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


New Developments in the Management of Migraine and Neuropathic Pain


GOAL
To provide physicians with current information on new advances in the management and treatment of migraine and neuropathic pain.

TARGET AUDIENCE
This activity is designed for neurologists, particularly those who treat migraine and/or neuropathic pain.

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

  • Describe several key epidemiological studies on headache and migraine.
  • Identify the different symptoms of cluster and chronic tension-type headache.
  • Discuss the prevalence and clinical presentation of diabetic neuropathy.

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 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 continuing medical education activity for a maximum of 2 hours in Category 1 credit toward the American Medical Association Physicians' Recognition Award. Each physician should claim only those hours of credit that are actually spent on the educational activity. Credits are available until the expiration date of December 31, 2003.

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

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: 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.

The contents of this issue of Advanced Studies in Medicine include highlights from the the XVII World Congress of Neurology held June 17-22, 2001, in London, United Kingdom.

FACULTY ADVISORS

    David R. Cornblath, MD
    Professor of Neurology
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    • Dr Cornblath reports serving as a consultant to SPRI, OMP-RWJ PRI, Avanir, and DP Clinical; and as a board member for Xenos, Amgen, Schwartz Biosciences, and Acorda.

    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, AstraZeneca, GlaxoSmithKline, Merck, Novartis, Ortho-McNeil, Pfizer, Pharmacia & Upjohn, and Vernalis Group, PLC.

PARTICIPATING FACULTY

    Bradley S. Galer, MD
    Vice President
    Scientific Affairs
    Endo Pharmaceuticals
    Chadds Ford, Pennsylvania
    • Dr Galer is an employee of Endo Pharmaceuticals.

    Rigmor Jensen, MD, PhD
    Neurologist
    Department of Neurology
    Glostrup Hospital
    University of Copenhagen
    Glostrup, Denmark
    • Dr Jensen reports no financial or advisory relationship with any pharmaceutical company.

    Richard B. Lipton, MD
    Professor of Neurology, Epidemiology, and Social Medicine
    Albert Einstein College of Medicine
    Bronx, New York
    Innovative Medical Research
    Stamford, Connecticut
    • Dr Lipton reports receiving grant/research support, honoraria, and serving as a
    consultant to Abbott, AstraZeneca, Bristol Myers Squibb, American Home Products, GlaxoWellcome, Pfizer, Merck, Pharmacia, and Johnson & Johnson.

    Gérard Said, MD
    Professeur de Neurologie
    Chef du Service de Neurologie
    Secteur Pierre Marie
    Centre Hospitaliar Universitaire de Bicêtre
    Paris, France
    • Dr Said reports no financial or advisory relationship with any pharmaceutical company.

    Jean Schoenen, MD, PhD
    Professor
    Department of Neuroanatomy and Neurology
    Université de Liege
    Liege, Belgium
    • Dr Schoenen reports receiving grant/research support from GlaxoWellcome; and serving as a consultant to GlaxoSmithKline, Allergan, Pfizer, Eli Lilly, AstraZeneca, and Johnson & Johnson.

    Stewart Webb, MD*
    Professor
    Institute of Neurology and Neurosurgery
    Southern General Hospital
    Glasgow, Scotland
    Glostrup, Denmark
    • Dr Webb did not report any financial or advisory relationships with any pharmaceutical company.

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

 

Clinical Updates on the Management of Migraine and Neuropathic Pain
Brian E. Mondell, MD ; and David R. Cornblath, MD *

This issue of Advanced Studies in Medicine focuses on recently reported data on developments in understanding and managing migraine, other types of headache, and neuropathic pain. Encompassing various symposium presentations, platform presentations, and poster presentations at the XVII World Congress of Neurology held in London, United Kingdom, June 17-22, 2001, the contents of this publication reflect the challenges of managing migraine and other types of headache and neuropathic pain in clinical practice.

The symposium presentations featured in this issue provide comprehensive overviews of the epidemiology and burden of headaches as well as the clinical features of migraine, cluster headaches, chronic tension-type headaches, and diabetic neuropathy. By comparison, the platform and poster presentations focus on findings from several studies, most of which evaluate the efficacy of various pharmacologic agents in the treatment of migraine and neuropathic pain.

As Richard B. Lipton, MD, of Innovative Medical Research, Inc, Stamford, Connecticut, and professor of neurology at Albert Einstein College of Medicine, Bronx, New York, notes in his symposium presentation, the epidemiology and burden of headache underscore the need to provide effective therapies for patients who require care. Dr Lipton reviews the importance of studying the epidemiology and impact of headache, the factors accounting for the variation in headache prevalence, approaches to estimating the burden of headache, work losses (ie, disability) attributed to migraine, patterns of diagnosis and treatment, and barriers to care. He cites disability as a powerful predictor of treatment needs and points out that failure to include it in the evaluation of a patient with migraine is a major barrier to care. Too often, there is a communication gap between physicians, who do not ask about disability, and patients, who do not tell. This gap in communication creates a gap in treatment.

Jean Schoenen, MD, PhD, University of Liege, Belgium, reviews the clinical hallmarks of cluster headache and related trigeminal autonomic cephalalgias, the pathophysiology of cluster headache, and acute and preventive treatment. He describes several recent advances in research that shed light on the mechanisms involved in the pain, autonomic symptoms, and periodicity of cluster headache, as well as the similarities and differences between cluster headache and migraine. In addressing acute treatment and prophylaxis, Dr Schoenen also outlines his own approach to inducing remission from cluster headache.

In her symposium presentation, Rigmor Jensen, MD, PhD, Glostrup Hospital and the University of Copenhagen, Glostrup, Denmark, addresses the epidemiology, prevalence, pathophysiology, treatment, as well as prevention of chronic tension-type headache. She notes that chronic tension-type headache is difficult for the patient because there is no truly effective treatment, and it is difficult for the physician because the diagnosis is not always clear-cut. Indeed, the diagnosis is often clouded by the fact that chronic tension-type headache and migraine may coexist in the same patient. Dr Jensen also points out that while tension in the muscles of the face, head, and scalp is prominently involved in chronic tension headache, genetic factors are involved as well.

Among the platform presentations featured in this issue is a hospital-based study of the treatment of acute severe thunderclap-type headache. In his report, Stewart Webb, MD, of the Institute of Neurology and Neurosurgery at Southern General Hospital, Glasgow, Scotland, emphasizes that the sudden onset of a severe headache raises the suspicion for subarachnoid hemorrhage and that an established hospital protocol is needed for the evaluation of suspected subarachnoid hemorrhage. From case records of patients at his institution with suspected subarachnoid hemorrhage but normal cranial images, and from questionnaire replies from 53 neurology units in the United Kingdom, Dr Webb and his colleagues note that evaluation of these patients varies considerably. With no written guidelines in many neurology units, spectrophotometry is used less often than expected and cerebral angiography is used more often than expected in evaluating patients with acute severe headache. They recommend a protocol that emphasizes the correct timing for computerized tomographic cranial scans and lumbar puncture, the need for spectrophotometric analysis of the cerebrospinal fluid to detect xanthochromia, and the indications for 4-vessel cerebral angiography.

Migraine Prophylaxis

Also included in this issue are 4 summaries of poster presentations on migraine-related issues. One very interesting poster explores the connection between gastrointestinal symptoms during migraine and gastric electrical activity; another presents the results of an open-label study evaluating the antiepileptic drug topiramate in patients with chronic migraine. A third poster presents findings from a retrospective chart-analysis study examining topiramate in migraine prophylaxis. The final poster reported in this issue presents the results of a physician questionnaire concerning postalcohol (hangover) headache, and its renowned author concludes his work by significantly advancing our understanding of this type of headache.

Neuropathic Pain

In his symposium presentation on diabetic neuropathy, Gérard Said, MD, of the Hôspital de Bicêtre, Paris, France, reviews the classification, the clinical heterogeneity, and the pathophysiology and pathogenesis of diabetic neuropathy. With regard to pathophysiology, Professor Said cites the 2 major hypotheses: the metabolic hypothesis and microangiopathy. He also reviews the mechanisms underlying the pathogenesis of length-dependent and focal and multifocal neuropathies.

Of the 3 poster presentations featured in this issue that deal with the treatment of neuropathic pain, one evaluates the efficacy of an antidepressant, one evaluates the efficacy of an antiepileptic agent, and one compares the efficacy of another antiepileptic agent with another antidepressant in this patient population.

Focusing on neuropathic pain, the senior clinical editor for this issue of Advanced Studies in Medicine conducted an interview with Bradley Galer, MD, a board-certified pain medicine neurologist with specialized training and a professional interest in the mechanisms and management of pain. Dr Galer was formerly an associate professor of neurology at Albert Einstein College of Medicine in the Bronx, New York. Dr Galer discusses the paradigm shift in pain management and the clinical features, diagnosis, and treatment considerations of neuropathic pain.

As with all major conferences addressing headache disorders and neuropathic pain, a considerable amount of new information is presented and alternative points of view are exchanged. Also common to these scientific forums is the realization that clinical research efforts must be intensified to provide even more effective therapy to our patients in the future.

*Baltimore Headache Institute, Johns Hopkins at Green Spring Station, Lutherville, Maryland; Department of Neurology, Johns Hopkins Medical Institutions, 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.