![](media/image1.png){width="5.96875in" height="0.41944444444444445in"}

Top of Form

## Complete Summary

#### GUIDELINE TITLE

EFNS guidelines on the treatment of cluster headache and other
trigeminal-autonomic cephalalgias.

#### BIBLIOGRAPHIC SOURCE(S)

May A, Leone M, Afra J, Linde M, Sandor PS, Evers S, Goadsby PJ, EFNS
Task Force. EFNS guidelines on the treatment of cluster headache and
other trigeminal-autonomic cephalalgias. Eur J Neurol 2006
Oct;13(10):1066-77. \[143 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16987158)

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory information
has been released.

-   [September 29, 2006 -- Lamictal
    (lamotrigine)](http://www.fda.gov/medwatch/safety/2006/safety06.htm#Lamictal):
    New preliminary information available regarding the effects of
    Lamictal on the baby if taken during the first three months of
    pregnancy.

-   [July 19, 2006,
    Triptans](http://www.fda.gov/medwatch/safety/2006/safety06.htm#Triptans):
    Healthcare professionals and consumers of new safety information
    regarding taking triptans together with selective serotonin reuptake
    inhibitors (SSRIs) and selective serotonin/norepinephrine reuptake
    inhibitors (SNRIs).

-   [June 15, 2005, Non-Steroidal Anti-Inflammatory Drugs
    (NSAIDs)](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#NSAID):
    U.S. Food and Drug Administration (FDA) recommended proposed
    labeling for both the prescription and over the counter (OTC) NSAIDs
    and a medication guide for the entire class of prescription
    products.

-   [April 7, 2005, Non-steroidal anti-inflammatory drugs (NSAIDS)
    (prescription and OTC, including ibuprofen and
    naproxen)](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#BEXTRA):
    FDA asked manufacturers of prescription and non-prescription (OTC)
    non-steroidal anti-inflammatory drugs (NSAIDs) to revise their
    labeling to include more specific information about potential
    gastrointestinal (GI) and cardiovascular (CV) risks.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Cluster headache

-   Paroxysmal hemicrania

-   Short-lasting unilateral neuralgiform headache attacks with
    conjunctival injection and tearing (SUNCT) syndrome

#### GUIDELINE CATEGORY

Assessment of Therapeutic Effectiveness\
Management\
Prevention\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Neurology\
Pharmacology\
Preventive Medicine

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To give evidence-based recommendations for the treatment of cluster
headache, paroxysmal hemicranias, and short-lasting unilateral
neuralgiform headache attacks with conjunctival injection and tearing
(SUNCT) syndrome

#### TARGET POPULATION

Patients suffering from cluster headache, paroxysmal hemicranias, and
short-lasting unilateral neuralgiform headache attacks with conjunctival
injection and tearing (SUNCT) syndrome

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Treatment**

*Cluster Headaches*

1.  100% oxygen

2.  Triptans (e.g., sumatriptan, zolmitriptan)

3.  Intranasal lidocaine

4.  Subcutaneous octreotide

**Prevention**

*Cluster Headaches*

1.  Verapamil

2.  Steroids

3.  Lithium carbonate

4.  Methysergide

5.  Topiramate

6.  Ergotamine tartrate

7.  Valproic acid

8.  Melatonin

9.  Baclofen

*Paroxysmal Hemicrania*

1.  Indomethacin

2.  Verapamil

3.  Non-steroidal anti-inflammatory drugs (NSAIDs)

*Short-lasting Unilateral Neuralgiform Headache Attacks with
Conjunctival Injection and Tearing (SUNCT) Syndrome*

1.  Lamotrigine

2.  Topiramate

3.  Gabapentin

#### MAJOR OUTCOMES CONSIDERED

-   Effectiveness of treatment

-   Prevention of attacks

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

A literature search was performed using the reference databases MedLine,
Science Citation Index and the Cochrane Library; the keywords used were
\'cluster headache\', \'paroxysmal hemicrania\', \'SUNCT\',
\'treatment\' and \'trial\' (last search in January 2006). All papers
published in English, German or French were considered if they described
a controlled trial or a case series on the treatment of at least five
patients (or less in paroxysmal hemicrania or short-lasting unilateral
neuralgiform headache attacks with conjunctival injection and tearing
\[SUNCT\] syndrome). Papers discovered by this search were reviewed, as
were references cited therein. In addition, review books, the German
treatment recommendations for cluster headache were consulted and
abstracts with new data from the most recent congress of the
International Headache Society (HIS) (Kyoto, October 2005) were hand
searched.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Evidence Classification Scheme for a Therapeutic Intervention**

**Class I**: An adequately powered prospective, randomized, controlled
clinical trial with masked outcome assessment in a representative
population or an adequately powered systematic review of prospective
randomized controlled clinical trials with masked outcome assessment in
representative populations. The following are required:

a.  Randomization concealment

b.  Primary outcome(s) is/are clearly defined

c.  Exclusion/inclusion criteria are clearly defined

d.  Adequate accounting for dropouts and crossovers with numbers
    sufficiently low to have minimal potential for bias

e.  Relevant baseline characteristics are presented and substantially
    equivalent among treatment groups or there is appropriate
    statistical adjustment for differences

**Class II**: Prospective matched-group cohort study in a representative
population with masked outcome assessment that meets a--e above or a
randomized, controlled trial in a representative population that lacks
one criteria a--e

**Class III**: All other controlled trials (including well-defined
natural history controls or patients serving as own controls) in a
representative population, where outcome assessment is independent of
patient treatment

**Class IV**: Evidence from uncontrolled studies, case series, case
reports, or expert opinion

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

The findings in these studies were evaluated according to the
recommendations of the European Federation of Neurological Societies
(EFNS) resulting in level A, B or C recommendations and good practice
points (see the \"Availability of Companion Documents\" field in this
summary).

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

All authors performed an independent literature search. All members of
the task force read the first draft and discussed changes by email. All
recommendations had to be agreed on by all members of the task force
unanimously. The background of the research strategy and of reaching
consensus and the definitions of the recommendation dosages used in this
paper follow the European Federation of Neurological Societies (EFNS)
guidelines (see \"Availability of Companion Documents\" field).

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Rating of Recommendations**

**Level A rating** (established as effective, ineffective, or harmful)
requires at least one convincing class I study or at least two
consistent, convincing class II studies.

**Level B rating** (probably effective, ineffective, or harmful)
requires at least one convincing class II study or overwhelming class
III evidence.

**Level C rating** (possibly effective, ineffective, or harmful)
requires at least two convincing class III studies.

**Good practice point** Where there was a lack of evidence but consensus
was clear, the Task Force has stated their opinion as good practice
points (GPPs).

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guidelines were validated according to the European Federation of
Neurological Societies (EFNS) criteria (see \"Availability of Companion
Documents\" field).

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The levels of evidence (class I-IV) supporting the recommendations and
ratings of recommendations (A-C, good practice point) are defined at the
end of the \"Major Recommendations\" field.

**Table 5. Treatment Recommendations for Cluster Headache, Paroxysmal
Hemicrania and Short-lasting Unilateral Neuralgiform Headache Attacks
with Conjunctival Injection and Tearing (SUNCT) Syndrome**

  ----------------------------------------------------------------------------
                 **Treatment of                                  
                 Choice**                                        
  -------------- -------------------- -------------------------- -------------
  **Therapy**    **Cluster Headache** **Paroxysmal Hemicrania**  **SUNCT
                                                                 Syndrome**

  Acute          100% oxygen, 15      None                       None
                 l/min **(A)**\                                  
                 Sumatriptan 6 mg,                               
                 subcutaneous                                    
                 **(A)**\                                        
                 Sumatriptan 20 mg                               
                 nasal **(A)**\                                  
                 Zolmitriptan 5 mg                               
                 nasal **(A/B)**\                                
                 Zolmitriptan 10 mg                              
                 nasal **(A/B)**\                                
                 Zolmitriptan 10 mg                              
                 oral **(B)**\                                   
                 Zolmitriptan 5 mg                               
                 oral **(B)**\                                   
                 Lidocaine intranasal                            
                 **(B)**\                                        
                 Octreotide **(B)**                              

  Preventative   Verapamil **(A)**\   Indomethacin **(A)**\      Lamotrigine
                 Steroids **(A)**\    Verapamil **(C)**\         **(C)**
                 Lithium carbonate    Non-steroidal              
                 **(B)**\             anti-inflammatory drugs    
                 Methysergide         (NSAIDs) **(C)**           
                 **(B)**\                                        
                 Topiramate **(B)**\                             
                 Ergotamine tartrate                             
                 **(B)**\                                        
                 Valproic acid                                   
                 **(C)**\                                        
                 Melatonin **(C)**\                              
                 Baclofen **(C)**                                
  ----------------------------------------------------------------------------

For exact doses see original guideline document (**A** denotes
effective, **B** denotes probably effective, **C** denotes possibly
effective).

**[Treatment of Cluster Headache]{.underline}**

**Level A Recommendation**

The first option for the treatment of acute attacks of cluster headache
should be the inhalation of 100% oxygen with at least 7 l/min over 15
min (**class II trials**) or with the subcutaneous injection of 6 mg
sumatriptan (**class I trials**). An alternative would be sumatriptan 20
mg nasal spray or zolmitriptan 5 mg nasal spray (**one class I trial
each**), with the disadvantage of a slower onset and the advantage of
being able to treat more attacks in 24 hours than with injected
sumatriptan.

Prophylaxis of cluster headache should be tried first with verapamil at
a daily dose of at least 240 mg (maximum dose depends on efficacy or
tolerability, electrocardiogram \[ECG\] controls are obligatory with
increasing doses). Although no class I or II trials are available,
steroids are clearly effective for treating cluster headache. Therefore,
the use of at least 100 mg methylprednisone (or equivalent
corticosteroid) given orally or up to 500 mg intravenously (i.v.) per
day over 5 days (then tapering down) is recommended.

**Level B Recommendation**

Intranasal lidocaine (4%) and subcutaneous octreotide (100 micrograms)
can be tried for treating acute cluster headache attacks if level A
medication is ineffective or contraindicated. Oral administration of
zolmitriptan at 5 to 10 mg is effective in some patients (**class I
trial**) but high doses produce more side effects and limit practical
use.

Methysergide and lithium are drugs of second choice if verapamil is
ineffective or contraindicated. Corticosteroids can be used for short
periods where bouts are short or to help establish another medication.
Topiramate is promising, but only open trials exist at this point.
Melatonin is useful in some patients. Except for lithium, the maximum
dose depends on efficacy and tolerability. Ergotamine tartrate is
recommended for short-term prophylaxis (**class III studies**). Despite
positive class II studies, pizotifen and intranasal capsaicin should
only be used in rare cases because of side effects.

**Level C Recommendation**

Baclofen 15 to 30 mg and valproic acid showed possible efficacy and can
be tried as drugs of third choice.

**Good Practice Point**

Surgical procedures are not indicated in most of the patients with
cluster headache. Patients with intractable chronic cluster headache
should be referred to centres with expertise in both destructive and
neuromodulatory procedures to be offered all reasonable alternatives
before a definitive procedure is conducted.

**[Treatment of Paroxysmal Hemicrania]{.underline}**

Paroxysmal hemicrania is to be treated with indomethacin up to 200 mg
(**level A recommendation**). Alternatively, verapamil and other NSAIDs
can be tried (**level C recommendation**).

**[Treatment of Short-lasting Unilateral Neuralgiform Headache Attacks
with Conjunctival Injection and Tearing (SUNCT) Syndrome]{.underline}**

Recent large case series outcomes suggest that lamotrigine is the
treatment of choice in SUNCT, followed by topiramate and gabapentin.

**[Definitions]{.underline}**:

**Evidence Classification Scheme for a Therapeutic Intervention**

**Class I**: An adequately powered prospective, randomized, controlled
clinical trial with masked outcome assessment in a representative
population or an adequately powered systematic review of prospective
randomized controlled clinical trials with masked outcome assessment in
representative populations. The following are required:

a.  Randomization concealment

b.  Primary outcome(s) is/are clearly defined

c.  Exclusion/inclusion criteria are clearly defined

d.  Adequate accounting for dropouts and crossovers with numbers
    sufficiently low to have minimal potential for bias

e.  Relevant baseline characteristics are presented and substantially
    equivalent among treatment groups or there is appropriate
    statistical adjustment for differences

**Class II**: Prospective matched-group cohort study in a representative
population with masked outcome assessment that meets a--e above or a
randomized, controlled trial in a representative population that lacks
one criteria a--e

**Class III**: All other controlled trials (including well-defined
natural history controls or patients serving as own controls) in a
representative population, where outcome assessment is independent of
patient treatment

**Class IV**: Evidence from uncontrolled studies, case series, case
reports, or expert opinion

**Rating of Recommendations**

**Level A rating** (established as effective, ineffective, or harmful)
requires at least one convincing class I study or at least two
consistent, convincing class II studies.

**Level B rating** (probably effective, ineffective, or harmful)
requires at least one convincing class II study or overwhelming class
III evidence.

**Level C rating** (possibly effective, ineffective, or harmful)
requires at least two convincing class III studies.

**Good practice point** Where there was a lack of evidence but consensus
was clear, the Task Force has stated their opinion as good practice
points (GPPs).

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected
recommendations (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate treatment of cluster headache, paroxysmal hemicranias, and
short-lasting unilateral neuralgiform headache attacks with conjunctival
injection and tearing (SUNCT) syndrome

#### POTENTIAL HARMS

**Adverse Effects of Medications**

-   The most uncomfortable side effects of sumatriptan are chest pain
    and distal paresthesia

-   Side effects of verapamil are bradycardia, ankle oedema,
    constipation, gastrointestinal discomfort, gingival hyperplasia and
    dull headache. Regular echocardiographic (ECG) controls are required
    to control for an increase in cardiac conduction time reflected in a
    prolongation of the PR interval. Sometimes, ECG may be necessary
    because of the negative inotropic effects of verapamil.

-   Major side effects of lithium are hyperthyreosis, tremor and renal
    dysfunction. The plasma level should be monitored and kept between
    0.6 and 1.2 mmol/l. Regular control of liver, renal and thyroid
    function and of electrolytes is required.

-   Methysergide should be used with caution when patients are receiving
    other ergotamine derivatives or triptans. As there is a definite
    incidence of pulmonary and retroperitoneal fibrosis under long-term
    use, the continuous use of methysergide is limited to 6 months.

-   Main side effects of topiramate are cognitive disturbances,
    paresthesias, and weight loss.

-   A proton pump inhibitor should be given with indomethacin as
    gastrointestinal discomfort and bleeding are the major side effects
    of indomethacin.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Contraindications to sumatriptan are cardio- and cerebrovascular
    disorders and untreated arterial hypertension.

-   Topiramate is contraindicated in nephrolithiasis.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This guideline provides the view of an expert task force appointed by
the Scientific Committee of the European Federation of Neurological
Societies (EFNS). It represents a peer-reviewed statement of minimum
desirable standards for the guidance of practice based on the best
available evidence. It is not intended to have legally binding
implications in individual cases.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

The European Federation of Neurological Societies has a mailing list and
all guideline papers go to national societies, national ministries of
health, World Health Organisation, European Union, and a number of other
destinations. Corporate support is recruited to buy large numbers of
reprints of the guideline papers and permission is given to sponsoring
companies to distribute the guideline papers from their commercial
channels, provided there is no advertising attached.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

May A, Leone M, Afra J, Linde M, Sandor PS, Evers S, Goadsby PJ, EFNS
Task Force. EFNS guidelines on the treatment of cluster headache and
other trigeminal-autonomic cephalalgias. Eur J Neurol 2006
Oct;13(10):1066-77. \[143 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16987158)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006 Oct

#### GUIDELINE DEVELOPER(S)

European Federation of Neurological Societies - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

European Federation of Neurological Societies

#### GUIDELINE COMMITTEE

European Federation of Neurological Societies Task Force on the
Treatment of Cluster Headache and other Trigeminal Autonomic
Cephalalgias

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Task Force Members*: A. May, Department of Systems Neuroscience,
University of Hamburg, Hamburg, Germany; M. Leone, Instituto Neurologico
Carlo Besta, Milan, Italy; J. Áfra, National Institute of Neurosurgery,
Budapest, Hungary; M. Linde, Cephalea Pain Centre and Institute of
Neuroscience and Physiology, Sahlgren Academy, Göteborg University,
Göteborg, Sweden; P. S. Sándor, Department of Neurology, University of
Zurich, Zurich, Switzerland; S. Evers, Department of Neurology,
University of Münster, Münster, Germany; P. J. Goadsby, Institute of
Neurology, Queen Square, London, UK

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The present guidelines were developed without external financial
support. None of the authors declares a conflict of interests. The
authors report the following financial supports:

Arne May: Salary from the University Hospital of Hamburg; honoraries and
research grants by Almirall, AstraZeneca, Bayer Vital, Berlin Chemie,
GlaxoSmithKline, Janssen Cilag, MSD, Pfizer.

Massimo Leone: Salary from the Istituto Nazionale Neurologico C. Besta;
honoraries by GlaxoSmithKline, Almirall, Medtronic.

Judit Áfra: Salary by the Hungarian Ministry of Health; honoraries by
GlaxoSmithKline.

Mattias Linde: Salary from the Swedish government; honoraries by
AstraZeneca, GlaxoSmithKline, MSD, Nycomed, Pfizer.

Peter S. Sándor: Salary from the University Hospital of Zurich;
honoraries by AstraZeneca, GlaxoSmithKline, Janssen Cilag, Pfizer, Pharm
Allergan.

Stefan Evers: Salary from the government of the State
Northrhine-Westphalia; honoraries and research grants by Almirall,
AstraZeneca, Berlin Chemie, Boehringer, GlaxoSmithKline, Ipsen Pharma,
Janssen Cilag, MSD, Pfizer, Novartis, Pharm Allergan, Pierre Fabre.

Peter J. Goadsby: Salary from the University College of London;
honoraries by Almirall, AstraZeneca, GlaxoSmithKline, MSD, Pfizer,
Medtronic, Advanced Bionics.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available to registered users from the [European
Federation of Neurological Societies Web
site](http://www.efns.org/content.php?pid=142).

Print copies: Available from Arne May MD, Department of Systems
Neuroscience, Universitäts-Krankenhaus Eppendorf (UKE), Martinistr. 52,
D-20246 Hamburg, Germany; Phone: 040 42803 9189; Fax: 040 42803 9955;
E-mail: <a.may@uke.uni-hamburg.de>

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Brainin M, Barnes M, Baron JC, Gilhus NE, Hughes R, Selmaj K,
    Waldemar G; Guideline Standards Subcommittee of the EFNS Scientific
    Committee. Guidance for the preparation of neurological management
    guidelines by EFNS scientific task forces -- revised
    recommendations 2004. Eur J Neurol. 2004 Sep;11(9):577-81.
    Electronic copies: Available in Portable Document Format (PDF) from
    the [European Federation of Neurological Societies Web
    site](http://www.efns.org/files/guideline_23.pdf).

-   Guideline papers. European Federation of Neurological Societies.
    Electronic copies: Available from the [European Federation of
    Neurological Societies Web
    site](http://www.efns.org/content.php?pid=141).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on April 11, 2007. The
information was verified by the guideline developer on May 15, 2007.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the Blackwell-Synergy copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

Bottom of Form

© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008