache Care Center
Clarksville, Tennessee
Associate Clinical Professor
Department of Neurology
Vanderbilt University School of Medicine
Nashville, Tennessee
Dr Johnson reports receiving grants/research support from Allergan, Inc, AstraZeneca, GlaxoSmithKline, Merck & Co., Inc, and UCB Pharma; serving as a consultant for AstraZeneca and MedPointe; and receiving honoraria from Allergan, Inc, AstraZeneca, GlaxoSmithKline, Ortho-McNeil, and Pfizer, Inc.

David Morledge, MD
Assistant Clinical Professor of Neurology
University of Texas Medical Branch 
Galveston, Texas
Austin Neurological Clinic
Austin, Texas
Dr Morledge reports having no significant financial or advisory relationships with corporate organizations related to this activity.

John F. Rothrock, MD
Professor of Neurology
Associate Dean for Clinical Research
University of South Alabama College of Medicine
Mobile, Alabama
Dr Rothrock reports receiving grants/research support from Allergan, Inc, Elan, GlaxoSmithKline, Merck & Co., Inc, Ortho-McNeil, Pfizer, Inc, and Pozen Pharmaceutical Development Company; serving as a consultant for Allergan, Inc, Merck & Co., Inc, Ortho-McNeil, Pfizer, Inc, and Pozen Pharmaceutical Development Company; holding stock in Elan, Johnson & Johnson, Pfizer, Inc, and Pozen Pharmaceutical Development Company; and receiving honoraria from Endo Pharmaceuticals, GlaxoSmithKline, Merck & Co., Inc, Ortho-McNeil, and Pfizer, Inc.

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

Dr Dodick—botulinum toxin type A, lamotrigine for migraine.
Dr Elkind—amitriptyline, botulinum toxin type A, divalproex sodium, topiramate.
Dr Forde—acupuncture and butterbur for migraines, coenzyme Q10, magnesium, riboflavin (vitamin B2).
Dr Johnson—botulinum toxin type A, levetiracetam, zonisamide.
Dr Morledge—botulinum toxin type A, methadone.
Dr Rothrock—botulinum toxin type A and zonisamide for headache prophylaxis.

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

Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins 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.

Finding A Fit: New Strategies For Chronic Daily Headache Prophylaxis
Brian E. Mondell, MD

In 2004, the International Headache Society published a revised International Classification of Headache Disorders in the form of the second edition. The first edition was published in 1988. In the second edition, an important advance in the understanding of chronic daily headaches (CDH) was the addition of diagnostic criteria for chronic migraine.1 In clinical practice we recognize the problem of CDH, a problem that can be extremely debilitating and that is not uncommon, as it affects roughly 4% to 5% of the adult population 2,3 and 1% to 2% of children.4 Despite advances in classification, this entity known as CDH remains still poorly understood and, not surprisingly, frequently mismanaged with no formal guidelines available for clinicians. It is estimated that 12 million people worldwide live with daily (or nearly daily) headaches,5 accounting for the majority of referrals to headache clinics and specialists in the United States and the United Kingdom.6,7

In light of this fact, an expert roundtable was convened in New York City on December 3, 2005, bringing together representatives from academic neurology and practicing community headache specialists (neurologists and internists) from across the United States to discuss the problem of CDH and to specifically address the state of management of CDH. Formal presentations were made regarding preventative strategies based on full recognition of any comorbidity and with full understanding of available pharmacologic and nonpharmacologic therapies. Case studies also were presented, and all presentations were followed by discussion as a means to challenge current knowledge and practices using personal clinical experience, in addition to available scientific information. The result of these collegial discussions are presented in this monograph and online to share this panel's thoughts for "Best Practices" in the areas of diagnosis and treatment—particularly the need to implement meaningful options for managing CDH in daily medical practice.

This issue of Johns Hopkins Advanced Studies in Medicine opens with an overview of CDH by Arthur H. Elkind, MD, including the epidemiology of the condition, risk factors associated with CDH, and classifications and criteria for subcategories of CDH (ie, chronic migraine and chronic tension-type headache [CTTH]). Dr Elkind reviews the differential diagnosis and red flags and provides information for the clinician about how to assess the severity of pain and degree of disability. He also reviews the pathophysiology of CDH, as we know it, because this may provide clues to the mechanism of action for successful treatments.

John F. Rothrock, MD, focuses on common prophylactic practices for CDH. Specifically, he reviews the categories of pharmacologic therapies currently in use for this condition, including tricyclic antidepressants, b blockers, and antiepileptic drugs. Dr Rothrock takes a step-by-step approach to the patient with CDH, focusing on identifying the specific subtype of headache to tailor therapy according to CDH type. He also discusses acute versus prophylactic therapy and pharmacologic versus nonpharmacologic interventions.

David W. Dodick, MD, FRCP(C), FACP, discusses emerging preventative options for CDH, including the results of randomized clinical trials with botulinum toxin type A for the management of related types of headache, episodic migraine, and CTTH. He also reviews other emerging therapies, including coenzyme Q10, Petasites hybridus, and more well-established members of the neurologic pharmacologic armamentarium.

Also included are case studies relating to psychiatric comorbidities by Constance J. Johnson, MD, examining the emerging therapy, botulinum toxin type A, by David Morledge, MD, and discussing the use of nonpharmacologic agents by Grace I. Forde, MD. Each case study is presented along with the highlights of various postpresentation discussions.

There is much potential on the horizon for expanding the appropriate use of novel and promising therapies for various manifestations of the problematic category of CDH. The contents of this issue of Johns Hopkins Advanced Studies in Medicine offer the practicing clinician the opportunity to learn of these emerging treatment options, with the aim of decreasing the incidence and impact of this common and debilitating condition.

REFERENCES

1. Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders. Cephalalgia. 2004;24:1-160.
2. Scher AI, Stewart WF, Liberman J, Lipton RB. Prevalence of frequent headache in a population sample. Headache. 1998;38:497-506.
3. Castillo J, Munoz P, Guitera V, Pascual J. Epidemiology of chronic daily headache in the general population. Headache. 1999;39:190-196.
4. Silberstein SD, Lipton RB. Chronic daily headache. Curr Opin Neurol. 2000;18:414-439.
5. Dodick DW, Mauskop A, Elkind AH, et al. Botulinum toxin type A for the prophylaxis of chronic daily headache: subgroup analysis of patients not receiving other prophylactic medications: a randomized, double-blind, placebo-controlled study. Headache. 2005;45:315-324.
6. Mathew NT, Reuveni U, Perez F. Transformed or evolutive migraine. Headache. 1987;27:102-106.
7. Dowson AJ. Analysis of the patients attending a specialist UK headache clinic over a 3-year period. Headache. 2003;43:14-18.

*Assistant Professor of Neurology, The Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland.
Address correspondence to: Brian E. Mondell, MD, The Johns Hopkins Hospital, Billings Administration 324, 600 North Wolfe Street, Baltimore, MD 21287.
E-mail: bmondell@jhmi.edu.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.