Metabolic treatments of migraine

ABSTRACT

Introduction: Most preventive migraine treatments modify the brain’s excitation/inhibition balance and/or serotonin metabolism, which likely accounts for their unfavorable adverse effect profile. Novel biological therapies blocking CGRP transmission are effective and better tolerated, but they are expensive and may not influence brain dysfunctions upstream in the pathophysiological cascade of migraine, including premonitory and aura symptoms. Biochemical and clinical studies suggest that there may be another complimentary treatment strategy, the one that targets the underestimated metabolic facet of migraine pathophysiology.

Areas covered: After a brief description of the metabolic abnormalities found in migraine patients, we will review and discuss published data on metabolic treatments of migraine. There is evidence that riboflavin and co-enzyme Q10 are effective for the prevention of migraine and quasi devoid of adverse effects. Response rates are close to those of topiramate, propranolol, and CGRP/CGRPrec mAbs. The evidence is weaker for thioctic acid. Dietary and pharmacological strategies inducing ketosis are novel promising approaches for which preliminary trials with favorable outcomes have been published.

Expert opinion: Metabolic treatments of migraine constitute an effective, well-tolerated, inexpensive, and evidence-supported therapeutic option for migraine prophylaxis, and may be considered as first treatment line in many patients, including in children and adolescents.

KEYWORDS:

• Migraine
• nutraceuticals
• metabolic treatments
• ketogenesis
• migraine prophylaxis

Article highlights

• Unlike most classical preventive migraine treatments discovered by serendipity, metabolic enhancers were specifically tested in order to restore the energetic deficit in the brain of migraineurs revealed through decades of research.

• Prophylactic metabolic enhancers have an efficacy/adverse effect profile much more favourable than classical migraine preventive drugs, although for most of them the level of evidence is lower.

• Until policy makers can be convinced that more cost-effective and tolerable alternatives for migraine care exist, it is unlikely that funds will be made available to perform the necessary RCTs of metabolic enhancers for migraine prophylaxis.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.