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## Complete Summary

#### GUIDELINE TITLE

EFNS guideline on the drug treatment of migraine -- report of an EFNS
task force.

#### BIBLIOGRAPHIC SOURCE(S)

Members of the task force:, Evers S, Afra J, Frese A, Goadsby PJ, Linde
M, May A, Sandor PS. EFNS guideline on the drug treatment of migraine -
report of an EFNS task force. Eur J Neurol 2006 Jun;13(6):560-72. \[171
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16796580)

#### GUIDELINE STATUS

This is the current release of the guideline.

These recommendations should be updated within 2 years and should be
complemented by recommendations for the non-drug treatment of migraine.

### \*\* 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.

-   [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.

**Additional Notices**

-   [May 2, 2007, Antidepressant
    drugs](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Antidepressant):
    Update to the existing black box warning on the prescribing
    information on all antidepressant medications to include warnings
    about the increased risks of suicidal thinking and behavior in young
    adults ages 18 to 24 years old during the first one to two months of
    treatment.

-   [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).

### 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)

Migraine

#### GUIDELINE CATEGORY

Assessment of Therapeutic Effectiveness\
Prevention\
Treatment

#### CLINICAL SPECIALTY

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

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To give evidence-based recommendations for the drug treatment of
migraine attacks and migraine prophylaxis

#### TARGET POPULATION

Adults, children, and adolescents with migraine

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Treatment/Prevention**

1.  Analgesics

2.  Antiemetics

3.  Ergot alkaloids

4.  Triptans

5.  Treatment of menstrual migraine: naproxen sodium

6.  Migraine in pregnancy: paracetamol, NSAIDs

7.  Migraine in children and adolescents: ibuprofen, paracetamol,
    domperidon, sumatriptan nasal spray

8.  Prophylaxis of migraine

    -   Drugs of first choice (e.g., beta blockers, calcium channel
        blockers, antiepileptic drugs)

    -   Miscellaneous drugs of second and third choice (see the \"Major
        Recommendations\" field for details)

    -   Prophylaxis of menstrual migraine

    -   Prophylaxis in pregnancy: magnesium and metoprolol

    -   Prophylaxis in children and adolescents: flunarizine and
        propranolol

**Note**: The non-drug management (e.g. behavioral therapy) is not
included in this guideline, although it is regarded as an important part
of migraine treatment.

#### MAJOR OUTCOMES CONSIDERED

-   Effectiveness of treatment in pain relief, headache recurrence,
    severity of pain, and analgesic requirements

-   Adverse effects of medications used to treat migraine

### 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 key words used
were \'migraine\' and \'aura\' (last search in January 2005). All papers
published in English, German, or French were considered when they
described a controlled trial or a case series on the treatment of at
least five patients. In addition, a review book and the German treatment
recommendations for migraine were considered.

#### 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

Review of Published Meta-Analyses\
Systematic Review

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

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

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

All authors performed an independent literature search. The first draft
of the manuscript was written by the chairman of the task force. All
other members of the task force read the first draft and discussed
changes by e-mail. A second draft was then written by the chairman which
was again discussed by e-mail. All recommendations had to be agreed to
by all members of the task force unanimously. The background of the
research strategy and of reaching consensus and the definitions of the
recommendation levels used in this paper have been described in the
European Federation of Neurological Societies (EFNS) recommendations
(see the \"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.

#### 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\").

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

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

**[Drug Treatment of Migraine Attacks]{.underline}**

**Analgesics**

**Table. Analgesics with Evidence of Efficacy in at Least One Study on
the Acute Treatment of Migraine**. The level of recommendation also
considers side effects and consistency of the studies.

  ------------------------------------------------------------------------
  **Substance**     **Dose**        **Level of         **Comment**
                                    Recommendation**   
  ----------------- --------------- ------------------ -------------------
  Acetylsalicylic   1000 mg (oral)\ A\                 Gastrointestinal
  acid (ASA)        1000 mg         A                  side effects, risk
                    (intravenous                       of bleeding
                    \[i.v.\])                          

  Ibuprofen         200 -- 800 mg   A                  Side effects as for
                                                       ASA

  Naproxen          500 -- 1000 mg  A                  Side effects as for
                                                       ASA

  Diclofenac        50 -- 100 mg    A                  Including
                                                       diclofenac-K

  Paracetamol       1000 mg (oral)\ A\                 Caution in liver
                    1000 mg         A                  and kidney failure
                    (suppository)                      

  ASA plus,         250 mg (oral),\ A                  As for ASA and
  paracetamol plus  200 -- 250 mg\                     paracetamol
  and caffeine      and 50 mg                          

  Metamizol         1000 mg (oral)\ B\                 Risk of
                    1000 mg (i.v.)  B                  agranulocytosis\
                                                       Risk of hypotension

  Phenazon          1000 mg (oral)  B                  See paracetamol

  Tolfenamic acid   200 mg (oral)   B                  Side effects as for
                                                       ASA
  ------------------------------------------------------------------------

**Antiemetics**

**Table. Antiemetics Recommended for the Acute Treatment of Migraine
Attacks**

  ---------------------------------------------------------------------------------
  **Substance**    **Dose**                    **Level**   **Comment**
  ---------------- --------------------------- ----------- ------------------------
  Metoclopramide   10-20 mg (oral), 20 mg      B           Side effect: dyskinesia;
                   (suppository), 10 mg                    contraindicated in
                   (intramuscular,                         childhood and in
                   intravenous, and                        pregnancy
                   subcutaneous)                           

  Domperidon       20-30 mg (oral)             B           Side effects less severe
                                                           than in metoclopramide;
                                                           can be given to children
  ---------------------------------------------------------------------------------

**Ergot Alkaloids**

The advantage of ergot alkaloids in some patients is a longer half life
time and a lower recurrence rate. Therefore, these substances should be
restricted to patients with very long migraine attacks or with regular
recurrence. The only compound with sufficient evidence of efficacy is
ergotamine tartrate 2 mg (oral or suppositories).

**Triptans (5-HT~1B/1D~-agonists)**

**Table. Different Triptans for the Treatment of Acute Migraine Attacks
(Order in the Time of Marketing)**. Not all doses or application forms
are available in all European countries

  -----------------------------------------------------------------------------------
  **Substance**   **Dose**                     **Level**   **Comment**
  --------------- ---------------------------- ----------- --------------------------
  Sumatriptan     25, 50 and 100 mg (oral      A           100 mg sumatriptan is
                  including rapid-release)                 reference to all triptans

                  25 mg (suppository)          A           

                  10 and 20 mg (nasal spray)   A           

                  6 mg (subcutaneous)          A           

  Zolmitriptan    2.5 and 5 mg (oral including A\           
                  disintegrating form)\        A           
                  2.5 and 5 mg (nasal spray)               

  Naratriptan     2.5 mg (oral)                A           Less but longer efficacy
                                                           than sumatriptan

  Rizatriptan     10 mg (oral including wafer  A           5 mg when taking
                  form)                                    propranolol

  Almotriptan     12.5 mg (oral)               A           Probably less side effects
                                                           than sumatriptan

  Eletriptan      20 and 40 mg (oral)          A           80 mg allowed if 40 mg not
                                                           effective

  Frovatriptan    2.5 mg (oral)                A           Less but longer efficacy
                                                           than sumatriptan
  -----------------------------------------------------------------------------------

**[Migraine Prophylaxis]{.underline}**

There is no commonly accepted indication for starting a prophylactic
treatment. In the view of the Task Force, prophylactic drug treatment of
migraine should be considered and discussed with the patient when

-   The quality of life, business duties, or school attendance are
    severely impaired

-   Frequency of attacks per month is two or higher

-   Migraine attacks do not respond to acute drug treatment

-   Frequent, very long, or uncomfortable auras occur

**Table. Recommended Substances (Drugs of First Choice) for the
Prophylactic Drug Treatment of Migraine**

  ------------------------------------------------------------------------
  **Substances**              **Daily Dose**                 **Level**
  --------------------------- ------------------------------ -------------
  **Betablockers**                                           

  Metoprolol                  50--200 mg                     A

  Propranolol                 40--240 mg                     A

  **Calcium channel                                          
  blockers**                                                 

  Flunarizine                 5--10 mg                       A

  **Antiepileptic drugs**                                    

  Valproic acid               500--1800 mg                   A

  Topiramate                  25--100 mg                     A
  ------------------------------------------------------------------------

**Table. Drugs of Second Choice for Migraine Prophylaxis (Evidence of
Efficacy, but Less Effective or More Side Effects than Drugs of the
Table above)**

  -----------------------------------------------------------------------
  **Substances**               **Daily Dose**               **Level**
  ---------------------------- ---------------------------- -------------
  Amitriptyline                50--150                      B

  Naproxen                     2 x 250--500                 B

  Petasites                    2 x 75                       B

  Bisoprolol                   5--10                        B
  -----------------------------------------------------------------------

**Table. Drugs of Third Choice for Migraine Prophylaxis (Only Probable
Efficacy)**

  -------------------------------------------------------------------------
  **Substances**                       **Daily Dose**           **Level**
  ------------------------------------ ------------------------ -----------
  Acetylsalicylic acid                 300 mg                   C

  Gabapentin                           1200--1600 mg            C

  Magnesium                            24 mmol                  C

  Tanacetum parthenium                 3 x 6.25 mg              C

  Riboflavin                           400 mg                   C

  Coenzyme Q10                         300 mg                   C

  Candesartan                          16 mg                    C

  Lisinopril                           20 mg                    C

  Methysergide                         4--12 mg                 C
  -------------------------------------------------------------------------

**Migraine in Pregnancy**

If migraine occurs during pregnancy, only paracetamol is allowed during
the whole period. Non-steroidal anti-inflammatory drugs (NSAIDs) can be
given in the second trimester. These recommendations are based on the
advices of the regulatory authorities in most European countries. There
might be differences in some respect between different countries (in
particular, NSAIDs might be allowed in the first trimester).

For migraine prophylaxis, only magnesium and metoprolol are recommended
during pregnancy (**level B recommendation**).

**[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.

#### 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 drug treatment and prophylaxis of migraine

#### POTENTIAL HARMS

**Analgesics**

-   *Acetylsalicylic acid (ASA)* and *non-steroidal anti-inflammatory
    drugs (NSAIDs)* are associated with gastrointestinal side effects
    and risk of bleeding.

-   *Paracetamol and Phenazon* should be given with caution in liver and
    kidney failure.

-   *Metamizol* is associated with risk of agranulocytosis and
    hypotension

-   In order to prevent drug overuse headache, the intake of simple
    analgesics should be restricted to 15 days/month and the intake of
    combined analgesics to 10 days/month.

**Antiemetics**

-   *Metoclopramide* is associated with dyskinesia

-   *Domperidon* has less severe side effects compared to metoclopramide
    and can be given to children.

**Ergot Alkaloids**

-   Major side effects of *ergot alkaloids* include nausea, vomiting,
    paresthesia, and ergotism.

-   Ergot alkaloids can induce drug overuse headache very fast and in
    very low doses. Therefore, their use must be limited to 10
    days/month.

**Triptans**

-   The use of *triptans* is restricted to maximum 10 days/month.
    Otherwise, the induction of a drug overuse headache is possible for
    all triptans.

-   General side effects for all *triptans*: chest symptoms, nausea,
    distal paresthesia, fatigue.

-   After application of *sumatriptan*, severe adverse events have been
    reported such as myocardial infarction, cardiac arrhythmias, and
    stroke.

**Antidepressants**

In several small studies *amitriptyline* showed central side effects.

**Miscellaneous Drugs**

*Methysergide* is recommended for short-term use only (maximum 6 months
per treatment period) because of potentially severe side effects

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   *Metoclopramide* is contraindicated in childhood and pregnancy.

-   *Ergot alkaloids* are contraindicated in cardiovascular and
    cerebrovascular diseases, Raynaud\'s disease, arterial hypertension,
    renal failure, and pregnancy and lactation.

-   *Triptan* contraindications: arterial hypertension (untreated),
    coronary heart disease, cerebrovascular disease, Raynaud\'s disease,
    pregnancy and lactation, age under 18 (except sumatriptan nasal
    spray) and age above 65 years, severe liver or kidney failure.

### 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)

Members of the task force:, Evers S, Afra J, Frese A, Goadsby PJ, Linde
M, May A, Sandor PS. EFNS guideline on the drug treatment of migraine -
report of an EFNS task force. Eur J Neurol 2006 Jun;13(6):560-72. \[171
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16796580)

#### ADAPTATION

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

#### DATE RELEASED

2006 Jun

#### 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 Drug
Treatment of Migraine

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Task Force Members*: S. Evers, Department of Neurology, University of
Münster, Münster, Germany; J. Áfra, National Institute of Neurosurgery,
Budapest, Hungary; A. Frese, Department of Neurology, University of
Münster, Münster, Germany; P. J. Goadsby, Headache Group, Institute of
Neurology, The National Hospital for Neurology and Neurosurgery, London,
UK; M. Linde, Cephalea Pain Center, Läkarhuset Södra vägen, Gothenburg,
Gothenburg, Sweden; A. May, Department of Neurology, University of
Hamburg, Hamburg, Germany; P. S. Sándor, Department of Neurology,
University of Zurich, Zurich, Switzerland

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The present guidelines were developed without external financial
support. The authors report the following financial supports:

Stefan Evers: Salary by 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.
Judit Áfra: Salary by the Hungarian Ministry of Health; honoraries by
GlaxoSmithKline. Achim Frese: Salary by the government of the State
Northrhine-Westphalia; no honoraries. Peter J. Goadsby: Salary by the
University College of London; honoraries by Almirall, AstraZeneca,
Glaxo- SmithKline, MSD, Pfizer, Medtronic. Mattias Linde: Salary by the
Swedish government; honoraries by AstraZeneca, GlaxoSmithKline, MSD,
Nycomed, Pfizer. Arne May: Salary by the University Hospital of Hamburg;
honoraries by Almirall, AstraZeneca, Bayer Vital, Berlin Chemie,
GlaxoSmithKline, Janssen Cilag, MSD, Pfizer. Peter S. Sándor: Salary by
the University Hospital of Zurich; honoraries by AstraZeneca,
GlaxoSmithKline, Janssen Cilag, Pfizer, Pharm Allergan

#### GUIDELINE STATUS

This is the current release of the guideline.

These recommendations should be updated within 2 years and should be
complemented by recommendations for the non-drug treatment of migraine.

#### 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 Stefan Evers, Department of Neurology,
University of Münster, Albert-Schweitzer-Str. 33, 48129 Münster,
Germany; Phone: +49-251-8348196; Fax: +49-251-8348181; E-mail:
<everss@uni-muenster.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 6, 2007. The information
was verified by the guideline developer on May 15, 2007. This summary
was updated by ECRI Institute on November 9, 2007, following the U.S.
Food and Drug Administration advisory on Antidepressant drugs.

#### COPYRIGHT STATEMENT

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

### DISCLAIMER

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Date Modified: 11/3/2008