Q. - National Headache Foundation

May/June 2005 • Number 144
NHF Head Lines
NATIONAL HEADACHE FOUNDATION - YOUR # 1 SOURCE FOR HEADACHE HELP www.headaches.org
An Award-Winning
Bimonthly Publication
of the National
Headache Foundation
In This Issue
Safety of Headache
Medications ________ 1
Evolution & the Origin
of Migraine ________ 4
News Briefs ________ 6
Ask the Pharmacist __ 8
Case Studies
in Headache ________ 9
Readers’ Mail ________ 10
Headache Research
Summit ______________ 13
Support Group Listings__ 14
Educational Materials __ 15
Subscribe to
NHF Head Lines ______ 16
Is Your
Headache
Medication
Safe?
By George R. Nissan, D.O., Diamond
Headache Clinic, Chicago, Illinois
Today in the United States, more
than 10,000 different prescription
drugs are available to consumers. It is
estimated that nearly 3.2 billion outpatient
prescriptions will be dispensed
in this country alone in 2005. Most
adults take at least one prescription or
other medicine in any given week,
while many take several medications.
Medications have altered the course
of many previously untreatable diseases,
and they have dramatically
improved the quality of the lives of
patients suffering from migraine, tension-type
and cluster headaches. In
the past year, however, the overall
safety of commonly used prescription
medications has been an issue of public
concern due to the withdrawal of
the arthritis and pain medication rofecoxib
(Vioxx ® ) by Merck & Co., Inc.
on September 30, 2004. There has
also been public concern over the
safety of long-term use of other
arthritis and pain medications including
celecoxib (Celebrex ® ), valdecoxib
(Bextra ® ) and naproxen (Naprosyn ® ,
Aleve ® ).
Since headache sufferers are among
those millions of Americans who regularly
take medications, including the
anti-inflammatories under question,
drug safety is an important issue to
address.
Continued on page 2

Founded in 1970 as a 501(c)(3)
charitable organization.
Robert S. Kunkel, M.D.
President
Arthur H. Elkind, M.D.
Vice President
Edmond J. Bergeron
Treasurer
R. Michael Gallagher, D.O.
Secretary
Seymour Diamond, M.D.
Executive Chairman
Suzanne Simons
Executive Director
Board of Directors
Margaret E. Azarian
Edmond J. Bergeron
Roger Cady, M.D.
Carolyn Climaco
Elaine J. Diamond
Seymour Diamond, M.D.
Arthur H. Elkind, M.D.
Frederick G. Freitag, D.O.
R. Michael Gallagher, D.O.
Lydia B. Krueger
Robert S. Kunkel, M.D.
John Lassiter
Lisa K. Mannix, M.D.
Iris Poure
Lynn Stegner
Janet Zlatoff-Mirsky
Editorial Board
Arthur H. Elkind, M.D., Chair
Frederick G. Freitag, D.O.
R. Michael Gallagher, D.O.
NHF HEAD LINES
PUBLISHED BY:
National Headache Foundation
820 N. Orleans, Suite 217
Chicago, IL 60610-3132
Toll-free 1-888-NHF-5552
© 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
Newsletter Graphic and Printing Production
HOBRATH GROUP LLC
Is Your Headache Medication Safe?
Understanding the Vioxx Controversy
For many years, over-the-counter and prescription
anti-inflammatory medications
have been used effectively to treat acute
pain, including migraine, although they
were not specifically approved by the
Food and Drug Administration (FDA) for
this use. On April 1, 2004, Vioxx became
the first anti-inflammatory medication to
receive FDA approval for the acute treatment
of migraine headache. Two large
placebo-controlled clinical studies had
shown Vioxx to be clinically superior to
placebo in treating migraine headaches.
The advantage of using this form of
anti-inflammatory medicine was that it
was thought to lead to less harm on the
gastrointestinal tract than older nonsteroidal
anti-inflammatory medications
(NSAIDs). It is well known that chronic
use of NSAIDs can lead to inflammation
of the esophagus and stomach, as well as
to stomach and duodenal ulcers. The
COX-2 inhibitors Vioxx, Celebrex and
Bextra offered a safer gastrointestinal profile
for patients suffering from chronic
arthritis and other pain.
The decision to withdraw Vioxx from
the pharmaceutical market was based on
two pivotal studies, the first of which was
the Vioxx Gastrointestinal Outcomes
Research (VIGOR) trial, originally submitted
to the FDA in June 2000. The study
showed an increased risk of cardiovascular
(CV) events, including heart attacks and
strokes, in patients taking Vioxx compared
to patients taking naproxen. In April 2002,
the FDA implemented labeling changes
about the increased risk of CV events to
reflect the findings from the VIGOR
study. Then, a second long-term study
called the Adenomatous Polyp Prevention
on Vioxx (APPROVe) trial was halted in
2004 because of concern over the
increased risk of CV events in patients
taking Vioxx compared to those taking
placebo. It is important to note, however,
that the risk of CV events was very small
in each of the studies, but overall, patients
taking the drug chronically faced a higher
risk of heart attacks than those taking
placebo.
2 National Headache Foundation • May/June 2005
On December 23, 2004, the FDA issued a
public health advisory regarding the use of
NSAIDs and announced that it would reevaluate
all prevention studies that involved
Celebrex and Bextra due to the possibility of
an increased risk of heart attacks and
strokes. Results of a long-term (up to three
years) study of naproxen were revealed in
the same month, which showed a possible
increase in CV events compared to placebo.
So far, long-term studies of Celebrex have
not conclusively linked it to an increased
risk of CV events.
Concerns about the FDA’s handling of
oversight of these drugs are leading to
important changes in the Administration. A
new Drug Safety Oversight Board was created
in February 2005 to increase input from
independent medical experts and patient
advocacy groups when analyzing the risks
and benefits of medications. The hope is that
the various offices of the FDA will have a
new checks-and-balances system that will
prevent any study information from being
withheld from healthcare providers and the
public. It will also encourage long-term safety
studies of currently available medications.
Good News for Triptans
Continued from page 1
The study found that those
patients taking triptans
were not at higher risk of
death or developing strokes
or heart attacks.
With the plethora of information that has
been made available to the public, it is easy
to understand why there is so much confusion
regarding the safety profiles of currently
available medications in the United States.
Headache specialists, however, are often
confronted with the need to weigh the risks
of a potential medication against the benefits
of improving the quality of life for patients
with chronic migraine.

Fortunately, the safety of the triptans,
particularly sumatriptan
(Imitrex ® ), is well known. The introduction
of Imitrex into the U.S. marketplace
in the early 1990’s revolutionized
the acute treatment of migraine
and cluster headaches. There are now
seven FDA-approved triptans available
in the U.S., the most recent one of
which is eletriptan (Relpax ® ). Because
of long-term and large studies done on
the triptans, headache specialists know
how to prescribe them and avoid any
serious side effects.
In particular, we know that the triptans
should never be used in patients
with a previous history of heart
attacks, strokes or uncontrolled hypertension.
This is due to the “constrictive”
properties of the triptans–during
migraines the blood vessels on the
outer portion of the brain are dilated
(opened) in response to pain and the
triptans help to constrict the vessels.
The serotonin receptors that the triptans
attach to are located on both brain
vessels and the coronary arteries. As a
result, in a patient with known cardiovascular
disease, there is the possibility
of constricting the cardiac vessels,
which could theoretically lead to a
heart attack.
For triptans, the recent news has
been good. A large study was published
in the journal Neurology in
February 2004, in which over 13,600
migraine patients who were prescribed
triptans were compared with nearly
50,000 patients who were not prescribed
triptans. The study found that
those patients taking triptans were not
at higher risk of death or developing
strokes or heart attacks. In fact, the
larger number of people who did not
use triptans actually had an increased
risk of stroke and heart disease compared
to the group of patients who
used triptans. This study helps confirm
the safety of selecting patients who are
at low risk of cardiac events when
starting a triptan. It is believed that the
“chest tightening” that occasionally
occurs when taking triptans is actually
due to spasm of the esophagus rather
than a cardiovascular problem.
Preventive Medications Have Long
Safety Record
The long-term safety data of the
headache preventive medications, such
as tricyclic antidepressants, beta-blockers,
calcium channel blockers and anticonvulsants,
are well known due to the
length of time these drugs have been
available in the U.S. for the treatment
of depression, hypertension and epilepsy.
Tricyclic antidepressants such as
amitriptyline (Elavil ® ), nortriptyline
(Pamelor ® ), and doxepin (Sinequan ® )
are associated with several side effects
including dry mouth, constipation,
blurry vision and heart palpitations,
but overall the medications are well
tolerated and have been in use for over
30 years. Caution should be advised in
patients who have a history of glaucoma,
cardiac disease, seizure disorder or
an enlarged prostate gland.
Anticonvulsants such as valproic
acid (Depakote ® ) and topiramate (Topamax
® ) are the most recent medications
approved by the FDA for the prevention
of migraine. Depakote was
Most of the commonly
available prescription
headache treatments
are safe to use even for
long periods.
given approval in the 1990’s after clinical
trials showed excellent headache
prevention results. The main side
effects associated with the use of
Depakote are weight gain, abdominal
pain, elevated liver enzymes, anemia
and rash. A complete blood count and
liver enzymes should be drawn prior to
starting Depakote and should be monitored
periodically.
Topamax received FDA approval for
the prevention of migraine in 2004
after several clinical trials showed it to
be effective in preventing migraine
when taken at doses lower than 200
mg. This is significantly lower than
doses taken to prevent seizures, which
can be greater than 400 mg in some
instances. The main side effects associated
with the use of Topamax are
tingling sensations, memory loss,
weight loss and changes in taste. It is
also recommended that baseline blood
bicarbonate levels be checked prior to
starting Topamax and periodically
afterwards, since in rare cases acidosis
can occur in the blood. Also, patients
with a history of kidney stones should
not take Topamax, since regular use of
Topamax can lead to repeat occurrence
of kidney stones in these
patients.
The Answer, in Most Cases, Is Yes
Most of the commonly available prescription
headache treatments are safe
to use even for long periods. The longterm
effects of common anti-inflammatory
medications such as ibuprofen
and naproxen are still being researched
and the results will be published in the
near future. A study released in
February 2005 instilled greater confidence
in the overall safety of Celebrex
and Bextra, especially in patients with
low cardiac risks who are not using
large amounts of the medications. An
FDA panel also reached the conclusion
that COX-2 inhibitors were safe
in a population with low risks of cardiovascular
problems, and even considered
the possibility of re-introducing
Vioxx to select patients with low
CV risks. This probably not will happen,
though, until further long-term
studies are evaluated.
The safety data of the triptans is
very encouraging in patients who have
low risks for cardiac events. The preventive
medications, though associated
with several side effects, appear to be
safe for chronic prevention with
appropriate management by a healthcare
provider. Finally, the FDA is
undergoing changes in its infrastructure
to decrease the probability that
the problems that occurred with the
release of results of the Vioxx studies
will not be repeated in the future. ✦
1-888-NHF-5552
3

Human Evolution and the Origin of Migraine
By Trishul Devineni, Ph.D., Research
Psychologist, Conemaugh Memorial
Medical Center, Johnstown, PA
Why me? All too many migraine sufferers
have asked this question of
themselves and others without finding
any satisfying answer. Doctors and
researchers continue to unravel the
mystery of what goes wrong in the
brain before, during and after a
migraine attack, but the question of
why so many people suffer frequent
and severe headache has eluded
scientists.
There are three parts to this puzzle:
(1) Why is migraine such a common
affliction; (2) Why do so many more
women than men bear the burden of
this disease; and (3) Why does
migraine appear to be growing more
common in Western industrialized
countries such as the United States?
Medical science does not have
enough knowledge about all the causes
of migraine to confidently answer
these questions, but we do have clues.
Migraine is at least three times more
common in women than in men, and
women tend to have worse symptoms
related to hormonal issues. Additionally,
we know that the risk for having
migraines runs strongly in family
members. This risk is likely to be carried
on many genes that interact in
complex ways, but geneticists have yet
to map out these intricate relationships
for the most common types of
migraine.
Recently, scientists have been considering
a very different and intriguing
explanation for the prevalence of
migraine. Based on the concepts of
4 National Headache Foundation • May/June 2005
evolution, some headache specialists
have been developing theories that
migraine may be the result of evolutionary
forces.
Evolutionary Medicine
The field of evolutionary biology has
been around for well over a century
since the watershed discoveries of the
British naturalist, Charles Darwin.
Since then, many biologists and scientists
have shaped our understanding of
how the body and its functions originally
came into being via the process
of natural selection, which says that
traits that confer the most “fitness”
will be favored over time. Sometimes
known as Darwinian Medicine, this
young but exciting area of biology
has the potential to pull together all the
disparate areas of medical research
and clinical practice into a single,
coherent body of scientific knowledge.
The theories and explanations proposed
by evolutionary medical
researchers are mostly speculation as
they have not undergone thorough scientific
testing—but they are not outside
the realm of possibility. Evolutionary
theorists recognize it is essential
to study the detailed workings of
Some headache special-
ists have been developing
theories that migraine
may be the result of
evolutionary forces.
the brain to advance our understanding
of the disease process and to develop
specialized treatments. But a description
of the brain mechanism, no matter
how detailed, cannot completely
explain the high incidence of
migraine, which is not caused by an
outside force such as an infection, but
is carried by genes. Why, given the
pain and suffering of migraine, does
this gene continue to be passed on?
Evolution and Migraine
Using the concepts of evolution, doctors
and scientists throughout the
world have recently begun to tackle
the difficult question of what might
have first brought about the existence
of migraine. There are a number of
theories. One is that migraine could be
a defense mechanism; i.e., that the
pain of migraine forces sufferers to
withdraw from or avoid situations that
provoke headache, situations that
might in some way be dangerous. For
migraineurs this typically involves
environments with high levels of sensory
or physical stimuli.
It has been speculated that the
migraineur’s heightened sensitivity to
smells may be the brain’s attempt to
stop the entry of toxins into the brain.
A low threshold for nausea and vomiting
may be a mechanism to eliminate
toxins ingested in foods. As Dr.
Elizabeth Loder, Director of the
Headache and Pain Management
Programs at Boston’s Spaulding
Rehabilitation Hospital, wrote in the
journal Cephalalgia, “Even a small
chance of protection from life-threatening
dangers—decreased brain perfusion,
predators, tumors, environmental
toxins—could make the evolutionary
cost of headache, painful as it is,
cheap in comparison with the alternatives.”
Another theory addresses the higher
prevalence of migraine among women
and could be called the hunter-gatherer
theory. The long history of human evolution
stretches over at least two million
years and took place in environments
far different from the modern
industrialized society we are all familiar
with today. Much of the evolutionary
development of our species took
place when humans lived in small,
tightly knit, band-level groups similar
to the few remaining hunter-gatherer
societies, not in the large and complex
environment of modern nation-states.

The migraineur’s height-
ened sensitivity to smells
may be the brain’s
attempt to stop the entry
of toxins into the brain.
Within this scenario, certain features
linked to what we now call migraine
may have been selected in greater
abundance in females than males
because they gave a greater biological
“fitness” advantage to women according
to their particular needs. This
hypothesis is based on the different
roles that men and women had through
most of history—males served primarily
as hunters, while females were
focused on the gathering or foraging of
food stuffs and on child-rearing and
social cohesion.
In this environment, a man who was
hunting a wild animal would have been
seriously disadvantaged in carrying out
his essential function if, for example,
he was endowed with the common
migraine-related traits of avoidance of
novel or threatening situations. Women,
on the other hand, would be strongly
advantaged by the possession of the
behavioral features associated with
migraine such as heightened sensitivity
to environmental and sensory cues.
Such a male-female distribution of the
migrainous pattern would presumably
assure that children and other family
members’ safety and well-being were
tended to, that there was awareness of
potential food sources, and that harmonious
group relations were maintained.
The process of evolution that may
have produced the male-female distribution
of migraine genes and the associated
behavioral traits throughout the
world’s population is slow and imperfect.
It takes thousands of generations
to evolve. The fact that our bodies are
left vulnerable to certain diseased
states, such as the symptoms of
migraine, may be an unfortunate “side
effect” of this natural legacy. This
could have happened either by accident
or by design as the migraineur’s behavioral
traits made it more likely that our
remote ancestors would survive and
reproduce, thus carrying into modern
generations the same genes that
increased these beneficial odds in the
original hunter-gatherer environment.
Is Migraine an Imperfect
Adaptation?
These possible explanations for the
origin of migraine leave us with the
surprising question of whether
migraine is in fact a disease or an
imperfect behavioral adaptation
shaped by forces of natural selection
for the environment in which our
human ancestors evolved. These ideas
are still only theoretical speculations
and need scientific testing to support
or refute them. Still, the implications
for our understanding of where
migraine came from, what it really is,
and why so many people have it, is
worthy of consideration.
In the remote past of our species,
bodily conditions that may result in
great pain and suffering by people living
in the modern world may have
produced some beneficial effects in
addition to the unpleasant experiences
that we know are associated, perhaps
only incidentally, with the migraine
syndrome. This possibility, should it
win scientific support, would account
for why the condition is so common
throughout the world’s population and
is particularly burdensome to women.
Migraine in Modern Society
Many more people are diagnosed with
migraine in the 21st century than were
in the past. It is unclear, however,
whether migraine was inadequately
diagnosed in the past or whether it is
actually becoming more common in
Western, industrialized nations such as
the U.S. If the latter is true, then one
possible explanation follows from the
idea that a genetic disposition that
already exists in much of the population
would express itself more in envi-
ronments that present ample triggering
events. In this case, chronic stressful situations
produced by unstable and rapidly
changing social environments disrupt
complex biological systems such as the
reproductive hormonal cycle in women.
Many human traits exposed throughout
evolutionary history to adaptive
pressures and shaped by natural selection
are designed to function by a “hairtrigger”
mechanism. Similar to a smoke
detector, they “react” quickly to perceived
threats; otherwise they would not
be reliable enough to increase the likelihood
of survival and thus be passed on
to the next generation. With this comes
the risk of “false alarms”—in this case,
many migrainous episodes occurring in
the absence of a real threat or biological
need. Our complex modern society, with
its excessive stimuli and high levels of
stress, provides many such instances of
recurring but non-threatening stimulation
that might set off the migraineur’s
exquisitely sensitive environmental
response system.
It is probably difficult to see the individual
“benefit” of migraine to someone
possessing the trait in our modern-day
environment. But this brief look into the
possible evolutionary reasons for the
disorder does speak to the complex connections
between basic, evolved human
traits and the environments in which
they are expressed. This new and more
complete understanding of migraine
could potentially lead to better management
strategies for what is less a conquerable
disease and more a common
and largely “normal” organization of the
human nervous system, particularly that
possessed by females.
None of this downplays the enormous
negative impact of migraine. The
immense suffering experienced by the
migraineur is undeniable. It simply
points out that not all seemingly deleterious
states of the human condition lend
themselves to straightforward explanation
and eradication by the biomedical
disease model. It also reminds us that
we share with our ancestors many complex
human traits, including those
linked to modern diseases such as
migraine, via the elaborate legacy of
development called evolution. ✦
1-888-NHF-5552
5

Butterbur Found Effective
in Preventing Migraine
Butterbur, an extract derived from
the petasites hybridus root, has
been used for medicinal purposes,
including migraine, since ancient
times. Now a study by an international
research team has found that
ancient wisdom regarding the natural
remedy is sound.
Researchers gave 245 migraine
patients two capsules daily of a 75mg
dose of butterbur, a 50-mg
dose, or a placebo for four months.
The 50-mg dose showed no significant
effect, but the 75-mg dose
reduced headache frequency overall
by 48%. It reduced headache frequency
by 50% or more in over
two-thirds of the patients.
“Our study shows that butterbur
really does reduce the frequency of
migraine attacks, so it’s a welcome
addition to the therapeutic arsenal
we have available to combat
migraine,” said Dr. Richard B.
Lipton from the Albert Einstein
College of Medicine of Yeshiva
University.
Side effects of butterbur were
infrequent. The most commonly
reported problems were gastrointestinal
in nature, primarily burping.
Dr. Lipton stressed the importance
of using a safe product, as
raw butterbur root contains toxic
chemicals that are filtered out during
the manufacturing process. The
study used the brand Petadolex ® ,
manufactured by Weber & Weber.
Neurology December 28, 2004 ✦
6 National Headache Foundation • May/June 2005
ZOMIG ® NASAL SPRAY WORKS
QUICKLY ON MIGRAINES
Zomig (zolmitriptan) Nasal Spray
provides significant migraine
headache relief and pain-free rates
in as little as 15-30 minutes,
according to a new study. Given its
fast action, patients who used this
form of triptan were also able to
return to normal activities more
quickly.
Over 1,000 patients were given
either the 5-mg nasal spray or
placebo to treat a migraine attack.
Significantly more patients using
Zomig Nasal Spray experienced
total symptom relief (defined as
freedom from pain, nausea, and
light sensitivity)—14.5% as compared
to 5.1% on the placebo.
Headache response (reduction in
pain) at two hours was 66.2% with
Zomig vs. 35.0% with placebo.
Finally, patients treated with
Zomig reported a reduced impact
on their activities after two hours
Eleven major drug manufacturers
have launched a new discount card to
help uninsured Americans save
money on prescription drugs. Dubbed
the Together Rx Access Card, the
program could potentially benefit
80% of the 45 million Americans
who don’t have prescription drug
coverage. Individuals who meet the
income and age requirements can
save 25% to 40% on more than 275
brand-name prescription drugs and a
host of generic drugs.
Eight of the pharmaceutical companies
created the Together Rx card for
low-income seniors in 2003. Since
then, nearly 1.5 million people have
enrolled and saved more than $600
million on prescription drugs.
and were more likely to be pain-free
after 24 hours.
The most commonly reported side
effect was unusual taste.
Headache January 2005 ✦
DRUGMAKERS CREATE NEW DISCOUNT
PROGRAM FOR UNINSURED
To find out if you qualify and to
enroll, visit www.Together-
RxAccess.com or call 800-444-
4106. Enrollment forms are also
available at participating pharmacies
and doctor’s offices. ✦
Check out the NHF’s Online
Store at www.headaches.org.
We’ve expanded the bookstore and
added CDs! There are over 60 books
that will help you become better
informed about your headaches and
gain control over them. The CDs offer
a range of music for relaxation as
well as CDs with instructions on
guided imagery to help diminish or
prevent stress and headaches. ✦

NATIONAL HEADACHE AWARENESS WEEK IS JUNE 5-11
Join with the National
Headache Foundation
for National Headache
Awareness Week June 5-
11. Let’s educate the
public about the impact
and severity of
headache, and support
the more than 45 million
sufferers of this neurobiological
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
Migraine as a risk factor for stroke
continues to be studied—and confirmed.
Canadian researchers correlated
data from 14 studies that examined
the association between
migraine and the risk of
ischemic stroke. They
found that the average
risk of stroke for all
migraineurs was 2.16
times that of people
without migraine.
Individuals with
migraine with aura had 2.27 times the
risk factor of that of non-migraineurs,
while those who have migraine without
aura had 1.83 times the risk factor of
that of non-migraineurs. Adding oral
contraceptives increased the risk of
stroke approximately eight times.
A separate study—the Stroke
Prevention in Young Women study—
found that the type of aura is also a
factor. Aura associated with visual loss
(as opposed to seeing spots or lines)
more than doubled the risk of stroke.
“Any person, regardless of age, with
new treatments
available.
This year’s theme,
Stop Migraines
Before They Stop
You, reminds
headache sufferers
that, by effectively
managing migraine
with the acute and
preventive medications
currently
available, migraine
doesn’t have to
diminish quality of
life. Get diagnosed,
get treated and get
on with your life.
There are a number
of activities that you can plan
locally. For example, host a headache
screening day, organize a public edu-
cation program to discuss headache
causes and treatments, schedule a
brown bag lunch program, work with
a radio station to speak about
headache, contact area newspapers to
do a story on headache, or offer free
literature.
The NHF is happy to assist you
with your program and will include
your event in the master calendar of
activities sent to media nationwide.
The NHF can also provide posters
and educational materials to help
make every event a success. Visit the
NHF Web site at www.headaches.org
to fill out the activity listing form
and materials order form. And call
NHF at 1-888-NHF-5552 if you have
questions or need assistance.
Together, we can bring nationwide
attention to the problem of
headache. ✦
New Results on Migraine and Stroke Risk
new onset of visual symptoms with
headache should not assume this is
associated with migraine,” lead investigator
Dr. Steven Kittner of the
University of Maryland, Baltimore
County, cautioned.
While these studies confirm the link,
specialists stress that the added risks
are not as bad as they sound, because
the risk of stroke is low to start with—
about two in 100,000 people. “There is
no doubt that there is a relationship
between migraine and stroke, and that
the risk is greater with aura migraines
and women on the pill,” said Dr. Ann
MacGregor, director of clinical
research at the City of London
Migraine Clinic and acting general secretary
of the International Headache
Society. “We do not want people with
migraine to think they are at high risk
of having a stroke.... The absolute numbers
are very small. You are far more
likely to get a stroke from smoking.
That’s the big risk factor.”
Migraineurs, particularly those who
experience aura, smoke or take birth
control pills, should consider talking
to their healthcare providers about risk
factors for stroke and lifestyle modifications
they can make to decrease
them. Weight loss, exercise, smoking
cessation and modification of oral
contraceptive use can all help to
reduce the risk. ✦
Signs to seek immediate care from
your doctor or emergency room:
• An unusually painful migraine or
headache
• Numbness or paralysis, if it hasn’t
been present with a migraine before
• Loss of consciousness, which hasn’t
occurred during previous migraines
• Severe, unremitting migraine for
more than 72 hours
• New onset of visual symptoms with
headache
Always remember to consult your doctor
when migraine patterns change, as
symptoms exhibited during migraine
attacks can also be the symptoms of
other conditions.
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.
Limits on Sumatriptan for Cluster
a Matter of Debate
Q. I’m a cluster sufferer and often
use injectable sumatriptan pens several
times daily during my worst
bouts. It’s the only thing that works.
But my local pharmacy and my
insurance company give me grief
about the amount of sumatriptan I
use, meaning I have to pay out of my
own pocket. Am I using too much
sumatriptan?
A. I suspect the limits of sumatriptan
imposed by your insurance company
are based on recommendations
for migraine treatment, not cluster
treatment. I am not aware of any
research that definitively states how
much sumatriptan is too much for
your condition, and this important
question is often a matter of debate
among headache specialists.
Furthermore, the severe, rapid
pain that characterizes cluster
attacks is well known, but we do not
know what risks, if any, exist with
repeated sumatriptan use. This raises
ethical questions regarding the
withholding of an effective medication
from individuals in extreme
pain.
There are several actions you can
take to help yourself. Though the
sumatriptan autoinjector (“pen”) is
designed to be easy to use, it delivers
6 mg of medication per dose.
Many cluster patients can obtain
relief with only 2 mg or 3 mg and do
not need the whole 6 mg. I would
encourage you to ask for vials of
sumatriptan at your local pharmacy,
instead of the pen. You will need to
learn how to draw up medication
8 National Headache Foundation • May/June 2005
into syringes, but you will then
have the option of administering a
smaller but still effective dose. As a
result, you’ll have two or three
doses at your disposal.
Once you puncture the vial, it’s
important that you dispose of it
after 24 hours, even if some medication
remains, to avoid contamination.
Since cluster patients generally
have multiple daily attacks,
leftover medication is a rare occurrence.
You can also ask your physician
to write a letter of appeal to your
insurance company, explaining
your condition, your treatment and
the lack of information regarding
limits on sumatriptan. Once educated,
your insurance company
should be more willing to assist
you.
Finally, you do not state whether
you take any medication to prevent
your cluster attacks. This is another
option to reduce the frequency
of your cluster headaches, thereby
reducing your need for sumatriptan.
GelStat ® Promising, But Needs
More Study
Q. I heard of a treatment for
migraines called GelStat. Can you
tell me anything about this drug?
A. GelStat is a newer, over-thecounter
combination product that
contains several ingredients,
notably feverfew, a substance that
has been shown beneficial for some
migraine sufferers. GelStat is taken
sublingually (under the tongue),
which may allow the drug to be
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.
absorbed into the bloodstream more
rapidly.
I am aware of only one study with
GelStat, which examined the product’s
effectiveness in only 30 people.
Since migraine affects 28 million
individuals, drawing conclusions
from such a small study may not be
wise, regardless of the study’s positive
results. More research (which
the company is currently conducting)
is needed before the proper role
of this product in migraine therapy
is understood. ✦
Find out whether migraine
prevention is right for you.
Check out
“Migraine Prevention:
A Guide to the Latest
Methods and Treatments”
at www.headaches.org under
Educational Resources.
This educational module will
bring you the most current
information on prevention.
Then take the quiz to
learn whether prevention might
be right for you.
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 2005
annual benefit raffle. ✦

Case Studies
IN HEADACHE:
David M. Biondi, D.O.
Director, Headache Management
Program, Spaulding Rehabilitation
Hospital and Instructor in Neurology,
Harvard Medical School
THE CASE
James is a 65-year-old man who woke
one day with severe pain on the right
side of his face. The pain, which
seemed to tear through his face like a
lightning bolt, lasted only a few seconds,
but then returned. For weeks, he
had been experiencing dozens of these
excruciating electrical shock-like
attacks. James could no longer shave
the right side of his face, brush his
teeth, chew foods or talk for any
length of time without triggering the
repeated jolts of pain. He could not
even tolerate a light breeze blowing
across his face. James’ dentist could
find no problems with his teeth or jaw
and over-the-counter pain relievers
provided no benefit.
DISCUSSION
James has a condition called trigeminal
neuralgia, also known as tic
douloureux, which is one of several
facial neuralgias. Neuralgia is a type
of pain that is caused by nerve injury
or irritation.
The trigeminal nerve provides all
sensation, including pain, to the face,
teeth, mouth, sinuses, meninges (coverings
of the brain) and blood vessels
of the head. There are two trigeminal
nerves, one on each side of the head,
and each has three branches supplying
the upper, middle and lower parts of
the face. The pain of trigeminal neuralgia
is felt in the territory of one or
Trigeminal Neuralgia
more branches of this nerve. Most
commonly, it affects the middle part of
the face and upper teeth. Trigeminal
neuralgia almost always occurs on one
side of the face, but in rare cases it can
affect both sides at the same time.
The pain of trigeminal neuralgia is
severe and, as James described, sharp,
jolting and shock-like. The duration of
each painful jab is very brief, lasting
only seconds, but people with trigeminal
neuralgia have numerous attacks
each day, sometimes hundreds. A
longer-lasting deep, burning or dull
pain may persist in between the lightening-like
jolts of episodic pain. The
pain can be triggered by chewing, talking,
shaving, brushing teeth, light
touch, and cold air or wind blowing on
the face. Remissions lasting weeks or
months can occur, but the pain usually
returns.
Trigeminal neuralgia most commonly
affects people over 60 years old, but
may begin at any age. Many cases of
trigeminal neuralgia have no easily
identifiable cause. When trigeminal
neuralgia occurs in a young person,
multiple sclerosis or other diseases of
the nerves can be possible causes. A
traumatic injury to the face or problems
with the teeth can also cause
trigeminal neuralgia. It can sometimes
occur after dental work or a tooth
extraction. Some cases are believed to
occur deep in the skull as a result of
pressure placed on the trigeminal
nerve by one or more blood vessels.
The intense pain of trigeminal neuralgia
is disabling because it occurs
frequently and rapidly without warning.
People who have this condition
may become depressed and frustrated,
and live in fear of the next attack.
They will often avoid washing, eating,
or talking because even these normal
activities of daily living can trigger the
pain.
Fortunately, there are many medical,
anesthetic and surgical treatment
options available for the management
of trigeminal neuralgia. Some of the
medications that might be prescribed
The duration of each
painful jab is very brief,
lasting only seconds, but
people with trigeminal
neuralgia have numer-
ous attacks each day,
sometimes hundreds.
alone or in combination to control
trigeminal neuralgia pain are carbamazepine,
phenytoin, baclofen, divalproex
sodium, gabapentin, amitriptyline
and clonazepam. Other medications
are also available. Pain relieving
procedures include anesthetic or neurolytic
trigeminal nerve blocks (blocking
pain signals that are coming from
the trigeminal nerve), radiofrequency
thermal neurolysis (using a focused
microwave to heat certain portions of
the trigeminal nerve as a way to partially
block its ability to carry pain signals),
and gamma knife radiosurgery
(using a focused radiation beam to heat
the root of the trigeminal nerve). While
these procedures may only provide partial
or temporary pain relief in some
cases, they can improve responsiveness
to medications. Cases of trigeminal
neuralgia that do not respond to these
less invasive treatments may need
surgery to expose and remove or cushion
blood vessels that may be compressing
the trigeminal nerve. ✦
1-888-NHF-5552
9

Readers’ Mail
We welcome your letters; please limit them to one page.
We reserve the right to edit them. Send your letters to:
Readers’ Mail, NHF, 820 N. Orleans, Suite 217,
Chicago, IL 60610-3132 or NHF1970@headaches.org.
The Search for a Cure
Q. As a migraine sufferer, I have
read everything I could find on
headaches. I believe my migraines are
caused by a number of factors including
hormonal fluctuations, fatigue,
stress and digestive problems.
Recently I discovered a report called
“An Innovative New Treatment for
Migraine” by Dr. Sergey A. Dzugan.
He reported 100% success by using
natural therapies to restore balance to
the hormonal, sympathetic and
parasympathetic systems, the pineal
gland and intestinal absorption.
There is also a plastic surgeon in
my area advertising surgical treatment
for migraine headaches, based on the
theory that if Botox ® injections in the
forehead muscles give temporary
relief, then removing tiny muscles in
the back of the neck and temple area
can permanently relieve migraines.
What do you think?
A. Most folks are constantly looking
for definitive causes and treatments
for their headaches. Unfortunately,
most headaches are a chronic condition
that can be adequately managed,
but not cured. I would be very wary of
anyone who boasts of total cessation
of headache.
There is some scientific evidence
that Botox may be effective for the
prevention of migraine headache;
however, the data is modest at best in
double-blinded studies. As for other
alternative approaches, there have
been small studies that showed some
efficacy with melatonin, Coenzyme
Q10 and riboflavin (B2) for migraine
prevention. There also have been several
studies showing benefit with
feverfew and butterbur root. We must
remember that these supplements are
not FDA-regulated and may contain
various chemicals. “Natural” does
not necessarily mean it is safe, and
10 National Headache Foundation • May/June 2005
many of our prescribed medications
are derived from natural products.
Loretta Mueller, D.O.
University Headache Center
Moorestown, NJ
Benign Intracranial Hypertension
Q. I suffer with benign intracranial
hypertension (BIH). I have had carbon
monoxide poisoning and was wondering
if this could have caused the condition.
I am partially blind as a result
of BIH. Any advice would be greatly
appreciated.
A. Benign intracranial hypertension,
or pseudotumor cerebri, is a disorder
of elevated spinal fluid pressure, usually
occurring in women of childbearing
years. A headache is the primary
presenting symptom, but patients can
experience double vision and visual
loss due to paralysis of the sixth cranial
nerve. More than 90% of BIH
patients are obese and are women. The
mean age at the time of diagnosis is 32
years.
The likelihood of carbon monoxide
poisoning causing the condition is
very low. There are several medical
disorders that are more likely to be
associated with BIH including
Addison’s disease, hypoparathyroidism,
arterio-venous malformations,
and diseases that obstruct drainage of
the veins. It has also been reported following
the use of excessive vitamin A
or the antibiotic tetracycline.
George R. Nissan, D.O.
Diamond Headache Clinic
Chicago, IL
Computer Screen Triggering
Migraines
Q. I’m convinced that my migraine
headaches (with symptoms of blind-
ness, light auras, dizziness, vomiting
and pain, in that order) are
caused by looking at my computer
display, which is a CRT (cathode
ray tube) computer monitor. I’m
thinking that flat panel display technology
may be a solution because of
its improved fidelity, resolution and
refresh frequency rate. Has anyone
researched this?
A. I don’t know of any specific
studies on the various aspects of the
effects of the CRT on triggering
migraine. Migraine is an inherited
condition so the CRT is not the
“cause,” but certainly many patients
feel it is commonly a trigger of
attacks. Patients with migraine tend
to be adversely affected by visual
flickering, strobe effects, glare, etc.
I strongly suspect that reactions to
computer displays are an individual
matter and that there are no guidelines
that will fit all migraineurs. It
would be a matter of trying various
monitors to see which is less irritating.
I agree that a flat screen with
LCD (liquid crystal display) would
probably be more tolerable.
Robert Kunkel, M.D.
Cleveland Clinic Foundation
Cleveland, OH
Migraines Stopped During
Chemotherapy
Q. Although I have a 39-year history
of debilitating migraines, for
the majority of the time that I was
on an aggressive chemotherapy
regime my migraines stopped altogether.
Because I was given a mix
of chemo medications and adjuvant
chemical therapies, it would be
impossible for me to know if it were
a single drug or the combination
that brought about such relief. Now
that I have been off the chemo for

an entire year, I can tell it is out of my
system because the migraines have
returned. Frankly, cancer was a whole
lot easier to deal with than frequent
migraines!
Perhaps others have encountered
this in all the research that is done,
but I’ve never heard or read anything
about it. Has any research been done
in this area?
A. There have been occasional
reports such as yours, but I don’t
think there have been any studies
done on the effects of chemotherapeutic
agents on migraine. Drugs such as
leuprolide and tamoxifen, which are
used to control some cancers, have
been reported to be helpful in some
individuals with migraine. Their benefit
seems to be due to suppression of
female hormones.
Robert Kunkel, M.D.
Cleveland Clinic Foundation
Cleveland, OH
Migraine Associated with Anxiety
and Depression
Q. Have any studies been done that
link migraine and anxiety disorders?
A. Migraine and especially chronic
daily headaches are highly associated
with depression and anxiety. The reason
for this link is unknown. In many
cases, headaches are the result of frequent
anxiety attacks or a permanent
anxious state; in other cases, patients
react to frequent migraine with
increased anxiety. There are certain
neurotransmitters implicated in both
anxiety and migraine, which may be
why they are comorbid disorders. In
addition, antidepressants and tranquilizers
used to treat anxiety can also
be very effective in the treatment of
migraine.
George J. Urban, M.D.
Diamond Headache Clinic
Chicago, IL
Sudden Explosive Headache
Worrisome
Q. Monday of last week, I was talking
to someone when I felt a slight
pressure in my neck and face.
Approximately one minute later I felt
like someone had hit the back of my
head with a baseball bat. Then my
head felt 10 times its normal size. The
pressure was unbelievable—it felt like
my whole head was going to explode.
By the time I got to the doctors 10-
15 minutes later, I could not walk
unaided. I was crying from the
extreme pain. I had double vision,
could not stand light, and was sick to
my stomach. My blood pressure was
185/108. I had all the tests at the hospital
and they all came back negative.
I was given morphine four times and
it still didn’t help. Then they gave me
Toradol® by IV and that made the
headache manageable. Wednesday
night, I was tired so I lay down and
instantly felt the baseball bat to the
back of the head and all other symptoms,
along with a blood pressure of
189/108. At the hospital they said it
was a severe migraine.
I have migraines with aura, but
never the pain like these two attacks. I
am wondering if this is unusual for a
migraine. I talked to people who are
migraine sufferers and none of them
have had a migraine like this. Since
my attacks, I have felt tired and
drugged out, with a loss of appetite.
Some food tastes different.
I’d really be interested in your perspective
on these strange headaches.
Two in three days is too much for me!
A. Sudden onset of an explosive
headache can be indicative of
intracranial bleeding from an
aneurysm. Therefore, every effort
should be made to rule out this cause.
Incapacitating, explosive headache
associated with high blood pressure
also can be a result of pheochromocytoma
(a tumor associated with hyper-
Readers’ Mail
tension). Talk to your healthcare
provider about these possibilities.
George J. Urban, M.D.
Diamond Headache Clinic
Chicago, IL
Is Daily Pain Part of Migraine?
Q. I have had migraines for about 40
years now and they are getting better, but
over the last six or seven years I have
developed a pain in the temple area and
around my eye on the left side. I have
been told that this is a normal migraine
thing. It just came on and now I rarely
have a day without this pain, which
varies from mild to migraine status.
Is this a part of a migraine? If so, is
there anything I can do to alleviate this
problem?
A. A chronic daily headache with
migraine qualities such as you describe
may be related to your previous
migraines. This is also called “transformed
migraine.”
Whenever there is a new pattern or a
change in the characteristics of
headaches, a physician must use his or
her clinical judgment as to whether or
not a further neurologic work-up is
required. We are not sure why episodic
migraine “transforms” into a daily
headache pattern, but it may sometimes
be due to mild head trauma, a brief
viral illness, or overuse of caffeine or
analgesic medications.
Standard daily preventive medications
such as a low dose of older antidepressant
drugs, blood pressure pills, or antiseizure
medications may work effectively
in treating this headache condition.
Seeking the help of a headache specialist
would be advised.
Loretta Mueller, D.O.
University Headache Center
Moorestown, NJ
(Editor’s note: The National Headache
Foundation has free state lists of physician
members, which can be obtained by
calling 1-888-NHF-5552.)
Continued on page 12
1-888-NHF-5552
11

Readers’ Mail
Answers from a Specialist in
Hormone-Related Headache
Anne H. Calhoun, M.D.
University Headache Clinic
University of North Carolina at
Chapel Hill
Endometriosis and
Migraines
Q. My 29-year-old daughter is
having surgery to treat
endometriosis. She has been a
migraine patient for over 10
years. What correlation
between endometriosis and
migraines have you observed, if
any? Hormones definitely play
a heavy role in her migraines, as
well as in the pain from
endometriosis.
A. In my own practice, 17% of
my menstrual migraine patients
carry a diagnosis of endometriosis.
I suspect that figure
underestimates the true prevalence,
however, as many women
have endometriosis for years
before their chronic pelvic pain
is diagnosed. In a recent study
from the National Institutes of
Health, 57-75% of young
women with chronic pelvic pain
had migraine.
You are quite right that hormones
play a role in both menstrual-related
migraine and
endometriosis. In fact, I consider
a co-diagnosis of endometriosis
to be an indication to
use hormonal prevention for
both conditions. One option is
to use continuous active-pillonly
oral contraceptives for
extended periods of time. It is
important to pick a pill with a
relatively heavy progestin component
and an adequate overall
potency in order to block ovula-
Continued from page 11
12 National Headache Foundation • May/June 2005
tion. Your daughter’s healthcare
provider could determine if she’s a
good candidate for this type of
therapy.
Impact of Hysterectomies on
Migraine
Q. I would like to know if women
who have hysterectomies notice a
decrease or increase in their incidence
of migraine occurrence.
And is there any relationship to
whether or not the ovaries are
removed?
A. This is an area of some debate.
A study published last year in
Headache found that in China,
migraines became less frequent
after menopause—unless the
woman had a surgical menopause.
Then, they claimed, the risk of
migraine was greater. But when
you look more closely, that study
had a major flaw: 81% of these
Chinese women who had “surgical
menopause” weren’t menopausal—
they still had one or both ovaries!
They were premenopausal from a
hormonal standpoint.
What I have noticed from over
20 years of treating hormonal
issues in women is that migraines
get better after menopause. This
includes natural menopause or
when it is due to removal of
ovaries. However, if a woman
enters menopause with chronic
daily headache, migraines often
get worse due to the superimposed
sleep disruptions of menopause. I
have never recommended hysterectomy
for prevention of migraine.
A complicating issue is
whether—or what type of—estrogen
therapy is used after ovaries
are removed. Gaps in estrogen
concentration can produce estrogen-withdrawal
migraines whether
they are due to interrupted therapy
or unintentional fluctuations
from interactions with other
drugs.
Hysterectomy without removal
of ovaries offers no mechanism by
which the operation would be
expected to affect menstrual
migraine, and my observations
support this. It simply makes it
more difficult to “time” specific
preventive strategies.
Adjusting Oral Contraceptives
to Reduce Headaches
Q. What type/brand of oral contraceptives
do you recommend for
headache sufferers, specifically
those with “common” migraine
possibly related to the menstrual
cycle? I’m presently taking a pill
called Kariva ® .
A. If a woman has menstrualrelated
migraine with her natural
cycle, there is no hormonal contraceptive
that will decrease that
risk. The drop in estrogen that
occurs with the natural cycle is
equal to the drop in estrogen with
the lowest-dose oral or patch contraceptives.
Those lowest-dose
products include Kariva, the 20microgram
pill you mentioned.
Two options for your healthcare
provider to consider are (1)
an extended active pill regimen
(such as Seasonale ® ) that delays
the period for 12 weeks but
increases the estrogen drop when
it does occur, or (2) supplementing
with estrogen during all 7
days of the placebo week. This
would be like taking 7 of Kariva’s
light blue pills during the last
week instead of only 5. With
Kariva, there is a placebo pill on
days 22 and 23. ✦

New Findings Presented
at Second Annual
Headache Research Summit
The National Headache Foundation
(NHF) hosted its 2 nd Annual Headache
Research Summit February 19, 2005 in
Rancho Mirage, CA. A main focus of
the Headache Research Summit was to
provide an opportunity for young
researchers in the field of headache to
present findings of their studies.
“The National Headache Foundation
Research Summit is unique in that it
welcomes the studies and findings of
up-and-coming physicians, whereas
other events tend to focus on healthcare
professionals who are established
in the field,” said Seymour Diamond,
M.D., founder and executive chairman
of the NHF.
The Headache Research Summit featured
two special presentations—the
2005 Seymour Diamond Lectureship
Award and the NHF Lectureship. For
the inaugural Seymour Diamond
Lectureship Award, named after Dr.
Diamond, the NHF appointed a com-
mittee of headache experts to select the
most outstanding paper published during
the previous year on the causes
and/or treatments of headache. The
committee reviewed 643 papers and
evaluated each on content, scientific
rigor and potential impact. The award
was given to Hans-Christoph Diener,
M.D., Ph.D., Professor of Neurology
and Chairman of the Department of
Neurology at the University of Essen
in Germany.
Dr. Diener’s paper was entitled
“Calcitonin Gene-Related Peptide
Receptor Antagonist BIBN 4096 BS
for the Acute Treatment of Migraine.”
This cutting-edge research determined
that an antagonist or neutralizer of a
protein called calcitonin gene-related
peptide (CGRP) can act effectively as
an acute treatment for migraine. CGRP
is released during a migraine attack,
initiating the pain and sterile inflammation
of the blood vessels. The multicenter
study demonstrated a 66%
response in the acute treatment of
migraine when CGRP was neutralized
by BIBN 4096 BS. Many patients had
a sustained response over 24 hours and
improvements in nausea, light sensitivity
and sound sensitivity. Dr. Diener’s
presentation confirms the role of
CGRP in migraine.
The NHF Lectureship Award recognizes
“rising star” physicians in the
field of headache. The NHF
Lectureship was presented by Hossam
H. M. AbdelSalam, M.D., of the
Cleveland Clinic Foundation
Department of Pediatric Neurology in
Cleveland. His paper, “New Daily
Persistent Headache in Children and
Adolescents,” discussed the frequency
and characteristics of new daily persistent
headache (NDPH) in pediatric and
adolescent patients. According to Dr.
AbdelSalam’s research, NDPH occurs
in approximately 20% of pediatric and
adolescent patients with chronic daily
headaches (CDH). Whether the diagnosis
of NDPH will prove to be an
entity separate from transformed
migraine and CDH and whether it will
be a diagnosis that is clinically useful
remains to be seen.
Among other highlighted presentations
made at the Research Summit
were:
“The Association of Migraine and
Other Comorbidities in a Population of
Patients with Depression” by Gary E.
Ruoff, M.D., Clinical Professor of
Family Medicine, Michigan State
University College of Medicine in East
Lansing, MI. In this study of over 110
patients with major depression, nearly
50% had migraine. Those patients who
had both depression and migraine had a
71% chance of having other comorbidities
such as irritable bowel syndrome,
TMJ, fibromyalgia, myofascial pain
syndrome, chronic pain, dysmenorrhea
and panic. On the other hand, the
depressed population without migraine
had only a 29% chance of having the
comorbidities. Migraine, Dr. Ruoff
concluded, is a marker for a population
that is more prone to disability.
“Prospective Evaluation of Menstrual
Migraine: Evaluation of a New
Probability Diagnostic Model” by
Dawn A. Marcus, M.D., Associate
Professor in the Department of
Anesthesiology at the University of
Pittsburgh School of Medicine. This
study compared the diagnosis of menstrual
migraine using International
Headache Society (IHS) criteria and a
probability diagnostic model. Based on
three months of diary entries kept by
38 women, the Rudy probability model
was found to be more accurate in the
diagnosis of menstrual migraine than
the IHS criteria.
“Inverse Correlation Between Family
History of Stroke and Chronic
Migraine” by Grace Yoon, M.D.,
Department of Medical Genetics and
Howard Hughes Medical Institute
Department of Neurology, University
of California San Francisco. This
research evaluated the importance of a
family history of stroke both in patients
with migraine with aura and those with
migraine without aura in the development
of chronic migraine. The results
indicated that patients with chronic
migraine were less likely to have a first
degree relative with stroke. This suggests
that vascular risk factors may not
be important in predisposing individuals
to chronic migraine. ✦
1-888-NHF-5552
13

Support Group
Meeting Information
The National Headache Foundation has established a nationwide network of
support groups for headache sufferers. The following list represents those
support groups that are meeting at the time this issue was printed, with contact
names and numbers. 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
nhf1970@headaches.org.
ALABAMA
Eufaula-Dothan: Trent Mathis 334-616-
0482
ARKANSAS
Jonesboro: Healthline 1-888-STB-4555
FLORIDA
Palm Beach County: Susan Barron 888-
NHF-5552
Margate:1-888-256-7720 or Sari
Rotenberg, PT/MBA, 954-978-4180
Niceville: Susan Webster 850-897-0542
St. Petersburg: 727-825-1100 or Michael
A. Franklin, MD, 727-820-7701
GEORGIA
Augusta: Walton Headache Center 706-
823-5252
GERMANY
Landstuhl: Gemma Smith, Maj, USAF,
NC, e-mail:
Gemma.Smith@ind.amedd.army.mil
or Susan Barron 888-643-5552
IDAHO
Boise: Mark Filicetti, RPh, 208-381-
3649 or 208-376-3781
ILLINOIS
Chicago: Susan Barron 312-274-2653
INDIANA
Greensburg: Diane McKinney, RN, BSN,
812-663-1163 or Joan Mokanyk 812-
663-2085
KENTUCKY
Shelbyville: Tammy Swigert, RN, 502-
647-1642
LOUISIANA
Shreveport: Donnie Laborde or Patty
318-377-1185
14 National Headache Foundation • May/June 2005
MASSACHUSETTS
Boston: Beth Israel Deaconess Learning
Center (BIDMC) Staff 617-667-9100, or
Margo 617-632-8483
Northampton—New Group!: Cooley
Dickinson Hospital 1-888-554-4CDH
MICHIGAN
Madison Heights: Kimberly Bialik, PhD,
248-967-7988
MISSOURI
Springfield: Debbie Arnold, PT, or Carol
Matthews, CFNP, 417-890-7888
NEBRASKA
Kearney: Jody Girard, RN, 308-237-7099
NEW HAMPSHIRE
Nashua: Judy Brown 603-888-8215
NEW YORK
New York City: Dr. Marc Goloff 212-844-
8934
Utica: Sue Cooper 315-798-8404, or
Cynthia DeTraglia, RN
NORTH DAKOTA
Fargo: Alicia Andrews, NP, 701-234-4036
OHIO
Cincinnati: Jan Welsh 513-385-5000
Beachwood: Sharon M. Bilek 216-642-
8506, or Ann 440-842-0501
Cleveland—New Group!: Dana
Brendza, PsyD, 216-445-1319 or Seth
Krieger, PsyD, 216-444-4432
OREGON
Corvallis: Kris Egan 541-745-7422
PENNSYLVANIA
Pittsburgh: Barb Wintermantel 412-647-
9494
Johnstown: Jan Goodard, RN, BSN,
1-814-269-5288 or 1-800-587-5875
RHODE ISLAND
Warwick: Brenda Bullinger, LCSW, 401-
732-3332, ext.133
TENNESSEE
Chattanooga: Steven Clifton, PA-C, 423-
698-0850
Memphis: Judy McGinnis, RN, 901-753-
4093
TEXAS
Dallas: 800-4-BAYLOR (1-800-422-
9567)
Houston: Ken Vales 713-660-9140 or email
houtexas@juno.com
VIRGINIA
Fredericksburg: Torita Proctor 540-374-
8223
WISCONSIN
Green Bay: Bonnie Groessl, MSN, AP-
NP, 920-405-1452
Please be sure to call to confirm all
meetings as meeting times and loca-
tions are subject to change and can-
cellations do occur. Seating is limit-
ed. 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.✦
www.headaches.org

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.
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.
(UPDATED) 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.
(UPDATED) 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.
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.
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.
(UPDATED) A Patient’s Guide to Migraine Prevention & Treatment
$1.50
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.
$1.50
Name NHF Subscriber #
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Cardholder Name Signature
Address
City State Zip
Daytime Phone E-mail
National Headache Foundation
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.
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

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with payment to:
NATIONAL HEADACHE
FOUNDATION
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Chicago, IL 60610-3132
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NATIONAL HEADACHE FOUNDATION
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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;
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