AAN Annual Meeting

WASHINGTON – Primary care providers are generally familiar with the prevalence and initial diagnosis of migraine but less so with the specifics of treating migraine or its psychiatric comorbidities.

Many primary care providers (PCPs) are uncomfortable with prescribing preventive medications, preferring to rely on abortives and other acute attack treatments, Dr. Mia Minen said at the annual meeting of the American Academy of Neurology. Her study on PCP knowledge of migraine also revealed a “concerning” lack of attention to depression and anxiety among migraine patients.

“Most of our participants did know that these are common comorbid conditions,” said Dr. Minen of New York University. “But only half of them were assessing patients for anxiety, and only 30% for depression. This is a significant problem, because we think there’s a bidirectional relationship here – treating the psychiatric problems may actually help the migraines as well.”

Migraine accounts for 5 million-9 million primary care visits each year, she said, and many migraine patients are managed by their PCPs. “Unfortunately, as many as 60% of these patients are unrecognized as having migraine,” and many go for as long as 4 years before being properly diagnosed. “Primary care physicians have limited time with patients, and a migraine intake and assessment is time-consuming – as is managing the patient. Studies show that treatment is often suboptimal, with simple analgesic prescribing. And few of those who do qualify for preventive treatment actually get it.”

Her study aimed to discover what PCPs know – and need to learn – about migraine.

The first portion was framed in three semi-structured 15-minute interviews, moderated by headache specialists. Eleven physicians from different backgrounds attended these. They were asked what they perceived as their knowledge gaps in migraine diagnosis and treatment, and what difficulties they had encountered in those areas.

“About half said they would order an MRI for a new type of headache,” Dr. Minen said. A quarter didn’t know that an MRI was indicated for a headache with neuralgic symptoms, and only a third knew to order one when a headache worsened or remained unresponsive to treatment.

“These four conditions are situations in which headache experts typically agree that imaging is necessary,” Dr. Minen said. “Our findings indicate that primary care physicians might not actually be ordering imaging studies in situations where it should be done.”

Participants were generally unaware of the AAN’s guidelines on preventive medications, or the “Choosing Wisely” campaign to limit opioids and imaging in migraine patients, except in particular cases.

While most had heard of medication overuse headache, they were uncertain about how to diagnose it and unaware of some of the medications implicated in it. Participants were comfortable with some abortive medications (sumatriptan and naratriptan) and only prescribed opioids as a last resort. Antiemetics were rarely offered without a specific patient request.

There was uncertainty and discomfort about prescribing preventive medications, particularly topiramate. Several physicians said that patients often don’t comply with a daily regimen, so they preferred to stick with abortives. None had used botulinum toxin.

The second part of the study was a more specific, online survey completed by about 80 PCPs.

Most (60%) weren’t familiar with the recommendation about limiting opioids. While 60% said they knew that nonsteroidal anti-inflammatories could spark medication overuse headache, only half know that butabital-containing drugs could. A third knew about the risks for it with acetaminophen and narcotics, and only 13% about the association of triptans with medication overuse headache.

Few patients were apparently referred to evidence-based nonpharmacologic treatments, like biofeedback and cognitive behavioral therapy (just 1% and 3% of physicians said that they did so).

“Doctors apparently just don’t know that these alternatives are supported by strong evidence,” Dr. Minen said.

She had no financial disclosures.

WASHINGTON – Primary care providers are generally familiar with the prevalence and initial diagnosis of migraine but less so with the specifics of treating migraine or its psychiatric comorbidities.

Many primary care providers (PCPs) are uncomfortable with prescribing preventive medications, preferring to rely on abortives and other acute attack treatments, Dr. Mia Minen said at the annual meeting of the American Academy of Neurology. Her study on PCP knowledge of migraine also revealed a “concerning” lack of attention to depression and anxiety among migraine patients.

“Most of our participants did know that these are common comorbid conditions,” said Dr. Minen of New York University. “But only half of them were assessing patients for anxiety, and only 30% for depression. This is a significant problem, because we think there’s a bidirectional relationship here – treating the psychiatric problems may actually help the migraines as well.”

Migraine accounts for 5 million-9 million primary care visits each year, she said, and many migraine patients are managed by their PCPs. “Unfortunately, as many as 60% of these patients are unrecognized as having migraine,” and many go for as long as 4 years before being properly diagnosed. “Primary care physicians have limited time with patients, and a migraine intake and assessment is time-consuming – as is managing the patient. Studies show that treatment is often suboptimal, with simple analgesic prescribing. And few of those who do qualify for preventive treatment actually get it.”

Her study aimed to discover what PCPs know – and need to learn – about migraine.

The first portion was framed in three semi-structured 15-minute interviews, moderated by headache specialists. Eleven physicians from different backgrounds attended these. They were asked what they perceived as their knowledge gaps in migraine diagnosis and treatment, and what difficulties they had encountered in those areas.

“About half said they would order an MRI for a new type of headache,” Dr. Minen said. A quarter didn’t know that an MRI was indicated for a headache with neuralgic symptoms, and only a third knew to order one when a headache worsened or remained unresponsive to treatment.

“These four conditions are situations in which headache experts typically agree that imaging is necessary,” Dr. Minen said. “Our findings indicate that primary care physicians might not actually be ordering imaging studies in situations where it should be done.”

Participants were generally unaware of the AAN’s guidelines on preventive medications, or the “Choosing Wisely” campaign to limit opioids and imaging in migraine patients, except in particular cases.

While most had heard of medication overuse headache, they were uncertain about how to diagnose it and unaware of some of the medications implicated in it. Participants were comfortable with some abortive medications (sumatriptan and naratriptan) and only prescribed opioids as a last resort. Antiemetics were rarely offered without a specific patient request.

There was uncertainty and discomfort about prescribing preventive medications, particularly topiramate. Several physicians said that patients often don’t comply with a daily regimen, so they preferred to stick with abortives. None had used botulinum toxin.

The second part of the study was a more specific, online survey completed by about 80 PCPs.

Most (60%) weren’t familiar with the recommendation about limiting opioids. While 60% said they knew that nonsteroidal anti-inflammatories could spark medication overuse headache, only half know that butabital-containing drugs could. A third knew about the risks for it with acetaminophen and narcotics, and only 13% about the association of triptans with medication overuse headache.

Few patients were apparently referred to evidence-based nonpharmacologic treatments, like biofeedback and cognitive behavioral therapy (just 1% and 3% of physicians said that they did so).

“Doctors apparently just don’t know that these alternatives are supported by strong evidence,” Dr. Minen said.

She had no financial disclosures.

WASHINGTON – Primary care providers are generally familiar with the prevalence and initial diagnosis of migraine but less so with the specifics of treating migraine or its psychiatric comorbidities.

Many primary care providers (PCPs) are uncomfortable with prescribing preventive medications, preferring to rely on abortives and other acute attack treatments, Dr. Mia Minen said at the annual meeting of the American Academy of Neurology. Her study on PCP knowledge of migraine also revealed a “concerning” lack of attention to depression and anxiety among migraine patients.

“Most of our participants did know that these are common comorbid conditions,” said Dr. Minen of New York University. “But only half of them were assessing patients for anxiety, and only 30% for depression. This is a significant problem, because we think there’s a bidirectional relationship here – treating the psychiatric problems may actually help the migraines as well.”

Migraine accounts for 5 million-9 million primary care visits each year, she said, and many migraine patients are managed by their PCPs. “Unfortunately, as many as 60% of these patients are unrecognized as having migraine,” and many go for as long as 4 years before being properly diagnosed. “Primary care physicians have limited time with patients, and a migraine intake and assessment is time-consuming – as is managing the patient. Studies show that treatment is often suboptimal, with simple analgesic prescribing. And few of those who do qualify for preventive treatment actually get it.”

Her study aimed to discover what PCPs know – and need to learn – about migraine.

The first portion was framed in three semi-structured 15-minute interviews, moderated by headache specialists. Eleven physicians from different backgrounds attended these. They were asked what they perceived as their knowledge gaps in migraine diagnosis and treatment, and what difficulties they had encountered in those areas.

“About half said they would order an MRI for a new type of headache,” Dr. Minen said. A quarter didn’t know that an MRI was indicated for a headache with neuralgic symptoms, and only a third knew to order one when a headache worsened or remained unresponsive to treatment.

“These four conditions are situations in which headache experts typically agree that imaging is necessary,” Dr. Minen said. “Our findings indicate that primary care physicians might not actually be ordering imaging studies in situations where it should be done.”

Participants were generally unaware of the AAN’s guidelines on preventive medications, or the “Choosing Wisely” campaign to limit opioids and imaging in migraine patients, except in particular cases.

While most had heard of medication overuse headache, they were uncertain about how to diagnose it and unaware of some of the medications implicated in it. Participants were comfortable with some abortive medications (sumatriptan and naratriptan) and only prescribed opioids as a last resort. Antiemetics were rarely offered without a specific patient request.

There was uncertainty and discomfort about prescribing preventive medications, particularly topiramate. Several physicians said that patients often don’t comply with a daily regimen, so they preferred to stick with abortives. None had used botulinum toxin.

The second part of the study was a more specific, online survey completed by about 80 PCPs.

Most (60%) weren’t familiar with the recommendation about limiting opioids. While 60% said they knew that nonsteroidal anti-inflammatories could spark medication overuse headache, only half know that butabital-containing drugs could. A third knew about the risks for it with acetaminophen and narcotics, and only 13% about the association of triptans with medication overuse headache.

Few patients were apparently referred to evidence-based nonpharmacologic treatments, like biofeedback and cognitive behavioral therapy (just 1% and 3% of physicians said that they did so).

“Doctors apparently just don’t know that these alternatives are supported by strong evidence,” Dr. Minen said.

She had no financial disclosures.

WASHINGTON – Primary care providers are generally familiar with the prevalence and initial diagnosis of migraine but less so with the specifics of treating migraine or its psychiatric comorbidities.

Many primary care providers (PCPs) are uncomfortable with prescribing preventive medications, preferring to rely on abortives and other acute attack treatments, Dr. Mia Minen said at the annual meeting of the American Academy of Neurology. Her study on PCP knowledge of migraine also revealed a “concerning” lack of attention to depression and anxiety among migraine patients.

“Most of our participants did know that these are common comorbid conditions,” said Dr. Minen of New York University. “But only half of them were assessing patients for anxiety, and only 30% for depression. This is a significant problem, because we think there’s a bidirectional relationship here – treating the psychiatric problems may actually help the migraines as well.”

Migraine accounts for 5 million-9 million primary care visits each year, she said, and many migraine patients are managed by their PCPs. “Unfortunately, as many as 60% of these patients are unrecognized as having migraine,” and many go for as long as 4 years before being properly diagnosed. “Primary care physicians have limited time with patients, and a migraine intake and assessment is time-consuming – as is managing the patient. Studies show that treatment is often suboptimal, with simple analgesic prescribing. And few of those who do qualify for preventive treatment actually get it.”

Her study aimed to discover what PCPs know – and need to learn – about migraine.

The first portion was framed in three semi-structured 15-minute interviews, moderated by headache specialists. Eleven physicians from different backgrounds attended these. They were asked what they perceived as their knowledge gaps in migraine diagnosis and treatment, and what difficulties they had encountered in those areas.

“About half said they would order an MRI for a new type of headache,” Dr. Minen said. A quarter didn’t know that an MRI was indicated for a headache with neuralgic symptoms, and only a third knew to order one when a headache worsened or remained unresponsive to treatment.

“These four conditions are situations in which headache experts typically agree that imaging is necessary,” Dr. Minen said. “Our findings indicate that primary care physicians might not actually be ordering imaging studies in situations where it should be done.”

Participants were generally unaware of the AAN’s guidelines on preventive medications, or the “Choosing Wisely” campaign to limit opioids and imaging in migraine patients, except in particular cases.

While most had heard of medication overuse headache, they were uncertain about how to diagnose it and unaware of some of the medications implicated in it. Participants were comfortable with some abortive medications (sumatriptan and naratriptan) and only prescribed opioids as a last resort. Antiemetics were rarely offered without a specific patient request.

There was uncertainty and discomfort about prescribing preventive medications, particularly topiramate. Several physicians said that patients often don’t comply with a daily regimen, so they preferred to stick with abortives. None had used botulinum toxin.

The second part of the study was a more specific, online survey completed by about 80 PCPs.

Most (60%) weren’t familiar with the recommendation about limiting opioids. While 60% said they knew that nonsteroidal anti-inflammatories could spark medication overuse headache, only half know that butabital-containing drugs could. A third knew about the risks for it with acetaminophen and narcotics, and only 13% about the association of triptans with medication overuse headache.

Few patients were apparently referred to evidence-based nonpharmacologic treatments, like biofeedback and cognitive behavioral therapy (just 1% and 3% of physicians said that they did so).

“Doctors apparently just don’t know that these alternatives are supported by strong evidence,” Dr. Minen said.

She had no financial disclosures.

[email protected]

On Twitter @alz_gal

WASHINGTON – Primary care providers are generally familiar with the prevalence and initial diagnosis of migraine but less so with the specifics of treating migraine or its psychiatric comorbidities.

Many primary care providers (PCPs) are uncomfortable with prescribing preventive medications, preferring to rely on abortives and other acute attack treatments, Dr. Mia Minen said at the annual meeting of the American Academy of Neurology. Her study on PCP knowledge of migraine also revealed a “concerning” lack of attention to depression and anxiety among migraine patients.

“Most of our participants did know that these are common comorbid conditions,” said Dr. Minen of New York University. “But only half of them were assessing patients for anxiety, and only 30% for depression. This is a significant problem, because we think there’s a bidirectional relationship here – treating the psychiatric problems may actually help the migraines as well.”

Migraine accounts for 5 million-9 million primary care visits each year, she said, and many migraine patients are managed by their PCPs. “Unfortunately, as many as 60% of these patients are unrecognized as having migraine,” and many go for as long as 4 years before being properly diagnosed. “Primary care physicians have limited time with patients, and a migraine intake and assessment is time-consuming – as is managing the patient. Studies show that treatment is often suboptimal, with simple analgesic prescribing. And few of those who do qualify for preventive treatment actually get it.”

Her study aimed to discover what PCPs know – and need to learn – about migraine.

The first portion was framed in three semi-structured 15-minute interviews, moderated by headache specialists. Eleven physicians from different backgrounds attended these. They were asked what they perceived as their knowledge gaps in migraine diagnosis and treatment, and what difficulties they had encountered in those areas.

“About half said they would order an MRI for a new type of headache,” Dr. Minen said. A quarter didn’t know that an MRI was indicated for a headache with neuralgic symptoms, and only a third knew to order one when a headache worsened or remained unresponsive to treatment.

“These four conditions are situations in which headache experts typically agree that imaging is necessary,” Dr. Minen said. “Our findings indicate that primary care physicians might not actually be ordering imaging studies in situations where it should be done.”

Participants were generally unaware of the AAN’s guidelines on preventive medications, or the “Choosing Wisely” campaign to limit opioids and imaging in migraine patients, except in particular cases.

While most had heard of medication overuse headache, they were uncertain about how to diagnose it and unaware of some of the medications implicated in it. Participants were comfortable with some abortive medications (sumatriptan and naratriptan) and only prescribed opioids as a last resort. Antiemetics were rarely offered without a specific patient request.

There was uncertainty and discomfort about prescribing preventive medications, particularly topiramate. Several physicians said that patients often don’t comply with a daily regimen, so they preferred to stick with abortives. None had used botulinum toxin.

The second part of the study was a more specific, online survey completed by about 80 PCPs.

Most (60%) weren’t familiar with the recommendation about limiting opioids. While 60% said they knew that nonsteroidal anti-inflammatories could spark medication overuse headache, only half know that butabital-containing drugs could. A third knew about the risks for it with acetaminophen and narcotics, and only 13% about the association of triptans with medication overuse headache.

Few patients were apparently referred to evidence-based nonpharmacologic treatments, like biofeedback and cognitive behavioral therapy (just 1% and 3% of physicians said that they did so).

“Doctors apparently just don’t know that these alternatives are supported by strong evidence,” Dr. Minen said.

She had no financial disclosures.

[email protected]

On Twitter @alz_gal

WASHINGTON – Primary care providers are generally familiar with the prevalence and initial diagnosis of migraine but less so with the specifics of treating migraine or its psychiatric comorbidities.

Many primary care providers (PCPs) are uncomfortable with prescribing preventive medications, preferring to rely on abortives and other acute attack treatments, Dr. Mia Minen said at the annual meeting of the American Academy of Neurology. Her study on PCP knowledge of migraine also revealed a “concerning” lack of attention to depression and anxiety among migraine patients.

“Most of our participants did know that these are common comorbid conditions,” said Dr. Minen of New York University. “But only half of them were assessing patients for anxiety, and only 30% for depression. This is a significant problem, because we think there’s a bidirectional relationship here – treating the psychiatric problems may actually help the migraines as well.”

Migraine accounts for 5 million-9 million primary care visits each year, she said, and many migraine patients are managed by their PCPs. “Unfortunately, as many as 60% of these patients are unrecognized as having migraine,” and many go for as long as 4 years before being properly diagnosed. “Primary care physicians have limited time with patients, and a migraine intake and assessment is time-consuming – as is managing the patient. Studies show that treatment is often suboptimal, with simple analgesic prescribing. And few of those who do qualify for preventive treatment actually get it.”

Her study aimed to discover what PCPs know – and need to learn – about migraine.

The first portion was framed in three semi-structured 15-minute interviews, moderated by headache specialists. Eleven physicians from different backgrounds attended these. They were asked what they perceived as their knowledge gaps in migraine diagnosis and treatment, and what difficulties they had encountered in those areas.

“About half said they would order an MRI for a new type of headache,” Dr. Minen said. A quarter didn’t know that an MRI was indicated for a headache with neuralgic symptoms, and only a third knew to order one when a headache worsened or remained unresponsive to treatment.

“These four conditions are situations in which headache experts typically agree that imaging is necessary,” Dr. Minen said. “Our findings indicate that primary care physicians might not actually be ordering imaging studies in situations where it should be done.”

Participants were generally unaware of the AAN’s guidelines on preventive medications, or the “Choosing Wisely” campaign to limit opioids and imaging in migraine patients, except in particular cases.

While most had heard of medication overuse headache, they were uncertain about how to diagnose it and unaware of some of the medications implicated in it. Participants were comfortable with some abortive medications (sumatriptan and naratriptan) and only prescribed opioids as a last resort. Antiemetics were rarely offered without a specific patient request.

There was uncertainty and discomfort about prescribing preventive medications, particularly topiramate. Several physicians said that patients often don’t comply with a daily regimen, so they preferred to stick with abortives. None had used botulinum toxin.

The second part of the study was a more specific, online survey completed by about 80 PCPs.

Most (60%) weren’t familiar with the recommendation about limiting opioids. While 60% said they knew that nonsteroidal anti-inflammatories could spark medication overuse headache, only half know that butabital-containing drugs could. A third knew about the risks for it with acetaminophen and narcotics, and only 13% about the association of triptans with medication overuse headache.

Few patients were apparently referred to evidence-based nonpharmacologic treatments, like biofeedback and cognitive behavioral therapy (just 1% and 3% of physicians said that they did so).

“Doctors apparently just don’t know that these alternatives are supported by strong evidence,” Dr. Minen said.

She had no financial disclosures.

[email protected]

On Twitter @alz_gal

WASHINGTON – One-quarter of valproate-exposed children in an ongoing study had a major birth defect or reduced IQ, Dr. Kimford Meador reported at the annual meeting of the American Academy of Neurology.

The findings reconfirm just how dangerous the antiepileptic drug can be to a developing fetus, especially when viewed along with findings of increased risk associated with even low valproate doses, said Dr. Meador of Stanford (Calif.) University.

“I don’t think we have even yet captured all the risks that are there,” he said. In addition, he stressed that valproate is a poor choice in a woman who plans a pregnancy, and it should not be used, unless absolutely necessary, in any woman of childbearing age who maintains her fertility.

The drug also is commonly employed to treat depression and migraine, he added.

The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study assessed neurodevelopmental outcomes in 311 children whose mothers took valproate, phenytoin, carbamazepine, or lamotrigine for epilepsy during pregnancy. These drugs were chosen because they were the most commonly prescribed when the study began.

Analyses in the prior Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) study have shown that valproate is linked to major congenital malformations and lower IQ in toddlers (N. Engl. J. Med. 2009;360:1597-605) and 6-year-olds (Lancet Neurol. 2013;12:244-52). In another study, the drug has also been linked to an increased risk of autism spectrum disorders and autism (hazard ratios of 3.0 and 5.2, respectively).

The new analysis examined the risk of either a negative physical or cognitive outcome, or a combination of both, among the entire NEAD group. The individual domain of verbal IQ also was examined because it was an area of particular concern in the previous analyses.

Because maternal IQ is the major predictor of child IQ in the general population, the analysis looked at how many children had an IQ less than one standard deviation lower than their mother’s IQ – about 15 points.

Of the children exposed to valproate, 7 of 69 children had some kind of a major congenital malformation, and 12 of 58 children had a decreased IQ, compared with the mother. A full 25% (17 of 69 children) had one or both of these problems.

All of the outcomes were significantly worse than those seen with carbamazepine (birth defect, 5%; low IQ, 11%; either or both, 10%); lamotrigine (birth defect, 1%; low IQ, 12%; either or both, 12%); and phenytoin (birth defect, 7%; low IQ, 6%; either or both, 13%).

The investigators also examined a variety of cognitive measures: verbal and nonverbal IQ, General Memory Index, Behavior Rating of Inventory of Executive Function, and Nepsy Executive Index.

“Whatever cognitive measure we employed, we saw a greater negative as the valproate dose increased,” Dr. Meador said. “At what level the dose confers no risk is unclear, though, because it’s hard to adjust for genetic risk factors and the individual drug absorption levels, among other things.”

However, a recent U.K. study showed an increased risk of both outcomes among children who were exposed to even a very low dose of the drug – below 800 mg daily (Neurology 2015;84:382-90).

It’s not clear how valproate might exert its deleterious effects, Dr. Meador noted.

“It may damage the developing brain by causing neuronal death, or causing dysfunction in the surviving cells. This risk of adverse drug-induced effects on the immature brain doesn't go away immediately when the baby comes out of the womb,” he observed. “It’s a complicated area to study, too, because we don’t normally expose neonates to antiepileptics unless they are already having seizures.”

There was also an “unexpected” finding in the analysis, Dr. Meador said. “We were collecting information on periconceptional folate as a confounding factor. There was a very robust positive effect of about a 6-point IQ gain in those children, compared to those whose mothers didn’t take folate at time of conception.

“This is consistent with the idea that periconceptual folate may not only be important for reducing fetal malformations, but may also have a positive effect on cognitive abilities,” Dr. Meador said. “So, I recommend that all women of childbearing age should be taking folate.”

Dr. Meador has received personal compensation for activities on behalf of the Epilepsy Study Consortium with Eisai, NeuroPace, Novartis, Supernus, UCB Pharma, Upsher-Smith Laboratories, and Vivus Pharmaceuticals as a consultant. He has received research support from Pfizer and UCB Pharma.

[email protected]

On Twitter @alz_gal

This article was updated May 5, 2015.

WASHINGTON – One-quarter of valproate-exposed children in an ongoing study had a major birth defect or reduced IQ, Dr. Kimford Meador reported at the annual meeting of the American Academy of Neurology.

The findings reconfirm just how dangerous the antiepileptic drug can be to a developing fetus, especially when viewed along with findings of increased risk associated with even low valproate doses, said Dr. Meador of Stanford (Calif.) University.

“I don’t think we have even yet captured all the risks that are there,” he said. In addition, he stressed that valproate is a poor choice in a woman who plans a pregnancy, and it should not be used, unless absolutely necessary, in any woman of childbearing age who maintains her fertility.

The drug also is commonly employed to treat depression and migraine, he added.

The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study assessed neurodevelopmental outcomes in 311 children whose mothers took valproate, phenytoin, carbamazepine, or lamotrigine for epilepsy during pregnancy. These drugs were chosen because they were the most commonly prescribed when the study began.

Analyses in the prior Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) study have shown that valproate is linked to major congenital malformations and lower IQ in toddlers (N. Engl. J. Med. 2009;360:1597-605) and 6-year-olds (Lancet Neurol. 2013;12:244-52). In another study, the drug has also been linked to an increased risk of autism spectrum disorders and autism (hazard ratios of 3.0 and 5.2, respectively).

The new analysis examined the risk of either a negative physical or cognitive outcome, or a combination of both, among the entire NEAD group. The individual domain of verbal IQ also was examined because it was an area of particular concern in the previous analyses.

Because maternal IQ is the major predictor of child IQ in the general population, the analysis looked at how many children had an IQ less than one standard deviation lower than their mother’s IQ – about 15 points.

Of the children exposed to valproate, 7 of 69 children had some kind of a major congenital malformation, and 12 of 58 children had a decreased IQ, compared with the mother. A full 25% (17 of 69 children) had one or both of these problems.

All of the outcomes were significantly worse than those seen with carbamazepine (birth defect, 5%; low IQ, 11%; either or both, 10%); lamotrigine (birth defect, 1%; low IQ, 12%; either or both, 12%); and phenytoin (birth defect, 7%; low IQ, 6%; either or both, 13%).

The investigators also examined a variety of cognitive measures: verbal and nonverbal IQ, General Memory Index, Behavior Rating of Inventory of Executive Function, and Nepsy Executive Index.

“Whatever cognitive measure we employed, we saw a greater negative as the valproate dose increased,” Dr. Meador said. “At what level the dose confers no risk is unclear, though, because it’s hard to adjust for genetic risk factors and the individual drug absorption levels, among other things.”

However, a recent U.K. study showed an increased risk of both outcomes among children who were exposed to even a very low dose of the drug – below 800 mg daily (Neurology 2015;84:382-90).

It’s not clear how valproate might exert its deleterious effects, Dr. Meador noted.

“It may damage the developing brain by causing neuronal death, or causing dysfunction in the surviving cells. This risk of adverse drug-induced effects on the immature brain doesn't go away immediately when the baby comes out of the womb,” he observed. “It’s a complicated area to study, too, because we don’t normally expose neonates to antiepileptics unless they are already having seizures.”

There was also an “unexpected” finding in the analysis, Dr. Meador said. “We were collecting information on periconceptional folate as a confounding factor. There was a very robust positive effect of about a 6-point IQ gain in those children, compared to those whose mothers didn’t take folate at time of conception.

“This is consistent with the idea that periconceptual folate may not only be important for reducing fetal malformations, but may also have a positive effect on cognitive abilities,” Dr. Meador said. “So, I recommend that all women of childbearing age should be taking folate.”

Dr. Meador has received personal compensation for activities on behalf of the Epilepsy Study Consortium with Eisai, NeuroPace, Novartis, Supernus, UCB Pharma, Upsher-Smith Laboratories, and Vivus Pharmaceuticals as a consultant. He has received research support from Pfizer and UCB Pharma.

[email protected]

On Twitter @alz_gal

This article was updated May 5, 2015.

WASHINGTON – One-quarter of valproate-exposed children in an ongoing study had a major birth defect or reduced IQ, Dr. Kimford Meador reported at the annual meeting of the American Academy of Neurology.

The findings reconfirm just how dangerous the antiepileptic drug can be to a developing fetus, especially when viewed along with findings of increased risk associated with even low valproate doses, said Dr. Meador of Stanford (Calif.) University.

“I don’t think we have even yet captured all the risks that are there,” he said. In addition, he stressed that valproate is a poor choice in a woman who plans a pregnancy, and it should not be used, unless absolutely necessary, in any woman of childbearing age who maintains her fertility.

The drug also is commonly employed to treat depression and migraine, he added.

The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study assessed neurodevelopmental outcomes in 311 children whose mothers took valproate, phenytoin, carbamazepine, or lamotrigine for epilepsy during pregnancy. These drugs were chosen because they were the most commonly prescribed when the study began.

Analyses in the prior Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) study have shown that valproate is linked to major congenital malformations and lower IQ in toddlers (N. Engl. J. Med. 2009;360:1597-605) and 6-year-olds (Lancet Neurol. 2013;12:244-52). In another study, the drug has also been linked to an increased risk of autism spectrum disorders and autism (hazard ratios of 3.0 and 5.2, respectively).

The new analysis examined the risk of either a negative physical or cognitive outcome, or a combination of both, among the entire NEAD group. The individual domain of verbal IQ also was examined because it was an area of particular concern in the previous analyses.

Because maternal IQ is the major predictor of child IQ in the general population, the analysis looked at how many children had an IQ less than one standard deviation lower than their mother’s IQ – about 15 points.

Of the children exposed to valproate, 7 of 69 children had some kind of a major congenital malformation, and 12 of 58 children had a decreased IQ, compared with the mother. A full 25% (17 of 69 children) had one or both of these problems.

All of the outcomes were significantly worse than those seen with carbamazepine (birth defect, 5%; low IQ, 11%; either or both, 10%); lamotrigine (birth defect, 1%; low IQ, 12%; either or both, 12%); and phenytoin (birth defect, 7%; low IQ, 6%; either or both, 13%).

The investigators also examined a variety of cognitive measures: verbal and nonverbal IQ, General Memory Index, Behavior Rating of Inventory of Executive Function, and Nepsy Executive Index.

“Whatever cognitive measure we employed, we saw a greater negative as the valproate dose increased,” Dr. Meador said. “At what level the dose confers no risk is unclear, though, because it’s hard to adjust for genetic risk factors and the individual drug absorption levels, among other things.”

However, a recent U.K. study showed an increased risk of both outcomes among children who were exposed to even a very low dose of the drug – below 800 mg daily (Neurology 2015;84:382-90).

It’s not clear how valproate might exert its deleterious effects, Dr. Meador noted.

“It may damage the developing brain by causing neuronal death, or causing dysfunction in the surviving cells. This risk of adverse drug-induced effects on the immature brain doesn't go away immediately when the baby comes out of the womb,” he observed. “It’s a complicated area to study, too, because we don’t normally expose neonates to antiepileptics unless they are already having seizures.”

There was also an “unexpected” finding in the analysis, Dr. Meador said. “We were collecting information on periconceptional folate as a confounding factor. There was a very robust positive effect of about a 6-point IQ gain in those children, compared to those whose mothers didn’t take folate at time of conception.

“This is consistent with the idea that periconceptual folate may not only be important for reducing fetal malformations, but may also have a positive effect on cognitive abilities,” Dr. Meador said. “So, I recommend that all women of childbearing age should be taking folate.”

Dr. Meador has received personal compensation for activities on behalf of the Epilepsy Study Consortium with Eisai, NeuroPace, Novartis, Supernus, UCB Pharma, Upsher-Smith Laboratories, and Vivus Pharmaceuticals as a consultant. He has received research support from Pfizer and UCB Pharma.

[email protected]

On Twitter @alz_gal

This article was updated May 5, 2015.

WASHINGTON – The development of new educational and training opportunities to increase primary care physicians’ knowledge in diagnosing and managing migraine should extend from medical school student to on-the-job training for attending physicians, according to Dr. Mia Minen, who presented results of a comprehensive survey of primary care physicians’ knowledge about migraine at the annual meeting of the American Academy of Neurology.

Primary care physicians were unsure about when it is best to perform imaging in migraine patients and what kinds of medications are associated with medication overuse headache, said Dr. Minen of the department of neurology at NYU Langone Medical Center. She suggested that a wide range of physicians, including ob.gyns and emergency physicians, could benefit from better knowledge of migraine.

That position was echoed in an interview with Dr. Peter Goadsby of King’s College London and the University of California, San Francisco, who noted that a bigger headache curriculum in medical school and residencies, as well as more on-the-job education, would help greatly.

[email protected]

WASHINGTON – The development of new educational and training opportunities to increase primary care physicians’ knowledge in diagnosing and managing migraine should extend from medical school student to on-the-job training for attending physicians, according to Dr. Mia Minen, who presented results of a comprehensive survey of primary care physicians’ knowledge about migraine at the annual meeting of the American Academy of Neurology.

Primary care physicians were unsure about when it is best to perform imaging in migraine patients and what kinds of medications are associated with medication overuse headache, said Dr. Minen of the department of neurology at NYU Langone Medical Center. She suggested that a wide range of physicians, including ob.gyns and emergency physicians, could benefit from better knowledge of migraine.

That position was echoed in an interview with Dr. Peter Goadsby of King’s College London and the University of California, San Francisco, who noted that a bigger headache curriculum in medical school and residencies, as well as more on-the-job education, would help greatly.

[email protected]

WASHINGTON – The development of new educational and training opportunities to increase primary care physicians’ knowledge in diagnosing and managing migraine should extend from medical school student to on-the-job training for attending physicians, according to Dr. Mia Minen, who presented results of a comprehensive survey of primary care physicians’ knowledge about migraine at the annual meeting of the American Academy of Neurology.

Primary care physicians were unsure about when it is best to perform imaging in migraine patients and what kinds of medications are associated with medication overuse headache, said Dr. Minen of the department of neurology at NYU Langone Medical Center. She suggested that a wide range of physicians, including ob.gyns and emergency physicians, could benefit from better knowledge of migraine.

That position was echoed in an interview with Dr. Peter Goadsby of King’s College London and the University of California, San Francisco, who noted that a bigger headache curriculum in medical school and residencies, as well as more on-the-job education, would help greatly.

[email protected]

WASHINGTON – Treatment with daclizumab high-yield process, a first-in-class interleukin-2 immunomodulator administered subcutaneously once a month, was significantly more effective on various outcomes in relapsing-remitting multiple sclerosis than was interferon beta-1a therapy during 96-144 weeks of treatment in the international DECIDE study.

The efficacy of daclizumab high-yield process (DAC HYP) was consistently superior to once-weekly intramuscular interferon (IFN) beta-1a “across key clinical, radiographic, and patient-reported MS outcome measures,” with a 45% reduction in the annualized relapse rate over that period, Dr. Ludwig Kappos said at the annual meeting of the American Academy of Neurology.

DAC HYP “has the potential to be a new once-monthly treatment option for patients with relapsing MS,” said Dr. Kappos, chair of neurology at University Hospital Basel and one of the DECIDE study investigators. Dr. Kappos serves as chair of the study’s advisory committee.

Treatment was associated with an increased risk of infections, cutaneous adverse effects, and hepatic enzyme abnormalities, which he said were “manageable with standard monitoring and medical interventions.”

DAC HYP is a humanized monoclonal antibody that selectively blocks the high-affinity interleukin-2 (IL-2) receptor subunit (CD25), which is expressed at high levels on T cells that are abnormally activated in MS. The biological effects of CD25 blockade include the inhibition of activated T cell responses and “normalization of lymphoid tissue inducer cell numbers,” he said.

The DECIDE study randomized 919 patients to treatment with 150 mg of DAC HYP administered subcutaneously once every 4 weeks and 922 patients to treatment with 30 mcg of IFN beta-1a (Avonex) administered intramuscularly once a week. Mean age of the patients was 36 years, 68% were women, and they had been diagnosed with MS for a mean of 5 years. Patients in both groups had had a similar mean number of relapses within the previous year (0.7-0.8); 21% had highly active MS, and 41% had been on disease-modifying treatments previously; their mean Expanded Disability Status Scale (EDSS) score was 1.2-1.3.

The study ended when the last patient had been treated for 2 years. In both arms, 29%-30% discontinued treatment, and adverse events were higher in the DAC HYP-treated group (14% vs. 9%).

During 96-144 weeks, the annualized relapse rate – the primary endpoint – was 0.393 among those on IFN beta-1a, vs. 0.216 among those on DAC HYP, a 45% reduction that was highly statistically significant (P < .0001), Dr. Kappos said.

Secondary endpoints included the proportion who remained relapse free, which was higher among those on DAC HYP at different points during the study (including 73% vs. 59% at week 96, and 67% vs. 51% at week 144). The risk of relapse was reduced by 41% (P < .0001).

Other secondary endpoints were MRI-defined lesions at week 96: The number of new or newly enlarging T2 hyperintense lesions at that point was reduced by 54%, compared with IFN beta-1a (P < .0001). There were similar reductions in new T1 hypointense lesions (black holes), which were reduced by 52% (P < .0001), and in gadolinium-enhancing lesions, which were reduced by 65% (P < .0001). There was a significant effect of treatment on brain volume over time, which was possible to detect because the study was so large, Dr. Kappos said.

At 3 months, the risk of progression was reduced by 16% among those on DAC HYP, compared with those on IFN beta-1a (P = .16), a favorable effect, although not statistically significant. At 6 months, the risk was reduced by 27% (P = .033), Dr. Kappos reported. The proportion of patients with a clinically meaningful worsening in patient-reported physical impact of MS (defined by at least a 7.5 point drop on the MSIS-29 PHYS) was reduced by 24% over those on IFN beta-1a, which was not statistically significant.

The incidence of any type of adverse event was 91% in both groups, and infections, cutaneous events, and hepatic abnormalities were more common among those treated with DAC HYP. Serious adverse events were higher among those on DAC HYP (24% vs. 21%); when MS relapses were excluded, the rate was 15% vs. 10%. Treatment discontinuations due to an adverse event, other than an MS relapse, was 14% among those on DAC HYP vs. 9% of those on IFN beta-1a. There were five deaths, one in a patient on the study drug and four among those on the comparator.

The rate of infectious adverse events was higher among those on DAC HYP (65% vs. 57%), as was the rate of serious infectious adverse events (4% vs. 2%). Cutaneous events were more common among those on DAC HYP (37% vs. 19%), as were serious cutaneous adverse events (2% vs. less than 1%).

Dr. Kappos said that hepatic abnormalities were more common among those on DAC HYP, but were reversible. The rate of ALT/AST greater than five times the upper limit of normal (ULN) was 6% among those on the DAC HYP vs. 3% among those on IFN beta-1a; but the rate of ALT greater than three times the ULN and total bilirubin more than twice the ULN was less than 1% in each group. There was one case that met the “Hy’s law” criteria in each group.

Biogen Idec and AbbVie Biotherapeutics funded the study. Dr. Kappos disclosed that University Hospital Basel has received research support from steering committee/consulting fees, and speakers fees from pharmaceutical companies that include Biogen.

[email protected]

WASHINGTON – Treatment with daclizumab high-yield process, a first-in-class interleukin-2 immunomodulator administered subcutaneously once a month, was significantly more effective on various outcomes in relapsing-remitting multiple sclerosis than was interferon beta-1a therapy during 96-144 weeks of treatment in the international DECIDE study.

The efficacy of daclizumab high-yield process (DAC HYP) was consistently superior to once-weekly intramuscular interferon (IFN) beta-1a “across key clinical, radiographic, and patient-reported MS outcome measures,” with a 45% reduction in the annualized relapse rate over that period, Dr. Ludwig Kappos said at the annual meeting of the American Academy of Neurology.

DAC HYP “has the potential to be a new once-monthly treatment option for patients with relapsing MS,” said Dr. Kappos, chair of neurology at University Hospital Basel and one of the DECIDE study investigators. Dr. Kappos serves as chair of the study’s advisory committee.

Treatment was associated with an increased risk of infections, cutaneous adverse effects, and hepatic enzyme abnormalities, which he said were “manageable with standard monitoring and medical interventions.”

DAC HYP is a humanized monoclonal antibody that selectively blocks the high-affinity interleukin-2 (IL-2) receptor subunit (CD25), which is expressed at high levels on T cells that are abnormally activated in MS. The biological effects of CD25 blockade include the inhibition of activated T cell responses and “normalization of lymphoid tissue inducer cell numbers,” he said.

The DECIDE study randomized 919 patients to treatment with 150 mg of DAC HYP administered subcutaneously once every 4 weeks and 922 patients to treatment with 30 mcg of IFN beta-1a (Avonex) administered intramuscularly once a week. Mean age of the patients was 36 years, 68% were women, and they had been diagnosed with MS for a mean of 5 years. Patients in both groups had had a similar mean number of relapses within the previous year (0.7-0.8); 21% had highly active MS, and 41% had been on disease-modifying treatments previously; their mean Expanded Disability Status Scale (EDSS) score was 1.2-1.3.

The study ended when the last patient had been treated for 2 years. In both arms, 29%-30% discontinued treatment, and adverse events were higher in the DAC HYP-treated group (14% vs. 9%).

During 96-144 weeks, the annualized relapse rate – the primary endpoint – was 0.393 among those on IFN beta-1a, vs. 0.216 among those on DAC HYP, a 45% reduction that was highly statistically significant (P < .0001), Dr. Kappos said.

Secondary endpoints included the proportion who remained relapse free, which was higher among those on DAC HYP at different points during the study (including 73% vs. 59% at week 96, and 67% vs. 51% at week 144). The risk of relapse was reduced by 41% (P < .0001).

Other secondary endpoints were MRI-defined lesions at week 96: The number of new or newly enlarging T2 hyperintense lesions at that point was reduced by 54%, compared with IFN beta-1a (P < .0001). There were similar reductions in new T1 hypointense lesions (black holes), which were reduced by 52% (P < .0001), and in gadolinium-enhancing lesions, which were reduced by 65% (P < .0001). There was a significant effect of treatment on brain volume over time, which was possible to detect because the study was so large, Dr. Kappos said.

At 3 months, the risk of progression was reduced by 16% among those on DAC HYP, compared with those on IFN beta-1a (P = .16), a favorable effect, although not statistically significant. At 6 months, the risk was reduced by 27% (P = .033), Dr. Kappos reported. The proportion of patients with a clinically meaningful worsening in patient-reported physical impact of MS (defined by at least a 7.5 point drop on the MSIS-29 PHYS) was reduced by 24% over those on IFN beta-1a, which was not statistically significant.

The incidence of any type of adverse event was 91% in both groups, and infections, cutaneous events, and hepatic abnormalities were more common among those treated with DAC HYP. Serious adverse events were higher among those on DAC HYP (24% vs. 21%); when MS relapses were excluded, the rate was 15% vs. 10%. Treatment discontinuations due to an adverse event, other than an MS relapse, was 14% among those on DAC HYP vs. 9% of those on IFN beta-1a. There were five deaths, one in a patient on the study drug and four among those on the comparator.

The rate of infectious adverse events was higher among those on DAC HYP (65% vs. 57%), as was the rate of serious infectious adverse events (4% vs. 2%). Cutaneous events were more common among those on DAC HYP (37% vs. 19%), as were serious cutaneous adverse events (2% vs. less than 1%).

Dr. Kappos said that hepatic abnormalities were more common among those on DAC HYP, but were reversible. The rate of ALT/AST greater than five times the upper limit of normal (ULN) was 6% among those on the DAC HYP vs. 3% among those on IFN beta-1a; but the rate of ALT greater than three times the ULN and total bilirubin more than twice the ULN was less than 1% in each group. There was one case that met the “Hy’s law” criteria in each group.

Biogen Idec and AbbVie Biotherapeutics funded the study. Dr. Kappos disclosed that University Hospital Basel has received research support from steering committee/consulting fees, and speakers fees from pharmaceutical companies that include Biogen.

[email protected]

WASHINGTON – Treatment with daclizumab high-yield process, a first-in-class interleukin-2 immunomodulator administered subcutaneously once a month, was significantly more effective on various outcomes in relapsing-remitting multiple sclerosis than was interferon beta-1a therapy during 96-144 weeks of treatment in the international DECIDE study.

The efficacy of daclizumab high-yield process (DAC HYP) was consistently superior to once-weekly intramuscular interferon (IFN) beta-1a “across key clinical, radiographic, and patient-reported MS outcome measures,” with a 45% reduction in the annualized relapse rate over that period, Dr. Ludwig Kappos said at the annual meeting of the American Academy of Neurology.

DAC HYP “has the potential to be a new once-monthly treatment option for patients with relapsing MS,” said Dr. Kappos, chair of neurology at University Hospital Basel and one of the DECIDE study investigators. Dr. Kappos serves as chair of the study’s advisory committee.

Treatment was associated with an increased risk of infections, cutaneous adverse effects, and hepatic enzyme abnormalities, which he said were “manageable with standard monitoring and medical interventions.”

DAC HYP is a humanized monoclonal antibody that selectively blocks the high-affinity interleukin-2 (IL-2) receptor subunit (CD25), which is expressed at high levels on T cells that are abnormally activated in MS. The biological effects of CD25 blockade include the inhibition of activated T cell responses and “normalization of lymphoid tissue inducer cell numbers,” he said.

The DECIDE study randomized 919 patients to treatment with 150 mg of DAC HYP administered subcutaneously once every 4 weeks and 922 patients to treatment with 30 mcg of IFN beta-1a (Avonex) administered intramuscularly once a week. Mean age of the patients was 36 years, 68% were women, and they had been diagnosed with MS for a mean of 5 years. Patients in both groups had had a similar mean number of relapses within the previous year (0.7-0.8); 21% had highly active MS, and 41% had been on disease-modifying treatments previously; their mean Expanded Disability Status Scale (EDSS) score was 1.2-1.3.

The study ended when the last patient had been treated for 2 years. In both arms, 29%-30% discontinued treatment, and adverse events were higher in the DAC HYP-treated group (14% vs. 9%).

During 96-144 weeks, the annualized relapse rate – the primary endpoint – was 0.393 among those on IFN beta-1a, vs. 0.216 among those on DAC HYP, a 45% reduction that was highly statistically significant (P < .0001), Dr. Kappos said.

Secondary endpoints included the proportion who remained relapse free, which was higher among those on DAC HYP at different points during the study (including 73% vs. 59% at week 96, and 67% vs. 51% at week 144). The risk of relapse was reduced by 41% (P < .0001).

Other secondary endpoints were MRI-defined lesions at week 96: The number of new or newly enlarging T2 hyperintense lesions at that point was reduced by 54%, compared with IFN beta-1a (P < .0001). There were similar reductions in new T1 hypointense lesions (black holes), which were reduced by 52% (P < .0001), and in gadolinium-enhancing lesions, which were reduced by 65% (P < .0001). There was a significant effect of treatment on brain volume over time, which was possible to detect because the study was so large, Dr. Kappos said.

At 3 months, the risk of progression was reduced by 16% among those on DAC HYP, compared with those on IFN beta-1a (P = .16), a favorable effect, although not statistically significant. At 6 months, the risk was reduced by 27% (P = .033), Dr. Kappos reported. The proportion of patients with a clinically meaningful worsening in patient-reported physical impact of MS (defined by at least a 7.5 point drop on the MSIS-29 PHYS) was reduced by 24% over those on IFN beta-1a, which was not statistically significant.

The incidence of any type of adverse event was 91% in both groups, and infections, cutaneous events, and hepatic abnormalities were more common among those treated with DAC HYP. Serious adverse events were higher among those on DAC HYP (24% vs. 21%); when MS relapses were excluded, the rate was 15% vs. 10%. Treatment discontinuations due to an adverse event, other than an MS relapse, was 14% among those on DAC HYP vs. 9% of those on IFN beta-1a. There were five deaths, one in a patient on the study drug and four among those on the comparator.

The rate of infectious adverse events was higher among those on DAC HYP (65% vs. 57%), as was the rate of serious infectious adverse events (4% vs. 2%). Cutaneous events were more common among those on DAC HYP (37% vs. 19%), as were serious cutaneous adverse events (2% vs. less than 1%).

Dr. Kappos said that hepatic abnormalities were more common among those on DAC HYP, but were reversible. The rate of ALT/AST greater than five times the upper limit of normal (ULN) was 6% among those on the DAC HYP vs. 3% among those on IFN beta-1a; but the rate of ALT greater than three times the ULN and total bilirubin more than twice the ULN was less than 1% in each group. There was one case that met the “Hy’s law” criteria in each group.

Biogen Idec and AbbVie Biotherapeutics funded the study. Dr. Kappos disclosed that University Hospital Basel has received research support from steering committee/consulting fees, and speakers fees from pharmaceutical companies that include Biogen.

[email protected]

WASHINGTON – Only 20% of women of childbearing age taking antiepileptic drugs also received a folate prescription, a small study revealed – but a brief intervention helped boost the rate above 60%.

Folic acid supplementation is de rigueur for women of childbearing age – and especially important in very early pregnancy. The need appears even greater in women who take antiepileptic drugs, many of which increase the risk of birth defects.

Despite current recommendations for folic acid supplementation in all women, prescription by neurologists seems low, according to Dr. Brian D. Moseley of the University of Cincinnati.

“We wanted to look at the rates of the prescription of folic acid to women on antiepileptic drugs who were seen in our general neurology clinic,” Dr. Moseley explained.

In an interview at the annual meeting of the American Academy of Neurology, Dr. Moseley discussed the study’s findings, how a brief intervention with the clinic’s physicians increased folic acid prescription rates, and which folic acid dosages may be optimal.

WASHINGTON – Only 20% of women of childbearing age taking antiepileptic drugs also received a folate prescription, a small study revealed – but a brief intervention helped boost the rate above 60%.

Folic acid supplementation is de rigueur for women of childbearing age – and especially important in very early pregnancy. The need appears even greater in women who take antiepileptic drugs, many of which increase the risk of birth defects.

Despite current recommendations for folic acid supplementation in all women, prescription by neurologists seems low, according to Dr. Brian D. Moseley of the University of Cincinnati.

“We wanted to look at the rates of the prescription of folic acid to women on antiepileptic drugs who were seen in our general neurology clinic,” Dr. Moseley explained.

In an interview at the annual meeting of the American Academy of Neurology, Dr. Moseley discussed the study’s findings, how a brief intervention with the clinic’s physicians increased folic acid prescription rates, and which folic acid dosages may be optimal.

WASHINGTON – Only 20% of women of childbearing age taking antiepileptic drugs also received a folate prescription, a small study revealed – but a brief intervention helped boost the rate above 60%.

Folic acid supplementation is de rigueur for women of childbearing age – and especially important in very early pregnancy. The need appears even greater in women who take antiepileptic drugs, many of which increase the risk of birth defects.

Despite current recommendations for folic acid supplementation in all women, prescription by neurologists seems low, according to Dr. Brian D. Moseley of the University of Cincinnati.

“We wanted to look at the rates of the prescription of folic acid to women on antiepileptic drugs who were seen in our general neurology clinic,” Dr. Moseley explained.

In an interview at the annual meeting of the American Academy of Neurology, Dr. Moseley discussed the study’s findings, how a brief intervention with the clinic’s physicians increased folic acid prescription rates, and which folic acid dosages may be optimal.

WASHINGTON – Only 20% of women of childbearing age taking antiepileptic drugs also received a folate prescription, a small study revealed – but a brief intervention helped boost the rate above 60%.

Folic acid supplementation is de rigueur for women of childbearing age – and especially important in very early pregnancy. The need appears even greater in women who take antiepileptic drugs, many of which increase the risk of birth defects.

Despite current recommendations for folic acid supplementation in all women, prescription by neurologists seems low, according to Dr. Brian D. Moseley of the University of Cincinnati.

“We wanted to look at the rates of the prescription of folic acid to women on antiepileptic drugs who were seen in our general neurology clinic,” Dr. Moseley explained.

In an interview at the annual meeting of the American Academy of Neurology, Dr. Moseley discussed the study’s findings, how a brief intervention with the clinic’s physicians increased folic acid prescription rates, and which folic acid dosages may be optimal.

[email protected]

WASHINGTON – Only 20% of women of childbearing age taking antiepileptic drugs also received a folate prescription, a small study revealed – but a brief intervention helped boost the rate above 60%.

Folic acid supplementation is de rigueur for women of childbearing age – and especially important in very early pregnancy. The need appears even greater in women who take antiepileptic drugs, many of which increase the risk of birth defects.

Despite current recommendations for folic acid supplementation in all women, prescription by neurologists seems low, according to Dr. Brian D. Moseley of the University of Cincinnati.

“We wanted to look at the rates of the prescription of folic acid to women on antiepileptic drugs who were seen in our general neurology clinic,” Dr. Moseley explained.

In an interview at the annual meeting of the American Academy of Neurology, Dr. Moseley discussed the study’s findings, how a brief intervention with the clinic’s physicians increased folic acid prescription rates, and which folic acid dosages may be optimal.

[email protected]

WASHINGTON – Only 20% of women of childbearing age taking antiepileptic drugs also received a folate prescription, a small study revealed – but a brief intervention helped boost the rate above 60%.

Folic acid supplementation is de rigueur for women of childbearing age – and especially important in very early pregnancy. The need appears even greater in women who take antiepileptic drugs, many of which increase the risk of birth defects.

Despite current recommendations for folic acid supplementation in all women, prescription by neurologists seems low, according to Dr. Brian D. Moseley of the University of Cincinnati.

“We wanted to look at the rates of the prescription of folic acid to women on antiepileptic drugs who were seen in our general neurology clinic,” Dr. Moseley explained.

In an interview at the annual meeting of the American Academy of Neurology, Dr. Moseley discussed the study’s findings, how a brief intervention with the clinic’s physicians increased folic acid prescription rates, and which folic acid dosages may be optimal.

[email protected]

WASHINGTON – A promising early Alzheimer’s treatment, a new finding in the brains of migraineurs, and a practice-changing stroke treatment study are the top picks for clinical research being presented at the annual meeting of the American Academy of Neurology, according to Dr. Natalia Rost, vice chair of the AAN Science Committee.

The first is an early-phase clinical study evaluating a new monoclonal antibody in 166 people with prodromal or mild Alzheimer’s disease. The second study evaluated the association between pain threshold and cortical thickness in patients with migraines. The third is a presentation of the MR CLEAN study results from the Netherlands, which compared standard of care versus standard of care plus mechanical embolectomy in 500 patients with acute stroke – a study that Dr. Rost, a stroke neurologist, described in this video interview as “game-changing.” Dr. Rost is associate professor of neurology at Harvard Medical School and associate director of acute stroke services at Massachusetts General Hospital, both in Boston.

[email protected]

WASHINGTON – A promising early Alzheimer’s treatment, a new finding in the brains of migraineurs, and a practice-changing stroke treatment study are the top picks for clinical research being presented at the annual meeting of the American Academy of Neurology, according to Dr. Natalia Rost, vice chair of the AAN Science Committee.

The first is an early-phase clinical study evaluating a new monoclonal antibody in 166 people with prodromal or mild Alzheimer’s disease. The second study evaluated the association between pain threshold and cortical thickness in patients with migraines. The third is a presentation of the MR CLEAN study results from the Netherlands, which compared standard of care versus standard of care plus mechanical embolectomy in 500 patients with acute stroke – a study that Dr. Rost, a stroke neurologist, described in this video interview as “game-changing.” Dr. Rost is associate professor of neurology at Harvard Medical School and associate director of acute stroke services at Massachusetts General Hospital, both in Boston.

[email protected]

WASHINGTON – A promising early Alzheimer’s treatment, a new finding in the brains of migraineurs, and a practice-changing stroke treatment study are the top picks for clinical research being presented at the annual meeting of the American Academy of Neurology, according to Dr. Natalia Rost, vice chair of the AAN Science Committee.

The first is an early-phase clinical study evaluating a new monoclonal antibody in 166 people with prodromal or mild Alzheimer’s disease. The second study evaluated the association between pain threshold and cortical thickness in patients with migraines. The third is a presentation of the MR CLEAN study results from the Netherlands, which compared standard of care versus standard of care plus mechanical embolectomy in 500 patients with acute stroke – a study that Dr. Rost, a stroke neurologist, described in this video interview as “game-changing.” Dr. Rost is associate professor of neurology at Harvard Medical School and associate director of acute stroke services at Massachusetts General Hospital, both in Boston.

[email protected]

WASHINGTON – Adult patients and their doctors should decide together whether to treat a first unprovoked seizure, according to a new recommendation issued by the American Academy of Neurology and the American Epilepsy Society. But although treatment reduces the risk of a recurrent seizure by 35%, it doesn’t appear to change the eventual prognosis – and balancing the risks of seizure and the risks of antiepileptic drugs is not easy.

In video interviews at the annual meeting of the American Academy of Neurology, Dr. Allan Krumholz of the University of Maryland, Baltimore, who headed the guideline writing committee, reviews the data, while Dr. Jacqueline French, professor of neurology at New York University puts it in clinical perspective.

But will the recommendations change practice? Dr. Derek Chong, a practicing neurologist at New York University’s Langone Comprehensive Epilepsy Center, shares his own thoughts in a video interview.

[email protected]

On Twitter @alz_gal

WASHINGTON – Adult patients and their doctors should decide together whether to treat a first unprovoked seizure, according to a new recommendation issued by the American Academy of Neurology and the American Epilepsy Society. But although treatment reduces the risk of a recurrent seizure by 35%, it doesn’t appear to change the eventual prognosis – and balancing the risks of seizure and the risks of antiepileptic drugs is not easy.

In video interviews at the annual meeting of the American Academy of Neurology, Dr. Allan Krumholz of the University of Maryland, Baltimore, who headed the guideline writing committee, reviews the data, while Dr. Jacqueline French, professor of neurology at New York University puts it in clinical perspective.

But will the recommendations change practice? Dr. Derek Chong, a practicing neurologist at New York University’s Langone Comprehensive Epilepsy Center, shares his own thoughts in a video interview.

[email protected]

On Twitter @alz_gal

WASHINGTON – Adult patients and their doctors should decide together whether to treat a first unprovoked seizure, according to a new recommendation issued by the American Academy of Neurology and the American Epilepsy Society. But although treatment reduces the risk of a recurrent seizure by 35%, it doesn’t appear to change the eventual prognosis – and balancing the risks of seizure and the risks of antiepileptic drugs is not easy.

In video interviews at the annual meeting of the American Academy of Neurology, Dr. Allan Krumholz of the University of Maryland, Baltimore, who headed the guideline writing committee, reviews the data, while Dr. Jacqueline French, professor of neurology at New York University puts it in clinical perspective.

But will the recommendations change practice? Dr. Derek Chong, a practicing neurologist at New York University’s Langone Comprehensive Epilepsy Center, shares his own thoughts in a video interview.

[email protected]

On Twitter @alz_gal

WASHINGTON – A new set of recommendations issued by the American Academy of Neurology and the American Epilepsy Society should help clinicians to determine an individual approach for deciding whether to treat an adult patient with a first unprovoked seizure.

The new guideline notes that immediate treatment lowers the risk of a subsequent seizure by 35% over 5 years, but probably does not affect the eventual seizure outcome, first author Dr. Allan Krumholz said at the annual meeting of the American Academy of Neurology.

“Over the long term, immediate antiepileptic therapy won’t change the prognosis,” said Dr. Krumholz of the University of Maryland, Baltimore. “Over 5 years, it’s unlikely to improve the chance for sustained remission. However, I would add that, in general, the prognosis for these patients, whether they have immediate treatment or wait until after a second seizure, is generally good, with 75% of them becoming seizure-free on medication.”

Rather than providing a step-by-step treatment algorithm, the guideline stresses the importance of collaborative decision making between doctor and patient. It was cosponsored by the American Epilepsy Society and simultaneously published in Neurology (Neurology 2015;84:1705-13).

“This paper can’t give a simple, black-and-white recommendation about whether to immediately start antiepileptic medications,” Dr. Krumholz said at a press briefing. “What we can say – and what is most important – is that these decisions need to be made on an individual basis. Clinicians should weigh individual seizure recurrence risks against the risks and benefits of antiepileptic drugs [AEDs], and consider the preferences of patients.”

An AAN task force reviewed 47 studies on first-seizure treatment and trichotomized them based on their strength of evidence.

Ten studies (two class I and eight class II) addressed the risk of seizure recurrence. These found that the risk of a subsequent seizure is lowest shortly after the first, and increases over time, from 21% to 45% by 5 years. Seizure recurrence was lowest if the patient started an AED, although this finding was not based on randomized, controlled studies.

The risk of recurrence was doubled for patients who had a predisposing clinical factor: a prior brain lesion, abnormal structural imaging of the brain, an EEG with epileptiform waves, or a nocturnal seizure. Clinicians should take these findings into account when assessing patients for treatment, Dr. Krumholz noted.

Five studies (one class I and four class II) evaluated the risk of additional seizures over short- and long-term follow-up. These found that the majority will happen within the first year, and that immediate AED treatment reduces that risk by 35%.

Five studies identified the risk of adverse events associated with AED treatment (four class II and one class III). The incidence of side effects ranged from 7% to 31%. These studies included the medications phenytoin, phenobarbital, carbamazepine, valproic acid, and lamotrigine. However, the guideline noted, several of these are older medications that may not be as commonly used now as the newer-generation drugs. The document also noted that most side effects are dose-related and reversible on drug discontinuation.

The guideline is a good companion to AAN’s 2007 recommendations on evaluating an unprovoked first seizure in adults, Dr. Krumholz added.

Dr. Krumholz had no financial disclosures relevant to the guidelines.

[email protected]

On Twitter @alz_gal

WASHINGTON – A new set of recommendations issued by the American Academy of Neurology and the American Epilepsy Society should help clinicians to determine an individual approach for deciding whether to treat an adult patient with a first unprovoked seizure.

The new guideline notes that immediate treatment lowers the risk of a subsequent seizure by 35% over 5 years, but probably does not affect the eventual seizure outcome, first author Dr. Allan Krumholz said at the annual meeting of the American Academy of Neurology.

“Over the long term, immediate antiepileptic therapy won’t change the prognosis,” said Dr. Krumholz of the University of Maryland, Baltimore. “Over 5 years, it’s unlikely to improve the chance for sustained remission. However, I would add that, in general, the prognosis for these patients, whether they have immediate treatment or wait until after a second seizure, is generally good, with 75% of them becoming seizure-free on medication.”

Rather than providing a step-by-step treatment algorithm, the guideline stresses the importance of collaborative decision making between doctor and patient. It was cosponsored by the American Epilepsy Society and simultaneously published in Neurology (Neurology 2015;84:1705-13).

“This paper can’t give a simple, black-and-white recommendation about whether to immediately start antiepileptic medications,” Dr. Krumholz said at a press briefing. “What we can say – and what is most important – is that these decisions need to be made on an individual basis. Clinicians should weigh individual seizure recurrence risks against the risks and benefits of antiepileptic drugs [AEDs], and consider the preferences of patients.”

An AAN task force reviewed 47 studies on first-seizure treatment and trichotomized them based on their strength of evidence.

Ten studies (two class I and eight class II) addressed the risk of seizure recurrence. These found that the risk of a subsequent seizure is lowest shortly after the first, and increases over time, from 21% to 45% by 5 years. Seizure recurrence was lowest if the patient started an AED, although this finding was not based on randomized, controlled studies.

The risk of recurrence was doubled for patients who had a predisposing clinical factor: a prior brain lesion, abnormal structural imaging of the brain, an EEG with epileptiform waves, or a nocturnal seizure. Clinicians should take these findings into account when assessing patients for treatment, Dr. Krumholz noted.

Five studies (one class I and four class II) evaluated the risk of additional seizures over short- and long-term follow-up. These found that the majority will happen within the first year, and that immediate AED treatment reduces that risk by 35%.

Five studies identified the risk of adverse events associated with AED treatment (four class II and one class III). The incidence of side effects ranged from 7% to 31%. These studies included the medications phenytoin, phenobarbital, carbamazepine, valproic acid, and lamotrigine. However, the guideline noted, several of these are older medications that may not be as commonly used now as the newer-generation drugs. The document also noted that most side effects are dose-related and reversible on drug discontinuation.

The guideline is a good companion to AAN’s 2007 recommendations on evaluating an unprovoked first seizure in adults, Dr. Krumholz added.

Dr. Krumholz had no financial disclosures relevant to the guidelines.

[email protected]

On Twitter @alz_gal

WASHINGTON – A new set of recommendations issued by the American Academy of Neurology and the American Epilepsy Society should help clinicians to determine an individual approach for deciding whether to treat an adult patient with a first unprovoked seizure.

The new guideline notes that immediate treatment lowers the risk of a subsequent seizure by 35% over 5 years, but probably does not affect the eventual seizure outcome, first author Dr. Allan Krumholz said at the annual meeting of the American Academy of Neurology.

“Over the long term, immediate antiepileptic therapy won’t change the prognosis,” said Dr. Krumholz of the University of Maryland, Baltimore. “Over 5 years, it’s unlikely to improve the chance for sustained remission. However, I would add that, in general, the prognosis for these patients, whether they have immediate treatment or wait until after a second seizure, is generally good, with 75% of them becoming seizure-free on medication.”

Rather than providing a step-by-step treatment algorithm, the guideline stresses the importance of collaborative decision making between doctor and patient. It was cosponsored by the American Epilepsy Society and simultaneously published in Neurology (Neurology 2015;84:1705-13).

“This paper can’t give a simple, black-and-white recommendation about whether to immediately start antiepileptic medications,” Dr. Krumholz said at a press briefing. “What we can say – and what is most important – is that these decisions need to be made on an individual basis. Clinicians should weigh individual seizure recurrence risks against the risks and benefits of antiepileptic drugs [AEDs], and consider the preferences of patients.”

An AAN task force reviewed 47 studies on first-seizure treatment and trichotomized them based on their strength of evidence.

Ten studies (two class I and eight class II) addressed the risk of seizure recurrence. These found that the risk of a subsequent seizure is lowest shortly after the first, and increases over time, from 21% to 45% by 5 years. Seizure recurrence was lowest if the patient started an AED, although this finding was not based on randomized, controlled studies.

The risk of recurrence was doubled for patients who had a predisposing clinical factor: a prior brain lesion, abnormal structural imaging of the brain, an EEG with epileptiform waves, or a nocturnal seizure. Clinicians should take these findings into account when assessing patients for treatment, Dr. Krumholz noted.

Five studies (one class I and four class II) evaluated the risk of additional seizures over short- and long-term follow-up. These found that the majority will happen within the first year, and that immediate AED treatment reduces that risk by 35%.

Five studies identified the risk of adverse events associated with AED treatment (four class II and one class III). The incidence of side effects ranged from 7% to 31%. These studies included the medications phenytoin, phenobarbital, carbamazepine, valproic acid, and lamotrigine. However, the guideline noted, several of these are older medications that may not be as commonly used now as the newer-generation drugs. The document also noted that most side effects are dose-related and reversible on drug discontinuation.

The guideline is a good companion to AAN’s 2007 recommendations on evaluating an unprovoked first seizure in adults, Dr. Krumholz added.

Dr. Krumholz had no financial disclosures relevant to the guidelines.

[email protected]

On Twitter @alz_gal