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9 Articles in Volume 14, Issue #6
Migraine Treatment From A to Z
Alternative Medicine in Chronic Migraine 2014: What Clinicians Need to Know
Hormone Abnormalities in Uncontrolled Chronic Pain Patients: Use of Hormone Profiles
Interpreting Negative Urine Drug Test Results
Case Challenge: Chronic Opioid Use Causing Adrenal Insufficiency
Editor's Memo: Toxic Insurance Plans
Guest Editor's Memo: The Forgotten Patients: Those Who Benefit From Opioid Treatment
Ask the Expert: Multiple Benzo Prescriptions
Ask the Expert: Burning Foot Syndrome

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.


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.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

Coenzyme Q10
Coenzyme Q10 (CoQ10) may work in a similar fashion to riboflavin by improving the function of impaired mitochondria.7 In a 2002 study by Rozen et al, 61.3% of patients (n=32) with episodic migraine had a greater than 50% reduction in the number of migraine headache days (P<0.0001) without any side effects noted.9 In most patients, the supplement took several months to reach full effects.9 A more recent study of 42 patients with migraine found that 47.6% of patients receiving 300 mg CoQ10 reduced their headache attack frequency by at least 50%, whereas only 14.4% of participants receiving placebo did.5 In children, the results for CoQ10 also have been promising. In a study of patients aged 3 to 22 years with migraines and CoQ10 deficits—levels out of the reference range—patients receiving treatment on average had an increased total CoQ10 level and a mean headache frequency reduction from 19.2 to 12.5 (P<0.001).10 Additionally, the headache disability in these patients assessed by the PedMIDAS improved from 47.4 to 22.8 (P<0.001).10

Fish Oil (Omega-3 Fatty Acids)
Fish oil, and other omega-3 fatty acids, are among the most commonly used CAM therapies because of the evidence showing their effectiveness in reducing cardiovascular disease. Because of the anti-inflammatory and vasodilatory effects of omega-3 polyunsaturated fatty acids, researchers postulated that fish oil might be an effective treatment for migraines. Two small pilot studies in the 1980s showed evidence that omega-3 polyunsaturated fatty acids could possibly be effective in reducing the frequency of migraine attacks.11 A larger study was completed in 2001 with the same premise, although the results were not as positive.11 Although the total number of migraines over 4 months of treatment was improved in patients receiving fish oil, the mean number of attacks were not significantly different between patients receiving fish oil and those receiving placebo during the last 4 weeks.11 Unfortunately, this study had a very strong placebo effect, with a 45% reduction of the number of migraines between run-in and 4 months of treatment, and had very broad inclusion criteria such that most of the patients had relatively few headaches to start off with. Thus, fish oil may still represent a beneficial adjunctive therapy for migraines, but its efficacy has not been proven. No research to date has focused specifically on its effects on chronic migraine.

Capsicum annuum and Zingiber officinale

Capsicum annuum is an extract from the chili pepper.12,13 Zingiber officinale is a homeopathic extract from the ginger root.12,13 The combination of the 2 are marketed as the non-prescription intranasal homeopathic preparation called Ausanil, which is used for acute abortive treatment of migraine. The exact mechanism is unknown, but it is postulated that Ausanil desensitizes the branch of the trigeminal nerve supplying the nose.14,15

Physical Therapies

Acupuncture

Acupuncture is one of the most popular and rapidly growing alternative medical therapies. One study evaluated the benefits of acupuncture compared with flunarizine (Sibelium), a prophylactic treatment that is not FDA approved in the United States.16 Patients receiving acupuncture not only had a reduction in mean duration and times of headache attack, they also had fewer adverse reactions, greater compliance, and better outcomes 1 year later.16 Despite these promising effects, an analysis of 14 trials comparing real acupuncture with sham interventions showed no statistically significant difference between the interventions with respect to migraine response rates (risk ratio, 1.38; 95% confidence interval, 0.96-1.97).17

Osteopathic Manipulation

Osteopathic manipulation refers to a system of hands-on techniques that help alleviate pain, restore function, and promote health and well being.18 In a European study of 42 women with migraine, patients who received five 50-minute osteopathic manipulative treatments over a 10-week period had reductions in their total MIDAS score, pain intensity, and disturbance in occupation.19 Another trial of 218 patients randomized to 14 sessions of osteopathic manipulative therapy over 2 months or oral amitriptyline showed no significant difference between both groups over the last 4 weeks of treatment.20 Although the manipulative therapy showed some trend toward longer-lasting effects, the result was not statistically significant.20

Chiropractic Manipulation

Chiropractic manipulation involves the manual adjustment of the spine and joints to influence the body’s nervous system to reduce pain and increase wellness.18 A systematic review of 9 trials involving 683 patients found moderate evidence that spinal manipulation therapy has short-term efficacy similar to that of amitriptyline in the prophylactic treatment of chronic tension-type headache and migraine.21

Medicinal Herbs and Teas

Tanacetum Parthenium

Feverfew, or Tanacetum parthenium, is a plant from the sunflower family, which has been used for hundreds of years in Europe as a treatment for headaches, arthritis, and fevers.22 Feverfew has shown some promise of treating patients with migraines. A multicenter randomized controlled study of 60 patients found that sublingual feverfew and ginger, used during a migraine, was significantly more effective than placebo at reducing pain.23 However, the study with the highest Jadad (quality) score, showed no beneficial effects.24

 

Pestasites

Pestasites, an extract of butterbur and marketed as Petadolex, has established efficacy for the prevention of episodic migraine.25 Petadolex has been investigated in 4 trials, 2 of which were randomized controlled studies.26 In a study of 60 patients treated with either placebo or Petadolex 100 mg per day for 12 weeks, 45% of patients receiving Petadolex had at least a 50% reduction in migraine frequency, whereas only 15% of those receiving placebo had the same reduction.5 In a larger, three-arm study of 245 patients, effects of Petadolex were visible after 1 month, and were found significant after 4 months.5 In postmarketing data, there was a very rare possibility of the development of reversible hepatitis. Of note, not all available products on the market pass good quality standards.26

Other Herbs

Lavender oil may have beneficial effects on migraines due to its ability to decrease sympathetic measures and relax patients, however, no study has shown it to be effective in treating migraines.27 Rosemary, dandelion leaf, lemon balm, cayenne, the watermelon cure, the Potato Remedy, and cilantro all have been proposed for treating migraines, although little to no research has been completed on their effects on migraineurs.

Relaxation Techniques

Meditation

Meditation commonly is employed by people as a means to relax or fulfill their lives spiritually. However, research has shown that the benefits of meditation go far beyond relaxation. According to a study in the Journal of Behavioral Medicine, spiritual meditation is effective in reducing migraine frequency, anxiety, and negative affect, while simultaneously increasing pain tolerance.28

Yoga

Yoga is a practice originating from India that combines breathing exercises, physical postures, and meditation to improve wellness. Although few studies have been completed on the effect of yoga on migraines, the effects are quite positive. In a study of 72 patients with migraine without aura, 3 months of yoga caused a statistically significant reduction in the participants’ headache frequency, intensity, pain rating, anxiety and depression scores, and symptomatic medication use (P<0.001).29 A pilot study on the effect of laughter yoga on chronic migraine reported reduction in headache disability, fatigue, and improved quality of life.30

Conclusion

A wide variety of CAM therapies exist for the treatment of migraine. Although varying results exist for each of the therapies, the majority showed positive benefits for patients with minimal side effects. More research specifically on chronic migraineurs is especially necessary, as the results may be more pronounced than for those with episodic migraine.

Last updated on: May 19, 2015

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1 comment.

By andrew_2 on 08/30/2014
Re chiropractic and related treatments it is of relevance to note that the use of botox for migraines is directed at spasm in the suboccipital muscles. The point that I am leading to is that any review of chiropractic efficacy would need to focus specifically on upper cervical interventions and would also need to look at the success of the intervention in correcting the identified upper cervical malalignment. In other words-- the metanalysis quoted here really is not enough to go on without further inspection of the studies reviewed, and the studies that failed to get included in the metanalysis.
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