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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 physicians 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.

LEARNING OBJECTIVES
After reading this issue, the participant should be able to:

  • Identify the barriers to care in patients with migraine.
  • Understand the 7 steps of the disease-management approach and how they can be implemented into clinical practice.
  • Evaluate the directionality of the relationship between migraine and depression.
  • Make evidence-based treatment choices for patients with migraine.

ACCREDITATION STATEMENT
This activity has been planned and produced in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education. The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 hours in Category 1 credit toward the American Medical Association (AMA) Physicians' Recognition Award. Each physician should claim only those hours of credit that he/she actually spends on this educational activity. Credits are available until the expiration date of November 30, 2004.

This continuing education activity was produced under the supervision of Brian E. Mondell, MD, Medical Director, Baltimore Headache Institute, Lutherville, Maryland, and Assistant Professor of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.

This program is supported by an unrestricted educational grant from Ortho-McNeil Pharmaceutical, Inc.

Publisher's Note and Disclaimer: The opinions expressed in this issue are those of the authors, presenters, and/or panelists and are not attributable to the publisher, editor, advisory board of Advanced Studies in Medicine, or The Johns Hopkins University School of Medicine or its Office of Continuing Medical Education. Clinical judgment must guide each professional in weighing the benefits of treatment against the risk of toxicity. Dosages, indications, and methods of use for products referred to in this issue are not necessarily the same as indicated in the package insert for the product and may reflect the clinical experience of the authors, presenters, and/or panelists or may be derived from the professional literature or other clinical sources. Consult complete prescribing information before administering.

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.

FACULTY ADVISOR

    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, Pharmacia & Upjohn, Pozen, UCB Pharma, and Vernalis Group.

PARTICIPATING FACULTY

    Naomi Breslau, PhD
    Department of Psychiatry
    Henry Ford Health System
    Detroit, Michigan
    • Dr Breslau reports having no financial or advisory relationships with corporate organizations related to this activity.

    David Dodick, MD, FRCP(C)
    Associate Professor of Neurology
    Mayo Clinic
    Scottsdale, Arizona
    • Dr Dodick reports having no financial or advisory relationships with corporate organizations related to this activity.

    Richard B. Lipton, MD
    Professor
    Departments of Neurology, Epidemiology & Social Medicine, and Psychiatry & Behavioral Medicine
    Albert Einstein College of Medicine
    Bronx, New York
    • Dr Lipton reports receiving grants and/or research support from, serving as a consultant to, and receiving honoraria from Abbott Laboratories, Allergan, Inc, AstraZeneca Pharmaceuticals LP, Bristol-Meyers Squibb Company, GlaxoSmithKline, Johnson & Johnson, Merck & Co, Inc, Pfizer, and Pharmacia Corporation.

    Jeffrey D. Rome, MD
    Medical Director
    Mayo Clinic Pain Management Program
    Mayo Clinic
    Rochester, Minnesota
    • Dr Rome reports having no financial or advisory relationships with corporate organizations related to this activity.

    John F. Rothrock, MD
    Professor of Neurology
    University of South Alabama
    Mobile, Alabama
    • Dr Rothrock reports receiving grants and/or research support and honoraria from Abbott Laboratories, GlaxoSmithKline, and Ortho-McNeil Pharmaceutical; and serving as a consultant to Abbott Laboratories, GlaxoSmithKline, and Merck & Co, Inc.

    Joel R. Saper, MD
    Director and Founder
    Michigan Head-Pain & Neurological Institute
    Ann Arbor, Michigan
    • Dr Saper reports having no financial or advisory relationships with corporate organizations related to this activity.

    Stephen D. Silberstein, MD
    Professor of Neurology
    Director, Jefferson Headache Center
    Thomas Jefferson University Hospital
    Clinical Professor of Neurology
    Temple University School of Medicine
    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 Products LP, Merck & Co, Inc, Ortho-McNeil Pharmaceutical, ParkeDavis, Pfizer, UCB Pharma, and Vernalis; and serving on the speakers' bureau or advisory panel for, or as a consultant to, Abbott Laboratories, Allergan, Inc, AstraZeneca Pharmaceuticals LP, Elan Corporation, Eli Lilly and Company, Ortho-McNeil Pharmaceutical, Merck & Co, Inc, and GlaxoSmithKline.

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.

Off Label Product Discussion
Faculty have disclosed that their articles have referenced the following unlabeled/unapproved uses of drugs or products:

Product
Topiramate

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

An advantage of attending headache and neurology conferences throughout the year is to observe incremental advances in headache management research and then to be able to incorporate these findings into clinical practice and improve patient outcomes. At this year's annual scientific meeting of the American Headache Society (AHS) held in Seattle, Washington (June 21-23, 2002), the results of years of research into migraine therapies are now coming into focus while newer drug targets are identified directly related to advances in our understanding of migraine pathophysiology. However, as Dr Richard B. Lipton, the past President of the AHS eloquently observed, there remains a problematic gap between the potential of these developments and the reality of treatment delivered to patients. The cause of the gap is multifactorial, involving both insufficient training and treatment at the primary care level and the reluctance of too many headache patients to seek medical care.

The annual scientific meeting of the AHS held in June (this year in Seattle) is the high point of the 3 yearly meetings sponsored by the AHS; a record 700 neurologists and pain specialists attended this conference. The AHS conferences seem to be increasingly attracting general pain specialists as the common mechanisms between migraine and neuropathic pain—as well as some of the treatments—are identified and better understood.

This issue of Advanced Studies in Medicine reviews several key presentations from this scientific congress including the need to look beyond acute treatment to therapeutic opportunities for scientifically sound preventive strategies—as well as specific treatments—that hold the promise to better prevent attacks and, very importantly, to prevent the progression to a chronic, treatment-resistant condition.

Dr Lipton has been at the forefront of research to optimize migraine diagnosis and treatment strategies. As the speaker at the Presidential Symposium, "Reducing the Burden of Headache," Dr Lipton offers a compelling discussion of applying disease-management models to migraine and reviews 2 concrete examples practicing neurologists can implement today to enhance their ability to care for patients.

Dr Naomi Breslau was one of the first clinical researchers to identify a comorbid relationship between migraine and depression. She continues her exploration of comorbidity and directionality between migraine and several psychiatric disorders, including depression, bipolar illness, and anxiety disorders. The relationship between these psychiatric disorders and other types of severe headache are explored, and their directionality appears to be different from that of migraine. She offers insight into why this may be occurring.

Dr Stephen D. Silberstein presents some of the most recent efficacy and safety data on topiramate, an antiepileptic drug that is under investigation for migraine prevention—such that it can be considered for approval by the US Food and Drug Administration. In recent years, antiepileptic drugs have significantly expanded options in pharmacotherapy for migraine prevention, and topiramate appears to offer an effective, well-tolerated, and safe alternative to currently available therapies.

Chronic daily headache (CDH) often originates from episodic migraine and can be one of the most difficult headache types to treat. A proportion of CDH patients are refractory to standard, established, or conventional headache or migraine therapies; therefore, a question exists as to whether long-acting opioids should be considered as an option. Opioid use for prevention of headache is undeniably controversial to the practicing neurologist—and for good reason, but Drs Joel R. Saper, John F. Rothrock, and Jeffrey D. Rome explore the possible safe and effective uses of opioids in CDH patients based on their extensive clinical experience and the results of studies they have conducted to answer some of the questions surrounding opioid use. A summary of their roundtable discussion is included.

Several of the articles in the section of poster presentations present data on other antiepileptic agents for migraine prevention: zonisamide and lamotrigine, oxcarbazepine, and a head-to-head comparison of gabapentin and valproate. Additionally, more data on topiramate in "real life" practice is presented.

Botulinum toxin type A (Btx-A) has also been tested for migraine therapy. Dr Ninan T. Mathew presented a poster analyzing the efficacy of Btx-A as a preventive therapy for CDH in more than 100 patients. The results after 2 years show that both headache disability and frequency were reduced and suggest that Btx-A may alter the course of chronic migraine in a subset of patients.

Research into migraine diagnosis and treatment continues to provide significant improvements in the lives of sufferers. The challenge now is to have migraineurs obtain rational care, rather than receive multiple prescriptions for acute therapy with no attention to the potential benefits of preventive treatment regarding disease modification. Educating migraineurs on all of the currently available therapeutic options available will undoubtedly help promote more contact with physicians; the correct diagnosis can then be established, and effective therapy can be instituted earlier. This can only serve to improve quality of life and potentially improve long-term outcomes by blocking disease progression to a treatment-resistant status—a place where neither the migraineur nor the attending physician want to be.

*Medical Director, Baltimore Headache Institute, Johns Hopkins at Green Spring Station, Lutherville, Maryland, and Assistant Professor of Neurology, 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.