TRANSCRIPT:

Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease.

This episode is brought to you in part by our generous sponsor, AbbVie.

Molly O’Brien: Hello and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. 

Today we’re diving into the topic of vitamins and supplements for migraine, and to help us get a better understanding is Dr. Margaret Slavin. Dr. Slavin is an associate professor of the Department of Nutrition and Food Studies at George Mason University. She’s also an affiliate of the Center for Study of Chronic Illness and Disability. She’s a registered dietician nutritionist trained in clinical nutrition, and she’s also trained as a food scientist. 

So you have lots of information and background and knowledge on this topic. Dr. Slavin, thanks so much for joining us today.

Dr. Margaret Slavin: Thank you for having me. It’s great to be here.

Molly: Well, we’re really excited for this. I know we get a lot of migraine patients out there that are really curious about vitamin supplements for migraine. There’s a lot of information out there, and not all of it is reliable. So I know this will be a popular topic for our followers out there. 

So let’s start off with that many supplements claim to be beneficial for migraine patients, but there is limited evidence. So can taking certain vitamins or supplements actually help with migraines? Kind of a broad question to start with.

Dr. Slavin: So a broad answer, then: yes. Yes, we absolutely do have evidence for some supplements as having the ability to prevent migraine attacks in folks who are susceptible. I’ll just briefly mention, the ones we have the best evidence for in terms of vitamins and minerals are magnesium and riboflavin. 

And when we talk about evidence, we’re talking about evidence in the form of the strongest study design that we have, the randomized controlled trial. So those supplements have been put head to head against placebo — a non-active dummy pill, if you will — and found to have benefits. So that’s why those are said to have evidence. 

And before we even get into too much deeper, I do want say they’re not miracles, and I think people with migraine are accustomed to hearing this. Unfortunately, they don’t eliminate migraine. But, for some people, it’s not unusual to hear of a reduction of migraine days by something like five days a month after they’ve taken it for a few months. So it does take some time to kick in. 

So the good news, yes, there are some supplements that people out there can consider, and in consultation with their doctor, for sure.

Molly: And I think that’s a good note to make. I think most of us who live with migraine are used to the fact that there’s no one size fits all and there is no cure. But knowing that there are some things out there that we can do that aren’t actual medications might be able to help, and if it can take out one or two migraine days a month, awesome. We’ll take it, right?

Dr. Slavin: Yeah, and if it’s safe.

Molly: Yeah, exactly, and that they’re safe. So you mentioned magnesium and riboflavin, also known to many people as B2. Can you walk us through these and explain how they work in the body, and how they might actually be able to help with migraine?

Dr. Slavin: Sure. So I think another thing — we talk about the evidence we don’t have. I want to keep mentioning that. I think it’s important to say that we have a lot of educated guesses as to why these nutrients are working or how they’re working, but we don’t truly know. So I’ll put that out there. I’ll share what we think is happening based on what we know of our understanding of nutrient metabolism and what overlaps with what we know about migraine. 

So starting with magnesium, magnesium is one of the major minerals of the body. It performs literally hundreds of functions in the body, and there are several, honestly, that might have something to do with migraine. Magnesium is associated with enzymes in the body. Enzymes are proteins that control the rate of different metabolic reactions that are happening in the body. So, basically, they control what goes on, what biochemistry, and how we function as biological organisms. 

So magnesium has a role in kind of tuning that system and which enzymes and which reactions are happening. And it is especially important in the regulation of energy metabolism, playing a key role in the conversion of the energy we consume as food. We know calories. We know carbohydrates, fats, proteins. And the body has an intricate system of converting that energy from carbs, fats, and proteins to energy that cells can use, what you may know as ATP. And so magnesium plays a key role in that process in the mitochondria of our cells that perform that work. So that’s one of the things that it does.

It also has a role in blocking certain receptors in the brain that may have a role in the process of aura, the symptom that often precedes the pain phase of migraine. And so there may be some role of magnesium to play in preventing aura. And we also see magnesium can regulate release of certain inflammatory substances with migraine. So all of these things overlap with migraine and could help to explain why magnesium might be helpful here. 

As for riboflavin, you mentioned it’s a B vitamin. It’s vitamin B2. And the family of B vitamins is generally known for two roles in the body: assisting enzymes in metabolism, like we saw with magnesium, and in building new cells. And riboflavin is also involved in energy metabolism and the production of ATP in mitochondria. And it also plays a role in reducing certain neuroinflammatory substances. So there are definite similarities to the roles riboflavin and magnesium and processes of migraine.

And so to put this in context maybe a little bit more, you may have heard that the nervous system of people with migraine are sensitive — that’s one of the new kind of overarching theories of migraine — and it’s especially sensitive to changes. And so this is why routine is so emphasized as part of lifestyle for people with migraine: go to sleep at the same time every day, eat at the same time every day, drink caffeine in the same amount every time, every day, and so on and so on. 

So when we’re talking about these nutrients, we’re talking in sort of the same vein, that we’re trying to ensure that the body has a consistent energy supply and giving the body the nutrients it needs for that biological pathway of energy metabolism to occur so that your brain has the energy when it needs it, as it needs it, without any extra blips in the pathway. So that’s a quick snapshot of magnesium and riboflavin.

Molly: Which is really interesting to learn how these supplements can affect our bodies and how it can help with migraine. So it’s really interesting to learn. 

I’m curious, can we consume more of these vitamins or supplements through dietary changes and through foods as opposed to just taking a pill or taking an actual vitamin?

Dr. Slavin: Yeah, absolutely. It’s a great question, and I think it’s important, maybe, for us to distinguish between different types of supplements. So we’re talking now about the vitamins and minerals. And so those, of course, are essential nutrients. It’s essential for us to consume them in food for us to survive. Otherwise, we would develop deficiencies and have other problems to contend with. So for the vitamins and minerals, absolutely. 

For some of the other supplements — there are categories of supplements, more like botanicals. If you’ve heard of butterbur or feverfew, are some that are commonly discussed with migraine. Those are botanical from plant leaves, and the active components of those plants are very specific to those plants. That’s why those are the ones that are studied. And so you won’t get those botanical supplements in food, typically. 

And so when we’re talking vitamins and minerals, absolutely. When we’re talking botanical supplements, not so much.

Molly: OK, OK. Do you have an idea of some types of foods that we could start incorporating in our diet to get more magnesium or riboflavin?

Dr. Slavin: Yes, it’s actually sort of conveniently — we’ve seen a lot of overlap already in their mechanisms. The foods overlap a lot too.

Molly: [inaudible]

Dr. Slavin: When we’re talking magnesium and riboflavin, nuts and seeds — so your sunflower seeds, peanuts would be good sources, peanut butter. Greens, the different leafy greens that we’re recommended to consume, those are high in both of those nutrients as well. Dairy, different dairy foods have a good amount of both magnesium, riboflavin.

Where they differ little, magnesium is high in beans, so beans and legumes — so kidney beans, lentils, that sort of food. And then riboflavin is one of the nutrients that is fortified in some of our grain supply. It’s naturally present in whole grains in the outer shell, the whole grain. But if you’re consuming a refined grain, like a white bread or a white rice or something like that, you can find fortified foods with riboflavin. So your breakfast cereals, your commercially produced breads will all have riboflavin in them as well. So lots of different options.

Molly: Well, that’s good to know, and it sounds like there’s a variety of foods out there too that people can eat. If you can’t have nuts, then maybe you can have dairy, or if you can’t have dairy, then maybe you can have nuts. 

Kind of on the flip side of that but also sticking with food, so is there any type of food that can help us absorb these minerals and vitamins better within our body?

Dr. Slavin: Yeah. So I love the emphasis on food too, so I’m happy to talk about that. So it’s a mixed bag of an answer. So the technical answer is yes.

Molly: OK. It’s always a mixed bag with migraine. You never know.

Dr. Slavin: Of course. But I think this is one where maybe I can make it easier for folks. So the technical answer is yes. If you’re concerned about absorbing enough magnesium, vitamin D has been shown to help enhance absorption of magnesium. They sort of work together in the body, and they have this mutually beneficial absorption pattern. Similar with calcium — vitamin D helps absorb calcium. 

But the reason I say maybe I can help is that, honestly, in an otherwise healthy person who’s eating a generally good diet, this isn’t something that I would worry about. So when I say “otherwise healthy,” I’m talking has intestines and stomach that are otherwise intact and functioning approximately normally. And so this is something — you might get a slight difference in absorption here and there.

But I think the bigger benefit is not from worrying about which foods to consume together, but worrying more so about getting those overall food patterns, those food groups that we just talked about: the beans and the nuts, the seed, the leafy greens, whole grains, if you can — whichever ones you can tolerate — so a variety of different foods from the different food groups, focusing on plant-based foods. If you can do that, you’re in good shape.

Molly: Wonderful. And do we know — so say either you’re incorporating more of these types of foods into your diet so you can add more magnesium or riboflavin to your body, or if you are taking supplements — because I’ve been prescribed magnesium, so I take a supplement or vitamin every day. I’m wondering, do we know if there’s a certain dosage that’s standard where we start to see improvement? Again, everybody’s different, but is there an idea of how many milligrams or grams we should be taking a day that where we can see some benefit and for how long?

Dr. Slavin: Yeah. So for how long? So I’m going back to the research again, to the clinical trials, what the evidence says. So, generally, we’re talking about three months before you can sort of get a more definitive answer if it’s working for you or not. So if you’re taking it for a month and it’s not doing anything, stay on the path for a little longer if you don’t have negative side effects. 

In terms of doses for magnesium, I generally look to the studies which say about 400 milligrams a day. And riboflavin, some of the studies went up to 400 milligrams a day. I generally would start at maybe 100. I don’t think 400 is necessary, necessarily. But it’s safe. It’s a water-soluble vitamin, so you’ll see it. It’s yellow, and you’ll see it in your urine as you excrete the extra water-soluble vitamin from your body. So you’ll see you might not need quite that dose. 

Anyway, so in terms of doses for magnesium, I think it’s important to mention and to talk about some of the side effects of magnesium. It’s generally conceived to be very safe as a supplement. And part of the reason is that one of the side effects is sort of a self-limiting side effect of magnesium, and that is if you take a high dose — which may be 400 milligrams for some people, and everyone’s different — but with a high dose, some people start to have gastrointestinal side effects, so loose stools, diarrhea, and similar, maybe some cramps associated with that. 

And so what I would recommend people do, if that’s you or if you’re concerned about that, is to start at a lower dose and to try to start to work your way up. So, generally, I think a lot of people can tolerate a 200-milligram dose of magnesium at a single time point to start. And so find a pill with 200 milligrams and then start with that once a day. See how you feel. Then maybe give it a week, maybe two, and increase to — maybe try 400 a day and see if you can tolerate that, if that works with your system. 

The other thing for magnesium that you could try is different salts of magnesium. So you’ll see when you go shopping for supplements, they will say magnesium oxide, magnesium citrate, magnesium glycinate. Magnesium oxide is the one that was most commonly used in the studies. However, it’s also the least bioavailable, “bioavailable” meaning when we take the pill and it runs through our intestines, we absorb a smaller proportion of it than some of the others, magnesium citrate or magnesium glycinate. 

And so that extra magnesium that’s left behind, that goes through your intestines to your colon, is what’s causing some of those symptoms of loose stools and so forth. So if you choose it, you might try choosing a different form of magnesium. I would try glycinate or citrate and see if that may agree with your system a little better. You might be able to tolerate a higher dose that way.

Molly: And that’s a really good point too, because sometimes if you get something prescribed from your doctor, that’s one thing, then you try that. But if you’re trying this on your own — hopefully, you’re talking to a medical provider as well — but you can go to the grocery store or a supplement store and be overwhelmed with different products. And so deciphering which one you should take can be really challenging. 

So that’s a really great tip. If you start with the magnesium oxide, and maybe it doesn’t agree with you quite as well, then you can try a different supplement or start with a different type of magnesium first. So that’s actually great advice for people because it can be really confusing.

Dr. Slavin: Absolutely, yeah.

Molly: Before we let you go, Dr. Slavin, I’m wondering if there’s anything else you think, either broadly or specifically, that people out there with migraine should know about vitamins and supplements that might be able to help them. We’ve talked specifically about riboflavin and magnesium in this episode, but anything else that you want to share?

Dr. Slavin: Always. I think there are a few more supplements that people may want to consider. The evidence either isn’t as strong or is kind of starting to trickle out in the literature, but it hasn’t been reviewed by full kind of scientist panels in the migraine community, as we like to do, to review the evidence before making broad recommendations. 

So there are a few that I think are interesting and maybe people can pay attention to, and they include CoQ10 — so coenzyme Q10 is a possibility, as well as vitamin D and omega-3, and especially the long-chain omega-3s, EPA and DHA, found in fish oils. So those are some supplements that — the mix of vitamins — let’s see, CoQ10 is neither, and then omega-3 is a fat, a fatty acid. So not exactly vitamins and minerals, but some supplements that might be helpful for either migraine or for prevention of other chronic diseases. 

All three of those have other health benefits associated with some of the research and risk of things like cardiovascular disease, which, again, we mentioned — talking about comorbidities — might be something for people to talk about with their doctors and consider as possibilities. 

And I think, since you opened the floor, I’ll pivot, and I’ll make one more push here for diet as part of this equation. Supplements are great. Supplements — especially for something like magnesium, where it’s hard to get that — if we’re talking 400 milligrams of magnesium in one supplement pill, that about doubles what you can get from diet. So supplements have their place, and I don’t want to discount that.

But I think we also need to be working with a healthy, balanced diet as a foundation and taking the supplements on top of that to give them and give us our best chance at reducing migraines. And so I continue to advocate for — nothing crazy, but a generally well-balanced diet, filling half your plate with fruits and vegetables. Whole grains, when you can; lean proteins, especially plant-based proteins; eating your omega-3s in foods, if you can, from fish; and I could go on and on. Watching sugar content — not that you should never have it, but moderating sugar in the diet a little bit. 

And all of these things are known to decrease inflammation in the body, which we know is related to migraine. So I think that just gives us a great foundation to have our healthy lifestyle and add supplements on top of that. 

And we do know the nutrients don’t work alone. I mentioned B2 is part of the B family of vitamins. There’s B1, B3, B6, B9. They often work together. So if you’re just taking riboflavin and not getting any of the other B vitamins, it might not be as effective as it could be, as if you have that good diet foundation below it.

Molly: I absolutely love it, and that’s why we wanted to make sure we touched on diet as well because that’s a big chunk of your background, and it all works together. And if you don’t have to take an extra pill — I know when you have migraine, swallowing another pill can be really difficult. So if we can make some changes in our diet and start to see some benefit, then I think that’s really beneficial. 

This has been such a great conversation. Thank you so much. I know that I’ve learned a lot, and I hope our listeners and followers have learned a lot as well. 

All right, well, that wraps up this episode of Spotlight on Migraine. I’d like to thank Dr. Margaret Slavin for joining us to fill us in on some supplements and vitamins that have some evidence that could help with migraine. So, Dr. Slavin, thanks so much for joining us.

Dr. Slavin: Thank you.

Molly: It’s been an excellent conversation. We really appreciate you listening, watching, and following along. And, until next time, I’m Molly O’Brien, with the Association of Migraine Disorders, and this is Spotlight on Migraine.

[music]

Voice-over: Thank you for tuning in to Spotlight on Migraine. For more information on migraine disease, please visit MigraineDisorders.org.

*The contents of this podcast are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The speaker does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.