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
To provide physicians with current information on new advances in the management and treatment of migraine and neuropathic pain.
This activity is designed for neurologists, particularly those who treat patients with migraine and/or neuropathic pain.
After reading this issue, the participant should be able to:
- Discuss the treatment options for managing cluster headache, transformed migraine, and primary headaches.
- Describe the elements of assessing neuropathic pain, including the sensory examination technique and various pain measurement tools.
- Describe the pathology of neuropathic pain.
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 September 30, 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 53rd annual meeting of the American Academy of Neurology held on May 5-11, 2001, in Philadelphia, Pennsylvania.
David R. Cornblath, MD
Professor of Neurology
Johns Hopkins University School of Medicine
• Dr. Cornblath reports serving as a consultant to SPRI, OMP-RWJ PRI, Avanir, and DP Clinical; and a board member for Xenos, Amgen, Schwartz Biosciences, and Acorda.
Brian E. Mondell, MD
Baltimore Headache Institute
Assistant Professor of Neurology
Johns Hopkins University School of Medicine
• Dr. Mondell reports receiving grant and research support from Abbott, AstraZeneca, GlaxoSmithKline, Merck, Novartis, Ortho-McNeil, Pfizer, Pharmacia and Upjohn, and Vernalis Group, PLC.
John T. Farrar, MD, MSCE
Center for Clinical Epidemiology and Biostatistics
University of Pennsylvania
• Dr. Farrar reports receiving grant and research support from Pfizer, Cephalon, SmithKline Beecham, Knoll, and Searle; serving as a consultant to Abbott, Alza, and Endo; and serving on the speakers bureau for Perdue Frederick.
Bradley S. Galer, MD
Chadds Ford, Pennsylvania
• Dr. Galer is an employee of Endo Pharmaceuticals.
Anne Louise Oaklander, MD, PhD
Assistant Professor of Anesthesiology and Neurology
Assistant in Neurology
• Dr. Oaklander reports receiving no grant support related to the topic of her paper from pharmaceutical companies.
Curtis P. Schreiber, MD
Headache Care Center
• Dr. Schreiber did not provide information regarding financial or advisory relationships with pharmaceutical companies.
Mark J. Stillman, MD
Head, Headache Section
Department of Neurology
Cleveland Clinic Foundation
• Dr. Stillman reports receiving research support from Abbott and Ortho-McNeil; and serving on the speakers' bureau for Abbott, Glaxo, Merck, AstraZeneca, Ortho-McNeil, and Allergan.
Advanced Studies in Medicine makes every effort to provide the reader with full disclosure information from major contributors. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts or other very brief summaries.
New Developments in the Management of Migraine and Neuropathic Pain
First in a Series of Three
Brian E. Mondell, MD1,2; and David R. Cornblath, MD2
We practice neurology with an ever-increasing understanding of pathophysiology and more and more valuable therapeutic options for many neurological disorders-especially headache and pain. This issue of Advanced Studies in Medicine recounts some of the most relevant and interesting developments in migraine and other primary headache disorders as well as in neuropathic pain that were presented at the 53rd Annual Meeting of the American Academy of Neurology (AAN) in Philadelphia, Pennsylvania, May 2001. This is the first in a series of 3 publications that will focus on migraine and neuropathic pain.
In migraine, the last decade has brought the release of the remarkably successful triptans for acute treatment. For preventive therapy, the antieplieptic drugs (AEDs) have shown consistent efficacy, and the number of different AEDs that appear to be useful in migraine and headache disorders is growing. Additionally, advanced imaging techniques have shed light on pathophysiology, and improvements in the diagnostic criteria have enhanced diagnostic accuracy ultimately leading to better paradigms that optimize treatment strategies.
Dr. Mark J. Stillman shared his experience with intravenous valproate as an acute treatment for moderate to severe headaches based on the drug's pharma-cokinetic profile in epilepsy-that of achieving rapid, high concentrations in the brain.
Additional research reported at the Academy meeting related to the value of anticonvulsant agents for the prevention of head pain. Drs. William Garnett and Alan Towne and their colleagues reviewed efficacy of topiramate in migraine prevention but went one step further to study topiramate for the more difficult to treat patients with chronic migraine or transformed migraine. Their data demonstrate very promising results in this typically treatment-resistant patient population of chronic, intractable headaches.
Because our understanding and identification of migraine and other primary headaches has expanded but remains imperfect, practitioners need to be vigilant to both established and, possibly new, not yet formally described headache disorders. Clarifications and revisions in our currently accepted diagnostic criteria will be undoubtedly forthcoming. Dr. Hua Siow and colleagues described 4 cases of cluster headache with hemiparesis. Hemiparesis associated with cluster headaches has not been previously described. This disorder seems to share some similarities to hemiplegic migraine and needs to be further investigated for diagnostic, therapeutic, and classification purposes. Other unusual headache syndromes reported at the Academy meeting include hemicrania continua with aura (by Dr. Mario Peres) and hemicrania continua responsive to indomethacin but found to be secondary to an underlying malignancy (by Dr. Eric Eross).
Regarding diagnostic accuracy, Dr. Curtis Schreiber presented a study detailing the difficulty that some practitioners have in distinguishing sinus headache (which is often patient self-diagnosed) from migraine. The implication from this study is that there is an opportunity for education of patients and some practitioners that can result in better diagnostic accuracy and, accordingly, more appropriate selection of therapeutics.
We have included information on neuropathic pain in this issue because of some similarities between neuropathic pain and migraine. There is a growing recognition that these 2 disease states had become unnecessarily neglected or deemphasized by some practitioners. For both disorders, there is a growing understanding of pathophysiology. These 2 distinct disorders may share some common mechanisms-eg, central sensitization and allodynia. Additionally, shared modulators of pain for these 2 disorders may include the same inflammatory agents, neuropeptides, and neurotransmitters. For both disorders, there is a growing base of useful diagnostic criteria and assessment tools. Finally, for both disorders, there is a growing number of new effective therapies producing a high likelihood for very favorable treatment outcomes. Accordingly, this issue contains 3 review articles on neuropathic pain based on presentations made as part of the educational program at this year's AAN meeting.
Neuropathology and Neurophysiology
Dr. Anne Louise Oaklander provides a useful review of the neuropathology and neurophysiology of chronic pain. Understanding these mechanisms can help to explain some of the clinical presentations of neuropathic pain. Dr. Oaklander's recent work on immunolabeling of epidermal sensory nerve endings also illustrates the breakthroughs in our understanding of the pathology and how it can be used for diagnosis.
Treating the Neuropathic Pain Patient
Dr. John T. Farrar focuses on the important clinical aspects in his discussion of what the neuropathic pain patient experiences. The psychological sequelae are just as important as the physical and, if not addressed, can hinder patient improvement. He identifies that the neurologist has 2 primary roles: understanding the advances in the underlying pathophysiologic mechanisms of pain and recognition of external factors that affect the patient's pain experience. Together, pharmacologic treatment and modification of external factors are necessary to optimize treatment outcomes.
Diagnostic and Assessment Tools
Dr. Bradley Galer reviews the role of the patient history and physical examination for the diagnosis and assessment of neuropathic pain. He describes the currently available pain assessment tools and shares recent developments in this area of study that now include, in addition to pain quality and quantification, the "softer" factors affecting outcomes-pain unpleasantness, quality of life, and disability.
Migraine and Neuropathic Pain
The materials in this issue of Advanced Studies in Medicine cover new developments in migraine and neuropathic pain research, expanded roles for currently available drug therapies, and the need to appreciate each patient's experience. From this knowledge, the need for individualized therapeutic strategies becomes self-evident. From all of this information, the possibilities for improved understanding of migraine and neuropathic pain can only help us better care for our patients.
1 Baltimore Headache Institute, Johns Hopkins at Green Spring Station, Lutherville, Maryland;
2 Johns Hopkins University School of Medicine, Baltimore, Maryland.