"Natural" or Alternative Medications for Migraine Prevention

Randolph W. Evans, MD; Frederick R. Taylor, MD

Disclosures

Headache. 2006;46(6):1012-1018. 

In This Article

Expert Opinion

This is a patient frequently encountered in clinical headache practice. Her interest in prevention should be honored with an adequate response, regardless of the number of days of headache she is experiencing or associated disability. Given the general interest in this area and the fact that complementary and alternative medicine (CAM) is often perceived by the public to be more helpful than conventional care for the treatment of headache and neck and back conditions, CAM for headache prevention should be considered early in care.[1,2] According to Rossi et al, physicians should be aware of patient-driven interests in CAM so as to prevent misuse of healthcare resources and to be better equipped to meet patients' needs.[1] Approximately 25% of modern prescription drugs are plant-derived, but rarely have "herbal remedies" undergone the same scientific scrutiny devoted to conventional drugs; Petadolex, a notable exception, may be approaching the conventional standard for drug investigation. Despite the unknowns regarding safety and the lack of proven efficacy, however, a myriad of such remedies are used.

Many migraineurs suffer significant functional disability, and individuals with episodic migraine are at risk for possible progression to chronic headache. Scher et al report that progression to greater than 15 headache days per month occurs at a rate of 3% per year, with an additional 6% progressing to more than 2 days per week.[3] Aggravating migraine's natural drift toward chronicity is the overuse of symptomatic medication(s). This increasing pervasiveness may have a rather grim biological basis and implications. Kruit et al have reported brain MRI findings consistent with stroke in a surprisingly high proportion of individuals with more severe forms of migraine; and Rome hypothesizes that inadequately treated migraine may lead to "limbically" augmented pain (affective distress/stress) creating daily headache.[4,5,6,7] John Edmeads speaks of the imperative need to keep the frequency and disability of attacks down and emphasizes the need to initiate "pre-emptive" prophylaxis when attack frequency increases (even if the increase is less than dramatic) when the requirement for "acute medications" increases (even if medication overuse per se is not yet evident), and in anticipation of situations or provoking factors known to increase frequency of attack (eg, stress) (personal communication).

For preemptive prophylactic therapy, CAM is not only a viable option, but should be a major consideration. Patients often balk at the use of daily drugs due to the perception such treatment may frequently cause side-effects. So, why not a "natural" agent, mineral, vitamin, or bodily substance? The modern equivalent to the "wild, wild, west" (ie, the Internet) informs us that petasites "reduces inflammation and spasms in blood vessel walls," that coenzyme Q10 (CoQ10) enhances energy through "sparking" energy production within cells, and that melatonin is a natural brain (pineal gland) secretion that is found in lower levels in migraineurs. The Internet, however, fails to inform our patients that these CAM therapies are not as strictly regulated by the Food and Drug Administration of the United States as are prescription therapies and devices; they are classified as dietary supplements and not drugs. Interestingly, this is not true for Canada, where the Health Protection Branch of Health Canada regulates herbal medications, and herbals such as brand Petadolex, a petasites extract, is regulated by the German Health Authority's Commission E.

Also of concern is the lack of industry standardization as regards the contents and purity of herbals, along with batch-to-batch consistency.[8] For example, to determine the actual parthenolide content and appropriate dosage of feverfew in OTC products currently available is a daunting proposition. Finally, one should recall that the total number of subjects involved in studies evaluating "herbals" for headache treatment typically is small. Thus, the admonition: "consumers beware."

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