Findings Fortify Low Riboflavin, Migraine Link

Damian McNamara

July 30, 2019

PHILADELPHIA — Riboflavin supplementation may decrease headache severity in patients with migraine who are deficient in vitamin B2 and other micronutrients, new research suggests.

In a small study, all participants experienced a 50% or greater reduction in both headache severity and frequency following nutritional supplementation.

In addition, a majority of the patients were migraine-free 2 years post treatment.

"Nutritional deficiencies could play an integral role in migraine," investigator Madhureeta Achari, MD, a neurologist in the Department of Physical Medicine and Rehabilitation, the University of Texas Medical School, Houston, told Medscape Medical News.

She added that in her experience in clinical practice, "I'm surprised how many micronutrient deficiencies I see."

The findings were presented here at the American Headache Society (AHS) Annual Meeting 2019.

Nutritional Neurology

"Previous research showed a link between riboflavin and migraine," said study coauthor César Escamilla-Ocanas, MD, Section of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, Houston.

In a prior trial, 59% of people with migraine who were randomly assigned to receive high-dose riboflavin for 3 months experienced at least 50% fewer headache days compared with 15% of those who received placebo.

In this and other clinical trials, 200-mg to 400-mg supplementation with riboflavin appeared effective in reducing both migraine frequency and severity. However, researchers did not assess vitamin B2 levels at study entry.

"It's important to look at baseline levels. This is a very data driven, not survey driven, study," Escamilla-Ocanas said.

In the current case series, the researchers assessed 42 patients (84% women; mean age, 35.5 years) with migraine whose serum riboflavin levels were in the deficient range. The cohort included patients who experienced migraine with aura and those who had migraine without aura, as well as other patients with chronic migraine.

The investigators provided supplements to increase serum riboflavin to a high level. They monitored complete vitamin and micronutrient levels through serial laboratory measurements over 2 years.

"I practice 'nutritional neurology' by doing blood levels of micronutrients," Achari said.

The researchers also assessed CoQ10, zinc, and vitamin C levels, but in the study presented at the AHS conference, their focus was on riboflavin levels.

"Inexpensive, Easy to Implement"

In total, 35 of the 42 participants did well on nutritional therapy alone, Achari noted. The remaining seven required additional prophylactic medications to treat their migraines.

Rescue medications were allowed, including over-the-counter treatments and triptans.

Results showed that the number of migraine days per month was reduced from an average of 14.4 at baseline to 3.4 after riboflavin treatment. In addition, 81% of the participants were migraine free at 2 years.

The findings suggest that a subset of patients with migraine could benefit from supplementation, Achari said.

"This could work for many people with migraine," she added. "Riboflavin is important for cellular function and influences the mitochondria of the cell."

Nutritional supplementation is inexpensive, easy to implement, and is well tolerated by people with migraine, she said.

Asked if the level of riboflavin is the only factor involved, Achari answered, "We don't know that. There could be other confounders."

"We are hoping this study leads to more research," Escamilla-Ocanas added.

Gives Reason for Benefits?

Commenting for Medscape Medical News, Huma Sheikh, MD, a neurologist who specializes in headache medicine and who is assistant clinical professor of neurology at Mount Sinai Beth Israel, New York City, noted that the study findings were particularly striking.

"This is interesting because it may be able to provide a reason that B2 supplementation is sometimes helpful in migraine and works as a migraine preventive," said Sheik, who was not involved with the research.

She pointed out that an advantage of vitamin B2 is that it is water soluble, so "extra is usually excreted out.

"It is also rare to have a vitamin B2 deficiency, since it is found in many common foods, but still, this is an interesting finding," added Sheikh, who is also co-chair of the special interest section on migraine and vascular disease at the AHS and is a member of the AHS committee to develop guidelines for vascular issues and headache.

Achari, Escamilla-Ocanas, and Sheikh have disclosed no relevant financial relationships.

American Headache Society (AHS) Annual Meeting 2019: Abstract P42. Presented July 12, 2019.

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