What's Hot - National Headache Foundation

January/February 2005 • Number 142
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In This Issue
What’s Hot in
Headache Research__ 1
Case Studies in
Headache__________ 5
News Briefs ________ 6
Ask the Pharmacist __ 8
Book Review:
The Essential Patient
Handbook__________ 9
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Educational Material ____ 15
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What’s Hot in
Headache Research:
Potential
Therapies for
Migraine, Cluster
and Chronic Daily
Headache
Headache specialists are constantly
searching for new treatments for
headache. To develop new therapies,
however, researchers must understand
the mechanisms of the disorders
themselves. This is then translated
into treatments that more precisely
target the source of the problem.
The last decade has seen a tremendous
growth both in knowledge and
in new treatments and potential therapies.
To learn more about the hot new
areas of headache research, we spoke
with Stewart Tepper, M.D., Director
of The New England Center for
Headache in Stamford, CT, and author
of Understanding Migraine and Other
Headaches.
Designing for Serotonin
The biggest discoveries in the last
decade were triggered by the finding,
in 1995, of a possible “migraine generator,”
the area of the brain where
migraine may originate (thought to be
the periaqueductal grey and dorsal
raphe nucleus in the brain stem).
When this “switch” is turned on, it
Continued on page 2

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Executive Director
Board of Directors
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© Copyright 2005
This publication discusses a broad range
of headache symptoms, medications, and
treatments in an effort to inform and
educate readers and it is not meant to
substitute your healthcare provider's
advice. Because each patient is different,
your healthcare provider should always
be consulted prior to beginning or
changing any treatment.
Editor
LESLEY REED
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What’s Hot in Headache Research
initiates a chain of reactions that trigger
inflammation of nerves in the coverings
of the brain (or meninges) and the dilating
of blood vessels, and thus to the pain
of migraine.
One of the biggest players in these
events is the neurotransmitter serotonin,
which can be understood as a chemical
that enables communication between
nerves. In this case, it enables the communication
that either turns migraine on
or off.
Contrary to what many people believe,
migraine is not caused by too much or
too little serotonin. Serotonin can both
excite and inhibit nerves, and the role of
serotonin in migraine has to do with an
imbalance that favors one end of the
“One way to think about
medicines to prevent
migraine is that you’re
trying to reduce the
excitability of the brain.”
spectrum over the other. First, it’s important
to know that there are seven classes
of serotonin and that the areas of the
nerves that receive these different classes
are called serotonin receptors.
Dr. Tepper explains: “One way to think
about it is that serotonin is a little bit like
a foot, and the serotonin receptors are
different in terms of the placement of the
foot when you’re driving – so you have
an accelerator, a brake and a clutch, and
the foot operates all three. The serotonin
1 receptors (which are subdivided into
1B, 1D and 1F) are primarily inhibitory.
They’re the brakes that terminate
migraine either in combination or alone.
Serotonin 2 receptors are excitatory, so
they could be the accelerators. Activation
of serotonin 2 is associated with activation
of migraine. It’s possible that
migraine is associated with too much
serotonin 2 activity and not enough serotonin
1 activity. ” (Serotonin is usually
2 National Headache Foundation • January/February 2005
abbreviated as 5-HT after its chemical
name; serotonin 2 receptors are 5-HT2.)
All these receptors provide drug
researchers with targets to stop the chain of
migraine events. They can design drugs that
will prevent the switch that starts migraine
from turning on, or drugs that will turn the
switch off once it’s on. They can design
drugs that will prevent or reverse inflammation,
or drugs that will either prevent the
dilation of blood vessels (vasodilation), or
constrict blood vessels (vasoconstriction)
once they’ve dilated.
For example, a drug that activates the 1B
receptors will cause vasoconstriction, while
activation of the 1D receptors turns off
inflammation and interferes with signals
that send pain messages. All triptans act on
both these receptors.
While vasoconstriction might be helpful
for some migraineurs, it’s a concern for
those at risk for heart disease and stroke.
According to Dr. Tepper, headache
researchers are particularly interested in
finding a serotonin-acting medication that
doesn’t have this effect. To date, though,
experimental medications that targeted 1D
receptors without affecting 1B receptors
have been ineffective.
“The future of serotonin is probably with
the 1F receptors,” Dr. Tepper theorizes. It’s
as yet unknown where the 1F receptors
have their primary activity, but it is known
that they do not vasoconstrict. So far, an
experimental drug that works on 1F receptors
did stop migraines, but it had too many
side effects in laboratory animals. Other
pharmaceutical companies are working on
medications that would block serotonin 2
receptors, which would, in effect, prevent
the “foot” from getting to the “accelerator.”
Preventing Nerve Inflammation
Continued from page 1
The chemical that is most likely to have
neuroinflammatory effects in migraine is
called calcitonin gene-related peptide, or
CGRP. Figuring out how to prevent its
release is another active area in headache
research, and a number of pharmaceutical
companies are currently doing drug trials.
It’s believed that activation of the serotonin
1D receptor may inhibit CGRP.
Botulinum toxin (Botox ® ) also prevents the

elease of CGRP and, according to
Dr. Tepper, it’s likely that this is its
primary mechanism of action in preventing
migraine. European
researchers recently reported on a
study using an intravenous CGRP
antagonist and, says Dr. Tepper, “It
worked very well in terminating
acute migraine.”
CGRP is not only a neuroinflammatory
chemical, but it’s also the
most potent vasodilator the body
makes. So, says Dr. Tepper, “if you
can either block CGRP or prevent its
release, you’ll have a combination of
preventing inflammation and preventing
vasodilation.”
Targeting Cluster
The central generator for cluster was
also discovered several years ago. It
lies in the hypothalamus, which is
the area of the brain that regulates
sleep cycles. This helps to explain
the cyclical nature of cluster
headaches.
The most intriguing area of new
research for cluster is being pursued
in Italy and Belgium. Physicians in
both countries have done studies in
which radiofrequency stimulators are
surgically inserted into the hypothalamus
in patients with very difficult
to treat cluster headache. So far, the
stimulator has been reported to be a
success – when the stimulator is
turned on, cluster headaches stop,
and when the stimulator is turned
off, cluster comes back. However,
researchers are concerned because
one of the Belgian patients died due
to a hemorrhage related to the
surgery, a complication that has been
reported in stimulator operations for
Parkinson’s and other neurological
illnesses.
Dr. Tepper says, “There is a move
afoot to do these operations somewhere
in North America. It’s a
designer treatment for very difficult
to treat cluster headaches, because
you put the stimulator right where
the headache generator is. It’s very
exciting, but there’s some anxiety
about it as well.”
According to Dr. Tepper, the only
new acute pharmaceutical treatment
that’s being studied for cluster is
called civamide, which is a derivative
of capsaicin, the active ingredient
in chili peppers. Researchers are
particularly interested in civamide
because it does not constrict blood
vessels. Since some cluster patients
who are smokers develop early coronary
disease, they need to avoid triptans,
which constrict blood vessels.
Helping the Migraine Brain
Convert Energy
Migraine brains tend to be hyperexcitable,
meaning the neurons fire too
easily, setting off the events that lead
to migraine. “One way to think about
medicines to prevent migraine,” says
Dr. Tepper, “is that you’re trying to
reduce the excitability of the brain.”
One possible source of this hyperexcitability
is that the neurons in the
brains of some migraine patients
have a problem metabolizing energy.
Their brain nerves have a tendency
to over-fire as a response
to the inadequate regeneration of
energy.
Certain vitamins help with energy
conversion. Riboflavin (B-2) has
already been shown to reduce the
incidence of migraines in some people.
More recently, attention has
Radiofrequency stimula-
tors are “a designer
treatment for very diffi-
cult to treat cluster head-
aches, because you put
the stimulator right
where the headache
generator is.”
turned to Coenzyme Q10, or CoQ10,
which is already used to treat certain
forms of neurological abnormalities
related to energy conversion. A successful
but small study was done in
Europe with an intravenous dose of
100 mg., 3 times a day, of a new, noncommercially
available form of
CoQ10. More studies need to be
done, but for patients who want natural
remedies, both B-2 and CoQ10
show promise.
The Hunt for Genes
Researchers are also hot on the trail
of genes related to headache. They
already know that familial hemiplegic
migraine can have a genetic basic.
Three genes that cause this form of
headache have already been mapped,
and two of them are coded for the calcium
channel. Calcium channels are
the gates that allow calcium to go in
and out of nerve cells so that there’s a
regulation of the total amount. These
gates also regulate the positive and
negative charges inside and outside
nerve cells.
“There’s a very complicated relationship
between the charge that’s
inside and out, the kind of ions that
are flowing in and out, and how
nerves fire and what their level of
Continued on page 4
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3

What’s Hot in Headache Research Continued from page 3
excitability is,” explains Dr. Tepper.
“If you have a genetic abnormality
that doesn’t allow you to regulate
that flow and allows too much calcium
into the cells, the nerves fire too
easily and you get ferocious, disabling
forms of migraines and other
neurological disorders.”
The big interest in pre-
venting chronic daily
headache and frequent
migraine is currently
with botulinum toxin
type A.
The forms of calcium channels
that are abnormal in familial hemiplegic
migraine are called the PQ
channels. Because PQ channels are
spread throughout the body, they
cannot be blocked without creating
toxicity. Researchers are looking at
other steps in the pathways that activate
calcium channels and trying to
create drugs that will safely modulate
the receptors that turn the channels
on and off.
Calcium channel abnormalities
have been linked to a variety of neurological
disorders, including degenerative
neurological conditions, certain
kinds of epilepsy, and susceptibility
to changes in the brain with
head injuries. The question now is
whether abnormal channels could
also cause other forms of migraine.
Research is being done to determine
if calcium channel dysfunction is at
play in migraine with aura. Some
pharmaceutical companies are creating
gene banks with the genes
of migraine patients. Finally,
researchers are also looking into
genes that code neurotransmitters,
particularly serotonin.
Stopping the Spread of Aura
It is now known that aura is caused
by an excitatory discharge of nerve
cells firing across the brain, which
increases blood flow. This is followed
by a period of decreased
blood flow and nerve activity, called
cortical spreading depression. It is
this activation of nerves that
accounts for the symptoms of aura.
Blocking the spreading depression
may stop aura and perhaps even the
pain of migraine.
The discharge of the nerves is
triggered by glutamate, which is an
excitatory neurotransmitter. Like
serotonin, glutamate has lots of
receptor types. There is evidence
that blocking glutamate NMDA
receptors can prevent or terminate
aura. For the most part, however,
attempts by drug companies to create
NMDA antagonists have created
drugs proven to be too toxic. There
are two drugs currently on the market
that have potential – ketamine
and memantine, which was recently
released for Alzheimer’s.
Other glutamate receptors are also
being researched. A new study of a
drug that blocks glutamate at ampa
kainite receptors showed that it was
not only able to terminate migraines,
but was also of comparable effectiveness
to sumatriptan.
Dr Tepper concludes, “It looks
like glutamate antagonists offer a
potential way of either terminating
or preventing aura, or of terminating
or preventing migraine.”
Botulinum Toxin for Chronic
Daily Headache
The big interest in preventing chronic
daily headache and frequent
migraine is currently with botulinum
toxin type A, or Botox. There are
four regulatory trials that have been
completed on Botox, and the results
will be announced sometime in
January 2005. Three of the trials
studied the effectiveness of Botox
4 National Headache Foundation • January/February 2005
for episodic migraine and one studied
chronic daily headache. If the results
of the regulatory trials are positive,
then the maker of Botox will ask the
Food and Drug Administration for
approval for an indication for
migraine, chronic daily headache or
both.
Dr. Tepper describes his own clinic’s
experience treating chronic daily
headache with Botox in an open label
study (i.e., no placebos were used).
“To be eligible for the study, patients
had to have failures on four or more
preventive agents and, in fact, the
average number of preventive agents
that had failed for these patients was
13.” Of the 100 patients studied,
more than half had a 50% or greater
reduction of their daily headache frequency
and severity within a month
of receiving Botox.
The drug topiramate (Topamax ® )
also shows promise for chronic daily
headache. One placebo-controlled
study that used topiramate vs. placebo
in the treatment of patients with
rebound headache (medication
overuse headache) found that 50 mg.
of topiramate was effective in getting
patients out of rebound and into an
episodic headache pattern.
The Future of Headache Research
In the last decade, our understanding
of migraine, cluster headache and
chronic daily headache has made
huge strides. Medications have followed
quickly and potential new
drugs are constantly in the pipeline.
Research into a variety of anti-seizure
and anti-Alzheimer medications also
show promise in treating headache.
“The pace of development has not
slowed,” says Dr. Tepper, “and so I
hope that the next 10 years will yield
even better news for my patients.”
—Lesley Reed ✦

Case Studies
IN HEADACHE:
Elizabeth Loder, MD, FACP,
Director, Headache and Pain
Management Programs, Spaulding
Rehabilitation Hospital, Boston, MA
THE CASE
A 32-year-old woman was referred by
her primary care doctor to a headache
clinic. She reported a history of “normal
headaches” until four months
before her appointment. At that time
she began to have mild, generalized
headaches that she described as “achy”
and which became more frequent and
intense. In fact, over the last two
months, she has had a constant
headache. No one in her family has a
history of headache problems, although
the occasional blurry vision that she
has experienced since the headaches
began makes her wonder if her problem
is migraine with aura, a condition she
learned about on an online headache
Unsuspected idiopathic
intracranial hyperten-
sion (IIH) is quite com-
mon in patients who seek
help in specialized
headache centers.
information site. A CT scan of her
head showed no abnormalities.
The headache specialist who evaluated
this patient was concerned by the
rapid progression of her headache syndrome,
and wanted to know if the
patient had a history of rapid weight
gain, was on any medications for other
conditions, or had any other unusual
A High Pressure Situation
symptoms. When the patient noted
that she was on tetracycline as treatment
for acne, and occasionally heard
“whooshing sounds” in both ears, the
doctor examined her eyes with an ophthalmoscope,
and then recommended
a lumbar puncture (spinal tap) to help
diagnose her condition. The doctor
also noted that the patient was overweight.
DISCUSSION
This case is a typical presentation of a
condition called idiopathic intracranial
hypertension (IIH), sometimes known as
“pseudotumor cerebri” because its
symptoms and signs can mimic those
seen with brain tumors. This headache
disorder is produced by elevated pressure
of the cerebrospinal fluid, and is
best diagnosed by directly measuring
spinal fluid pressure with a lumbar
puncture. The reason elevated pressures
develop in the absence of a tumor or
other structural cause is not well understood.
The disorder can develop for no
obvious reason, or can be associated
with elevated weight or the use of certain
medications, among them tetracycline.
In this patient’s case, lumbar puncture
showed a clearly elevated cerebrospinal
fluid pressure. The patient was advised
to discontinue tetracycline and was
started on the diuretic medication acetazolamide,
which reduces spinal fluid
formation. She was also advised to lose
weight.
IIH is the most common cause of elevated
cerebrospinal fluid pressure. For
unknown reasons, it is more common in
women during childbearing years, especially
those who are overweight.
Headache is the most common symptom,
present in 90% of cases. Specific
criteria are required to make a diagnosis
of IIH, to avoid missing other serious
causes of increased pressure. These cri-
teria include: 1) signs and symptoms of
increased intracranial pressure; 2)
absence of examination findings that
suggest a specific neurological problem;
3) no deformity, obstruction or displacement
of the ventricular system and
normal test results except for elevated
Timely treatment may
decrease the occurrence
of visual loss.
intracranial pressure on lumbar puncture;
4) normal level of alertness; and 5)
no other cause of increased cerebrospinal
fluid pressure.
In this case the doctor suspected the
diagnosis of IIH because of several features
in the history and because of the
finding of papilledema (swelling of the
optic disc). The “whooshing noises”
and occasional visual disturbances
reported by the patient are common in
IIH and are clues to the diagnosis.
The headache of IIH can resemble
that of almost any other headache disorder.
It can be similar to migraine, with
severe, throbbing pain, nausea and/or
sensitivity to light. In 14% of cases, the
headache is daily and chronic, with few
clues to the diagnosis. For this reason,
unsuspected IIH is quite common in
patients who seek help in specialized
headache centers.
It is important to make a diagnosis of
IIH because timely treatment may
decrease the occurrence of visual loss,
one of the most serious outcomes of the
disorder. Five to ten percent of untreated
patients develop blindness. Once IIH
is diagnosed, patients should be referred
to an ophthalmologist for visual function
testing. The potentially serious
complications of IIH help explain
why this is a high pressure situation
in more ways than one. ✦
1-888-NHF-5552
5

Migraine and
Endometriosis
Linked
Women with endometriosis are
at increased risk of developing
migraines, according to a new
study. Endometriosis is a condition
in which uterine tissue
spreads outside the uterus,
often resulting in abdominal
pain.
Investigators in Italy studied
the presence and characteristics
of headaches in 133 women
with endometriosis, compared
to 166 women without the condition.
Thirty-eight percent of
the women with endometriosis
suffered from migraines, compared
to 15% of those in the
control group. Women with
endometriosis were also more
likely to have migraine with
aura. The average age when
migraines began was five years
earlier in women with
endometriosis.
Migraine with aura may be
associated with high estrogen
levels, which could also contribute
to endometriosis.
Human Reproduction, October
2004 ✦
Oxygen therapy is considered the
safest and most effective treatment
for cluster headache sufferers who
smoke and are at a high risk for coronary
artery disease. A recent study
found that patients in this group may
require a higher flow rate of oxygen
therapy than previously thought.
Typically, 100 percent oxygen
delivered at 7 to 10 liters per minute
through a rebreather (high concentration)
mask is suggested. In the study,
patients who had tried oxygen at the
recommended rate without success
got relief when they received flow
rates of 15 liters per minute. The
study also found that women were
less responsive to oxygen therapy
than men.
In other cluster news, research suggests
that cluster headache often
occurs with a heart defect called
patent foramen ovale (PFO). The
defect is a small hole in the heart that
allows blood to flow from the right to
the left side of the heart without
going through the lungs first. Italian
After two clinical studies found that
Petadolex ® , an extract of butterbur
root, was effective and well tolerated
by adults with migraine, headache
researchers decided to study its
effects on children, for whom there
are fewer pharmaceutical treatments.
The latter study looked at the effects
of butterbur root as a migraine preventive
in 108 children, aged 6 to 17,
who had suffered from migraines for
more than one year, with at least 12
attacks per year.
Children under age 10 received 25mg.
capsules twice per day, while
6 National Headache Foundation • January/February 2005
Cluster Sufferers May Need
to Turn Up the Oxygen Flow
researchers used ultrasound to look
for PFO in 40 people with cluster
headache and 40 without. They found
evidence of PFO in 17 patients with
cluster compared
with 7
in the control
subjects.
Further
studies are
needed to
better understand
the
association
between the
two conditions,
but the
investigators
theorize that
blood that
bypasses the
lungs carries less oxygen than normal
and that poorly oxygenated blood
may trigger cluster headaches.
Neurology, August and October 2004 ✦
Butterbur Root Shows Promise for
Children as Well as Adults
children 10 and over were given two
50-mg. capsules. Eighty-eight percent
of the younger age group and 74% of
the teenagers reported fewer attacks.
The medication was well tolerated by
85% of the 6-9 year olds and 89% of
the 10-17 year olds. The most common
side effect was belching. The
study concluded that butterbur root
extract seems to be an effective, welltolerated
first-choice migraine preventive
for children and teenagers.
Journal of Headache and Pain, April
2004 ✦

Melatonin for
Migraine
Melatonin has long been known to be
involved in regulating the circadian cycle
and is widely used as a sleep aid. Now,
increasing evidence points to a relationship
between melatonin secretion and
headache disorders.
“Altered melatonin levels have been
found in cluster headache, migraine with
and without aura, menstrual migraine,
100%
80%
60%
40%
20%
0%
MELATONIN EFFECTIVENESS IN
MIGRAINE PREVENTION
% reduction in headache frequency
after three months of treatment
50% 75%
25
Patients
8
Patients
and chronic migraine,” according to a
report on the first study to assess melatonin
effectiveness in migraine prevention.
The report’s authors gave 3 mg. of
melatonin, 30 minutes before bedtime, to
32 people with migraine (with or without
aura). After three months of treatment,
25 patients experienced at least a 50%
reduction in headache frequency. Eight
patients had complete headache relief,
seven had more than a 75% reduction in
headache frequency, and ten had a 50-
75% reduction. Melatonin decreased
headache intensity and duration. Overall
use of painkillers and drugs to treat
migraine also decreased.
Neurology, August 2004 ✦
75 -
50%
10
Patients
Can’t afford your headache medications?
Some pharmaceutical
companies make medications available
at no charge to eligible patients.
Chronic Morning Headache May
Signal Other Problems
Waking up with a
headache in the morning
may be more than just a
minor nuisance. Chances
are, if a headache occurs
daily, is present when a
person wakes, remains
for most of the day and
has been occurring for an
extended period of time,
it may be an indicator of
a depressive disorder or
another medical condition.
“It should be noted that
too little attention is
given to the depressive aspects of
chronic pain and its treatment,” said
Seymour Diamond, M.D., executive
chairman of the NHF and director of
the Diamond Headache Clinic in
Chicago, IL. “The physical complaints
dominate the situation so that the
underlying depression tends to be overlooked.”
In a recent online survey conducted
by the NHF, 40% of respondents
reported that the majority of their
headaches occur between 4 a.m. and 8
a.m. and 4 p.m. and 8 p.m. These
headaches usually appear
at regular intervals in relation
to daily life, occurring
on weekends, Sundays and
holidays, or on the first
days of vacation. These
may be the periods of
greatest family stress.
Though headaches may
be a symptom of depression,
there is a chance that
the converse is true – people
with chronic pain may
also suffer from depression
as a symptom of their condition.
Because of the myriad
of possible underlying causes of
headache and depression, it’s important
to understand both conditions and learn
what can be done to treat them.
The availability of effective treatment
options for depression and headache
has increased dramatically. The tricyclic
antidepressants, the selective serotonin
re-uptake inhibitors, and the
monoamine oxidase inhibitors are
agents of choice in the treatment of
headaches associated with depression.
Biofeedback has also been demonstrated
to be useful. ✦
Implant for Migraines Tested
A 47-year-old woman has been the
first patient to be implanted with a
device that delivers electrical impulses
that may relieve intractable
migraine symptoms. The device,
called Synergy and developed by
Medtronic, Inc., sends impulses
through wires tunneled under the
skin to nerves at the base of the
head. It will be tested on 68 patients
to see if the treatment warrants fur-
Find out if you qualify for a patient
assistance program by visiting the
NHF Web site at www.headaches.org
and clicking on Educational
ther investigation. Participants have
suffered from chronic migraines at
least 15 days per month over a threemonth
period.
Migraines are the latest in a growing
list of diseases and disorders
being treated with implantable
devices. The Medtronic study was
approved by the U.S. Food and Drug
Administration. ✦
Resources. There you’ll find a list of
pharmaceutical companies that provide
discounted or free medications
along with contact information. ✦
1-888-NHF-5552
7

Ask the Pharmacist
Rich Wenzel, Pharm.D.
Inpatient Headache Unit, St. Joseph’s Hospital, Chicago, IL
We welcome your medication-related questions for this
column. Address them to “Ask the Pharmacist,” NHF Head Lines,
820 N. Orleans, Suite 217, Chicago, IL 60610-3132, or email
them to NHF1970@headaches.org. Please write “Attn: Ask the
Pharmacist” in the subject line.
When Is a Medication a Failure?
Q. Ever since having a baby I have
been experiencing an average of one
migraine attack per week. For home use,
I was given Migranal ® (dihydroergotamine
nasal spray). Last night I had to
take the Migranal for the first time and
much to my disappointment got little
relief. Is this a drug that takes a couple
of uses before it works? I sometimes
wait until my headache is really bad
before using drugs. Was I just too late in
the headache for the medication to be
effective?
A. In other words, when should an
acute migraine medication be viewed as
a failure? This is an important question.
Unfortunately, there is not a clear
answer. For a variety of reasons, medications
may never relieve a migraine
attack, or just sometimes fail to help
relieve an attack.
There are several actions you can take
to ensure a medication works best.
Many patients, including yourself, often
wait until an attack is full blown before
using a drug, yet we have research
showing that the earlier a migraine
attack is treated, the better the results.
Thus, one of the best ways to optimize a
drug’s effects is to use it as early as possible
in an attack.
Treatment with medications not taken
orally is not always simple. Patients typically
have to learn the proper techniques
for administering injections, but
may not perform this technique properly
while suffering from an attack. Some
nasal sprays, such as Migranal, need to
be assembled immediately prior to use
and then inhaled correctly. Again, while
in the midst of migraine pain, patients
may make an error. Thoroughly educating
yourself about how to use injections,
nasal sprays or any other device is
important.
Assuming patients perform these
actions correctly, when is a medication a
failure? Lack of effect for a single attack
is probably not enough to completely dismiss
a drug. As a general rule, headache
specialists recommend patients treat
between three to five attacks with a particular
drug. If the medication fails to
relieve the attack for the majority of
treatments, then it is time to consider a
different medication. When using this
approach, it is important that patients
have a back-up medication for instances
when the initial drug does not work.
Thus, all migraine patients should have a
minimum of two acute drugs available.
Dihydroergotamine is among the most
effective acute medications we have for
migraine attacks, even attacks that are
“really bad.” Unfortunately, this medication
only comes as a shot and nasal
spray, thus somewhat limiting its use
since most patients prefer tablets. I
would encourage you to treat at least two
more attacks. If it fails those times, too,
then call your healthcare provider.
Daily Ibuprofen Use May Lead to
Rebound Headache
Q. I need to know how much is too
much. My 8-year-old has daily tensiontype
headaches and takes two chewable
Junior Motrin ® (ibuprofen) to relieve the
pain once a day at the onset of headache.
Is this too much and could it cause
rebound headaches? His doctor also has
him on Periactin ® two times daily.
A. The daily or near-daily use of any
acute medications, including ibuprofen,
is a risk factor for the development of
rebound headaches. This topic has been
8 National Headache Foundation • January/February 2005
Letters that are deemed more appropriate for a physician’s
response will be forwarded to the Reader’s Mail department.
Letters may be edited for publication and all names are withheld.
Due to the large volume of letters we receive, not all questions can
be answered.
discussed before in this column, but it is
an important message that merits repeating.
Sadly, millions of people suffer with
treatable, often preventable rebound
headaches.
I do not know the details of your son’s
health, but daily ibuprofen use is not
ideal. Furthermore, daily ibuprofen use
can decrease the effects of Periactin,
which is a reasonable choice as a preventive
agent. Aside from less ibuprofen
use, if Periactin does not help, the dose
could be adjusted or there are alternative
medications such as amitriptyline or
protriptyline.
Please know that children often
respond well to non-drug treatments for
headache. For example, biofeedback or
other relaxation techniques are options
during an attack. The importance of a
headache diary cannot be over-emphasized.
Keep a diary and eliminate any
headache precipitating factors. In this
country, children’s diets often contain
excessive amounts of sugar, caffeine and
other potentially headache-triggering
foods such as hot dogs. If a diary reveals
a pattern between diet and headaches,
changes should be made. Perhaps there
is a relationship between headache and
poor sleep habits, school attendance, or
long hours playing computer games. If
suspected, these issues need to be appropriately
addressed.
Daily headache in children is a difficult
situation that can be caused by a
variety of reasons, not all of which are
treatable with medications. I would
encourage you to seek the help of a
headache specialist.
(Editor’s note: The National Headache
Foundation has free state lists of physician
members, which can be obtained by
calling 1-888-NHF-5552.) ✦

BOOK REVIEW The Essential Patient Handbook: Getting
the Health Care You Need – From Doctors Who Know
By Alan B. Ettinger, M.D. and
Deborah M. Weisbrot, M.D.
Demos Medical Publishing, $19.95
You’ve heard it before – the
importance of coming prepared to
an appointment with your healthcare
provider. But what exactly does
being prepared mean? How do you
know what information will be most
useful to your healthcare provider?
What are the important questions to
ask? When is it appropriate to call
your doctor’s office? And what do
you do if your doctor rushes you or
gives you too little information?
These are just some of the quandaries
answered in this new book by
a husband-and-wife team of doctors.
The book was inspired by Dr.
Deborah Weisbrot’s own confrontation
with the medical system when
she suffered from a life-threatening
A book that demystifies
the medical process and
the doctor-patient rela-
tionship.
illness. After years of being the one
wearing the white coat, she learned
first-hand the challenges of being a
patient and the importance, she
writes, “of communicating effectively
and efficiently with doctors,
preparing information to generate a
complete history, and knowing what
to expect in return.” The result: a
book that demystifies the medical
process and the doctor-patient relationship.
The Essential Patient Handbook
walks readers through each step of
the medical evaluation process,
from developing your own patient
history to important questions to
ask about specific medications.
The book is based on the premise
that you know your body best and
doctors need help in collecting
and organizing the information
that will lead to the most accurate
diagnosis and treatment. The
book is full of useful forms to
complete, from a “History of
Present Illness” to a “Review of
Symptoms,” which consists of
brief questions about each system
of the body.
Once you’ve got your history and
present complaints documented,
Drs. Ettinger and Weisbrot offer
suggestions on how to be prepared
for the doctor’s visit, complete with
a list of questions a healthcare
provider might ask about two dozen
complaints, ranging from dizziness
to pain in the head or neck. For
headache sufferers, knowing the
answers to these questions before a
visit will without a doubt make
diagnosis an easier task.
Drs. Ettinger and Weisbrot
explain what doctors are typically
looking for in each part of a physical
exam and list questions to ask
about specific tests that may be recommended,
questions which most
patients would never know to ask.
Finally, the doctors explain how
healthcare providers put all this
information together to reach a
diagnosis, using as their example a
60-year-old woman with sudden
onset severe headache.
Once the diagnosis is made, Drs.
Ettinger and Weisbrot take readers
through return visits, pointing out
which symptoms to look for with
specific conditions. Valuable chapters
include: “Questions About Your
Diagnosis and When to Get a
Second Opinion,” “If You Do Not
Ask Questions About Your
Medications, You Are Asking for
Trouble,” and “Don’t Compliment a
Doctor Who Will Not Discuss
Complimentary Medicine.” The latter
chapter includes information on
a number of popular herbal products,
including common uses and
even more useful warnings regarding
negative interactions with prescription
drugs or medical conditions.
“Doctors: The Good, the Bad
and the Ugly” and “Feelings You
May Have When You See the
Doctor” address problems that may
come up between patient and
healthcare provider.
Good health care relies on a partnership
between doctor and patient,
which means patients need to be
informed, prepared and empowered.
The Essential Patient Handbook is a
practical and informative guide and
the antidote to the feelings of intimidation
and anxiety that so many
patients experience. This book
belongs on the shelf right next to
other essential home references.
(The Essential Patient Handbook,
can be purchased through the NHF’s
Web site www.headaches.org.)
—Lesley Reed ✦
1-888-NHF-5552
9

Reader’s Mail
We welcome your letters; please limit them to one page.
We reserve the right to edit them. Send your letters to:
Reader’s Mail, NHF, 820 N. Orleans, Suite 217,
Chicago, IL 60610-3132 or NHF1970@headaches.org.
Hypertension and Headache
Q. I was diagnosed with migraine
syndrome after a hospital admission
with aura, inability to speak and
blood pressure of 200/99. Until this
experience I was a person who had
never had blood pressure above 120.
That was three years ago when I was
65 years old. I was put on one aspirin
a day and since have had only two
slight auras and no other symptoms,
except an onset of high blood pressure
that my internist is attempting to
control with medications, all of
which give me side effects I cannot
tolerate.
My blood pressure fluctuates from
very high to very low during a
migraine attack. My doctors don’t
believe they are related, but one doesn’t
happen without the other. They
are treating me for heart trouble with
migraines on the side.
My question: could this high blood
pressure be related to the migraine
syndrome, and if so what can I do to
overcome it? My diet is a healthy one
and I exercise 4-5 times a week. I do
not want to be on medications, as I
have always been very sensitive to
drugs, but of late I can’t see an alternative.
Is there one?
A. Hypertension, defined as blood
pressure above 140/90, can occur
with a severe headache and can
sometimes present as a medical
emergency with changes in a
patient’s mental status and vision. In
the most severe cases, kidney dysfunction
can also occur. Migraine
itself is not a likely cause of hypertension,
although sometimes patients
with severe pain can experience periodic
increases in their blood pressure.
In addition to diet, exercise and
weight loss, relaxation/biofeedback
training is an important component
of treating migraine in hypertensive
patients. A blood-pressure lowering
medication should be initiated in most
patients with persistent hypertension
to prevent the development of coronary
artery disease and stroke. In
migraine patients, a good choice for
an anti-hypertensive medication would
be one that helps prevent migraine as
well as treats hypertension. These
include beta-blockers, calcium-channel
blockers, and angiotensin-receptor
blockers (ARB’s).
Patients should discuss their treatment
with their primary care physician.
Unfortunately, hypertension is
usually treated with medications for
the remainder of one’s lifetime due to
the high risk of cardiovascular disease
if the blood pressure is not controlled.
George R. Nissan, D.O.
Diamond Headache Clinic
Chicago, IL
Hemiplegic Migraine Often Begins
in Childhood
Q. My 8-year-old son has had two
“episodes” in the last six months that
sound like they may be hemiplegic
migraines. Both times he was asleep
and then awoke with a scream. When
we got to his room, he could not sit
up, stand or walk (he was floppy) and
could not see at all. These episodes
lasted approximately 30 minutes and
then his motor skills and sight
returned completely. He then complained
of a throbbing headache right
behind his eyes. He wanted to vomit
but didn’t (we gave him Tylenol ® ). He
did, however, throw up prior to us getting
to his room. He recovered completely
and the next day, you would
never know it had happened.
We were calling these seizures, but
never witnessed any convulsions. Is it
possible for an 8-year-old boy who
never has regular headaches to suffer
from this kind of migraine?
10 National Headache Foundation • January/February 2005
A. Hemiplegic migraine, both the
sporadic and familial (genetic) forms,
typically begins in childhood and
often ceases in adulthood. If there is
no first- or second-degree relative
with the disorder, then it is called
sporadic hemiplegic migraine.
Changes in consciousness ranging
from confusion to coma are common
in childhood cases. Sometimes the
hemiplegia may be part of the aura
and last less than one hour or may
last for days or weeks. The aura is
usually followed by a headache. The
symptoms are fully reversible and
include some degree of motor weakness
plus visual, sensory, and/or
speech disturbances. The onset of
paralysis may be abrupt and simulate
a stroke or seizure.
There is also another variant of
migraine called confusional migraine.
It is characterized by a typical aura,
headache and confusion. The confusion
can include the inability to maintain
speech and other motor activities.
It is definitely possible for an 8year-old
boy to suffer from sporadic
or familial hemiplegic migraine or
confusional migraine. It is important
to rule out a more serious disorder
including stroke, or seizure disorder.
A CT scan or MRI of the brain should
be included as part of the neurologic
workup of a patient with suspected
migraine variants.
George R. Nissan, D.O.
Diamond Headache Clinic
Chicago, IL
What is SUNCT Syndrome?
Q. I was originally diagnosed with
cluster headaches, but recently a neurologist
suggested that my headaches
are SUNCT Syndrome. Could you
give me information on this condition
and treatment options?

A. SUNCT Syndrome is a headache
syndrome characterized by short-lasting
attacks of unilateral pain occurring
around the eye or supraorbitally
(SUNCT stands for short-lasting, unilateral,
neuralgiform headache
attacks with conjunctival injection
and tearing). The attacks usually last
5 to 240 seconds in duration. The
pain is usually very sharp, but may
throb, and is usually associated with
significant redness and tearing in the
eye. Attacks are very frequent and
can occur from 3 to 200 times in a
day.
This is different from cluster
headache in that the attacks are
shorter in duration and more frequent
in occurrence. Cluster
headache is also a severe pain in or
around the eye associated with eye
redness and tearing, but it lasts 15 to
180 minutes and usually occurs from
once up to 8 times in a day.
Treatment of SUNCT has been historically
difficult. There are no clear-cut
treatment options but some response
to antiseizure drugs, such as lamotrigine,
gabapentin and topiramate,
has been reported.
Nancy Juopperi, D.O.
Michigan Institute for
Neurological Disorders
Farmington Hills, MI
Barometric Pressure Changes
Triggering Vestibular Migraine
Q. We live in Florida. Every time
the rainy season comes I have problems.
I have extreme pressure in my
ears and my equilibrium is off. I
don’t get true vertigo because my
head does not spin. I do not usually
get nausea. I get weak. I get
headaches. I have neck and shoulder
stiffness. I get truly frustrated.
Last year my doctor thought
migraine medications would help.
Well they did not. I went to an eye
specialist. He said no problems with
the eyes. We know it has to do with
pressure – the minute the barometric
pressure changes I am not well. I
have also traveled and when in high
altitudes I have similar problems.
I have had sinus surgery (which we
thought might be the cause). I was
better for about two years, but am
worse again. The ENT said my nose
is clear. I have taken Sudafed ® , antimotion
medications and Tylenol. I
even tried earplugs. Any suggestions?
A. You bring up a very interesting
problem: vestibular migraine. When
you experience ear pressure and poor
equilibrium you may be experiencing
a migraine aura. This is then followed
by headache and neck and
shoulder stiffness typical of the
headache phase of migraine. You may
also get nausea but not usually. You
already know some of your triggers:
changes in barometric pressure (with
the rainy season) and altitude change.
These are typical migraine triggers.
Vestibular migraine is really just
being recognized as an entity of
symptoms involving the central and
peripheral balance systems in
patients who experience migraine.
Symptoms may or may not be associated
with headache at the time of
their occurrence. Often the use of
migraine preventives is the best treatment.
These may include antiseizure
drugs and blood pressure medication.
You would need to be on the medication
for a minimum of six weeks at
the appropriate dose to see an effect.
Nancy Juopperi, D.O.
Michigan Institute for
Neurological Disorders
Farmington Hills, MI
Worried About Slow Heart Rate
Q. My son suffers from migraines
almost every day. Do you know if the
headaches affect vital signs in serious
ways? His pulse has been extremely
low during his headache, 45-47;
blood pressure is 133/88-138/84. I am
extremely worried and wish to have
him examined by a doctor who knows
what he’s doing.
A. By all means have your son
examined by a physician. You can
Reader’s Mail
begin with your primary care
provider first and see where that
leads. To sum up your problem, your
son has a near daily headache with
bradycardia (a heart rate less than
60 bpm). This can happen for a variety
of reasons including benign
headache, such as migraine or cluster
headache, when the autonomic
brain, which controls heart rate and
blood pressure, is affected. However,
slow heart rate with severe daily
headache can be seen for more serious
reasons and these should be
ruled out by a physical exam, lab
tests and brain imaging before you
are satisfied with a diagnosis of
benign headache.
Nancy Juopperi, D.O.
Michigan Institute for
Neurological Disorders
Farmington Hills, MI
Clonidine for Migraine
Prevention
Q. I have had migraines since I was
38. I have tried all kinds of treatment,
yet I still struggle with them.
Last week, my local doctor prescribed
something new: clonidine in
the 1-mg. strength. The directions are
to take 1-3 per day as needed. I take
one at a time when I think a
headache will be starting. I also take
Maxalt ® for migraines. Since I started
the clonidine, I’ve reduced how
much Maxalt I take so I don’t use it
daily anymore.
I have two questions for you:
Question 1: Is there anything you
can point out about clonidine use for
treating migraines?
Question 2: What is your current
position on Botox ® injections for
headache treatment?
A. Clonidine is sometimes used as a
preventive treatment for migraine as
well as for detoxification from narcotics
to reduce withdrawal symptoms.
It is an anti-hypertensive agent
Continued on page 12
1-888-NHF-5552
11

Reader’s Mail
that reduces sympathetic tone.
Sympathetic tone is a constant wave
of nerve impulses generated in the
autonomic nervous system (which
controls all inner organs, blood vessels,
glands, etc.). Increased sympathetic
tone causes rapid heartbeat,
sweating, diarrhea, nervousness and
other symptoms typically experienced
during the withdrawal from
narcotics.
Botox is used for both migraine
and tension-type headaches. The
results are variable, but in some
studies efficacy has reached up to
60%. In my opinion, Botox can be
effective, but I also believe that it has
been misused for inappropriate indications
and used more frequently
than recommended.
George J. Urban, M.D.
Diamond Headache Clinic
Chicago, IL
Continued from page 11
Preventing Early Morning
Headaches
Q. I read an article on early morning
headaches, but unfortunately it didn’t
say how to prevent them. Are they
preventable?
A. Early morning headaches per se
are preventable only be preventing
the migraines themselves. The most
common time of day for migraine to
begin is in the early morning hours
due to the combination of lowered
pain thresholds and increased adrenalin
levels. Since sleep is critical for
migraine patients, a good night’s
sleep, starting and ending at around
the same time each day, tends to be
best.
Good sleep hygiene is also important.
If your partner says you snore
or stop breathing at night, then a visit
to your healthcare provider and/or a
NHF IS RAFFLING A BRAND NEW 2005 BMW MINI COOPER
12 National Headache Foundation • January/February 2005
as the first prize at the annual fund raising benefit Saturday, April 30, 2005 (base
list price approximately $21,000). The winner also has a choice of a $20,000 U.S.
savings bond or $10,000 cash. Second prize is a Holland America Line Seven-
Day Cruise while third place winner will receive a Sony Cyber-shot ® Digital
Camera. The winning ticket will be drawn at the annual dinner, but the winner need
not be present to win. If you would like to purchase a ticket for one of these great
prizes, simply complete the form below and mail it with your check (or credit card
information) for $100 per ticket, made payable to the National Headache
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sleep lab may be in order. If you are
overweight, then the first order of
business may be to lose some pounds.
This often helps with snoring and
sleep apnea. Being overweight has
also been linked to an increased tendency
for migraine to become chronic.
Caffeine avoidance is very important
since it can not only disrupt the
quality of sleep, but is one of the
leading causes of medication overuse
headache characterized by headaches
occurring in the early morning hours.
Finally, if you are taking a preventive
medication for your headaches,
ask your healthcare professional if it
might be more effective against morning
migraines if you took the medicine
prior to going to bed. This is sometimes
the case.
Frederick Freitag, D.O.
Diamond Headache Clinic
Chicago, IL ✦
Name _______________________________________________________ Address __________________________________________________
City, State, Zip ____________________________________________________________ Daytime Phone (____) __________________________
Credit Card VISA ___ MasterCard ___ Amex ___ Discover ___ Card # ______________________________ Expiration Date _____________
Cardholder Name _____________________________________________ Signature __________________________________________________
All taxes and shipping charges are the responsibility of the winner. NHF makes no warranties of merchantability or fitness of purpose.

Support Group
Program Update
Dear NHF Readers:
By now the New Year is in full swing and most of us
are remembering to write 2005 on our checks. Even
though it’s a new year, it doesn’t necessarily mean that
our headaches have taken a hiatus or disappeared with
2004.
I am certain that you have already noticed that this
issue is again filled with a tremendous amount of information,
from what’s new in headache research to
answers to a remarkable range of reader’s questions.
The simple fact is that every issue of NHF Head Lines
is also representative of the quality of our support
group meetings.
For instance, the Parma, OH group closed out 2004
with What the Otolaryngologist “Nose” About Sinus
Headaches, presented by an NHF physician member.
The Chicago, IL group finished their year by hosting
two massage therapists who demonstrated trigger point
therapy as an alternative approach to muscle tension
relief. One of our newer groups, Green Bay, WI, provided
an introduction to self-hypnosis and relaxation techniques
as a method to decrease the impact stress has on
all of our lives. The group in Boston, MA hosted a
Headache Survivors Roundtable, a discussion group
NHF Support Group
Meeting Information
ALABAMA
Eufaula-Dothan: HealthSouth
Rehabilitation Center
Contact: Trent Mathis, 334-616-0482
ARKANSAS
Jonesboro: St. Bernards Medical Center
Contact: Healthline, 1-888-STB-4555
FLORIDA
Palm Beach County: City of Atlantis,
City Chambers Room
Cosponsored by JFK Medical Center
Contact: Beau Solomon, 561-964-4371
Margate: Northwest Medical Center
Contact: 1-888-256-7720 or Sari
Rotenberg, PT/MBA, at 954-978-4180
Niceville: Twin Cities Hospital
Wellness Center
Contact: Susan Webster, 850-897-0542
NEW GROUP!
St. Petersburg: St. Anthony’s Hospital
Contact: 727-825-1100, or Michael A.
Franklin, MD at 727-820-7701
GEORGIA
Augusta: Walton Rehabilitation Hospital-
Walton Headache Center
Contact: Walton Headache Center,
706-823-5252
GERMANY
NEW GROUP!
Landstuhl: Landstuhl Regional Medical Ctr.
Contact: Anothay Sirithongdy, email:
anothay.sirithongdy@ind.amedd.army.mil, or
Susan Barron at 1-888-643-5552
IDAHO
Boise: St. Luke’s Regional Medical Ctr.
Contact: Mark Filicetti, RPh, 208-381-
3649 or 208-376-3781
ILLINOIS
Chicago: Cenacle Retreat & Conference Ctr.
Contact: Susan Barron, 312-274-2653
focusing on management methods. And the Kearney, NE
group invited a professor, who is also the husband of an
attendee, to present A Spouse’s Point of View.
I could list even more discussion topics or guest speakers
who have presented at groups around the country, but I suspect
you understand that you are likely to discover a wealth
of valuable information and tools at all our NHF support
group meetings. You are already learning a great deal from
this newsletter—attending a support group makes it easier
for you to apply the information presented here to your daily
life!
As you look over your New Year’s resolutions, why not add
one more to the list: “Find headache support.” Call 1-888-
NHF-5552 and we’ll provide you with directions to the location
of an existing support group or we can work together to
establish a new group in your area.
Sincerely,
Susan Barron
NHF Support Group and Membership Services Coordinator
Peoria: OSF Saint Francis Medical Center
Contact: Alicia Freidman at 309-681-1822
or Robert Glazeski, Ph.D. at 309-683-7373
INDIANA
Greensburg: Decatur County Memorial
Hospital
Contact: Diane McKinney, RN, BSN at
812-663-1163 or Joan Mokanyk at
812-663-2085
KANSAS
Lawrence: Lawrence Memorial Hospital
Contact: Susan Barron at 1-888-643-5552
LOUISIANA
Shreveport: Promise Specialty Hospital
Contact: Donnie Laborde or Patty,
318-377-1185
MASSACHUSETTS
Boston: Beth Israel Deaconess
Learning Center (BIDMC)
Contact: BIDMC staff, 617-667-9100,
or Margo, 617-632-8483
1-888-NHF-5552
13

MICHIGAN
Madison Heights: St. John Oakland
Hospital/Education Center
Contact: Kimberly Bialik, PhD, 248-967-
7988
MISSOURI
Springfield:The Headache Care Center
Contact: Debbie Arnold, PT, or
Carol Matthews, CFNP, 417-890-7888
NEBRASKA
NEW GROUP!
Kearney: Platte Valley Medical Group
Contact: Jody Girard, RN, 308-237-7099
NEW YORK
New York City: Beth Israel Medical Ctr.
Phillips Ambulatory Care Ctr.
Contact: Dr. Marc Goloff, 212-844-8934
Utica: St. Elizabeth Hospital
Contact: Sue Cooper, 315-798-8404,
or Cynthia DeTraglia, RN
OHIO
Cincinnati: Tri-Health Hospitals-
Bethesda North Hospital,
co-sponsored by the Headache Center at
the Balance Disorder Institute
Contact: Jan Welsh, 513-385-5000
Parma: Parma Health Education Center,
co-sponsored by Parma Community
General Hospital
Contact: Sharon M. Bilek, 216-642-8506,
or Debbie Sternen, PT at 216-682-0413
PENNSYLVANIA
Pittsburgh: University of Pittsburgh
The Headache Center
Contact: Barb Wintermantel,
412-647-9494
Johnstown: Conemaugh Health System/
John P. Murtha Neuroscience and Pain
Institute
Contact: Jan Goodard, RN at
1-814-269-5288 or 1-800-587-5875
RHODE ISLAND
Warwick: Neuro Health Building
Contact: Brenda Bullinger, LCSW,
401-732-3332 ext.133
TENNESSEE
Chattanooga: Specialist in Pain Management
Contact: Steven Clifton, PA-C,
423-698-0850
Memphis: Germantown Hospital
Contact: Judy McGinnis, RN,
901-753-4093
TEXAS
Dallas: Baylor University Medical
Center/ Truett Hospital
Contact: 800-4-BAYLOR
(1-800-422-9567)
Houston: Memorial-Hermann
Southwest Hospital
Contact: Ken Vales, 713-660-9140,
or e-mail houtexas@juno.com
VIRGINIA
NEW GROUP!
Fredericksburg: Mary Washington
Hospital
Contact: Torita Proctor, 540-374-8223
WISCONSIN
NEW GROUP!
Green Bay: A Woman’s Place Education
Center
Contact: Bonnie Groessl, NP, 920-405-
1452
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 at
sbarron@headaches.org.✦
Be sure to check out the
latest online survey at
www.headaches.org.
Each monthly survey features a
new topic, so log on and weigh in.
14 National Headache Foundation • January/February 2005
National Headache
Foundation
Vision Statement
The National Headache
Foundation works to create an
environment in which headaches
are viewed as a legitimate
biological disease, so that sufferers
can confidently receive
successful treatment from
knowledgeable healthcare
practitioners.
Mission Statement
The National Headache
Foundation is a nonprofit
organization dedicated to serving
headache sufferers, their
families, and the healthcare
practitioners who treat them;
promoting research into
headache causes and treatments;
and educating the public
to the fact that headaches are a
legitimate biological disease
and sufferers should receive
understanding and continuity of
care.
www.headaches.org

NHF is proud to announce that The
Standards of Care for Headache
Diagnosis and Treatment is newly
updated. These guidelines establish a
set of standards to ensure comprehensive
and consistent delivery of medical
care for headache sufferers, setting
forth criteria for diagnosis, treatment
and hospitalization. The 100-page doc-
Educational Materials Order Form
BROCHURES (Prices include postage & handling. For 11-20 brochures add $2.
For 21–75, add $3. For more than 75 brochures, please call for information.)
Price Quantity Price
The Complete Headache Slide Chart
Lists 21 different types of headaches, their symptoms, precipitating factors, treatment & prevention.
The Headache Handbook
$2.00
8-page brochure with information on causes, types of headaches, & available treatments.
About Headaches
$1.50
16-page in-depth look at headaches, tips on when to seek medical advice, treatments, etc.
About Stress Management
$1.75
16-page brochure discusses stress management techniques and how to locate help for managing stress.
About Relaxation Techniques
$1.75
16-page step-by-step instructions for relaxation methods such as meditation, deep-breathing & visualization.
About Over-the-Counter Medications
$1.75
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
$1.75
8-page brochure on when to seek help for a headache problem, keeping a diary, & working with a doctor.
Headache: A Guide to Prevention & Treatment
$1.50
6-page guide covers different types of headache; drug & non-drug therapy; when & how to discuss headache
symptoms with your doctor.
Alternative Therapies & Headache Care
$1.50
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
$3.00
19-page brochure explains the relationship between caffeine & headache; lists caffeine contents of foods & beverages.
Keeping Track of Your Migraine Patient Diary
$1.50
36-page logbook has detailed calendars to keep track of headaches & associated symptoms.
NEW! Ten Tips on When to See Your Healthcare Provider for Headache
$1.50
Two-sided easy reference card lists warning signs for serious headaches & questions to ask to get
the most from your medical visit.
NEW! Talking to Your Headache Doctor
$1.50
12-page guide to enhancing communication with your doctor to get the best information & help in
developing an effective treatment plan.
NEW! A Patient’s Guide to Headaches
$1.50
16-page brochure on types of headache, with a focus on migraine including dietary triggers,
the phases of migraine, medications, & alternative treatments.
$1.50
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Address
City State Zip
Daytime Phone
STANDARDS OF CARE NEWLY UPDATED
ument contains the latest information
on medications used to treat headache
and incorporates material from the US
Headache Consortium Guidelines.
Written for healthcare providers, it
would make a great gift for your
provider, or purchase one for yourself.
To obtain a copy, please send a check or
money order for $12, made payable to
the National Headache Foundation, to:
National Headache Foundation,
Department SOC, 820 N. Orleans,
#217, Chicago, IL 60610-3132. Credit
card orders will also be accepted by
phone, fax or mail. Be sure to include
your card type, number and expiration
date. ✦
TOTAL
Outside of North America, please add $3.00 postage.
Please make checks payable to
National Headache Foundation
or include credit card information.
Mail completed forms to
National Headache Foundation
820 N. Orleans, Suite 217
Chicago, IL 60610-3132.
1-888-NHF-555215

Return your subscription
with payment to:
NATIONAL HEADACHE
FOUNDATION
820 N. Orleans, Suite 217
Chicago, IL 60610-3132
NHF
Does Not Sell,
Rent or Otherwise Make
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All trademarked names
are the property of
their respective owners.
NATIONAL HEADACHE FOUNDATION
820 N. Orleans, Suite 217
Chicago, IL 60610-3132
ADDRESS SERVICE REQUESTED
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National Headache Foundation - Your #1 Source for Headache Help
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the real comfort your newsletter provides.”
If you’re not already an NHF subscriber, sign up today! Subscribers receive:
• NHF Head Lines – An award-winning bimonthly publication
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NHF was founded in 1970 as a non-profit organization dedicated to three major goals:
• 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;
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P.S. I am including a contribution to support NHF programs that aid headache sufferers nationwide. The amount of my tax
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16 National Headache Foundation • January/February 2005
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• 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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