What supplements are recommended for migraine prophylaxis?

Supplements for Migraine Prophylaxis

Magnesium (400-600mg daily), riboflavin (400mg daily), and Coenzyme Q10 are the most evidence-based supplements recommended for migraine prophylaxis, with feverfew showing some promising results as well. 1

Evidence-Based Supplement Options

First-Line Supplement Options:

1. Magnesium

   • Dosage: 400-600mg daily 1
   • Evidence: Two studies showed benefits of magnesium over placebo, though a third study failed to show benefit 2
   • Mechanism: Helps regulate neurotransmitter release and vascular tone
   • Best for: Patients with menstrual migraine or migraine with aura

2. Riboflavin (Vitamin B2)

   • Dosage: 400mg daily 1
   • Evidence: Significant benefit noted after 3-4 months of supplementation 2
   • Mechanism: Improves mitochondrial energy metabolism
   • Best for: Patients seeking a well-tolerated option with minimal side effects

3. Coenzyme Q10

   • Dosage: Typically 100-300mg daily 1
   • Evidence: Shown to reduce migraine frequency
   • Mechanism: Improves mitochondrial function and reduces oxidative stress
   • Best for: Patients with mitochondrial dysfunction or those who cannot tolerate other preventives

Second-Line Supplement Option:

1. Feverfew
   • Evidence: Three trials suggest potential benefit 2
   • Key findings:
     • Withdrawal of feverfew led to increased headache frequency in regular users
     • Significant reduction in pain intensity and associated symptoms (nausea, vomiting, photophobia, phonophobia)
     • Available as a homeopathic preparation combined with ginger 3
   • Caution: Not recommended during pregnancy or breastfeeding 3

Clinical Decision Algorithm for Supplement Selection

1. Assess migraine frequency and disability:

   • Consider preventive therapy if migraines occur ≥2 times per month, attacks are prolonged and disabling, or quality of life is reduced between attacks 1
   • Target 50% reduction in attack frequency with preventive therapy 1

2. Select appropriate supplement based on migraine characteristics:

   • For menstrual migraine: Start with magnesium
   • For migraine with aura: Consider magnesium or riboflavin
   • For patients with comorbid fatigue: Consider CoQ10 or riboflavin

3. Implementation guidelines:

   • Allow 6-8 weeks at therapeutic dose to assess effectiveness 1
   • Consider combination therapy (e.g., magnesium + riboflavin) for enhanced efficacy
   • Maintain consistent dosing schedule for optimal results

Important Considerations and Caveats

• Efficacy expectations: Supplements generally have modest effects compared to prescription medications but with fewer side effects
• Timing: Begin treatment as soon as possible after migraine onset to optimize effectiveness 1
• Combination approaches: A proprietary combination of magnesium, riboflavin, and CoQ10 showed significant reduction in migraine pain intensity and burden of disease compared to placebo 4
• Monitoring: Track response using a headache diary to document frequency, severity, and medication use 1
• Medication overuse: Limit acute medication use to prevent medication overuse headache (NSAIDs ≤15 days/month and triptans ≤10 days/month) 1

Safety Profile

• Magnesium: May cause diarrhea at higher doses; contraindicated in severe renal insufficiency
• Riboflavin: Generally well-tolerated; may cause yellow discoloration of urine
• CoQ10: Well-tolerated; occasional gastrointestinal effects
• Feverfew: Contraindicated in pregnancy; may interact with blood thinners; do not use if allergic to ragweed or other members of the Asteraceae family 3

While these supplements show promise for migraine prevention, they should be considered as part of a comprehensive approach that includes lifestyle modifications such as regular sleep schedule, consistent meal times, adequate hydration, regular physical activity, and stress management techniques 1.