Alternative Medicine in Chronic Migraine 2014: What Clinicians Need to Know

Migraine patients are increasingly turning to complementary and alternative medicine (CAM) for therapy. Therefore, clinicians who treat headache patients should gain a basic understanding of the efficacy and safety of these therapies.

By Soma Sahai-Srivastava, MD, Anne Csere, DO and Andrew Joyce, MD
Practical Pain Management Volume 14, Issue 6, July 2014, p 59-61

A wide variety of complementary and alternative medicine (CAM) therapies exist for the treatment of migraine, including pharmacologic supplements, physical therapies, medicinal herbs and teas, and relaxation techniques. Although varying results exist for each of the therapies, the majority showed positive benefits for patients with minimal side effects. One survey of patients attending an outpatient headache clinic showed that 85% had used alternative therapies for headache relief, and 60% felt that the treatment had been useful.1 Because migraine patients increasingly are turning to CAM therapy, practitioners should gain a basic understanding of the efficacy and safety of these treatments. This review will provide a brief overview of CAM treatments that are available to migraineurs.

Pharmacologic Supplements

Ribofavin
Some of the most widely studied alternative therapies are vitamins and supplements. High-dose riboflavin, although only included in a few studies, has shown some results for reducing headache frequency and abortive medication use. The theory is that a deficit in mitochondrial energy metabolism may play a role in the pathogenesis of migraines.2

According to a study by Schoenen et al, 59% of patients receiving 400 mg riboflavin daily reduced their headache frequency by at least 50%, whereas only 15% of patients receiving placebo improved by 50% or more.2 It may be possible that only some participants respond because of mitochondrial DNA haplotypes, which may have been shown to influence patients’ responses to riboflavin.3

Another study found evidence that 50 mg of riboflavin could help treat mild migraines or tension-type headaches in pediatric populations.4 A third study used a combination of riboflavin, magnesium, and feverfew to treat migraines. This study showed that 42% of patients experienced a 50% or greater reduction in the number of headaches, although the results were not statistically different compared with a “placebo” or 25 mg riboflavin alone (Table 1).5

Magnesium
Magnesium is another promising alternative treatment for migraine patients. Multiple studies have reported low brain magnesium levels in migraineurs and the activities of magnesium in the body—counteracting vasospasm, inhibiting platelet aggregation, and stabilizing cell membranes—may be helpful in treating the cause of migraine.5,6 Although many of the studies have shown positive results, a few have been inconclusive. The first study completed was on women with menstrual migraine. This study showed that 120 mg of magnesium pyrrolidonecarboxylic acid taken three times per day led to a significant reduction in the number of days with headache (P<0.01) and total pain index (P<0.03).7

Following that study, a placebo-controlled randomized study of 81 patients with migraines showed improvement in patients taking trimagnesium dicitrate in a granular powder. Attack frequency was reduced by 41.6% in the magnesium group, compared to only 15.8% in the placebo group.7 However, the next placebo-controlled, double-blind trial showed no effects of oral magnesium on migraine.7 Roughly half of the patients taking magnesium suffered from diarrhea, and therefore were unlikely to absorb the magnesium adequately. Additionally, magnesium is a preventative agent with a category A pregnancy rating, and thus may be helpful for patients trying to become pregnant.

More recently, a 12-week trial of 600 mg magnesium citrate in patients with migraines without aura demonstrated a reduction in the migraine attack frequency, severity, and P1 amplitude in visual-evoked potential examination.8 Additionally, blood flow to the cortex, inferolateral temporal region, and insular regions increased significantly after magnesium treatment. These results indicate that magnesium may alter the blood flow to the brain and prevent migraine. Finally, a study on patients aged 3 to 17 years with migraine were given 9 mg/kg of magnesium oxide thrice daily. The magnesium oxide group showed a significant reduction in headache days compared with those patients given placebo. However, the slope of treatment trends was not statistically significantly different, and as such, the study could not say unequivocally that magnesium is a beneficial therapy for children.5

Overall, magnesium appears to be a beneficial prophylactic therapy for many patients as long as they are able to control its side effects.

Studies have been inconsistent with whether magnesium may be helpful in a random sampling of patients with acute migraine.7 One study found that 86% of patients with a serum ionized magnesium (IMg2+) less than 0.54 mmol/L had relief of pain and associated symptoms that lasted more than 24 hours. However, in patients with a level greater than 0.54 mmol/L, only 16% improved.7 Thus, serum IMg2+ levels may be key to predicting responders to IV magnesium therapy. It also should be noted that patients in the emergency room who received metoclopramide did just as well as patients receiving magnesium, and that a combination of magnesium and metoclopramide actually was worse than metoclopramide alone.7

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