MIGRAINE FAQ MIGRAINE FAQ MIGRAINE FAQ MIGRAINE FAQ MIGRAINE FAQ Migraine FAQ part II December 1997 (Drug Section in continuous draft) This FAQ was updated by Harriet Whitlock. She is now having a well earned rest The Drug related sections are being restructured by David Meldrum Comments are welcome at faq@meldrum.demon.co.uk This FAQ will be reposted on the first of each month with sugestions / requests incorporated. UPDATED catagories are marked with an * *1) Drug and non-drug Treatments + Drugs in pregnancy 2) Treatment Side Effects 3) Treatment centers 4) Government Agencies 5) Migraine associations 6) Support groups 7) Related associations 8) Equipment suppliers 9) Emoticons WARNING: the following information is informally collected and, unless otherwise stated explicitly, reflects knowledge gleaned from the group itself. Thus it does not represent expert opinion or knowledge. DO NOT attempt to use any information found here as a replacement for your doctor's or other professional's expert opinions. In the treatment of diabetes or thyroid deficiency for example there is no serious dispute that insulin and thyroxin are the best treatment. In illnesses where multiple treatments are offered it is practically always the case that none of them is completely effective or satisfactory. Such is the case in migraine. Preferences may to have more to do with drug company promotion than properly designed trials. Some Migraine drugs are taken prophylactically (to prevent the occurrence of an attack). Others are abortive (they stop an attack that has begun) also there are those drugs that are used to treat the peripheral symptoms of nausea, etc This section mainly uses Generic names, Trade names are (will be)in the index. 1. DRUG TREATMENTS TREATMENT OF THE ACUTE MIGRAINE ATTACK Most migraine headaches respond to analgesics such as aspirin or acetaminophen (US) paracetamol (UK) but as peristalsis is often reduced during migraine attacks the medication may not be sufficiently well absorbed to be effective; dispersible or effervescent preparations can be used. Ergotamine is used in patients who do not respond to analgesics; it should not be given in hemiplegic migraine. It relieves migraine headache by constricting cranial arteries but visual and other prodromal symptoms are not affected; vomiting may be made worse (but can be relieved by the addition of an anti- emetic ). The value of ergotamine is limited by difficulties in absorption and by its side-effects, particularly nausea, vomiting, abdominal pain, and muscular cramps. The recommended doses of ergotamine preparations should not be exceeded and treatment should not be repeated at intervals of less than 4 days. In some patients repeated administration of ergotamine may cause habituation and headache may be provoked, either by chronic overdosage or by sudden withdrawal of the drug. To avoid habituation the frequency of administration should be limited to no more than twice a month. It should never be prescribed prophylactically but In the management of cluster headache, a low dose of ergotamine is occasionally given daily for 1-2 weeks [unlicensed indication]. There are various ergotamine preparations designed to improve absorption and best results are obtained when the dose is given early in an attack. An aerosol form is acceptable to some patients. Sublingual ergotamine probably has no advantage over oral treatment. Trade Names Cafergot, Wigraine (also contain caffeine), Ergostat, dihydroergotamine (DHE) Unfortunately, many forms of ergot are disappearing from the market. Though Sandoz is discontinuing some forms of Cafergot, there are some generics available (Ercaf), Cafergot and Cafergot PB are still available thru a pharmacy in Orlando and some in Canada that will compound your written prescription. Check below under Equipment Suppliers for Thayler's. If you want ergotamine without the caffiene, sublingual (goes under the tongue) tablets of 2mg ergotamine tartrate are again availiable under the name Ergomar (from Lotus Biochemical). Sumatriptophen / Sumatriptan is a new 5-HT1 agonist. It appears to be of considerable value in the treatment of an acute attack but experience is relatively limited. There is much made of the side effects see later, but many feel that the major benefit this new class of drug offers far outweighs the known problems. Sumatriptan should not be taken until 24 hours after ergotamine has been stopped. Conversely ergotamine should not be taken until 6 hours after sumatriptan. Anti-emetics such as metoclopramide by mouth or, if vomiting is likely, by intramuscular injection, or the phenothiazine and anti-histamine anti-emetics, relieve the nausea associated with migraine attacks. Domperidone or prochlorperazine may be given rectally if vomiting is a problem. Metoclopramide has the added advantage of promoting gastric emptying and normal peristalsis. A single dose should be given at the onset of symptoms. Oral analgesic preparations containing metoclopramide are available (important: extrapyramidal effects particularly in children and young adults). Meclizine is an Anticholinergic, antiemetic Usual Usage: Motion sickness ANALGESICS Over the counter pain killers and medications Many of these can be used both as abortive or preventive measures. However, one must be careful of creating a problem with rebound headaches. Acetaminophen (US)/ Paracetamol (UK) (Tylenol Panadol etc) This drug is available worldwide under hundreds of trade names. It has proved very safe if used in the recommended dosages. 4G a day or less It is very toxic to the liver in moderate overdose. Large numbers of deaths occur annually from overdoses as low as 15 Grammes (30 tablets). Many of these deaths appear to truly accidental in that the patients had not realised that drugs with different names may contain Acetaminophen. NDAID = Non-Steriodal Anti-Inflammatory Drug. NSAIDS block the production of Prostaglandins; these are the chemicals released at the site of an injury, and believed to be responsible for producing pain and inflammation following tissue damage, and in immune reactions. Common NSAIDS are: Benorylate, Fenbufen, Ibrprofen, Indomethacin, Mefanamic Acid, Naproxen, Phenylbutazone, Piroxicam. NSAIDS are so-called to distinguish them from similar corticosteroid drugs. Abortive / some are used as prophylactics, work by inhibiting inflammation and prostaglandin formation, which has been implicated in vascular changes associated with migraine. Side effects of this group are mainly gastrointestinal Indigestion, drowsiness, anemia, confusion, reactions in aspirin sensitive people. Aspirin, Fenoprofen calcium (Nalfon) Ibuprofen (Motrin, Advil ,Nuprin, Nurofen ) Indomethacin (Indocin, Apo-Indomethacin) Ketoprofen ORUDIS: Has effect of slight lethargy. May need to lie down and let it take effect (45 minutes). Naproxen Sodium (Aleve Anaprox Naprosyn) Tolfenamic acid ( Tolectin ) ULTRAM Tramadol (Ultram US, Zydol Searle UK ) Has been recently introduced in the US & UK. It is claimed to produce analgesia by two mechanisms: an opioid effect and an enhancement of serotoninergic and adrenergic pathways. It is reported to have fewer of the typical opiod side-effects (notably, less respiratory depression, less constipation and less addiction potential) Dirk boujong (pain control unit, Univ. Erlangen, Germany) Writes that: Tramadol has been available in Germany for more than 10 years, and I consider it to be a very safe opioid (although every opioid is safe when used properly). The risk of addic- tion and of respiratory depression is VERY low and constipation is not a great problem, compared to other opioids. Nausea and vomiting are quite common, but anti-emetics like metoclopramide work very well. Combinations with any kind of non-opioid makes sense (e.g. ibuprofen) A very good combination is with dipyrone (metamizol), but i think it isnt available in the USA. Some people of this group posted a dosage maximum of 400mg/day. 500 or 600 may improve analgesia (e.g. in cancer patients), but more than 600 leads to much more side effects (switch to a stronger opioid). - it is a good drug, but no magic bullet ... The most frequently reported side effects have been dizziness, nausea, constipation, headache, and somnolence. These occurred at rates similar to those for codeine- containing analgesics. Tramadol is contraindicated for patients with hypersensitivity to the drug and in cases involving acute intoxication with alcohol, hypnotics, centrally acting analgesics, opioids, or psychotropic drugs. Seizures have been observed in laboratory animals receiving the drug in excessive doses. Tramadol should be used with caution in patients receiving monoamine oxidase inhibitors and in those with respiratory distress, intracranial pressure or head injury, acute abdominal conditions, or renal or hepatic disease. (Information excerpted fromttp://pharminfo.com/pubs/msb/tramadol.html) A daily aspirin is sometimes used as a preventative Ibuprophen is often used to potentiate the effect of Midrin COMBINATION Acetaminophen, Caffeine, Butalbital Esgic, Fioricet Aspirin, Caffeine, Butalbital Fiorinal Fiorinal/Fioricet are widely used, there are reports of habituation perhaps due to the butalbital. Darvocet consists of Darvon (propoxephene) and Acetaminopphen. Darvon has a chemical stucture similar to Methadone, *but*, it is *not* Methadone. ANALGESICS WITH ANTI-EMETICS Paracetamol 500 mg. Codeine phosphate 8 mg. Migraleve yellow tablets,(Charwell) Buclizine hydrochloride 6.25 mg. Paracetamol 500 mg. Codeine phosphate 8 mg: Migraleve pink tablets, Metoclopramide hydrochloride 5mg, aspirin 325 mg. Migravess (Bayer) Paracetamol 500 mg, metoclopramide hydrochloride 5 mg. Paramax(Bencard) ERGOTAMINE TARTRATE Indications: acute attacks of migraine and migraine variants unresponsive to analgesics. Cautions: risk of peripheral vasospasm (see advice below); elderly; should not be used for migraine prophylaxis; interactions: sumatriptan PERIPHERAL VASOSPASM Warn patient to stop treatment immediately if numbness or tingling of extremities develops and contact doctor. Contra-indications: peripheral vascular disease, coronary heart disease, obliterative vascular disease and Raynaud's syndrome, hepatic or renal impairment, sepsis, severe or inadequately controlled hypertension, hyperthyroidism, pregnancy and breast-feeding, porphyria Side-effects headache, nausea, vomiting and abdominal pain , muscle cramps, and occasionally increased headache (see also notes above); precordial pain, myocardial ischaemia, rarely myocardial infarction; repeated high dosage may cause ergotism with gangrene and confusion; pleural and peritoneal fibrosis may occur with excessive use. CAFERGOT Has side effect of sensitizing one to caffeine. Can cause vomiting. Also has tendency to cause extreme nasal congestion. Can cause chronic rebound headaches. WIGRAINE: Side effects include hallucinations if taken in excess . Sleeplessness (lots of caffeine in this drug) listlessness and upset stomach (if you do not eat). Can cause dependancy and cause rebound headaches. Ergotamine tartrate 1 mg, Caffeine 100 mg. Cafergot (Sandoz) Ercaf Ergotamine tartrate 2 mg. Lingraine (Sterling-Winthrop) Ergotamine tartrate 360 micrograms/metered inhalation.Medihaler-Ergotamine(3M) Ergotamine tartrate 2mg. cyclizine hydrochloride 50 mg. caffeine hydrate 100 mg. Migril (Wellcome) DIHYDROERGOTAMINE MESYLATE (A SEPARATE DRUG and not a version of ergotamine) Indications: migraine attack unresponsive to analgesics. Cautions; Contra-indications; Side-effects; see under Ergotamine Tartrate, as well as numbness and tingling of extremities, precordial pain reported; also contra-indicated in shock; avoid intra-arterial injection Dihydroergotamine mesylate 1 mg/ml. Dihydergot (Sandoz) DHE Injection, John Drager writes I've just looked at the treatments section of the migraine FAQ, and dihydroergotamine mesylate is talked about as being ergotamine. It's not. It's an entirely different drug from ergotamine. It doesn't constrict arteries quite as much as ergotamine tartrate. It is called an ergot derivative, and each drug in that class works on a slightly different combination of neurotransmitter receptors. The important thing is that it doesn't pose anywhere near the potential for rebound HA effect as ergotamine does. This was why the drug was developed in the first place, along with several other ergot derivatives, some of which are used in other medical applications. I'm just concerned that people will pass this drug and others by when they read the wrong information in the FAQ. Perhaps you could put some mention of web sites where all the information on all of the drugs mentioned in the FAQ could be looked up in detail. I use a drug database called Micromedex to look up drug info. I'm not sure if everyone can access it, but here's the web address. http://kochab.biostat.wisc.edu:81/prodsrch.html?CTL=pdx.SYS ISOMETHEPTENE MUCATE Indications: migraine attack Cautions: cardiovascular disease hepatic and renal impairment, diabetes mellitus, hyperthyroidism. Contra-indications: glaucoma; severe cardiac hepatic and renal impairment severe hypertension, pregnancy and breast feeding; porphyria Side-effects: dizziness, circulatory disturbances, rashes, blood disorders also reported. Isometheptene mucate 65 mg, Paracetamol 325 mg. Midrid (Shire UK) Isometheptene murate, dichloralphenazone,acetaminophen Midrin (US) LIDOCAINE /Lignocaine generic. A local anaesthetic recently tried for the relief of Migraine. In 1982 it was shewn that nasal drops of cocaine could relieve cluster headaches. This was followed up by trials with other local anaesthetics with the same effect. The mechanism is probably an effect on the spheno- palatine ganglion (SPG). Trials were suggested in migraine, early reports did shew an effect. The first controlled trial was reported in the Journal of The American Medical Association July 1996. This was a small trial which needs further follow up. The trial shewed that in ambulant patients attending emergency rooms migraine could be treated by lignocaine nose drops. The dose was 4% Lidocaine/lignocaine administered from a 1 ml syringe. 0.5ml was given over 30 seconds, a result was then awaited. If after 2 minutes there was no result the rest was given. The precise method of administration appears crucial since the intention is to reach the SPG. The patient lies supine (on his back) with the head hyperextended (stretched back) 45 degrees and rotated 30 degrees to the side of the headache. This would appear difficult (though not impossible) for reliable self administration. Results: 55% of ambulatory patients had a 50% reduction of the level of pain. There was no significant effect on the disability score (ability to get on with their job). This article says "Relapse of headache is common and occurs early after treatment" This result conflicts with some other results, but is the best there is at present. SUMATRIPTOPHEN / SUMATRIPTAN Indications: acute treatment of migraine attacks; cluster headache (subcutaneous injection only) Cautions: not for prophylaxis; conditions which predispose to coronary artery disease (exclude pre-existing cardiac disease); hepatic or renal impairment; pregnancy and breast feeding; see also notes above; recommended as monotherapy and should not be taken with other acute migraine therapies- should not be taken until 24 hours after stopping an ergotamine-containing preparation (conversely, ergotamine- containing preparations should not be taken until 6 hours after sumatriptan); avoid concomitant use with MAOIs (including moclobemide), selective serotonin re-uptake inhibitors (SSRIs) or lithium; DRIVING. Drowsiness may affect performance of skilled tasks (e.g. driving) Contra-indications: ischaemic heart disease; previous myocardial infarction; Prinzmetal's angina, coronary vasospasm; uncontrolled hypertension. Following reports of chest pain and tightness (coronary vasoconstriction) it is emphasised that sumatriptan should not be used in ischaemic heart disease or Prinzmetal's angina and that use with ergotamine should be avoided. Side-effects: chest pain and tightness (may be intense, involve throat, and mimic angina pectoris- vasospasm may result in arrhythmia, ischaemia or myocardial infarction - discontinue until appropriate investigations and also consider possibility of anaphylaxis), sensations of tingling, heat heaviness, pressure, or tightness in any part of the body; flushing, dizziness, feeling of weakness, parasthesia; fatigue, drowsiness, altered liver function tests, transient increase in blood pressure, hypotension, bradycardia, seizures reported; nausea and vomiting also reported; anaphylaxis also reported; transient pain at injection site. Chest constriction, jaw locking, neck stiffness and, needless to say, the migraine could get worse (if that's possible) from these things, if not From the medication itself. Does not seem to work on tension headaches. Lab/hospital reports indicate possible short term increase in blood pressure, usually not harmful. However, U.S. News & World Report, in the January 9, 1995 issue, reported anecdotal incidents of serious side effects from Imitrex. According to the article, 43 deaths and 139 life threatening reactions have been linked to sumatriptan. The article specifically refers to the death of a woman who, when injected with Imitrex by a doctor, suffered a fatal cardiac arrest. A Glaxo subsidiary, has sent an advisory letter to doctors and has revised the medication's label. Also: Excerpted from the November 1994 issue of Medical Sciences Bulletin , published by Pharmaceutical Information Associates, Ltd. " Extensive evaluations of the cardiovascular effects of sumatriptan have turned up little evidence that the chest symptoms reflect changes in myocardial function. There is evidence, however, that the chest pain may be esophageal in origin. In a double-blind, crossover study, Houghton et al. examined 24 volunteers after subcutaneous administration of either placebo or a large dose of sumatriptan (16 mg). Five patients had chest pain, which occurred 4 to 23 minutes after injection and lasted 2 to 45 minutes. Sumatriptan did not alter the electrocardiogram for any patient, but it did increase the strength and duration of esophageal contractions in all patients, sometimes markedly, without increasing the velocity of propagation. . . . 'The effect of sumatriptan on esophageal function provides an alternative explanation for the chest symptoms,' concluded the investigators." (Houghton LA et al. Lancet. 1994; 344: 985-986.) The following was contributed by Thomas A. Daugherty: I get the single dose vials, and use an ultra-fine insulin syringe to inject myself. I highly recommend this method to anyone who uses Imitrex.... for the following reasons: 1. The drug is MUCH cheaper in this form...5 doses is about $115 in the US...where 2 doses of the other is about $50. 2. There is much less pain at the time of injection....the stinging sensation is GREATLY reduced! 3. There is much less chance of wasting the dose, if you accidently set the autoinjector off, you're out $30 or so... The single dose vials come in boxes of 5 and are available at any pharmacy, although they will probably have to special order them for you. IMPORTANT: DO NOT USE IMITREX OR SUMATRIPTAN WITH DHE OR ANY ERGOTAMINE COMPOUND Can be serious or fatal if this combination is used. Dose; by mouth, 100mg (50mg effective in some patients) as soon as possible after onset (patients not responding should not take second dose for same attack); dose may be repeated if migraine recurs ; max. 300mg in 24 hours The recommended doses vary between countries. Early studies were done with 100, 200 & 300mg oral tablets. The original license was for 100mg and later 50mg. In the USA the FDA requested information at lower doses. The trial that led to the approval of oral Imitrex showed the same 70% response rate no matter whether 25 mg, 50 mg, or 100 mg was used. This trial has been described as "pivotal",*but* The trials were on only 259 and 187 patients treating one attack. Recognize that these rates don't reflect what happens in individual patients. Therefore you may or may not repsond to 25 mg. But because the side effects are lower at the lower dose, it is worth trying this dose first, and then going up in dose if it doesn't work. Watch the group for individual reports. By subcutaneous injection using auto-injector,6mg as soon as possible after onset (patients not responding should not take second dose for same attack); dose may be repeated once after not less than 1 hour if symptoms recur ; max. 12mg in 24 hours ELDERLY over 65 years and CHILD not recommended IMPORTANT: Not for intravenous injection which may cause coronary vasospasm and angina Imigran (Glaxo UK) Imitrex (Glaxo US) PURE OXYGEN Abortive Commonly used to treat cluster headaches. The dose regimen is critical, a whiff of Oxygen is not enough. STEROIDS These are extremly valuable drugs in some life threatening situations. They have many side effects, weight gain, thinning skin, osteoporosis, etc. Their use is unlikely to be justified on a continuing basis in headache. Prednisolone. Has been used to treat cluster headache and was the most effective drug in trials some years ago. In one rare form of headache, Temporal Arteritis, steroid treatment is mandatory. Untreated temporal arteritis may lead on to blindness, treated the headache goes and the prevention of blindness totally outweighs any side effects. Temporal arteritis normally occurs only in the elerly. PROPHYLAXIS OF MIGRAINE Where attacks are frequent, search should be made for provocative factors such as stress or diet (chocolate, cheese, alcohol, etc.). Benzodiazepines should be avoided because of the risk of dependence. In patients with more than one attack a month, one of three main groups of prophylactic agents may be tried: pizotifen, beta-blockers, or antidepressants (even when the patient is not obviously depressed). Long term treatment with any of these prophylactic drugs is undesirable; the need for continuing therapy should be reviewed at intervals of about 6 months. Oral contraceptives may precipitate or worsen migraine; patients reporting a sharp increase in frequency of migraine or focal features should be recommended alternative contraceptive measures. Pizotifen(UK) Pizotyline (US) is an antihistamine and serotonin antagonist structurally related to the tricyclic anti-depressants. It affords good prophylaxis but may cause weight gain. To avoid undue drowsiness treatment may be started at 500 micrograms at night and gradually increased to 3 mg; it is rarely necessary to exceed this dose. SANDOMIGRAN: *After prolonged use, hepatotoxic effects might occur and patients should be advised to report for adequate laboratory evaluation.* Adverse Effects: Increased appetite, weight gain and drowsiness are the most frequent side effects. An appropriate diet should berecommended by the physician for patients benefiting from the drug but gaining excessive weight. A gradual increase in the dosage of pizotyline is recommended to mimimize or reduce the incidence of drowsiness. Relative to theoccurrence of the above-mentioned reactions the following adverse effects have been less frequently observed: fatigue, nausea, dizziness, headache, confusion,edema, hypotension, depression, weakness, epigastric distress, dry mouth, nervousness, impotence and muscle pain. The beta-blockers propranolol, nadolol, and timolol are all effective. Propranolol is the most commonly used in an initial dose of 40 mg 2 to 3 times daily by mouth. Beta-blockers may also be given as a single daily dose of a long-active preparation. The value of beta-blockers is limited by their contra-indications and by interaction with ergotamine Work by preventing arterial dilation, blocking platelet aggregation and decreasing adhesiveness which decreases prostaglandins Includes: Timolol (Blocadren), Nadolol (Corgard), Propranolol (Inderal), Metoprolol (Lopressor),Atenolol (Tenormin) Side Effects All beta-blockers cause some side effects. The side effects vary, but there are effects fundamental to beta-blockers, slow pulse, fatigue, cold extremities. They all can make asthma worse. Some are fat soluble and cross the "blood brain barrier" and some are more water soluble and dont affect the brain directly. The fat soluble ones tend to cause sleep disturbance and nightmares, the water soluble ones are less likely to have that effect. In migraine it is probably the effect on blood vessels and not a direct effect on the brain that helps. So the fat soluble ones are not noticably better in treating migraine. Calcium-channel blockers e.g. verapamil and nifedipine may be useful in migraine prophylaxis, they work by promoting vasoconstriction Includes: Verapamil (Calan Isoptin), Nimodipine (Nimotop), Nifedipine (Procardia),Flunarizine (Sibelium) Side Effects VERAPAMIL (Calan): tiredness, dizziness, nausea, Atrioventricular heart block Antidepressants may usefully be prescribed in a dose, for example, of amitriptyline 10 mg at night, increasing to a maintenance dose of 50 to 75 mg at night. Even when the patient is not depressed. Individual responses vary, there are no completely valid trials of all the antidepressants in migraine. Watch the group for personal views. A major problem with antidepressants is their name. They do not act solely by affecting mood. Their use can be seen to imply that a migraine sufferer is a sad person needing encouragement. This is *not* the case and there is no scientific evidence of such a link. Their mode of action appears to be related to the metabolism of serotonin (aka 5-hydroxytryptamine, 5HT). Side effects vary from person to person, dry mouth and sedation are common, some report insomnia with these drugs. TRICYCLIC ANTIDEPRESSANTS (contributed by Aharon D. Shulimson, Ph.D. ) Desipramine and nortriptyline are tricyclic antidepressants which are similar to amitriptyline (Elavil). Amitriptyline, which is rather sedating, is used in our headache clinic when patients are not sleeping well. We often find that normalizing sleep can help reduce migraine activity substantially. Some people find amytriptyline to be too sedating. In those instances, nortriptyline (less sedating) or desipramine (least sedating) are used. Amitriptyline(Elavil,Endep), Nortriptyline (Pamelor,Aventyl), Imipramine, Desipramine (Norpramin, Pertofrane). SSRIs Selective Serotonin Reuptake Inhibitors Fluoxetine hydrochloride (Prozac) Paroexetine HCl (Paxil US, Seroxat UK) Nefazodone (Serzone BMS US) Monoamine Oxidase Inhibitors (MAO`s) Prophylactic May relieve migraines in people for whom it fails to relieve depression Includes: Phenylzine sulfate (Nardil) Isocarboxazid (Marplan) NARDIL: *It is extremely important to remain tyramine free while taking this medication.* blurred vision, decreased amount of urine, decreased sexual ability, dizziness or lightheadedness (mild), drowsiness, increasedappetite or weight gain, sweating, tiredness, troublesleeping Cyproheptadine an antihistamine with serotonin-antagonist and calcium channel-blocking properties, may also be tried in refractory cases. Cyproheptadine Includes: Peritactin Clonidine (Dixarit) is probably little better than placebo and may aggravate depression or produce insomnia. PIZOTIFEN Indications: prevention of vascular headache, including classical migraine, common migraine and cluster headache Cautions: urinary retention; closed-angle glaucoma, renal impairment; pregnancy and breast feeding; DRIVING: Drowsiness may affect performance of skilled tasks (e.g. driving); effects of alcohol enhanced Side-effects: antimuscarinic effects, drowsiness, increased appetite and weight gain; occasionally nausea, dizziness Pizotifen (as hydrogen malate) Sanomigran (Sandoz UK) Sandomigran (Sandoz US) CLONIDINE HYDROCHLORIDE Indications: prevention of recurrent migraine (but see notes above), vascular headache, menopausal flushing; hypertension, Cautions: depressive illness, concurrent antihypertensive therapy; avoid in porphyria Side-effects dry mouth, sedation, dizziness, nausea, nocturnal restlessness; occasionally rashes Clonidine, hydrochloride 25 micrograms. Dixarit (Boehringer Ingelheim) LITHIUM Prophylactic / abort cluster headaches Drug Class: Antidepressant,antimanic,anticonvulsant Other names: Eskalith, Carbolith, Lithizine Lithobid (Blood levels must be monitored carefully) METHYSERGIDE Indications: prevention of severe recurrent migraine and cluster headache in patients who are refractory to other treatment and whose lives are seriously disrupted (important: hospital supervision only, see notes above) This is a highly effective drug which is probably under used because of its side effects. Cautions: history of peptic ulceration; avoid abrupt withdrawal of treatment; after 6 months withdraw for reassessment for at least 1 month (see also notes above) Contra-indications: renal, hepatic, pulmonary and cardiovascular disease, severe hypertension, collagen disease, cellulitis, urinary tract disorders, cachectic or septic conditions, pregnancy, breast-feeding Side-effects: nausea, vomiting, heartburn, abdominal discomfort, drowsiness and dizziness occur frequently in initial treatment; psychic reactions, insomnia, oedema, weight gain, rashes, loss of scalp hair, cramps, arterial spasm, paraesthesias of extremities, postural hypotension, and tachycardia also occur. Retroperitoneal and other abnormal fibrotic reactions may occur on prolonged administration, requiring immediate withdrawal of treatment (May only be used in six-month cycles; longer use may result in fibrosis of chest and abdominal tissue) Methysergide 1 mg (as maleate). Deseril (Sandoz UK) Sansert ANTI CONVULSANTS VALPROIC ACID, DIVALPROEX SODIUM GABAPENTIN (NEURONTIN) Drug class: Anticonvulsant Usual Usage: anticonvulsant(seizure medicine) Recent trials have shewn clear benefits of this class of drugs in migraine. Several new possibilities of research examing the pathways in the brain affected have been opened up. *Not for pregnant women* VALPROIC ACID(from post by L.D.Sitwell) "The hepatitis syndrome can occur in infants given this drug, but adults are rarely affected in this way. I have prescribed it for migraine hundreds of times and it has never led to this complication. The most prominent side effects are weight gain, stomach upset and tremor." Also, vertigo, weakness, fatigue. You should have frequent liver function tests run. INDEX This is still under construction as at 1 September 1996 Comments/constructive suggestions are welcome at faq@meldrum.demon.co.uk Actron Generic Name: Ketoprofen (NSAID) Antivert......Generic Name: Meclizine (Anticholinergics,Antiemetic) Anexia Generic Name: Hydrocodone Apo-Indomethacin........... Indomethacin Axotal Combination Butalbital & Aspirin BC-105 .... Generic Name:.Pizotifen Calan .... Generic Name: Verapamil Carbolith, Generic Name: Lithium Catapres......Generic Name: Clonidine Compazine.....Generic Name: Prochlorperazine Darvocet Combination Propoxyphene, Acetaminophen DHE ( D.H.E. 45 Injection) Generic Name: Dihydroergotamine Mesylate Depakote,Depa,Depakene,Deproic Generic Name: Valproic Acid, Divalproex sodium Dolobid.......Generic Name: Diflunisal Doxepin.......Generic Name: Doxepin HCl Dramamine Generic Name: Dimenhydrinate (Anti emetic) Dramamine II Generic Name: Meclizine (Anti emetic) Duradrin Compound Generic version of Midrin Efexor (UK) Generic Name: Venlafaxine (SNRI Antidepressant) Effexor(US) Generic Name: Venlafaxine (Serotonin Noradrenaline Reuptake I) Elavil...... Generic Name: Amitriptyline HCl Esgic.........Compound: Acetaminophen, Caffeine, Butalbital Eskalith......Generic Name: Lithium Fioricet......Generic Name: Acetaminophen, Caffeine, Butalbital Fiorinal .....Generic Name: Aspirin, Caffeine, Butalbital Flexeril......Generic Name: Cyclobenzaprine Hydergine/Gerimal Ergoloid Mesylates Imipramine Tricyclic Antidepressant Imigran Generic Name: Sumatriptan / Sumatriptophen Imitrex Generic Name: Sumatriptophen Indocin Generic Name: Indomethacin Klonopin Generic Name: Clonazepam Drug Class: Benzodiazepines Lithobid Generic Name: Lithium Lithizine Generic Name: Lithium Midrin Isometheptene murate,Dichloralphenazone, acetaminophen Nadolol Generic Beta Blocker Nardil........Generic Name: Phenylzine sulfate Neurontin Generic Name: Gabapentin (anti-epileptic) Nurofen Generic Name: Ibuprofen NSAID Orudis Generic Name: Ketoprofen NSAID Pamelor Generic Name: Nortriptyline HCl Aventyl Paxil...... Generic Name: Paroxetine HCl SSRI Antidepressant Phenergan Generic Name: Promethazine HCl (Antihistamine) Prozac Generic Name: Fluoxetine SSRI Antidepressant Reglan........Generic Name: Metoclopramide REPAN CF......Compound: Butalbital and tylenol but not caffeine. Sanomigran Generic Name: Pizotifen/Pizotyline Sansert Generic Name: Methsergyside Serzone Generic Name: Nefazodone (Antidepressant) Sibelium Generic Name: Flunarizine Soma Generic Name: Carisoprodol (Muscle Relaxant) Stadol Generic Name: Butorphanol Tartrate Thorazine Generic Name: Chlorpromazine HCl Toradol Generic Name: Ketorolac Tromethamine Tylenol 3 Compound: Acetaminophen, Codeine Ultram Generic Name: Tramadol hydrochloride Valium Generic Name: Diazepam (Benzodiazepine tranquilizer) Viocodin Generic Name: Hydrocodone Vistaril Generic Name: Hydroxzine Zoloft Generic Name: Sertraline SSRI Antidepressant Pregnancy Here is a brief summary of drugs in pregnancy (wrt migraine) -- mostly from "Drugs in Pregnancy" 3rd ed. Australian Drug Classification Committee. (It closely parallels your FDA classification) The classifications refer to drugs when taken in the recommended or prescibed manner only. =================================================== The following drugs are safe in pregnancy, and have a Category A pregnancy rating in Australia: --codeine phosphate; dihydrocodeine. --paracetamol (acetaminophen) --metoclopramide (Reglan, Maxolon) --diphenhydramine (Benadryl); dimenhydrinate (Dramamine); doxylamine (and most other sedative antihistamines --but check) My favourite safe treatment for migraine attacks in pregnancy is intramuscular Maxolon and oral Panadeine Forte (codeine 30 + paracetamol 500 ie. Tylenol with codeine No.3) or Mersyndol Forte (above + doxylamine) or IM Pethidine (Demerol) if necessary. (Cat A is the safest possible rating: Officially: "Drugs which have been taken by a large number of pregnant women without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed". ====== Drugs to be avoided in pregnancy if possible (Cat C = drugs which have caused harmful, but often reversible effects of the fetus, but not malformations) are : All NSAIDs (naproxen, ibuprofen, diclofenac -- Aleve, Motrin, Voltarol, Toradol etc.); aspirin (avoid in last trimester; prochlorperazine (Compazine); promethazine (Phenergan); tricyclic antidepressants (Elavil etc), benzodiazepines (Valium etc); ergotamine; DHE; methysergide (Sansert, Deseril); barbiturates. Sometimes these effects are dependent on the stage of pregnancy and other factors. The butalbital is safe in intermittent doses after the first 3 months. The advice for barbiturates is "continuous use during pregnancy should be avoided". As far as narcotics go, they are safe. Morphine, pethidine (demerol) etc are given a Cat C, but the proviso is: "The only concern with these drugs in pregnancy is with their use during labour when narcotic analgesics may cause respiratory distress in the newborn infant" So the comparative safety of narcotics is vindicated yet again. =========== Drugs known or suspected to increase the incidence of fetal malformations (Cat D) are: carbemazepine (Tegretol), valproic acid/divalproex (Depakote, Epilim, Depakene etc.). Don't take them even if you think you're pregnant! ============ Cat X = drugs which have a high incidence of causing fetal malformations: Eg; isotretinoin (Accutance, for acne); misoprostol (Cytotec -- for stomach ulcers -- beware NSAIDS with added misoprostol eg. Arthrotec, Napratec); Thalidomide. Little needs to be added here. ============ There are a wide range of drugs in Categories B1-3 B1 = no evidence of harm in animal studies, no evidence but limited experience in use in pregnant humans: Examples are: pizotifen (Sandomigran); gabapentin (Neurontin) B2 = no evidence of harm, but inadequate animal studies and limited human experience; Eg. hyoscine; mebeverine (anti-cholic drugs) B3 = limited experience in humans, but no evidence of harm. Animal studies show increase in fetal damage, significance of which is not known in humans. Eg; sumatriptan (Imitrex); clonidine (Catapres, Dixarit)) Obviously, it's the Cat B and C drugs which give most decision problems, and a risk/benefit analysis has to be made. Often the stage of pregancy and general health issues are factors. All these categories are only a guide, and the rules are a bit laxer during the second trimester. In general acetaminophen is safer than aspirin, ergo Fioricet is better then Fiorinal etc. But every pregnancy is different, so check with your GP, obstetrician or pharmacist. Raymot (GP) ========== Brisbane, Australia ============== International CNS and Psychotropic Drug Dictionary: http://www.powerup.com.au/~rmottare/drugs.htm [It just keeps getting better! -- suggestions still welcome] -------------------------------------------------------------- -------------------------------------------------------------- Non-drug and some alternative Treatments ------------------------------------------------------------- -------------------------------------------------------------- BIOFEEDBACK Article Submitted by, Jack Sandweiss, Sandweiss Biofeedback Institute Beverly Hills, CA Past President Biofeedback Society of California "Biofeedback refers to a class of physiological training techniques centered around the "feeding back" (displaying) of physiological measures of clinical interest to the person undergoing such training. Specifically designed bioelectric instruments are used for this purpose. The goal is voluntary control of one or more physiologcal parameters in order to bring about a desired clinical outcome. Although biofeedback "began" with the control of autonomic signals (such as heart rate and skin conductance), the most commonly used biofeedback instrument has always been a surface electromyogram (EMG), which measures skeletal (voluntary) muscle contraction (or tone). Regarding migraines, the biofeedback technique usually employed is known as peripheral temperature training or "handwarming". This is a vasodilatory exercise and is easily learned by most people with a feedback thermometer. If brought about during the aura phase of a classic migraine, in some instances, the aura aborts and there is no subsequent headache. Some common migraineurs experience reduced frequency of attacks with routine practice of this technique. There is far more clinical experience than experimental proof of these phenomena. Most reviewers of this medical literature point out that poorly designed experiments make determination of efficacy difficult. Biofeedback therapy is not psychotherapy, and, not relaxation therapy, although biofeedback techniques may be used adjunctively in these situations. However, much clinical work is done in physical rehabilitation, and, in many of these instances, biofeedback is utilized to *increase* activity of a particular physiological parameter. Biofeedback is based upon Western science. It has nothing to do with "holistic" health. As the practice of biofeedback is not regulated by any state, consumers face a difficult challenge in choosing a biofeedback therapist who has been scientifically trained, and who has basic medical knowledge in medical pathology, effects of ongoing medications, and so forth. COMBINATION HERBS Relax (in New Zealand) - prophylactic remedy Contents: tablets are made up of B complex vitamins (10 mg each). They also contain per tablet; Valerian 120mg,Scullcap 160mg, Passion flower 60mg,Pulsatilla 60mg and Mistletoe 120mg. FEVERFEW (Thanks to Trudy Crossman for the following information): NOTE: Feverfew is a prophylactic remedy. I.E.it only works to prevent migraines if taken regularly over time.Once a migraines has begun, feverfew will NOT help the current attack. According to "Graedon's Best Medicine": "Feverfew (Chyrsanthemum parthenium) is a common flowering plant akin to the daisy family.Feverfew contains chemicals that inhibit secretions of blood platelets and white blood cells. The platelets secrete serotonin, which constricts blood vessels and hence contributes to migraine headaches. The active ingredient in feverfew is Parthenolide. Several studies have been done to validate its effectiveness. A placebo-controlled study resulted in 24% reduction in the number of migraines, and lessened the severity of those migraines that did occur. This study used a ground-up leaf dosage of 80 mg. DOSAGE: To duplicate the dosage in the clinical studies most people must eat a leaf or two a day, or ingest 1-2 capsules.This assumes that you are getting potent feverfew. According to Dr.Tyler of Purdue University School of Pharmacy, you're very unlikely to get a quality product in the United States.Hence, he suggests more than the recommended dosage of standard store-bought feverfew capsules. Dr. Tyler says taking up to 6 300-400mg tablets daily is perfectly safe. There is research to suggest that eating a whole leaf is better than using the ground,dried plant in tablet form. You should be able to pick up a bottle of feverfew at your favorite healthfoods store. Many have had good experience with the brand name "Nature's Way". FEVERFEW: Eating the whole leaf may cause irritation or ulcers on the mouth and tongue. Ulceration is not a problem with the capsule form of the herb. Also, avoid it if you are allergic to chamomile or chrysanthemum. Those with blood clotting disorders or taking anti-clotting drugs should probably avoid feverfew as well. CHIROPRACTIC neck adjustments: Neck "adjustments" made by chiropractors are controversial. The procedure, which consists of "twisting" of the neck.There have been some instances where a "stroke" has been induced because an adjustment has caused the major blood vessels that weave through the neck bone to become stressed and in some cases to rupture 3. TREATMENT CENTERS The usual disclaimers apply to the information below. Call ahead to ask about what facilities are available at each center before making an appointment. Some offer full medical team treatment (several doctors from related specialties), some are strictly out patient clinics run primarily by neurologists, some operate as part of a full-fledged hospitals complete with in patient facilities. CALIFORNIA Sandweiss Biofeedback Institute 436 N. Bedford Drive, #301 Beverly Hills, CA 90210 310-274-0981 The new address for the California Medical Clinic for Headache is: California Medical Clinic for Headache 16500 Ventura Blvd. , #245 Encino, CA 91436 Phone number is the same. 818-986-4248 Connecticut: The New England Center for Headache Drs. Fred Sheftell & Alan Rapoport 778 Long Ridge Road Stamford, CT 06902 (203) 968-1799 ILLINOIS Larry Robbins, M.D He wrote Headache Help, Houghton Mifflin, which has had excellent reviews. He also wrote :- Management of Headache & Headache Medications. Springer-Verlag 1994. A superb book, which would have saved me much effort if I had known about it before writing this FAQ We are lucky in that he contributes to this group. How he finds the time I have no idea Northbrook, Ill. tel 847 4809399 fax 847 9409044 Dr. Alan Hirsch Neurologist and Smell Clinic Water Tower Place Chicago LOUISIANA Tulane University Medical Center Headache Clinic 7th Floor 1415 Tulane Av. New Orleans, LA (Not sure of the ZIP) (504) 584-2589 MASSACHUSETTS The Falkner Hospital houses the Graham Headache Centre 1153 Centre Street Boston MA. Phone (617) 983-7246 NEW JERSEY Headache)Neurology of Central New Jersey Mark Lazar MD 527 Cranbury Road Suite A5 East Brunswick, NJ 08816 Phone (908) 254)5101 OHIO Cincinnati Headache Institute The Drake Center Galbraith Rd. Cincinati OH 513-948-2710 PENNSYLVANIA Franklin Headache Institute Germantown TEXAS Dr. Ninan T. Matthew Houston Headache Clinic Park Plaza Professional Bldg. 1213 Hermann Dr., Suite 350 Houston (713)528-1916 4. GOVERNMENT AGENCIES ***5. MIGRAINE ASSOCIATIONS AASH The American Association for the Study of Headaches Referral line 1-609-845-0322 ACHE ACHE is a patient-physician partnership dedicated to advancing the treatment and management of headache and to raising public awareness of headache as a valid, biologically-based illness. 1-800-255-ACHE M.A.G.N.U.M., Inc, (Migraine Awareness Group: a National Understanding for Migraineurs), is an incorporated, non-profit organization founded in 1994 with the express mission "to bring public awarenss to the knowledge that migraine is a true organic neurological disease...." M.A.G.N.U.M.,headquartered in Washington, DC, is working to change federal legislation to include migraine as a disability, to direct migraineurs to positive medical organizations and quality regional medical facilities, and to increase public awareness of fact vs fiction of migraines. M.A.G.N.U.M., Inc. may be reached at: M.A.G.N.U.M., Inc. 315 Cameron Street, 2nd Floor Alexandria, VA 22314, USA Phone: (703) 739-9384 Fax: (703) 739-2432 NATIONAL HEADACHE FOUNDATION membership 15.00 dollars, quarterly newsletter, non- profit research organization, referral service New Address: ----------- National Headache Foundation 428 West St. James Place 2nd Floor Chicago, IL 60614-2750 The phone number remains the same at: 1-800-843-2256 THE BRITISH MIGRAINE ASSOCIATION 178A, High Road, Byfleet, Surrey, KT14 7ED Help line +44-1932-352468 THE MIGRAINE TRUST 45, Great Ormond Street, London, WC1N 3HD ****6. SUPPORT GROUPS PLEASE NOTE: I cannot be held responsible for the accuracy of the phone numbers found here. A. ACHE RUN SUPPORT GROUPS. April 23, 1996 ACHE Headache Support Groups ---------------------------- ACHE support groups are open to all members of the American Council for Headache Education at no additional charge. If there is no group presently meeting in your area perhaps you would be willing to start a group. If you are interested, our office will be happy to tell you how to proceed. Please write and inquire about the initial criteria needing to be met in order to get a group started. American Council for Headache Education (ACHE) 875 Kings Hwy, Suite 200 Woodbury, NJ 08096 (609) 845-0322 (phone) (609) 384-5811 (fax) LOCATION CONTACT -------- ------- Arizona, Phoenix Renee Eisenbeis (602) 406-3434 California Los Angeles Susan Shuster (310) 472-9981 Sacramento Nancie Wisemen (916) 443-6238 (w) (916) 394-9132 (h) Colorado Boulder Marcia Seawell (303) 832-6236 Colorado Springs Marcia Seawell (303) 832-6236 Denver Marcia Seawell (303) 832-6236 Evergreen Marcia Seawell (303) 832-6236 Connecticut, Stamford Andrea DeFusco (203) 255-9409 Florida Pensacola Richard Weaver,PhD (904) 474-0740 Tampa Ken Everett, RN (813) 875-8800 Miami Joe West (305) 598-0702 Winter Park Creta Hildebrandt (407) 331-1104 St. Petersburg Betty Wagner (813) 345-0716 West Palm Beach Joan Baker, RN (407) 845-0500 Georgia, Atlanta Maureen Moore (404) 501-1000 Illinios, Champagne-Urbana Terri Auteberry, RN (217) 383-3440 Kentucky, Louisville Debbie Lockridge, RN (502) 895-7265 Maryland, Baltimore Pam DeSantis (410) 298-4056 Massachusetts, Boston William Baker, PhD (617) 983-7268 Michigan Ann Arbor Scott Madden (313) 973-1155 Midland Scott Madden (313) 973-1155 Kalamazoo Scott Madden (313) 973-1155 Lansing Scott Madden (313) 973-1155 Grand Rapids Scott Madden (313) 973-1155 Livonia Scott Madden (313) 973-1155 Minnesota, Minneapolis Nancy Kirby (612) 636-2564 Missouri, Springfield Carolyn Hart (417) 831-4844 New Hampshire Hanover Susan Rankin (802) 633-3214(w) Bedford Suzanne Kane (603) 472-7450 New York New York City Dorothy Figlioli (212) 794-3550 Long Island Dr. Robert Duarte (516) 365-2510 Westchester Debra Naughton (203) 267-9610 New Jersey, Lakewood Sandra Eklund, NP (908) 367-8280 North Carolina Charlotte-Davidson Robin Hudson, RN (704) 892-3712 Greensboro Iris Paul (910) 674-9930 Raleigh Paula Smith (919) 231-2306 Ohio, Cincinnati Laurie Housemeyer (513) 624-8197 Oklahoma Oklahoma City Charlotte Grigsby (405) 755-9266 (h) (405) 271-3282 (w) Pennsylvania Philadelphia Steve Labov (215) 663-1535 Pittsburgh Barb Wintermantle (412) 321-2162 Tennessee Oak Ridge Cherry Lane (615) 457-3093 Texas San Antonio Vicki Goebel (210) 805-8484 Houston Sylvia Villareal (713) 528-1916 Fort Worth Leanne Bernard (817) 370-6019 Vermont Rutland Mary Dalto, RN (802) 747-1740(w) (802) 773-6873(h) **** B. THE FOLLOWING GROUPS ARE CO-SPONSERED BY THE NATIONAL HEADACHE FOUNDATION FOR GENERAL INFORMATION CALL: ELLEN BLAU, SUPPORT GROUP COORDINATOR 1-800-372-7742 (Updated 8/95) ILLINOIS Chicago/Columbus Cabrini Hospital 2520 N.Lakeview. Room 11A Meets First Wednesday at 6:30-8:00pm Call Steve (312) 761-9210 Highland Park/Highland Park Hospital 718 Glenview Ave. Meeting Room 3A or AV lecture Hall Second Thursday of each month 7:00-8:30 pm Call Ellen at 1-800-372-7742 KANSAS Leawood/ Headache and Pain Center 11111Nall, Suite 202 Third Thursday 7:00-8:30 p.m. Call (913)491-3999 MICHIGAN (Call Ellen for all Michigan Groups at 1-800-372-7742) Flint: Hurley Fitness Center 4500 S. Saginaw Third Tuesday 7:00-8:30 p.m. Lansing: Sparrow Hospital 1215 E Michigan Ave. Rm 208 Fourth Thursday 7:00-8:30 Southfield: Providence Medical Building 22250 Providence Drive Rm 8H Second Monday 7:00-8:30 MISSOURI St. Louis: Deaconess Medical Center 2345 Dougherty Ferry Road First Floor Community Room. Second Thursday 7:00-9:00 Call Rick Foristel at 314-572-1721 NEBRASKA Omaha: Papillion Metropolitan area. Call Norma at 402-572-2721 NEW JERSEY Stratford: UMDNJ At Laurel Road Academic Center Rm 277 First Thursday 7:00-8:30 Call Andy (609) 489-1758 NEW YORK New York City: Mt.Sinai Medical Center 100th St.& Madison Ave, Guggenhiem Pavilion 2nd Flr. Conference Rm 2C Wednesday 6:00-7:30 PM Call Lorraine (212) 316-1501 Scarsdale: Scarsdale Library-- Olmstead Road, Jaffen Room First Tuesday 7:00-8:30 (Due to construction at the library, the Nov. and Dec. Meetings will be held at the YWHA, 30 Oakley Ave, Mount Vernon--for directions call 914-664-0500) Call Mike (914) 961-7524 NORTH CAROLINA Charlotte: Presbyterian Hospital Call Rhonda (704) 527-1203 Durham: Durham Regional Hospital Health Services Center Third Tuesday 7:00-8:30 Call (919) 470-4294 Pinehurst: Moore Regional Hospital Second Tuesday of each month. Call Margaret 910-692-2717 Winston Salem: Call Glenda (910) 788-0790 OHIO Cleveland Cleveland Clinic Foundation 9500 Euclid Avenue, Bldg. A-12-800 Third Thursday of each month 5:30-7:00pm Call Karen 216-445-8799 Euclid: Euclid Sq. Mall 100 Euclid Sq. Euclidian Rm Second Tues 7:00-8:30 Call Barbara 216-383-1552 Massillon Community Hospital - Group now forming Call Michelle, 216-837-6870 Sylvania: (Toledo area) Flower Hospital-- 5200 Harroun Road. Rm 8A Second Tuesday 7:30-9:00 PM Call Carol 419-473-3637 WEST VIRGINIA Charleston: St. Francis Hospital-- 333 Laidley St. West Conference Room 2nd and 4th Thurs. 7:30-9:00 Call Jane 304-744-1936 7. RELATED ASSOCIATIONS NATIONAL CENTER FOR HOMEOPATHY Alexandria, Va. 703-548-7790 Lists practitioners in the U.S. THE NATIONAL LUPRON VICTIMS NETWORK P.O. Box 193 Collingswood, NJ 08108 (609) 858-2131 CERENEX PHARMACEUTICALS Division of Glaxo, Inc. Five Moore Drive Research Triangle Park, NC 27709 (Imitrex Suppliers in US) THE ASSOCIATION FOR APPLIED PSYCHOPHYSIOLOGY AND BIOFEEDBACK 10200 West 44 Avenue, #304 Wheat Ridge, CO 80033-2840 (800-477-8892). AAPB can help you find a biofeedback practitioner in your area. 8. EQUIPMENT SUPPLIERS Thayler's pharmacy: 1-800-848-4809. For Ergot Compounds: You or your doctor can talk to a pharmacist at Thayler's They will ship your filled script Federal Express (no extra charge) to you for delivery next day air. DHE-45 nasal spray is also available at Thayer's. Wayne Loveland, R.Ph. The Prescription Center 1907 West Avenue South LaCrosse, WI 54601 608-788-4500 1-800-203-9066 Self Care Catalog. (US)800-345-3371. Home Biofeedback System. Item A1140. $119.95, plus shipping and handling. 9. EMOTICONS Thanks for these go to Jonathan Parkinson |-( Headache #|-( Migraine ##|-( Severe Migraine ###|-( Three Pounder Migraine ####|-( Four Pounder Migraine ... ... ##########|-( Add pounds to suit intensity (envision repeated blows from an eight-pound sledge-hammer) ,oOOo (@ *) > ---------oOOo-(_)------------- The End /||\