Headache Prevention Protocol: A Resource for Practitioners


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by Fullscript’s Integrative Medical Advisory Team

Approximately one out of every six Americans struggle with migraine headaches. The statistic is even higher for women, with one in five women reporting a migraine over a 3-month period. (4) Unfortunately, there is no known medical cure for migraines. (10) Current medications used for prevention include antiepileptic drugs, such as topiramate (17) and valproate (18), antidepressants such as amitriptyline, β-blockers, and calcium channel antagonists. (14) Dietary supplements such as butterbur, feverfew, and magnesium, which will be discussed later, have also been shown to be effective preventative measures against migraines.

What is a migraine?

Migraines are a chronic health condition that involve episodic headaches and associated symptoms. (14) Migraine attacks can range from 4 to 72 hours with symptoms ranging from mild to debilitating. Chronic migraines are distinguished from episodic migraines when the patient has migraine headaches occurring more than 15 days per month. (11)

man holding his head in pain

As there is no cure for migraines, treatment focuses on prevention and acute symptom treatment.

What are the signs and symptoms?

A migraine attack involves several phases. In most patients, it begins with prodrome or premonitory symptoms, which include tiredness, mood changes, gastrointestinal symptoms, and sensitivity to light and sound. (5)(15)

The next phase is characterized by neurological symptoms. The International Headache Society has classified two major types of migraine that present with different neurological symptoms:

Migraine without aura – The headache lasts between 4 and 72 hours. The patient can experience nausea and/or vomiting, photophobia (sensitivity of the eyes to light), and phonophobia (a fear or aversion to sounds). In addition, the headache itself exhibits at least two of the following characteristics: unilateral location, pulsating quality, moderate or severe pain, and/or aggravation by routine physical activity. (11)

Migraine with aura – Involves central nervous system symptoms that develop gradually and may be followed by a headache and other migraine symptoms. The patient experiences at least one of the following aura symptoms: visual, sensory, speech, motor, brainstem, and/or retinal symptoms. (11) The aura phase overlaps with the headache itself. (5)

Once the headache subsides with either of these migraine types, some sufferers will still experience migraine symptoms referred to as the postdromal phase. (5)

Risk factors and triggers

Risk factors for chronic migraines include:

  • Overusing migraine medication
  • Ineffective acute treatment
  • Depression
  • Stressful life events
  • Having a lower educational status
  • Being female (22)
  • Being either obese or underweight (12)

Migraine triggers can be challenging to pinpoint as they may vary between individuals. Tracking personal data, including triggers and symptoms, can be used to identify an individual’s specific migraine triggers. Some of the studied trigger factors include:

  • Fasting or not eating in time (21)(30)
  • Sleep disturbances (21)(30)
  • Alcohol (21)(26)
  • Premenstrual periods in women (21)(30)
  • Weather changes, specifically low barometric pressure (21)
  • The time after stress when the relaxation or “letdown” occurs (21)(26)(30)

Integrative protocol for headaches

Butterbur (Petasites hybridus)

Butterbur is a perennial shrub from the daisy family, Asteraceae, whose root can be used for preventative treatment of migraines. (20) The plant itself contains pyrrolizidine alkaloids (PA), which are known to be hepatotoxic. However, certain butterbur extracts are found to be alkaloid-free and therefore, do not pose the same risks. (2)

Research findings:

  • Petasites hybridus is well-tolerated and is recommended as an alternative for prophylactic treatment in migraine patients (1)(8)(13)(19)
  • A 50% to 68% decrease in frequency of migraine attacks was observed (1)(8)(13)(19)

US: Search for Petasites hybridus in the Fullscript catalog.
CAN: Search for Petasites hybridus in the Fullscript catalog.

butterbut plant

Butterbur root extract has been found to be safe for migraine prevention.

Feverfew (Tanacetum parthenium)

Feverfew is a perennial plant native to Europe, North America, and South America. The aerial parts of the plant (leaves, flowers, and stems) are used in herbal supplements. (24) The chemical constituents of the plant include sesquiterpene lactones, flavonoids, and volatile oils. Supplementing with feverfew has been shown to be safe, with only mild adverse effects being reported, such as inflammation of the tongue or oral mucosa. (25)

Research findings:

  • Feverfew has been shown to be beneficial in the prevention of migraines (9)(29)
  • Migraine frequency, severity, and degree of vomiting was shown to be reduced (7)(23)(28)
  • Although shown to be safe, Tanacetum parthenium possesses cyclooxygenase-2 (COX-2) inhibition activity; long-term use could be of concern (7)(9)(23)(28)(29)

US: Search for Tanacetum parthenium in the Fullscript catalog.
CAN: Search for Tanacetum parthenium in the Fullscript catalog.

daily-like flowers

Feverfew has daisy-like flowers and commonly grows in gardens or along roadsides.

Magnesium

Magnesium is an abundant mineral required by over 300 enzymes involved in many physiological processes in the body. Magnesium is present in drinking water and in foods such as leafy green vegetables, grains, nuts, and legumes. Food processing and cooking, specifically boiling, can lower the magnesium content in food. Low magnesium status has been linked to adverse clinical outcomes, including diabetes, hypertension, coronary heart disease, osteoporosis, and migraines. (31)

Research findings:

  • A reduction in the intensity and number of migraine attacks was observed when a high level of magnesium is administered (600 mg qd) (27)(32)
  • An increase in cortical blood flow in the insular regions, inferolateral frontal and inferolateral temporal was observed after magnesium treatment (16)
  • Intravenous magnesium has been shown to decrease acute migraine attacks within 15 minutes to 24 hours after the initial administration (3)(6)
  • High dose of magnesium is well-tolerated, however, adverse events including diarrhea and gastric irritation have been noted (27)(32)

US: Search for Magnesium citrate in the Fullscript catalog.
CAN: Search for Magnesium citrate in the Fullscript catalog.

woman leaning back on her couch with both hands behind her head, resting

Migraine frequency can be reduced with the prophylactic supplements butterbur, feverfew, and magnesium.

The bottom line

Incorporating these dietary supplements into your prophylactic treatment plans may help migraine sufferers reduce the frequency and severity of migraine attacks. A protocol using dietary supplements can be used therapeutically on its own or as an adjunct to existing treatment. If you are not an integrative healthcare provider, we recommend speaking with one to learn whether these supplements are right for your wellness plan.


Disclaimer

The Fullscript Integrative Medical Advisory team has developed or collected these protocols from practitioners and supplier partners to help health care practitioners make decisions when building treatment plans. By adding this protocol to your Fullscript template library, you understand and accept that the recommendations in the protocol are for initial guidance and may not be appropriate for every patient.

  1. Agosti, R., Duke, R. K., Chrubasik, J. E., Chrubasik, S. (2006). Effectiveness of Petasites hybridus preparations in the prophylaxis of migraine: a systematic review. Phytomedicine, 13(9-10), 743-6.
  2. Aydin, A. A., Zerbes, V., Parlar, H., & Letzel, T. (2013). The medical plant butterbur (Petasites): Analytical and physiological (re)view. Journal of Pharmaceutical and Biomedical Analysis, 75, 220-229.
  3. Bigal, M. E., Bordini, C. A., & Speciali, J. G. (2002). Arquivos de Neuro-Psiquiatria, 60(2-B), 406-9.
  4. Burch, R., Rizzoli, P., Loder, E. (2018). The prevalence and impact of migraine and severe headache in the United States: figures and trends from government health studies. Headache, 58(4), 496-505.
  5. Charles, A. (2013). The evolution of a migraine attack – a review of recent evidence. Headache, 53(2), 413-9.
  6. Chiu, H. Y., Yeh, T. H., Huang, Y. C., & Chen, P. Y. (2016). Effects of intravenous and oral magnesium on reducing migraine: a meta-analysis of randomized controlled trials. Pain Physician, 19(1), E97-112.
  7. Diener, H. C., Pfaffenrath, V., Schnitker, J., Friede, M., & Henneicke-von Zepelin, H. H. (2005). 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, 25(11), 1031-41.
  8. Diener, H. C., Rahlfs, V. W., Danesch, U. (2004). The first placebo-controlled trial of a special butterbur root extract for the prevention of migraine: reanalysis of efficacy criteria. European Neurology, 51(2), 89-97.
  9. Ernst, E., & Pittler, M. H. (2000). The efficacy and safety of feverfew (Tanacetum parthenium L.): an update of a systematic review. Public Health Nutrition, 3(4A), 509-14.
  10. Fenstermacher, N., Levin, M., Ward, T. (2011). Pharmacological prevention of migraine. BMJ, 342, d583.
  11. Headache Classification Committee of the International Headache Society (IHS). (2018). The International Classification of Headache Disorders, 3rd edition. Cephalalgia, 38(1), 1–211.
  12. Gelaye, B., Sacco, S., Brown, W. J., Nitchie, H. L., Ornello, R., & Peterlin, B. L. (2017). Body composition status and the risk of migraine: A meta-analysis. Neurology, 88(19), 1795-1804.
  13. Grossman, W., Schmidramsl, H. (2001). An extract of Petasites hybridus is effective in the prophylaxis of migraine. Alternative Medicine Review, 6(3):303-10.
  14. Gürsoy, A. E., Ertaş, M. (2013). Prophylactic treatment of migraine. Nöropsikiyatri Arşivi, 50(1), S30-S35.
  15. Kelman, L. (2004). The premonitory symptoms (prodrome): a tertiary care study of 893 migraineurs. Headache, 44(9), 865-72.
  16. Köseoglu, E., Talaslioglu, A., Gönül, A. S., & Kula M. (2008). The effects of magnesium prophylaxis in migraine without aura. Magnesium Research, 21(2), 101-8.
  17. Linde, M., Mulleners, W. M., Chronicle, E. P., & McCrory, D. C. (2013). Topiramate for the prophylaxis of episodic migraine in adults. Cochrane Database of Systematic Reviews, 6, CD010610.
  18. Linde, M., Mulleners, W. M., Chronicle, E. P., & McCrory, D. C. (2013). Valproate (valproic acid or sodium valproate or a combination of the two) for the prophylaxis of episodic migraine in adults. Cochrane Database of Systematic Reviews, 6, CD010611.
  19. Lipton, R. B., Göbel, H., Einhäupl, K. M., Wilks, K., & Mauskop, A. (2004). Petasites hybridus root (butterbur) is an effective preventive treatment for migraine. Neurology, 63(12), 2240-4.
  20. Malone, M., Tsai, G. (2018). The evidence for herbal and botanical remedies, Part 1. The Journal of Family Practice, 67(1), 10-16.
  21. Marmura, M. J. (2018). Triggers, protectors, and predictors in episodic migraine. Current Pain and Headache Reports, 22(12), 81.
  22. May, A., Schulte, L. H. (2016). Chronic migraine: risk factors, mechanisms and treatment. Nature Reviews Neurology, 12(8), 455-64.
  23. Murphy, J. J., Heptinstall, S., & Mitchell, J. R. (1988). Randomised double-blind placebo-controlled trial of feverfew in migraine prevention. Lancet, 2(8604), 189-92.
  24. National Institutes of Health (NIH). (2016). Feverfew. Retrieved from: https://nccih.nih.gov/health/feverfew
  25. Pareek, A., Suthar, M., Rathore, G. S., & Bansal, V. (2011). Feverfew (Tanacetum parthenium L.): a systematic review. Pharmacognosy reviews, 5(9), 103–110.
  26. Park, J. W., Chu, M. K., Kim, J. M., Park, S. G., Cho, S. J. (2016). Analysis of trigger factors in episodic migraineurs using a smartphone headache diary applications. PLoS One, 11(2, e0149577.
  27. Peikert, A., Wilimzig, C., & Köhne-Volland, R. (1996). Prophylaxis of migraine with oral magnesium: results from a prospective, multi-center, placebo-controlled and double-blind randomized study. Cephalalgia, 16(4), 257-63.
  28. Pfaffenrath, V., Diener, H. C, Fischer, M., Friede, M., Henneicke-von Zepelin, H. H. (2002). The efficacy and safety of Tanacetum parthenium (feverfew) in migraine prophylaxis–a double-blind, multicentre, randomized placebo-controlled dose-response study. Cephalalgia, 22(7), 523-32.
  29. Saranitzky, E., White, C. M., Baker, E. L., Baker, W. L., & Coleman, C. I. (2009). Feverfew for migraine prophylaxis: a systematic review. Journal of Dietary Supplements, 6(2):91-103.
  30. Spierings, E. L., Donoghue, S., Mian, A., Wöber, C. (2014). Sufficiency and necessity in migraine: how do we figure out if triggers are absolute or partial and, if partial, additive or potentiating? Current Pain and Headache Reports, 18(10), 455.
  31. Swaminathan, R. (2003). Magnesium metabolism and its disorders. Clinical Biochemist Reviews, 24(2), 47–66.
  32. von Luckner, A., & Riederer, F. (2018). Magnesium in migraine prophylaxis- is there an evidence-based rationale? A systematic review. Headache, 58(2),199-209.