Headaches and Complementary Health Approaches: What the Science Says

Butterbur

Butterbur appears to help reduce the frequency of migraines in adults and children. However, butterbur contains pyrrolizidine alkaloids (PA), which are hepatotoxic. The American Academy of Neurology stopped recommending butterbur in 2015 because of serious concerns about possible liver toxicity. Some butterbur preparations have had PA toxins removed to ensure safety. Only butterbur products that have been processed to remove PAs and are labeled or certified as PA-free should be considered for use.

What Does the Research Show?

• A 2022 narrative review of the literature examined the safety and clinical efficacy of the butterbur root extract Petadolex. The review of randomized, double-blinded and placebo-controlled trials with Petadolex found that migraine attack frequency was reduced significantly at 150 mg/day, and no relevant abnormal liver function was reported. The reviewers concluded that butterbur is effective in the prevention of migraine attacks by blocking calcitonin gene-related peptide signaling.
• A 2012 study analyzed 21 commercial butterbur products in the United States for petasins (the active ingredient in butterbur) and PAs, and found only 7 products to be safe and effective, with petasin present and no detectable PAs. The study also found that six products had no detectable amounts of petasin and seven had toxic levels of PAs.

Safety

• Some butterbur products contain chemicals called pyrrolizidine alkaloids (PAs). PAs can damage the liver, lungs, and blood circulation, and possibly cause cancer. Only butterbur products that have been processed to remove PAs and are labeled or certified as PA-free should be considered for use.
• Not enough is known about whether it’s safe to apply butterbur products to the skin.
• Several studies, including a few studies of children and adolescents, have reported that PA-free butterbur products seem to be safe when taken by mouth in recommended doses for up to 16 weeks. However, some products claiming to be PA-free may not in fact be. For example, Petadolex is marketed as a PA-free butterbur product, but it has been associated with liver damage in some people, suggesting that it may have had PAs. Also, the safety of longer-term use of butterbur has not been established.
• Butterbur products with PAs should not be used during pregnancy or while breastfeeding because they may cause birth defects or liver damage. Little is known about whether it’s safe to use PA-free butterbur during pregnancy or while breastfeeding.
• PA-free butterbur is generally well tolerated but can cause side effects such as belching, headache, itchy eyes, diarrhea, breathing difficulties, fatigue, upset stomach, and drowsiness.
• Butterbur may cause allergic reactions in people who are sensitive to plants such as ragweed, chrysanthemums, marigolds, and daisies.

Coenzyme Q10

There is some limited evidence that coenzyme Q10 may help reduce the duration and frequency of migraines but not their severity.

What Does the Research Show?

• A 2021 systematic review and meta-analysis of 6 studies (371 total participants), which compared coenzyme Q10 with a placebo, showed that coenzyme Q10 may help reduce the duration and frequency of migraines but not their severity. Because both the amount of evidence and the size of the effects observed in the studies were small, there are still uncertainties about whether coenzyme Q10 is helpful for migraines.

Safety

• No serious side effects of coenzyme Q10 have been reported. Coenzyme Q10 may interact with some medications, including the anticoagulant (blood-thinning) medication warfarin and the diabetes drug insulin.

Feverfew

Some research suggests that feverfew may help prevent migraine headaches, but results have been mixed. Some research suggests it may reduce migraine headache frequency, as well as some symptoms, such as pain, nausea/vomiting, and light sensitivity.

What Does the Research Show?

• A 2020 Cochrane review (an update to a previous Cochrane review, which added one larger rigorous study) of 6 studies involving 561 participants found a difference in effect between feverfew and placebo of 0.6 migraine attacks per month. However, the reviewers noted that this constitutes low quality evidence, which needs to be confirmed in larger rigorous trials with stable feverfew extracts and clearly defined migraine populations before firm conclusions can be drawn.

• Based on the evidence, the Canadian Headache Society (CHS), American Academy of Neurology/American Headache Society (AAN/AHS), and European Federation of Neurological Societies (EFNS) have different recommendations. The CHS made a strong recommendation based on moderate quality evidence to not offer feverfew for migraine, citing the evidence is no better than placebo for the prophylaxis of migraine. The AAN/AHS recommended that feverfew is probably effective and should be offered for prevention. The EFNS stated that feverfew is possibly beneficial for migraine prevention.

Safety

• Side effects of feverfew can include nausea, digestive problems, and bloating; if the fresh leaves are chewed, sores and irritation of the mouth may occur. In addition, there is some evidence that parthenolide (a substance found in feverfew) may cause glutathione depletion. 
• People who are sensitive to ragweed and related plants may experience allergic reactions to feverfew.
• Do not take feverfew while pregnant because it may affect uterine contractions. Little is known about whether it’s safe to use feverfew while breastfeeding.

Magnesium

Research on the use of magnesium supplements to prevent or reduce symptoms of migraine headaches is limited. 

What Does the Research Show?

• A 2018 systematic review of five studies found Grade C (possibly effective) evidence for prevention of migraine with magnesium. However, a 2021 review concluded that even if the preliminary results are very promising, more rigorous studies have to be designed to confirm the efficacy of magnesium for headache.
• A 2009 review found that three of four small, short-term, placebo-controlled trials showed modest reductions in the frequency of migraines in patients given up to 600 mg/day magnesium. Because the typical dose of magnesium used for migraine prevention exceeds the Tolerable Upper Intake Level (UL), this treatment should be used only under the direction and supervision of a health care provider.

• According to a 2016 summary of existing guidelines on nutraceuticals for migraines, based on research from the CHS, there is low quality evidence that supports the use of magnesium in the prophylaxis of migraine, suggesting a daily dose of 24 mmol (600 mg) or elemental magnesium as magnesium citrate. The AAN/AHS gave magnesium a Level B recommendation, and the EFNS gave magnesium a Level C. The EFNS recommended use of the same dose of magnesium as the Canadian guidelines.

Safety

• High doses of magnesium from dietary supplements or medicines can cause diarrhea, nausea, and stomach cramps, and very large doses can cause serious toxicity. Magnesium can interact with medicines, including some antibiotics, diuretics, and drugs used to treat osteoporosis. Because the amounts of magnesium people take for migraines are greater than the largest daily intake of magnesium from supplements and medicines that is considered safe, magnesium supplements for migraine should be used only under the supervision of a health care provider.

Riboflavin

What Does the Research Show?

• A 1998 randomized controlled trial of 55 participants with migraines compared treatment with 400 mg riboflavin daily with placebo for 12 weeks. The results, 4 months after the trial, showed that the reduction in migraine attacks per month was greater for patients treated with riboflavin (56 percent) compared to the placebo group (19 percent).
• A 2020 review concluded that overall, studies to date report that riboflavin has similar efficacy to valproate for migraine prophylaxis, but has a more tolerable side effect profile.

• According to a 2016 summary of existing guidelines on nutraceuticals for migraines, the CHS gave riboflavin a strong recommendation based on low quality evidence for benefit and minimal side effects. The CHS guidelines recommend 400 mg daily to eligible patients for migraine prophylaxis. The AAN/AHS guidelines state that riboflavin is “probably effective” and should be considered for migraine prevention (with a Level B recommendation). The EFNS guidelines state that riboflavin is possibly helpful (with a Level C recommendation). 

Safety

• Adverse effects from high riboflavin intakes from foods or supplements (400 mg/day for at least 3 months) have not been reported. A 2021 review found that in all of the studies included in the review, riboflavin was well tolerated without major side effects or safety concerns.

Omega-3 Fatty Acid Supplements

Diets high in omega-3 fatty acids may be helpful for migraines; however, omega-3s in supplement form have not been shown to reduce the frequency or severity of migraines. There is a small amount of evidence that suggests that omega-3 supplements might reduce the duration of migraine attacks. 

What Does the Research Show?

• In a 2021 study of 182 adults with frequent migraines, researchers from the National Institutes of Health, in cooperation with other investigators, assigned participants to one of three groups for 16 weeks comparing a diet high in omega-3 fatty acids from high-fat fish and low in linoleic acid, a diet high in omega-3s but with as much linoleic acid as in the average U.S. diet, and a control diet containing omega-3s and linoleic acid in the amounts found in the average U.S. diet. Participants in the two groups receiving higher amounts of omega-3s had fewer hours of headaches and fewer hours of moderate-to-severe headaches per day, as well as fewer days per month with headaches compared to the control group. The greatest decrease in headache days per month was seen in the group that received a diet high in omega-3s and low in linoleic acid. 
• A 2021 analysis of the VITamin D and OmegA-3 TriaL (VITAL) showed that omega-3 supplementation did not affect migraine frequency or severity among the 1,032 study participants with a reported a history of probable migraine. 
• A 2018 review of 5 small studies involving a total of 382 participants found that while omega-3s did not affect the frequency of migraines, there was a reduction in duration of migraine attacks.

Safety

• Omega-3 fatty acid supplements usually do not have negative side effects. When side effects do occur, they typically consist of minor gastrointestinal symptoms. 

Acupuncture

Results from studies indicate that acupuncture may help relieve headache pain, but that much of its benefit may be due to nonspecific effects including expectation, beliefs, and placebo responses rather than specific effects of needling.

What Does the Research Show?

• A 2018 update to a 2012 meta-analysis (of 39 studies involving a total of 20,827 participants) concluded that acupuncture is effective for the treatment of 4 chronic pain conditions, including migraine, with treatment effects lasting over time. 
• A 2016 Cochrane review of 22 randomized trials found that acupuncture was more effective than no acupuncture, was slightly more effective than sham, and may be similarly effective as preventative drug treatment for chronic pain. 
• A 2021 systematic review of 8 studies involving 3,846 participants found evidence that acupuncture and manual therapy can be valuable nonpharmacologic treatment options for tension-type headaches. 
• A 2022 systemic review of 15 randomized controlled trials compared acupuncture to sham acupuncture, and acupuncture to medical treatment. In 7 out of 10 trials comparing acupuncture to sham, reviewers found acupuncture showed a more significant reduction in the frequency of migraine attacks and headache intensity. 

Safety

• Acupuncture is generally considered safe when performed by an experienced practitioner using sterile needles. Improperly performed acupuncture can cause potentially serious side effects.

Biofeedback

Many studies have tested biofeedback for tension headaches, and several evaluations of this research have concluded that biofeedback may be helpful. Studies have shown decreases in the frequency of migraines in people who were using biofeedback. However, it’s unclear whether biofeedback is better than a placebo for migraines.

What Does the Research Show?

• A 2009 review of 44 randomized trials with 2,618 participants concluded that there is conflicting evidence about whether biofeedback is helpful for tension headaches. 
• A 2016 review of 5 studies involving 137 children and adolescents found that biofeedback seemed to be helpful with migraines, especially with reducing their frequency. The number of participants in the studies, however, was small.
• A 2007 meta-analysis of 55 studies found medium effect sizes for the short- and long-term outcome of biofeedback for migraine in adults. The meta-analysis concluded that biofeedback significantly and substantially reduced the pain and psychological symptoms of patients with chronic migraines within the scope of only 11 sessions.

Safety

• Biofeedback generally does not have harmful side effects.

Massage

Only a small number of studies of massage for headache have been completed, and their results are not consistent.

What Does the Research Show?

• A 2021 systematic review of 8 studies involving 3,846 participants found evidence that acupuncture and manual therapy, including massage therapy, can be valuable nonpharmacologic treatment options for tension-type headaches. 
• A 2016 study with 64 participants evaluated lymphatic drainage and traditional massage (once a week for 8 weeks) in patients with migraine and found that the frequency of migraines decreased in both groups, compared with people on a waiting list. 
• A 2011 study of 83 participants evaluated the effect of adding hand massage to multimodal behavior treatment of migraine and found that hand massage had no effect on migraine frequency.

Safety

• Massage therapy appears to have few risks when performed by a trained practitioner. However, people with health conditions and pregnant women may need to avoid some types of massage and should consult their health care providers before having massage therapy.

Relaxation Techniques

Some studies have found that relaxation techniques such as autogenic training or biofeedback-assisted autogenic training, hypnotherapy (and self-hypnosis paired with guided imagery) may help to reduce headache pain; however, the findings should be viewed cautiously because many of the studies have not been of high quality. 

What Does the Research Show?

• A 2019 review of 7 studies involving 571 children looked at the effects of relaxation training on migraine headaches, tension-type headache, or both. Although some studies reported decreased headache frequency, duration, and intensity after relaxation training, other studies did not. Overall, the results were inconsistent, and the research was of very low quality.
• In a 2018 review of 6 studies involving a total of 274 participants, 5 of the studies found that autogenic training or biofeedback-assisted autogenic training helped to reduce headache pain; however, because of the small sample size and study limitations, the review authors noted that the findings should be viewed cautiously. 
• In a 2018 review, five of eight studies found that hypnosis—usually self-hypnosis and often paired with guided imagery—resulted in less headache activity in people diagnosed with migraine or chronic headache disorder; however, none of the studies in this review were rated high quality. 

Safety

• Relaxation techniques generally don’t have side effects. However, rare harmful effects have been reported in people with serious physical or mental health conditions.

Spinal Manipulation

Spinal manipulation may be one of several complementary health approaches (including massage therapy) that’s as helpful as medications used for migraine prevention, but the research isn’t conclusive.

What Does the Research Show?

• A 2020 AHRQ systematic review of noninvasive, nonpharmacologic treatment for chronic pain reported spinal manipulation therapy was associated with slight-to-moderate improvements in function compared to usual care on the Headache Impact Test and the Headache Disability Inventory (scale 0–100) and in pain over the short term (i.e., 1–6 months) in one trial. The standard of evidence was rated as low.
• A 2022 systematic review and meta-analysis of 20 studies involving 1,439 participants found evidence suggesting that manual and exercise therapy may reduce headache intensity, frequency, and disability over the short and long term in people with cervicogenic headaches; however, the overall risk of bias in many of the trials included in the analysis was high. A sensitivity meta-analysis on studies with low risk of bias showed moderate-quality evidence supporting the use of spinal manipulation compared to sham interventions. 

Safety

• Side effects from spinal manipulation can include temporary headaches, tiredness, or discomfort in the area that was manipulated. There have been rare reports of strokes occurring after manipulation of the upper (cervical) spine, but whether manipulation actually caused the strokes is unclear.

Tai Chi

Data are too limited to draw meaningful conclusions about whether tai chi is useful for tension headaches. 

What Does the Research Show?

• One small, randomized study has evaluated tai chi for tension headaches and found some evidence of improvements in headache status and health-related quality of life among patients in the tai chi program compared to others on a wait list. However, these data are too limited to draw meaningful conclusions about whether this practice is helpful for tension headaches.

Safety

• Tai chi is generally considered to be a safe practice.

References