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

Top of Form

## Complete Summary

#### GUIDELINE TITLE

Special treatment situations: behavioral interventions for management of
primary head pain. Standards of care for headache diagnosis and
treatment.

#### BIBLIOGRAPHIC SOURCE(S)

Farmer K, Freitag F. Special treatment situations: behavioral
interventions for management of primary head pain. In: Standards of care
for headache diagnosis and treatment. Chicago (IL): National Headache
Foundation; 2004. p. 83-92. \[18 references\]

#### 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.

On April 7, 2005, after concluding that the overall risk versus benefit
profile is unfavorable, the U.S. Food and Drug Administration (FDA)
requested that Pfizer, Inc voluntarily withdraw Bextra (valdecoxib) from
the market. The FDA also asked manufacturers of all marketed
prescription nonsteroidal anti-inflammatory drugs (NSAIDs), including
Celebrex (celecoxib), a COX-2 selective NSAID, to revise the labeling
(package insert) for their products to include a boxed warning and a
Medication Guide. Finally, FDA asked manufacturers of non-prescription
(over the counter \[OTC\]) NSAIDs to revise their labeling to include
more specific information about the potential gastrointestinal (GI) and
cardiovascular (CV) risks, and information to assist consumers in the
safe use of the drug. See the [FDA Web
site](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#Bextra) for
more information.

Subsequently, on June 15, 2005, the FDA requested that sponsors of all
non-steroidal anti-inflammatory drugs (NSAID) make labeling changes to
their products. 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. All sponsors of marketed
prescription NSAIDs, including Celebrex (celecoxib), a COX-2 selective
NSAID, have been asked to revise the labeling (package insert) for their
products to include a boxed warning, highlighting the potential for
increased risk of cardiovascular (CV) events and the well described,
serious, potential life-threatening gastrointestinal (GI) bleeding
associated with their use. FDA regulation 21CFR 208 requires a
Medication Guide to be provided with each prescription that is dispensed
for products that FDA determines pose a serious and significant public
health concern. See the [FDA Web
site](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#NSAID) for
more information.

### 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\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Primary headache disorders

#### GUIDELINE CATEGORY

Management

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Neurology

#### INTENDED USERS

Health Care Providers\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To improve the medical treatment of headache

-   To discuss the theory and application of behavioral approaches in
    the management of primary headache disorders

#### TARGET POPULATION

Patients with primary headache disorders

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Cognitive behavioral therapy (CBT)

    -   Assertiveness training

    -   Cognitive restructuring

    -   Coping skills

2.  Relaxation training

    -   Progressive muscle relaxation

    -   Autogenic training

    -   Meditation

3.  Biofeedback

    -   Thermal biofeedback (hand-warming)

    -   Electromyographic (EMG) biofeedback

#### MAJOR OUTCOMES CONSIDERED

-   Headache frequency, intensity, and/or duration

-   Headache activity

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

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

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

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

Expert Consensus

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

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

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

The guidelines presented in this monograph represent the consensus of an
advisory panel of practitioners chosen by the National Headache
Foundation (NHF) for their expertise. In addition to incorporating the
US Headache Consortium\'s recommendations, their conclusions reflect
clinical experience and the most recent medical literature.

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

Not applicable

#### COST ANALYSIS

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

#### METHOD OF GUIDELINE VALIDATION

Not stated

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not applicable

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Behavioral Interventions for Management of Primary Head Pain**

When patients seek medical consultation for headaches, they often feel
like failures because, despite efforts at self-treatment, nothing seems
to provide relief. And they are usually concerned that their lives are
being ruined by disabling headaches. They cannot make plans for fear of
being unable to follow through or they may recognize that their
productivity at home, work, or school is diminishing. A few may wonder
if they have a brain tumor. Of course, they expect to receive a thorough
physical and neurological examination, appropriate lab tests, and
prescription medication for their pain. In addition, however, they need
to learn how to regain control over their condition and their lives.
Because disabling headaches affect the person\'s entire system and the
ability to function, the treatment plan needs to include behavioral as
well as pharmacological measures.

Behavioral intervention may be as simple as education about primary
headache disorders. If anxiety or depression is complicating the
headache pattern, cognitive behavioral therapy may be indicated. For
those patients who complain of cold hands and cold feet and are having
an increasingly difficult time in meeting the demands of home, work, or
school, relaxation training and biofeedback are useful. Behavioral
options help patients become involved in their own treatment, which
greatly assists compliance with the management plan and increases
satisfaction with treatment. In addition, behavioral interventions
increase the efficacy of the medications used to treat disabling
headaches. When patients meet certain criteria for therapy (see Table
below), behavioral treatments can be used to reduce headache frequency,
severity, associated disability, and the need for medication at the same
time that they instill a sense of control over headache attacks. This
review, directed to the primary care provider, covers the theory and
application of behavioral approaches in the management of primary
headache disorders.

+-----------------------------------------------------------------------+
| **Identifying Patients for Behavioral Interventions**                 |
+=======================================================================+
| -   Preference for nonpharmacologic interventions                     |
|                                                                       |
| -   Poor tolerance of pharmacologic treatment                         |
|                                                                       |
| -   Medical contraindications to pharmacologic treatments             |
|                                                                       |
| -   Inadequate response to pharmacologic treatment                    |
|                                                                       |
| -   Pregnancy, planned pregnancy, or nursing                          |
|                                                                       |
| -   History of excessive use of analgesics or other acute medications |
|                                                                       |
| -   Life stress, defiant coping skills, or comorbid psychological     |
|     disorder                                                          |
+-----------------------------------------------------------------------+

**Cognitive Behavioral Therapy (CBT)**

CBT combines cognitive therapy with behavior therapy. Individuals
identify, through the help of a therapist, certain thinking patterns
that are exacerbating the physical condition, in this case disabling
headaches. By these habitual, often automatic thoughts, distortions
occur in perception, making individuals feel anxious, depressed, or
angry, which leads to self-defeating behaviors. The behavioral part of
therapy teaches patients to stop these habitual reactions to troublesome
events. It also focuses on methods to calm the body and mind for
enhanced productivity, creativity, and a sense of relaxation and
control. Stress management training is a type of cognitive behavioral
therapy that teaches headache patients how to cope with everyday
stressors in order to avoid precipitating, exacerbating, or prolonging
headache attacks. Ideally, patients treated with CBT learn and adopt
strategies for dealing with their headache-causing stressors and
stressful situations. The duration of CBT depends on the individual, but
a course of treatment typically lasts from 3 to 12 sessions.

A wealth of evidence supports the use of CBT in the management of
primary headache. For example, in a recent review of 7 studies assessing
the clinical benefits of CBT in migraine patients, Campbell et al
estimated an average of 49% improvement in headache activity (a
composite score of headache frequency, intensity, and/or duration).
Similarly, among tension-type headache patients, CBT can reduce headache
activity by almost 50%. Judicious patient selection is crucial, however,
as one study found that patients with chronic head pain are minimally
responsive to cognitive behavioral interventions. Combining behavioral
modalities may also be helpful, particularly if a patient does not
respond to CBT alone. One group of investigators combined cognitive
behavioral training with biofeedback and achieved an average of 38%
improvement in headache activity. Examples of cognitive behavioral
approaches include assertiveness training, cognitive restructuring, and
coping skills. These approaches may increase treatment compliance among
headache patients.

*Assertiveness Training*

Some headache patients, especially migraineurs, have low self-esteem and
have a difficult time saying no, especially to family members, because
of fear of rejection, abandonment, or an aggressive confrontation. Many
patients in this situation might benefit from assertiveness training.

Assertiveness training involves 4 steps:

1.  Identify when a behavior is being asked that the person does not
    want to do - usually signaled by feelings of guilt, anxiety,
    ignorance, or dread

2.  Practice saying no in unimportant situations, such as to a cashier
    in a supermarket

3.  Say no to those who will understand, such as a friend

4.  Finally, say no to the person who demands behaviors that produce
    negative feelings

The process of identifying and mastering these issues can significantly
improve a headache patient\'s condition.

[Case Study]{.underline}

Christina is relaxing at home, tired after a busy day at the office. The
phone rings, and she thinks, \"Mom\'s nightly phone call is early.\"
After reporting to her mother the events of the day, she has to cut the
call short because of a headache that is developing behind her right
eye. These headaches are starting to happen more frequently, at least 4
times a week, and they usually occur after speaking to her mother.

[Recommendations]{.underline}

The guideline authors advised Christina to purchase an answering machine
and to screen her phone calls. They also suggested that she return the
phone calls at her convenience. Since her mother usually slept late, the
authors recommended that she call her mother at 7 a.m. (when Christina
first woke up), rather than wait for her mother to contact her. Within a
week, her mother stopped the practice of nightly phone calls. Soon
afterwards, Christina\'s headache frequency decreased to 1 or 2 per
month.

*Cognitive Restructuring*

Cognitive restructuring is identifying and changing negative self-talk
that occurs automatically. With a recurrent, episodic pain syndrome such
as headache, the individual may begin to feel like a victim, helpless,
at the mercy of the attack. In cognitive restructuring, a physician or a
psychologist and the patient create affirmations to replace negative
self-talk. Getting patients to make statements such as \"I deserve
health\" to replace \"I have to suffer like my mother\" is an important
first step in cognitive restructuring.

Some migraineurs feel like failures because they cannot control their
attacks. They judge themselves as unreliable because they cannot meet
their responsibilities and sometimes let others down. Disabling
headaches prevent them from doing what they want to do but may also be
punishment for being such a \"bad\" person. A powerful affirmation for
migraineurs is \"I forgive myself for being imperfect.\"

[Case Study]{.underline}

With the approach of her menstrual period, Phyllis feels anxious and
dreads this time of the month. She knows she will have to spend a day or
two in bed in a dark room, making excuses for not being able to work, to
care for her family, or to be with friends. Her mother used to suffer
the same way until she went through menopause. Phyllis wonders whether a
hysterectomy would get rid of these sick headaches.

[Recommendations]{.underline}

Instead of accepting that disabling headaches are inevitable and that
she is a failure who is destined to be miserable, Phyllis was asked to
recite affirmations (\"I deserve health and harmony\") to counteract the
negativity of her defeatist thinking. In addition, the guideline authors
worked to develop ways to reduce the frequency, severity, and duration
of her attacks. The authors instructed her that taking a nonsteroidal
anti-inflammatory drug (NSAID) beginning 2 or 3 days before the
anticipated menstrual migraine might reduce the intensity of the attack
or prevent it altogether. Emboldened by the success of treatment,
Phyllis developed a more positive outlook. Finally, the authors
initiated a program of exercise and biofeedback training, which further
shortened the duration of her menstrually-related attacks.

*Coping Skills*

Change is a common risk factor for disabling headaches. Once headache
patients recognize this trigger, they need to bolster their vulnerable
nervous systems with positive behaviors, such as exercise, recreation,
and self-nurturing activities. With these skills, individuals find that
control over headaches generalize to other aspects of life. No longer do
their headaches occur \"out of the blue.\"

[Case Study]{.underline}

It\'s allergy season and Fred seems to get a headache every day. He also
just started a new job and is learning the business. He used to exercise
regularly, but recently he has been skipping his morning walk, sometimes
for a week at a time. Lately, he seems to function at only one speed,
full steam ahead. At work, he takes an over-the-counter remedy and
closes his office door to get away from the pressure cooker at the
office.

[Recommendation]{.underline}

The guideline authors recommended that Fred find time to relax in his
office, using mental imagery to push his worries about his demanding
boss from his mind. The authors instructed him to visualize himself in
successful professional situations, such as winning a big contract for a
project he developed and presented to a client. The authors also pointed
out that he needed to reestablish the routine of a brisk workout before
he leaves for work. With these coping measures in place, the authors
were able to work with Fred to reduce his attack frequency and severity.

**Relaxation Training**

Relaxation training has been recognized as an effective therapy for more
than a century. In headache management, as with other nonpharmacologic
approaches, clinicians most often use relaxation training as a
prophylactic treatment. Three types of relaxation training are still
widely used today: progressive muscle relaxation, autogenic training,
and meditation (see table below); it is important to be familiar with
each of the types and to understand when and how to apply them in
clinical practice. Patients can usually be taught to incorporate 20 to
30 minutes of relaxation exercises into their daily routine within 10
treatment sessions, although sometimes fewer sessions are required.

Research supports the use of relaxation training in the treatment of
migraine and tension-type headache. Several studies have shown that
migraine patients who are taught to use relaxation techniques have been
able to reduce their headache activity by about 40%. Significantly,
thermal biofeedback combined with relaxation training can be less
effective in migraine prevention than relaxation alone. Tension-type
headache patients have been able to use relaxation training to cut
headache activity by about 40%, similar to rates seen in migraine.
However, when investigators combined relaxation techniques with
electromyographic biofeedback, they improved the rates of reduction of
tension-type headache activity to about 50%.

+-----------------------------------------------------------------------+
| **Types of Relaxation Training**                                      |
+=======================================================================+
| -   Progressive muscle relaxation: Alternately tensing and relaxing   |
|     muscle groups throughout the body                                 |
|                                                                       |
| -   Autogenic training: Using self-instructions of warmth and         |
|     heaviness                                                         |
|                                                                       |
| -   Meditation: Using a silently repeated word or sound               |
+-----------------------------------------------------------------------+

**Biofeedback**

In biofeedback, which uses principles derived from Ayurvedic medicine,
headache patients learn to monitor and regulate physiologic functions in
order to gain control of their condition. There are 2 major types of
biofeedback instruction: thermal (also called hand-warming) and
electromyographic (EMG). Thermal biofeedback records skin temperature
from a finger thermometer. EMG biofeedback measures electrical activity
in the muscles through an electrode. The downside to EMG biofeedback is
that the patient must return to the office to practice with the EMG
machine.

Biofeedback essentially instructs patients to regulate their nervous
system to respond to stressors through the parasympathetic rather than
the sympathetic system. To train headache patients well enough in
biofeedback techniques to realize benefits requires repetitive treatment
sessions. Patients need to practice at least 10 minutes daily;
otherwise, more sessions are required with a therapist.

When practiced regularly, biofeedback techniques can achieve significant
reductions in headache activity. In subjects with migraine, EMG
biofeedback has reduced headache activity by approximately 55%; thermal
biofeedback, when combined with relaxation training, reduced headache
activity by about 35%. Among tension-type headache patients, EMG
biofeedback cut headache activity by around 50%. Among tension-type
headache patients, EMG biofeedback, when combined with relaxation
training, reduced headache activity slightly less than EMG alone.

Both types of biofeedback training can be effective in headache
management but only when used in appropriate patients. For example, both
migraine and tension-type headache patients can use EMG and thermal
techniques, but cluster patients find that relaxation triggers a
headache during their cluster period. Although biofeedback techniques
are employed mainly as a preventive treatment, some patients may be able
to use them to modify the course of an existing headache, such as during
prodrome or mild headache, thereby reducing or eliminating the need for
acute medication.

In a 3-year study that compared the effectiveness of ergotamine tartrate
and relaxation-biofeedback training, both methods reduced headache
activity by 50% or more. However, over time, the subjects treated with
ergotamine were more likely to have obtained additional medical
treatment for headaches and to use either prophylactic or narcotic
medications.

Behavioral interventions for primary headaches have their origins in the
pioneering work of Wolff, whose careful observations led him to describe
how thoughts, behaviors, and bodily reactions evolve in response to
stress to induce migraine attacks. Green et al made the seminal
observation that headache sufferers tended to have finger temperatures
around 70 degrees Fahrenheit (F). By contrast, individuals without
severe headaches recorded finger temperatures of about 85 degrees F.

With recent work suggesting that migraine and tension-type headache are
manifestations of a continuum of head pain (as opposed to distinct
disease states), Wolff\'s ideas are equally persuasive for tension-type
patients. Thus, the available research on nonpharmacologic headache
therapies suggests a common-sense approach to headache management, in
which risk factors are avoided and health-promoting, protective factors
are encouraged (refer to Figure 8.1 of the original guideline document).
Teaching headache patients to regulate their reactions to stressors with
CBT, relaxation training, biofeedback - or some combination of
behavioral techniques - can improve overall therapeutic outcomes by
reducing headache activity as well as the need for acute and preventive
medications.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically
stated.

In addition to incorporating the US Headache Consortium\'s
recommendations, the conclusions reflect clinical experience and the
most recent medical literature.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

When patients meet certain criteria for therapy, behavioral treatments
can be used to reduce headache frequency, severity, associated
disability, and the need for medication at the same time that they
instill a sense of control over headache attacks.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

Drug therapy is constantly evolving as new research, clinical trials,
case reports, and opinions are published. Many of the drugs recommended
in these guidelines are not approved by the US Food and Drug
Administration (FDA) for treatment of headache, nor are they necessarily
the same as those therapies recommended by the manufacturer for labeled
indications. Their use in headache, however, may be supported by the
scientific literature and by the authors\' clinical experiences. While
efforts have been made to ensure accuracy, the authors and publisher do
not assume responsibility for the consistent updating of available
information for these guidelines, nor for any errors or omissions, nor
for any consequences thereof. The onus is on the practitioner to
evaluate recommendations in light of the clinical condition of the
patient and recent medical literature. The authors advise the
practitioner to consult other sources, especially the manufacturers\'
warnings and precautions, before prescribing any drug with which they
are unfamiliar. Practitioners are also advised that while these
guidelines will address the needs of many patients, there will be
circumstances calling for exceptions to these recommendations.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms\
Foreign Language Translations\
Patient Resources\
Slide Presentation

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

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

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Farmer K, Freitag F. Special treatment situations: behavioral
interventions for management of primary head pain. In: Standards of care
for headache diagnosis and treatment. Chicago (IL): National Headache
Foundation; 2004. p. 83-92. \[18 references\]

#### ADAPTATION

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

#### DATE RELEASED

2004

#### GUIDELINE DEVELOPER(S)

National Headache Foundation - Private Nonprofit Organization

#### SOURCE(S) OF FUNDING

National Headache Foundation

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Kathleen Farmer, PsyD, and Fred Freitag, DO

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: None available

Print copies: Available from the National Headache Foundation, 820 N.
Orleans, Suite 218, Chicago, IL 60610; Phone: (888) NHF-5552; Web
address: [www.headaches.org](http://www.headaches.org/)

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   The complete headache chart. Chicago (IL): National Headache
    Foundation (NHF); 2 p. Electronic copies available in Portable
    Document Format (PDF) from the [National Headache Foundation Web
    site](http://www.headaches.org/consumer/presskit/hachart.pdf)

-   National Headache Foundation fact sheet. Chicago (IL): National
    Headache Foundation (NHF); 2004 Oct. 2 p. Electronic copies
    available in Portable Document Format (PDF) from the [National
    Headache Foundation Web
    site](http://www.headaches.org/consumer/presskit/factsheet.pdf).

Print copies: Available from the National Headache Foundation, 820 N.
Orleans, Suite 218, Chicago, IL 60610; Phone: (888) NHF-5552; Web
address: [www.headaches.org](http://www.headaches.org/)

#### PATIENT RESOURCES

The National Headache Foundation (NHF) has created a variety of
educational resources for patients, including informative brochures, a
patient diary for migraines, Power Point presentations, and patient
guides; many of these resources are available in both Spanish and
English. Some of these items are available as print copies for purchase
through the [NHF online
store](http://www.headaches.org/consumer/storeindex.jsp). Electronic
versions of other resources are available through the consumer education
section of the [NHF Web
site](http://www.headaches.org/consumer/educationindex.html).

Print copies: Available from the National Headache Foundation, 820 N.
Orleans, Suite 218, Chicago, IL 60610; Phone: (888) NHF-5552; Web
address: [www.headaches.org](http://www.headaches.org/).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on April 12, 2005. The
information was verified by the guideline developer on April 26, 2005.
This summary was updated by ECRI on June 16, 2005, following the U.S.
Food and Drug Administration advisory on COX-2 selective and
non-selective non-steroidal anti-inflammatory drugs (NSAIDs).

#### COPYRIGHT STATEMENT

These guidelines are for reference purposes only and are not to be mass
produced. This information is copyrighted by the National Headache
Foundation, 2005.

### 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: 11/3/2008