Case 4: Managing Chronic Migraine
Jointly provided by
Support for this activity has been provided through educational grants from Allergan, Inc. and Teva Pharmaceuticals.
Release date: 5/25/2016
Expiration date: 12/17/2016
Estimated time to complete: 30 minutes
Migraine affects 12% of the US population and is classified as either episodic or chronic. Migraine is most frequently diagnosed between the ages of 30 and 40 years, and it is more common in women. Diagnosis is based on excluding other causes of headache and on assessing patient symptoms against the International Classification of Headache Disorders diagnostic criteria. Treatment includes both fast-acting acute therapies and prophylactic therapies designed to prevent the onset of migraine. Despite the availability of these therapies, the 2010 Global Burden of Disease study reported that migraine remains one of the most disabling medical conditions.
This case follows Jaime, a patient with a long history of migraine headache. For many years Jaime’s headaches were adequately controlled with acute and preventive therapy. Today, Jaime is seeing a neurologist because the severity and frequency of her migraine headaches are not responding to her current therapies. Case 4 discusses the overall management of chronic migraine, from diagnosis to treatment, and also addresses the differences between chronic migraine and medication overuse headache, which can present similarly.
The Resource Library, which can be accessed from the main Virtual Practice map, houses tools that can aid in migraine diagnosis and management. The Resource Library also contains Day in the Life of Three Migraine Patients. This patient-focused activity identifies common causes of migraine medication nonadherence and discusses why such behaviors are detrimental to treatment efficacy. Clinicians can view Day in the Life of Three Migraine Patients for themselves and are encouraged to share it with their patients through email or in person during office visits.
Sheena K. Aurora, MD—Program Chair
Clinical Associate Professor
Department of Neurology and Neurological Sciences
Susan L. Hutchinson, MD
Associate Clinical Professor
Department of Family Medicine
University of California-Irvine Medical Center
Director and Founder
Orange County Migraine & Headache Center
B. Lee Peterlin, DO
Director, Johns Hopkins Headache Research
Associate Professor of Neurology
Johns Hopkins University School of Medicine
This activity has been designed to meet the educational needs of neurologists, primary care physicians, and other clinicians who provide care to patients with migraine.
Upon completion of this activity, participants should be able to:
- Develop an effective treatment plan for the management of chronic migraine
Accreditation and Credit Designation
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Penn State College of Medicine and RedMedEd. Penn State College of Medicine is accredited by the ACCME to provide continuing medical education for physicians.
Penn State College of Medicine designates this enduring material for a maximum of 0.5 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Penn State College of Medicine is committed to offering CME programs that promote improvements or quality in health care and are developed free of the control of commercial interests. Reasonable efforts have been taken to ensure that our programs are balanced, independent, objective, scientific, and in compliance with regulatory requirements. Faculty, course directors, and planners have disclosed relevant financial relationships with commercial companies, and Penn State has a process in place to resolve any conflict of interest. Disclosure of a relationship is not intended to suggest or condone bias but is made to provide participants with information that might be of potential importance to their evaluation of this educational activity. Disclosures are as follows:
Sheena K. Aurora, MD, has disclosed the following relevant financial relationships:
Consultant/Advisor: Anavir, Allergan, Eneura, Nupathe
Research Grant: Allergan, Amgen, Gammacore, Teva Pharmaceuticals
Susan L. Hutchinson, MD, has disclosed the following relevant financial relationships:
Speakers Bureau: Allergan, Forest, Impax, Takeda, Zogenix
Consultant/Advisor: Allergan, Takeda, Zogenix
B. Lee Peterlin, DO, has disclosed the following relevant financial relationships:
Research Grant: Luitpold Pharmaceuticals, GSK Pharmaceuticals, National Institutes of Health
Penn State College of Medicine staff involved in the development and review of this activity have disclosed no relevant financial relationships.
The RedMedEd staff members involved in the development and review of this activity have disclosed no relevant financial relationships:
Thomas Finnegan, PhD, Medical Director
Denise LaTemple, PhD, Director, Scientific Services
Lauren Showers, Project Manager
Jonathan S. Simmons, ELS, Senior Managing Editor
Karen Smith, Creative Director
Unapproved Product Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the US Food and Drug Administration. Penn State College of Medicine and RedMedEd do not recommend the use of any agent outside the labeled indications.
|Generic Name||Trade Name||Approved Use (if any)||Unapproved/ |
|Amitriptyline||Elavil, Endep, Levate||Relief of symptoms of depression||Preventive migraine therapy; treatment of chronic migraine|
|Atenolol||Tenormin||Hypertension, angina pectoris due to coronary atherosclerosis, and acute myocardial infarction||Preventive migraine therapy|
|Fluoxetine||Prozac||Acute and maintenance treatment of major depressive disorder in adult patients and pediatric patients (8–18 years); acute and maintenance treatment of obsessions and compulsions in adult patients and pediatric patients (7–17 years) with obsessive compulsive disorder; acute and maintenance treatment of binge-eating and vomiting behaviors in adult patients with moderate to severe bulimia nervosa; acute treatment of panic disorder, with or without agoraphobia, in adult patients; in combination with olanzapine for the acute treatment of depressive episodes associated with bipolar disorder in adult patients||Treatment of chronic migraine|
|Frovatriptan||Frova||Acute treatment of migraine with or without aura in adults||Preventive treatment for menstrual migraine|
|Gabapentin||Neurontin||Management of postherpetic neuralgia in adults; adjunctive therapy in the treatment of partial-onset seizures, with and without secondary generalization, in adults and pediatric patients (≥3 years) with epilepsy||Treatment of chronic migraine|
|Ketorolac||Toradol||Short-term (≤5 days) management of moderately severe acute pain that requires analgesia at the opioid level, usually in a postoperative setting||Acute treatment of migraine|
|Metoprolol||Lopressor||Treatment of hypertension, used alone or in combination with other antihypertensive agents; long-term treatment of angina pectoris; treatment of hemodynamically stable patients with definite or suspected acute myocardial infarction to reduce cardiovascular mortality||Preventive migraine therapy|
|Nadolol||Corgard||Long-term management of patients with angina pectoris; treatment of hypertension, to lower blood pressure. May be used alone or in combination with other antihypertensive agents, especially thiazide-type diuretics||Preventive migraine therapy|
|Naratriptan||Amerge||Acute treatment of migraine with or without aura in adults||Preventive treatment for menstrual migraine|
|Tizanidine||Zanaflex||Management of spasticity||Treatment of chronic migraine|
|Topiramate||Topamax||Initial monotherapy in patients ≥2 years of age with partial-onset or primary generalized tonic-clonic seizures; adjunctive therapy for adults and pediatric patients (2–16 years) with partial-onset seizures or primary generalized tonic-clonic seizures, and in patients ≥2 years of age with seizures associated with Lennox-Gastaut syndrome; for adults and adolescents (≥12 years of age) for the prophylaxis of migraine headache||Treatment of chronic migraine|
|Valproate||Depakene, Valproic, Stavzor||Monotherapy and adjunctive therapy in the treatment of patients with complex partial seizures that occur either in isolation or in association with other types of seizures; sole and adjunctive therapy in the treatment of simple and complex absence seizures, and adjunctively in patients with multiple seizure types, which include absence seizures||Treatment of chronic migraine|
|Venlafaxine||Effexor||Treatment of major depressive disorder; treatment of generalized anxiety disorder; treatment of social anxiety disorder; treatment of panic disorder, with or without agoraphobia||Preventive migraine therapy|
|Zolmitriptan||Zomig||Acute treatment of migraine with or without aura in adults||Preventive treatment for menstrual migraine|
The information presented in this activity is for continuing medical education purposes only and is not meant to substitute for the independent medical judgment of a physician regarding diagnosis and treatment of a specific patient’s medical condition.
The opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of Penn State College of Medicine, RedMedEd, Allergan, Inc., or Teva Pharmaceuticals. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Method of Participation
There are no fees to participate in the activity. To receive CME credit, participants must review all activity information (including the learning objectives, disclosure statements, and content) and complete the posttest and program evaluation. Certificates can be printed immediately.
For questions regarding CME credit, contact Penn State Continuing Education at (717) 531-6483 or ContinuingEd@hmc.psu.edu. Please reference activity code G5640-15-T.
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