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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

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

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 this last 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 are explored, it is hoped that future investigations will provide answers that will improve treatment and quality of life.

This activity is designed for neurologists, particularly those who treat patients with migraine.

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

  • Distinguish between primary and secondary headache disorders.
  • Understand the newest concepts underlying headache pathophysiology.
  • Make evidence-based treatment choices for patients with migraine.
  • Discuss the use of neuroimaging for the diagnosis of headache.

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.

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 Physician's Recognition Award. Each physician should only claim those hours of credit that he/she actually spends on this educational activity. Credits are available until the expiration date of September 30, 2004.

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

This program is supported by an unrestricted educational grant from Ortho-McNeil Pharmaceuticals, 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: 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.

The contents of this issue of Advanced Studies in Medicine include highlights from the Scientific Proceedings of the 54th Annual Meeting of the American Academy of Neurology held April 13-20, in Denver, Colorado.


    Brian E. Mondell, MD
    Medical Director
    Baltimore Headache Institute
    Assistant Professor of Neurology
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    • Dr Mondell reports receiving grant and research support from Abbott Laboratories, Allergan, and AstraZeneca; serving as a consultant to Bristol Myers Squibb, GlaxoSmithKline, Merck, and Novartis; and receiving honoraria from Pfizer, Pharmacia & Upjohn, Pozen, Vernalis Group, and UCB Pharma.


    Jan Lewis Brandes, MD
    Nashville Neuroscience Group
    Nashville, Tennessee
    • Dr Brandes reports receiving research support from Merck, GlaxoSmithKline, UCB Pharma, Allergan, R.W. Johnson, AstraZeneca, Pfizer, BMS, and Novartis; serving as a consultant to Merck, GlaxoSmithKline, Allergan, AstraZeneca, Pfizer, Ortho McNeil, and Elan; and receiving honararia from Merck, GlaxoSmithKline, Allergan, AstraZeneca, Pfizer, Ortho McNeil, and Pharmacia.

    Roger K. Cady, MD
    Headache Care Center
    Springfield, Missouri
    • Dr Cady reports receiving research grants from AstraZeneca, Allergan, GlaxoSmithKline, Merck & Co, Pfizer, Pozen, and Winston Labs; and he reports serving on the advisory board of Abbott Laboratories, AstraZeneca, Allergan, Elan, GlaxoSmithKline, Merck, and Pfizer; and serving on the speakers bureau of AstraZeneca, GlaxoSmithKline, Merck, and Pfizer.

    David E. Hart, MD
    Upstate Neurology Consultants LLP
    Albany, New York
    • Dr Hart reports receiving research support from Ortho-McNeil Pharmaceuticals.

    Edwin U. Keates, MD
    Jenkintown, Pennsylvania
    • Dr Keates reports serving as a consultant to Johnson & Johnson, World Research Group.

    Alvin E. Lake III, PhD
    Michigan Head Pain and Neurological Institute
    Ann Arbor, Michigan
    • Dr Lake reports receiving research support and honorarium from and serves as a consultant to Elan Pharmaceuticals.

    Licia Grazzi, MD
    National Neurological Institute C.Besta
    Milan, Italy
    • Dr Grazzi reports no financial or advisory relationship with any pharmaceutical company.

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:

Tizanidine (Zanaflex)
Topiramate (Topamax)
Quetiapine (Seroquel)
Fluoxetine (Prozac)
Nortriptyline (Pamelor)
Petasites hybridus (Petadolex)


Developmental Advances in Migraine Management
Brian E. Mondell, MD*

One might be tempted to refer to headache specialists as "triptanologists" because of the enormous impact the triptans have made in the lives of migraineurs. However, important advances in expanding options for migraine prevention have also been made, especially as we begin to understand and appreciate the conditions that are comorbid with migraine. Similarly, our ability to more accurately diagnose different types of headaches provides greater insight into the pathophysiology of headache disorders and therefore points the way to more specific therapeutic targets.

The migraine research presented at the 54th Annual Meeting of the American Academy of Neurologists (Denver, Colorado) underscored the great strides we have made in migraine diagnosis, treatment, and prevention. This issue of Advanced Studies in Medicine provides highlights of some of the key presentations and posters given at the meeting.

Antiepileptic drugs (AEDs) have been used for migraine prevention, albeit mostly as off-label usage, for almost a decade. Divalproex is the most studied of all AEDs for this type of treatment and is the first to receive Food and Drug Administration (FDA) approval for migraine. Topiramate, another AED that was FDA approved for epilepsy after divalproex, has now been under extensive investigation as an agent for migraine prevention. Dr David E. Hart presents the results of an open-label extension of the original double-blind, placebo-controlled trial of topiramate. The results show that patients can expect sustained improvement in their migraine frequency with 1 year of topiramate therapy. The benefits of prophylaxis extend to those originally in the placebo group.

Years of use of topiramate have shed light on a rare but reversible ophthalmologic adverse event. Dr Edwin U. Keates presents important data on the frequency of a rare ocular syndrome—acute myopia and secondary angle closure glaucomaÑthat may occur in patients receiving topiramate treatment. Although it is reversible, it can be problematic to patients who are not educated appropriately before treatment initiation. The syndrome is easily identifiable, typically occurs within the first few weeks of treatment, and will resolve with drug discontinuation. Dr Keates provides the key clinical points concerning this syndrome.

Other drug classes are also under investigation for migraine prophylaxis. Tizanidine, an alpha2-adrenergic agonist, was evaluated in a double-blind, placebo-controlled study as adjunctive therapy for chronic daily headache. Although this was a small study, the results show a significant benefit with tizanidine treatment in several outcome measures. In general, tizanidine is well tolerated, and as Dr Alvin E. Lake III discusses in his presentation, the efficacious results point to a possible central alpha2-adrenergic mechanism in the pathophysiology of chronic daily headache. Along similar themes, Dr Jan Lewis Brandes presented a poster of her results evaluating quetiapine, an antipsychotic drug, for possible use as a migraine preventive agent, and Dr Richard Lipton evaluated an herbal medicine commonly used in Germany for migraine prevention.

Finally, Dr Roger K. Cady reviews the challenges of migraine diagnosis in patients who report their own diagnoses of "sinus headache." Interestingly, patients repeatedly took sinus medications without meaningful benefit for their self-described sinus headaches. Some of these sinus medications were prescribed by their doctors, even with an established diagnosis of migraine. When asked to treat their "sinus headaches" with sumatriptan, 73% experienced pain relief and 64% indicated that they preferred sumatriptan to their current sinus headache therapy. Patient mislabeling of their headaches can have significant ramifications in migraine acute treatment as well as in preventive therapy as we can now prescribe better, more specific therapies based on the correct diagnosis and not just selected patient symptoms.

Neurologist and headache specialists are in an advantageous position as we can fine-tune our ability to make accurate diagnoses and tailor therapy to the individual patient. These advances will, without doubt, improve the success rates of migraine management.

*Medical Director, Baltimore Headache Institute, Johns Hopkins at Green Spring Station, Lutherville, Maryland.

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