May/June 2007• Number 156
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  Changing Sleep Habits to
Reduce Headaches
  News Briefs
  New Findings in
Headache Research
  Ask the Pharmacist:
Off-Label Prescribing
  Case Study: Paroxysmal

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Changing Sleep Habits May Lead to Fewer Headaches

Each year, the National Headache Foundation gives the NHF Lectureship Award to an individual who is making a significant contribution to the field of headache. This year’s award was given to Anne Calhoun, MD, University Headache Clinic, University of North Carolina at Chapel Hill. This article is an adaptation of her lecture.

For over a century, physicians have been aware of an association between sleep problems and headaches, but whether headaches are the cause or the result of disrupted sleep is still unknown. At the University of North Carolina Department of Neurology, my colleagues and I have been working to shed light on this important relationship. We have been studying sleep problems in women with “transformed migraine.”

Transformed migraine is the most common condition seen in headache clinics. Individuals with this disorder report a past history of migraines that, over time, progressed to daily or near-daily frequency. The character of the near-daily headache is often described as a dull or tension-like discomfort in the head or neck. Migraines continue to emerge episodically from this background of daily headaches and are often resistant to treatment.

Most adult patients with transformed migraine take excessive quantities of analgesics or other medications to deal with their headaches. But since the headache is usually the only pain condition that they are treating, logic suggests that the headache had to come first, not the medication overuse. When we look at studies of children or adolescents with chronic migraine (vs. those with episodic migraine), a key distinguishing factor is that these children are more likely to have sleep problems.

Non-Restorative Sleep Linked to Transformed Migraine

A number of medical articles have pointed out that primary sleep disorders (conditions such as obstructive sleep apnea or movement disorders during sleep) are associated with chronic headaches. The majority of headache patients, however, do not have primary sleep disorders. Nevertheless, from years of treating headache patients, our group had noticed that patients with transformed migraine almost universally awakened feeling “tired” in the morning.

We tested this observation in a pilot study looking at sleep problems in 147 women with transformed migraine. We not only confirmed our clinical impression (86% of the women felt tired on arising; none felt restored), but found that the poor sleep quality might be, at least in part, due to a variety of poor sleep habits: 80% of these women watched TV or read in bed; 70% awakened one to six times a night to urinate; two-thirds had trouble falling asleep; and over 60% took naps to compensate for daytime fatigue and drowsiness.

 Five Sleep Habits to Reduce Headaches
  Set regular sleep times. Bedtime and waking times shouldn’t vary more than half an hour from day to day, including weekends. Eight hours of sleep is ideal.
  Don’t watch TV, read, listen to music or do work in bed.
  Practice visualization techniques to fall asleep quickly.
  Eat dinner at least four hours before bedtime and limit fluids within two hours of bedtime.
  Do not nap.

Although it is well-known that behavioral approaches can improve sleep quality in people with poor sleep habits, the impact of sleep habit modification on transformed migraine had never been studied. To test our theory that nonrestorative sleep might be implicated in migraine’s transformation process, we randomly assigned 43 women with transformed migraine to receive either five sleep instructions or five placebo behavioral instructions in addition to their standard medical care.

Standard care included the instruction to discontinue any overused medications while supportive therapy was provided (two weeks of naratriptan in a scheduled taper). A quarter of the women were not using excessive amounts of analgesics or triptans, but to keep medical therapy standard for all participants, all of the women received the two weeks of supportive therapy whether or not they were coming off overused medications. All headaches were recorded in standardized diaries, and the patients returned to the clinic after six weeks.

The women averaged 24 headache days in the preceding four weeks and their migraines had transformed to chronic headaches an average of 11 years prior to study enrollment. Their average age was 34.

In those who received the placebo behavioral instructions, we found no improvement in headache frequency or intensity, and no member of that group reverted from chronic headaches back to episodic migraine. However, among those who received the sleep instructions, there was significant improvement—they recorded a 29% decrease in headache frequency and a 40% decrease in headache intensity. Most importantly, a third of the women receiving sleep instructions reverted back to experiencing only episodic migraine, reversing 11 years of chronic daily headache.

At this point, we “crossed over” the placebo group and gave them the sleep instructions. We encouraged the original sleep modification group to continue working on any instructions they had not fully mastered. By the third visit, 48.5% of the total group (who had received sleep instructions at either or both visits) had reverted to episodic migraine (43% of the original placebo group and 58% of those who had had two sessions of sleep instruction).

Sleep Habits Alter Headache Patterns—For Better or Worse

The five sleep instructions were developed from information gleaned from our earlier pilot studies of sleep habits in women with transformed migraine.

1 The first instruction was to set a regular time for sleep that allowed for eight hours in bed. Bedtime and rise time could not vary more than half an hour from day to day—including weekends. In one of our earlier pilot studies, we found that excessive time in bed (9.5 hours or more) was just as common as inadequate time in bed (6.5 hours or less). Spending too much time in bed was often associated with watching TV or reading in bed, trouble falling asleep, or nighttime awakenings, whereas inadequate time in bed was associated with taking naps. Optimal time in bed for women with transformed migraine had never been determined, but from our second pilot study, we found that those spending eight hours in bed had the greatest overall reduction in headache burden.
The next two instructions were designed to address problems with initiating sleep:
2 Patients were asked to stop watching television in bed, reading in bed, listening to radio or music in bed, doing work in bed, etc. We explained that these habits were associated with a very rapid brainwave pattern which is normally quickly extinguished when we get in bed. Continuing this behavior in bed “conditions” the individual to maintain rapid brainwave patterns. This is why these patients often report that they lie in bed “thinking” (which is associated with the same rapid brainwaves) when they first try to sleep without first watching TV or reading.
3 We taught patients a visualization technique to learn to fall asleep quickly. They were instructed to imagine that they were at the beach, filming a silent movie of children putting sand in a pail. They were to stay on one image until they were either asleep, or they became aware that they were thinking with words again (rapid brainwave activity). If this happened, they were simply to “redirect the camera” and film another imaginary scene, such as a couple walking down the beach. Pure visualization is associated with slowing brainwaves.
The final two instructions were designed to enhance sleep continuity:
4 Patients were instructed to have dinner at least four hours before bedtime and to limit fluids within two hours of bedtime. From our earlier study, we had found that the most disruptive and predictable awakening during the night was associated with getting up to urinate. Interestingly, these women usually did not believe that they woke up because of the need to urinate, but simply felt that they would return to sleep better once they did. (Refuting this perception, the volume of urine voided at night was reported to be “normal,” similar to daytime voidings.) The medical literature says that normal non-pregnant women void 4-6 times a day and rarely at night; however, 70% of women with transformed migraine were getting up to urinate. Most of our patients were unaware that the majority of urine volume comes from solid food (only one-third to one-half comes from liquids) and requires hours to be excreted. In our pilot study, waking to urinate was not associated with the participant’s age; it was associated with the time of her evening meal in relation to her bedtime.
5 Finally, patients were instructed to stop all naps. Most felt tired or drowsy during the day, but we asked them to use this drowsiness to help consolidate the next night’s sleep.

We will quickly admit that advocating sleep changes to benefit chronic headaches is a simple plan, but not easy. In our study, adherence to the sleep instructions was strictly graded—decreasing TV viewing from nightly to a few times a month did not count for mastering that item, because the habit of rapid brainwave activity in bed is maintained by intermittent reinforcement. But achieving the five sleep goals was strongly associated with improvement—among participants who adhered to all five sleep instructions, all but one reverted back to episodic migraine. Among those who still had three or more poor sleep habits remaining at follow-up, none reverted to episodic migraine.

This study suggests that behavioral sleep modification may be effective in conjunction with standard medical care for women with transformed migraine. Additional work is needed to understand the mechanisms that might cause nonrestorative sleep to influence the process of migraine transformation and to determine if the findings also hold true for men.

My colleagues and I gratefully acknowledge the National Headache Foundation for its support of this research.



Women with Migraine with Aura Cautioned to Rethink Taking the “Pill”

While the connection between migraine with aura, oral hormonal contraceptives and stroke are still being studied, one group of researchers has made a recommendation that women with migraine with aura consider avoiding the “pill.” Both oral contraceptives and aura are associated with an increased risk of stroke. The risk is especially high for women who also smoke.

“Uncertainty exists as to the best advice for females under the age of 35 with migraine plus aura regarding use of the oral contraceptive pill,” the researchers from the University of Alberta, Canada, told attendees at the meeting in February.

However, they added that “if unwanted pregnancy is considered to be even a mildly undesirable state of health then the decision analysis supports continuation of the oral contraceptive pill.” Treatment of other stroke risk factors, such as smoking, are more critical than switching to other contraceptive methods.

“The combination of migraine with aura, use of oral contraceptives and smoking has long been recognized as a risk factor for stroke in the young female,” said NHF President Arthur Elkind MD. “This is not a new concept but implied from earlier studies and clinical suspicions of neurologists and headache specialists. The pill should be used with caution by individuals with migraine with aura and particularly by those who are active smokers.”

Manawadu D, et al. “Decision Analysis for the Use of Oral Contraceptive Pill in Migraine Sufferers with Respect to Ischemic Stroke”

Antioxidants for Hard-to-Treat Migraine

Is it possible that antioxidants could help reduce intractable headaches? According to Sirichai Chayasirisobhon, MD, a neurologist at the Kaiser Permanente Medical Center in Anaheim, California, antioxidant combinations may, in fact, be beneficial.

Twelve patients with a long-term history of migraines who had failed to respond to multiple treatments were given an antioxidant formulation of 120 mg pine bark extract, 60 mg vitamin C and 30 IV vitamin E. They took ten capsules of the formula each day for three months. After the three-month period, the average number of headache days for the 12 patients was reduced from 44.4 days to 26. Headache severity was also reduced while quality of life measures, such as migraine impact on work, school, domestic and social activities, improved by over 50%.

According to Dr. Chayasirisobhon, the finding “suggests that this antioxidant supplementation may mitigate some, as yet unknown, mechanisms involved in a migraine attack” and “supports other evidence that free radicals may play an important role in the pathogenesis of migraine.”
In particular, he suggests that antioxidant supplementation may protect cells from oxidative stress, in so doing reduce headache frequency and severity. Dr. Chayasirisobhon called for further investigation into the possibility.

Headache, May 2006

National Headache Awareness Week Is June 3-9

Join with the National Headache Foundation for National Headache Awareness Week June 3-9. Let’s educate the public about the impact and severity of headache, and support the more than 45 million sufferers of this neuro-biological disease.

The goals of National Headache Awareness Week are:

  • to gain recognition of headache pain as a real and legitimate condition,
  • to encourage sufferers to see a healthcare provider for proper diagnosis and treatment,
  • and to let sufferers know that there are new treatments available.

This year’s theme, Seven Healthy Habits of Headache Sufferers, will offer seven easy-to-implement suggestions for living life fully with headaches.

There are a number of activities that you can plan locally. For example, host a headache screening day, organize a public education program to discuss headache causes and treatments, work with a radio station to speak about headache, contact area newspapers to do a story, or offer free literature.
The NHF is happy to assist with your program and include your event in the master calendar of activities sent to media nationwide. We can also provide posters and educational materials to help make every event a success.

Visit the NHF Web site at to fill out the activity listing form and materials order form, and mail the forms to National Headache Foundation , 820 N. Orleans, Ste 217, Chicago, IL, 60610-3132 or fax to 312-640-9049. Please call the NHF at 1-888-NHF-5552 if you have questions or need assistance.

Treating Orgasmic Headaches with Triptans

At some point in their lives, about one percent of people will have headaches associated with sexual activity. The headaches can be a dull pain that increases with sexual excitement, or a sudden and severe pain triggered by orgasm. The latter, called orgasmic headache, can last for hours. Orgasmic headaches are typically treated preventively with indomethacin taken half an hour to an hour before sex. However, indomethacin can have difficult intestinal side effects.

A small study done at the University of Munster in Germany has found that triptans may also be an effective preventive treatment if taken about a half hour before sex. They may also shorten orgasmic headaches after they’ve begun. However, triptans should only be taken if other standard treatments are ineffective or not tolerated because of side effects.

Always seek medical attention the first time a severe headache is experienced with an orgasm to rule out any serious underlying medical conditions.

Cephalalgia, December 2006

Unapproved Ergotamine Drugs Ordered Off the Market

On March 1st, the U.S. Food and Drug Administration (FDA) ordered 15 unapproved migraine drugs containing ergotamine tartrate off the market. While the drugs were available by prescription only, most lacked a required “black box” safety warning. They were also manufactured and distributed without undergoing FDA review for safety and efficacy.

The FDA sent warning letters to eight manufacturers and 12 distributors regarding the 15 unapproved ergotamine drugs. The companies were given 60 days to stop making the drugs and 180 days to take the drugs off the market.

The FDA’s action doesn’t affect five FDA-approved ergotamine drugs: Migergot® suppository marketed by G and W Labs, generic ergotamine tartrate and caffeine tablets marketed by Mikart and West Ward, Cafergot® tablets marketed by Sandoz, and Ergomar® sublingual tablets marketed by Rosedale Therapeutics.

The approved products listed above have updated their labeling to include the black box warning (the strongest FDA warning) against using ergotamine-containing products when also taking potent CYP 3A4 inhibitors, including certain antifungal agents, protease inhibitors and antibiotics. CYP 3A4 is a metabolic enzyme that helps the body eliminate drugs or other chemicals. The enzyme is needed to break down and remove ergotamine from the body. Serious and life-threatening ischemia (a restriction in blood supply) have resulted when ergotamine and CYP 3A4 inhibitors have been used together.
FDA spokeswoman Sandy

Walsh noted that a number of the unapproved drugs “have been around a long time and never got FDA approval…. The best thing to do is educate yourself about what you are taking, see if the product contains ergotamine, and ask your doctor or pharmacist if you have questions.”

Watch the next issue for an announcement of the winner of the National Headache Foundation’s Healthcare Provider of the Year Award, as well as winners of the 2007 annual benefit raffle.

Inhaled Form of Dihydroergotamine Shows Potential

Dihydroergotamine (DHE) has been used in the treatment of migraine since 1946. It is typically administered by intravenous injection in a clinical setting, or subcutaneous injection by the patient, or via a nasal spray. Recent studies of a newly developed, inhaled form of DHE demonstrated a reduced incidence of nausea compared to intravenous administration, while achieving DHE levels in the body similar to intravenous levels and rapid relief. Tempo® Migraine delivered via the Tempo Inhaler showed statistically significant pain relief at ten minutes and sustained relief 24 hours later in a study at nine U.S. headache centers. It was also found to be safe for patients with impaired pulmonary function.

DHE is not affected by the FDA warning listed above


New Findings Presented at the Fourth Annual Headache Research Summit

To support and advance research into the diagnosis and treatment of headache, the NHF hosted its Fourth Annual Headache Research Summit in Rancho Mirage, California, February 13-14. The Summit is intended to attract a range of healthcare providers including generalists, specialists, mid-level providers and researchers, including up-and-coming physicians.

“We must continue to focus on the studies and findings of our future leaders, as these individuals will develop tomorrow’s advances in the diagnosis and treatment of headache,” explained Seymour Diamond, MD, executive chairman and co-founder of the NHF.

“The quality of the research work submitted for presentation at the Research Summit continues to improve and enlighten,” added NHF board member Robert Kunkel, MD. “We expect the Summit to become an increasingly important venue for headache researchers to present their work.”

The Headache Research Summit featured two special presentations: the 2007 Seymour Diamond Lectureship Award and the NHF Lectureship Award. The NHF Lectureship Award recognizes the work of outstanding physicians in the field of headache. Anne Calhoun, MD, presented her paper, “Behavioral Sleep Modification May Revert Transformed Migraine to Episodic Migraine,” which was adapted for this issue of NHF Head Lines.

For the Seymour Diamond Lectureship, the NHF appointed a committee of headache experts to select the most outstanding paper on headache, its causes and treatment, published during the previous year. The committee reviewed 2,244 papers and selected “Suppression of Cortical Spreading Depression in Migraine Prophylaxis,” by Michael A. Moskowitz, MD, a physician-
scientist in the Neuroscience Center at Massachusetts General Hospital-East in Charlestown, Massachusetts, and a professor at Harvard Medical School.

The primary purpose of this research was to examine a mechanism by which drugs work in migraine prevention. To accomplish this, Dr. Moskowitz focused on a brain event that has been closely linked to migraine—cortical spreading depression—which appears to be responsible for migraine aura and has been linked to excitable events within the brain. The most commonly used drugs for migraine prevention block or suppress a type of electrical activity. The study revealed that the longer these drugs are administered in experimental studies, the more effective they appear to be in suppressing these electrical waves. Identifying a specific action of preventive drugs for migraine could point the way toward developing newer and more specific treatments for this condition and provide a clearer mechanism for how and why migraine develops in certain humans.

Other presentations made at the Research Summit were:

Using the Migraine Assessment of Current Therapy (Migraine-ACT) to Detect Medication Treatment Differences in Migraineurs,” by Steven Burch, PhD, RPh, the senior manager with Applied Outcomes and Analysis within GlaxoSmithKline.

The Migraine Assessment of Current Therapy (Migraine-ACT) is a short questionnaire that patients complete to help determine whether their current migraine medication is working effectively. The objectives of this study were to determine whether Migraine-ACT is sensitive to differences between migraine therapies, to assess the usefulness of the tool in a non-office setting, and to explore the need for better migraine management by type of current therapy. The Migraine-ACT clearly detected differences in outcomes between acute migraine therapies and was found to be a useful tool for assessing treatment differences in non-office settings by evaluating effectiveness, consistency, daily activities and functioning.

Development and Validation of the Migraine Interictal Burden Scale: A Self-Administered Instrument for Measuring the Burden of Migraine Between Attacks,” by Dawn C. Buse, PhD, Director of Psychology at the Montefiore Headache Center, Bronx, New York.

In addition to the pain and suffering experienced during migraine attacks, migraineurs may experience substantial challenges between attacks (called the interictal period). A questionnaire that captures this interictal burden is needed to raise awareness about the total burden of migraine, enhance clinical care, inform treatment decisions and guide research. Dr. Buse reported on the development of the Migraine Interictal Burden Scale (MIBS), the first self-administered instrument that measures the multidimensional burden of migraine between attacks. The 16-item questionnaire focuses on four key areas: disruption at work or school, interference in family and social life, difficulty planning activities and emotional consequences. Buse and fellow researchers hypothesize that the MIBS can be used by healthcare providers to measure the effect of headache on all important aspects of sufferers’ lives. This information could then be used to provide the highest quality medical care. Researchers hope the instrument will guide healthcare providers to ask questions about quality of life and emotional issues. Work is also underway on a shorter version of the instrument for use in primary care settings.

Efficacy of Rizaptriptan for ICHD-II Menstrual Migraine,” by Lisa K. Mannix, MD, Medical Director of Headache Associates in Cincinnati, Ohio.

These studies examined the effectiveness and tolerability of rizatriptan for the treatment of menstrual migraine, as defined by the 2004 revision of the International Classification of Headache Disorders (ICHD-II). Patients in parallel, placebo-controlled, double-blind studies were assigned to either a rizatriptan 10-mg tablet or a placebo and were instructed to treat a single menstrual migraine attack of moderate or severe pain intensity. The study concluded that rizatriptan 10-mg was effective for the treatment of menstrual migraine, as measured by two-hour pain relief and a 24-hour sustained pain relief.

Red Ear Syndrome,” by A. David Rothner, MD, a pediatric neurologist at the Cleveland Clinic Foundation located in Cleveland, Ohio.
Red Ear Syndrome (RES) is an unusual type of head pain in which the ear becomes red and burning. Researchers reviewed three cases of RES in children and adolescents seen at the Cleveland Clinic and ten cases seen in children and adolescent cases abstracted from literature. In addition, 22 adult cases were reviewed from the literature to better define the clinical features, differential diagnosis and pathophysiology of RES. In seven of the cases, migraine accompanied the RES attacks, two cases of migraine followed the RES attacks, while four RES cases were unrelated to migraine. The frequency of attacks varied from one to two per day and two to three per month and lasted anywhere from ten minutes to one hour. In eight of the cases, RES attacks occurred spontaneously with no precipitating factor. Further studies are needed to better understand the epidemiology in children and adolescents, clinical features, effective treatments and prognosis.

Butalbital-Containing Product (BCP) Usage Among a Hospitalized Headache Patient Population,” by Richard G. Wenzel, PharmD, pharmacist at the Diamond Headache Clinic Inpatient Unit at St. Joseph’s Hospital, Chicago, Illinois.

The objective of this study was to assess patterns of butalbital-containing product (BCP) use among patients admitted to a headache unit. One hundred and one patients were admitted during the study period and 97 were examined. Seventy-five of those admitted had a diagnosis of chronic daily headache disorder, while 22 had medication-overuse headache. Thirty-nine percent of the patients had been prescribed a BCP at some point in their lifetime. Of the 22 medication-overuse admissions, eight of them, or 37%, were due to a BCP.

The National Headache Foundation would like to acknowledge GlaxoSmithKline for their support of the 4th Annual Headache Research Summit and acknowledge Merck & Co., Inc. for their support of the NHF Lectureship and resident travel grants and Endo Pharmaceuticals for resident travel grants.


Your Contributions Are a Step Toward the Solution

What’s being done to help your headache problem? Today, an unprecedented amount of scientific research is being done to help piece together the puzzle of migraine and headache pain. Several new research projects are being undertaken with the help of funding from the National Headache Foundation. Member contributions are a key part of the financial support of important headache research!

Your gift provides funds for:

  • NHF-financed research projects like those described in this issue;
  • Education for healthcare providers, so you can benefit from your provider’s updated knowledge and training;
  • New patient-education initiatives from the NHF, which help you make use of the latest solutions.

You can help! The National Headache Foundation, Your #1 Source for Headache Help, provides these services and many others through the generosity of people like you!

Please select one of the following giving categories, or fill in an amount.
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Enclose this form with your credit card information or a check payable to the National Headache Foundation. Mail to NHF, 820 N. Orleans, Suite 217, Chicago, IL 60610-3132. Gifts to the NHF are tax deductible as allowed by law. Your gift will be acknowledged.


Richard Wenzel, PharmD
Diamond Headache Clinic Inpatient Unit
St. Joseph’s Hospital, Chicago, IL

“Off-Label” Prescribing: Why Drugs Ranging from Antidepressants to Antiseizure Medications Are Used for Headache Management

When educating headache patients, I commonly encounter questions regarding the use of medications designed for an illness other than headache. “Why did my doctor give me a blood pressure pill if my blood pressure is fine?” I’m asked. Or, “Why am I being prescribed an antidepressant? Does my doctor think my migraines are just depression?” These questions arise primarily because patients are unaware of the varied uses of drugs for multiple illnesses.

The U.S. Food and Drug Administration (FDA) is the government agency responsible for determining the effectiveness and safety of prescription and non-prescription medications. The FDA requires drugs to successfully complete an approval process, in which research is conducted among individuals suffering from a particular disease. Upon successful approval, a drug is assigned an “indication,” which signifies that the FDA officially recognizes that the medication is safe and effective for that particular illness.

Yet once FDA approved, drugs can be legally prescribed for illnesses other than the original indication, a practice known as “off-label” use. Off-label prescribing has been practiced for decades with many medications and for countless diseases.

Off-label prescribing is widespread for rare or poorly researched illnesses as a practical reality. Since healthcare providers have few FDA-approved drug choices for these illnesses, they may attempt off-label treatment with a medication they reasonably expect to be of benefit. Historically, headache has been inadequately researched. Thus a large portion of therapy has been, and still remains, off-label.

One Medication, Multiple Diseases

Off-label prescribing has been practiced for decades with many medications and diseases, especially for diseases that share a similar problem. For example, blood vessel changes occur during migraine attacks. Therefore, it is not surprising that drugs that affect blood vessels, such as certain blood pressure medications, can also be successfully used for migraine. Seizures and migraine are both partially caused by inappropriate activity of chemicals in the brain. Thus, medications that affect chemicals in the brain can be used for either illness.

For example, topiramate (Topamax®) was originally FDA-approved a decade ago for treatment of seizures. Over time, patients with migraine as well as seizures reported that their headaches improved when they were prescribed topiramate. These reports prompted researchers to study the drug in migraineurs who did not have seizures, which ultimately led to topiramate receiving an FDA indication for migraine prevention.

This situation highlights an important patient role—if you are taking a drug for an illness other than headache, but notice an improvement in your headaches, please inform your healthcare provider or pharmacist. They will forward this information to the pharmaceutical company, which will evaluate if further studies are warranted.

Patients should also be aware that the dose of a medication when used to treat headache may differ from the FDA-approved dose for its original indication. Topiramate’s seizure dose usually exceeds 200 mg per day, but the migraine dose is typically less that 200 mg daily. As an added benefit, lower doses generally cause fewer side effects.

Topiramate is one of the few examples of successful off-label usage resulting in an FDA migraine indication. Depakote® (divalproex sodium) followed a similar path to its FDA approval for migraine prevention. Older medications that have been found to be effective for headache—for example, the antidepressant amitriptyline and the blood-pressure medication propranolol—are unlikely to ever obtain an FDA headache indication. The FDA approval process requires many years of research and costs tens of millions of dollars. Older drugs tend to be only available as generics and few, if any, generic pharmaceutical companies are willing to incur large expenses. Furthermore, these medications are already widely prescribed for migraine, diminishing any economic incentive to seek an FDA indication.

So, the next time your healthcare provider prescribes an off-label drug, for example a blood pressure, antiseizure or other non-headache drug, ask why. The provider’s rationale may range from something simple, such as other headache patients reporting benefits from the drug, to stronger evidence, such as findings from a large study published in a medical journal. Or the drug may now be FDA-approved for headache. And remember, if you are taking the drug for your headache, then it is in fact a headache drug, regardless of the medication’s FDA indication.


Paroxysmal Hemicrania

By George R. Nissan, DO, Diamond Headache Clinic, Chicago, Illinois, and Clinical Assistant Professor of Medicine, The Chicago Medical School of Rosalind Franklin University of Medicine and Science


‘Ellen’ is a 43-year old female who experiences a right-sided, stabbing and sometimes throbbing headache primarily in the orbital and temporal regions (i.e., eye socket and temple areas), with up to 15 headache attacks per day. Each attack lasts from 5 to 30 minutes. The head pain is associated with tearing of the right eye, nasal congestion of the right nostril, and droopiness of the right eyelid, all of which disappear when the head pain resolves. She prefers to lie down in bed in the fetal position when the attacks occur.

Ellen has no significant family history of either migraine or cluster headaches, nor any significant medical history. She is a non-smoker and exercises regularly.


Ellen’s symptoms do not appear to fit the diagnostic criteria for migraine or tension-type headaches, and while some of the features are similar to cluster headache, the number of headache attacks she has per day is much greater than what a typical cluster headache sufferer experiences (15 per day versus 2 to 5 per day). Also, patients with cluster headache prefer to pace around the room during an attack, while this patient prefers to lie down.

The presentation of uncommon primary headache disorders (i.e., not caused by a secondary, underlying condition) can pose a dilemma for many healthcare providers both in primary care and in general neurology. These disorders can be very disabling and are often undiagnosed or misdiagnosed unless a detailed medical history is obtained.

Ellen has a condition called chronic paroxysmal hemicrania (CPH). CPH was not officially named until 1976. The disorder was originally described as multiple, short-lived, one-sided attacks that occurred on a daily basis without remission. However, it became clear that not all patients suffered an unremitting course. Some patients reported a remitting pattern with discrete periods of headache and then prolonged periods of pain-free remission. This pattern was then later named episodic paroxysmal hemicrania (EPH). The International Headache Society, however, only recognizes the term chronic paroxysmal hemicrania. In clinical practice we prefer the terms CPH, EPH, and CPH that evolved from EPH.

Unlike cluster headache, CPH is predominantly a disorder of females, with a 2:1 female to male ratio. The onset is usually in adulthood, with a mean age of approximately 33 years. Some cases have also been reported in children and teenagers. Most patients have no family history of the disorder though approximately 20% to 25% have a positive family history of migraine.

The pain of CPH is often described as pulsating, throbbing or stabbing, and ranges from moderate to excruciating in severity. Headache attacks can recur from one to forty times daily. The majority of patients report 15 or more attacks a day. Each individual headache can last from 2 minutes to 2 hours, although most commonly last less than 25 minutes. Attacks can occur throughout the day and night, even during REM sleep. Approximately 60% of patients report tearing from one eye on the same side of the headache. Other associated symptoms on the same side as the headache include droopiness of the eyelid, redness and irritation of the eyelid, and nasal congestion.

CPH can occur in conjunction with migraine, cluster or trigeminal neuralgia. It is important to have an imaging study, such as an MRI or CT scan of the brain with contrast, to evaluate for rare secondary causes of paroxysmal hemicrania such as a stroke, collagen vascular disease or a tumor.

Indomethacin, a nonsteroidal anti-inflammatory medication (NSAID), is the treatment of choice for CPH and EPH. Headache resolution is often prompt. In fact, a positive response to indomethacin is often used as a diagnostic indicator for CPH. Dosage adjustments are typically necessary during the initial phase of treatment. Sustained-release indomethacin taken before bed can sometimes help prevent nighttime attacks. When normally therapeutic doses of indomethacin do not provide headache relief, the diagnosis of CPH should be reconsidered. Other medications that may be of some clinical benefit include verapamil, steroids, naproxen and acetylsalicylic acid. It is also very important for patients who are taking indomethacin daily to monitor for gastrointestinal side effects, as is the case with all NSAID medications. To help minimize these side effects, patients may be treated with over-the-counter antacids, histamine receptor antagonists (i.e., Pepcid®, Zantac®, etc.), or omeprazole.

After initial treatment with indomethacin three times a day, Ellen became pain-free within seven days. She has been able to return to work full-time and is on maintenance doses of indomethacin in addition to omeprazole to help minimize gastrointestinal side effects.


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Bending Over Triggered Headache
Q. Yesterday I bent over to do some gardening and, boom, it triggered a migraine with sharp pain in the top right side of my head. That’s the first time a migraine came on that way. I took Imitrex® and it subsided a few hours later. Is this a dangerous situation or is this normal? Can it be from an old head injury? Do I need an MRI?

I’m almost 60 and have had migraines since my 20s. They’ve become worse as time goes on, despite daily nortriptyline and atenolol. I had quite a few acupuncture and chiropractic treatments many years ago for injuries from a car accident, and even months after discontinuing them I still didn’t have any migraines. Coincidence? I want to try acupuncture and chiropractic again.?

A. The Vasalva maneuver (holding one’s breath and bearing down) commonly worsens a migraine and can occasionally trigger an attack, as in your case. Bending, stooping, straining, lifting, etc. and even coughing or vigorous sneezing can do this, by causing a momentary rise in the pressure of the veins and fluid in the head.

It is unusual, however, for this activity to trigger a migraine for the first time at your age. If this same scenario recurs, I think you should have an evaluation, including an MRI.

Minor head trauma such as you had may aggravate headaches in individuals with migraine, but I doubt it would cause any permanent problems. Acupuncture can be very helpful in some migraine sufferers. Chiropractic treatment and massage may also help if there is a trigger area in the neck.

Robert Kunkel, MD
Cleveland Clinic Foundation
Cleveland, OH

Screening for Patent Foramen Ovale
Q. My daughter and I read Dr. Ishkanian’s article addressing patent foramen ovale (PFO) in NHF Head Lines 152. He reported on a study in which “closure of the common heart defect in patients resulted in significant reduction or even cessation of migraines.” It appears that the majority of the patients had suffered a neurological event such as a stroke.

My daughter does not meet this criteria, but I am still wondering if she may have a PFO and if closing it would relieve her unrelenting migraines. The frequency and intensity of her migraine attacks have not changed over many years, despite trying medications such as Botox® injections, Topamax® and prednisone, to name a few.

Is there a way to screen for PFO which is non-invasive? We are very interested in exploring different treatments that may allow my daughter to leave her darkened room and return to her life prior to being stricken with migraines.

A. The usual way of screening for a PFO is with an echocardiogram, which is a non-invasive test. Another procedure that can determine PFO is a Doppler “bubble” study, which requires an injection. Sometimes, for better definition of the heart chambers and possible defects like a PFO, a cardiologist will want to do a transesophageal echocardiogram, also known as a TEE. This involves putting the instrument down the throat into the esophagus. I suppose this might be called “invasive” but it does not involve surgery or entering the blood vessels.

Robert Kunkel, MD
Cleveland Clinic Foundation
Cleveland, OH

Right for Patent Foramen Ovale Repair?
Q. I have chronic daily migraine with aura. I had one light stroke which was considered due to migraine. Subsequently, at my urging, I was tested for patent foramen ovale and it was positive. My doctors are reluctant to pursue repair, but I have had enough and I will accept the risks—whatever they are.

A. There is increasing evidence that some people who have migraine with aura will benefit from closure of a patent foramen ovale. Those most likely to benefit are those who have had neurological symptoms as well as migraine with aura.

Double blind studies are currently being done in which some patients will have the defect closed and some will have a catheter inserted but not have the defect closed. This should answer the question as to whether the actual closure of the atrial defect is better than placebo.

There are some risks associated with the repair and that is why some healthcare providers are hesitant to recommend that it be done for migraine until the results of the studies mentioned above are known. Some cardiologists at my institution will not do a PFO closure for migraine. The main risks are cardiac arrhythmias (irregular heart beat) and formation of blood clots.

With your situation and your willingness to accept the risks of the procedure, I would be in favor of you undergoing closure of the PFO.

Robert Kunkel, MD
Cleveland Clinic Foundation
Cleveland, OH

Birth Control Injection Reduced Her Migraines
Q. I started having migraines at the age of 19, but they got much worse after having children. Looking back, I remember that pregnancies were the only time I didn’t have migraines.
I recently heard about a birth control injection, Depo-Provera®, that blocks periods for three months at a time. It was worth a try. Since the injection six months ago, my migraines have been cut in half, from ten or more a month down to five. This has helped me and I think it may help others who have tried everything else.

A. It does appear that you are one of the 60% of female migraineurs whose headaches worsen with hormonal triggers. Many women with migraines will get them more frequently around the time of their menstrual period, and the majority of women will have fewer attacks during the second and third trimesters of pregnancy when estrogen is at a higher and more stable level.

The Depo-Provera that you mention is a progesterone compound used primarily for birth control. Hormonal manipulation for headaches can be very unpredictable and is generally reserved as a last treatment resort. I’m glad for you that Depo-Provera has helped. In my experience, I note more women have a worsening of headaches on Depo-Provera and, unfortunately, once it is injected, its effects may last for three months. Therefore, I do not recommend it for my patients.

Loretta Mueller, DO
University Headache Center
Moorestown, NJ

Dosages of Supplements Taken for Migraine Prevention
Q. I have been taking supplements (500 mg magnesium, 150 mg butterbur, 400 mg feverfew and 400 mg B-2) for a number of months for my migraines. The supplements were really helping with the frequency and severity of my headaches. For the past three weeks my headaches have been coming more often and the severity is a little stronger. My question is, can I up my supplement doses?

A. There are no studies to address the efficacy or safety of higher doses of these supplements, so I would not recommend increasing the doses. If your headaches remain frequent, your doctor can add a medication that is used for the prevention of migraines.

Mark Green, MD
Headache Center
New York, NY

Hemicrania Continua
Q. Is hemicrania continua harmful?

A. Hemicrania continua is a relatively rare primary headache disorder (“primary” meaning there is no identifiable cause) characterized by continuous pain on one side of the head (hence the term hemicrania). It is categorized as one of the “indomethacin responsive headaches” because patients almost invariably get relief when treated with regular doses of a nonsteroidal anti-inflammatory medication called indomethacin (Indocin®). The response is typically complete and lasting, as long as the patient remains on the medication (some patients have had no recurrence for extended periods of time even after stopping the medication).

While hemicrania continua is painful, it is not harmful. However, indomethacin may irritate the stomach, cause ulcers or increase the tendency to bleed. Doses of 75-150 mg twice a day are typical, starting at the lower dose range. Interestingly, the response often occurs within a few days (sometimes after the first dose). If a patient doesn’t have any response after 7-10 days it probably isn’t going to be effective. If there is some response but not complete, we usually recommend increasing the dose to 150 mg twice daily. Patients should be monitored closely at the initiation of therapy and regularly as long as they stay on the medication.

James Banks, MD
Ryan Headache Center
St. Louis, MO

Chronic Headaches after Spinal Fusion
Q. Two and a half years ago I had spinal fusion surgery of the third, fourth and fifth vertebrae. Since then I have suffered with chronic headaches in the back and top of my head. I have been going to a pain clinic and have had two procedures done in which the nerves in my neck, which register pain from that area of the skull, were treated with ultrasound. The first treatment worked for three months. The second didn’t work at all. I’ve tried several pain killers, and the only one that I can function with is a low dose of morphine IV, although I can’t take it at night because it doesn’t allow me good sleep.

My doctor tells me that I have arthritis in my spine, which is putting pressure on the nerves. He wants to implant a stimulator into these nerves to impede the pain signal to my brain. It would include a hand-held device, which would allow me to self administer electrostimulation as needed.

Is this a good and reliable procedure? What are the down sides to it? I’m about at the end of my nerves with this.

A. The relationship between neck pain and headache is a significant one, because of the interaction between the main nerve that carries pain messages in the head (called the trigeminal nerve) and the upper cervical nerve roots that extend from the spinal cord in the neck. Neck pain, in fact, is often a prominent feature of migraine headache.

Treatment of neck pain, however, is often difficult and requires a multi-disciplinary approach. Occipital nerve and spinal cord stimulators are currently under scientific trial for both headache syndromes and cervical pain. I believe more clinical trials will be important to fairly judge their efficacy and safety.
I am concerned about your ongoing use of morphine, particularly since it seems to be interfering with sleep. You may benefit from a combination of therapies including physical therapy with strengthening and relaxation exercises for your neck, medications that can be used safely without the risk of dependency (such as the anticonvulsants gabapentin, pregabalin or topiramate), and muscle relaxants. This multi-disciplinary approach can be overseen by a healthcare provider skilled in the complexities of treating chronic pain.

Tarvez Tucker, MD
University of Kentucky
Headache Clinic
Lexington, KY

Mother and Three Young Daughters All Suffer Severe Attacks
Q. For at least the last ten years, I have been getting migraines in which I lose coordination of the right side of my body and my ability to walk, stand and communicate. I remember having migraine symptoms as early as four years old. I am now 28-years-old and have four lovely daughters ranging from ages one to five. The oldest three have been getting similar symptoms since their second birthday. They have episodes lasting 14-20 hours long, two to three times a week (on different days just to make it exciting) in which they are nauseous, bump into the wall when walking, sway, drop toys from their right hand, and complain that their legs hurt. Occasionally, they’ve said their heads hurt (always on the left side), but it’s not their predominant complaint. Their speech slows down and sometimes they stop talking altogether.

These episodes have many characteristics unique to children. During these episodes the potty trained ones have accidents, can’t get dressed, and can’t pick up a toothbrush. They can scream for an hour or more in pain, look catatonic and stare at the ceiling, or act extremely anxious and hyper-alert. At points, they can’t understand what I’m saying and get very distressed and disoriented.

What are the possible causes of such a strong genetic link in migraine symptoms? We have an appointment with a pediatric neurologist eight months from now. What can I do in the meantime to help them through these episodes? Tylenol® doesn’t do anything and the pediatrician wants them evaluated before she will prescribe a medication. Is there anything else I can do? We already keep a regular schedule and avoid migraine-triggering foods. I also have each of the girls seeing a counselor.
It is so hard watching my children scream or be catatonic, or flailing and saying, “Help me, Mommy.” I try to stay calm, but I still get migraines, too!

A. This is a tough problem, to say the least. I discussed your letter with a pediatric neurologist. He and I both agree that your family probably has familial hemiplegic migraine, but other possibilities include a mitochondrial disorder or other inherited metabolic disorders.

You and the children should have a thorough workup including MRI/MRA, and studies for coagulation defects and vasculitis. The pediatric neurologist also suggests trying to get a brain wave test (EEG) during a spell if possible.

Familial hemiplegic migraine is a migraine disorder where many members of a family all have the same neurological symptoms with their attacks. From your description, this seems to be the most reasonable diagnosis.

It appears that you are doing all you can with your daughters’ diets, getting them adequate rest, etc. I would suggest you keep pushing for an earlier appointment with the neurologist and get on the cancellation list so that the appointment may be moved up.

Robert Kunkel, MD
Cleveland Clinic Foundation
Cleveland, OH

Worried about Serotonin Syndrome
Q. I just started taking Relpax® for my migraines last month, which is working, and I have been taking Zoloft® for the past ten years. I read an article the other day that said that Relpax and Zoloft can cause a deadly condition called serotonin syndrome. Is this true? What should I do? I am very nervous now. I need the Zoloft and I finally found a medication that relieves my migraines.

A. It is true that a serotonin syndrome can occur when certain antidepressants are combined with triptans. Fortunately, this serious interaction is rare. Countless people have been on triptans as well as these antidepressants without any problems. You and your healthcare provider simply have to monitor any side effects.

Mark Green, MD
Headache Center
New York, NY


When to See a Healthcare Provider about Your Headache

Most likely you or someone you know will have a headache today, but do you know when you should see a healthcare provider about your headaches? While 45 million Americans have chronic headaches and nearly 30 million of these people experience migraines, most patients mention their headaches to their healthcare provider only as an afterthought.

Results from a recent online survey conducted by the NHF found that only 11% of respondents sought immediate medical attention for their headaches and 31% have never seen a healthcare provider for their headaches. Millions of people seek medical attention every year due to headache pain, but even more might benefit from a visit with their healthcare provider. Those headache sufferers who benefit the most see their provider shortly after the onset of their disease. In fact, according to the NHF survey, 66% percent of respondents see their healthcare provider within a year.

It’s easy to put off medical appointments or to just wait until a headache passes. But there are clear signs that indicate when medical attention could make a real difference in your quality of life.

You should seek immediate medical attention if:

  • Your headaches (the pain and duration) have gotten worse over days and weeks. An increase in headache severity or frequency prompted 72% of survey respondents to see their healthcare provider.
  • You (particularly if you’re over 50) have never had headaches before, and these came on suddenly. Fifty-two percent of survey respondents said they had a severe headache that came on suddenly or a headache that would not go away before they saw their healthcare provider.
  • You experience weakness or numbness or a change in your hearing or sight.
  • Your headache is unrelenting, and none of the over-the-counter analgesics you have taken seem to relieve the pain. Sixty percent of survey respondents were taking pain relievers more than two to three days per week or their current medication was no longer working prior to seeing their healthcare provider.
  • Your memory, personality or cognitive abilities seem to be changing.
  • Your headache is accompanied by a stiff neck, rash, nausea, vomiting, fever, breathing problems or head injury. Dizziness and nausea/vomiting preceded the onset of a headache for 61% of survey respondents, while 52% noted sensitivity to light and/or sound brought on an attack.
  • Your headaches are interfering with your daily activities. Headaches interfered with the ability of 67% of respondents to perform work and/or household functions or pursue leisure activities.

Getting the Most from Your Visit

Start with your primary healthcare provider when seeking treatment for your headache. Discuss his or her experience and approach to headaches, including diagnosis and treatment. There are a variety of ways that headache sufferers can find relief. According to the survey, headache sufferers use the following methods: sleep (47%), prescription medications provided by their healthcare provider (42%), lying in a dark room (39%), and over-the-counter medications (38%).

In order to get the most from your visit, keep a headache diary. This can be a useful tool when discussing your headaches with your healthcare provider. Track your headaches in an organized way, including the date and time, length, severity, symptoms and triggers. Make note of what medication was taken, if any, and the effectiveness of that medication in alleviating the symptoms. A copy of a headache diary can be found at under Educational Resources.

Also prepare for your visit by identifying your concerns, questions, fears and expectations. Taking an active role in your health care will help you and your healthcare provider work as a team.

Headaches are a legitimate neurobiological disease and are treatable. If you are experiencing headache pain that affects your life, make an appointment with your healthcare provider specifically to discuss your headache problem and seek accurate diagnosis and treatment. By talking to your healthcare provider about your headaches, you can make a real difference in your own headache management.


Support Group Meeting Information

The National Headache Foundation has established a nationwide network of headache education and support groups for headache suffers. The following list represents those support groups that are meeting at the time this issue was printed, with contact names and numbers. Check our Web site,, for more complete listings. If you need additional information about any of these locations, or want to learn if a new group is about to open in your area, please contact the NHF at 888-NHF-5552 or e-mail NHF staff at

Support Groups in the U.S.
Dothan: Trent Mathis, 334-699-8433

Phoenix: Anne Sutherland, MD, 480-353-2291

Jonesboro: Healthline, 1-888-STB-4555

Margate:1-888-256-7720 or Sari Rotenberg, PT/MBA, 954-978-4180
St. Petersburg: 727-825-1100 or Michael A. Franklin, MD, 727-820-7701

Boise: Mark Filicetti, RPh, 208-381-3649 or 208-376-3781

Chicago: Susan Barron, 312-274-2653

Greensburg: Diane McKinney, RN, BSN, 812-663-1163 or Joan Mokanyk, 812-663-2085

KANSAS – New Group!
Kansas City-UKMC: David Burkett, LSCSW, at 913-588-0608; co-facilitated by Dr. Jennifer Bickel.

Shelbyville: Tammy Swigert, RN, 502-647-1642

Shreveport: Donnie Laborde or Patty, 318-377-1185

Boston: Beth Israel Deaconess Learning Center (BIDMC) staff, 617-667-9100, or Margo, 617-632-8483
Northampton: Cooley Dickinson information line, 1-888-854-4234, or Jackie Compton, 413-268-7265

Madison Heights: Kimberly Bialik, PhD, 248-967-7988
Port Huron - New Group! Mercy Hospital Pain Center/Donna Smith, RN, 810-989-7461

Nashua: Judy Brown 603-557-8216 or

Utica: Sue Cooper 315-798-8404, or Cynthia DeTraglia, RN

Fargo: Alicia Andrews, NP, 701-234-4036

Cincinnati: Jan Welsh, 513-385-5000
Cleveland: Sharon M. Bilek at 216-642-8506

Corvallis: Kris Egan, 541-745-7422

Pittsburgh: Barb Wintermantel at 412-647-9494
Johnstown: Jan Goodard, RN, BSN, 1-814-269-5288 or 1-800-587-5875

Warwick: Brenda Bullinger, LCSW, 401-732-3332, ext.133

Chattanooga: Steven Clifton, PA-C, 423-698-0850
Memphis: Judy McGinnis, RN, at 901-753-4093

Dallas: 800-4-BAYLOR (1-800-422-9567)

Green Bay: Bonnie Groessl, MSN, APNP, 920-965-7719

Kirkland: Evergreen Healthcare, 425-899-3000

Overseas Support Groups
Dhaka: Pytt HartWong, RN, or Sunzida at 88-555-00, ext. 2760, at the Medical Unit or email

Landstuhl: Landstuhl Regional Medical Center, near Ramstein Air Base in Rheinland-Pfalz, Neurology Center. Susan Barron, 888-643-5552, or

Please be sure to call to confirm all meetings as meeting times and locations are subject to change and cancellations do occur. Seating is limited. If you are interested in helping to organize a support group in your area, please call Susan Barron at 888-NHF-5552 or e-mail


National Headache Foundation

Mission Statement
The NHF exists to enhance the healthcare of headache sufferers. It is a source of help to sufferers’ families, physicians who treat headache sufferers, allied healthcare professionals and to the public. The NHF accomplishes its mission by providing educational and informational resources, supporting
headache research and advocating for the understanding of headache as a legitimate neurobiological disease.

Vision Statement
The NHF will be the premier educational and informational resource for headache sufferers, their families, physicians, allied healthcare professionals and health policy decision makers. The NHF will advocate for headache sufferers. The organization will employ the most effective means to disseminate
information and knowledge to headache sufferers and non-sufferers.


Educational Materials Order Form

(Prices include postage & handling. For 11-20 brochures add $2.
For 21–75, add $3. For more than 75 brochures, please call for information.)
The Complete Headache Slide Chart
Lists 21 different types of headaches, their symptoms, precipitating factors, treatment & prevention.
The Headache Handbook
8-page brochure with information on causes, types of headaches, & available treatments.
About Headaches
16-page in-depth look at headaches, tips on when to seek medical advice, treatments, etc.
About Stress Management
16-page brochure discusses stress management techniques and how to locate help for managing stress.
About Relaxation Techniques
16-page step-by-step instructions for relaxation methods such as meditation, deep-breathing & visualization.
About Over-the-Counter Medications
16-page brochure explains the potential risks and precautions to take with certain medications,
how to read medication labels, & other valuable information.
How to Talk to Your Healthcare Provider About Headaches
8-page brochure on when to seek help for a headache problem, keeping a diary, & working with a doctor.
Alternative Therapies & Headache Care
20-page guide to the vast array of alternative headache remedies & methods. Recipient of a Silver Award from the National Health Information Awards.
New Perspectives On Caffeine And Headache: Straight Talk For Headache Sufferers
19-page brochure explains the relationship between caffeine & headache; lists caffeine contents of foods & beverages.
Keeping Track of Your Migraine Patient Diary
36-page logbook has detailed calendars to keep track of headaches & associated symptoms.
Ten Tips on When to See Your Healthcare Provider for Headache
Two-sided easy reference card lists warning signs for serious headaches & questions to ask to get
the most from your medical visit.
Talking to Your Headache Doctor
12-page guide to enhancing communication with your doctor to get the best information & help in
developing an effective treatment plan.
A Patient's Guide to Headaches
16-page brochure on types of headache, with a focus on migraine including dietary triggers, the phases of migraine, medications, & alternative treatments.
A Patient's Guide to Migraine Prevention & Treatment
17-page guide discusses prevention and treatment of migraine, including nondrug approaches,
with lists of commonly used medications, and foods and other headache triggers to avoid.

Visit for more materials, including Spanish translations, audiotapes and videos.

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National Headache Foundation - Your #1 Source for Headache Help

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  • To serve as an information resource for headache sufferers, their families and the healthcare practitioners who treat them;
  • To promote research into potential headache causes and treatments;
  • To educate the public to the fact that headaches are a legitimate biological disease and sufferers should receive understanding and continuity of care.

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