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Guideline Summary
Guideline Title
EFNS guideline on the drug treatment of migraine – revised report of an EFNS task force.
Bibliographic Source(s)
Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, Sandor PS, European Federation of Neurological Societies. EFNS guideline on the drug treatment of migraine--revised report of an EFNS task force. Eur J Neurol. 2009 Sep;16(9):968-81. [215 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, Sandor PS. EFNS guideline on the drug treatment of migraine - report of an EFNS task force. Eur J Neurol 2006 Jun;13(6):560-72.

These recommendations should be updated within 3 years and should be complemented by recommendations for the non-drug treatment of migraine.

Scope

Disease/Condition(s)
  • Migraine attack (migraine headache)
  • Status migrainosus
Guideline Category
Assessment of Therapeutic Effectiveness
Management
Prevention
Treatment
Clinical Specialty
Family Practice
Neurology
Obstetrics and Gynecology
Pediatrics
Preventive Medicine
Intended Users
Advanced Practice Nurses
Physician Assistants
Physicians
Guideline Objective(s)

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

Target Population

Patients with migraine attacks

Note: There is a section in the guideline that briefly discusses children and adolescents with migraine.

Interventions and Practices Considered

Treatment/Prevention

  1. Analgesics
  2. Antiemetics
  3. Ergot alkaloids
  4. Triptans
  5. Migraine prophylaxis (e.g., beta blockers, calcium channel blockers, antiepileptic drugs, nonsteroidal anti-inflammatory drugs [NSAIDs])
  6. Specific situations:
    • Emergency situation/severe migraine attack (e.g., intravenous application of 1000 mg acetylsalicylic acid [ASA] with or without metoclopramide)
    • Menstrual migraine (e.g., triptans, naproxen sodium)
    • Migraine in pregnancy (e.g., paracetamol, NSAIDs)
    • Migraine in children and adolescents (e.g., ibuprofen, paracetamol, domperidone, sumatriptan nasal spray)

Note: Non-drug management (e.g., behavioral therapy) is not included in this guideline.

Major Outcomes Considered
  • Frequency of migraine recurrence
  • Adverse effects of medications used to treat migraine
  • Quality of life

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

A literature search was performed using the reference databases MedLine, Science Citation Index, and the Cochrane Library; the key words used were 'migraine' and 'aura' (last search in January 2009). All papers published in English, German, or French were considered when they described a controlled trial or a case series on the treatment of at least five patients. In addition, a review book and the German treatment recommendations for migraine were considered.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Evidence Classification Scheme for a Therapeutic Intervention

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

  1. Randomization concealment
  2. Primary outcome(s) is/are clearly defined
  3. Exclusion/inclusion criteria are clearly defined
  4. Adequate accounting for dropouts and crossovers with numbers sufficiently low to have minimal potential for bias
  5. Relevant baseline characteristics are presented and substantially equivalent among treatment groups or there is appropriate statistical adjustment for differences

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

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

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

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

All authors performed an independent literature search. The first draft of the manuscript was written by the chairman of the task force. All other members of the task force read the first draft and discussed changes by e-mail. A second draft was then written by the chairman and again discussed by e-mail. All recommendations had to be agreed to by all members of the task force unanimously.

The background of the research strategy and of reaching consensus and the definitions of the recommendation levels used in this paper have been described in the European Federation of Neurological Societies (EFNS) "Guidance for the preparation of neurological management guidelines" (see the "Availability of Companion Documents" field).

Rating Scheme for the Strength of the Recommendations

Rating of Recommendations

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

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

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

Cost Analysis

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

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

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

Recommendations

Major Recommendations

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

Drug Treatment of Migraine Attacks

Analgesics

Drugs of first choice for mild or moderate migraine attacks are analgesics. Table 1 presents an overview of analgesics with efficacy in acute migraine treatment.

Table 1: Analgesics with Evidence of Efficacy in at Least One Study on the Acute Treatment of Migraine. The level of recommendation also considers side effects and consistency of the studies

Substance Dose Level of Recommendation Comment
Acetylsalicylic acid (ASA) 1000 mg (oral) A Gastrointestinal side effects
ASA 1000 mg (intravenous [i.v.]) A Risk of bleeding
Ibuprofen 200 – 800 mg A Side effects as for ASA
Naproxen 500 – 1000 mg A Side effects as for ASA
Diclofenac 50 – 100 mg A Including diclofenac-K
Paracetamol 1000 mg (oral) A Caution in liver and kidney failure
Paracetamol 1000 mg (suppository) A Caution in liver and kidney failure
ASA plus paracetamol plus caffeine 250 mg (oral),
200 – 250 mg,
50 mg
A As for ASA and paracetamol
Metamizole 1000 mg (oral) B Risk of agranulocytosis
Metamizole 1000 mg (i.v.) B Risk of hypotension
Phenazone 1000 mg (oral) B See paracetamol
Tolfenamic acid 200 mg (oral) B Side effects as for ASA

Antiemetics

The use of antiemetics in acute migraine attacks is recommended to treat nausea and potential emesis and because it is assumed that these drugs improve the resorption of analgesics. Table 2 presents the antiemetics recommended for the use in migraine attacks.

Table 2: Antiemetics Recommended for the Acute Treatment of Migraine Attacks

Substance Dose Level Comment
Metoclopramide 10-20 mg (oral), 20 mg (suppository), 10 mg (intramuscular, intravenous, and subcutaneous) B Side effect: dyskinesia; contraindicated in childhood and in pregnancy; also analgesic efficacy
Domperidone 20-30 mg (oral) B Side effects less severe than in metoclopramide; can be given to children

Ergot Alkaloids

There are only very few randomized, placebo-controlled trials on the efficacy of ergot alkaloids in acute migraine treatment. In comparative trials, triptans showed better efficacy than ergot alkaloids. The advantage of ergot alkaloids is a lower recurrence rate in some patients. Therefore, these substances should be restricted to patients with very long migraine attacks or with regular recurrence. The only compounds with sufficient evidence of efficacy are ergotamine tartrate and dihydroergotamine 2 mg (oral and suppositories, respectively). Ergot alkaloids can induce drug overuse headache very fast and in very low doses.

Triptans (5-HT1B/1D-agonists)

The 5-HT1B/1D receptor agonists sumatriptan, zolmitriptan, naratriptan, rizatriptan, almotriptan, eletriptan, and frovatriptan (order in the year of marketing), so-called triptans, are migraine medications and should not be applied in other headache disorders except cluster headache. The different triptans for migraine therapy are presented in Table 3.

Owing to safety aspects, triptans should not be taken during the aura although no specific severe adverse events have been reported. The best time for application is the very onset of headache. Furthermore, triptans are not efficacious when taken during the aura phase before headache has developed.

Some minor differences between triptans exist which will be discussed in order to give a guidance which triptan to use in an individual patient. A triptan can be efficacious even if another triptan was not. Subcutaneous sumatriptan has the fastest onset of efficacy of about 10 minutes. Oral rizatriptan and eletriptan need about 30 minutes; oral sumatriptan, almotriptan, and zolmitriptan need about 45–60 minutes; and naratriptan and frovatriptan need up to 4 hours for the onset of efficacy. Zolmitriptan nasal spray has a shorter duration until efficacy than oral zolmitriptan. There is no evidence that different oral formulations such as rapidly dissolving tablets, wafer forms, or rapid release forms act earlier than others. (See the original guideline document for more information on triptans.)

Table 3: Different Triptans for the Treatment of Acute Migraine Attacks (Order in the Time of Marketing). Not all doses or application forms are available in all European countries.

Substance Dose Level Comment
Sumatriptan 25, 50 and 100 mg (oral including rapid-release) A 100 mg sumatriptan is reference to all triptans
25 mg (suppository) A
10 and 20 mg (nasal spray) A
6 mg (subcutaneous) A
Zolmitriptan 2.5 and 5 mg (oral including disintegrating form) A  
2.5 and 5 mg (nasal spray) A
Naratriptan 2.5 mg (oral) A Less but longer efficacy than sumatriptan
Rizatriptan 10 mg (oral including wafer form) A 5 mg when taking propranolol
Almotriptan 12.5 mg (oral) A Probably less side effects than sumatriptan
Eletriptan 20 and 40 mg (oral) A 80 mg allowed if 40 mg not effective
Frovatriptan 2.5 mg (oral) A Less but longer efficacy than sumatriptan

Migraine Prophylaxis

Prophylactic drugs for the treatment of migraine with good efficacy and tolerability and evidence of efficacy are beta blockers, calcium channel blockers, antiepileptic drugs, nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants, and miscellaneous drugs. The use of all these drugs, however, is based on empirical data rather than on proven pathophysiological concepts. The decision to introduce a prophylactic treatment has to be discussed with the patient carefully. The efficacy of the drugs, their potential side effects, and their interactions with other drugs have to be considered in the individual patient. There is no commonly accepted indication for starting a prophylactic treatment. In the view of the Task Force, prophylactic drug treatment of migraine should be considered and discussed with the patient when:

  • The quality of life, business duties, or school attendance are severely impaired
  • Frequency of attacks per month is two or higher
  • Migraine attacks do not respond to acute drug treatment
  • Frequent, very long, or uncomfortable auras occur

Table 4: Recommended Substances (Drugs of First Choice) for the Prophylactic Drug Treatment of Migraine

Substances Daily Dose Level
Beta Blockers
Metoprolol 50–200 mg A
Propranolol 40–240 mg A
Calcium Channel Blockers
Flunarizine 5–10 mg A
Antiepileptic Drugs
Valproic acid 500–1800 mg A
Topiramate 25–100 mg A

Table 5: Drugs of Second Choice for Migraine Prophylaxis (evidence of efficacy, but less effective or more side effects than drugs of Table 4)

Substances Daily Dose Level
Amitriptyline 50–150 mg B
Venlafaxine 75–150 mg B
Naproxen 2 x 250–500 mg B
Petasites 2 x 75 mg B
Bisoprolol 5–10 mg B

Table 6: Drugs of Third Choice for Migraine Prophylaxis (only probable efficacy)

Substances Daily Dose Level
Acetylsalicylic acid 300 mg C
Gabapentin 1200–1600 mg C
Magnesium 24 mmol C
Tanacetum parthenium 3 x 6.25 mg C
Riboflavin 400 mg C
Coenzyme Q10 300 mg C
Candesartan 16 mg C
Lisinopril 20 mg C
Methysergide 4–12 mg C

Special Situations

Emergency Situation

Treatment of first choice in this situation is the intravenous application of 1000 mg ASA with or without metoclopramide. Alternatively, 6 mg subcutaneous sumatriptan can be given. For the treatment of a status migrainosus, 50–100 mg prednisone or 10 mg dexamethasone is recommended by expert consensus.

Also by expert consensus and supported by open label studies, dihydroergotamine 2 mg (nasal spray or suppositories) is recommended for severe migraine attacks.

Menstrual Migraine

Naproxen sodium (550 mg twice daily) has been shown to reduce pain including headache in the premenstrual syndrome. Its specific effects on menstrual migraine (550 mg twice daily) have also been evaluated. In one trial, patients reported fewer and less severe headaches during the week before menstruation than patients treated with placebo. In the other two placebo-controlled trials, naproxen sodium, given during 1 week before and 1 week after the start of menstruation, resulted in fewer perimenstrual headaches; in one study, severity was not reduced, but in the other both severity and analgesic requirements were decreased. Even triptans have been used as short-term prophylaxis of menstrual migraine. For naratriptan (2 X 1 mg per day for 5 days starting 2 days prior to the expected onset of menses) and for frovatriptan (2 X 2.5 mg given for 6 days perimenstrually), superiority over placebo has been shown; however, it can happen that the menstrual migraine attack is delayed into another time of the menstrual cycle.

Another prophylactic treatment regime of menstrual migraine is oestrogen replacement therapy. The best evidence, although not as effective as beta blockers or other first line prophylactic drugs, has been achieved for transdermal estradiol (not <100 micrograms given for 6 days perimenstrually as a gel or a patch). A recent study, however, did not show efficacy of hormone replacement with respect to attack frequency during the whole menstrual cycle.

Migraine in Pregnancy

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

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

Migraine in Children and Adolescents

The only analgesics with evidence of efficacy for the acute migraine treatment in childhood and adolescents are ibuprofen 10 mg per kg body weight and paracetamol 15 mg per kg body weight. The only antiemetic licensed for the use in children up to 12 years is domperidone. Sumatriptan nasal spray 5–20 mg is the only triptan with positive placebo-controlled trials in the acute migraine treatment of children and adolescents; the recommended dose for adolescents from the age of 12 is 10 mg. Oral triptans did not show significant efficacy in the first placebo-controlled childhood and adolescents studies. This was in particular because of high placebo responses of about 50% in this age group. In post hoc analyses, however, 2.5–5 mg zolmitriptan were effective in adolescents from the age of 12 to 17. In recent trials, oral zolmitriptan 2.5 mg, nasal zolmitriptan 5 mg, and oral rizatriptan 5–10 mg have been superior to placebo in acute migraine treatment. Ergotamine should not be used in children and adolescents. Also children and adolescents can develop drug-induced headache due to analgesic, ergotamine, or triptan overuse.

For migraine prophylaxis, flunarizine 10 mg and propranolol 40–80 mg per day showed the best evidence of efficacy in children and adolescents. Recently, topiramate in a dose between 15 and 200 mg showed efficacy in children and adolescents as well.

Definitions:

Evidence Classification Scheme for a Therapeutic Intervention

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

  1. Randomization concealment
  2. Primary outcome(s) is/are clearly defined
  3. Exclusion/inclusion criteria are clearly defined
  4. Adequate accounting for dropouts and crossovers with numbers sufficiently low to have minimal potential for bias
  5. Relevant baseline characteristics are presented and substantially equivalent among treatment groups or there is appropriate statistical adjustment for differences

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

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

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

Rating of Recommendations

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

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

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

 

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

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

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate drug treatment and prophylaxis of migraine

Potential Harms

Analgesics

  • Acetylsalicylic acid (ASA), ibuprofen, naproxen, and tolfenamic acid are associated with gastrointestinal side effects and risk of bleeding.
  • Paracetamol and phenazone should be given with caution in liver and kidney failure.
  • Metamizole is associated with risk of agranulocytosis and hypotension.
  • In order to prevent drug overuse headache, the intake of simple analgesics should be restricted to 15 days/month and the intake of combined analgesics to 10 days/month.

Antiemetics

  • Metoclopramide is associated with dyskinesia.
  • Domperidone has less severe side effects compared to metoclopramide and can be given to children.

Ergot Alkaloids

  • Major side effects of ergot alkaloids include nausea, vomiting, paresthesia, and ergotism.
  • Ergot alkaloids can induce drug overuse headache very fast and in very low doses. Therefore, their use must be limited to 10 days/month.

Triptans

  • The use of triptans is restricted to maximum 9 days/month. Otherwise, the induction of a drug overuse headache is possible for all triptans.
  • General side effects for all triptans: chest symptoms, nausea, distal paresthesia, fatigue.
  • After application of sumatriptan, severe adverse events have been reported such as myocardial infarction, cardiac arrhythmias, and stroke.

Antidepressants

In several small studies amitriptyline showed central side effects.

Miscellaneous Drugs

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

Contraindications

Contraindications
  • There are no specific clinical trials evaluating drug treatment of migraine during pregnancy; most of the migraine drugs are contraindicated.
  • Metoclopramide is contraindicated in childhood and pregnancy.
  • Ergot alkaloids are contraindicated in cardiovascular and cerebrovascular diseases, Raynaud's disease, arterial hypertension, renal failure, and pregnancy and lactation.
  • Triptan contraindications: arterial hypertension (untreated), coronary heart disease, cerebrovascular disease, Raynaud's disease, pregnancy and lactation, age under 18 (except sumatriptan nasal spray) and age above 65 years, severe liver or kidney failure.

Qualifying Statements

Qualifying Statements

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

Implementation of the Guideline

Description of Implementation Strategy

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

Implementation Tools
Staff Training/Competency Material
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, Sandor PS, European Federation of Neurological Societies. EFNS guideline on the drug treatment of migraine--revised report of an EFNS task force. Eur J Neurol. 2009 Sep;16(9):968-81. [215 references] PubMed External Web Site Policy
Adaptation

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

Date Released
2006 Jun (revised 2009 Sep)
Guideline Developer(s)
European Academy of Neurology - Medical Specialty Society
Source(s) of Funding

European Federation of Neurological Societies

Guideline Committee

European Federation of Neurological Societies Task Force on the Drug Treatment of Migraine

Composition of Group That Authored the Guideline

Task Force Members: S. Evers, Department of Neurology, University of Münster, Münster, Germany; J. Áfra, National Institute of Neurosurgery, Budapest, Hungary; A. Frese, Department of Neurology, University of Münster, Münster, Germany; Academy of Manual Medicine, Münster, Germany; P. J. Goadsby, Headache Group, Department of Neurology, University of California, San Francisco CA, USA, UCL, Institute of Neurology Queen Square, London, UK; M. Linde, Cephalea Headache Centre, Lakarhuset Sodra vagen, Gothenburg, Sweden; A. May, Department of Neurology, University of Hamburg, Hamburg, Germany; P. S. Sándor, Department of Neurology, University of Zurich, Switzerland

Financial Disclosures/Conflicts of Interest

The present guidelines were developed without external financial support. The authors report the following financial supports: Stefan Evers: Salary by the University of Münster; honoraries and research grants by Addex Pharm, AGA Medical, Allergan, Almirall, AstraZeneca, Berlin Chemie, Boehringer, CoLucid, Desitin, Eisai, GlaxoSmithKline, Ipsen Pharma, Janssen Cilag, MSD, Novartis, Pfizer, Pharm Allergan, Pierre Fabre, Reckitt-Benckiser, UCB. Judit Áfra: Salary by the Hungarian Ministry of Health. Achim Frese: Private Praxis; honorary by Berlin Chemie. Peter J. Goadsby: Salary from University of California, San Francisco; honorarium or research grants in 2008 from Almirall, Boston Scientific, Colucid, Eli Lilly, GSK, J&J, MAP Pharmaceuticals, MSD, Medtronic and Neuralieve. Mattias Linde: Salary by the Swedish government; honoraries by AstraZeneca, GlaxoSmithKline, MSD, Nycomed, Pfizer. Arne May: Salary by the University Hospital of Hamburg; honoraries by Almirall, AstraZeneca, Bayer Vital, Berlin Chemie, GlaxoSmithKline, Janssen Cilag, MSD, Pfizer. Peter S. Sándor: Salary by the University Hospital of Zurich; honoraries by AstraZeneca, GlaxoSmithKline, Janssen Cilag, Pfizer, Pharm Allergan.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, Sandor PS. EFNS guideline on the drug treatment of migraine - report of an EFNS task force. Eur J Neurol 2006 Jun;13(6):560-72.

These recommendations should be updated within 3 years and should be complemented by recommendations for the non-drug treatment of migraine.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the European Federation of Neurological Societies (EFNS) Web site External Web Site Policy.

Print copies: Available from Stefan Evers, Department of Neurology, University of Münster, Albert-Schweitzer-Str. 33, 48129 Münster, Germany; Phone: +49-251-8348196; Fax: +49-251-8348181; E-mail: everss@uni-muenster.de

Availability of Companion Documents

The following is available:

  • Brainin M, Barnes M, Baron JC, Gilhus NE, Hughes R, Selmaj K, Waldemar G; Guideline Standards Subcommittee of the EFNS Scientific Committee. Guidance for the preparation of neurological management guidelines by EFNS scientific task forces – revised recommendations 2004. Eur J Neurol. 2004 Sep;11(9):577-81. Electronic copies: Available in Portable Document Format (PDF) from the European Federation of Neurological Societies (EFNS) Web site External Web Site Policy.
  • Continuing Medical Education (CME) questions are available from the EFNS Web site External Web Site Policy.
Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on April 6, 2007. The information was verified by the guideline developer on May 15, 2007. This summary was updated by ECRI Institute on November 9, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs. This summary was updated by ECRI Institute on April 1, 2009, following the FDA advisory on Reglan (metoclopramide). This summary was updated by ECRI Institute on May 1, 2009, following the U.S. Food and Drug Administration advisory on antiepileptic drugs. This summary was updated by ECRI Institute on January 8, 2010, following the U.S. Food and Drug Administration advisory on Valproate sodium. This summary was updated by ECRI Institute on January 15, 2010, following the U.S. Food and Drug Administration (FDA) advisory on Voltaren Gel. This NGC summary was updated most recently by ECRI Institute on February 1, 2011. The updated information was verified by the guideline developer on April 13, 2011. This summary was updated by ECRI Institute on July 10, 2013 following the U.S. Food and Drug Administration advisory on Valproate. This summary was updated by ECRI Institute on October 28, 2013 following the U.S. Food and Drug Administration advisory on Acetaminophen.

Copyright Statement

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

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