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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 and Emerging Therapies in the Treatment of Migraine


GOAL
To provide physicians with up-to-date information on the prevention and treatment of migraine with a focus on new and emerging therapies such as antiepileptic drugs.

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

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

  • Describe the prevalence of migraine and headache disorders.
  • Describe the relationship between calcitonin gene-related peptide and chronic tension-type headache.
  • Define the pain characteristics of cluster headache.
  • Describe the role of genetics in migraine pathophysiology.

DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this continuing medical education activity for up to 2 credit hours in Category 1 of the Physician’s Recognition Award of the American Medical Association. Each physician should claim only those hours of credit that he or she actually spends on the educational activity. Credits are available until the expiration date of February 28, 2003.

ACCREDITATION
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. This continuing education activity was planned and produced in accordance with the ACCME Essentials and Standards for Commercial Support.

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.

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

Publisher’s Note and Disclaimer: The opinions expressed in this Special Report are those of the authors, presenters, and/or panelists and are not attributable to the sponsor or the publisher, editor, advisory board of Advanced Studies in Medicine, or The Johns Hopkins University School of Medicine or 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 Special Report 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.

The contents of this issue of Advanced Studies in Medicine are based on proceedings of the Fifth Congress of the European Federation of Neurological Societies 2000 held in Copenhagen, Denmark, October 14-18, 2000.

PARTICIPATING FACULTY

    Messoud Ashina, MD, PhD
    Department of Neurology
    Glostrup Hospital
    University of Copenhagen
    Copenhagen, Denmark
    • Dr. Ashina reports no financial or advisory relationship with any corporate organization.

    Lars Bendtsen, MD, PhD
    Department of Neurology
    Glostrup Hospital
    University of Copenhagen
    Copenhagen, Denmark
    • Dr. Bendtsen reports no financial or advisory relationship with any corporate organization.

    Alfredo Costa, MD
    University Center for Adaptive Disorders and Headache
    University of Pavia
    Pavia, Italy
    • Dr. Costa reports no financial or advisory relationship with any corporate organization.

    Frederick Freitag, DO
    Diamond Headache Clinic
    Chicago, Illinois
    • Dr. Freitag reports conducting research for and/or serving on the speaker's bureau and/or serving as a consultant for Abbott Laboratories, Allergan, Bayer, Bristol-Myers Squibb, Carnrick, Elan, Glaxo Wellcome, Merck, Novartis, Pfizer, Pozen, Winston, AstraZeneca, CAPNIA, Pharmacia Upjohn, Epicept, Janssen, and Wyeth-Ayerst.

    Hartmut Göbel, MD, PhD
    Kiel Pain Clinic
    Kiel, Germay
    • Dr. Göbel reports no financial or advisory relationship with any corporate organization.

    Inger Jansen-Olesen, PhD
    Department of Biological Sciences
    The Royal School of Pharmacy
    Copenhagen, Denmark
    • Dr. Jansen-Olesen reports no financial or advisory relationship with any corporate organization.

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

    Gian Camillo Manzoni, MD
    Headache Center
    Institute of Neurology
    Parma, Italy
    • Dr. Manzoni reports no financial or advisory relationship with any corporate organization.

    Giuseppe Nappi, MD
    University Center for Adaptive Disorders and Headache
    University of Pavia
    Pavia, Italy
    Institute of Mental and Nervous Diseases
    University of Rome "La Sapienza"
    Rome, Italy
    • Dr. Nappi reports no financial or advisory relationship with any corporate organization.

    Jes Olesen, MD, PhD
    Department of Neurology
    Glostrup Hospital
    University of Copenhagen, Glostrup
    Coenhagen, Denmark
    • Dr. Jansen-Olesen reports no financial or advisory relationship with any corporate organization.

    Giorgio Sandrini, MD
    University Center for Adaptive Disorders and Headache
    University of Pavia
    Pavia, Italy
    • Dr. Sandrini reports no financial or advisory relationship with any corporate organization.

    Filippo Santorelli, MD
    Institute of Mental and Nervous Diseases
    University of Rome "La Sapienza"
    Rome, Italy
    • Dr. Santorelli reports no financial or advisory relationship with any corporate organization.

    Søren Schifter, MD, PhD
    Department of Clinical Physiology and Nuclear Medicine
    Glostrup Hospital
    University of Copenhagen
    Copenhagen, Denmark
    • Dr. Schifter reports no financial or advisory relationship with any corporate organization.

    Paola Torelli, MD
    Headache Center
    Institute of Neurology
    Parma, Italy
    • Dr. Torelli reports no financial or advisory relationship with any corporate organization.

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.

New and Emerging Therapies in the Treatment of Migraine
Brian E. Mondell, MD

This issue of Advanced Studies in Medicine is the second in a series of 3 publications focusing on new and emerging treatments for migraine. This issue covers the proceedings of the Fifth Congress of the European Federation of Neurological Societies 2000 (EFNS2000), which was held in Copenhagen, Denmark October 14-18, 2000. The proceedings of the congress included discussions of: 1) the International Headache Society (IHS) criteria for the diagnosis and classification of migraine; 2) the complex interaction of genetics and the environment in the pathogenesis of migraine and related headache disorders; 3) the continuum between tension-type headache and migraine; and 4) the concept of stratified vs step-care treatment strategies. The topics of these discussions were relevant not only to current clinical practices for managing migraine but also to the development of new migraine treatments for the future.

The IHS criteria have proven to be a valuable resource for the diagnosis and treatment of migraine and related headache disorders. The international acceptance of the criteria has given headache specialists a common language for their practice. This international language, in turn, has been of benefit to epidemiologists, by allowing them to evaluate the total burden of migraine and headache disorders worldwide. In this issue, Dr. Hartmut Göbel of the Kiel Pain Clinic in Germany presents a review of the international prevalence and costs associated with migraine, tension-type headache, cluster headache, and headache in general. As he states in his article, "...there is no other group of neurological disorders that can be diagnosed with the same degree of precision. Without these criteria for classification, the advances in headache therapy in recent years would not have been possible."

Nonetheless, there have been discussions of revising the 12-year-old criteria. Clinicians are realizing that the criteria may lack the flexibility necessary for clinical practice even though they may offer the standardization required for patient selection in clinical trials. Whereas some criteria may need refining, additional criteria for new forms of headache may need to be included. At EFNS2000, Dr. Paola Torelli discussed findings from her research on how patients with cluster headaches describe their pain and their behavior during an attack. Her findings showed that patients are quite explicit when describing the extent of their pain and that the descriptions are far more specific than the 3-item scale used in the IHS criteria. In addition, patients behavior, including measures for obtaining pain relief, suggested patterns of behavior that may be useful in developing more specific criteria for differential diagnoses.

Dr. Messoud Ashina presented findings from his research on calcitonin gene-related peptide (CGRP) levels in chronic tension-type headache (CTTH). According to Dr. Ashina, a relationship between CTTH and migraine can be inferred by the headache continuum theory. If there is indeed a relationship, the CGRP levels in CTTH with certain headache qualities may provide clues for the pathophysiology of migraine and may be useful in determining treatment options.

Another clue to migraine pathophysiology lies in the interaction between the genes involved in migraine pathogenesis and the environmental factors that affect its clinical manifestation. As Dr. Giorgio Sandrini discussed in his presentation, migraine is often described in terms of attacks (i.e., the duration of the attack, the characteristics of the pain, the presence of nausea or vomiting, and the presence of photo- or phonophobia) and the characteristics of the disorder (the association/comorbidity with other diseases, age of onset, response to provocation tests, response to prophylaxis, evolution, and outcome). However, these descriptions do not provide a full understanding of migraine. Genetic studies are beginning to reveal the complex interactions between the genes involved in migraine susceptibility and environmental factors such as comorbidity (and its change over time) and psychosocial stressors in migraine development. It is only by understanding the complex interaction of genetics and the environment in clinical expression that the heterogeneity of migraine can be fully appreciated. It is this heterogeneity that will hopefully enable tailored pharmacotherapy in the future.

The poster sessions held at the EFNS2000 also covered important topics in migraine management such as the use of topiramate for prophylaxis, the evolution to chronic daily headache from migraine and tension-type headache in the elderly, the prognosis of tension-type headache over 10 years, and the concepts of stratified care and step-care treatment. The research presented on the treatment strategies showed that step care across attacks may be preferred in the managed care industry, but stratified care based on disability appears to be more effective, and is predicted to be ultimately more cost effective.

Also featured in this issue is an interview with Dr. Frederick Freitag of the Diamond Headache Clinic in Chicago, Illinois. Dr. Freitag believes that the greatest challenge of treating headache disorder is that patients are often reluctant to seek medical attention believing that their headaches are not severe or frequent enough to warrant a visit to the doctor. Dr. Freitag explains the importance of physicians taking a thorough medical history to ensure a proper diagnosis and thus an appropriate course of treatment. Dr. Freitag also discusses the usefulness and challenges of the IHS criteria for identifying headache disorder.

The current status of migraine research, as with other areas of scientific research, raises more questions than it answers. However, the multidisciplinary approach to understanding migraine pathophysiology will streamline therapeutic efforts in the future.





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