Migraines are debilitating and can be challenging to prevent and manage. Many people with migraines and their providers are frustrated by a deficiency in scientific understanding of migraine mechanisms and why patients respond to treatment in such varying ways. This article discusses an inexpensive, readily available option for migraine management. Studies show that high-dose riboflavin can reduce migraines by nearly 50 percent in at least half of patients.1-4
Burden of Migraines
Migraines affect approximately 11 percent of the populations in North America and Europe.5 Due to the prevalence and incapacitating features of migraine, the World Health Organization (WHO) considers the global burden of migraine substantial.5,6 U.S. employers lose $13 billion in productivity annually due to migraines.7
Migraines are categorized into two major types: migraine with aura and migraine without aura. The most common type is migraine without aura. The frequency of migraines is variable and can range from once a year to multiple times a week. The most common frequency is monthly.5
Although migraines are burdensome, the affected population is generally underestimated and undertreated. Many people with migraines are self-diagnosed and only use over-the-counter treatments.5 In addition, only half of people with the proper diagnosis of migraine receive prescription medications.6
The nurse practitioner's role in the management of migraine encompasses assessment, education and acute and preventive treatments. Preventive treatments are often initiated or considered after acute treatments fail and when attacks are debilitating and frequent. But the proper time to consider preventive treatment is before migraines adversely affect quality of life. Prevention should be a focus as soon as migraine is identified.
Migraine Mechanisms and Riboflavin
Just as there is variability in the frequency and severity of migraines, there appears to be variability in causes. Migraines are most often driven by genetics and hormones.5
The most common triggers of migraines are missed meals, alcohol consumption, caffeine use and menstruation. Triggers cause an enhanced sensitivity in the nervous system.8 The American Academy of Neurology (AAN) additionally associates migraine attacks with activation of the trigeminal-vascular system.8 Another identified mechanism of migraine is a deficit of mitochondrial energy reserves.1,3 Riboflavin (vitamin B2) influences mitochondrial dysfunction, thus preventing migraine.2-4
Riboflavin as Prophylaxis
Riboflavin can improve the condition of patients with mitochondrial impairment.4 A pilot study in 1998 documented a 68 percent decrease in the frequency of migraine attacks among patients who took 400 mg riboflavin daily. This study, which was the first to examine the effects of riboflavin on migraine, produced such significant symptom improvement that researchers stopped the pilot research and initiated a randomized, controlled, double-blind trial.1 In this published study, attack frequency decreased after just 1 month of daily use, and after 3 months of use, 59 percent of patients reported a 50 percent or more reduction in the frequency of migraines.1 The study used beta carotene in the placebo to imitate the discoloration of urine that occurs with riboflavin and other B vitamins.
Other studies of riboflavin followed, but the more recent studies have not been as rigorously controlled. A 2004 open study of 400 mg riboflavin for migraine prophylaxis was not placebo controlled.2 Still, the results were consistent with the initial study.1,2 In this trial, the 400-mg treatment group demonstrated a significant reduction in migraine occurrence - a decrease from a median of four migraines per month to two per month after 3 months of treatment.2 The study also documented a decrease in the use of abortive medications.2 It did not, however, document a decrease in migraine intensity.2
Another study compared the prophylactic powers of riboflavin with beta blockers.3 This study sought to examine auditory evoked cortical potentials in people affected by migraines. The researchers also compared patient symptoms before and after prophylactic treatment with a beta blocker (metoprolol or bisoprolol) or 400 mg riboflavin.3 Both groups reported a significant reduction in migraine frequency.3 Approximately half the participants in each group had a 50 percent or greater reduction in headache frequency (55 percent of beta blocker recipients and 53 percent of riboflavin recipients).3 This study was not placebo controlled, but the authors did provide pre- and post-treatment evaluations.3