Efficacy of Nortriptyline and Migraine Lifestyle Modifications in Vestibular Migraine Management

OBJECTIVE

To evaluate the effectiveness of nortriptyline regimen and migraine dietary/lifestyle modifications on dizziness and stress levels in patients diagnosed with vestibular migraine (VM).

METHODS

A total of 35 patients diagnosed with definite VM based on the International Classification of Headache Disorders were included in this intervention study. Patients self-selected to receive either nortriptyline regimen alone (10-40 mg daily with biweekly escalation) (group A, n = 17) or migraine dietary/lifestyle modifications alone (group B, n = 18). Main outcome measures were dizziness severity and stress level measured by the visual analog scale (VAS).

RESULTS

At 4-week post-treatment, dizziness decreased from 6.0 ± 2.5 to 4.2 ± 3.4 (p = 0.069) in group A and from 8.7 ± 1.5 to 3.6 ± 3.0 (p < 0.001) in group B. VAS for stress changed from 5.5 ± 1.3 to 5.4 ± 2.9 (p = 0.93) and from 6.9 ± 3.2 to 5.0 ± 2.7 (p = 0.025) in groups A and B, respectively. The δ values of the VAS score for dizziness were 1.8 ± 3.7 and 5.1 ± 3.1 and the δ values of the VAS score for stress were 0.06 ± 2.9 and 1.9 ± 3.3 in groups A and B, respectively. Quality of life (QOL) improved in 88% patients in group A and 94% patients in group B.

CONCLUSIONS

Nortriptyline, at a maximum dose of 40 mg, effectively alleviates patient symptoms, while a migraine diet and lifestyle modifications notably reduce vertiginous symptoms and stress levels in VM patients in 4 weeks. Both interventions are equally effective in ameliorating the QOL of patients. The ideal treatment for patients would likely need to include both medication and diet/lifestyle changes.

Heavy metal and trace element alterations in patients during a migraine attack

OBJECTIVE

The aim of the study was to determine the heavy metal and trace element (HMTE) profile in patients with migraine (PwM) and to compare it to that of healthy individuals without migraine.

BACKGROUND

Migraine is a universal disease that affects more than 10% of the world's population; however, its pathophysiology is still obscure.

METHODS

A total of 100 participants were included in this prospective matched case-control study (50 PwM during acute attack and 50 age- and sex-matched healthy controls). The study was conducted in the university hospital in Yozgat, Turkey, where the inductively coupled plasma mass spectrometry system was used to measure the HMTE profile. The calibration curve was created with 11 points for heavy metals (arsenic [As], cadmium [Cd], cobalt [Co], lead [Pb], mercury [Hg], nickel [Ni], and tin [Sn]) and trace elements (antimony [Sb], chromium [Cr], copper [Cu], iron [Fe], magnesium [Mg], manganese [Mn], molybdenum [Mo], and zinc [Zn]).

RESULTS

The median age was 27 (23-37) years, and the female/male ratio was 37/13 for both groups. The PwM group had significantly higher As, Co, Pb, and Ni levels among the heavy metals (p = 0.033, 0.017, 0.022, and 0.021, respectively). Also, PwM had significantly lower Cr, Mg, and Zn levels among the trace elements (p = 0.007, 0.024, and < 0.001, respectively). The only trace element that was elevated in the PwM group was Mn (p = 0.001). The PwM and control groups did not differ in terms of Cd, Sn, Sb, Cu, Fe, and Mo (p = 0.165, 0.997, 0.195, 0.408, 0.440, and 0.252, respectively).

CONCLUSION

Some HMTE parameters are altered in PwM, which may provide additional insight into understanding migraine etiology.

Zinc Administration Favorably Affects Prophylactic Therapy-refractory Migraine Attacks: A Case Series

Notably, certain nutrients are effective in preventing migraine. Nonetheless, zinc replacement therapy for migraine treatment has yet to be explored. We herein report four patients with migraine who were refractory to prophylactic therapy and whose headache frequency and severity improved with zinc supplementation. Zinc administration may be an option for treating patients with prophylaxis-refractory migraine. Further investigation is required to determine the efficacy of zinc replacement therapy as a treatment option for migraine.

Headache Management in Individuals with Brain Tumor

Headache occurs commonly in individuals diagnosed with cerebral neoplasm. Though the features of a brain tumor-associated headache may vary, a progressive nature of headache and a change in headache phenotype from a prior primary headache disorder often are identified. Pathophysiologic mechanisms proposed for headache associated with brain tumor include headache related to traction on pain-sensitive structures, activation of central and peripheral pain processes, and complications from surgical, chemotherapeutic and/or radiotherapy treatment(s). Optimization of headache management is important for an individual's quality of life. Treatments are based upon patient-specific goals of care and may include tumor-targeted medical and surgical interventions, as well as a multimodal headache treatment approach incorporating acute and preventive medications, nutraceuticals, neuromodulation devices, behavioral interventions, anesthetic nerve blocks, and lifestyles changes.

Non-Pharmacological Treatment of Primary Headaches-A Focused Review

Headache disorders are a significant global health burden, leading to reduced quality of life. While vast pharmacological treatments are available, they may be associated with adverse effects or inadequate efficacy for some patients, therefore there is a need for exploring alternate treatment strategies. This review gives a brief explanation and evaluation of some established and emerging non-pharmacological approaches for headache management, focusing on nutraceuticals and diet, acupuncture, cognitive behavioral therapy (CBT), biofeedback, relaxation techniques, autogenic training, and neuromodulation. Special consideration is given to psychological interventions as they increase patient self-efficacy and provide strategies for managing chronic pain. Future research should focus on optimizing these therapies, identifying patient-specific factors influencing their effectiveness, and integrating them into holistic headache management strategies.

Migraine drugs

According to recent studies, migraine affects more than 1 billion people worldwide, making it one of the world’s most prevalent diseases. Although this highly debilitating illness has been known since ancient times, the first therapeutic drugs to treat migraine, ergotamine (Gynergen) and dihydroergotamine (Dihydergot), did not appear on the market until 1921 and 1946, respectively. Both drugs originated from Sandoz, the world’s leading pharmaceutical company in ergot alkaloid research at the time. Historically, ergot alkaloids had been primarily used in obstetrics, but with methysergide (1-methyl-lysergic acid 1′-hydroxy-butyl-(2S)-amide), it became apparent that they also held some potential in migraine treatment. Methysergide was the first effective prophylactic drug developed specifically to prevent migraine attacks in 1959. On the basis of significantly improved knowledge of migraine pathophysiology and the discovery of serotonin and its receptors, Glaxo was able to launch sumatriptan in 1992. It was the first member from the class of triptans, which are selective 5-HT1B/1D receptor agonists. Recent innovations in acute and preventive migraine therapy include lasmiditan, a selective 5-HT1F receptor agonist from Eli Lilly, the gepants, which are calcitonin gene-related peptide (CGRP) receptor antagonists discovered at Merck & Co and BMS, and anti-CGRP/receptor monoclonal antibodies from Amgen, Pfizer, Eli Lilly, and others.

Graphical abstract

Recently approved and emerging drug options for migraine prophylaxis

INTRODUCTION

: Migraine occupies the first position regarding to the disability caused in female working population (15-49 years). Research in the field of prophylaxis of this pathology has made enormous strides in recent years.

AREAS COVERED

In this narrative review we retrace the most important scientific evidence regarding recently approved and emerging drug for prophylactic treatment of migraine. The purpose of this article is in fact to evaluate currently approved or emerging pharmacological agents for migraine prophylaxis. This review is based on literature published in peer review journal obtained through PubMed, Cochrane library, Clinicaltrials.gov and US FDA.

EXPERT OPINION

: Monoclonal antibodies (mAbs) that target the calcitonin gene-related peptide signalling pathway (CGRP) have marked an innovation in prophylactic migraine therapy. The combination of Onabotulinumtoxin-A (OBTA) and mAbs appears to be an effective, but costly, therapeutic option for resistant cases. New classes of molecules like gepants and ditans seem to give exceptional results. In addition, new prophylactic drugs are emerging with several targets: the pituitary adenylate cyclase-activating polypeptide (PACAP), ion channels, several receptors coupled to G proteins, orexin, and glutamate. All these therapies will implement and improve migraine management, as well as personalized medicine for each patient.

Decreased plasma levels and dietary intake of minerals in women with migraine

It has been suggested that an imbalance in mineral levels is involved in the pathophysiology of migraine. However, only a few studies have investigated the circulating levels of mineral in patients with migraine during the pain-free period (i.e. interictal). This study aimed to investigate whether the interictal plasma levels of minerals of women with migraine differ from those of women without migraine (controls). This is a cross-sectional study involving 67 women, of which 38 were diagnosed with migraine and 29 were controls. The groups were similar in age and body mass index. Plasma levels of magnesium (Mg), copper (Cu), calcium (Ca), zinc (Zn), iron (Fe), and selenium (Se) were measured. Dietary intake was assessed using a 24-hour food recall, and migraine impact was evaluated using the Headache Impact Test, version 6 (HIT-6). The association between migraine disability, and plasma levels and dietary intake of minerals was assessed through correlation and logistic regression analyses. Women with migraine had significantly lower plasma levels of Mg, Ca, Cu, and Zn than controls. In parallel, dietary intake of Mg, Cu, and Fe was significantly lower in patients with migraine. Migraine impact was not associated with plasma levels or dietary intake of minerals. The results suggest that patients with migraine have lower plasma levels of minerals, and dietary intervention to ensure adequate mineral intake should be considered as a therapeutic strategy for migraine.

Revised guidelines of the French headache society for the diagnosis and management of migraine in adults. Part 3: Non-pharmacological treatment

The French Headache Society proposes updated French guidelines for the management of migraine. This article presents the third part of the guidelines, which is focused on the non-pharmacological treatment of migraine, including physical exercise, dietary supplements and plants, diets, neuromodulation therapies, acupuncture, behavioral interventions and mindfulness therapy, patent foramen ovale closure and surgical nerve decompression.

The quality and inflammatory index of the diet of patients with migraine

BACKGROUND

The association between diet and migraine has been reported in the literature, but only a few studies have evaluated whether the diet consumed by patients with migraine differs from individuals without migraine.

OBJECTIVE

Herein, we aimed to investigate whether the quality and the Dietary Inflammatory Index (DII) of diet consumed by migraine patients differ from that consumed by healthy controls. We also evaluated whether the severity of migraine and headache frequency were associated with these parameters.

METHODS

Patients of both sexes, aged between 18 and 65, with episodic migraine and healthy controls were enrolled in this cross-sectional study. Disability and impact caused by migraine and depressive symptoms were evaluated. Dietary intake was assessed using a 24-hour dietary recall and a three-day non-consecutive food record. The quality of the diet was calculated using the Healthy Eating Index (HEI)-2015 adapted to the Brazilian population, and DII was calculated based on the method developed by Shivappa et al. (2014).

RESULTS

Ninety patients with migraine and 62 individuals without migraine were included in this study. The groups did not differ regarding age, sex, marital status, years of schooling, anthropometric characteristics, and depressive symptoms. Patients with migraine had lower HEI total score than controls, indicating that these patients have a lower quality of the diet. Patients with migraine also had higher DII than controls. Nevertheless, HEI and DII scores did not correlate with migraine frequency and severity.

CONCLUSION

This study corroborates the view that the characteristics of the diet might be involved in migraine pathophysiology.

De novo Migraine with Aura in the Third Trimester of Pregnancy: A Case Report and Literature review

Background

Among all headache disorders, migraine has the highest prevalence during gestation. The majority of migraineurs experience improvement during pregnancy, but a few may experience migraine for the first time. This poses a diagnostic challenge in the differential diagnosis between primary and life-threatening secondary headache disorders. Because pregnancy itself is an independent risk factor for secondary headache disorders, it is mandatory to exclude these conditions in order to diagnose migraine. There is a large body of literature about pre-existing migraine course during pregnancy and its link with adverse pregnancy outcomes, but there are no studies examining these aspects among women with new-onset migraine during pregnancy.

Case report

A 31-year-old female at 33 weeks of gestation (gravida 2, para 2) was referred to the neurologist eds disturbances, which were followed by pressing severe headache, rated as 8 out of 10 on a numeric rating scale and accompanied by dizziness. The headache lasted for one day, and dizziness continued to the following day. The patient was investigated for a secondary headache disorder, but laboratory and neuroimaging results were unremarkable. A migraine with aura was diagnosed. The patient was advised to keep a consistent sleep schedule, maintain regular low physical activity, eat regularly and take magnesium supplementation. The patient was informed about a safe treatment approach in case of an acute attack. At 40 weeks of gestation the patient delivered female newborn, weighing 3750g, with Apgar scores of 8 and 9 (due to a nuchal cord). The postpartum period was uneventful. During the subsequent 4 years, the patient did not experience any recurrent migraine attacks and had no pregnancies.

Conclusion

In order to diagnose a migraine during pregnancy, exclusion of secondary headache disorders is mandatory. Pregnant migraineur should be regularly monitored for adverse birth outcomes. It is essential to educate patients, provide information about the safe treatment of migraine attacks, and explain nonpharmacological prevention and supplementation benefits.

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.

Dietary Intake of Calcium and Magnesium in Relation to Severe Headache or Migraine

Background: Migraine is a common neurological disorder and is affected by nutrients. Calcium and magnesium are essential minerals that play an important role in nerve function. So we investigated the association between dietary calcium and magnesium and migraine.

Methods: We extracted 10,798 adults from the National Health and Nutrition Examination Surveys (NHANES) of America in 1999 to 2004. We classified patients who reported having severe headache or migraine as having possible migraine. Multivariable logistic regression and restricted cubic spline regression were conducted to determine the association between dietary calcium and magnesium and migraine.

Results: We found that the adjusted ORs of the association between dietary calcium and magnesium and migraine for comparing the highest quintile intake with the lowest quintile intake were 0.77 (95% CI: 0.63–0.93, P = 0.008) and 0.69 (95% CI: 0.55–0.86, P = 0.001), respectively. For women, the adjusted ORs of dietary calcium and magnesium were 0.72 (95% CI: 0.56–0.93, P = 0.009) and 0.62 (95% CI: 0.47–0.83, P = 0.001), respectively. For men, the adjusted OR was 0.71 (95% CI: 0.52–0.97, P = 0.028) comparing the highest and the lowest quintile of calcium intake, but there was no statistically significant association between dietary magnesium intake and migraine. Joint analyses showed that the OR in the high-calcium and high-magnesium group was 0.74 (95% CI: 0.60–0.92, P = 0.006) compared with the low-calcium and low-magnesium group in women.

Conclusions: High dietary intake of calcium and magnesium, independently or in combination, were inversely associated with migraine in women. For men, high dietary calcium was negatively related to migraine, but magnesium was not associated with migraine.

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.

The efficacy of magnesium oxide and sodium valproate in prevention of migraine headache: a randomized, controlled, double-blind, crossover study

Migraine is a disabling disorder that affects the quality of life of patients. Different medications have been used in prevention of migraine headache. In this study, we evaluated the effectiveness of magnesium oxide in comparison with valproate sodium in preventing migraine headache attacks. This is a single-center, randomized, controlled, crossover trial which is double-blind, 24-week, 2-sequence, 2-period, 2-treatment. After patient randomization into two sequences, the intervention group received magnesium oxide 500 mg and the control group received valproate sodium 400 mg two tablets each day (every 12 h) for 8 weeks. The primary efficacy variable was reduction in the number of migraine attacks and number of days with moderate or severe headache and hours with headache (duration) per month in the final of 8 weeks in comparison with baseline. Seventy patients were randomized and seven dropped out, leaving 63 for analysis. In an intention-to-treat analysis, 31 patients were in group 1 (magnesium oxide-valproate) and 32 patients were in group 2 (valproate-magnesium oxide). The mean number of migraine attacks and days per month was 1.72 ± 1.18 and 2.09 ± 1.70, with a mean duration of 15.50 ± 21.80 h in magnesium group and 1.27 ± 1.27 and 2.22 ± 1.96, with a mean duration 13.38 ± 14.10 in valproate group. This study has shown that 500 mg magnesium oxide appears to be effective in migraine prophylaxis similar to valproate sodium without significant adverse effect.

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 Association Between Hospital Length of Stay and Treatment With IV Magnesium in Patients With Status Migrainosus

Status migrainosus (SM) is a subtype of migraine defined by migraine lasting >72 hours and is difficult to treat in clinical practice. Magnesium is commonly used in the treatment of migraine. We conducted a retrospective cohort study to determine if length of admission was associated with IV magnesium therapy in patients with SM. We reviewed the charts of all patients admitted to a large military treatment facility from October 2013 to December 2018 with the admission diagnosis of migraine. There were 333 patients that were reviewed and 141 met the inclusion criteria. Nearly half of patients received IV magnesium therapy with routine care (46.8%, n = 66). IV magnesium therapy was not associated with length of admission (58 hours (IQR 25.5, 86) compared to 42 hours (IQR 25.5, 80.5) respectively, p = 0.47). Of the cases without Neurology consultation, patients who received magnesium therapy (n = 5) had numerically shorter admission but this difference did not meet statistical significance (n = 12) (17 hours (IQR 13.75, 31.25) versus 24.5 hours (IQR 15.25, 58.75), p = 0.0534). This study contributes to the limited pool of available data on the treatment of SM. Prospective research is needed to study magnesium therapy in patients with prolonged migraine.

Zinc supplementation affects favorably the frequency of migraine attacks: a double-blind randomized placebo-controlled clinical trial

BACKGROUND

Observational studies have shown a link between zinc deficiency and migraine headaches. We aimed to examine the effect of zinc supplementation on the characteristics of migraine attacks in patients with migraine.

METHODS

This randomized clinical trial was conducted on 80 patients with migraine. Patients were randomly assigned to receive either zinc sulfate (220 mg/d zinc sulfate) or placebo (lactose) for 8 weeks. Anthropometric measures, serum zinc concentrations, and characteristics of migraine attacks (headache severity, frequency and duration of migraine attacks, and headache daily results) were assessed at baseline and end of the trial.

RESULTS

Compared with the placebo, zinc supplementation resulted in a significant reduction in headache severity (- 1.75 ± 1.79 vs. -0.80 ± 1.57; P = 0.01) and migraine attacks frequency (- 2.55 ± 4.32 vs. -0.42 ± 4.24; P = 0.02) in migraine patients. However, the observed reduction for headache severity became statistically non-significant when the analysis was adjusted for potential confounders and baseline values of headache severity. Other characteristics of migraine attacks including the duration of attacks and headache daily results were not altered following zinc supplementation either before or after controlling for covariates.

CONCLUSION

Zinc supplementation had a beneficial effect on the frequency of migraine attacks in migraine patients. Additional well-designed clinical trials with a long period of intervention and different dosages of zinc are required.

TRIAL REGISTRATION CODE

IRCT20121216011763N23 at www.irct.ir .

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.

Cross-trait analyses with migraine reveal widespread pleiotropy and suggest a vascular component to migraine headache

BACKGROUND

Nearly a fifth of the world's population suffer from migraine headache, yet risk factors for this disease are poorly characterized.

METHODS

To further elucidate these factors, we conducted a genetic correlation analysis using cross-trait linkage disequilibrium (LD) score regression between migraine headache and 47 traits from the UK Biobank. We then tested for possible causality between these phenotypes and migraine, using Mendelian randomization. In addition, we attempted replication of our findings in an independent genome-wide association study (GWAS) when available.

RESULTS

We report multiple phenotypes with genetic correlation (P  < 1.06 × 10-3) with migraine, including heart disease, type 2 diabetes, lipid levels, blood pressure, autoimmune and psychiatric phenotypes. In particular, we find evidence that blood pressure directly contributes to migraine and explains a previously suggested causal relationship between calcium and migraine.

CONCLUSIONS

This is the largest genetic correlation analysis of migraine headache to date, both in terms of migraine GWAS sample size and the number of phenotypes tested. We find that migraine has a shared genetic basis with a large number of traits, indicating pervasive pleiotropy at migraine-associated loci.

Is the Treatment of Constipation Can Relieve the Migraine Symptoms? A Randomized Clinical Trial Study

Background

Many patients presenting with migraine also complain of constipation. The relationship between these two symptoms has not been explored yet in detail. This study, therefore, was carried out to investigate the effect of treatment of constipation with lactulose on the improvement of migraine headache in patients who referred to neurology clinics in Arak.

Materials and Methods

A total of 50 patients with migraine were selected based on the Headache International Society (HIS) index and the Rome Foundation is an independent not for profit 501(c) 3 organization that provides support for activities designed to create scientific data and educational information to assist in the diagnosis and treatment of functional gastrointestinal disorders (FGIDs) (ROME III) scale so as to diagnose their migraine and constipation. The patients were randomly divided into an experimental group and a control group. A 15 cc daily of lactulose syrup was prescribed to the experimental group with the antimigraine drugs (10-mg nortriptyline and 10-mg propranonol daily). In contrast, only the standard treatment for migraine was prescribed for the control group. The severity of disability was assessed based on the severity of migraine-induced disability (MIDAS) questionnaire. Having collected the data, the data analysis was carried out using Statistical Package for the Social Sciences (SPSS) (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) statistical t-tests, and repeated measures test.

Results

The results of the independent sample t-test showed no significant difference between the control and intervention group's main variables of the research before the intervention (P < 0.05). On the contrary, the results of the repeated measures test indicated that the mean scores ‑of the severity of disability and the severity of migraine pain between the measurement times were significantly different for the intervention and control groups, in a way that after one and/or two months of using lactulose syrup, the severity of disability and pain in the intervention group was lower than those of the control group (P < 0.001).

Conclusion

Short-term follow-up of this study showed that lactulose syrup could remove the constipation with no significant side effects--can be used as an adjunct for the treatment of patients with migraine. However, future studies suggested for long-term consequences of constipation control.

Headache in the elderly

Headache is the most common neurologic symptom and affects nearly half the world's population at any given time. Although the prevalence declines with age, headache remains a common neurologic complaint among elderly populations. Headaches can be divided into primary and secondary causes. Primary headaches comprise about two-thirds of headaches among the elderly. They are defined by clinical criteria and are diagnosed based on symptom pattern and exclusion of secondary causes. Primary headaches include migraine, tension-type, trigeminal autonomic cephalalgias, and hypnic headache. Secondary headaches are defined by their suspected etiology. A higher index of suspicion for a secondary headache disorder is warranted in older patients with new-onset headache. They are roughly 12 times more likely to have serious underlying causes and, frequently, have different symptomatic presentations compared to younger adults. Various imaging and laboratory evaluations are indicated in the presence of any "red flag" signs or symptoms. Head CT is the procedure of choice for acute headache presentations, and brain MRI for those with chronic headache complaints. Management of headache in elderly populations can be challenging due to the presence of multiple medical comorbidities, polypharmacy, and differences in drug metabolism and clearance.

Correction of magnesium deficiency in the body with balneological means: experimental studies

In the modern world, a lack of magnesium in the body is one of the most common deficient conditions in humans. Low levels of magnesium have been associated with a number of chronic diseases. This work is devoted to the study of the effect of the use of the balneological means "Magnesium oil" for the correction of the manifestations of experimentally induced magnesium deficiency. The experiment was conducted on 50 white female rats of the Wistar auto-breeding line which were divided into 3 equal groups: (1) control, (2) model of magnesium deficiency, (3) received "Magnesium oil". As a result of modeling the state of magnesium deficiency, significant changes are observed in the central nervous system, vegetative nervous system, and kidneys of animals. The use of balneological means "Magnesium oil" can significantly reduce the negative manifestations of magnesium deficiency.

Effect of coenzyme Q10 supplementation on clinical features of migraine: a systematic review and dose-response meta-analysis of randomized controlled trials

Objective: Coenzyme Q10 is an antioxidant and an essential mitochondrial cofactor which has been suggested to improve the clinical features of migraine. Several randomized clinical trials have examined the effects of Coenzyme Q10 on migraine with inconclusive results. The aim of this systematic review and meta-analysis was to evaluate the impact of Coenzyme Q10 supplementation on the frequency, severity, and duration of migraine attacks. Methods: A systematic review of the literature was conducted using ISI Web of Science, PubMed, Cochrane library and Scopus to identify eligible studies up to April 2018. Studies included were randomized clinical trials of Coenzyme Q10 supplementation that reported the frequency, severity, or duration of migraine attacks as a primary outcome. A meta-analysis of eligible studies was performed using the fixed effects model or the random effects model to estimate pooled effect size. Results: Four randomized clinical trials with 221 participants were included. Coenzyme Q10 supplementation significantly reduced the frequency of migraine attacks (weighted mean difference: -1.87 attacks/month, 95% CI: -2.69 to -1.05, p < 0.001) without significant heterogeneity among the studies (I ² = 36.6%, p = 0.192). Coenzyme Q10 supplementation had no significant effect on severity (weighted mean difference: -2.35 visual analog scale score, 95% CI: -5.19 to 0.49, p = 0.105) and duration of migraine attacks (weighted mean difference: -6.14 h, 95% CI: -13.14 to 0.87, p = 0.086) with high heterogeneity. Conclusion: Pooled analyses of available randomized clinical trials suggest that Coenzyme Q10 supplementation may reduce the frequency of migraine attacks per month without affecting the severity or duration of migraine attacks.

Experiences of an outpatient infusion center with intravenous magnesium therapy for status migrainosus

OBJECTIVES

Exploratory study to investigate the effectiveness of intravenous magnesium as an abortive for status migrainosus in an outpatient infusion center, and characterize the patients who benefit from the therapy.

PATIENTS & METHODS

Retrospective analysis of 234 migraine patients who received IV magnesium as a headache abortive, at the headache clinic of University of Southern California. Additional intramuscular (IM) injections for nausea (prochlorperazine, odansetron, metoclopramide) or for refractory pain (ketorolac, dexamethasone, sumatriptan, dihydroergotamine), were administered as necessary. Immediately before and after treatment, self-reported pain levels were recorded using an 11-point numeric pain rating scale (0-10).

RESULTS

Our patient sample has a mean age of 44 years and was predominantly female (79%). 36 (19%) had migraine with aura. Overall, pain score decreased from 5.46±2.39 to 3.56 ± 2.75 (P < 0.001) after magnesium infusion. One hundred twenty-seven (54%) patients had clinically significant pain reduction, as defined by pain decrease ≥ 30%. One hundred and four patients (44%) received IV magnesium and did not require additional intramuscular (IM) medications for pain. In patients who did not receive additional IM medications for pain, pain score decreased from 4.76 ± 2.41 to 2.95 ± 2.70 (p < 0.001), and 61 out of 104 (59%) experienced ≥ 30% pain reduction. Patients with less severe pain tended to have a better response than patients with more severe pain, as patients with ≥30% pain reduction had a significantly lower pre-treatment pain score (p = 0.018).

CONCLUSION

For a subset of patients with status migrainosus, IV magnesium therapy results in clinically significant pain relief without the need for intramuscular pain medications. Therefore, IV magnesium may be useful as a cost-effective first-line parental therapy for status migrainosus, especially for patients who initially present with lower pain intensity.

Unique Populations with Episodic Migraine: Pregnant and Lactating Women

PURPOSE OF REVIEW

Migraine is a disabling and prevalent neurological disease, commonly affecting women during their reproductive years. It is crucial for providers to be able to adequately counsel women who are pregnant, planning pregnancy, or nursing, regarding preventive and abortive treatment options for episodic migraine. This review will discuss (1) the expected course of migraine during pregnancy and the post-partum period, (2) recommended preventive therapies for migraine during pregnancy and lactation, and (3) recommended abortive medications for migraine during pregnancy and lactation.

RECENT FINDINGS

Recent research has indicated safety for triptan use during pregnancy and ibuprofen use during the first trimester of pregnancy. Considerations for use of emerging migraine-preventive treatment, such as non-invasive neurostimulators, are discussed. For clinical decision-making and patient counseling, it is important to understand both the limitations in determining teratogenic effects in humans and the principles affecting medication transmission from mother to breast milk.

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.

Usefulness of nutraceuticals in migraine prophylaxis

Several studies have supported the efficacy of complementary and alternative medicine approaches (physical, behavioral and nutraceutical therapies) in the treatment of headache disorders. Nutraceutical treatment consists of taking vitamins, supplements (magnesium, riboflavin, coenzyme Q10, and alpha lipoic acid) and herbal preparations (feverfew and butterbur), and its usage is frequently determined by dissatisfaction with conventional medical therapies. There is a growing body of research on nutraceutical use for migraine prophylaxis. This brief overview provides information about the potential efficacy and side effects of various nutraceutical products summarizing randomized controlled trials of some of the most commonly used non-pharmacological treatments for the prophylaxis and treatment of migraine, including magnesium, coenzyme Q10, riboflavin (vitamin B₂), petasites, and feverfew.

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.

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.

Magnesium in pregnancy

Magnesium deficiency is prevalent in women of childbearing age in both developing and developed countries. The need for magnesium increases during pregnancy, and the majority of pregnant women likely do not meet this increased need. Magnesium deficiency or insufficiency during pregnancy may pose a health risk for both the mother and the newborn, with implications that may extend into adulthood of the offspring. The measurement of serum magnesium is the most widely used method for determining magnesium levels, but it has significant limitations that have both hindered the assessment of deficiency and affected the reliability of studies in pregnant women. Thus far, limited studies have suggested links between magnesium inadequacy and certain conditions in pregnancy associated with high mortality and morbidity, such as gestational diabetes, preterm labor, preeclampsia, and small for gestational age or intrauterine growth restriction. This review provides recommendations for further study and improved testing using measurement of red cell magnesium. Pregnant women should be counseled to increase their intake of magnesium-rich foods such as nuts, seeds, beans, and leafy greens and/or to supplement with magnesium at a safe level.

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.