Neutraceuticals: Effective for Migraines?

Nutraceutical: Marketing term without regulatory definition[1]
-Includes vitamins, supplements, herbal preparations
Use related to dissatisfaction with conventional medicine
-Belief that natural medicines are good, pharmaceuticals are bad
Some studies do suggest efficacy for certain neutraceuticals in migraine prophylaxis
Awareness of potential benefits and harms of neutraceuticals is important for the clinician-patient relationship

Magnesium
Fairly good evidence for decreased attack frequency:
-IV magnesium sulfate 1-2 mg daily: decrease in attacks
-IV magnesium chloride 32 mg daily:  decrease in attacks
-Oral magnesium citrate 400-600 mg daily: decrease in frequency and severity of attacks
BUT: Recent review suggests limited evidence supports oral magnesium for migraine prevention; recommends increased dietary intake of magnesium[2]

Riboflavin
Fairly good evidence for decreased attack frequency
Riboflavin 400 mg: decreased frequency and severity of attacks
No evidence for efficacy in preventing pediatric migraine
Improves energy metabolism
-Possible mechanism: corrects abnormal mitochondrial energy processing and cortical information processing possibly involved in migraine pathogenesis
Excellent tolerability

Butterbur (Petasites hybridus)
Fairly good evidence in children and adults:
- Butterbur 50-150 mg: decreased frequency and severity of attacks
Anti-spasmodic, anti-inflammatory, blocks calcium channels
Concern for hepatotoxicity

Feverfew
Inconsistent evidence for benefits:
-Feverfew 50-300 mg: controversial results
Preparation strength and stability differs between products
Cochrane Review: insufficient evidence that feverfew is more effective than placebo in migraine prevention[3]
No major safety concerns noted

Coenzyme Q10
Evidence in adults:
-Coenzyme Q10 300 mg: decreased frequency, duration, intensity of attacks
-Not replicated in pediatric patients
Improves energy metabolism

Nutraceutical Combinations
Combinations that have shown some efficacy:
-Fixed combination of magnesium, riboflavin, and coenzyme Q10
-Feverfew plus ginger
-Ginkgo biloba, coenzyme Q10, Vitamin B2

Take Home Points
Nutraceuticals are non-regulated vitamins, supplements, and herbal preparations that are often perceived as benign and safe
Studies suggest the following may have efficacy in preventing migraine: magnesium, riboflavin, butterbur, coenzyme Q10, and certain nutraceutical combinations
Nutraceuticals are associated with mild, transient adverse effects; there is concern for hepatotoxicity with butterbur
Long-term safety monitoring is needed

References:
1. D'Onofrio F, Raimo S, Spitaleri D, et al. Usefulness of nutraceuticals in migraine prophylaxis. Neurol Sci. 2017 May;38(Suppl 1):117-120.
2. Teigen L, Boes CJ. An evidence-based review of oral magnesium supplementation in the preventive treatment of migraine. Cephalalgia. 2015 Sep;35(10):912-22.
3. Wider B, Pittler MH, Ernst E. Feverfew for preventing migraine. Cochrane Database Syst Rev. 2015 Apr 20;4:CD002286.