Timothy C. Hain, MD, Chicago IL. Page last modified: February 25, 2013
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, as well as "nutritional supplements for migraine".
Acupuncture: Positive recommendation. Works in about 40% of headaches, for uncertain reasons. Usually must be repeated on a weekly basis. (Schiapparelli, Allais et al. 2011). Can be expensive as insurance usually doesn't cover.
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. Overall, seems worth a try. However, we have not been very impressed in our large headache practice, as patients usually try it for a month and then stop. Also see (Schiapparelli, Allais et al. 2010)
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 and dopamine 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. There is an immense literature about Flunarizine, and it seems pretty clear that it is effective. The calcium channel effect is probably not the important one -- dopamine blocking is probably the reason it works.
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 at all in our patients. This differs from recommendations of those who generally favor alternative medication, e.g (Schiapparelli, Allais et al. 2010; Holland et al, 2012). We think no harm, but also no real benefit. It appears to us that the studies of this drug were mainly funded by the drug maker. Placebo.
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 recommended
Feverfew (Tanacetum parthenium, Chrysanthemum parthenium) is advocated to prevent migraine. We are currently not sure. 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. Feverfew was not found effective in a Cochrane review (Schiapparelli, Allais et al. 2010).
On the other hand, the purified feverfew seems to have less side effects, and a recent review suggested that it might be effective (Holland et al, 2012). We think the jury is still out and are dubious that it works. None of our patients here in Chicago have come back and told us that it works.
Histamine (subcutaneous). Bizarrely enough, this treatment was reported as "probably effective" for migraine by Holland et al (2012), who authored an "evidence based review" . We are very dubious that a substance that breaks down in 5 minutes could modify migraine. Placebo
Ketamine nasal spray. Afridi et al (2013) recently reported that intransal ketamine reduces aura severity in patients with prolonged aura. As Ketamine is an animal tranquilizer, similar to the drug PCP, and half of the recipients reported feelings of "unreality, euphoria or mild giddiness", it would seem that doses sufficient to reduce migraine are also accompanied by some interesting side effects. Dangerous
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. We often recommend magnesium for migraine headache in our practice in Chicago Illinois, generally in the form of a combination calcium/magnesium supplement, as is available over the counter. We suggest 500 mg/day. (Holland et al. 2012). We often have patients report that it helps.
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.
Homeopathic: Homeopathy in the strict sense, using very tiny amounts of herbal substances, is certainly 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. Others suggest that it works too (Schiapparelli, Allais et al. 2010)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. Overall, the ordinary dose may be worth a try. We have not had ANY patients improve from this. We think it is a placebo.
TENS -- transcutaneous nerve stimulation. Again, a conventional treatment of very limited practicality. Similar in effectiveness to acupuncture, and Botox, a "supraorbital transcutaneous stimulator" has been reported to be modestly effective for migraine prevention (Schoenen et al, 2013). We are dubious that most migraine patients will accept wearing a stimulator, even though TENS units are available at much lower cost than Botox or acupuncture.
Botulinum toxin injection (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 reduces 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 insurance companies make it extremely difficult to obtain. However, it seems worth a try as a last resort.
The procedure is to make about 50 injections of a small amount of drug (typically 0.1 cc). The injections are just under the skin, in the forehead, temple and posterior neck muscles. Side effects are minimal -- sometimes some flattening of the skin around the site of injection (as is seen with wrinkles). Typical "up front" cost, per injection series, is $1500. The procedure is classified under "chemodenervation", 64612 or 64613. See this page, Botox, for our ongoing experience with this method.
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.
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