Migraine Treatment Landscape and the Role of the Pharmacist - Episode 7

OTC Products for Migraine Prevention

Factors that need to be considered when determining patient candidacy for over-the-counter herbal products and nutritional supplements available as preventive therapy for migraine and recommendations for educating patients about their use.

Mark Percifield, PharmD: Thank you. Amy, if I could ask you again—are there any over-the-counter herbal products or nutritional supplements that can be used in preventive migraine treatment?

Amy R. Dunleavy, PharmD: We have a number of over-the-counter items that can be used for migraine prevention. When we look at more of those herbal things, we’re looking at things called butterbur or feverfew, which have some evidence saying they could be helpful but do have things that we want to be cautious of. With butterbur, we do want to pay close attention to liver function of the individual using it. It can cause those liver enzymes to increase and can become toxic if used inappropriately. In 2012, it had been something frequently recommended, but as we’ve learned more about it, there are some more reservations about its use. Really, if someone comes to you asking about it, we need to be evaluating the appropriateness for that individual and finding out if they have liver impairment or can be monitored. Those are things you’d want to ask before starting on it.

Some of the vitamins and over-the-counter medicines that we see more frequently used in migraine prevention are things like riboflavin or vitamin B2. We tend to find those used in combination, and most studies have seen it used in combination with magnesium and then feverfew. We find that at a dose of about 400 mg. It’s superior to a placebo in reducing the attack frequency and number of headache days an individual experiences within a month. With magnesium, we tend to see it used to some possible benefit; that dosing is about 600 mg a day. We find that individuals who maybe have a bit of a magnesium deficiency may experience more migraines, so supplementing that magnesium can be beneficial for some individuals. The last thing is that coenzyme Q10. That’s where the most studies have focused, especially on children and adolescents experiencing migraines. They tended to find that individuals who were using about 150 mg of that daily were having earlier improvement in the headache severity than the placebo. But as for long term use, we didn’t see a lot of difference in headache outcome. We’re still a little questionable about its use long term and how it’s affecting headache, but it’s an option for an individual seeking over-the-counter herbal or vitamin supplements.

Mark Percifield, PharmD: That’s great to hear, that there are some options available to patients over the counter. It’s very good to be educated because they want to try anything to get relief, right?

Amy R. Dunleavy, PharmD: Yes. These individuals are people with whom you’re going to want to have that conversation. What are their migraines looking like? Have they tried anything else? Have they been evaluated? You’re really determining the appropriateness for the individual, which is important before making a solid recommendation on these over-the-counter products.

Transcripts edited for clarity.