Vitamins & Supplements
Introduction
The management of chronic pain through vitamin therapy has been a source of great interest in recent years, for scientists and researchers. Some physicians and patients are interested in vitamin and herbal abilities to control headache pain. Physicians refer to this area of medical science as Complementary and Alternative Medicines (CAM). 1
Complementary and Alternative Medicine (CAM) accounts for an ever-increasing portion of health care expenditures. In the United States, the National Institutes of Health (NIH) defines CAM as a 'group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. 1
According to a presentation at the American Headache Society by a Canadian neuroscience professor, the world-wide nutraceuticals market is expected to reach $250 billion (U.S.) by 2018. 2
Many terms have been attached to this area on migraine treatment including vitamins, supplements, herbals, minerals, nutraceuticals, etc. The CAM therapies that are beneficial to treat migraine include Riboflavin (Vitamin B2), Magnesium, Coenzyme Q10 (CoQ10), Butterbur and Feverfew.
The vitamins/supplements/herbal preparations listed below are the most studied and have shown the greatest scientific evidence, for when treating a migraine headache. Unlike medications, vitamin and herbal preparations often do not undergo rigorous tests that prove their efficacy. For this reason patients, researchers and physicians need to use a cautious approach when recommending them - especially in children. 3
Dr. Werner Becker, Neuroscience Professor (retired)
University of Calgary, Calgary, Alberta
Riboflavin (Vitamin B2)
Riboflavin, also known as Vitamin B2 is found in small amounts in the body. It is a vitamin in the body needed for converting food to energy and acts as an antioxidant. Lean meats, eggs, legumes, nuts, green leafy vegetables, dairy products, and milk provide riboflavin in the diet. Many breads and cereals also contain riboflavin. 4
It is a vitamin (off-the-shelf) that has been proven to help alleviate migraine headaches. Scientific evidence suggests that riboflavin is effective for treating children and adolescents, however experts have reached opposite conclusions as to its therapeutic use. 4
However, in one scientific study with migraine sufferers - 59% of those that took riboflavin on a daily basis for 3 months, noticed a 50% decrease in their headaches. The Canadian Headache Society recommends dosages around 400 mg daily, to reach optimal levels that are needed to treat migraines. This can be a discussion to have with your physician. 5
According to a presentation by Dr. Rose Giammarco a headache neurologist from McMaster University in Hamilton, Canada in 2010, riboflavin has no major adverse effects. On very rare occasions migraineurs have listed diarrhea, excessive passing of urine, and change in urine colour as a remote side effect. 6
Scientists published an article in the Canadian Medical Association Journal and found riboflavin as having an excellent tolerance toward migraine patients. The profile suggested that it had no risk of drug interactions and the Headache Neurologists who published this study recommend it’s use for migraine prevention. 7
Migraine Canada mentions that in clinical trials it took about 3 months of use to note a beneficial effect. They further suggest side effects can include numbness, itching and tingling.
- Migraine Canada (national migraine charity)
www.migrainecanada.org 8
Magnesium
Magnesium is a vitamin supplement that is found naturally in human bodies. It is required to help with calcium absorption. Rich sources of magnesium include some spices, nuts, cereals, coffee, cocoa, tea, and vegetables. Caffeine, alcohol and stress can increase excretion from the human body. 9
There are many kinds of magnesium - magnesium citrate has been found beneficial in treating migraines. 10
"Caffeine, alcohol, and stress increase magnesium excretion by the body"
- Dr. Werner Becker, Neuroscience Professor (retired)
University of Calgary, Calgary, Alberta. - 12
Scientific studies report that some migraine sufferers have low levels of magnesium during their migraine attacks, and as a consequence may be magnesium deficient. Taking a Magnesium vitamin daily should help with this issue, however this is a conversation to have with your physician. 11
Other studies have shown that magnesium is an effective preventative treatment for women who suffer from Menstrual Migraine. Further studies have shown its effectiveness in treating children with Tension Type Headache. 11
In a US presentation by Dr. Werner Becker on Nutraceuticals, he noted that "nearly 50 % of Americans have a magnesium deficient diet"...... he further concluded that "Caffeine, alcohol, and stress increase magnesium excretion by the body." 12
However, it’s important to remember that even though these products are available over-the-counter (OTC) you should still advise your physician if you wish to explore this therapy.
Side effects from increased magnesium intake are not common because the body removes excess amounts. However, rare side effects that have been reported can include soft stools and diarrhea. 13
Scientists conclude that the risks associated with magnesium use as a migraine preventative are minimal.
The Canadian Headache Society gives a strong recommendation to magnesium even though some contrary evidence was found. They recommend magnesium citrate 600mg be used. 14
Coenzyme Q10 (CoQ10)
Coenzyme Q10 (CoQ10) occurs naturally in the body and can be found in some meats and fish. It can also be found in dietary sources that include oily fish (such as salmon and tuna), organ meats (such as liver), and whole grains. Most of us have sufficient amounts of CoQ10 in our diets, however, supplementation may be required for certain health conditions. 15
This vitamin supplement has shown confirmed scientific results from the medical community in the treatment of migraine headaches. 16
Professional physician-based headache associations like the International Headache Society, the Canadian and American Headache Societies, and the American Academy of Neurology have all endorsed the use of CoQ10 as a valid treatment for migraine prevention. 16
CoQ10 is involved in the creation of a substance referred to as adenosine triphosphate (ATP) - an energy-producing molecule that carries energy within cells. 17
When ingested it acts as an antioxidant on the body by removing unwanted properties.
In one study, over 61% of migraine sufferers reported a 50% decrease in their migraine headaches after taking CoQ10. 18
According to the Migraine Trust “CoQ10 appears to be associated with no significant adverse events and is extremely well-tolerated.” It also appears to be a safe option for children who suffer from migraines. Please consult with your physician if you intend on taking CoQ10. 19
Dr. Rose Giammarco from Hamilton, Ontario suggests it is a well tolerated vitamin in doses up to 600mg per day. However, in less than 1% of patients mild nausea, heartburn and diarrhea were reported. 20
The Canadian Headache Society gives Coenzyme Q10 a strong recommendation as a preventative vitamin for the treatment of migraine headaches. 21
Note: According to Dr. Alexander Mauskop, MD, FAAN, (Headache Neurologist with an interest in natural therapies) Professor of Neurology and Director of the New York Headache Center, in New York, NY - the vitamins he recommends for his patients in reducing migraine pain are magnesium and CoQ10 as they are the most proven for migraines. 22
Herbs
Feverfew (Tanacetum parthenium)
The herbal preparation feverfew is a perennial shrub that is found in Europe, Asia and North America. It has yellow-green leaves and yellow flowers. It is a member of the daisy plant and has a long history of treating fever (where the name came from) and Bubonic plague, asthma and lung disease. It has also been used for centuries to treat headache, pain, and inflammation. 23
It has been the herbal preparation most studied for the prevention of migraines. Researchers are unclear as to its method of therapeutic use. Scientists have studied this herb and have reached mixed conclusions as to its therapeutic benefit. Researchers concluded in the Cochrane Review of 2015 that an overall low quality of evidence exists when feverfew was used for the management of migraine prevention. 24
If you have any health problems that may be treated with feverfew, consult your doctor before use. Caution is advised if you have diabetes, alcohol dependence or liver disease. Liquid preparations of this product may contain sugar and/or alcohol, and feverfew is not recommended for use in children under 2 years of age. Because of the potential risk to the infant, breast-feeding while using this product is not recommended, and feverfew is contraindicated during pregnancy. 25
Side effects are mild but cases of burping have been rerecorded. Additional side effects include a sore mouth, swollen lips and tongue, and occasionally GI upset and abdominal pain. 26
“Although feverfew (Tanacetum parthenium) has been used for migraine prevention, it appears to be no better than placebo and is no longer recommended for migraine prevention according to Canadian migraine guidelines. When someone takes feverfew for a while and then stops taking it, they can experience "post-feverfew syndrome" (severe headache, insomnia, nervousness, joint pain)."
- Canadian Headache Society guideline for migraine prophylaxis - 36
Almost all Headache Organizations concluded that the evidence for feverfew was moderate, or poor that was dependent upon numerous factors. The Canadian Headache Society noticed poor quality control and therefore could not recommend its use as an effective treatment for migraine headaches. Some patients may benefit from its use.
Butterbur (Petasites hybidus)
Butterbur Root (Petasites hybridus), is a perennial shrub that grows in marshy ground\riverbanks in Germany and is found in many regions in Europe, Asia and North America. It has large rhubarb-like leaves during the growing season. It is an extract of the butterbur root, which has been used for medicinal purposes - particularly in the prophylactic treatment of migraine. Its large leaves were used to wrap butter in warm weather, in the UK. 27
Scientists suggest that it contains a substance that inhibits inflammation and also serves as a calcium channel blocker resulting in improvement in migraine symptoms. In its raw form, it is a toxic plant, but when purified (patented by a German company and marketed as Petadolex®) it is an effective preventive for the treatment of migraine headaches. 28
This herbal therapy extract contains pyrrolizidine alkaloids (PAs), which can be damaging to the liver and have also been shown to be carcinogenic in animal studies.
It is therefore critical that a manufactured version be used, that has had PA’s removed. The only brand that has shown complete safety is Petadolex ® 29
These toxins need to be removed in commercial preparation, but not all marketed butterbur formulations have adequate quality control. Butterbur is therefore best avoided, although the Petadolex® brand appears to have good quality control and appears to contain the required amount of ingredients and has had the toxins removed adequately. 29
The Canadian Headache Society (CHS) and The American Headache Society (AHS) have both given recommendation for its use in the treatment of migraine prevention, however safety concerns remain, and may affect future recommendations. 30 As of the writing of the article, long-term safety of its use remains unclear.
Is Butterbur Safe?
- Only if all the pyrrolizidine alkaloids are removed
- Lack of stringent regulations for marketing of natural products is a major problem for patients who would like to use butterbur
- Only Petadolex based products consistently met standards 31
Migraine Trust - Potential Side Effects
Studies have reported safety and good tolerability of commercially available butterbur products that are free of potentially carcinogenic pyrrolizidine alkaloid constituents, when used short-term, orally and in recommended doses. 32
Raw, unprocessed butterbur plant should not be eaten due to the potential for liver damage by pyrrolizidine alkaloids with long-term use. This includes any teas, capsules of raw herb, or unprocessed tinctures or extracts. Use should be limited to commercially available products free of pyrrolizidine alkaloids, and is not recommended in women who are pregnant or breastfeeding due to a lack of safety studies.” 32
According to Canadian Headache Neurologists the safest and only kind of Butterbur to use is ‘Petadolex’. Other brands of Butterbur can be very harmful.
WebMD - Vitamin and Supplement Effectiveness for Migraine Headaches
WebMD studied the effectiveness of Vitamins and Herbs used to treat migraine headaches. A list of vitamins showing possible effectiveness, or insufficient evidence is listed below.
Possibly Effective
These include: Butterbur, Caffeine, Coenzyme Q10, Feverfew, Magnesium, and Riboflavin
Insufficient Evidence
These include: 5-HTP, Alpha-Lipoic Acid, Black Cohosh, Capsicum, Dong Quai, Ginger, Lavender, Melatonin, Olive, others. 33
Dr. Alexander Mauskop from the New York Headache Centre in New York, NY adds to this list Boswellia, Triphala, Rhodiola, and omega-3. 34
Experts have reached opposite conclusions as to the efficacy of Feverfew. 34
Canadian Broadcasting Corporation - the Fifth Estate
In November 2015, the Canadian award-winning documentary, The Fifth Estate did an investigation into the billion dollar vitamin and supplement industry in Canada. Reporters and researchers were checking for ingredients listed on the bottle, authenticity, and false marketing practices. Here are a few of their findings.
Fast facts uncovered by the Fifth Estate journalists
- Herbal products are often contaminated or substituted with alternative plant species.
- The World Health Organization says the adulteration of herbal products is a threat to consumer safety.
- Most (59%) of the tested products did not contain the ingredients that were listed on the label.
- A study in 2012 by University of Guelph Botanist Steven Newmaster found that 60 percent of vitamin and supplement products contained ingredients not listed on their labels, and 1 in 3 proved to be fakes. 35
Read the entire documentary (including website links) at www.cbc.ca/fifth
Conclusion
By considering vitamin or herbal preparations - either concurrently with traditional pharmacological treatments, or separately - patients (as well as their physicians) have many more choices to choose from when treating migraine.
There appears to be lax regulations surrounding “natural health” products that do not undergo the same rigorous testing that medicines do. We also need to take into account the fact that these products are readily available.
The Canadian Headache Society noted that there is sufficient evidence available for patients to consider nutraceuticals, however the evidence is modest. This is especially true for patients who wish to pursue non-drug headache treatments for migraine and wish to avoid the side-effects that some medicines produce.
Be sure and advise your physician regarding any vitamin/herbal preparation you are taking.
References
- 1. US National Library of Medicine. Complementary and Alternative Medicine, http://www.nlm.nih.gov/tsd/acquisitions/cdm/subjects24.html
- American Headache Society, Nutraceuticals Presentation, Dr. Werner Becker, 2015
- Dr. Werner Becker, Supplements - use with caution
- The Migraine Trust, Vitamins and Supplements
- Canadian Headache Society, Riboflavin
- Dr. Rose Giammarco, slide presentation, nutraceuticals, 2015
- Canadian Medical Association Journal, Riboflavin
- Migraine Canada - Riboflavin
- The Migraine Trust, Vitamins and Supplements, Magnesium
- Headache Network Canada (dissolved), Magnesium
- Dr. Rose Giammarco, slide presentation, 2015
- Dr. Werner Becker, American Headache Society, presentation, 2015
- Slide presentation, Dr. Rose Giammarco, nutraceuticals
- Canadian Headache Society, Magnesium
- The Migraine Trust, Vitamins and Supplements, CoQ10
- American Headache Society, Dr Werner Becker, Supplements Presentation
- BiologyDictionary.net/ATP
- Dr. Rose Giammarco, Slide Presentation, Vitamins and Supplements
- The Migraine Trust, Vitamins and Supplements
- Giammarco, R. Vitamins, Herbs & Botanicals - slide presentation June 2015,
- Canadian Headache Society- Coenzyme Q10
- New York Headache Centre, Dr.Alexander Mauskop, Neurologist, New York, NY
- Giammarco, R. Vitamins, Herbs & Botanicals - slide presentation June 2015,
- Wider, B, Pittler MH, et el The Cochrane Library Feverfew for preventing migraine
- The Migraine Trust, Supplements and Vitamins, Feverfew, Safety Concerns
- Dr. Giammarco, slide presentation, 2015, Feverfew side effects
- The Migraine Trust, Butterbur
- Dr. Werner Becker, Neuroscience Professor, Butterbur
- Doherty, C - Safety of Butterbur for Migraine Therapy, July 2016
- Canadian Headache Society, Butterbur Recommendations
- Becker, W J, Power Point Presentation - Nutraceuticals in the Treatment of Headache: Evidence-based Approaches, Scottsdale Symposium, 2015 - is Butterbur safe?
- The Migraine Trust, Supplements and Vitamins, Butterbur
- WebMD - Vitamin Evidence and insufficient evidence
- Dr. Alexander Mauskop, New York Headache Centre, New York, NY
- Canadian Broadcasting Company (CBC) - Fifth Estate investigation, Vitamins
- Pringsheim T, et al. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci 2012
