Causes of migraines:

1. Reduced serotonin levels – when serotonin levels drop, blood vessels become more swollen and inflamed. This can link with a drop in oestrogen levels associated with menstrual migraines.
2. Vessel changes– initially vasoconstriction followed by vasodilation and stretching of blood vessels which might activate nociceptors and trigger migraines.
3. Increased cerebral blood flow– prior to a migraine it has been suggested there is a large increase in cerebral blood flow however once the migraine has occurred blood flow is normal.
4. Sensitisation of the trigemino-cervical nucleus
5. Brain stem– certain regions of the brain stem have been shown to be more active during and after migraine even when blood flow is normal, and vessels are normal patency)
6. Mutation of dysfunction of certain genes– clearly a complex topic in itself
7. Some have described migraine like Chronic Regional Pain Syndrome of the brain with ^ levels of Substance P and CGRP (neuropeptides) and neurogenic inflammation.

Incidence

1. Many starts at puberty, peaks 35-45 years, lowers >60 years.
2. Affects 10-14% of the population.
3. Increased prevalence in women (5-25% vs 2-10%)

Types of Migraines

Common migraine triggers: 

• Example of Food or drinks
  • Wheat
  • Dairy esp pasteurized, including cheese
  • Sugar esp refined
  • Artificial preservatives and sweeteners and processed foods
  • Chemical additives
  • Cured/processed meats
  • Alcohol
  • Aspartame (artificial sweetener)
  • Caffeine
  • MSG
• Allergies e.g. to food or chemicals
• Dehydration and/or hunger
• Changes in sleep cycle e.g. insufficient sleep or oversleeping (potentially linked with dehydration)
• Stress
• Physical exertion esp intense exercise
• Hormones e.g. menstrual cycle (pre-menstrual, mid cycle), during pregnancy, menopause, related to use of OCP or HRT
• External stimuli e.g. bright lights, loud noises, strong smells
• Changes in weather, seasons, altitude

Typical Medication (note can have side effects):

• Triptans
• B-blockers e.g. propranolol
• Calcium channel blockers e.g. flunarizine
• Anticonvulsants e.g. topiramate or valproic acid
• Selective serotonin reuptake inhibitors

What does this have to do Vitamin B supplementation?

1. Certain gene mutations (MTHFR) can lead to increase production of homocysteine (an amino acid)
2. Higher levels associated with migraine sufferers (also associated with heart attack and stroke risk)
3. Possibly as it is involved in vasodilation or temporary thrombosis of cerebral blood vessels, others think it is due to oxidative stress.
4. Vit B6, B12 and folic acid are involved in breakdown of homocysteine so supplementation can reduce homocysteine levels.
5. Note the evidence to support increase homocysteine levels in migraine sufferers is weak, so if Vit B supplementation assists migraine sufferers perhaps it works in other ways not currently well understood.

Vit B12 – What does it do?

• Make red blood cells, nerve, DNA and lots of other functions
• Normal recommended daily intake = 2.4micrograms
• Need to get this from food/supplements (not synthesised by the body)
• Vit B12 deficiency common esp amongst older people as they might not consume enough or absorb enough from their diet v gastric acid production in older age, which is needed to absorb Vit B12)
  • Estimated 3% those >50 years

Causes of Vit B12 deficiency:

• Strict vegetarian diet- they need to eat grains fortified with Vit B12 or take supplements
• Weight-loss surgery (it interferes with ability to absorb Vit B12)
• Celiac disease
• Crohn’s disease
• Reflux medications (need gastric acid to absorb Vit B12)

Other symptoms of Vit B12 deficiency:

• Numbness, tingling in hands, legs, feet
• Ataxia, balance problems
• Anaemia
• Swollen tongue
• Weakness
• Fatigue
• Memory loss, poor cognition

Foods containing Vit B12:

• Meat
• Eggs
• Poultry
• Dairy
• Other animal foods
• No plant-based foods

Vitamin D 

• An observational study showed that 42% of patients with chronic migraine were Vit D deficient.
• Note this is just an observational study, it does not mean causation and understand that if Vit D deficiency is common in the population anyway (23% in Australia, 2011-12) then it might not be relevant just yet so watch this space.

Vit E 

• It has been linked with menstrual migraine as it inhibits release of arachidonic acid and conversion to Prostaglandin.
• Some of the theories related to menstrual migraine relate it to prostaglandin release so Vit E supplementation might assist to reduce Prostaglandin levels.
• Typically used for 5 days during menstruation (400IU/daily) and there is some evidence to support its efficacy to reduce migraine attacks- further studies with larger subjects needed.

Vit C:

• It is an antioxidant that has been associated with reduced CRPS levels la neuropeptide found in higher doses in chronic pain states including migraines)
• Not tested in the research to date

Research:

• An RCT looked at 52 patients with migraines randomised to either Vit B supplementation (B6, B9, B12) or placebo. They found the Vit B group had a twofold reduction in migraine disability after 6 months (frequency and severity were also reduced). However, they were given 2X recommended daily intake.
• A 2004 study showed Vit B2 supplementation can help prevent migraines- but participants were taking 400mg daily (200x > recommended daily intake) so needs medical discussion.

Conclusion:

• Vit supplementation offers alternate options for migraine suffers with fewer side effects.
• More research needed to understand how they work, how well they work in a large population and what is the ideal dose.

References:

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4359851/

Prepared by:

Goh Weng Yee

Your Physio Penang

Edited by:

Teh Qi Shun

Your Physio Alam Damai