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


Concept to Practice: Developmental Advances in Migraine Management


GOAL
To provide neurologists with the most current information available for the treatment and management of migraine and other headache disorders.

PROGRAM SERIES RATIONALE
This program is designed to provide neurologists with current and practical information for the diagnosis, acute treatment, and prevention of migraine as well as other headache disorders. In the past decade, advances have been made in the use of triptans and antiepileptic drugs for acute and preventive treatment. Advanced imaging techniques have shed light on pathophysiology, and improvements in diagnostic criteria have enhanced diagnostic accuracy. As with other areas of scientific research, recent and current investigations of migraine and other forms of headache continue to raise new issues. As these issues are explored, it is hoped that future investigations will provide answers that will improve treatment and quality of life.

TARGET AUDIENCE
This activity is designed for neurologists, particularly those who treat patients with migraine. 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, participants should be able to:

  • Identify the barriers to care in patients with migraine.
  • Understand effective methods for addressing migraine treatment failures.
  • Review nonpharmacologic approaches for preventing migraine and tension-type headache.
  • Understand how to identify and manage patients with rebound headache.
  • Evaluate 2 possible new treatments for migraine prevention.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor 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: March 15, 2003. Expiration date: March 15, 2005.

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 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 unrestricted educational grant from Ortho-McNeil Pharmaceutical, Inc.

Advanced Studies in Medicine (ISSN-1530-3004) is published by Galen Publishing, LLC, an HMG Company. P.O. Box 340, Somerville, NJ 08876. (908) 253-9001. Web site: www.galenpublishing.com. Copyright ©2001 by Galen Publishing, LLC. 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. Bulk postage paid at Somerville, NJ Post Office and at additional mailing offices. Advanced Studies in Medicine is a registered trademark of The Healthcare Media Group, LLC. Printed on acid-free paper. BPA Membership applied for December 2000.

Full Disclosure Policy Affecting CME Activities:
As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of 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. Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

    Brian E. Mondell, MD
    Medical Director
    Baltimore Headache Institute
    Johns Hopkins at Green Spring Station
    Lutherville, Maryland
    Assistant Professor of Neurology
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    • Dr Mondell reports receiving grants and/or research support from Abbott Laboratories; Allergan, Inc; AstraZeneca Pharmaceuticals LP; Bristol-Myers Squibb Company; Elan Corporation; GlaxoSmithKline; Merck & Co, Inc; Novartis Corporation; Pfizer, Inc; Pharmacia Corporation; Pozen; UCB Pharma; and Vernalis Group.

PARTICIPATING FACULTY

    Donald B. Penzien, PhD
    Co-Director
    UMC Head Pain Center
    Associate Professor
    Department of Psychiatry and Human Behavior
    University of Mississippi Medical Center
    Jackson, Mississippi
    • Dr Penzien reports having no financial or advisory relationships with organizations related to this activity.

    Stephen D. Silberstein, MD, FACP
    Director, Jefferson Headache Center
    Professor of Neurology
    Thomas Jefferson University
    Clinical Professor of Neurology
    Temple University
    Philadelphia, Pennsylvania
    • Dr Silberstein reports receiving grants and/or research support from Abbott Laboratories; Allergan, Inc; AstraZeneca Pharmaceuticals LP; Bristol-Myers Squibb Company; Eli Lilly and Company; GlaxoSmithKline; Janssen Pharmaceutica; Merck & Co, Inc; Ortho-McNeil Pharmaceutical, Inc; Pfizer, Inc; UCB Pharma; and Vernalis Group; and serving on the advisory panel, speakers' bureau, or as a consultant for Abbott Laboratories; Allergan, Inc; AstraZeneca Pharmaceuticals LP; Elan Corporation; Eli Lilly and Company; GlaxoSmithKline; Merck & Co, Inc; and Ortho-McNeil Pharmaceutical, Inc.

    Gretchen E. Tietjen, MD
    Professor and Chair
    Department of Neurology
    Medical College of Ohio
    Toledo, Ohio
    • Dr Tietjen reports receiving grants and/or research support from GlaxoSmithKline and Merck & Co, Inc; serving as a consultant for GlaxoSmithKline; and being a stock shareholder in Merck & Co, Inc.

    Paul Winner, DO, FAAN
    Clinical Associate Professor
    Nova Southeastern University
    Fort Lauderdale, Florida
    Director
    Palm Beach Headache Center
    Co-Director of Research
    Premiere Research Institute
    West Palm Beach, Florida
    • Dr Winner reports receiving grants and/or research support from, serving as a consultant for, and receiving honoraria from Abbott Laboratories; AstraZeneca Pharmaceuticals LP; Elan Corporation; GlaxoSmithKline; Merck & Co, Inc; Ortho-McNeil Pharmaceutical, Inc; and Pfizer, Inc.

Notice:
In accordance with the ACCME Standards for Commercial Support, the audience is advised that one or more articles in this continuing medical education activity contains reference(s) to unlabeled or unapproved uses of drugs or devices. The following faculty members have disclosed that their articles have referenced the following unlabeled/unapproved uses of drugs or products:

Antiepileptic drugs—Drs Tietjen and Silberstein
Beta blocking agents—Drs Tietjen and Silberstein
Botulinum toxin A—Drs Tietjen and Silberstein
Calcium channel blocking agents—Drs Tietjen and Silberstein
Nonsteroidal anti-inflammatory drugs—Drs Tietjen and Silberstein
Selective serotonin reuptake inhibitors—Drs Tietjen and Silberstein
Tricyclic antidepressants—Drs Tietjen and Silberstein

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.

Concept to Practice: Developmental Advances in Migraine Management
Brian E. Mondell, MD*

The annual American Headache Society (AHS) Fall Headache Symposium held in Scottsdale, Arizona offers a wonderful opportunity for all practitioners who are interested in treating headache disorders to share information. This year's meeting (November 15-17, 2002) provided some very practical insights regarding how to optimize the diagnosis and management of migraine and other primary headache disorders-in all age groups.

In order to assist practitioners, migraine (and other primary headache) treatment guidelines are becoming more standardized and, as described by Stephen D. Silberstein, MD, FACP, have been rated and ranked by the US Headache Consortium. Although there are increasing numbers of effective therapies available for migraine prevention, no single class of medication—much less any single agent—works for every patient, suggesting the involvement of multiple mechanisms (most likely under the control of several genes) for the root cause of migraine. As Dr Silberstein asserts, as we have the epilepsies, so we also have the migraines.

Two of the most recent entrants into the migraine prevention arena are topiramate and botulinum toxin A. Topiramate continues to gain solid scientific evidence to support its use as a front-line preventive therapy for migraine (and possibly other types of primary headaches). As we gain greater understanding of its efficacy potential with more widespread use, the safety profile associated with this expanded use similarly becomes well established. Faculty at the AHS Scottsdale Symposium shared their experiences on how to manage some potential side effects of topiramate. Botulinum toxin A appears to offer real potential value as a treatment option, and further work is ongoing to clarify optimal dosing and injection sites. Being such a novel treatment, coverage in the lay press has been extensive, generating much interest in this therapy.

Moving along to the entire picture of caring for migraineurs, headache prevention may require elimination of acute drug therapy—if misused or overused—at least in the short term. Rebound headache is a common factor for many of the difficult-to-treat patients seen in neurology practices. Gretchen E. Tietjen, MD, provides an important overview of medication overuse or rebound headache. She stresses the need for recognition and offers practical advice on how to manage these patients. Dr Tietjen correctly characterizes the detoxification process as a very difficult period for the patient as well as the practitioner. Positive outcomes require the patient's acceptance of his or her headaches getting worse before they get better. Practitioners need to be prepared to provide appropriate support structures to help the patient through the detoxification process. Our well-meaning efforts to offer patients immediate relief of headache pain symptoms, as well as treatment in emergency departments, contribute to the high prevalence of medication overuse or rebound headache. Careful attention must be paid to each patient's pattern of headache and medication use over time.

Paul Winner, DO, FAAN presents 3 challenging headache cases that illustrate what the practicing neurologist typically confronts, in order to highlight the common causes of misdiagnosis or underdiagnosis and undertreatment. Perceived treatment ineffectiveness can be averted with careful initial diagnosis or reassessment of any working diagnosis and frank discussions with patients on appropriate expectations for prescribed treatment.

Headache patients also have numerous options for nonpharmacologic therapy, but these useful options are often underutilized. Behavior therapy is supported by the American Academy of Neurology; the US Headache Consortium states that Grade A evidence supports relaxation training, biofeedback, combined biofeedback plus relaxation training, and cognitive-behavior therapy as treatment options for migraine prevention. Beyond the documented short-term or "immediate" benefits, behavioral treatments have been shown to offer significant improvement lasting several years. Grade B evidence supports a combination of behavior plus preventive drug therapy for additional improvement. Donald B. Penzien, PhD, shares his vast experience with clinic-based behavior therapy alone or in conjunction with pharmacotherapy as well as some innovative work with home-based behavior treatments that reduce the time and cost requirements for patients.

Clearly, the take-home message from the topics covered in this issue of Advanced Studies in Medicine—reporting proceedings from the 2002 AHS Scottsdale Symposium—is that acute and preventive treatment of migraine (as with all other headache disorders) must be tailored to the individual patient and carefully monitored for ongoing success. An accurate diagnosis determines treatment and is based on recognizing the individual patient's full spectrum and pattern of symptoms as well as any symptom changes over time. Additionally, patient needs, preferences, and expectations for treatment must all be addressed for optimal outcomes. With sufficient attention to these details, practitioners can ensure the highest probability of prescribing the right treatment for the right patient at the right time. The end result will be effective headache disability reduction and satisfied patients. For headache patients and their practitioners in 2003, this is as good as it gets. And, it's all good.

*Medical Director, Baltimore Headache Institute, Johns Hopkins at Green Spring Station, Lutherville, Maryland; Assistant Professor of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.





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.