“Migraine” is a complex, chronic neurologic disorder characterized by recurrent debilitating headaches. Over 30 million Americans suffer at least one migraine headache each year. (1) The condition affects 18% of females and 6% of males and is the leading cause of “severe” headaches. (1) Over 80% of migraineurs miss work as a result of their headaches, with an average of 4-6 absences per year. (2)
Early explanations for the genesis of migraine focused on cerebrovascular vasoconstriction with subsequent vasodilation. (3) Migraine is now recognized as a more complex series of neurologic and vascular events wherein vasodilation may or may not be present. (4-8) Evidence suggests that a migraineur’s brain is hyperexcitable and uniquely predisposed migraine headaches in much the same way that an epileptic is susceptible to seizures. (8,9) The hyperexcitable migraineur brain is susceptible to various “triggers”. Migraines develop when the number of triggers exceeds a critical threshold for a given patient.
Migraine treatment is subdivided into “abortive” therapies that seek to stop or reverse the progression of an existing headache and “prophylactic” treatments, which seek to prevent or reduce the frequency of future attacks. Abortive treatments are most effective when given within the first minutes of an attack. (10) Unfortunately, once the migraine brain has been “triggered”, conservative therapy may not always abort that particular episode. However, prophylactic management directed at controlling migraine triggers is often helpful.
Spinal manipulation is a useful tool in migraine prophylaxis. One study demonstrated a “significant reduction” of migraine intensity in almost half of those patients receiving spinal manipulation. Nearly ¼ of migraine patients reported greater than 90% fewer attacks. (11) Spinal manipulation has demonstrated similar effectiveness but longer lasting benefit with fewer side effects when compared to a well-known and efficacious medical treatment (amitriptyline). (11,12,13,14)
Conservative care should also include evidence-based dietary and nutraceutical recommendations. An excellent literature review by Orr, provides the following recommendations for migraine prophylaxis (15):
1. Lose Weight
Weight loss may decrease the frequency of migraine and other primary headaches (tension, cluster). (16-18) “Migraine has a specific association with obesity. Furthermore, obese individuals appear to be more likely to suffer from chronic migraine as compared to their peers. There is increasing evidence to suggest that migraine and obesity may be linked through inflammatory mediators released by adipose tissue.” (15)
2. Limit Fats
Dietary fats trigger synthesis of prostoglandins which are known migraine triggers (19). Low fat diets have been shown to play a role in migraine prophylaxix. (20,21)
3. Drink Water
Increased hydration may produce subjective improvement in headache disability and intensity, however no difference in frequency. (22)
4. Decrease Sodium
Patients on a low sodium (DASH) diet report a decrease in headache frequency vs those on a high sodium diet. (23)
5. Feverfew (125mg)
Feverfew may be a useful tool for preventing migraines. (24,25,26) Dosage recommendations vary, however the average dose used in the studies was 125mg/day.
Adding ginger to feverfew may provide relief for acute migraine. (27,28) The proprietary ginger preparation used was (LipiGesic™ M)
7. Riboflavin (400mg)
Riboflavin (Vit B2) may help prevent migraines. (26, 29-38) Dosage recommendations vary, however the average dose used in the studies was 400mg/day.
8. Magnesium (400-600mg)
Magnesium may provide migraine prophylaxis. (26, 39-42) Dosage recommendations vary, however the average dose used in the studies is
400-600mg/ day for the prevention of migraine in non-pregnant patients.
9. CoEnzyme Q10 (100mg TID)
CoEnzyme Q10 may be effective in migraine prophylaxis. (26, 43-46) Dosage recommendations vary, however the average dose used in the studies was 100mg TID.
1. Lipton RB, Scher AI, Kolodner K, Liberman J, Steiner TJ, Stewart WF. Migraine in the United States: epidemiology and patterns of health care use. Neurology. Mar 26 2002;58(6):885-94.
2. Burton WN, Landy SH, Downs KE, Runken MC. The impact of migraine and the effect of migraine treatment on workplace productivity in the United States and suggestions for future research. Mayo Clin Proc. May 2009;84(5):436-45.
3. Wolff, HG. Headache and other head pain. New York: Oxford University Press: 1948.
4. May A, Goadsby PJ. The trigeminovascular system in humans: pathophysiologic implications for primary headache syndromes of the neural influences on the cerebral circulation. J Cereb Blood Flow Metab. Feb 1999;19(2):115-27.
5. Dodick DW, Gargus JJ (August 2008). “Why migraines strike”. Sci. Am. 299 (2): 56–63
6. Waeber C, Moskowitz MA. Therapeutic implications of central and peripheral neurologic mechanisms in migraine. Neurology. Oct 28 2003;61(8 Suppl 4):S9-20.
7. Moskowitz MA. The visceral organ brain: implications for the pathophysiology of vascular head pain. Neurology. 1991;41(2(Pt 1)):182–186.
8. Chawla J. Migraine Headache. Medscape. http://emedicine.medscape.com/article/1142556-overviewAccessed 2/1/14
9. Welch KM. Contemporary concepts of migraine pathogenesis. Neurology. Oct 28 2003;61(8 Suppl 4):S2-8.
10. Kelman L. Women’s issues of migraine in tertiary care. Headache. Jan 2004;44(1):2-7.
11. Nelson CF, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV: The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headaches. J Manipulative Physiol Ther 1998, 21 :511-519
52. Biondi DM. Physical treatments for headache: a structured review. Headache. 2005;45(6):738–746.
53. Bronfort G, Assendelft WJ, Evans R, et al. Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther. 2001;24(7):457–466.
14. Boline P et al. Spinal Manipulation vs. Amitriptyline for the Treatment of Chronic Tension-type Headaches: A Randomized Clinical Trial J Manipulative Physiol Ther 1995 (Mar); 18 (3): 148–154
15. Orr SL. Diet and nutraceutical interventions for headache management: A review of the evidence. Cephalalgia. 2015 Jun 11.
16. Hershey AD, Powers SW, Nelson TD, et al. Obesity in the pediatric headache population: A multicenter study. Headache 2009; 49: 170–177.
17. Di Lorenzo C, Coppola G, Sirianni G, et al. Migraine improvement during short lasting ketogenesis: A proofof-concept study. Eur J Neurol 2015; 22: 170–177.
18. Verrotti A, Agostinelli S, Dinelli SD, et al. Impact of a weight loss program on migraine in obese adolescents. Eur J Neurol 2013; 20: 394–397.
19. Antonova M, Wienecke T, Olesen J, et al. Prostaglandins in migraine: Update. Curr Opin Neurol 2013; 26: 269–275.
20. Bic Z, Blix G, Hopp H, et al. The influence of a low-fat diet on incidence and severity of migraine headaches. J Womens Health Gend Based Med 1999; 8: 623–630. 3
21. Bunner AE, Agarwal U, Gonzales JF, et al. Nutrition intervention for migraine: A randomized crossover trial. J Headache Pain 2014; 15: 1–9.
22. Spigt M, Weerkamp N, Troost J, et al. A randomized trial on the effects of regular water intake in patients with recurrent headaches. Fam Pract 2012; 29: 370–375.
23. Amer M, Woodward M and Appel LJ. Effects of dietary sodium and the DASH diet on the occurrence of headaches: Results from randomised multicentre DASHSodium clinical trial. BMJ Open 2014; 4: 1–7.
24. Pittler M and Ernst E. Feverfew for preventing migraine. Cochrane Database Syst Rev 2004; CD002286.
25. Diener HC, Pfaffenrath V, Schnitker J, et al. Efficacy and safety of 6.25 mg t.i.d. feverfew CO2-extract (MIG-99) in migraine prevention—a randomized, double-blind, multicentre, placebo-controlled study. Cephalalgia 2005; 25: 1031–1041.
26. Holland S, Silberstein SD, Freitag F, et al. Evidencebased guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012; 78: 1346–1353.
27. Cady RK, Schreiber CP, Beach ME, et al. Gelstat Migraine (sublingually administered feverfew and ginger compound) for acute treatment of migraine when administered during the mild pain phase. Med Sci Monit 2005; 11: 65–70.
28. Cady RK, Goldstein J, Nett R, et al. A double-blind placebo-controlled pilot study of sublingual feverfew and ginger (LipiGesicTM M) in the treatment of migraine. Headache 2011; 51: 1078–1086.
29. Maizels M, Blumenfeld A and Burchette R. A combination of riboflavin, magnesium, and feverfew for migraine prophylaxis: A randomized trial. Headache 2004; 44: 885–890.
30. Smith C. The role of riboflavin in migraine. Can Med Assoc J 1946; 54: 589–591.
31. Boehnke C, Reuter U, Flach U, et al. High-dose riboflavin treatment is efficacious in migraine prophylaxis: An open study in a tertiary care centre. Eur J Neurol 2004; 11: 4750477.
32. Schoenen J, Lenaerts M and Bastings E. High-dose riboflavin as a prophylactic treatment of migraine: Results of an open pilot study. Cephalalgia 1994; 14: 328–329.
33. Di Lorenzo C, Pierelli F, Coppola G, et al. Mitochondrial DNA haplogroups influence the therapeutic response to riboflavin in migraineurs. Neurology 2009; 72: 158891594.
34. Sa´ndor PS, Afra J, Ambrosini A, et al. Prophylactic treatment of migraine with beta-blockers and riboflavin: Differential effects on the intensity dependence of auditory evoked cortical potentials. Headache 2000; 40: 30–35.
35. Schoenen J, Jacquy J and Lenaerts M. Effectiveness of high-dose riboflavin in migraine prophylaxis: A randomized controlled trial. Neurology 1998; 50: 466–470.
36. Nambiar N, Aiyappa C and Srinivasa R. Oral riboflavin versus oral propranolol in migraine prophylaxis: An open label randomized controlled trial. Neurol Asia 2011; 16: 223–229.
37. Condo` M, Posar A, Arbizzani A, et al. Riboflavin prophylaxis in pediatric and adolescent migraine. J Headache Pain 2009; 10: 361–365.
38. Markley HG. Prophylactic treatment of headaches in adolescents with riboflavin. Cephalalgia 2009; 29(Suppl 1): 100.
39. Facchinetti F, Sances G, Borella P, et al. Magnesium prophylaxis of menstrual migraine: Effects on intracellular magnesium. Headache 1991; 31: 298–301.
40. Ko¨seoglu E, Talaslioglu A, Go¨nu¨l AS, et al. The effects of magnesium prophylaxis in migraine without aura. Magnes Res 2008; 21: 101–108.
41. Esfanjani A, Mahdavi R, Ebrahimi Mameghani M, et al. The effects of magnesium, L-carnitine, and concurrent magnesium-L-carnitine supplementation in migraine prophylaxis. Biol Trace Elem Res 2012; 150: 42048.
42. Peikert A, Wilimzig C and Ko¨hne-Volland R. Prophylaxis of migraine with oral magnesium: Results from a prospective, multi-center, placebo-controlled and double-blind randomized study. Cephalalgia 1996; 16: 257–263.
44. Rozen TD, Oshinsky ML, Gebeline CA, et al. Open label trial of coenzyme Q10 as a migraine preventive. Cephalalgia 2002; 22: 1370141.
45. Sa´ndor PS, DiClemente L, Coppola G, et al. Efficacy of coenzyme Q10 in migraine prophylaxis: A randomized controlled trial. Neurology 2005; 64: 713–715.
46. Hershey AD, Powers SW, Vockell AL, et al. Coenzyme Q10 deficiency and response to supplementation in pediatric and adolescent migraine. Headache 2007; 47: 73–80.
Cliff Atwell, B.S., D.C.