arrow Log In to View Account     |      
HOME
Johns Hopkins Medicine
Hopkins Logo


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


Neurology Update: Educational Continuum On Chronic Daily Headache


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:

  • Describe the pathophysiology of chronic daily headache (CDH).
  • Delineate diagnostic approaches to headache disorders.
  • Evaluate pharmacologic and nonpharmacologic prophylactic options for CDH.
  • Identify and treat CDH and its associated comorbidities.

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: October 15, 2006. Expiration date: October 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

Sheena K. Aurora, MD
Director, Swedish Headache Center
Swedish Pain Service
Seattle, Washington
Dr Aurora reports receiving grants/research support from Alexza Pharmaceuticals, Allergan, Inc, AstraZeneca, GlaxoSmithKline, Merck & Co., Inc, and Winston Laboratories, Inc.; serving as a consultant for Allergan, Inc, AstraZeneca, GlaxoSmithKline, Merck & Co., Inc, NMT, Ortho-McNeil, and Pfizer, Inc; and receiving honoraria from AstraZeneca, GlaxoSmithKline, Merck & Co., Inc, Ortho-McNeil, Pfizer, Inc, and Valeant Pharmaceuticals International.

John Claude Krusz, PhD, MD
Board of Directors Texas Pain Society
Vice President, American Board of Electroencephalography and Neurophysiology
Director, ANODYNE Headache and PainCare Center
Dallas, Texas
Dr Krusz reports receiving grants/research support from Abbott Laboratories, Allergan, Inc, Eisai Inc, and Endo Pharmaceuticals; and receiving honoraria from and serving on the speakers' bureau for Accorda, GlaxoSmithKline, Ortho-McNeil, Pfizer, Inc, Sanofi-Aventis, and Valeant Pharmaceuticals International.

Paul B. Rizzoli, MD
Clinical Director
John R. Graham Headache Center
Faulkner Hospital
Boston, Massachusetts
Dr Rizzoli reports serving on the speakers' bureau for Pfizer, Inc.

Ernestina M. H. Saxton, MD, PhD
Professor Emeritus of Neurology
University of California Los Angeles
Comprehensive Headache and Migraine~Pain Clinic
A Medical Corporation
Los Angeles, California
Dr Saxton reports serving on the speakers' bureau for Cephalon Inc., GlaxoSmithKline, Merck & Co., Inc, Ortho-McNeil, and Pfizer, Inc.

Jack D. Schim, MD
The Headache Center of Southern California
Encinitas, California
Assistant Clinical Professor of Neurology
University of California San Diego
San Diego, California
Dr Schim reports receiving grants/research support from and serving as a consultant for Allergan, Inc; and receiving honoraria from and serving on the speakers' bureau for Allergan, Inc, GlaxoSmithKline, Merck & Co., Inc, Ortho-McNeil, and Pfizer, Inc.

Stephen D. Silberstein, MD, FACP
Director, Jefferson Headache Center
Professor of Neurology
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania
Dr Silberstein reports receiving grants/research support from Abbott Laboratories, AGA, Allergan, Inc, ANS, AstraZeneca, Endo Pharmaceuticals, Eli Lilly and Company, GlaxoSmithKline, Medtronic, Merck & Co., Inc, Ortho-McNeil, Pfizer, Inc, Pozen Pharmaceutical Development Company, and Valeant Pharmaceuticals International; receiving honoraria for serving on the speakers' bureau for AstraZeneca, GlaxoSmithKline, Merck & Co., Inc, Ortho-McNeil, and Pfizer, Inc; and receiving honoraria for serving as an advisory board member for Allergan, Inc, Endo Pharmaceuticals, Medtronic, Merck & Co., Inc, Ortho-McNeil, Pfizer, Inc, Pozen Pharmaceutical Development Company, and Valeant Pharmaceuticals International.

Maureen Wooten Watts, MD
Adult Neurology
Dallas Headache Association
Dallas, Texas
Dr Watts reports serving on the speakers' bureau for Allergan, Inc, 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 Aurora—botulinum toxin type A injection.
Dr Krusz—tizanidine.
Dr Rizzoli—amitriptyline, botulinum toxin type A, venlafaxine, verapamil.
Dr Schim—botulinum toxin type A for headache prevention.
Dr Silberstein—almost all preventive migraine drugs are off-label.

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.

Neurology Update: Educational Continuum On Chronic Daily Headache
Brian E. Mondell, MD

Chronic daily headache (CDH) is a common and extremely debilitating condition that accounts for the majority of referrals to headache clinics and specialists in the United States and United Kingdom.1,2 An estimated 12 million people worldwide live with these daily (or nearly daily) headaches,3 with approximately 4% to 5% of the adult population 4,5 and 1% to 2% of children affected by CDH.6 In addition, the cost of lost productivity as a result of migraine in the United States is estimated to be between $5.6 billion and $17.2 billion annually.7 Diagnosis of and research in CDH has been difficult because there has been no clear classification. Originally, the International Classification of Headache Disorders (ICHD) first edition, which was published in 1988 by the International Headache Society (IHS), referred to CDH as a combination of chronic tension-type headache (CTTH) with or without migraine features.8 Then in 1996, the Silberstein and Lipton criteria9 described CDH as a group of disorders including, CTTH, transformed migraine, new daily persistent headache, and hemicrania continua. Revisions were made again in 2004, when IHS published the second edition of the ICHD, which included the diagnostic criteria for chronic migraine.10 However, despite these updates, CDH remains poorly understood and frequently suboptimally managed.

To address these issues, a series of expert roundtables was convened this year throughout the United States, which brought together the most prominent clinicians from academic neurology and practicing  community headache specialists (neurologists and internists) to discuss the most updated clinical research and speak to the state of CDH management. The classification, epidemiology, and risk factors for CDH were thoroughly discussed. In addition, preventive strategies were detailed, based on full recognition of any comorbidity and with full understanding of available pharmacologic and nonpharmacologic therapies. Faculty also presented case studies examining different challenges in CDH diagnosis and treatment. All presentations were followed by discussion, in which current knowledge and practices were challenged, using a combination of personal clinical experience and available clinical and scientific information.

This issue of Johns Hopkins Advanced Studies in Medicine opens with an overview of CDH by Stephen D. Silberstein, MD, FACP, covering the classifications, epidemiology, and risk factors associated with CDH. Dr Silberstein reviews the specific IHS diagnostic criteria for various headache conditions that are crucial to the assurance of appropriate clinical treatment, in addition to consistency in research studies. Sheena K. Aurora, MD, discusses strategies to treat and prevent CDH based on her exploration of the underlying pathophysiology of CDH and the biologic basis for migraine prevention. Dr Aurora proposes a 3-pronged approach to migraine treatment and prevention. In effect, strategies for migraine treatment optimally include acute and preventive therapies, in addition to preemptive treatment in certain circumstances, such as when a patient knows of and preempts specific lifestyle triggers. Guidelines are presented for determination of appropriate initiation of preventive migraine therapy, and commonly prescribed medications are reviewed, along with highlights from clinical trial data regarding these various therapies.

Also included are case studies presenting different scenarios in CDH treatment and management. Ernestina M. H. Saxton, MD, PhD, provides a case study examining day-to-day living with CDH. Jack D. Schim, MD, discusses a patient with cervical dystonia-associated headache. The importance of early and aggressive intervention is outlined by Paul B. Rizzoli, MD. One will note that individual faculty members have selected botulinum toxin type A therapy for their CDH case studies. The intent is not to advocate or promote any single treatment but rather to best reply to reader inquiries and to try to further explore current, unanswered questions. With this in mind, I encourage the reader to critically consider available research evidence and the faculty's clinical practice experience. In this way, I hope that the end result is to help practitioners determine whether or not this particular treatment represents an overlooked therapeutic option for them. Finally, the last 2 case studies are particularly instructive as they demonstrate the real need to consider and appropriately address secondary causes of CDH—specifically, intracranial hypertension and chronic meningitis, as discussed by John Claude Krusz, PhD, MD, and Maureen Wooten Watts, MD, respectively.

Each presentation in this expert roundtable series was followed by a lively discussion and debate among the faculty. Highlights from these "Best Practices" in diagnosis and treatment are available at the Web site, www.jhasim.com/cdh. Here, you can follow up on an article read within this issue to understand how different experts reacted to a particular subject or viewpoint.

Also at the Web site, you will find new review articles and case studies from the expert roundtable series which were not included in this monograph due to space constraints. These provide more evidence-based content on prevention and treatment options for CDH. The extra case studies cover the management of patients with CDH and special circumstances, such as CDH and the patient with obesity or management of CDH during pregnancy. 

Although there is currently no cure for CDH, advances are being made to expand the currently accepted therapeutic armamentarium through the appropriate use of novel and promising therapies for the different manifestations of CDH, therefore improving the quality of life of these patients. The content provided in this issue of Johns Hopkins Advanced Studies in Medicine and on the Web site offers further information about these emerging treatment options to minimize the impact of this common and debilitating condition, and, perhaps, serve to decrease the incidence through proactive efforts.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.

REFERENCES

1. Mathew NT, Reuveni U, Perez F. Transformed or evolutive migraine. Headache. 1987;27:102-106.
2. Dowson AJ. Analysis of the patients attending a specialist UK headache clinic over a 3-year period. Headache. 2003;43:14-18.
3. 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.
4. Scher AI, Stewart WF, Liberman J, Lipton RB. Prevalence of frequent headache in a population sample. Headache. 1998;38:497-506.
5. Castillo J, Munoz P, Guitera V, Pascual J. Epidemiology of chronic daily headache in the general population. Headache. 1999;39:190-196.
6. Silberstein SD, Lipton RB. Chronic daily headache. Curr Opin Neurol. 2000;18:414-439.
7. Osterhaus JT, Gutterman DL, Plachetka JR. Healthcare resource and lost labour costs of migraine headache in the US. Pharmacoeconomics. 1992;2:67-76.
8. Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias, and facial pain. Cephalalgia. 1988;8:1-96.
9. Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily headaches: field trial of revised IHS criteria. Neurology. 1996;47:871-875.
10. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders: 2nd ed. Cephalalgia. 2004;24:9-160.

*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.