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Timothy C. Hain, MD, Chicago
IL. 
Page last modified:
January 5, 2008
Introduction:
There are an immense number of procedures, nostrums, activities that may modify migraine. Although there are presently widely available and very effective (in general) conventional medications for migraine, the best of these are prohibitively priced (the triptans), with each pill in the US commonly costing $50 ! Accordingly, there is great interest in alternative, cheaper approaches.
This page contains Dr. Hain's unabashed recommendations on these alternative approaches. Also see -- at the bottom of this page, a list of medications that are simply of uncertain use.
Acupuncture: Neutral recommendation. Works in about 40% of headaches, for uncertain reasons. Usually must be repeated on a weekly basis.
Avoidance of drugs: Certain medications and recreational drugs cause headaches. For example, many cold capsules increase blood pressure. Alcohol commonly causes headache. Caffeine can be a problem (see end of this section). Read the PDR or ask your doctor. Avoidance is highly recommended.
Biofeedback: Used for headaches with a tension component. Not worth the expense.
Chiropractic treatment: Not recommended because manipulation of the neck bones may lead to stroke. Nevertheless, some patients report successful reduction in migraines through chiropractic.
Coenzyme-Q. This vitamin (100 mg three times/day) was compared in a randomized double-blind trial and found to be well tolerated for reducing attack frequency, headache-days, and days with nausea. (Standor et al, 2005). The effect was strongest for attack frequency and nausea days. Placebo
Diet: Highly recommended. Foods may provoke migraine, and your doctor may advise a trial of selected food withdrawal. See list of foods which may provoke migraine.
Drugs available in foreign countries. Flunarizine, a calcium channel blocker, is used extensively for migraine in Europe. It can be obtained legally through the mail, with an appropriate prescription. The usual dose is 5-15 mg daily. However, it seems unlikely that it is much better than drugs available in the US (Verapamil instead of Flunarizine).
Heat or Cold: Recommended. Some headaches, such as tension and sometimes sinus, benefit from heat to the head, such as from a hot shower. Others, usually including Migraine, get worse with heat but may respond to cold packs. Might be worth a cautious try. Don't burn yourself !
Herbal Medicines: Unsure. All herbals are categorized by the FDA as having insufficient data to ensure safety and efficacy.
Butterbur. While there were several papers published indicating that butterbur is useful in migraine, allergy and migraine associated vertigo, we don't find it effective.
Caffeine-containing herbs. Used for migraine to cause vasoconstriction. We see no point in using a herbal preparation for this purpose when there are better standardized preparations. Not recommendedFeverfew (Tanacetum parthenium, Chrysanthemum parthenium) is advocated to prevent migraine. We don't think that this drug is worth the risk. It contains Parthenolide, a plant-related chemical. Legally, feverfew is a dietary supplement, because it was "grandfathered" into the US regulatory system. Average daily dose is 125 mg of dried leaves. Mouth ulceration occurs in roughly 10% of users of the leaf. This is attributed to contact dermatitis. Feverfew is also available as a capsule, which should not have this problem. Feverfew prolongs the bleeding time. Feverfew interacts with both the NSAIDS and steroids and patients on anticoagulants must be monitored closely. Contraindications include pregnancy and breast feeding. There is no information about the risks of long term use.
Salix alba (White willow bark) is used to treat mild headache. Similar to aspirin in side effects . It is estimated that 1-5 Liters of white willow bark tea must be consumed daily to achieve therapeutic effects (in other words, it isn't very potent). Large amounts of intake has been associated with liver toxicity. Not recommended.
St. Johns wort (Hypericum perforatum). Used mainly as an antidepressant but a common component of herbal headache preparations. May interact with SSRI's, meperidine, dextromethorphan, tyramine-containing foods, sympathomimetic amines and trazodone. Can cause photodermatitis, orthostatic hypotension and serotonin syndrome. We don't see why someone would take this drug instead of (say) fluoxetine.
Lavender (lavandula angustifolia) used as extract, absorbed through the skin. Evening primrose oil (Oenothera biennis) also anecdotal evidence that it alleviates headache. Placebo
Magnesium is a dietary supplements that are reported to reduce migraine. Magnesium is usually taken as a combination calcium/magnesium supplement. Not sure
Homeopathic: Homeopathy in the strict sense, using very tiny amounts of herbal substances, is a placebo. There is nothing wrong with placebo treatment, and if it works -- great !
Massage: Recommended. Especially useful for tension headache. Massage of the temples may be helpful. However, we advise against compression of the arteries in the neck, as this may be dangerous !
Oxygen (10 min, about 7 L/m). This is not really an alternative treatment -- it is a conventional though little used approach for a migraine variant -- cluster headache. Recommended for cluster headache.
Physical Therapy for neck pain and headaches : Recommended after medical clearance (basically a reviewed neck X-ray). Useful for headaches due to arthritis in the neck. Not recommended if there is significant disk disease or unstable neck.
Relaxation and sleep: Highly recommended. Migraines are typically triggered by stress, and relieved by sleep. Oversleep may also trigger migraine. Stimulants (like caffeine) help headache in the short term, but may increase headache in the long term by disturbing sleep. Relaxation techniques and careful assessment of sleeping habits is highly recommended. Relaxation techniques such as used in TM are often helpful.
Riboflavin (vitamin B2). It has been reported that riboflavin taken in a dose of 400 mg/day was effective in improving migraine by at least 50% in 59% of 55 patients with predominantly common migraine (Schoenen et al, 1998). The therapeutic "gain" over placebo was 37% for attack frequency. Adverse effects were rare. This is an extremely high dose, 200 times higher than the RDA. While generally thought to be safe, this safety of this particular dose has not been well established. At this writing (2007), Riboflavin is rarely used for treatment of migraine, so this approach probably doesn't work. Not sure
Botulinum toxin injection (BT, Botox). Injections of this medication that paralyzes muscles and removes wrinkles have been used to treat migraine. The injections are made into the neck muscles, muscles in the temples, or forehead. Surprisingly, it seems to reduce headache frequency and also vomiting. The mechanism is unclear and perhaps completely due to placebo effect or some other factor (often wrinkles are treated at the same time). Most studies to date are "open label" design, meaning that a placebo effect could easily be present. As people usually develop antibodies to botulinum toxin, it seems likely the this treatment will not afford permanent relief. Botox is also very expensive and not FDA approved for headache treatment. However, it seems worth a try as a last resort.
Bromocriptine. This dopamine agonist (i.e. agent that might be used to treat Parkinson's disease) was reported effective in reducing the frequency of menstrual migraine attacks when given daily (Herzog, 1997). This medication is not commonly used for this purpose, and in fact, the logic here is opposite of that below (see dopamine blockers). Not recommended.
Dopamine blockers: Haloperidol (Haldol), Prochlorperazine (Compazine), Domperidone, Chlorpromazine, Flunarizine, Metoclopramide have all been reported helpful for migraine (See Perotka article in reference list). These drugs would seem far more likely than many of the others above to produce significant side-effects. They are not used frequently.Recommended only in refractory situations.
Helicobacter Pylori eradication. It has been reported that eradication of this bacteria from the stomach will improve 20% of Migraine sufferers who test positive for Helicobacter (Gasbarrini et al, 1998). Whether this will be borne out is unclear. We are very dubious.
(c) 2002-2007 Timothy C. Hain, MD, all rights reserved
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