Nutraceuticals and headache: the biological basis

[Complementary and supplementary procedures in the treatment of headache]

In Germany, headache is one of the illnesses that most frequently leads to health impairments and to consultation with physicians. Even in children, headache is often associated with restricted activities of daily life. Nevertheless, the level of care for headache disorders is disproportionate to the medical needs. As a result, patients regularly use complementary and supportive therapeutic procedures. This review shows the procedures currently used for primary headache in childhood and adulthood, the methodological approaches and existing scientific evidence. The safety of the therapeutic options is also classified. These methods include physiotherapy, neural therapy, acupuncture, homeopathy, phytotherapy and the intake of dietary supplements. For children and adolescents with headaches, there are studies in the field of dietary supplements for coenzyme Q10, riboflavin, magnesium and vitamin D, which indicate specific effects in the reduction of headaches.

Use of Nutraceutical Ingredient Combinations in the Management of Tension-Type Headaches with or without Sleep Disorders

Headache is the most common pain complaint in the pediatric population, with tension type headache (TTH) having a prevalence of 10–15% in children. Up to 70% of pediatric patients with chronic headache also experience sleep disruption, with a likely bidirectional relationship between headache and poor sleep. Treatment options include specific pharmacological approaches as well as non-pharmacological alternatives; nutraceuticals have the advantage of a relative lack of side effects. Exogenous melatonin has been shown to be useful and safe in improving sleep-wake cycles and quality of sleep in children, helping to regulate the circadian rhythm, with a secondary positive impact on headache. Supplementation with other nutraceutical ingredients, such as tryptophan, magnesium, and B vitamins, can have significant additional effects in children with primary headache, with or without sleep disorders. Tryptophan may reduce night awakenings and improve the efficiency of sleep. Primary headache has been related to low amounts of magnesium in serum, and integration with magnesium appears to be effective in reducing headache attacks without adverse effects. There are different observational reports and uncontrolled studies suggesting a possible synergistic effect for these nutraceuticals, but there is now a need for high-quality randomized controlled trials in order to confirm these positive preliminary findings.

Nutraceuticals and Behavioral Therapy for Headache

PURPOSE OF REVIEW

Headache affects and disables at least 1 billion people worldwide. Patients and providers seek new therapies to relieve headache without the side effects and financial burden of current treatments. This narrative review highlights recent treatment advances in integrative headache medicine: nutraceuticals and behavioral therapies.

RECENT FINDINGS

Growing use of complementary and alternative medicine (CAM) therapies for headache (riboflavin, coenzyme Q10, magnesium, vitamin D, melatonin) alongside mainstream treatments is increasing with improving evidence of quality, safety, and tolerability. Increasing interest in medical cannabis is tempered by lack of evidence regarding safety and efficacy. Behavioral therapies including cognitive behavioral therapy (CBT), biofeedback, mindfulness-based stress reduction (MBSR), and acceptance and commitment therapy (ACT) improve patient resiliency and self-efficacy outcomes and reduce disability. The body of evidence for nutraceutical and behavioral CAM interventions for headache continues to grow and improve in quality. Providers and patients should educate themselves regarding CAM therapies as part of integrative headache management. Future studies should examine combinatorial trials of CAM therapies against current standards of headache care.

Food for Special Medical Purposes and Nutraceuticals for Pain: A Narrative Review

Introduction

The present paper focuses on the possible contribution of food compounds to alleviate symptomatic pains. Chronic pain can more easily be linked to anticipatory signals such as thirst and hunger than it is to sensory perceptions as its chronicity makes it fall under the behavioural category rather than it does senses. In fact, pain often negatively affects one’s normal feeding behavioural patterns, both directly and indirectly, as it is associated with pain or because of its prostrating effects.

Nutritional Compounds for Pain

Several nutraceuticals and Foods for Special Medical Purposes (FSMPs) are reported to have significant pain relief efficacy with multiple antioxidant and anti-inflammatory properties. Apart from the aforementioned properties, amino acids, fatty acids, trace elements and vitamins may have a role in the modulation of pain signals to and within the nervous system.

Conclusion

In our opinion, this review could be of great interest to clinicians, as it offers a complementary perspective in the management of pain. Trials with well-defined patient and symptoms selection and a robust pharmacological design are pivotal points to let these promising compounds become better accepted by the medical community.

Non-Pharmacological Approaches to Headaches: Non-Invasive Neuromodulation, Nutraceuticals, and Behavioral Approaches

Significant side effects or drug interactions can make pharmacological management of headache disorders very difficult. Non-conventional and non-pharmacological treatments are becoming increasingly used to overcome these issues. In particular, non-invasive neuromodulation, nutraceuticals, and behavioral approaches are well tolerated and indicated for specific patient categories such as adolescents and pregnant women. This paper aims to present the main approaches reported in the literature in the management of headache disorders. We therefore reviewed the available literature published between 2010 and 2020 and performed a narrative presentation for each of the three categories (non-invasive neuromodulation, nutraceuticals, and behavioral therapies). Regarding non-invasive neuromodulation, we selected transcranial magnetic stimulation, supraorbital nerve stimulation, transcranial direct current stimulation, non-invasive vagal nerve stimulation, and caloric vestibular stimulation. For nutraceuticals, we selected Feverfew, Butterbur, Riboflavin, Magnesium, and Coenzyme Q10. Finally, for behavioral approaches, we selected biofeedback, cognitive behavioral therapy, relaxation techniques, mindfulness-based therapy, and acceptance and commitment therapy. These approaches are increasingly seen as a valid treatment option in headache management, especially for patients with medication overuse or contraindications to drug treatment. However, further investigations are needed to consider the effectiveness of these approaches also with respect to the long-term effects.

Complementary and Integrative Medicines as Prophylactic Agents for Pediatric Migraine: A Narrative Literature Review

Complementary and integrative medicines (CIMs) are increasingly used as a preventive antimigraine therapy. In this review, we aimed to summarize the evidence for the efficacy and safety of eight CIMs (riboflavin, coenzyme Q10, magnesium, melatonin, polyunsaturated fatty acids, and combination therapy of feverfew, vitamin D, and ginkgolide B) in pediatric migraine prevention. The level of evidence for riboflavin was relatively high; it was investigated by many studies with five/seven studies demonstrating its efficacy. Five studies investigated the use of melatonin, with one reporting negative results. There was insufficient evidence on the effectiveness of coenzyme Q10, magnesium, and polyunsaturated fatty acids. Combination therapy showed positive potential; however, reports on the individual antimigraine effects of the CIMs were lacking. A definitive conclusion was not reached regarding the specific integrative drugs clinicians should choose for pediatric migraines, owing to low-quality evidence and a limited number of studies. Integrative medications are becoming more common for pediatric migraine prevention as they do not produce serious side effects, and underlying research data suggest their efficacy in preventing migraine. Additional studies are warranted to confirm the role of CIMs in treating patients with migraines.

The Role of Magnesium in Pathophysiology and Migraine Treatment

Migraine is one of the most common recurrent types of headache and is the seventh cause of disability. This neurological disorder is characterized by having pain in head and other various symptoms such as nausea, emesis, photophobia, phonophobia, and sometimes visual sensory disorders. Magnesium (Mg) is a necessary ion for human body and has a crucial role in health and life maintenance. One of the main roles of Mg is to conserve neurons electric potential. Therefore, magnesium deficiency can cause neurological complications. Migraine is usually related to low amounts of Mg in serum and cerebrospinal fluid (CSF). Deficits in magnesium have significant role in the pathogenesis of migraine. Mg has been extensively used in migraine prophylaxis and treatment. This review summarizes the role of Mg in migraine pathogenesis and the potential utilizations of Mg in the prevention and treatment of migraine with the emphasis on transdermal magnesium delivery.

Effectiveness of low-dose riboflavin as a prophylactic agent in pediatric migraine

BACKGROUND

Riboflavin may prevent migraine episodes; however, there is limited evidence of its effectiveness in pediatric populations. This study investigated the effectiveness of riboflavin and clinical predictors of response in children with migraines.

METHODS

We retrospectively reviewed data from 68 Japanese children with migraines, of whom 52 also exhibited another type of headache. Patients received 10 or 40 mg/day of riboflavin. We evaluated the average migraine frequency per month as a baseline and after 3 months of riboflavin therapy to determine the effectiveness and clinical predictors of response.

RESULTS

The frequency of migraine episodes was significantly lower at 3 months than at baseline (median, [interquartile range], 5.2 (3-7) vs. 4.0 (2-5); p < 0.01). Twenty-five patients (36.7%) showed 50% or greater reduction in episode frequency (responders), while 18 (26.5%) showed a 25%-50% reduction. We compared responders (n = 25) and non-responders (n = 43) and found no significant differences in sex, familial history, riboflavin dose, migraine type (i.e., presence or absence of aura), age at headache onset, or age at consultation. However, non-responders were more likely to have co-morbid non-migraine headaches (odds ratio, 4.11; 95% confidence interval [CI], 1.27-13.33; p = 0.02); this variable was also significant in a multivariate analysis (adjusted odds ratio, 3.8; 95% CI, 1.16-12.6; p = 0.03). Of the co-morbid headache types, only tension headaches were significant (odds ratio, 0.176; 95% CI, 0.04-0.73; p = 0.013). No adverse effects of riboflavin were identified.

CONCLUSIONS

Low-dose riboflavin is safe and modestly effective for migraines in children. It may be especially beneficial for children without other co-morbid headache types.

Migraine and Diet

Migraine is characterized by recurrent attacks of disabling headaches, often accompanied by sensory and motor disturbances. Clinical manifestations of migraine are influenced by dietary behaviors and dietary elements. Several dietary triggers for migraine have been identified, leading to the definition of strategies such as elimination diets, ketogenic diets, and comprehensive diets, mainly to help prevent migraine. Although inconsistency is present in the literature and no consensus exists, the available data are promising in supporting beneficial dietary interventions for some migraine patients. Several factors influence the net outcome, including age, sex, genetics, and environmental factors. Advancement in understanding the underlying mechanisms of migraine pathogenesis and how dietary factors can interfere with those mechanisms has encouraged investigators to consider diet as a disease-modifying agent, which may also interfere with the gut–brain axis or the epigenetics of migraine. Future work holds potential for phenotyping migraine patients and offering personalized recommendations in line with biopsychosocial models for the management of migraine. Diet, as an important element of lifestyle, is a modifiable aspect that needs further attention. Well-designed, systematic, and mechanism-driven dietary research is needed to provide evidence-based dietary recommendations specific to migraine. This narrative review aims to present the current status and future perspective on diet and migraine, in order to stimulate further research and awareness.

Phytomedicines in the Treatment of Migraine

Migraine is a disabling neurovascular disorder with few targeted, tolerable and effective treatments. Phytomedicines, or plant-based medicinal formulations, hold great promise in the identification of novel therapeutic targets in migraine. Many patients also turn toward herbal and plant-based therapies for the treatment of their migraines as clinical and preclinical evidence of efficacy increases. Patients seek effective and tolerable treatments instead of or in addition to current conventional pharmacologic therapies. We review some phytomedicines potentially useful for migraine treatment-feverfew (Tanacetum parthenium), butterbur (Petasites hybridus), marijuana (Cannabis spp.), Saint John's Wort (Hypericum perforatum) and the Damask rose (Rosa × damascena)-with respect to their mechanisms of action and evidence for treatment of migraine. The evidence for feverfew is mixed; butterbur is effective with potential risks of hepatotoxicity related to preparation; marijuana has not been shown to be effective in migraine treatment, and data are scant; Saint John's Wort shows relevant physiological activity but is a hepatic enzyme inducer and lacks clinical studies for this purpose; the Damask rose when used in topical preparations did not show efficacy in one clinical trial. Other plant preparations have been considered for migraine treatment but most without blinded randomized, placebo-controlled trial evidence.

An observational study of fixed-dose Tanacetum parthenium nutraceutical preparation for prophylaxis of pediatric headache

Background

Migraine is one of the most prevalent chronic pain manifestations of childhood. Despite the multitude of available treatments, parents are often concerned about chronic therapies and pediatricians have insufficient confidence in prescribing prophylactic drugs. Therefore, there is now growing interest for natural supplements used to control recurrent migraine headaches. Such approach may increase acceptance and adherence to long-term prophylaxis therapy in children.

Methods

This is an observational multicenter study performed in children (n = 91) with migraine, with (MO) or without aura (MA), or tension-type headache (TTH). A fixed-dose Andrographis paniculata, CoQ10, riboflavin, and magnesium, was administered for 16 weeks. Patients were evaluated at baseline (T0), at week 8 (T1) and at the end of treatment at week 16 (T2). A follow-up period occurred at week 20 (T3) and week 32 (T4).

Results

The herbal supplement significantly reduced the frequency of headaches in TTH patients during treatment period (T0: 11.97 + 1.92 vs T2: 5.13 + 1.93; p < 0.001) and the efficacy was maintained after 16 weeks of treatment withdrawal (T4: 4.46 + 1.75; p < 0.001 vs T0). The frequency of migraine attacks was also reduced in the MO group during treatment (T0: 9.70 + 0.96 vs T2: 4.03 + 0.75; p < 0.01) and after withdrawal (T4: 2.96 + 0.65; p < 0.01 vs T0). Conversely, MA patients showed reduction in migraine’s frequency during treatment (T0: 8.74 + 1.91 vs T2: 3.78 + 2.02; p < 0.01) but not at the end of the study (T4: 5.57 + 3.31; p > 0.05 vs T0).

TTH patients did not report significant improvement of pain intensity. A significant effect was observed in the MO group during treatment (T0: 3.06 + 0.11 vs T2: 2.14 + 0.19; p < 0.001) and after treatment withdrawal (T4: 2.20 + 0.21; p < 0.001 vs T0). Likewise, MA group showed a significant treatment effect (T0: 2.57 + 0.20 vs T2: 0.86 + 0.45; p < 0.001) and the efficacy persisted at the end of the study (T4: 1.00 + 0.58; p < 0.001 vs T0).

Conclusion

This fixed-dose Tanacetum parthenium preparation improved headache frequency and pain intensity in children affected by TTH. Despite the main limits, this study supports the use of nutraceutical in pediatric headache/migraine.

Pediatric Headache Clinic Model: Implementation of Integrative Therapies in Practice

The demand for integrative medicine has risen in recent years as research has demonstrated the efficacy of such treatments. The public has also become more conscientious of the potential limitations of conventional treatment alone. Because primary headache syndromes are often the culmination of genetics, lifestyle, stress, trauma, and environmental factors, they are best treated with therapies that are equally multifaceted. The Children’s Mercy Hospital, Kansas City, Missouri Headache Clinic has successfully incorporated integrative therapies including nutraceuticals, acupuncture, aromatherapy, biofeedback, relaxation training, hypnosis, psychology services, and lifestyle recommendations for headache management. This paper provides a detailed review of the implementation of integrative therapies for headache treatment and discusses examples through case studies. It can serve as a model for other specialty settings intending to incorporate all evidenced-based practices, whether complementary or conventional.

The Evidence for the Role of Nutraceuticals in the Management of Pediatric Migraine: a Review

PURPOSE OF REVIEW

Nutraceuticals are a form of complementary and alternative medicine that is commonly used by children and adolescents with migraine. In this review, observational studies, randomized controlled trials, systematic reviews, and meta-analyses on the efficacy and safety of single compound nutraceuticals for the management of migraine in children and adolescents were identified through a literature search of MEDLINE, Embase, and EBM Reviews-Cochrane Central Register of Controlled Trials.

RECENT FINDINGS

Twenty-one studies were reviewed, of which 11 were observational studies, 7 were randomized controlled trials, and 3 were systematic reviews. Six different nutraceuticals were included in the review: vitamin D, riboflavin, coenzyme Q10, magnesium, butterbur, and polyunsaturated fatty acids. All but three of the studies assessed the role of nutraceuticals in migraine prevention, while three studies evaluated the role of intravenous magnesium for acute migraine management. Overall, the quality and size of the studies were limited. Due to low quality evidence and limited studies, no definite conclusions can be drawn on the efficacy of nutraceuticals for the treatment of pediatric migraine. Future studies are warranted in order to establish evidence upon which to define the role of nutraceuticals in this patient population.

Genetic bases of the nutritional approach to migraine

Migraine is a common multifactorial and polygenic neurological disabling disorder characterized by a genetic background and associated to environmental, hormonal and food stimulations. A large series of evidence suggest a strong correlation between nutrition and migraine and indicates several commonly foods, food additives and beverages that may be involved in the mechanisms triggering the headache attack in migraine-susceptible persons. There are foods and drinks, or ingredients of the same, that can trigger the migraine crisis as well as some foods play a protective function depending on the specific genetic sensitivity of the subject. The recent biotechnological advances have enhanced the identification of some genetic factors involved in onset diseases and the identification of sequence variants of genes responsible for the individual sensitivity to migraine trigger-foods. Therefore many studies are aimed at the analysis of polymorphisms of genes coding for the enzymes involved in the metabolism of food factors in order to clarify the different ways in which people respond to foods based on their genetic constitution. This review discusses the latest knowledge and scientific evidence of the role of gene variants and nutrients, food additives and nutraceuticals interactions in migraine.

Current Prophylactic Medications for Migraine and Their Potential Mechanisms of Action

A relatively high number of different medications is currently used for migraine prevention in clinical practice. Although these compounds were initially developed for other indications and differ in their mechanisms of action, some general themes can be identified from the mechanisms at play. Efficacious preventive drugs seem to either suppress excitatory nervous signaling via sodium and/or calcium receptors, facilitate GABAergic inhibition, reduce neuronal sensitization, block cortical spreading depression and/or reduce circulating levels of CGRP. We here review such mechanisms for the different compounds.

Non-Pharmacological Approaches for Migraine

Migraine is one of the most common and debilitating neurological disorders. However, the efficacy of pharmacological therapies may have unsatisfactory efficacy and can be poorly tolerated. There is a strong need in clinical practice for alternative approaches for both acute and preventive treatment. Occasionally, this need might arise in the context of low-frequency migraneurs who are not keen to use medication or fear the potential side effects. At the opposite end of the spectrum, clinicians might be faced with patients who have proven refractory to numerous medications. These patients may benefit from invasive treatment strategies. In recent years, promising strategies for migraine therapy have emerged alongside a progressively better understanding of the complex pathophysiology underlying this disease. This review discusses the most recent and evidence-based advances in non-pharmacological therapeutic approaches for migraine, offering alternatives to drug treatment for both the commonly encountered episodic cases as well as the more complex migraine phenotypes, which are capable of challenging even the headache specialist.

A combination of coenzyme Q10, feverfew and magnesium for migraine prophylaxis: a prospective observational study

BACKGROUND

Feverfew (Tanacetum parthenium L.), magnesium and coenzyme Q10 are frequently used for migraine prophylaxis. Supplementation with a fixed combination of these three agents (Antemig®, PiLeJe) was investigated in an observational study.

METHODS

Adult patients suffering from migraine according to the criteria of the International Headache Society were enrolled by general practitioners (≥2 migraine attacks during previous month; exclusion of chronic migraine and medication overuse) and after a one-month baseline phase, supplemented with one tablet of 100 mg feverfew, 100 mg coenzyme Q10 and 112.5 mg magnesium per day for 3 months.

RESULTS

Supplementation significantly reduced the number of days with migraine headache during third month of supplementation compared to baseline phase (1.3 days ±1.5 versus 4.9 days ±2.6, p < 0.0001; n = 68 intention to treat; primary criterion). The decrease was progressive over the period of supplementation and significant from first month (1st month: -2.5 days ±3.1, p < 0.0001; 2nd month: -3 days ±2.8, p < 0.0001). The proportion of patients with a reduction of at least 50% in the number of days with migraine headache was 75% (51/68) after 3 months, with a progressive increase over the period of supplementation (63.2% [43/68] after 1 month and 70.6% [48/68] after 2 months). The proportion of patients with anxiety and depressive symptoms (Hospital Anxiety and Depression Scale) decreased between baseline phase and third month of supplementation from 61.9% (39/63 patients with information available) to 35% (21/60) for depression and from 52.4% (33/63) to 30% (18/60) for anxiety. An improvement of quality of life (Qualité de Vie et Migraine questionnaire) was also observed. The combination was well tolerated.

CONCLUSIONS

Results suggest that the proprietary supplement containing feverfew, coenzyme Q10 and magnesium assessed could be beneficial and safe for the prevention of migraine in adult patients and merits further study.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02901756 , retrospectively registered on August 24, 2016.

Headaches: a Review of the Role of Dietary Factors

Dietary triggers are commonly reported by patients with a variety of headaches, particularly those with migraines. The presence of any specific dietary trigger in migraine patients varies from 10 to 64 % depending on study population and methodology. Some foods trigger headache within an hour while others develop within 12 h post ingestion. Alcohol (especially red wine and beer), chocolate, caffeine, dairy products such as aged cheese, food preservatives with nitrates and nitrites, monosodium glutamate (MSG), and artificial sweeteners such as aspartame have all been studied as migraine triggers in the past. This review focuses the evidence linking these compounds to headache and examines the prevalence of these triggers from prior population-based studies. Recent literature surrounding headache related to fasting and weight loss as well as elimination diets based on serum food antibody testing will also be summarized to help physicians recommend low-risk, non-pharmacological adjunctive therapies for patients with debilitating headaches.

Intravenous caffeine citrate vs. magnesium sulfate for reducing pain in patients with acute migraine headache; a prospective quasi-experimental study

Background

Current evidence suggests that intravenous magnesium sulfate might be effective for reducing migraine pain. In a recent pilot study, we showed that intravenous caffeine citrate could reduce the severity of migraine headache. The objective of this study is to investigate the efficacy of intravenous caffeine citrate vs. magnesium sulfate for management of acute migraine headache.

Methods

We conducted a prospective quasi-experimental study from January until May 2016 in two educational medical centers of Shahid Beheshti University of Medical Sciences (Shoahadaye Tajrish Hospital and Imam Hossein Hospital), Tehran, Iran. The study included patients who were referred to the emergency department and met the migraine diagnosis criteria of the International Headache Society. Patients were allocated into 2 groups receiving either 60 mg intravenous caffeine or 2 g intravenous magnesium sulfate. The pain scores, based on the visual analog scale, were recorded on admission, as well as one and two hours after receiving the drug. A Chi-Square test and student t-test were used for analysis of baseline characteristics. A Mann-Whitney U test and Wilcoxon singed rank test were used to analyze differences in the visual analogue scale (VAS) score between and within the groups respectively.

Results

In total, 70 patients (35 patients in each group) with the mean age of 33.1 ± 11.3 years were included (64.3% female). For the Caffeine citrate group, the median pain score decreased from 9.0 (2.0) to 5.0 (4.0) after one hour and to 3.0 (4.0) after two hours. For the magnesium sulfate group, the pain score decreased from 8.0 (2.0) to 2.0 (2.0) after one hour and to 0.0 (1.0) after two hours. Both intravenous caffeine citrate and intravenous magnesium sulfate reduced pain scores significantly but the magnesium sulfate group showed more improvement than the Caffeine citrate group after one hour (P < 0.001) and after two hours (P < 0.001).

Conclusions

It is likely that both intravenous caffeine and intravenous magnesium sulfate can reduce the severity of migraine headache. Moreover, intravenous magnesium sulfate at a dose of 2 g might be superior to intravenous caffeine citrate 60 mg for the short term management of migraine headache in emergency departments.

Diet and nutraceutical interventions for headache management: A review of the evidence

Background

The use of complementary and alternative medicines (CAM) is common among patients with primary headaches. In parallel, CAM research is growing. Diet interventions comprise another category of non-pharmacologic treatment for primary headache that is of increasing clinical and research interest.

Methods

A literature search was carried out to identify studies on the efficacy of diet and nutraceutical interviews for primary headache in the pediatric and adult populations. MEDLINE, Embase and EBM Reviews—Cochrane Central Register of Controlled Trials were searched to identify studies.

Results

There is a growing body of literature on the potential use of CAM and diet interventions for primary headache disorders. This review identified literature on the use of a variety of diet and nutraceutical interventions for headache. Most of the studies assessed the efficacy of these interventions for migraine, though some explored their role in tension-type headache and cluster headache. The quality of the evidence in this area is generally poor.

Conclusions

CAM is becoming more commonplace in the headache world. Several interventions show promise, but caution needs to be exercised in using these agents given limited safety and efficacy data. In addition, interest in exploring diet interventions in the treatment of primary headaches is emerging. Further research into the efficacy of nutraceutical and diet interventions is warranted.

Nutraceuticals in Migraine: A Summary of Existing Guidelines for Use

BACKGROUND

The use of nutraceuticals or food/herbal products for health benefits is expanding in adults with migraine as they seek relief from pain in an effective and tolerable manner not always afforded by current conventional pharmacologic therapies. Guidelines from the American Academy of Neurology/American Headache Society, Canadian Headache Society, and European Federation of Neurological Societies have discussed nutraceuticals in varying degrees of detail with at times conflicting recommendations.

CONCLUSION

This review serves to provide a summary of existing guidelines for the use of certain nutraceuticals including riboflavin, coenzyme Q10, magnesium, butterbur, feverfew, and omega-3 polyunsaturated fatty acids. The review will also discuss the regulation of nutraceuticals in North America and the current controversy regarding butterbur and its safety.

Complementary and Integrative Approaches for Pediatric Headache

In this article, the use of complementary and integrative medicine for the management of pediatric headache is reviewed. Despite limited numbers of studies for pediatric headaches, children and families seek these services. Integrative medicine focuses on treating the whole person, integrating conventional medicine with mind-body-spirit methods. Nutriceuticals include dietary supplements in the form of vitamins (vitamin D), minerals (magnesium), coenzyme Q, butterbur, and melatonin. Acupuncture, stimulation, physical therapy and Transcutaneous Electrical Nerve Stimulations (TENS) or Transcranial Magnetic Stimulation (TMS) may also be useful in selected patients. The efficacy of all these therapeutic alternatives in pediatric headache is presented here. Primary care providers, neurologists, and headache specialists alike need to be informed of such interventions and integrate these approaches, when appropriate, in the management of children with headaches.

Riboflavin in cyclic vomiting syndrome: efficacy in three children

Cyclic vomiting syndrome is an episodic disorder considered to be a migraine variant. Riboflavin is efficient in the prophylactic treatment of migraines in adults. We describe the effectiveness and tolerance of riboflavin treatment in three children with cyclic vomiting syndrome. All of them fulfilled the diagnosis criteria for cyclic vomiting syndrome. They received prophylactic monotherapy with riboflavin for at least 12 months. Excellent response and tolerability was observed.

CONCLUSION

Based on clinical observation in three cases, riboflavin may be an effective and safe prophylactic treatment for children with cyclic vomiting syndrome.

WHAT IS KNOWN

CVS is one of the "childhood periodic syndromes" classified as a migraine subtype by the International Headache Society. Riboflavin is currently used as a prophylactic treatment in patients with migraine.

WHAT IS NEW

Riboflavin may be an effective and safe prophylactic treatment for children with CVS. Increasing doses of riboflavin and long periods of prophylaxis may be needed in some children..

Normobaric and hyperbaric oxygen therapy for the treatment and prevention of migraine and cluster headache

BACKGROUND

Migraine and cluster headaches are severe and disabling. Migraine affects up to 18% of women, while cluster headaches are much less common (0.2% of the population). A number of acute and prophylactic therapies are available. Hyperbaric oxygen therapy (HBOT) is the therapeutic administration of 100% oxygen at environmental pressures greater than one atmosphere, while normobaric oxygen therapy (NBOT) is oxygen administered at one atmosphere. This is an updated version of the original Cochrane review published in Issue 3, 2008 under the title 'Normobaric and hyperbaric oxygen for migraine and cluster headache'.

OBJECTIVES

To examine the efficacy and safety of normobaric oxygen therapy (NBOT) and hyperbaric oxygen therapy (HBOT) in the treatment and prevention of migraine and cluster headache.

SEARCH METHODS

We updated searches of the following databases up to 15 June 2015: CENTRAL (the Cochrane Library), MEDLINE, EMBASE, and CINAHL. For the original review we searched the following databases up to May 2008: CENTRAL, MEDLINE, EMBASE, CINAHL, DORCTIHM, and reference lists from relevant articles. We handsearched relevant journals and contacted researchers to identify trials.

SELECTION CRITERIA

Randomised controlled trials comparing HBOT or NBOT with one another, other active therapies, placebo (sham) interventions, or no treatment in participants with migraine or cluster headache.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data and assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

In this update, we included 11 trials with 209 participants. Five trials (103 participants) compared HBOT versus sham therapy for acute migraine, three trials compared NBOT to sham therapy or ergotamine tartrate for cluster headache (145 participants), two trials evaluated HBOT for cluster headache (29 participants), and one trial (56 participants) compared NBOT to sham for a mixed group of headache. The risk of bias varied considerably across these trials but in general trial quality was poor to moderate. One trial may not have been truly randomised and two included studies were reported as abstracts only. Seven trials did not indicate allocation concealment or randomisation method. Notably, 10 of the 11 trials used a sham comparator therapy and masked the outcome assessor to allocation.We pooled data from three trials, which suggested that HBOT was effective in relieving migraine headaches compared to sham therapy (risk ratio (RR) 6.21, 95% CI 2.41 to 16.00; 58 participants, three trials). The quality of evidence was low, having been downgraded for small crossover studies with incomplete reporting. There was no evidence that HBOT could prevent migraine episodes, reduce the incidence of nausea and vomiting, or reduce the requirement for rescue medication. There was no evidence that HBOT was effective for the termination of cluster headache (RR 11.38, 95% CI 0.77 to 167.85; P = 0.08) (one trial), but this trial had low power.NBOT was effective in terminating cluster headache compared to sham in a single small study (RR 7.88, 95% CI 1.13 to 54.66), but not superior to ergotamine administration in another small trial (RR 1.17, 95% CI 0.94 to 1.46; P = 0.16). A third trial reported a statistically significant difference in the proportion of attacks successfully treated with oxygen (117 of 150 attacks were successfully treated with NBOT (78%) versus 30 of 148 attacks treated with NBOT (20%)). The proportion of responders was consistent across these three trials, and suggested more than 75% of headaches were likely to respond to NBOT.No serious adverse events during HBOT or NBOT were reported.

AUTHORS' CONCLUSIONS

Since the last version of this review, two new included studies have provided additional information to change the conclusions. There was some evidence that HBOT was effective for the termination of acute migraine in an unselected population, and some evidence that NBOT was similarly effective in cluster headache. Given the cost and poor availability of HBOT, more research should be done on patients unresponsive to standard therapy. NBOT is cheap, safe, and easy to apply, so will probably continue to be used despite the limited evidence in this review.

Feverfew for preventing migraine

BACKGROUND

This review is an update of a previously published review in the Cochrane Database of Systematic Reviews on 'Feverfew for preventing migraine' (2004, Issue 1). Feverfew (Tanacetum parthenium L.) extract is a herbal remedy, which has been used for preventing attacks of migraine.

OBJECTIVES

To systematically review the evidence from double-blind randomised controlled trials (RCTs) assessing the clinical efficacy and safety of feverfew monopreparations versus placebo for preventing migraine.

SEARCH METHODS

For this updated version of the review we searched CENTRAL, MEDLINE, EMBASE and AMED to January 2015. We contacted manufacturers of feverfew and checked the bibliographies of identified articles for further trials.

SELECTION CRITERIA

We included randomised, placebo-controlled, double-blind trials assessing the efficacy of feverfew monopreparations for preventing migraine in patients of any age. We included trials using clinical outcome measures, while we excluded trials focusing exclusively on physiological parameters. There were no restrictions regarding the language of publication.

DATA COLLECTION AND ANALYSIS

We systematically extracted data on patients, interventions, methods, outcome measures, results and adverse events. We assessed risk of bias using the Cochrane 'Risk of bias' tool and evaluated methodological quality using the Oxford Quality Scale developed by Jadad and colleagues. Two review authors (BW and MHP for this update, MHP and EE for the original version) independently selected studies, assessed methodological quality and extracted data. We resolved disagreements concerning evaluation of individual trials through discussion.

MAIN RESULTS

We identified one new study for this update, resulting in six trials (561 patients) meeting the inclusion criteria. Five of the six trials reported on the main outcome, migraine frequency. Although five of the trials were generally of good methodological quality, all studies were either of unclear or high risk of bias with regards to sample size. Pooled analysis of the results was not possible due to the lack of common outcome measures and heterogeneity between studies in terms of participants, interventions and designs.The most recent trial added to this version of the review is rigorous and larger (n = 218), using a stable feverfew extract at a dose determined by a previous dose-finding trial. It reports that feverfew reduced migraine frequency by 1.9 attacks from 4.8 to 2.9 and placebo by 1.3 from to 4.8 to 3.5 per month, resulting in a difference in effect between feverfew and placebo of 0.6 attacks per month. For the secondary outcome measures intensity and duration of migraine attacks, incidence and severity of nausea and vomiting, and global assessment no statistically significant differences were reported. Results of previous trials are not convincing: three trials reporting positive effects of feverfew are all of small sample size (17 to 60 participants), while two rigorous trials (n = 50, 147) did not find significant differences between feverfew and placebo. Only mild and transient adverse events, most commonly gastrointestinal complaints and mouth ulcers, were reported in the included trials.

AUTHORS' CONCLUSIONS

Since the last version of this review, one larger rigorous study has been included, reporting a difference in effect between feverfew and placebo of 0.6 attacks per month. This adds some positive evidence to the mixed and inconclusive findings of the previous review. However, this constitutes low quality evidence, which needs to be confirmed in larger rigorous trials with stable feverfew extracts and clearly defined migraine populations before firm conclusions can be drawn. It appears from the data reviewed that feverfew is not associated with any major safety concerns.

A Medical Food Formulation of Griffonia simplicifolia/Magnesium for Childhood Periodic Syndrome Therapy: An Open-Label Study on Motion Sickness

Motion sickness (MS) is a disabling condition dominated by disagreement between visually perceived movement and the vestibular system's sense of movement, with symptoms like dizziness, fatigue, and nausea, and other autonomic disabling symptoms. Preparations of Griffonia simplicifolia, containing high concentrations of 5-HTP, might be effective for serotonin-related disorders, including MS. Therefore, the aim of the present study is to assess the efficacy and safety of the G. simplicifolia/magnesium complex in a pediatric population with MS. The Griffonia/magnesium complex (50 and 200 mg, respectively) was orally administered as a prophylactic therapy for MS twice a day for 3 months to group A, and no therapy for MS was administered to group B. The MS clinical signs were recorded by parents or, where possible, directly from children by a specific module, which included validated questions for the diagnoses that were administered to all subjects and parents of both groups. Two study groups were matched for age (P=.224), sex (P=.801), and z-score body-mass index (P=.173). At T0, all recruited subjects in both groups complained about MS. After 3 months (T1), group A showed an MS prevalence of 36%, significantly lower than MS prevalence in group B (73%) (P<.001). The findings of the present study suggest the role of the Griffonia/magnesium complex as a potential treatment with middle-term efficacy even for MS.

Riboflavin and migraine: the bridge over troubled mitochondria

Brain energy metabolism has been found to be disturbed in migraine. A mitochondrial defect may reduce the threshold for migraine attacks both increasing neuronal excitability and leading migrainous brain to a hyper-responsiveness to triggering stimuli. Riboflavin, a major co-factor in oxidative metabolism, may overcome this impairment. RCT studies in adult confirmed that riboflavin is safe and probably effective in migraine prophylaxis, based on level B evidence. Improving brain energy metabolism may reduce the susceptibility to migraine when brain energy demand increases due to both physiological and biopsychological factors.

An evidence-based review of oral magnesium supplementation in the preventive treatment of migraine

Background

Migraine is an incompletely understood, debilitating disorder that lacks a universally effective treatment. Magnesium participates in a variety of biochemical processes related to migraine pathophysiology, and a deficiency could contribute to migraine development.

Methods

A review of the literature from 1990 to the present on magnesium and migraine was conducted.

Review

The authors identified 16 studies aimed at magnesium status assessment in migraine, and four intervention trials assessing the efficacy of oral magnesium supplementation, independent of other therapies, in the prevention of migraine.

Conclusion

The strength of evidence supporting oral magnesium supplementation is limited at this time. With such limited evidence, a more advantageous alternative to magnesium supplementation, in patients willing to make lifestyle changes, may be to focus on increasing dietary magnesium intake.

Pediatric migraine: common, yet treatable

Migraine headache is a common problem among children and adolescents that is now recognized as a significant and often debilitating condition in this population. Improved recognition and management of pediatric migraine in primary care is necessary, as there is a knowledge gap in understanding the unique features of this condition and a general reluctance to treat children.

Pediatric headache: where have we been and where do we need to be

In this article, we hope to summarize current understanding of pediatric headache. We discuss epidemiology, genetics, classification, diagnosis, outpatient, emergency and inpatient treatment options, prevention strategies, and behavioral approaches. For each section, we end with a series of questions for future research and consideration.

Nutraceuticals in the prophylaxis of pediatric migraine: Evidence-based review and recommendations

Introduction

The literature on complementary and alternative medicine (CAM) is expanding. One of the most common conditions for which CAM is studied in the pediatric population is migraine. Nutraceuticals are a form of CAM that is being used for pediatric migraine prophylaxis.

Methods

A literature search was carried out in order to identify both observational studies and randomized controlled trials on the use of nutraceuticals for the prophylaxis of pediatric migraine. Adult studies on included nutraceuticals were also reviewed.

Review

Thirty studies were reviewed on six different nutraceuticals: butterbur, riboflavin, ginkgolide B, magnesium, coenzyme Q10 and polyunsaturated fatty acids.

Conclusion

Overall, the quality of the evidence for the use of nutraceuticals in pediatric migraine prophylaxis is poor. Further research needs to be done in order to study the efficacy of nutraceuticals for the prophylaxis of pediatric migraine.

The pathophysiological and pharmacological basis of current drug treatment of migraine headache

Migraine is a common neurological syndrome that affects approximately 10-20% of the population. The pathophysiology of migraine is unclear. 5-hydroxytriptamine is a key mediator in the pathogenesis of migraine and thus 5-HT1-receptor agonists are the principal drugs for acute migraine therapy. There are three classes of drugs for migraine: over-the-counter analgesics and nonsteroidal anti-inflammatory drugs for acute mild migraine, specific prescription drugs (triptans and ergot alkaloids) for acute severe migraine and pharmacological agents for prophylaxis of migraine. Sumatriptan, naratriptan and others, referred to as 'triptans', are the mainstay for acute treatment of migraine. Ergot alkaloids (ergotamine, dihydroergotamine) are used in patients with frequent, moderate migraine, but are less effective than triptans. There are several agents for prevention of migraine occurrence in patients with frequent or severe disabling migraine attacks. New drugs with improved efficacy and reduced side effects are needed for effective treatment and prevention of migraine.

Complementary and conventional medicine use among youth with recurrent headaches

OBJECTIVE

To identify prevalence and patterns of complementary and alternative medicine (CAM) use among youth with recurrent headaches (HA) and evaluate associations with co-occurring health problems and limitations as well as with the use and expenditures for conventional medical care.

METHODS

Variables were constructed for youth aged 10 to 17 by using linked data from the 2007 National Health Interview Survey and the 2008 Medical Expenditures Panel Survey. Bivariate, logistic, and 2-part regression analyses were used.

RESULTS

Of the 10.6% of youth experiencing HA, 29.6% used CAM, rising to 41% for the many HA sufferers who also experienced difficulties with emotions, concentration, behavior, school attendance, or daily activities. Biologically based products (16.2%) and mind-body therapies (13.3%) were most commonly used, especially by the 86.4% of youth with HA experiencing at least 1 other chronic condition. Compared with non-CAM users, youth with HA who used CAM also had higher expenditures for and use of most types of conventional care.

CONCLUSIONS

CAM use is most common among youth with HA experiencing multiple chronic conditions and difficulties in daily functioning. Associations among CAM use, multiple chronic conditions, and higher use of conventional care highlight the need for medical providers to routinely ask about CAM use to meet the complex health needs of their patients and facilitate the optimal integration of care. Research is needed to identify models for coordinating complementary and conventional care within a medical home and to understand the health benefits or risks associated with CAM use in conjunction with conventional treatments for patients with HA.

Pharmacological targeting of spreading depression in migraine

Migraine, particularly with aura, is a genetically heterogeneous disorder of ion channels, pumps or transporters associated with increased cortical excitability. Spreading depression, as one reflection of hyperexcitability, is the electrophysiological event underlying aura symptoms and a trigger for headache. Endogenous (e.g., genes and hormones) and exogenous factors (e.g., drugs) modulating migraine susceptibility have also been shown to modulate spreading depression susceptibility concordantly, suggesting that spreading depression can be a relevant therapeutic target in migraine. In support of this, several migraine prophylactic drugs used in clinical practice have been shown to suppress spreading depression susceptibility as a probable mechanism of action, despite belonging to widely different pharmacological classes. Hence, susceptibility to spreading depression can be a useful preclinical model with good positive and negative predictive value for drug screening.

Pediatric headache: a clinical review

In this review we describe the epidemiology, classification, and approach to the diagnosis and treatment of episodic and chronic migraine in children. We review both traditional and alternative medications, and offer a glimpse into the future of pediatric headache.