1. The Migraine Headache An Integrative Approach Rick McKinneyOctober 2012

2. The Integrative Menu Lifestyle Nutritional Supplement/Botanical Mind-Body Manual Medicine Other systems – TCM/Acupuncture – Ayurvedic

3. Lifestyle measures Regular Exercise Keeping HYDRATED! Food Triggers? SLEEPING Regular Hours Regular Mealtimes Relaxation Practice

4. Nutritional Recognition & avoidance of dietary triggers by: – Observation – Oligoantigenic Diets – Elimination Diet with rechallenge Increase helpful nutrients – Mg - Nuts,red meat, legumes, green leafy vegetables, whole grain cereals, seafood. – Riboflavin - milk, eggs, meats, yogurt, broccoli, almonds, cheese, soy, fortified grains, and dark green vegetables

5. SUPPLEMENTS: Where’s the evidence?

6. High for Efficacy Low for safety High for Efficacy High for Safety Low for Efficacy Low for Safety Low Efficacy High Safety Weighing the Evidence

7. High for Efficacy Low for safety High for Efficacy High for Safety Low for Efficacy Low for Safety Low Efficacy High Safety Weighing the Evidence

8. Other issues about supplements Cost – Huge for our patients Any of these agents can be purchased for $1 to $6/month from Vitacost.com, or for $3 to $12/month if bought retail. Sources –a health food store with knowledgable staff. In SF: Rainbow Grocery, Folsom and 13 th, the edge of the Mission. Scarlet Sage, Valencia @ 23 rd. SF Herb Co, for loose herbs only, 14 th St @ Van Ness Pharmaca,Cole and Carl, very near Parnassus. Quality – huge variation Quality is largely reflected in cost. Chain drug stores accept lower quality to hold prices down, but may be all our patients can afford. Best to advise about specific brands, after checking quality at consumerlab.com Favorite lower cost brands are: Gaia Herbs - $$, v high quality Nature Made - $, high quality Rainbow Light - $, good quality Jarrow - $$, v high quality

9. Mg Magnesium often deficient in migraneurs, esp with menstrual migraines seen principally in intracellular concentration multiple CNS, vascular, & neuromuscular effects Study results are mixed, from 41% vs 15% response rate to no benefit after 3 mo, p < 0.05%. Usual dose studied is 600 mg/day. If renal function is not seriously impaired side effects are limited to loose stools / diarrhea. Anecdotally, Mg rocks! ________________________________ Peikert A, et al. Prophylaxis of migraine with oral magnesium: results from a prospective, multicentre, placebo-controlled and DBRS. Cephalalgia. 1996;16:257-63. Köseoglu E, Talaslioglu A, Gönül AS, Kula M. The effects ofmagnesium prophylaxis in migraine without aura. Magnes Res. 2008 Jun;21(2):101-8.

10. B2 Riboflavin 400 mg/day most studied; 42% reduction of headache frequency >50% at 3 months, p = 0.002; NNT = 2.3; 35% decrease in use of rescue meds. lower dosage? - 42 vs 44% response rate of Migralief vs. Riboflavin 25 mg control, but other studies differ. I start with 100 mg most often, combined with Mg. _____________________ Schoenen J, Jacquy J, Lenaerts M. Effectiveness of high dose riboflavin in migraine prophylaxis. Neurology 1998;50:466–70. Boehnke C, Reuter U, Flach U, et al. High-dose riboflavin treatment is efficacious in migraine prophylaxis... Eur J Neurol. 2004 Jul;11(7):475-7. Maizels M, Blumenfeld A, Burchette R. A combination of riboflavin, mag-nesium, and feverfew for migraine prophylaxis. Headache 2004;44:885– 890.Eur J Neurol.

11. CoQ10 CoQ-10 Ubiquinone 47% pts with >50% Sx reduction @ 4 months (14% placebo rate) p = 0.02. 100 mg tid most studied dosage 150 mg/day → 61% response at 3 months; but no placebo arm, n=32, p = 0.0001. ___________________ Sandor, P, et al. Efficacy of coenzyme Q10 in migraine prophylaxis: a randomized controlled trial. Neurology. 2005 Feb 22;64(4):713-5. Rozen TD, et al. Open label trial of coenzyme Q10 as a migraine preventative, Cephalalgia. 2002;22:137-41Neurology.

12. Feverfew - tanacetum parthenium MIG-99, a new CO2 extract, is best studied 6.25 mg tid → HAs/ mo ↓ from 4.5 to 3.0 (Δ 0.3 for placebo), p = 0.045. Less well studied than other agents discussed, withdrawal sx possible, and CO2 extract not now available in USA. ___________________ S. Holland, et al, Evidence Based Guideline update Neurology 2012;78;1346 Diener HC, Pfaffenrath V, Schnitker J, et al. Efficacy and safety of 6.25 mg t.i.d. feverfew CO2-extract (MIG-99) in migraine prevention“ a randomized, double-blind, multicentre, placebo-controlled study. Cephalalgia. 2005;25:1031-41.

13. Butterbur – Petasites 75 mg bid →48% reduction in attacks after 12 weeks. 50 mg bid → 36% reduction, with less burping. Placebo bid → 26% reduction, p = 0.0012 & 0.127. 50 mg bid → >50% reduction in 45% of pts (15% placebo) p = 0.011. ___________________ S. Holland, et al, Evidence Based Guideline update Neurology 2012;78;1346 Lipton RB, et al. Petasites hybridus root (butterbur) is an effective preventive treatment for migraine. Neurology 2004;63:2240–2244. HC Diener, et al, Placebo-Controlled Trial of Butterbur Root Extract for the Prevention of Migraine: Reanalysis of Efficacy Criteria. Eur Neurol 2004;51:89–97

14. Can he learn new tricks?

15. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society S. Holland, PhD, S.D. Silberstein, MD, FACP, F. Freitag, DO, D.W. Dodick, MD, C. Argoff, MD and E. Ashman, MD S. HollandS.D. SilbersteinF. FreitagD.W. DodickC. ArgoffE. Ashman Neurology April 24, 2012 vol. 78 no. 17 1346-1353 He can if his name is “the AAN”

16. AAN and AHS conclusions: ABSTRACT Objective: To provide updated evidence-based recommendations for the preventive treatment of migraine headache. The clinical question addressed was: Are nonsteroidal anti-inflammatory drugs (NSAIDs) or other complementary treatments effective for migraine prevention? Methods: The authors analyzed published studies from June 1999 to May 2009 using a structured review process to classify the evidence relative to the efficacy of various medications for migraine prevention. Results: The author panel reviewed 284 abstracts, which ultimately yielded 49 Class I or Class II articles on migraine prevention; of these 49, 15 were classified as involving nontraditional therapies, NSAIDs, and other complementary therapies that are reviewed herein. Recommendations: Petasites (butterbur) is effective for migraine prevention and should be offered to patients with migraine to reduce the frequency and severity of migraine attacks (Level A). Fenoprofen, ibuprofen, ketoprofen, naproxen, naproxen sodium, MIG-99 (feverfew), magnesium, riboflavin, and subcutaneous histamine are probably effective for migraine prevention (Level B). Treatments considered possibly effective are cyproheptadine, Co-Q10, estrogen, mefenamic acid, and flurbiprofen (Level C). Data are conflicting or inadequate to support or refute use of aspirin, indomethacin, omega-3, or hyperbaric oxygen for migraine prevention. Montelukast is established as probably ineffective for migraine prevention (Level B). Neurology April 24, 2012vol. 78 no. 17 1346-1353

17. Other CAM Modalities Acupuncture - Cochrane review, 2009:... consistent evidence that acupuncture provides additional benefit to treatment of acute migraine attacks... Available studies suggest that acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects. Acupuncture should be considered a treatment option for patients willing to undergo this treatment. 22 trials, > 4400 pts. Single trial with long term f/u showed no loss of effect at 9 months. Relaxation Training - Long hx of trials demonstrating effectiveness. 35 - 50 decrease in HAs, >50% if combined with thermal biofeedback; greater yet with blood volume pulse monitoring and home program. _______________________________ Cochrane Database Syst Rev. 2009 January 21; (1): CD001218. Nestoriuc, Yvonne; Martin, Alexandra (2007). "Efficacy of biofeedback for migraine: A meta- analysis". Pain 128 (1–2): 111–27 Penzien PB et al Behavioral management of recurrent HA. Appl Psychophysiol Biofeedback 2002;27:163-81 Astin, JA Mind body therapies for management of pain. Clin J Pain, 2004;20:27-32

18. Additional resources S Holland et al. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults - Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society Neurology April 24, 2012 vol. 78 no. 17 1346-1353 Detailed review of the evidence for effectiveness and safety of alternative agents. T Pringsheim et al. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci. 2012 Mar;39(2 Suppl 2):S1-59.Can J Neurol Sci. Detailed review of all approaches to migraine prophylaxis with discussions of selections for different patient groups. Long but divided into eight sections, so fairly easy to find the data you are seeking. ORGANIZED FOR THE CLNICIAN!