© 2011 CogniMed Inc. All rights reserved. HD13001 June 2011

Jointly sponsored by the Annenberg Center for Health Sciences at Eisenhower and CogniMed Inc.

This activity is supported by an independent educational grant provided by Allergan, Inc.

This CME-certified lunch symposium is not part of the 53rd Annual Scientific Meeting of the American Headache Society®.

Thursday, June 2, 2011Grand Hyatt WashingtonWashington, DC

12:30 PM Program2:00 PM Adjourn

Thursday, June 2, 2011

Jointly sponsored by the Annenberg Center for Health Sciences at Eisenhower and CogniMed Inc.

This activity is supported by an independent educational grant provided by Allergan, Inc.

This CME-certified lunch symposium is not part of the 53rd Annual Scientific Meeting of the American Headache Society®.

To participate in other CME/CE programs about chronic migraine, please visitPrimaryPerspective.org/migraine

Grand Hyatt WashingtonWashington, DC

12:30 PM Program2:00 PM Adjourn

© 2011 CogniMed Inc. All rights reserved. HD13001 June 2011

Offering in-depth analysis and highly interactive audience discussion

THURSDAY, JUNE 2, 2011 AGENDA

12:30 PM Registration and Lunch

12:35 PM Welcome and Introduction Richard B. Lipton, MD Chairperson

12:40 PM Minimizing Migraine Chronification: Early Diagnosis and Recognition

Richard B. Lipton, MD

1:00 PM Chronic Migraine: Mechanisms and Targets for Therapy

Peter J. Goadsby, MD, PhD, DSc,FRACP, FRCP

1:20 PM Epidemiologic Evidence: Risk Management and Reducing Burden of Chronic Migraine

Dawn C. Buse, PhD

1:40 PM Treatments for Chronic Migraine

Joel R. Saper, MD, FACP, FAAN

2:00 PM Closing Comments and Adjourn

CHAIRPERSON Richard B. Lipton, MD Professor and Vice Chair of Neurology Professor of Epidemiology and Population Health Director, Montefiore Headache Center Albert Einstein College of Medicine Bronx, New York FACULTY Dawn C. Buse, PhD Assistant Professor, Department of Neurology Albert Einstein College of Medicine of Yeshiva University Assistant Professor, Clinical Health Psychology Doctoral Program Ferkauf Graduate School of Psychology of Yeshiva University Director of Behavioral Medicine Montefiore Headache Center Bronx, New York Peter J. Goadsby, MD, PhD, DSc, FRACP, FRCP Professor of Neurology Director, Headache Center University of California San Francisco, California Joel R. Saper, MD, FACP, FAAN Founder and Director Michigan Headache & Neurological Institute Ann Arbor, Michigan Director Head Pain Treatment Unit Chelsea Community Hospital Chelsea, Michigan Clinical Professor of Medicine (Neurology) Michigan State University East Lansing, Michigan INTENDED AUDIENCE This activity was developed for neurologists and headache specialists in attendance at the 53rd Annual Scientific Meeting of the American Headache Society®. STATEMENT OF NEED Chronic migraine (CM) is a highly disabling neurologic disorder, with heterogeneous characteristics resulting in a range of symptom profiles, burden, and disability, that remains largely underdiagnosed and undertreated. Affecting nearly 2% of the general population, CM is one of the most disabling of the primary headache disorders, imposing considerable economic burden while interfering with social, occupational, and educational functioning; it remains an enormous challenge in neurologic and headache practices.

Treatment of CM has evolved into a multifaceted approach, including lifestyle modification, trigger management, behavioral therapy, pharmacologic therapy, education, support, management of expectations, and close follow-up. Topiramate, divalproex, and onabotulinumtoxinA have been evaluated as prophylactic treatment of CM in randomized, double-blind, placebo-controlled or active comparator-controlled trials. OnabotulinumtoxinA received approval October 15, 2010, from the US Food and Drug Administration for prophylactic treatment of CM. This educational activity will review the diagnosis, risk factors, economic burden, and optimal treatment of CM. This activity will be highly interactive, with brief presentations and extended discussion sessions between faculty and audience members after each presentation. EDUCATIONAL OBJECTIVES At the conclusion of this activity, participants should be better able to:

Integrate diagnostic criteria for chronic migraine (CM) into clinical practice to facilitate earlier diagnosis

Identify changes in brain structure and function associated with CM and examine mechanisms of action for acute and prophylactic therapies

Assess the increased cost of CM and the burden on medical resources Define CM patient populations for whom prophylactic therapy has shown clinical benefit and

utilize prophylaxis in this population as needed ACCREDITATION AND CERTIFICATION This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Annenberg Center for Health Sciences at Eisenhower and CogniMed Inc. The Annenberg Center is accredited by the ACCME to provide continuing medical education for physicians. The Annenberg Center for Health Sciences designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Statements of Credit will be provided by mail following activity participation and upon completion and return of the evaluation form to CogniMed Inc. via submission at the end of the symposium. Mail the completed form to CogniMed Inc., 70 South Orange Avenue, Suite 200, Livingston, NJ 07039, or fax it to 877-403-5765. Please allow 4 to 6 weeks for the delivery of your statement. DISCLOSURE STATEMENT It is the policy of the Annenberg Center to ensure fair balance, independence, objectivity, and scientific rigor in all programming. All faculty and planners participating in sponsored programs are expected to identify and reference off-label product use and disclose any significant relationships with those supporting the activity or any others whose products or services are discussed. In accordance with the Accreditation Council for Continuing Medical Education standards, parallel documents from other accrediting bodies, and Annenberg Center policy, the following disclosures have been made: All staff at the Annenberg Center for Health Sciences at Eisenhower have nothing to disclose.

All staff at CogniMed Inc. have nothing to disclose. Richard B. Lipton, MD, receives research support from the Migraine Research Fund, the National Headache Foundation, and the National Institutes of Health. He is a consultant for Advanced Bionics Corporation; Allergan, Inc.; Boehringer Ingelheim; Endo Pharmaceuticals; GlaxoSmithKline; Kowa Pharmaceuticals America, Inc.; Merck & Co., Inc.; Minster Pharmaceuticals; Neuralieve Inc.; Ortho-McNeil Pharmaceutical, Inc.; and Pfizer Inc and has received honoraria from Allergan, Inc.; GlaxoSmithKline; and Merck & Co., Inc. Dawn C. Buse, PhD, is a consultant for Allergan, Inc.; Endo Pharmaceuticals; Iroko Pharmaceuticals; and MAP Pharmaceuticals, Inc. Peter J. Goadsby, MD, PhD, DSc, FRACP, FRCP, receives research support from Amgen Inc.; Boston Scientific Corporation; GlaxoSmithKline; MAP Pharmaceuticals, Inc.; Merck Sharp & Dohme Limited; and Neuralieve Inc. He is a consultant for Air Products and Chemicals, Inc.; AstraZeneca; Bristol-Myers Squibb Company; NeuroTherapeutics Pharma, Inc.; Pfizer Inc; and Vertex Pharmaceuticals Incorporated, and serves on the speakers bureaus of Almirall, Merck Sharp & Dohme Limited, and Pfizer Inc. Joel R. Saper, MD, FACP, FAAN, receives research support from Allergan, Inc.; AstraZeneca; Boston Scientific Corporation; Eli Lilly and Company; Forest Laboratories, Inc.; Johnson & Johnson; Medtronic, Inc.; Merck & Co., Inc.; NeurogesX Inc.; Novartis; NuPathe Inc.; Pfizer Inc; St. Jude Children’s Research Hospital, Inc.; and Vanda Pharmaceuticals Inc. He is a consultant for Allergan, Inc.; Autonomic Technologies, Inc.; Gerson Lehrman Group, Inc.; Medtronic, Inc.; St. Jude Children’s Research Hospital, Inc.; and WellPoint, Inc., and serves on the speakers bureau of Merck & Co., Inc., and the advisory board of Bristol-Myers Squibb Company. He is a significant shareholder of POZEN, Inc. The ideas and opinions presented in this educational activity are those of the faculty and do not necessarily reflect the views of the Annenberg Center and/or its agents. As in all educational activities, we encourage the practitioners to use their own judgment in treating and addressing the needs of each individual patient, taking into account that patient’s unique clinical situation. The Annenberg Center disclaims all liability and cannot be held responsible for any problems that may arise from participating in this activity or following treatment recommendations presented. This program will contain discussion of investigational therapies. Individual clinical judgments should be used in all patient care decisions. The American Headache Society® does not endorse products discussed in this activity. Jointly sponsored by the Annenberg Center for Health Sciences at Eisenhower and CogniMed Inc. This activity is supported by an independent educational grant provided by Allergan, Inc. © 2011 CogniMed Inc. All rights reserved. HD13001 June 2011

RICHARD B. LIPTON, MD

Richard B. Lipton, MD, is Professor and Vice Chair of Neurology, Professor of Epidemiology

and Population Health, and Director of the Montefiore Headache Center at Albert Einstein

College of Medicine, in Bronx, New York. He is also the Lotti and Bernard Benson Faculty

Scholar at Albert Einstein College of Medicine.

Dr Lipton earned a medical degree at the University of Chicago Pritzker School of Medicine, in

Illinois. He completed a neurology residency and clinical neurophysiology fellowship at Albert

Einstein College of Medicine and a fellowship in neuroepidemiology at Columbia University, in

New York, New York.

His research interests include headache epidemiology and clinical trials, cognitive aging and

dementia, and outcomes research.

Dr Lipton is Associate Editor of Cephalalgia and serves on the editorial boards of Neurology and

several other journals. He has published 11 books and more than 400 original articles and

reviews.

Dr Lipton is Past President of the American Headache Society (AHS). He is a 3-time recipient of

the AHS H. G. Wolff Research Award and received the Medical Book Award from the British

Medical Association in 1998 for Headache in Clinical Practice.

 

Minimizing Migraine Chronification: Early Diagnosis and Recognition

Richard B. Lipton, MD

Chronic migraine (CM) is the most disabling of the 4 types of primary chronic daily headache

(CDH) of long duration, a syndrome defined by primary headaches 15 or more days per month

for at least 3 months with attacks that last 4 hours or more per day on average.

Diagnosis of CDH requires a systematic approach that includes these steps: (1) exclude a

secondary headache disorder, (2) identify a primary headache syndrome based on duration and

frequency (eg, long-duration episodic or chronic, short-duration episodic or chronic), and (3)

with a headache duration of at least 4 hours, use symptomatology to determine the specific

headache disorder(s) (CM, chronic tension-type headache, new daily persistent headache,

hemicrania continua).

CM is considered a complication of migraine in the appendix to the second edition of the

International Classification of Headache Disorders (ICHD-II) and defined by the following

features: (a) 15 or more headache days/month over the past 3 months and (b) at least 8 headache

days meet criteria for migraine without aura or respond to migraine-specific treatment.

CM often develops from episodic migraine (EM) after a period of increasing headache

frequency. This process, chronification, occurs in approximately 2% to 3% of EM sufferers in

the general population annually. Chronification is associated with a number of risk factors, some

of which cannot be modified, including age and race, and some that are potentially modifiable or

avoidable, including obesity, snoring, head injury, stressful life events, depression, and overuse

of opioids or barbiturates.

Further studies are needed to determine the possible benefits of risk factor modification in

preventing chronification and potential predictors of remission of CM to EM. Furthermore, it is

critical to understand the role of medication overuse as it applies to the current definition of CM

and its appropriate treatment. The need for clinical vigilance that is highly sensitive yet specific

to the diagnosis of CM and when to initiate treatment to help mitigate the risk of chronification

will be discussed.

Peter J. Goadsby, MD, PhD, DSc, FRACP, FRCP, Biography

PETER J. GOADSBY, MD, PHD, DSC, FRACP, FRCP

Peter J. Goadsby, MD, PhD, DSc, FRACP, FRCP, is Professor of Neurology at the University of

California, San Francisco, and a consultant neurologist to the Hospital for Sick Children, in

London.

Dr Goadsby received medical degrees and doctorates from the University of New South Wales,

in Sydney, Australia, and completed a medical internship and residency at Prince Henry/Prince

of Wales Hospital, in Sydney.

Dr Goadsby’s major research interests are in the neural control of cerebral circulation and the

basic mechanisms of head pain both in experimental settings and in the clinical context of

headache. He specializes in the diagnosis and treatment of headache disorders, including

migraines, cluster headache, and other forms of chronic daily headache.

He serves on the editorial boards of numerous journals and served as Editor of Cephalalgia from

2000 to 2008. He is also an ad hoc reviewer for Brain, Headache, Lancet, Neurology, New

England Journal of Medicine, and Pain, among many others, and has written more than 1000

abstracts, articles, reviews, chapters, and books.

Dr Goadsby is a fellow in the Royal Astralasian College of Physicians and the Royal College of

Physicians. Among his many honors, he is a 5-time recipient of the H.G. Wolff, MD, Award

from the American Association for the Study of Headache, most recently in 2009.

 

Chronic Migraine: Mechanisms and Targets for Therapy

Peter J. Goadsby, MD, PhD, DSc, FRACP, FRCP

As our understanding of migraine evolved from a vascular disorder to a brain disorder,

approaches to treatment and therapeutic targets for drug development have dramatically changed.

Physiologic changes associated with chronic migraine (CM) are now recognized as

manifestations of altered neurobiology, including changes in excitability and central sensitization

of nociceptive pathways, which may offer new targets for therapy.

Although the pathogenesis of migraine pain has not been fully elucidated, the innervation of the

dura mater and large intracranial vessels by trigeminal afferents and reflex connections with the

cranial parasympathetic outflow are likely to play a role. Various mechanisms have been

implicated in the progression of migraine, including both exogenous factors (eg, medication

overuse, and trauma) and endogenous factors.

It seems clear that brain changes occur in CM that are pivotal to expression of the disorder.

Morphologic and structural changes, including reduced cortical gray matter of the pain-

processing areas of the brain, have been reported in some forms of the disorder. Changes in the

periaqueductal gray matter causing trigeminovascular nociception dysmodulation may also be a

critical factor in the pathophysiology of CM. As the trigeminocervical complex is recognized to

play a pivotal role in nociceptive signaling in migraine, it is increasingly being accepted as a

target for putative antimigraine agents.

Opioid overuse in some migraine patients is clearly a problem in terms of management and

resolution of their disability. A clearer understanding of the pathophysiology of CM may lead to

improved treatment of these patients. The primary classes of migraine-specific drugs, including

ergot alkaloid derivatives and triptans, each seems to have the propensity to be troublesome in

particular patients when used frequently.

The targets of CM therapy and the proposed mechanisms of action of acute and prophylactic

migraine treatments will be discussed.

DAWN C. BUSE, PHD

Dawn C. Buse, PhD, is a licensed psychologist and Director of Behavioral Medicine for the

Montefiore Headache Center, in New York, New York. She is also Assistant Professor in the

Department of Neurology of Albert Einstein College of Medicine of Yeshiva University and

Assistant Professor in the Clinical Health Psychology Doctoral Program of Ferkauf Graduate

School of Psychology of Yeshiva University, also in New York.

After earning a master’s degree and a doctorate in psychology from the University of Utah, in

Salt Lake City, Dr Buse completed an internship in medical psychology in the Boston VA

Medical System and Harvard Medical School and 3 years of postdoctoral fellowships in adult

and pediatric headache and pain management at Spaulding Rehabilitation Hospital,

Massachusetts General Hospital, Children’s Hospital, Boston, and Harvard Medical School.

Dr Buse conducts research on headache and pain and is involved in the American Migraine

Prevalence and Prevention (AMPP) study, a large, longitudinal US population-based study of

severe headache. She is co-investigator on another National Headache Foundation study,

Familial Risk of Transformed Migraine, and is also investigating migraine attack prediction

using an electronic diary.

She has published widely and lectured nationally on the challenges of managing migraine in

women, the burden of migraine, and managing migraine and cardiovascular risk and serves as a

consultant and reviewer for several journals, including Neurology, Headache, and Cephalalgia.

Dr Buse also provides clinical care, including assessment, cognitive behavioral therapy, and

biofeedback to patients suffering with headache and other forms of pain. She is a member of the

American Headache Society’s Electronic Media Committee, serves on the “Occupational Burden

of Headache” and “Outcome Measures for Headache” working groups of the World Health

Organization “Lifting the Burden” campaign, and co-chairs the AMPP Investigator Initiated

Grant Program. She received the National Headache Foundation’s Partners in Excellence Award

in 2009.

 

Epidemiologic Evidence: Risk Management and Reducing Burden of Chronic Migraine

Dawn C. Buse, PhD

Chronic migraine (CM) has been demonstrated to be a disabling and burdensome condition. The

majority of studies suggest that the population prevalence of CM ranges from 1.3% to 2.4%,

although it is one of the most common disorders seen in headache specialty practices.

Both clinic- and population-based studies have demonstrated that CM, in comparison with

episodic migraine (EM), results in greater migraine-related disability, reduced health-related

quality of life, increased healthcare resource utilization and related costs, and higher rates of

medical and psychiatric comorbidities, including depression and anxiety. According to a cross-

sectional analysis of data from the American Migraine Prevalence and Prevention (AMPP)

study, when compared with respondents with EM, respondents with CM were significantly less

likely to be employed full-time and almost twice as likely to be occupationally disabled. Those

with CM were approximately twice as likely to have anxiety or depression and 2.5 times more

likely to also have other chronic pain conditions. In addition, they were at higher risk for

respiratory and cardiovascular disorders, 40% more likely to have heart disease and angina, and

70% more likely to have a history of stroke.

These findings highlight the paramount importance of accurate diagnosis, an appropriate

treatment plan consisting of a combination of effective pharmacologic and nonpharmacologic

strategies, and a patient-centered, multidisciplinary approach to the treatment and management

of CM to improve patient outcomes. The tremendous individual and societal burden of CM and

how outcomes research may help elucidate and shape future management paradigms will be

discussed.

JOEL R. SAPER, MD, FACP, FAAN

Joel R. Saper, MD, FACP, FAAN, is Founder and Director of the Michigan Headache &

Neurological Institute, in Ann Arbor, and Clinical Professor of Medicine (Neurology) at

Michigan State University, in East Lansing. He is also Director of the Head Pain Treatment Unit

of Chelsea Community Hospital, in Michigan.

A board-certified neurologist and certified in pain medicine and headache medicine, Dr Saper is

an invited lecturer before universities, medical centers, government and business groups, and lay

audiences around the world. He is featured in major television programs and newspapers as an

authority in headache and pain and their personal, social, and economic impact. Dr Saper is the

author of 8 books and more than 200 medical articles and textbook chapters.

Dr Saper is Past President of the American Association for the Study of Headache, Past

Chairman of the American Council for Headache Education, and an educator in the American

Academy of Neurology, the American Academy of Pain Medicine, the American Headache

Society, and the American Pain Society. He has been cited repeatedly in Best Doctors in

America and The Best in Medicine.

 

Treatments for Chronic Migraine

Joel R. Saper, MD, FACP, FAAN

Chronic migraine (CM) is the most common of type of chronic headache and frequently

associated with medication overuse, serious comorbidity, and disability. Identifying factors that

possibly promote the progression of this disorder from episodic migraine (EM) to daily or almost

daily headache may optimize treatment approaches, including both pharmacotherapeutic and

nonpharmacologic interventions.

Advances in understanding have led to improved diagnosis, CM prophylaxis, and treatment

paradigms for EM and intractable CM. For each patient, clinicians must determine whether

medication overuse is present and treat accordingly; assessment and management must include

carefully weighing when to administer pharmacotherapy, when to utilize interventional and

behavioral approaches, and when to impose comprehensive inpatient evaluation and infusion

treatment. A comprehensive approach should include appropriate management of behavioral,

personality, motivational, and compliance factors, as well as a thorough evaluation of modifiable

risk factors, including obesity, stressors, and sleep disturbances. Clinicians should recognize that

frequent use of opioids is potentially pro-nociceptive, promoting headache progression and

behavioral and physiologic dependency.

While the need to effectively and aggressively control pain is a mainstay of clinical care,

treatment of CM remains complex. The dramatic evolution of headache care will be reviewed,

including an examination of how current treatment paradigms and inpatient programs have

affected the continuity of care to comprehensively and optimally target factors that may provoke

CM, helping to close the gaps in the treatment algorithm using an individualized, patient-

centered approach.

SUGGESTED READING

Afridi SK, Goadsby PJ. Neuroimaging of migraine [review]. Curr Pain Headache Rep. 2006;10(3):221-224. Antonucci F, Rossi C, Gianfranceschi L, Rossetto O, Caleo M. Long-distance retrograde effects of botulinum neurotoxin A. J Neurosci. 2008;28(14):3689-3696. Aurora SK, Dodick DW, Turkel CC, et al; PREEMPT 1 Chronic Migraine Study Group. OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 1 trial. Cephalalgia. 2010;30(7):793-803. Bigal ME, Golden W, Buse D, Chen YT, Lipton RB. Triptan use as a function of cardiovascular risk: a population-based study. Headache. 2010;50(2):256-263. Bigal ME, Lipton RB. Excessive opioid use and the development of chronic migraine. Pain. 2009;142(3):179-182. Bigal ME, Lipton RB. Migraine chronification. Curr Neurol Neurosci Rep. 2011;11(2):139-148. Bigal ME, Lipton RB. Overuse of acute migraine medications and migraine chronification [review]. Curr Pain Headache Rep. 2009;13(4):301-317. Blumenfeld AM, Varon SF, Wilcox TK, et al. Disability, HRQoL and resource use among chronic and episodic migraineurs: results from the International Burden of Migraine Study (IBMS). Cephalalgia. 2011;31(3):301-315. Buse DC, Lipton RB. Facilitating communication with patients for improved migraine outcomes [review]. Curr Pain Headache Rep. 2008;12(3):230-236. Buse DC, Manack A, Serrano D, Turkel C, Lipton RB. Sociodemographic and comorbidity profiles of chronic migraine and episodic migraine sufferers. J Neurol Neurosurg Psychiatry. 2010;81(4):428-432. Chankrachang S, Arayawichanont A, Poungvarin N, et al. Prophylactic botulinum type A toxin complex (Dysport®) for migraine without aura. Headache. 2011;51(1):52-63. Charbit AR, Akerman S, Holland PR, Goadsby PJ. Neurons of the dopaminergic/calcitonin gene-related peptide A11 cell group modulate neuronal firing in the trigeminocervical complex: an electrophysiological and immunohistochemical study. J Neurosci. 2009;29(40):12532-12541.

Christie SN, Giammarco R, Gawel M, Mackie G, Gladstone J, Becker WJ. Botulinum toxin type A and acute drug costs in migraine with triptan overuse. Can J Neurol Sci. 2010;37(5):588-594. Diener HC, Dodick DW, Aurora SK, et al; PREEMPT 2 Chronic Migraine Study Group. OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 2 trial. Cephalalgia. 2010;30(7):804-814. Dodick DW, Turkel CC, DeGryse RE, et al; PREEMPT Chronic Migraine Study Group. OnabotulinumtoxinA for treatment of chronic migraine: pooled results from the double-blind, randomized, placebo-controlled phases of the PREEMPT clinical program. Headache. 2010;50(6):921-936. Gazerani P, Au S, Dong X, Kumar U, Arendt-Nielsen L, Cairns BE. Botulinum neurotoxin type A (BoNTA) decreases the mechanical sensitivity of nociceptors and inhibits neurogenic vasodilation in a craniofacial muscle targeted for migraine prophylaxis. Pain. 2010;151(3):606-616. Goadsby PJ. Pathophysiology of migraine. Neurol Clin. 2009;27(2):335-360. Goadsby PJ, Charbit AR, Andreou AP, Akerman S, Holland PR. Neurobiology of migraine [review]. Neuroscience. 2009;161(2):327-341. Kurth T, Mohamed S, Maillard P, et al. Headache, migraine, and structural brain lesions and function: population based Epidemiology of Vascular Ageing-MRI study. BMJ. 2011;342:c7357. Lipton RB, Silberstein S, Dodick D, et al. Topiramate intervention to prevent transformation of episodic migraine: the topiramate INTREPID study. Cephalalgia. 2011;31(1):18-30. Manack A, Buse DC, Serrano D, Turkel CC, Lipton RB. Rates, predictors, and consequences of remission from chronic migraine to episodic migraine. Neurology. 2011;76(8):711-718. Manack AN, Buse DC, Lipton RB. Chronic migraine: epidemiology and disease burden [review]. Curr Pain Headache Rep. 2011;15(1):70-78.

Mathew NT, Jaffri SF. A double-blind comparison of onabotulinumtoxinA (BOTOX) and topiramate (TOPAMAX) for the prophylactic treatment of chronic migraine: a pilot study. Headache. 2009;49(10):1466-1478. Munakata J, Hazard E, Serrano D, et al. Economic burden of transformed migraine: results from the American Migraine Prevalence and Prevention (AMPP) study. Headache. 2009;49(4):498-508. Natoli JL, Manack A, Dean B, et al. Global prevalence of chronic migraine: a systematic review. Cephalalgia. 2010;30(5):599-609. Obermann M, Nebel K, Schumann C, et al. Gray matter changes related to chronic posttraumatic headache. Neurology. 2009;73(12):978-983. Sandrini G, Perrotta A, Tassorelli C, et al. Botulinum toxin type-A in the prophylactic treatment of medication-overuse headache: a multicenter, double-blind, randomized, placebo-controlled, parallel group study. J Headache Pain. 2011 Apr 16 [Epub ahead of print]. Saper JR, Dodick DW, Silberstein SD, McCarville S, Sun M, Goadsby PJ; ONSTIM Investigators. Occipital nerve stimulation for the treatment of intractable chronic migraine headache: ONSTIM feasibility study. Cephalalgia. 2011;31(3):271-285. Saper JR, Lake AE III, Bain PA, et al. A practice guide for continuous opioid therapy for refractory daily headache: patient selection, physician requirements, and treatment monitoring. Headache. 2010;50(7):1175-1193. Silberstein S, Lipton R, Dodick D, et al. Topiramate treatment of chronic migraine: a randomized, placebo-controlled trial of quality of life and other efficacy measures. Headache. 2009;49(8):1153-1162. Stewart WF, Wood GC, Bruce C, Buse DC, Runken MC, Lipton RB. Longitudinal change in migraine headache-days and indirect cost consequences. J Occup Environ Med. 2011;53(5):478-487. Stewart WF, Wood GC, Manack A, Varon SF, Buse DC, Lipton RB. Employment and work impact of chronic migraine and episodic migraine. J Occup Environ Med. 2010;52(1):8-14. Summ O, Charbit AR, Andreou AP, Goadsby PJ. Modulation of nocioceptive transmission with calcitonin gene-related peptide receptor antagonists in the thalamus. Brain. 2010;133(9):2540-2548.

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CME Lunch SymposiumGrand Hyatt Washington • Washington, DC • June 2, 2011

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Presentations Excellent PoorMinimizing Migraine Chronification: Early Diagnosis and RecognitionRichard B. Lipton, MD

Overall presentation 5 4 3 2 1Clinical relevance 5 4 3 2 1Presentation style/visuals 5 4 3 2 1

Chronic Migraine: Mechanisms and Targets for TherapyPeter J. Goadsby, MD, PhD, DSc, FRACP, FRCP

Overall presentation 5 4 3 2 1Clinical relevance 5 4 3 2 1Presentation style/visuals 5 4 3 2 1

Epidemiologic Evidence: Risk Management and Reducing Burden of Chronic MigraineDawn C. Buse, PhD

Overall presentation 5 4 3 2 1Clinical relevance 5 4 3 2 1Presentation style/visuals 5 4 3 2 1

Treatments for Chronic MigraineJoel R. Saper, MD, FACP, FAAN

Overall presentation 5 4 3 2 1Clinical relevance 5 4 3 2 1Presentation style/visuals 5 4 3 2 1

(Please see next page)

Activity Agree Disagree

As a result of this activity, I am better able to:

Integrate diagnostic criteria for chronic migraine (CM) into clinical 5 4 3 2 1practice to facilitate earlier diagnosis

Identify changes in brain structure and function associated with CM 5 4 3 2 1and examine mechanisms of action for acute and prophylactic therapies

Assess the increased cost of CM and the burden on medical resources 5 4 3 2 1

Define CM patient populations for whom prophylactic therapy has 5 4 3 2 1shown clinical benefit and utilize prophylaxis in this population as needed

The activity:

Met my expectations 5 4 3 2 1

Was relevant to my clinical practice 5 4 3 2 1

Was presented without commercial bias 5 4 3 2 1

Logistics were well-organized 5 4 3 2 1

Environment was conducive to learning 5 4 3 2 1

After participating in this activity, I will change my clinical practice by: ____________________________________________________

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© 2011 CogniMed Inc. All rights reserved. HD13001 June 2011