Guide to Dietary Supplements Most Commonly Used in Pain Management

Dietary supplements can be a useful part of an integrative approach to the treatment of pain.

By David Kiefer, MD and Traci Pantuso, MS

Page 1 of 3

Patients with chronic pain who seek medical advice about choosing a vitamin or supplement need to be educated about the risks/benefits of these agents. This article reviews the evidence for the most common supplements used to treat pain, recognizing the importance of an appropriate work-up, including a comprehensive history, physical examination, and relevant diagnostic studies to establish a correct diagnosis and treatment plan. Although in some cases there is overlap, pain supplements can be divided into those used to treat fibromyalgia, headache, or joint pain—osteoarthritis (OA) or rheumatoid arthritis (RA) (Tables 1 and 2). Treatments for other pain entities, such as low back pain, pain from acute injuries, and cancer-related pain are beyond the scope of this article.

Fibromyalgia

Reviews of dietary supplements for the treatment of fibromyalgia have found some supplements to be of benefit for specific indications, such as anthocyanidins for sleep disturbances and topical capsaicin (0.025%) for joint tenderness but not for overall pain.^1,2 However, the results of clinical trials of soy, malic acid, and some Chinese medicines have either been inconclusive or negative.^1-3 For the treatment of fibromyalgia, some of the best evidence supports the use of S-adenosylmethionine (SAMe), a compound that exists naturally as a result of mammalian metabolism but is used in supraphysiologic doses for some medical conditions.⁴ A review of seven clinical trials found that SAMe benefits fibromyalgia-related depression and tender point pain severity.⁴

The amino acid 5-hydroxytryptophan (5-HTP) crosses the blood–brain barrier and may have effects on serotonin levels. The agent was researched in two small clinical trials more than 20 years ago.⁵ In the first trial, an open- label, 3-month study using 100 mg of 5-HTP three times daily in 50 people, researchers reported improvements in number of tender points, anxiety, sleep, and pain scores compared with baseline (P<0.001).⁶ The second trial, a double-blind, placebo-controlled trial, documented similar improvements in symptoms after 1 month of 5-HTP at a dosage of 100 mg three times daily.⁷ Concerns about eosinophilia myalgia syndrome due to a suspect batch of 5-HTP more than 20 years ago still compels clinicians to use reputable 5-HTP manufacturers.

Headache

Most research on dietary supplements has explored the use of supplements to prevent or treat migraine headaches.⁹ One agent, vitamin B2 (riboflavin) practically has become standard of care in the prevention of migraines. One study demonstrated that 400 mg per day of riboflavin significantly decreased migraine frequency (P=0.005) and the number of days with headache (P=0.012) in 55 people after 3 months of treatment.¹⁰

Another supplement that is commonly used to prevent migraines is feverfew (Tanacetum parthenium), although reviews have shown conflicting results about its efficacy.^11,12 Variability in the type of feverfew tested—from powdered herb in capsules to alcohol extracts—can lead to a range in concentrations of parthenolide, the active component.¹³ One research group found that a feverfew C02 extract (MIG-99), at a dosage of 6.25 mg three times daily, decreased migraine frequency over 16 weeks.14 From the baseline of 4.76 attacks per month, migraine frequency decreased by 1.9 attacks in the MIG-99 group and by 1.3 attacks in the placebo group (P=0.0456).

A rhizome extract of the butterbur plant (Petasites hybridus) also has shown efficacy for migraine prevention, likely due to smooth muscle relaxation and leukotriene inhibition.¹⁵ Clinical trials have shown that 50 to 75 mg twice daily of a standardized butterbur extract (Petadolex, Weber & Weber) decreased the number of migraine attacks per month and led to fewer patients needing migraine medication treatments.^16,17 A standardized extract (eg, Petadolex) free of the hepatotoxic pyrrolizidine alkaloids must be used.

Coenzyme Q10 (CoQ10), with a dosage range of 150 to 300 mg per day, and magnesium, 300 to 600 mg per day also have been studied for migraine prevention.^13,18,19 These two nutritents have been found to decrease migraine frequency and severity, the number of headache days, and, in the case of CoQ10, days with nausea. In addition, both CoQ10 and magnesium are considerations for pediatric migraines, whereas magnesium is also used for migraine headaches associated with mentruation.

Joint Pain

As demonstrated by in vitro research, many dietary supplements affect the production or activity of pro-inflammatory mediators, in some cases via cyclooxygenase-1 or -2 (COX-1, COX-2) or lipoxygenase (LOX) inhibition. For example, turmeric (Curcuma longa), with the active ingredient curcumin, has been shown to inhibit numerous inflammatory mediators, such as nuclear factor-kappa B (NF-κB), prostaglandin-E2, leukotrienes, and nitric oxide.²⁰ References are made in review articles to preliminary clinical trials (one used 1,200 mg of curcumin daily in patients with RA), but more definitive research is needed to establish dosages and efficacy.²¹

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First published on: July 1, 2011

Guide to Dietary Supplements Most Commonly Used in Pain Management

Fibromyalgia

Headache

Joint Pain

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