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Cluster Headache has been described as the most painful type of headache one can endure. Fortunately, it is not very common.Using a Non-Prescription $6.99Therapy for Headache Volume 4, Issue 3 • 2015For those experiencing severe headache and www.headaches.orgmigraine, the search for additional treatmentoptions that may provide fast relief of theirpain is continuous.Legislating HeadacheDr. Larry Charleston, IV, describes his fellow-ship on Capitol Hill and the need for advocatesfor headache – physicians and patients.The Headache at AppomattoxAs we celebrate the 150th anniversary ofthe end of the U.S. Civil War, the impact ofmigraine on one of the major figures, UlyssesS. Grant, is examined.Headache ClinicsFeaturing the Michigan Headache ClinicEast Lansing, Michigan

GetBecomaet ahmomembeer today!If you think a headache is just a headache, think again. Millions ofAmericans su er from migraines, ,cluster headaches, and other seriousheadache disorders. Chances are, headache disorders a ect you orsomeone you love.Join the cause by becoming a member of the National HeadacheFoundation, the world’s largest voluntary organization for the supportof people with migraine and headache disorders. For 45 years, theNHF has assisted millions of individuals and inspired hope throughawareness, advocacy, education, and research.Individual membership: $20 per yearProfessional membership: $125 per year Physician (M.D. or D.O.): $75 per year Allied health:With your membership, you’ll receive:A subscription to HeadWise® magazine e NHF News to Know monthly e-newsletter:Access to a wealth of headache research, support,and information. Plus, your donation will supportthe NHF and help advance headache advocacy,education, and research. To join, go to www.headaches.org/become-a-member/ or call 1-888-NHF-55522 HeadWise® | Volume 4, Issue 3 • 2015

In this issue, Doctor George Urban of the Diamond Headache Clinic in Chicago,explores the complexities of cluster headache and its treatment. While reading thisarticle, I thought of my friend and colleague, Robert E. Ryan, Sr., MD, of St. Louis,who passed on March 30, 2015. Bob Ryan was truly a pioneer of headache medicine.He was a founding member of the American Association for the Study of Head-ache (now the American Headache Society) and helped facilitate the founding ofthe National Headache Foundation. He also was one of the original editors of theprofessional journal, Headache. Drs. Seymour Diamond, Marcia Wilkinson, Robert Ryan Sr. at City Migraine Clinic, London, 1971 Dr. Ryan was a great proponent of histamine desensitization therapy for headaches– a treatment which is still used for chronic cluster headaches at the Diamond Head-ache Clinic. Bob had completed an otolaryngology (ENT) residency at the MayoClinic in Rochester, MN, and was a student of Dr. Bayard T. Horton who publishedextensively on histamine for headaches. When I first started treating headaches,Bob invited me to the Ryan Headache Clinic in St. Louis to observe his patientsreceiving histamine therapy. Histamine has never been utilized extensively with theexception of colleagues and students of Bayard Horton, and with those who havehad the opportunity to observe its efficacy at the Diamond Headache Clinic or theRyan Headache Clinic. Despite the publication of articles documenting the successof histamine therapy in recidivist cluster headache patients, the medical professionhas long ignored an effective therapy. Dr. Bob Ryan was known for his devotion to his patients and to the St. LouisCardinals. His contributions to headache medicine are significant. On behalf of theBoard of the National Headache Foundation, I would like to express our condolencesto his son, Robert E. Ryan, Jr., MD, a former NHF Board member, and the rest ofthe Ryan family.Seymour Diamond, M.D.Chicago, Illinois www.headaches.org | National Headache Foundation 3

The National Headache Foundation • www.headaches.orgNHF Board of Directors Merle L. Diamond, MD Ian Phillips Joshua Friedman, Esq. A. David Rothner, MDEXECUTIVE CHAIRMAN Mark W. Green, MD Gary Ruoff, MDAND FOUNDER Marc D. Lefkowitz Oliver Sacks, MDSeymour Diamond, MD Roger Plummer James M. Staulcup, Esq. Alan B. Rosenberg, MD Walter Stewart, PhD, MPHASSOCIATE EXECUTIVE Timothy R. Smith, MD, RPh, FACP K. Michael Welch, MB, ChB, FRCPCHAIRMAN Stephen Stern, Esq. Janet Zlatoff-MirskyRoger K. Cady, MD Honorary Board Editorial BoardPRESIDENT Donald J. Dalessio, MD Arthur H. Elkind, MD, ChairArthur H. Elkind, MD Carol Girard-de-Frain Margaret E. Azarian, PhD Philip E. Hixon Jan Lewis Brandes, MDVICE PRESIDENT Patrick P.A. Humphrey, PhD, DSc Roger K. Cady, MDVincent T. Martin, MD Emily Kaplan Kandel A. David Rothner, MD Paul KandelSECRETARY Richard B. Lipton, MD Editorial ConsultantMargaret E. Azarian, PhD Edmund Messina, MD Mary A. FranklinTREASURERChad J. BesteNHF Board MembersJames BeasleyJan Lewis Brandes, MD Mission Vision To cure headache, and end its pain and suffering. A world without headache.HeadWise ® ISSN 2167.4280 (2015, This publication discusses a broad Mail: Seymour Diamond, MDVolume 4, Issue 3) is published quarterly range of headache information in an Executive Chairman and Founderby the National Headache Foundation, effort to inform and educate readers, National Headache Foundation820 North Orleans, Suite 411, Chicago, but is not intended to substitute for 820 North Orleans, Suite 411IL 60610. the advice of your health care provider. Chicago, IL 60610Periodicals postage paid at Carol Statements expressed herein are not Email: [email protected], IL 60188 and at additional necessarily those of NHF.mailing offices. HeadWise ® is sent to members of the Send Us Your Feedback National Headache Foundation. ForPostmaster: Letters, manuscripts, stories, materials information on membership, call 888-Please send address changes to or photographs are welcomed but will NHF-5552.HeadWise ®, NHF, 820 N. Orleans St., not be returned. Submission of lettersSte. 411, Chicago, IL 60610 implies the right to edit and publish all Check out additional HeadWise ® and or in part. Submissions may be sent NHF content at www.headaches.org.Copyright© 2015, National to: [email protected]. PleaseHeadache Foundation (NHF), all indicate your name, address and phonerights reserved. No portion of the number.magazine may be reproduced in wholeor in part without the written consentof NHF.4 HeadWise® | Volume 4, Issue 3 • 2015

12 contentsVolume 4, Issue 3 • 2015 Cluster Headache– The Most Severe Headache Cluster headache is a relatively uncommon headache disorder, but its excruciating pain has earned it the title of “suicide headache.” What are the symptoms of this headache condition, and how is it treated?Using a Non-Prescription Therapy for Headache 16Dissatisfaction with available therapies is a common complaint ofthose patients experiencing chronic headaches and migraine. The search for alternative therapies is continuous and this article exam ines the use of a non-prescription, homeopathic nasal spray which was formulated using raw extract of the chili pepper, capsicum annuum.18 Legislating for Headache Larry Charleston, IV, MD, FAHS of the University of Michigan Head- ache and Medicine was awarded the Kenneth M. Viste Jr. Neurology Public Policy Fellowship (NPPF), in 2012. He describes his experi- ence with the 112th Congressional session and how he was able to advocate for headache patients.The Headache at Appomattox 26The surrender at Appomattox Court House, VA, on April 9, 1865 isrecognized as the official date of the end of the U.S. Civil War. Themeeting between General Robert E. Lee of the Confederacy andGeneral Ulysses S. Grant of the Union has a “migraine” aspect to it. 28 6 NHF News Learn what’s happening in and around theThe Headache Clinics National Headache Foundation.This issue focuses on The Michigan Headache 9 Reader MailCenter, East Lansing, Michigan, and a conver- You ask, our physician experts answer.sation with its Director, Edmund Messina, MD. Get information from leaders in headache medicine. 30 Headache Diary Keeping a headache diary can help your doctor help you. www.headaches.org | National Headache Foundation 5

NHF news What’s Happening Now Run for Sheree Flying High On June 28, 2014, the first annual 5k race, Run for Sheree Flying High, was held on Main Street in Pine Mountain, GA. This event was to honor the memory of long-time NHF member and migraine sufferer, Sheree Shelton. It was organized by her dear friend, Angie Moore. Sheree’s husband and parents were in attendance. Planning for the event took 3 months and was very successful. Over 130 individuals, age 1 to 85 years, participated, and one runner traveled from California for the event. The run stretched 3.1 miles through the town of Pine Mountain, and the runners were escorted by the Pine Mountain police. The Volunteer Fire Department was also on hand. A DJ provided music for the festivities. The entry fee was $25, and each runner received a racer’s bib, t-shirt, and bracelet. Awards were given to the youngest and oldest runners, as well as the top runner in each age group. Through Angie’s diligence and enthusiasm, the event raised almost $6,000 which was donated to the National Headache Foundation. The goal for the 2015 event is to double the participation and donation. With Angie and Sheree’s family, the NHF would like to thank the sponsors of the race: AmWINS Group, Inc; Longevity Fitness; Coca-Cola; Sebring Custom Carts; Advocare–Gina Boren; ASA Performance; Beres Chiropractic Clinic; Kings Automotive; Markel Insurance Co.; San Marcos; Southern Touch Photography; The Cornett Family; Super Valu; Eli Lawncare; and First Peoples Bank. If you would like information about the 2015 race, please con- tact the NHF at [email protected] or 1-888-NHF-5552, and we will forward your information to the organizers. HW6 HeadWise® | Volume 4, Issue 3 • 2015

NHF newsWhat’s Happening Now LUNCH & LEARN to YouTube where anyone can then Merle L. Diamond, MD listen to the event, in perpetuity. Diamond Headache ClinicOn December 12, 2014, one of Chicago, ILour physician members, Marc The hosts are invited to lead theseSharfman, M.D. presented a lecture 1-to-2 hour Q&A sessions based Mark Green, MDto the employees of the City on their expertise in areas such as Mount Sinai Medical Centerof Winter Park, Florida. Doctor chronic migraine, post-concussion New York, NYSharfman focused on diagnosis headache, cluster headache,and treatment of headaches, pediatric headache, tension-type Howard Jacobs, MDparticularly migraine, and how headache, etc. These sessions Nationwide Children’s Hospitalheadaches impact the labor force. provide an excellent resource for the Columbus, OH headache community. Typically, weWe want to thank Doctor Sharfman host two chat rooms per month and Robert Kaniecki, MDfor his service, and to the City of four are presented during National University of Pittsburgh MedicalWinter Park for their consideration. Migraine and Headache Awareness Center; Pittsburgh, PA Month. Not only are these sessionsWe are happy to provide speakers reaching a large audience, through Edmund Messina, MDand materials for similar programs. day-of participation and thereafter Michigan Headache ClinicIf you or your employer would be podcast viewing, but we are East Lansing, MIinterested in a “lunch-time” lecture reaching an under served audienceor a presentation for your “Wellness who sometimes lack traditional George Nissan, DOProgram,” please contact us at access to information and advice. Baylor Headache Center1-888-5552 or [email protected]. Dallas, TX We would like to thank those THANK YOU CHAT ROOM health care practitioners who M. Duren Ready, MD MODERATORS led chatrooms during 2014: Baylor, Scott White; Temple, TXDuring 2014, the National Headache Shannon Babineau, MDFoundation continued its outreach Mount Sinai Medical Center Christine Treppendahl, NPto those with headaches as well as New York, NY Headache Centertheir families, through our webinars Ridgeland, MSor “chat rooms.” These events Jan Lewis Brandes, MDallow participants to sign on and Nashville Neuroscience Group Richard Wenzel, Pharm. D. communicate with a health care Nashville, TN Presence Healthcarepractitioner who is an expert in a Saint Joseph Hospitalcertain area of care. During the chat Susan Broner, MD Chicago, ILroom, participants can direct any Manhattan Headache Centerquestions about the headache topic New York, NY Deborah Zajac, RN, BSNbeing covered that evening. The Cleveland Clinicquestions are submitted through Larry Charleston, IV, MD Cleveland, OHa moderator, who then organizes University of Michigan Health Centerand asks the questions live for a Ann Arbor, MI Webinars are available forbetter recordable format. The audio viewing on our websiteQ&A is later placed into podcast John Kent Dexter, MDformat by our staff, and uploaded Headache Center www.headaches.org Springfield, MO www.headaches.org | National Headache Foundation 7

NHF news What’s Happening NowSpecial LectureshipsOn Sunday, February 15, 2015, the National Headache Prophylactic Treatment,” is based on the article, “Disabil-Foundation presented two lectureships at the course, The ity, Anxiety, and Depression Associated With Medication-28th Annual Practicing Physician’s Approach to the Difficult Overuse Headache Can Be Considerably Reduced byHeadache Patient. The course is sponsored by the Diamond Detoxification and Prophylactic Treatment. Results fromHeadache Clinic Research and Educational Foundation, a Multicentre, Multinational Study (COMOESTAS Proj-and was held this year at the Balboa Bay Resort, Newport ect),” which appeared in the journal, Cephalalgia 2014;Beach, CA. 34:426-433. His coauthors were: SB Munksgaard, C Tassorelli, G Nappi, Z Katsarava, M Lainez, JA Leston, Alexander Feoktistov, MD, PhD, Director of Research R Fadic, S Spadafora, A Stoppini, R Jensen, and the CO-at the Diamond Headache Clinic, Chicago, was awarded MOESTAS Consortium.the National Headache Foundation Lectureship. The Na-tional Headache Foundation Lectureship is presented to Dr. Bendtsen is Associate Professor at the Departmentan up-and-coming physician or scientist who has demon- of Neurology and Danish Headache Center, Glostrupstrated interest in headache medicine. Dr. Feoktistov’s pre- Hospital, University of Copenhagen. Currently, Dr.sentation was “Interventional Management of Intractable Bendtsen is co-director of The Danish Headache Centre.Headache.” Dr. Feoktistov received his MD with honors at He received his PhD and Dr Med Sci degrees at the Uni-Moscow Medical Academy, Moscow, Russia, where he also versity of Copenhagen. He has actively been involved incompleted a residency in neurology. In 2002, he received headache research since 1991 and has authored over 130a PhD in neurology at the Department of Neurology at papers and book chapters on headache topics. Dr. Bendt-the Moscow Medical Academy, received board certifica- sen is the recipient of the 1997 GlaxoWellcome Researchtion in neurology and psychotherapy in Russia, and served Prize, 2000 Danish Headache Society Prize for scientificas Deputy of Medical Director at the Professor Alexander achievements, and 2001 Danish Neurological Society’sVein Pain Clinic in Moscow. In 2001, Dr. Feoktistov Roche Prize for scientific achievements in neurology. He isreceived a Presidential award for a 1-year fellowship of past President of the Danish Headache Society. HWhis choice, and he was approved to study headache at theDiamond Headache Clinic in Chicago, working directly Drs. Roger Cady and Lars Bendtsenwith Seymour Diamond, MD and the other physicians, Drs. Roger Cady and Alexander Feoktistovwhere he remained until 2007, conducting research andassisting in clinical duties. In 2007, Dr. Feoktistov starteda residency in medicine at Saint Joseph Hospital, Chicago.From 2010 through 2011, he completed a fellowship inpain medicine at the Cleveland Clinic Foundation. Hehas received Certification in Headache Medicine from theUnited Council of Neurological Subspecialties. Dr. Feok-tistov returned to the Diamond Headache Clinic in 2011as a staff physician. Lars Bendtsen, MD, PhD, Dr Med Sci was the recipi-ent of the 2015 Seymour Diamond, MD Lectureship. Thelectureship was established in 2005 to honor the ExecutiveChairman and Founder of the National Headache Foun-dation – Seymour Diamond, MD. The award recognizesthe most significant paper in headache medicine whichwas published during the past year. Dr. Bendtsen’s lecture, “Disability, Anxiety, and De-pression Associated With Medication-Overuse HeadacheCan Be Considerably Reduced by Detoxification and8 HeadWise® | Volume 4, Issue 3 • 2015

reader mailYou ask. Our headache experts answer.It’s time to learn from those in the know. In every issue of HeadWise®, our expertsrespond to reader-submitted questions about migraine and headache disorders.Music – A Headache Trigger? Treating Menstrual HeadachesI was a patient with the Diamond Headache I have been dealing with migraines that I in-Clinic and hospitalized in August, 1992. It herited from my mother (who got them fromseems that certain types of music, especially her mother) for almost 20 years now. I loseloud, manufactured/synthesizer-type music a week of my life every month when I get mytriggers my migraine headaches. I was menstrual cycle. I’ve been looking for a waywondering if any research has been done to to prevent this without the use of birth controldetermine the correlation of certain sounds or pills because they only seem to aggravate mymusic to the onset of migraine headaches. An condition even more. When I was pregnantexample of this music can be heard in some with my son, the second half of my pregnancysteak house-type restaurants. Sometimes, my was incredible-no headaches, never felt better.headaches are triggered by being placed “on I should also add that once my mother andhold” during a business phone call. I cannot grandmother went through menopause, theirlisten to music using earplugs. “Easy listening” headaches disappeared. Is there anything thatmusic, live piano music, and/or Lawrence Welk- you could recommend? I seem to do prettytype music do not give me headaches. Shop well the rest of the month due to some dietaryvacuums and power scrubbers used in large changes I’ve made over the past year.–Erinstores also trigger my migraine headaches.Sometimes, it is almost impossible to avoid “The most common way to prevent these headachesthis type of music/noise. I have non-classical, is a strategy called “mini prophylaxis,” which meansatypical migraine headaches. –Ann M. that you take a medication preventatively for 4 to 5 days before and during your menstrual period in order “Migraine people are sensitive to very specific triggers, to prevent or reduce the severity of these headaches. such as smells, light or sound; usually the intensity One takes medications starting 1 to 2 days prior to the makes a stimulus more of a trigger. Distinct sound onset of the migraine and then stops the medication 4 patterns, as described, can be very specific to the in- to 5 days later. These medications are generally given dividual. It may be helpful to use earplugs or to listen 2 to 3 times per day depending on the medication. to less offensive music with earbuds when in uncon- You take them whether you have a headache or not for trolled environments.” that 4 to 5 day time period. One group of medications that can be used is the triptans such as naratriptan, Edmund Messina, MD frovatriptan, zolmitriptan, and sumatriptan. Another group is the nonsteroidal anti-inflammatories, such as East Lansing, MI naproxen. Whether this treatment is appropriate for you should be determined by your physician.” Vincent Martin, MD Cincinnati, OHwww.headaches.org | National Headache Foundation 9

reader mail You ask. Our headache experts answer.Transformed Migraine not an event that I look forward to, and I would like to do everything in my power to bring my migrainesI am having trouble keeping my migraine head- under control before that day arrives. – Timaches under control. I have been a lifelong mi-graineur. I am 51 years old (my migraines began “Many patients with migraine find they enter cycles ofwhen I was age 6), and I am the patient of an increased headache activity. In the general population,excellent neurologist, who, fortunately for me, also the chance of “transforming” from episodic migrainehappens to be a headache specialist. (<15 days per month) to chronic migraine (15 or more days per month) is approximately 3% each year. Some- Three years ago, my migraines changed: they times, such transformation is triggered by an externalbecame more frequent, more painful, and more event, such as a major life stressor, or by an internal is-difficult to manage. My neurologist diagnosed this sue, such as hormonal changes with menopause. Manynew direction in head pain as a “transformed mi- times, the transition to frequent headache is spontane-graine.” Initially, one daily 25 mg. dose of amitrip- ous or merely follows a particularly severe headache.tyline HCL blissfully relieved all of my transformed At the age of 51, hormonal changes are quite possiblymigraine difficulties. Unfortunately, over the past the inciting event. Once in motion, chronic migrainethree years, my transformed migraines have grad- is then frequently perpetuated by the overuse of painually outmaneuvered every attempt to keep them relievers or other medications aimed at treating theunder control. I have steadily progressed from 1 to migraine symptoms. Also, patients tend to change2 to 3 amitriptyline HCL tablets per day. When my sleep, meal, hydration, or exercise patterns becauseheadaches began to break through with greater of the frequent headaches. Either the overused painfrequency and intensity, my neurologist also pre- relievers or the altered lifestyle program could result inscribed two daily 80 mg. doses of propranolol. failure of preventive medications such as amitriptyline or propranolol. Finally, other neurological or medical During September, 2014, my migraines once conditions could aggravate migraine headaches, andagain became very assertive. The preventative we usually check a brain MRI while also probingmedicines (the daily 3x25mg. amitriptyline, and for hormonal, mood, anxiety, or sleep disturbances.2x80mg propranolol) that I am taking became Typically with chronic migraine, we recommend re-progressively less effective: I began having weekly sumption of strictly regulated sleep, meal, hydration,and then daily breakthrough headaches. In Decem- and exercise patterns. We adjust preventive medica-ber, 2014, my neurologist prescribed a treatment tions as necessary. Topiramate is particularly helpfulof Botox in an attempt to alleviate my transformed for chronic migraine, and the Botox might eventuallymigraine symptoms. The Botox seemed to blunt help as well. Drugs for the symptoms of migrainethe breakthrough migraines for a short while, but, should be limited to 10 days per month. Most patientsbetween December, 2014, and January, 17, will eventually transition back to episodic migraine2015. I have begun to experience breakthrough within several months, but some conditions are moreheadaches on practically a daily basis. resistant. Some patients may require steroid courses or even hospitalization to break the most active and I am using all of the experience that I have ac- severe cycles. It sounds like you are in good hands, socumulated over a lifetime to keep my headachepain under control (avoiding all known triggers: best of luck.”alcohol, chocolate, weariness, stress, but I seem to Robert Kaniecki, MDbe steadily losing ground in my effort to keep mymigraines under control. I fear that, in the not too Pittsburgh, PAdistant future, I will wake up one morning with anincapacitating headache and be unable to reduce,much less eliminate, the nauseating pain. That is10 HeadWise® | Volume 4, Issue 3 • 2015

www.headaches.org | National Headache Foundation 11

CLUSTERHEADACHETHE MOST SEVERE HEADACHE George Urban, MD Co-Director Diamond Headache Clinic Diamond Inpatient Headache Unit Presence-Saint Joseph Hospital Chicago, IllinoisCluster Headache has been described as the most painful from 3.5:1 to 6.7:1 in favor of males. No racial, ethnic,type of headache one can endure. Fortunately, it is not or genetic factor has been documented. Cluster headachevery common. Cluster headache is one of the primary can begin at any age, but the average mean age of onset isheadaches that is not caused by other disorders. Although during the late 20s and early 30s.this headache was recognized for at least a century, theterm, Cluster Headache, was coined relatively recently, What is characteristic forin 1952 by Doctor E. Charles Kunkle and his colleagues. this condition?Prior to this title, cluster headache was known undera variety of names including: Migrainous neuralgia; The acute attack of cluster headache occurs suddenly,Horton’s headache; Harris-Horton’s disease; Histaminic without any warning. It peaks in intensity within 10 to 15Cephalalgia; Ciliary neuralgia; and, Erythromelalgia of minutes, and lasts usually from 40 to 90 minutes. The painthe head. is excruciating and described most commonly as boring, burning, piercing, sharp, knife-like, or “a hot poker in In 1745, Gerhard van Swieten presented a case of a the eye.” A soreness or lingering dull pain may persist for“healthy, robust man of middle age [who] was suffering hours after the main attack. The pain is strictly one-sided,from troublesome pain which came on every day at the and occurs on the same side at the same location duringsame hour at the same spot above the orbit of left eye…” a cycle. It may change sides in the next cycle. The typicalThis description fulfills the current diagnostic criteria of location is at the temple, above the eye, or behind theCluster Headache. eye. The area of pain is small, and often the patient can point to the pain’s location with the tip of a finger. TheHow common is this disorder? headache has been described as the most severe form of pain a human can endure. It is not unusual for womenCluster headache is a relatively uncommon headache who experience cluster headache to describe the pain asdisorder. The prevalence is about 10 per 100,000 in male worse than the pain associated with labor and delivery. Thepatients, which is about 19 to 25 times less than the cluster headache has been nicknamed by some sufferers asprevalence of migraine headache in men. Most cluster the “killer” or “suicide” headache.headache sufferers are males, with the gender ratio varying12 HeadWise® | Volume 4, Issue 3 • 2015

The headache episodes occur in peculiar periodicity. The incorrect diagnosis of sinus headache or sinus infection.term “cluster” derives from attacks occurring repeatedly Some patients may also experience nausea, vertigo, neckwithin a relatively limited time span, called the period, muscle stiffness or tenderness, and possibly fluctuations incycle, bout, or cluster. On average, a cluster cycle lasts the heart rate and blood pressure.6 to 12 weeks. Many patients experience one cycleevery year, usually at the same time each year. Typically, Another distinguishing feature of cluster headache iscluster headaches manifest during spring or autumn, a the behavior of patients during the attacks. As opposedphenomenon called circannual rhythm. During the cycle, to migraine sufferers, cluster patients cannot remain still.the attacks appear daily, usually once a day at the same They are agitated, moving around, pacing, rock backtime–circadian periodicity. In between the cycles, the and forth, moan, and rub the affected temple with theirpatient is completely headache-free. thumb, knuckles, or fist. Some patients would even bang their head against the wall in a futile attempt to alleviate More than 50 percent of cluster patients report that the the pain. These patients may become violent and self-attacks occur at night, most commonly about 2 to 3 hours destructive, and sometimes suicidal.after falling asleep. Many patients will have their attacks ata predictable rate. The number of attacks usually do not During the attacks, sufferers apply ice or cold objects onexceed three in 24 hours. However, some patients with their head, preferring a cold environment, and may venturechronic cluster headache may experience more than five outside during the winter without appropriate warmattacks a day. clothing. The appearance and behavior of these patients, during the cluster attacks, resembles a manic phase. During The typical symptoms, which must be present for remission periods, the patient will demonstrate a normalthe correct diagnosis, are autonomic responses. These psychological profile.responses include eye tearing and redness, runny nose andcongestion, sweating of half of the face, and sometimes What is causing thea droopy eyelid. These symptoms occur on the same side cluster headache?of the headache, and continue throughout the entireattack. Nasal congestion and runny nose may lead to an There is a difference between the trigger factors and the cause. During the cluster cycle, acute attacks canwww.headaches.org | National Headache Foundation 13

be induced by alcohol, nitroglycerine, or histamine. How to treat this disease?Many patients voluntarily abstain from drinking alcoholduring the cycle until they are in remission when they The diagnosis is fairly straightforward. The clinical picturecan consume alcohol without provoking the attack. Low of cluster headache is so characteristic that it should notoxygen saturation, especially as a result of sleep apnea or be misdiagnosed for some other headache or disorder. Iffrom being in higher altitudes, may trigger a cluster attack the patient has only recently experienced the initial cycleduring the cycle. In contrast to migraine, food, hormonal of cluster headache, an MRI of the brain is recommendedchanges, and weather changes do not play a major role as to rule out secondary headache due to a brain tumor,cluster attack triggers. aneurysm, or other intracranial process. No other testing is necessary. The cause and the mechanism of cluster headache are verycomplex and not well understood. All scanning, including The treatment of cluster is twofold. Its aim is to aborthead CT and brain MRI, are always negative and do not the acute headache attack as well as shorten and stop theelucidate the cause. However, studies using MRA (an MRI cluster cycle. During remission periods, the patient doesof the intracranial blood vessels) have revealed dilatation – not need to continue any treatment. Therapy should beswelling of a short segment of artery behind the eye on the initiated at the very beginning of a new cycle. The mostsame side of pain. Furthermore, PET scans that measure effective and safest therapeutic modality is pure 100important bodily functions, such as blood flow, oxygen use, percent oxygen, delivered via mask at the high flow rate ofand sugar (glucose) metabolism, demonstrated activation 10 to 15L per minute. Usually, the attack is aborted withinof a part of the hypothalamus on the same side of pain. The 5 to 10 minutes with oxygen therapy. Many patients willhypothalamus is a very important part of the brain, just use a small oxygen tank at home as well as at work, so thatabove the brainstem, that controls the endocrine system, it can be used whenever an attack commences.hormonal cycles, autonomic system, and “biological clock.”That result indicates that the hypothalamus is a generator Because of the brevity of attacks (lasting less than oneor modulator of the mechanism of cluster headache. hour), no oral medication, including narcotic analgesicsThe autonomic symptoms, hormonal fluctuation, and will have time to be effective. The triptans in eitherclockwise periodicity are influenced by the hypothalamus injectable or nasal spray formulations are effective for aand its dysfunctional biological clock (pacemaker). The brief period and in aborting the attacks. The triptanspain is generated by activation of the trigeminal neuro- include sumatriptan and zolmotriptan. However, theirvascular system. use is contraindicated in patients with uncontrolled high blood pressure or cardiovascular disease. Other options that may be effective are injectable dihydroergotamine or the nonsteroidal anti-inflammatory agents (NSAIDs).14 HeadWise® | Volume 4, Issue 3 • 2015

“Histamine desensitization treatment has been done at a number of specialty clinics, such as the Diamond Headache Clinic in Chicago, for more than 40 years… The treatment is well-tolerated and about 70 percent of patients with chronic cluster headache who have not responded to previous therapy do benefit from this treatment modality.”Preventative treatment should be initiated as soon as not respond to standard treatment or the combination ofthe new cycle starts. Steroid burst and verapamil are different medications. Lithium has been used successfully,drugs of choice. Other drugs are added if the attacks although some patients are refractory to recommendedare not alleviated, including valproic acid, doxepin, therapy. Histamine desensitization treatment has beenindomethacin, topiramate, gabapentin, and triptans with done at a number of specialty clinics, such as the Diamonda longer duration of effects. Lithium may be quite effective Headache Clinic in Chicago, for more than 40 years…particularly in the treatment of the chronic form of cluster the histamine is infused slowly over several days, while theheadache. All medications may cause adverse reactions and patient receives other preventative and abortive therapy,the patient needs to be cautioned to avoid exceeding the and is usually undertaken in a dedicated hospital facilitymaximum individual or daily dose when attempting to such as the Diamond Inpatient Headache Unit at Saintstop the terrible pain. Joseph Hospital in Chicago. The treatment is well- tolerated and about 70 percent of patients with chronic Some nerve blocks, mainly the occipital and cluster headache who have not responded to previoussphenopalatine, may also be effective for a short time. therapy do benefit from this treatment modality. The cycleTreatment with botulinum toxin has not been proven is stopped and the patient experiences the remission phaseto be beneficial in cluster headache. Surgical procedures, for several months and possibly years. When the next cycleincluding cutting or chemically destroying a nerve pathway starts and standard therapy is initiated, patients have aor a ganglion (cluster of nerve cells), are seldom performed. much improved response.These intervenetions are only performed in select patientswho experience continuous one-sided headache and who Cluster headache is a neurological disorder withare not depressed. These surgical procedures have a high excruciating pain, that sometimes leads to suicidal thinking.rate of failure or complications. This type of headache is easy to diagnose, but also easy to mislabel as a “sinus headache.” It is of utmost importance Chronic cluster is a complicated form of cluster headache. for patients to seek immediate medical attention from aThe attacks occur daily, sometimes multiples times a day neurologist or a specialized headache clinic in order toor a few times a week. There is no respite nor remission, alleviate the cluster attacks and stop the cycle as early asand the attacks will affect the patient day after day, week possible. HWafter week, and month after month. These headaches dowww.headaches.org | National Headache Foundation 15

Currently, an estimated 12 million or more severe of the trigeminal nerve and resultant depletion of calcitonin headache and migraine patients are dissatisfied with gene-related peptides (CGRP), which have been identifiedtherapies available to them. They continuously search for as the “pain” neurotransmitters responsible for migraineadditional treatment options that may provide fast relief pain. Reduction in the release of CGRP leads to a decreaseof their pain without the limitations of adverse drug in the swelling and inflammation of blood vessels thatinteractions, systemic side effects, or for some individuals surround the brain, thus resulting in pain relief.– accessibility and affordability. Specifically targeting the source of headache pain, the For several decades, research has demonstrated that nasal spray is intended to provide rapid relief. According to aadministration of extracts from the oleoresin capsicum real-world patient analysis presented at the 2014 Americanplant (chili pepper plant), such as capsaicin, have been Academy of Neurology (AAN) Annual Meeting, nearly 83effective in treating migraine and cluster headaches. A percent of patients reported onset of relief within 1 to 3non-prescription, homeopathic nasal spray is now available minutes of use with the treatment.which was specifically formulated using raw extract of thechili pepper, capsicum annuum. It is observed to be a viable Attempting to address one of the biggest commontreatment option for many patients in search of rapid pain challenges headache sufferers confront, developers of therelief from severe headaches, including migraine, cluster, treatment, Ausanil®, worked to ensure that only smalland tension-type headaches. quantities of the nasal spray are needed for rapid pain relief. This allows patients to use it in addition to other Acting locally in the nose, this non-prescription spray is medications, including triptans and over-the-counter painthought to work by the calcium-mediated desensitization relievers, without adverse drug interactions. Additionally,16 HeadWise® | Volume 4, Issue 3 • 2015

as a nasal spray, Ausanil® specifically works locally in the lasted between 2 to 10 minutes. However, the majoritynose, does not cause stomach or liver issues, and is safe touse for patients with kidney or cardiovascular issues. of patients noted that the sting would not dissuade them “When you see a patient time and time again and nothing from using the medication again for pain relief.seems to give them relief or they’re limited on treatmentsdue to drug-drug interactions or notable side effects, it The manufacturers of Ausanil® developedcan be a very frustrating and heartbreaking process,” said instructions for first time users:Maria Alexianu, MD, PhD of the Atlantic NeuroscienceInstitute at Overlook Medical Center in Summit, NJ. “It’s • Only use Ausanil® in the nostril of the same side youvital that we are able to offer new options like Ausanil® are experiencing painto patients who are still searching for pain relief and arecontinuously incapacitated in their daily life.” • Before using, prime the spray 1 to 2 times – away from your face Although free of systemic side effects, when usedcorrectly, non-prescription Ausanil® will sting upon use. • When using Ausanil®, aim the spray towards theThis stinging sensation is part of the mechanism of action outer part of your nasal cavity, not towards your nasaland is an indication that the treatment is working. Results septumfrom the AAN patient analysis found that all patientsexperienced the local adverse event of the nasal sting, which • DO NOT inhale Ausanil® upon use • After a minute of use, blow your nose Non-prescription Ausanil® is currently available for purchase online at Ausanil.com and at select pharmacies throughout the U.S. Each bottle retails for $34.95 per bottle and includes approximately 50 doses per bottle. HW Contributors: Reena Patel & Mary Franklin Photo credit: Franz Eugen Köhler, Köhler’s Medizinal-Pflanzenwww.headaches.org | National Headache Foundation 17

Legislating for Headache Larry Charleston, IV, MD, FAHS Headache and Medicine Assistant Professor Department of Neurology University of Michigan Ann Arbor, MichiganQuality measurements, prevention of God’s.” Because, I believe in that statement chronic diseases, patient-centered and to advocacy within the political process,homes, small business tax credit, reporting of I decided to obtain “hands-on” experiencehealth care insurance, hospice reform, limiting within the political process as a Congressionaland elimination of physician-owned hospitals, Legislative Fellow.health care exchanges, health insurancemandates, accountable care organizations, After completing a neurology residencyannual fee on health insurance providers, at Baylor College of Medicine, I finished aexcise tax on indoor tanning services, and an one-year fellowship in the management ofestimated $570 billion dollar tax increase on headache and facial pain disorders at theAmericans by 2019. What do all of these have Jefferson Headache Center in Philadelphia. Myin common? POLITICS! legislative fellowship was spent during the first session of the 112th Congress in Washington, Essentially, the topics stated above are DC. This opportunity was awarded throughincluded in what was called H.R. 3590 the Kenneth M. Viste Jr. Neurology Public(House Resolution 3590), otherwise known Policy Fellowship (NPPF) that is providedas the Patient Protection and Affordable Care by the American Academy of NeurologyAct (PPACA), and frequently described as Professional Association (AANPA), whichObamaCare. Whether you agree or disagree includes specifically the American Academywith PPACA is not the focus of this article. of Neurology (AAN), the Child NeurologyHowever, the question and statement above Society (CNS), and the American Neurologicalhelps to support the idea that politics play Association (ANA). The NPPF was completeda major role in the administration and in partnership with the American Academy forregulation of health care services and delivery. the Advancement of Sciences (AAAS) SciencePolitical decisions have a phenomenal impact and Technology Policy Fellowship program,on the practice of medicine, health insurance, which was started in 1973 in an effort toand the payment of medical services. Patients provide education and outreach experiences forneed competent providers who, in addition scientists and engineers while simultaneouslyto providing high quality patient care, will providing scientific and technical expertise toadvocate for change when they recognize policy-makers.injustice in clinical practice. As the sixthPresident of the United States, John Quincy I was oriented within the AAAS ScienceAdams, once said, “Duty is ours, results are and Technology Policy Fellowship Program which provided opportunities for professional18 HeadWise® | Volume 4, Issue 3 • 2015

development, education, and networking through articulation, reform, and implementation. Thethe AAAS. The AAAS served as a significant and goals I established for my fellowship are listed invaluable resource during my fellowship. the Table: During my year at Congress, I interviewed with Dr. Charleston’s Goals forseveral offices and committees within the U.S.House of Representatives (HOR) and Senate. The Legislative Fellowship – Team Hergeroffice of Representative Wally Herger ®– California)office and the House of Representatives Ways and • Assist Team Herger in reaching their healthMeans (WM) Subcommittee on Health, chaired care policy goals with excellence for theby Congressman Herger, (The current chair of the 112th Congress.House Ways and Means Committee is Rep. Paul Ryan • Understand the current physician payment[R-Wisconsin]), were ideal for my experience, due formula, strengths, weaknesses, and proposedto a great fit for me based on a variety of factors, alternatives.including my background, their needs, our values,etc. The House Committee on Ways and Means is • Understand Medicare hospital payment andthe oldest committee of the United States Congress ambulatory center formulas.and is the chief tax-writing committee in the HOR.The WM Committee exercises jurisdiction of • Effectively and strategically communicaterevenue related to Medicare and the Social Security with health provider, insurance, hospital,system. To better understand the WM Committee, and industry organizations.please visit the website, • Relate real life health care provider andwww.waysandmeans.house.gov/About/History.htm. patient experiences to legislative ideas. Prior to my fellowship, I participated in several • Help introduce a Medicare Reform Bill.grassroots and advocacy groups as they relate to • Introduce a Physician Payment Reform Bill.the fields of headache and neurology. However, it • Understand tax code involving health careis important to note that this fellowship was not a‘lobbyist’ position. In fact, my role was similar to issues.that of a staff member. I should note that within • Provide assistance to Ways and MeansCongress, the word “staff” encompasses “personal,”“committee,” and “subcommittee” staff. Personal Subcommittee on Health.staff work within the Member’s district, state, and • Effectively network with legislators, staff,District of Columbia offices. During the 110thCongress, more than 14,000 individuals worked and health care authorities.as staff. Committee and subcommittee staff are • Enjoy this congressional fellowship to theassociated with a particular committee withinCongress. max! My main area of concentration or what we called U nderstand how Congress works “portfolio” on the Hill (“Hill” refers to Capitol Hill) included sustainable health care solutions, Throughout the year, I reviewed books, legislation, Congressional Research Service reports, Medicare Payment Advisory Committee reports, proposals, columns, etc. It was important to understand the culture of not only my office and subcommittee, but of Congress, the federal government, and Washington D.C. As an active member of Team Herger, I staffed meetings, participated in speech writing, updated Rep. Herger on current key ©“US Capitol West Side” by Martin Falbisonerwww.headaches.org | National Headache Foundation 19

health care policy issues, attended several national health patients, researchers, families, and other individuals whocare policy forums and alliance for health care reform are concerned about the impact of headache on patients,discussions, and provided medical insight and prior their families, and the public in general. The AHDA offersexperiences to many health care issues raised by constituents opportunities of advocacy to help improve the lives ofand organizations. In addition, I discussed pertinent issues patients with headache disorders and the profession ofwith the Medicare Payment Advisory Committee, helped headache medicine. The National Headache Foundation isformulate questions for the WM Subcommittee Hearings, a member organization, which serves as a great resource forand assisted in the drafts of legislation. I worked most those who would like to become more involved in advocacyclosely with Rep. Herger’s Senior Policy Advisor. Although for patients with headache disorders and the profession ofthe majority of my time was focused on current health headache medicine. Each year, the National Headachecare policy issues and Medicare reform, I remained current Foundation and other advocacy groups for headache,with other important political issues, especially within the participate in “Headache on the Hill.” These groups sendHouse’s Ways and Means Committee. representatives to meet with various congressional offices in hopes to garner support for research funds for headache During the second year of the 112th Congress, Rep. issues and raise awareness among legislators.Herger introduced the “Save and Strengthen MedicareAct of 2012” that included five principles of reform, each Overall, the legislative fellowship was very gratifying,with a history of bipartisan support, and based on the enabling me to gain some legislative insight in a brief time.principle that cost savings should be driven by physicians I was fortunate to be include in discussions on importantand patients. health policy issues which were very helpful and extremely instrumental in creating a rewarding fellowship experience I encourage physicians and other health care providers to for me, becoming more knowledgable and/or involvedbecome involved in the political process. Although voting in health care policy especially as it relates to headacheis a privilege that significantly impacts political decisions medicine.and should be exercised, I would encourage health careproviders to stretch beyond the ballot and become part Headache medicine is a medical speciality that oftenof the process. However, this involvement should not be requires the effort of a team. I encourage all of us to becomelimited to providers. Frequently, health care providers try more informed and examine health care policy-relatedto become the voice of their patients and relate their stories legislation (actual and proposed) as well as proposed ruleson Capitol Hill. Patients, however, would serve as better through direct, unfiltered sources. Together, we can helpand more sympathetic storytellers. foster positive changes that can improve the health of our nation and affect generations to come. HW Therefore, I encourage patients to get involved. Youare important and your voice does count and will make • Koempel, ML, Schneider, J. Congressional Deskbook,a difference. Unfortunately, there is a stigma associated The Practical and Comprehensive Guide to Congress. 5th Ed.with individuals with headaches, especially migraine. The The Capitol.Net Inc. 2007.foundations of our government were established more than200 years ago, and continue to allow us to be influential in • http://allianceforheadacheadvocacy.org/who_is.htmpolitical decisions. • http://fellowships.aaas.org/01_About/01_History.shtml • http://waysandmeans.house.gov/About/History.htm The Alliance for Headache Disorders Advocacy(AHDA) is an organization comprised of physicians,20 HeadWise® | Volume 4, Issue 3 • 2015

There are different ways that individuals can support the mission of the NationalHeadache Foundation through donations. A present donation of money or otheritems of value is the most frequent manner of support. Provisions for specificbequests or residual bequests in one’s will or trust are often utilized. As part ofone’s estate planning or planned giving, an individual can provide for charitablegiving that may minimize gift and estate taxes while providing for (a) the smoothtransfer of ownership, (b) the care and support of dependents, and (c) theavoidance of disputes among survivors.Three commonly used planned giving vehicles are: 1. Charitable remainder annuity trust. Assets (generally securities) are transferred to a trust. The trust makes fixed annual payments to the donor or other specified beneficiaries named by the donor. When the trust terminates upon the death of the donor or other specified beneficiaries, the remainder of the assets in the trust pass to the charity. A trust document is required. The donor retains the ability to change the designated charity. 2. Charitable remainder unitrust. Assets are transferred to a trust. The donor or other specified beneficiaries named by the donor receive fluctuating payouts from the trust (a percentage of the value of the principal) and, upon the death of the donor or other specified beneficiaries, the remainder of the assets passes to the designated charity. A trust document is required. The donor retains the ability to change designated charity. 3. Charitable gift annuity. The donor, under a contract with a charity, transfers cash or securities to the charity. The charity pays the designated beneficiary a fixed income for life. Upon the death of the beneficiary, the remaining balance passes to the charity. No trust document is required and the charity cannot be changed. www.headaches.org | National Headache Foundation 21

JUNE IMPORTANT SAFETY INFORMATION (Continued) is NationalMigraine and Headache Do not take BOTOX® (onabotulinumtoxinA) if you: Awareness Month are allergic to any of the ingredients in BOTOX® (see Medication Guide for ingredients); had an allergic reaction to any other botulinum toxin product such as Myobloc® (rimabotulinumtoxinB), Dysport® (abobotulinumtoxinA), or Xeomin® (incobotulinumtoxinA); have a skin infection at the planned injection site. The dose of BOTOX® is not the same as, or comparable to, another botulinum toxin product. Serious and/or immediate allergic reactions have been reported. These reactions include itching, rash, red itchy welts, wheezing, asthma symptoms, or dizziness or feeling faint. Tell your doctor or get medical help right away if you experience any such symptoms; further injection of BOTOX® should be discontinued. Tell your doctor about all your muscle or nerve conditions such as amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease), myasthenia gravis, or Lambert-Eaton syndrome, as you may be at increased risk of serious side effects including severe dysphagia (difficulty swallowing) and respiratory compromise (difficulty breathing) from typical doses of BOTOX®. Tell your doctor about all your medical conditions, including if you: have or have had bleeding problems; have plans to have surgery; had surgery on your face; weakness of forehead muscles, such as trouble raising your eyebrows; drooping eyelids; any other abnormal facial change; are pregnant or plan to become pregnant (it is not known if BOTOX® can harm your unborn baby); are breastfeeding or plan to breastfeed (it is not known if BOTOX® passes into breast milk). Tell your doctor about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal products. Using BOTOX® with certain other medicines may cause serious side effects. Do not start any new medicines until you have told your doctor that you have received BOTOX® in the past. Especially tell your doctor if you: have received any other botulinum toxin product in the last 4 months; have received injections of botulinum toxin such as Myobloc®, Dysport®, or Xeomin® in the past (be sure your doctor knows exactly which product you received); have recently received an antibiotic by injection; take muscle relaxants; take an allergy or cold medicine; take a sleep medicine; take anti-platelets (aspirin-like products) or anti-coagulants (blood thinners). Other side effects of BOTOX®include: dry mouth, discomfort or pain at the injection site, tiredness, headache, neck pain, and eye problems: double vision, blurred vision, decreased eyesight, drooping eyelids, swelling of your eyelids, and dry eyes. For more information refer to the Medication Guide or talk with your doctor. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088. Please refer to full Medication Guide including Boxed Warning on the following pages.22 HeadWise® | Volume 4, Issue 3 • 2015 injection

For adults with Chronic Migraine, FOR ADULTS WITH15 or more headache days a month,each lasting 4 hours or more, CHRONIC MIGRAINEBOTOX® is the first and only preventive treatment injectionproven to reduce headache days every month. Find a headache specialist near you atBOTOX® is the only FDA-approved, preventive treatment that isinjected by a doctor every 3 months for people with Chronic Migraine. BotoxChronicMigraine.comBOTOX® prevents up to 9 headache days a month, versus up to 7 daysfor placebo. BOTOX® is not approved for adults with migraine whohave 14 or fewer headache days a month.BOTOX® is a prescription medicine that is injected to prevent headaches in adults with Chronic Migraine who have 15 or more dayseach month with headache lasting 4 or more hours each day in people 18 years or older. It is not known whether BOTOX® is safeor effective to prevent headaches in patients with migraine who have 14 or fewer headache days each month (episodic migraine).IMPORTANT SAFETY INFORMATION • Spread of toxin effects. The effect of botulinum toxin may affect areas away from the injection site and cause serious symptomsBOTOX® may cause serious side effects that can be life including: loss of strength and all-over muscle weakness, doublethreatening. Call your doctor or get medical help right away if vision, blurred vision and drooping eyelids, hoarseness or changeyou have any of these problems any time (hours to weeks) after or loss of voice (dysphonia), trouble saying words clearlyinjection of BOTOX®: (dysarthria), loss of bladder control, trouble breathing, trouble swallowing. If this happens, do not drive a car, operate• Problems swallowing, speaking, or breathing, due to weakening machinery, or do other dangerous activities. of associated muscles, can be severe and result in loss of life. You are at the highest risk if these problems are pre-existing before There has not been a confirmed serious case of spread of toxin injection. Swallowing problems may last for several months. effect away from the injection site when BOTOX® has been used at the recommended dose to treat Chronic Migraine. Please see additional Important Safety Information on adjacent page.© 2014 Allergan, Inc., Irvine, CA 92612. ® marks owned by Allergan, Inc. Dysport is a registered trademark of Ipsen Biopharm Limited Company. 23Myobloc is a registered trademark of Solstice Neurosciences, Inc. Xeomin is a registered trademark of Merz Pharma GmbH & Co KGaA. APC43DI14 www.headaches.org | National Headache Foundation

MEDICATION GUIDE • double vision BOTOX Cosmetic is a prescription medicineBOTOX® and BOTOX® Cosmetic • blurred vision and drooping eyelids that is injected into muscles and used to(Boe-tox) (onabotulinumtoxinA) • hoarseness or change or loss of voice improve the look of moderate to severe frownfor Injection (dysphonia) lines between the eyebrows (glabellar lines) inRead the Medication Guide that comes • trouble saying words clearly (dysarthria) adults for a short period of time (temporary).with BOTOX or BOTOX Cosmetic before • loss of bladder control BOTOX Cosmetic is a prescription medicineyou start using it and each time it is given • trouble breathing that is injected into the area around the sideto you. There may be new information. • trouble swallowing of the eyes to improve the look of crow’sThis information does not take the place of feet lines in adults for a short period of timetalking with your doctor about your medical These symptoms can happen hours, days, (temporary).condition or your treatment. You should to weeks after you receive an injection of You may receive treatment for frown linesshare this information with your family BOTOX or BOTOX Cosmetic. and crow’s feet lines at the same time.members and caregivers. It is not known whether BOTOX is safe orWhat is the most important information These problems could make it unsafe for effective in people younger than:I should know about BOTOX and BOTOX you to drive a car or do other dangerous • 18 years of age for treatment of urinaryCosmetic? activities. See “What should I avoid while incontinenceBOTOX and BOTOX Cosmetic may cause receiving BOTOX or BOTOX Cosmetic?” • 18 years of age for treatment of chronicserious side effects that can be life migrainethreatening, including: There has not been a confirmed serious • 18 years of age for treatment of spasticity• Problems breathing or swallowing case of spread of toxin effect away from • 16 years of age for treatment of cervical• Spread of toxin effects the injection site when BOTOX has been dystoniaThese problems can happen hours, days, used at the recommended dose to treat • 18 years of age for treatment ofto weeks after an injection of BOTOX or chronic migraine, severe underarm hyperhidrosisBOTOX Cosmetic. Call your doctor or get sweating, blepharospasm, or strabismus, • 12 years of age for treatment ofmedical help right away if you have any or when BOTOX Cosmetic has been used strabismus or blepharospasmof these problems after treatment with at the recommended dose to treat frown BOTOX Cosmetic is not recommended forBOTOX or BOTOX Cosmetic: lines and/or crow’s feet lines. use in children younger than 18 years of age.1. Problems swallowing, speaking, or It is not known whether BOTOX andbreathing. These problems can happen What are BOTOX and BOTOX Cosmetic? BOTOX Cosmetic are safe or effective tohours, days, to weeks after an injection prevent headaches in people with migraineof BOTOX or BOTOX Cosmetic usually BOTOX is a prescription medicine that is who have 14 or fewer headache days eachbecause the muscles that you use to injected into muscles and used: month (episodic migraine).breathe and swallow can become weak It is not known whether BOTOX andafter the injection. Death can happen • to treat overactive bladder symptoms BOTOX Cosmetic are safe or effective foras a complication if you have severe such as a strong need to urinate with other types of muscle spasms or for severeproblems with swallowing or breathing leaking or wetting accidents (urge urinary sweating anywhere other than your armpits.after treatment with BOTOX or incontinence), a strong need to urinate Who should not take BOTOX orBOTOX Cosmetic. right away (urgency), and urinating often BOTOX Cosmetic?• People with certain breathing problems (frequency) in adults when another type of Do not take BOTOX or BOTOX Cosmeticmay need to use muscles in their neck to medicine (anticholinergic) does not work if you:help them breathe. These people may be at well enough or cannot be taken. • are allergic to any of the ingredientsgreater risk for serious breathing problems • to treat leakage of urine (incontinence) in BOTOX or BOTOX Cosmetic. See thewith BOTOX or BOTOX Cosmetic. in adults with overactive bladder due to end of this Medication Guide for a list of• Swallowing problems may last for several neurologic disease when another type of ingredients in BOTOX and BOTOX Cosmetic.months. People who cannot swallow well medicine (anticholinergic) does not work • had an allergic reaction to any othermay need a feeding tube to receive food well enough or cannot be taken. botulinum toxin product such as Myobloc®,and water. If swallowing problems are • to prevent headaches in adults with Dysport ®, or Xeomin®severe, food or liquids may go into your chronic migraine who have 15 or more • have a skin infection at the plannedlungs. People who already have swallowing days each month with headache lasting injection siteor breathing problems before receiving 4 or more hours each day. • are being treated for urinary incontinenceBOTOX or BOTOX Cosmetic have the • to treat increased muscle stiffness in and have a urinary tract infection (UTI)highest risk of getting these problems. elbow, wrist, and finger muscles in adults • are being treated for urinary incontinence2. Spread of toxin effects. In some cases, with upper limb spasticity. and find that you cannot empty yourthe effect of botulinum toxin may affect • to treat the abnormal head position bladder on your own (only applies to peopleareas of the body away from the injection and neck pain that happens with cervical who are not routinely catheterizing)site and cause symptoms of a serious dystonia (CD) in adults. What should I tell my doctor before takingcondition called botulism. The symptoms • to treat certain types of eye muscle BOTOX or BOTOX Cosmetic?of botulism include: problems (strabismus) or abnormal spasm• loss of strength and muscle weakness of the eyelids (blepharospasm) in peopleall over the body 12 years and older. BOTOX is also injected into the skin to treat the symptoms of severe underarm sweating (severe primary axillary hyperhidrosis) when medicines used on the skin (topical) do not work well enough.24 HeadWise® | Volume 4, Issue 3 • 2015

Tell your doctor about all your medical • take a sleep medicine to use disposable self-catheters to empty yourconditions, including if you: • take anti-platelets (aspirin-like products) bladder up to a few times each day until your• have a disease that affects your muscles and/or anti-coagulants (blood thinners) bladder is able to start emptying again.and nerves (such as amyotrophic lateral Ask your doctor if you are not sure if your • allergic reactions. Symptoms of an allergicsclerosis [ALS or Lou Gehrig’s disease], medicine is one that is listed above. reaction to BOTOX or BOTOX Cosmeticmyasthenia gravis or Lambert-Eaton may include: itching, rash, red itchy welts,syndrome). See “What is the most important Know the medicines you take. Keep a list wheezing, asthma symptoms, or dizziness orinformation I should know about BOTOX and of your medicines with you to show your feeling faint. Tell your doctor or get medical helpBOTOX Cosmetic?” doctor and pharmacist each time you get a right away if you are wheezing or have asthma• have allergies to any botulinum toxin product new medicine. symptoms, or if you become dizzy or faint.• had any side effect from any botulinum Tell your doctor if you have any side effect thattoxin product in the past How should I take BOTOX or bothers you or that does not go away.• have or have had a breathing problem, such BOTOX Cosmetic? These are not all the possible side effectsas asthma or emphysema • BOTOX or BOTOX Cosmetic is an injection of BOTOX and BOTOX Cosmetic. For more• have or have had swallowing problems that your doctor will give you. information, ask your doctor or pharmacist.• have or have had bleeding problems • BOTOX is injected into your affected Call your doctor for medical advice about side• have plans to have surgery muscles, skin, or bladder. effects. You may report side effects to FDA at• had surgery on your face • BOTOX Cosmetic is injected into your 1-800-FDA-1088.• have weakness of your forehead muscles, affected muscles. General information about BOTOX andsuch as trouble raising your eyebrows • Your doctor may change your dose of BOTOX Cosmetic:• have drooping eyelids BOTOX or BOTOX Cosmetic, until you and Medicines are sometimes prescribed• have any other change in the way your face your doctor find the best dose for you. for purposes other than those listed in anormally looks • Your doctor will tell you how often you Medication Guide.• have symptoms of a urinary tract infection will receive your dose of BOTOX or This Medication Guide summarizes the(UTI) and are being treated for urinary BOTOX Cosmetic injections. most important information about BOTOXincontinence. Symptoms of a urinary tract and BOTOX Cosmetic. If you would likeinfection may include pain or burning with What should I avoid while taking BOTOX more information, talk with your doctor.urination, frequent urination, or fever. or BOTOX Cosmetic? You can ask your doctor or pharmacist• have problems emptying your bladder on BOTOX and BOTOX Cosmetic may for information about BOTOX andyour own and are being treated for urinary cause loss of strength or general muscle BOTOX Cosmetic that is written forincontinence weakness, or vision problems within healthcare professionals.• are pregnant or plan to become pregnant. hours to weeks of taking BOTOX or What are the ingredients in BOTOX andIt is not known if BOTOX or BOTOX Cosmetic BOTOX Cosmetic. If this happens, do not BOTOX Cosmetic?can harm your unborn baby. drive a car, operate machinery, or do other Active ingredient: botulinum toxin type A• are breast-feeding or plan to breastfeed. It dangerous activities. See “What is the most Inactive ingredients: human albumin andis not known if BOTOX or BOTOX Cosmetic important information I should know about sodium chloridepasses into breast milk. BOTOX and BOTOX Cosmetic?” This Medication Guide has been approved by the U.S. Food and Drug Administration.Tell your doctor about all the medicines What are the possible side effects of Manufactured by: Allergan Pharmaceuticalsyou take, including prescription and BOTOX and BOTOX Cosmetic? Ireland a subsidiary of: Allergan, Inc.nonprescription medicines, vitamins and BOTOX and BOTOX Cosmetic can cause 2525 Dupont Dr.herbal products. Using BOTOX or serious side effects. See “What is the most Irvine, CA 92612BOTOX Cosmetic with certain other important information I should know about Revised: 09/2013medicines may cause serious side effects. BOTOX and BOTOX Cosmetic?” © 2013 Allergan, Inc.Do not start any new medicines until you ® marks owned by Allergan, Inc.have told your doctor that you have received Other side effects of BOTOX and BOTOX Myobloc®is a registered trademarkBOTOX or BOTOX Cosmetic in the past. Cosmetic include: of Solstice Neurosciences, Inc. • dry mouth Dysport ®is a registered trademarkEspecially tell your doctor if you: • discomfort or pain at the injection site of Ipsen Biopharm Limited Company.• have received any other botulinum toxin • tiredness Xeomin®is a registered trademarkproduct in the last four months • headache of Merz Pharma GmbH & Co KGaA.• have received injections of botulinum toxin, • neck pain Patented. See: www.allergan.com/products/such as Myobloc®(rimabotulinumtoxinB), • eye problems: double vision, blurred patent_noticesDysport ®(abobotulinumtoxinA), or Xeomin® vision, decreased eyesight, drooping eyelids,(incobotulinumtoxinA) in the past. Be sure swelling of your eyelids, and dry eyes. Based on 72284US16your doctor knows exactly which product • urinary tract infection in people being APC13NF13you received. treated for urinary incontinence• have recently received an antibiotic by • painful urination in people being treated forinjection urinary incontinence• take muscle relaxants • inability to empty your bladder on your own• take an allergy or cold medicine and are being treated for urinary incontinence. If you have difficulty fully emptying your bladder after getting BOTOX, you may need www.headaches.org | National Headache Foundation 25

Mary A. Franklin Seymour Diamond, MD Director of Operations Executive Chairman and FounderNational Headache Foundation National Headache Foundation Director Emeritus and Founder Chicago, IL Diamond Headache Clinic Chicago, ILEditor’s Note: Because we have recently celebrated the 150th anniversary of the end of the Civil War, it seemed appropriate torepublish this article about a famous general, president, and migraineur. The headaches and the depressive bouts suffered by Ulysses S. Grant are frequently cited in his biographical notes.This article is based on a previously published article of the same name which appeared in Headache Quarterly 1999; 10:145-146.One of the major figures of the U.S. Civil War was the in business. In St. Louis, Grant tried his hand at farming, best known of the Union commanders, Ulysses S. real estate, politics, and civil service as a customs agent – allGrant (1822-1885), who later served as the 18th President to no avail. With financial obligations at a critical point,of the United States. Born in Ohio, where his father had Grant moved his family to Galena, IL, and worked as aa leather tannery, Grant developed an early proficiency clerk in a leather goods store owned by his brothers. Liv-for handling horses. He was a precise child, did well in ing in Galena was interrupted by the outbreak of the Civilmathematics, and earned an appointment at the U.S. War, and Grant was again called to serve his country. HeMilitary Academy in West Point, New York. His tenure received an appointment as a colonel in an Illinois regi-at the Academy was undistiguished – graduating 21st in a ment. Due to his military experience and leadership skills,class of 39 – except for his masterful equestrian skills. After he was soon appointed a brigadier general of volunteers. Itgraduation in 1843, he was posted to St. Louis where he should be noted that the Union Army was conspicuouslymet his future wife, Julia Dent, whom he married in 1848. lacking in experienced military leadership. The cream ofGrant served with distinction during the Mexican War, the pre-war army had allied with the Confederacy, leavingearning two brevets for meritorious conduct at the battles a void at the top of the U.S. army.of Molino del Rey and Chapultepec. Throughout his military career, Grant demonstrated A military life seemed his destiny until he was trans- consistent behavior, serious judgement, and unflinchingferred to the Pacific Northwest in 1852, and Grant became courage in the face of great odds. While the armies in theextremely depressed during his absence from his family. Eastern theater of war were losing major battles, Grant inThroughout Grant’s life, his depression usually triggered the West, started charting military victories. Unlike manya bout with excessive alcohol consumption. This problem of his colleagues, Grant did not pursue his own politicalforced him to resign from the Army in 1854. agenda, but dealt with the matters at hand. The first major battle in the West was at Shiloh, Tennessee. On the first Success on the battlefields did not translate into success26 HeadWise® | Volume 4, Issue 3 • 2015

day of the battle (April 5, 1862), all seemed lost was dying of throat cancer, Grant began work-for the Union. However, Grant’s arrival in the ing on his memoirs. He finished them daysevening helped the Union forces regroup, and before his death on July 23, 1885, at Mountthey soundly defeated the rebels on the battle’s McGregor, NY. He is interred in “Grant’ssecond day. Due to political machinations by Tomb” on Riverside Drive, in New York City.his superiors (primarily, General Henry Hal- The two volumes of his memoirs were profit-leck), Grant’s leadership was ignored. He again able, and have become classics.fell into a depression and reportedly, his drink-ing problem reappeared. The talents of this Unlike Thomas Jefferson, Grant did not leavegreat military leader were squandered during extensive journals nor correspondence. Grantthe next few months, until he was appointed commander did maintain a wartime journal, as did manyof the Department of Tennessee, and was instructed to lay of his colleagues. George Meade, his second-in-commandsiege to Vicksburg, MS – a major Confederate supply cen- recalled Grant riding into camp on the evening of Aprilter located on bluffs above the Mississippi river. Despite 8, 1865:many maneuvers by Grant’s forces and naval gunboats on “(Grant) had one of his sick headaches, which are rare,the river, the city did not capitulate until July 4, 1863. This but cause him fearful pain, such as almost overcomes hisevent, combined with the Union victory at Gettysburg, iron stoicism.”PA, on July 3, 1863, signaled the turning point of the war. Grant’s journal for that date truly gives testimony to his migraine problem: Because of Grant’s continuing successes, he was appoint- “I was suffering very severely with a sick headache, anded general-in-chief of all Union forces in February, 1864. stopped at a farm house on the road some distance to theGrant’s self-reliance, tenacity, and confidence impressed rear of the main body of the army. I spent the night inPresident Abraham Lincoln, who noted to a Grant detrac- bathing my feet in hot water and mustard, and puttingtor that “I can’t spare this man, he fights.” Now leading mustard plasters on my wrists and the back part of mytroops in the Eastern theater, Grant was confronting the neck, hoping to be cured by morning.”exceptional skills of General Robert E. Lee who had been Unfortunately, the headache remained when GrantGrant’s superior during the Mexican War. The remaining awakened. Soon after he rose, a messenger arrived with amonths of the war became a battle of wits between Grant communication from General Lee. On the previous day,and Lee. Through extraordinary efforts, the Confederate Lee had refused to surrendr but now indicated that hearmy was finally in total retreat in April, 1865, culminat- was willing to talk peace terms. Grant’s next journal entrying in the surrender at Appomattox Court House, VA, on reports:April 9, 1865. “When the officer reached me, I was still suffering from the sick headache; but the instant I saw the contents of In peace, and following the assassination of Lincoln the note I was cured.”on April 14, 1865, Grant remained general-in-chief, and Grant later commented to his aide, Colonel Horacethen served as Secretary of War under Lincoln’s successor, Porter, that “The pain in my head seemed to leave me theAndrew Johnson. Because Grant believed in rigorous Re- moment I got Lee’s letter.” This was a sentiment shared byconstruction policies for the defeated Confederate states, many Americans, on both sides of the Mason-Dixon line.he made many allies in the Republican party. Like manygenerals before and after him, Grant was successful in Recommended reading:politics – winning the 1868 Presidential election. He wasreelected in 1872. And similar to many military figures 1. McFeely WS. Grant. New York: WW Norton; 1982.turned politicians, Grant was not an effective president. 2. Grant US. Personal Memoirs of U.S. Grant, 2 volsHis two terms are remembered for rampant graft, scandal,and corruption. (McFeely WS, ed). New York: DaCapo Press; 1982. Following his retirement from the presidency, Grant Photo credits: (cover) Lee Surrenders To Grant Ending The Civil War –tried for success in business and again was repulsed. To re- Appomattox, Courthouse, Old, Virginia, Fame (Left) Lt. Gen. Ulysses S. Grantgain financial security for his family, and knowing that he standing by a tree in front of a tent, Cold Harbor, Va., June 1864. 111-B-36. (Right) Lee, Gen. Robert E.; full-length, standing, April 1865. Photographed by Mathew B. Brady. 111-B-1564. U.S. Postage Stamp, 1965 issue, commemo- rating the centennial anniversary of the Confederate surrender at Appomattox Court Housewww.headaches.org | National Headache Foundation 27

THE HEADACHE CLINICS featuring: The Michigan Headache Clinic East Lansing, MichiganThe Michigan Headache Clinic was founded in 1981 as a private practice byEdmund Messina, MD, and Jayne Bailey Messina, RN The following is based on an interview with Doctor Edmund Messina, the Director of the Clinic.Doctor Edmund Messina attended medical school at MI. Ms. Messina serves as a clinical nurse as well as ad- the University of Illinois in Chicago. He remained ministrator. Their staff includes nurse practitioner, Noellein Chicago to complete an Internal Medicine internship Helmic, CNP, CS, RN; clinical nurse, Judy Calhoun, RN;at the former Michael Reese Hospital, and then traveled medical assistants, Christina Buckmaster, MA and Jillto Saint Louis, MO for a neurology residency at Wash- Sewell, MA; and the administrative staff – Julie Hill, Calieington University. Dr. Messina reflects on his years in Risch, with IT specialist Tim Thelen.medical school and internship in the book, The SpatteredWhite Coat. He advised that his introduction to headache The typical patient at the Michigan Headache Clinicmedicine occurred when he attended a lecture on head- presents with painful disorders of the head or face, andache in medical school which was presented by Seymour usually with a complex medical history. Adults, as wellDiamond, MD, the Executive Chairman of the National as children, 12 years and older, may be seen at the clinic.Headache Foundation. Self-referrals are accepted if the Clinic participates with the patient’s insurance. He is certified in Neurology by the American Board ofPsychiatry and Neurology, and received subspecialty certi- The first appointment consists of an in-depth inter-fication in Headache Medicine from the United Council view by the nurse, a thorough history and neurologicalfor Neurologic Subspecialties in 2008. He became a Fel- examination conducted by Dr. Messina, and followed bylow of the American Headache Society on November personalized patient education by the nurse. A typical day15, 2012. Dr. Messina is Clinical Associate Professor of at the Clinic consists of new patient visits, return visitsMedicine at Michigan State University’s College of Hu- which start with the nurse or medical assistant taking anman Medicine. He is the founder and Medical Director interval history, and a detailed encounter with Dr. Mes-of Arbor Medicus™, a patient and physician advocacy and sina or the nurse practitioner. The nurse will conclude theeducational website. visit with additional patient teaching. Some return visits are conducted through remote telemedicine for patients In 1981, with his wife, Jayne Bailey Messina, RN, they living at greater distances. Because of the pain being ex-founded the Michigan Headache Clinic in East Lansing, perienced by new patients, all efforts are made to evaluate28 HeadWise® | Volume 4, Issue 3 • 2015

Noelle L. Helmic, CNP, CS, RN Michigan Headache Clinic Staff Edmund Messina, MDthem within a couple of weeks. Initial visits are expedited Dr. Messina became interested in headache medicine be-even if it means modifying the schedule. If a colleague has cause he had experienced migraine since the age of 8 years,an urgent request for a referral, the staff will make every and he recalled watching his mother suffer from headacheseffort to accommodate the patient’s evaluation. all of his life. There is a long history of migraine in his family, and several of his staff are also migraine sufferers. The main philosophy of the Clinic is to consider the“entire patient” in order to not only establish the diag- In addition to his clinical practice, Dr. Messina has beennosis (or diagnoses) but also to identify and treat those active in headache education through the media. Withfactors which will interfere with a successful outcome. his son, Dan Messina, he wrote, produced, and directed aFactors that may impact the patient’s treatment include documentary on headaches, Life and Migraine, which wasother neurological problems, neck pain, sleep disorders, broadcast on public television and was released on DVDanxiety, depression, and other issues. All painful disorders in 2006. The documentary was featured in an interna-of the head and face are treated at the Michigan Headache tional film festival, and in 2006, Dr. Messina received theClinic. The treatment plan is individualized according to National Headache Foundation Award for Media Excellence.the patient’s needs. Another film, The Headache Which Would Not Go Away, was completed in 2008, and aired on The Learning Chan- Treatment may include medications, counseling, physi- nel and the Discovery Health Channel. The feature-lengthcal therapy, and intervention therapies, such as Botox. At film, Lily’s Mom, was released in 2011. Dr. Messina wrote,the Clinic, patients are taught auto-relaxation techniques produced, and directed the film (and had a supportingand cervical muscle exercises, and are encouraged to utilize role) which focuses on self-advocacy in a woman sufferingonline and personal counseling services, including mind- from severe migraine and depression. It was a recipient offulness. If inpatient therapy is indicated, Dr. Messina has an independent film festival Drama Award and a nomineea long-standing relationship with the Diamond Headache for the Voice Award in Hollywood in 2012.Clinic in Chicago for possible referral of recidivist patients. Dr. Messina was asked what general advice he would The biggest immediate change that Dr. Messina de- give to the patient experiencing headache. He noted thatscribed for the Clinic is the ability to offer virtual visits headache patients need to take the initiative to modifyfor established patients, via telemedicine. Patients living their lifestyle and to seek help from those who are willingat great distances are now able to complete a visit through to spend the time to help them. Patients must realize thata secure video connection. The Clinic is also expanding most headache disorders, no matter how daunting theyits artificial intelligence expert system to more efficiently seem, are probably quite treatable when the best individu-gather medical histories. A pioneer in the use of electronic alized treatment plan is established. HWmedical records, Dr. Messina has been utilizing computer-assisted history taking since the 1980s. He believes that the FOR MORE INFORMATION ON THE CLINIC, PLEASE VISIT:future medical climate will be driven by cost effectivenessand that its advanced technology will continue to make www.michiganheadache.comthe Michigan Headache Clinic affordable to the averagepatient, despite the rise in insurance deductibles. Michigan Headache Clinic When asked what he enjoyed most about working in 1675 Watertower Place, Suite 600headache medicine, Dr. Messina revealed that it is gratify-ing to see patients improving. From visit to visit, patients East Lansing, Michigan 48823change for the better, making the practice very worthwhile. (517) 324-3445 www.headaches.org | National Headache Foundation 29

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GIVE THE GIFT OFDO YOU KNOW FAMILY, FRIENDS OR CO-WORKERSWHO STRUGGLE WITH A HEADACHE DISORDER? IFSO, EMPOWER THEM TO BE THEIR OWN ADVOCATEBY GIFTING A MEMBERSHIP TO THE NHF, WHICH IN -CLUDES A SUBSCRIPTION TO HEADWISE MAGAZINE.3 WAYS TO ORDER: ORDER NOW AND THE RECEIPIENT WILL RECEIVE THE FOLLOWING:CALL:1–800–NHF–5552VISIT: PREVIOUS EDITION E-NEWSLETTERWWW.HEADACHES.ORG Payment: VIA EMAIL1. select “Become a Member” at the top right hand side2. be sure to place a check in the “I wish to give a gift membership” boxMAIL:Gift Membership: $20.00 to send HeadWise plus the monthly e-newsletter, NHF News to Know.  Payment enclosed (Make check payable to National Headache Foundation)In addition, I’d like to make a tax-deductible contribution to the NHF in the Charge to my credit card:amount of:  $5  $10  $20  Other: $______  Amex  Discover  Mastercard  Visa_______________________________________________________________ ___________________________________________________________Receipient’s Name (Please Print) Credit Card Number Expiration Date_______________________________________________________________ ___________________________________________________________Receipient’s Address Cardholder’s Name Cardholder’s Signature_______________________________________________________________ ___________________________________________________________City/State/Zip Billing Address City/State/Zip_______________________________________________________________ ___________________________________________________________Preferred Phone # E-mail Address (to get the e-newsletter) Preferred Phone # E-mail Address Please mail this form with your payment to: National Headache Foundation, 820 N. Orleans, Ste. 411, Chicago, IL 60610 www.headaches.org | National Headache Foundation 33

Your Contributions to theNational Headache FoundationHelp Fund ProjectsWhat’s being done to help your Please select one of the following giving categories:headache problem? There is an ❒ $250 ❒ $125 ❒ $100 ❒ $75 ❒ Other _________________unprecedented amount of research Name: _______________________________________________being undertaken regarding migraine Address: _____________________________________________and other headache pain. The National City: _________________________________________________Headache Foundation is involved in this State/Zip: ____________________________________________effort with the help of funding from you. Daytime Phone:________________________________________Contributions are a key part of the Method of Payment:financial support of important headache Check or Money Order payable to National Headache Foundationresearch. Your gift provides funds for ❒ Visa ❒ MasterCard ❒ Amex ❒ Discover(a) NHF-financed research projects, Card #: _____________________ Expiration Date: ___________(b) advocacy with health policy decisionmakers, and (c) patient-educationinitiatives. You can help! The NationalHeadache Foundation, the #1 source forheadache help, provides these servicesand many others through the generosityof people like you.New Membership | Toll-Free (888) NHF-5552 | www.headaches.orgIndividual Membership: Payment: $20.00 to receive HeadWise® plus the monthly e-newsletter, NHF News to Know,  Payment enclosed (check payable to National Headache Foundation)when you join the National Headache FoundationIn addition, I’d like to make a tax-deductible contribution in support of NHF’s Charge to my credit card:  Amex  Discover  Mastercard  Visaeducational programs in the amount of:  $10  $25  $50  Other: $____________________________________________________________________ ___________________________________________________________Name (Please Print) Credit Card Number Expiration Date_______________________________________________________________ ___________________________________________________________Address Cardholder’s Signature_______________________________________________________________ ___________________________________________________________City/State/Zip/Country Billing Address (If di erent from mailing address)_______________________________________________________________ ___________________________________________________________Preferred Phone # E-mail Address City/State/Zip/CountryPlease mail this form with your payment to: National Headache Foundation, 820 N. Orleans, Ste. 411, Chicago, IL 60610 or renew online by visting www.headaches.org34 HeadWise® | Volume 4, Issue 3 • 2015

The practice of asking for donations to a favorite charity in memory of a de-ceased relative or friend is very thoughtful. A gift may also be given as a trib-ute in the name of a friend or relative to commemorate significant occasions,such as birthdays, anniversaries, or special events.During the past year, such requests have resulted in donations which benefitthe National Headache Foundation. Acknowledgments of memorial gifts andtributes are mailed to the family or individual. We thank those benefactors andtheir families who have supported the NHF and its mission. In Memoriam Susan Abrams Lisa Barrett Joan Davis Sheree Shelton Duszynski Mildred GK Michaelina Ifasi Marianne Principe Markey In Tribute Roger Cady, MD Seymour Diamond, MD Julie Fleck Abby Friedman Daniel Gaitan, MD Andrea Gallo Carter Golden Robert S. Kunkel, MD Joey Wilder Xiaobin Yi, MD www.headaches.org | National Headache Foundation 35

820 N. Orleans Street–Suite 411Chicago, Illinois 60610