Is riboflavin (Vitamin B2) used to prevent migraine headaches?

Riboflavin for Migraine Prevention

Riboflavin (Vitamin B2) has fair evidence for modest efficacy in migraine prevention, but is not considered a first-line preventive treatment compared to agents with stronger evidence such as beta-blockers, antidepressants, and anticonvulsants. 1

Evidence for Riboflavin in Migraine Prevention

• The American College of Physicians and the U.S. Headache Consortium acknowledge riboflavin as having fair evidence for modest efficacy in migraine prevention, though more trials are needed due to methodological limitations in existing studies 1
• High-dose riboflavin (400 mg daily) has demonstrated efficacy in reducing migraine attack frequency and headache days in randomized controlled trials, with 59% of patients experiencing at least 50% reduction in headache days compared to 15% for placebo 2
• Riboflavin is generally well-tolerated with minimal adverse effects, making it an attractive option despite its modest efficacy 2

Indications for Preventive Migraine Therapy

• Preventive therapy should be considered when patients experience:
  • Two or more migraine attacks per month with disability lasting 3 or more days per month 1
  • Contraindication to or failure of acute treatments 1
  • Use of abortive medications more than twice per week 1
  • Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura, migrainous infarction) 1

First-Line Preventive Treatments with Stronger Evidence

• Beta-blockers:

  • Propranolol (80-240 mg/day) and timolol (20-30 mg/day) have consistent evidence supporting efficacy 1, 3
  • Beta-blockers with intrinsic sympathomimetic activity are ineffective for migraine prevention 3

• Antidepressants:

  • Amitriptyline (30-150 mg/day) is the only antidepressant with consistent evidence for efficacy in migraine prevention 1, 4
  • Amitriptyline may be superior for patients with mixed migraine and tension-type headache 1

• Anticonvulsants:

  • Divalproex sodium and sodium valproate have good evidence for efficacy in migraine prevention 4

Practical Considerations for Riboflavin Use

• Dosing:

  • Most studies showing efficacy used 400 mg daily 2
  • Lower doses (10-40 mg/day) have shown modest effectiveness in pediatric populations 5, 6

• Treatment duration:

  • An adequate trial requires 2-3 months as clinical benefits may not become apparent immediately 1, 7
  • Continuous assessment of efficacy and side effects is recommended 3

• Safety profile:

  • Riboflavin is generally well-tolerated with minimal adverse effects 7, 2
  • Reported side effects are minor and include diarrhea and polyuria 2

Clinical Pitfalls and Considerations

• Riboflavin should not replace first-line agents with stronger evidence (beta-blockers, antidepressants, anticonvulsants) in patients without contraindications to these medications 1
• Patients should be informed about the modest efficacy of riboflavin compared to other preventive options 7
• Riboflavin may be particularly beneficial for patients who cannot tolerate other preventive medications due to side effects 7
• Response to riboflavin may be influenced by comorbid headache types, with evidence suggesting less effectiveness in patients with tension-type headaches 5