ࡱ>  bjbj A}&8"8"8"8"8"L"L"L"8"($<L"vu d$z$"$$$%% %ttttttt$x2{t8"-%%--t8"8"$$u.???-B8"$8"$t?-t??Q_wb$f&RV52`(t.uHvu al |5 |Pwbwb" |8"e%'?K)4*t%%%tt6&%%%vu---- |%%%%%%%%% : Continuum: Lifelong Learning in NeurologyHeadache, Volume 18, Issue 4, August 2012 Nonmedication, Alternative, and Complementary Treatments for Migraine Alexander Mauskop, MD, FAAN Address correspondence to Dr Alexander Mauskop, New York Headache Center, 30 East 76th Street, New York, NY 10021,  HYPERLINK "mailto:drmauskop@nyheadache.com" drmauskop@nyheadache.com. [end of author information] [insert disclosure information in page margin] Relationship Disclosure: Dr Mauskop has served as a speaker for Allergan, Inc, GlaxoSmithKline, and Zogenix, Inc. Unlabeled Use of Products/Investigational Use Disclosure: Dr Mauskop reports no disclosure. [end disclosure information] ABSTRACT Purpose of Review: The efficacy of some nonpharmacologic therapies appears to approach that of most drugs used for the prevention of migraine and tension-type headaches. These therapies often carry very low risk of serious side effects and frequently are much less expensive than pharmacologic therapies. Considering this combination of efficacy, minimal side effects, and cost of nondrug approaches, medications should, in general, not be prescribed alone, but rather in combination with nonpharmacologic therapies. Recent Findings: In addition to the established and proven nonpharmacologic therapies, such as biofeedback, relaxation training, butterbur, riboflavin, magnesium, and coenzyme Q10 (CoQ10) supplementation, recent data provide additional support for the use of aerobic exercise and acupuncture. Discovery of the high incidence of methylenetetrahydrofolate reductase (MTHFR) C677T mutation and attendant elevation of homocysteine levels in patients with migraine with aura led to a trial of cyanocobalamin, folate, and pyridoxine in these patients. This trial showed that taking these three supplements resulted in a reduction of homocysteine levels and improvement of migraines. Summary: Therapies proven (to various degrees) to be effective include aerobic exercise; biofeedback; other forms of relaxation training; cognitive therapies; acupuncture; and supplementation with magnesium, CoQ10, riboflavin, cyanocobalamin with folate and pyridoxine, as well as herbal preparations, such as butterbur and feverfew. [end of abstract] PSYCHOLOGICAL APPROACHES Extensive literature indicates that pain patients with internal locus of control perform significantly better than those who believe that they have no control over their condition because external factors are dominant. This locus of control is modifiable and can be shifted.1 Patients can learn that they are not entirely at the mercy of genetic factors, weather, or unpredictable behavior of people around them, which causes their headaches. They can utilize self-management techniques including biofeedback, avoid triggers when possible, try alternative and pharmacologic therapies, and become aware of other options such as acupuncture. The knowledge that they have these options, even without trying all of them, can give them a sense of control over their headaches. Changing the outlook from powerless to empowered will often result in a reduction of headaches. Another psychological factor is catastrophizing. Examples of catastrophizing are I will never get better, My husband will leave me, and I am a total failure. Independent of anxiety, depression, and physical symptoms, this negative view of life circumstances can lead to impaired functioning and lower quality of life in patients with migraine.2 Psychological approaches found to be effective in patients with pain are cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT).3 Tables 4-1 and 4-23 explain the steps used in CBT and ACT sessions. Biofeedback has been proven to provide long-term benefits in the treatment of both migraine4 and tension-type headaches,5 although self-administered progressive relaxation training might also be effective. Biofeedback involves learning to control bodily functions that normally are not under our conscious control, such as skin temperature and muscle tension. Neurofeedback is a variant of biofeedback and involves learning how to alter ones own EEG patterns. This ability requires first learning to achieve a state of deep relaxation. The most important factor in achieving success with biofeedback is adherence to regular daily practice. The usual course of biofeedback consists of 10 weekly sessions, but some patients may require fewer sessions, particularly children and those who are diligent about their daily practice and are skilled at imagery. Any form of meditation done on a daily basis (the author recommends starting with 20 minutes of daily practice) is also likely to provide significant benefits.6Patients with disabling headaches should be referred to a psychologist or CBT or ACT. Among other benefits, CBT or ACT can help shift from external locus of control to internal locus of control, which improves outcomes. Biofeedback is simple technique that has proven to relieve migraine and tension-type headaches, and the benefits have been shown to persist for up to 5 years.7 Self-taught progressive relaxation is equally effective if the patient is motivated and compliant with daily practice. PHYSICAL METHODS Aerobic exercise is proven to be effective in the prevention of migraine headaches. A study of 46,648 Swedes8 showed that In the cross-sectional analyses, low physical activity was associated with higher prevalence of migraine and non-migraine headache. In both headache groups, there was a strong linear trend (P<.001) of higher prevalence of low physical activity with increasing headache frequency. A follow-up study9 compared aerobic exercise (40 minutes 3 times a week) with topiramate and relaxation training and found these three treatments to be equally effective. Only topiramate caused side effects, which occurred in 33% of patients. Neck pain is a more frequent accompanying symptom than nausea during a migraine attack.10 Some patients feel that their migraines are triggered by neck pain, although it is possible that neck pain is just an early sign of an impending migraine. Isometric neck exercise can be effective in the treatment of cervicogenic headaches and migraines accompanied by neck pain, whether triggered by or associated with neck muscle spasm. The goal of the exercises is to strengthen neck muscles, which will render them more resilient and less likely to return to spasm. A simple 1-minute exercise (Figure 4-1)11 needs to be repeated throughout the day, 10 or more times: sustained pressure is exerted with ones hand on one side of the head, then the other side, then forehead, and, finally, the occiput for 10 to 15 seconds in each direction, while the head remains stationary in a neutral position. Patients can be advised to set an hourly alarm. Along with the neck exercise, patients can also scan their body for areas of muscle tension and perform some breathing and relaxation exercises. Improvement can be expected after about 2 weeks of diligent exercise, but if exercise is discontinued, muscles will weaken and neck pain and headaches may relapse (Case 4-1). [KP 1] [KP 2] Case 4-1 A 29-year-old woman was very concerned about her headaches, which began after a long airplane ride 2 weeks prior to her visit. She had never before had headaches. The pain was constant and mostly involved the right side of her head. She felt numbness and pins-and-needles sensation over the right occipital area. She was afraid that this was a sign of an impending stroke and was eager to have an MRI of her brain. She had no nausea, photophobia, phonophobia, or any other neurologic symptoms but admitted to having neck pain. She had not tried any medications because she did not want to mask her symptoms. She was in good health, exercised regularly, refrained from abusing alcohol, and drank only one cup of coffee daily. At work she spent hours on the phone and cradled the receiver on her shoulder. Her physical examination was normal, except for diminished sensation over the right occipital area and tenderness of suboccipital and neck muscles. She had cervicogenic headaches with an element of occipital neuralgia caused by muscle spasm, which in turn was triggered by sleeping in an awkward position on the airplane. She agreed to delay an MRI scan for 2 weeks and see whether treatment stopped her headaches. She no longer cradled the phone receiver on her shoulder, performed isometric neck exercises 10 times a day, and took naproxen, 500 mg 2 times a day as needed. Within 2 weeks she had complete relief of her headaches and continued her neck exercises to prevent recurrence. Comment. This case describes a woman who is suffering from cervicogenic headaches with symptoms of an occipital neuralgia. Isometric neck exercise and ergonomic adjustment can be very effective for the treatment of cervicogenic headaches. Some patients may also require biofeedback or relaxation training since stress, which can cause tension in neck muscles, is a frequent contributing factor. [end of case] DIETARY INTERVENTIONS Caffeine can be a major trigger in transforming episodic migraines into more frequent or even chronic headaches. It insidiously increases attacks but at first may be an effective adjuvant analgesic. Over time, as with opioid analgesics, patients develop tolerance and physical dependence. It is not the caffeine use but the withdrawal that causes headaches. Patients may not recognize how much caffeine they consume since two cups of coffee with breakfast, one to two cans of caffeine containing soft drinks, and a few caffeine-containing analgesics may not seem to them to be excessive. Also, some large coffee chains market 12-oz cups containing as much as 240 mg of caffeine, and 16-oz cups with 320 mg of caffeine. Regular consumption of as little as two to three cups of coffee is sufficient to trigger a withdrawal headache in patients prone to headaches. A small number of patients seen by the author report improvement in headaches and general well-being after elimination of gluten from their diets, even in the absence of celiac disease. Gluten sensitivity may be a different and milder form of allergy to gluten. It is thought to be a result of the expression of an innate immunity and its marker, toll-like receptor (TLR). TLR was found to be elevated in gluten-sensitive patients but not in those with celiac disease or healthy controls. Some patients with known celiac disease note improvements in headache when their disease is better controlled, but this is variable. Many patients get headaches when they skip a meal. A meal high in simple carbohydrates can also bring on a headache, probably because many patients with migraine have reactive hypoglycemia.12 More frequent and smaller meals daily, often with complex carbohydrates, can be helpful. Tyramine-rich foods, such as chocolate, cheese, and other products of fermentation, as well as alcohol, aspartame, and nitrites can trigger migraine in some susceptible individuals. Keeping a food diary can be helpful. Several free smartphone applications for tracking headaches and various potential triggers are available. [KP 3] [KP 4] MAGNESIUM Magnesium deficiency is well documented in some patients with migraine. Studies of serum ionized magnesium,13,14 whole brain nuclear magnetic resonance spectroscopy,15 intracellular levels in various types of cells,16,17 and magnesium loading test18 have consistently shown that patients with migraine and cluster headache frequently have a magnesium deficiency. Only 1% of body magnesium is present in the serum; therefore, a serum magnesium level correlates poorly with the true magnesium status of the brain. Serum levels are only useful when the value is below normal. Red blood cell magnesium level is a commercially available test, which is somewhat more accurate, and if the value is at the lower end of normal range, a magnesium deficiency might be present. The normal range is 4.0 mg/dL to 6.4 mg/dL, and when the patients value is below 5.0, magnesium supplementation might be of benefit. Clinical symptoms other than headaches are also useful in assessing a potential magnesium deficiency. Symptoms include muscle twitching or leg or foot muscle cramps (often nocturnal); fatigue, cold extremities or just intolerance to cold; insomnia; palpitations; and, in women, premenstrual syndrome symptoms (bloating, breast tenderness, irritability). [KP 5] [KP 6] [KP 7] Several double-blind, placebo-controlled (DBPC) studies of magnesium supplementation have been conducted. Of the two largest studies with over 80 patients in each, one was positive19 and one was negative.20 The active treatment in the negative study caused diarrhea in 45% of patients, indicating that the magnesium salt used in the study (magnesium-L-aspartate-hydrochloride trihydrate) was not absorbed. The positive study used a different magnesium salt (trimagnesium dicitrate), which caused diarrhea in only 18% of patients. Another positive but smaller DBPC study of supplementation with magnesium pyrrolidone carboxylic acid21 showed a reduction in the number of days with headache in women with menstrual migraines as well as improvement in premenstrual syndrome symptoms (measured by Menstrual Distress Questionnaire scores). A DBPC pediatric study of magnesium oxide for the prevention of frequent migrainous headaches22 failed on the primary outcome measure of migraine frequency, but was positive for secondary measures of headache days and headache severity. In practice, when magnesium deficiency is suspected, 400 mg of magnesium oxide or chelated magnesium (eg, magnesium gluconate, glycinate, aspartate) can be taken daily with food. Magnesium and other supplements often have to be taken for 1 month or more before any benefits are noticed. These are inexpensive supplements but may be poorly absorbed and cause diarrhea. The slow release form of magnesium lactate is more expensive, but may have better bioavailability and tolerability. If a dosage of 400 mg is tolerated but not beneficial, it can be increased to 400 mg 2 or 3 times a day. Renal disease is the only contraindication, since it is accompanied by reduced magnesium excretion. Recently published evidence-based guideline update (13A) placed the evidence of the efficacy of magnesium in the prevention of episodic migraines in category B probably effective. IV infusion of magnesium has been shown to relieve acute migraine in 86% of patients with low serum ionized magnesium levels and in only 16% of those with normal levels, as seen in Figure 4-2.14 In that study half of the 40 patients had low ionized magnesium levels. Another study demonstrated that an infusion of magnesium aborted migraines with aura but not without aura.23 Infusions can be administered to patients during a severe attack of migraine headache or prolonged aura to treat the attack. A study of IV infusion of magnesium sulfate in patients with cluster headaches showed that the 40% of patients who had low serum ionized magnesium levels had a good response to the infusion, while those with normal levels did not respond.24 I infuse patients who are intolerant to or who do not benefit from oral magnesium in the presence of symptoms of deficiency or low red blood cell serum levels. Serum levels are useful only when they are low. Infusions are simple and safe, considering that only 1 g of magnesium sulfate is used. The patient is infused in a recumbent position because of possible orthostasis from vasodilation; the patient should remain in a recumbent position until the sensation of warmth subsides. One g of magnesium sulfate (available as a 50% solution) is diluted with normal saline, filling a 10 mL syringe, and is administered throughout a 5-minute period by slow push using a butterfly needle. If the sensation of heat is too intense, causing nausea and dizziness, the infusion rate is reduced. If a patient comes to an emergency department, physicians may consider using magnesium infusion as a first-line therapy (Case 4-2). Case 4-2 A 39-year old woman had been suffering from menstrual migraine since puberty. Her headaches started the day before her period and lasted 3 days, during which she was incapacitated by pain, nausea, and vomiting. On review of organ systems she reported having frequent leg muscle cramps and coldness of extremities, both of which worsened during her periods. Sumatriptan injections and prochlorperazine suppositories provided partial relief, but did not restore her to normal functioning because of the residual pain, fatigue, and drowsiness. She had tried propranolol but developed dizziness without relief of headaches. Topiramate caused cognitive impairment. Mini-prophylaxis (taking a prophylactic agent for 1 week, starting 2 days before her period) with naproxen and frovatriptan was ineffective. Continuous contraception stopped her periods for only 2 months and then her period broke through and was accompanied by a severe migraine. Dexamethasone, 8 mg daily for the 3 days of headache provided sufficient relief to allow her to go to work, but she still had a mild headache and nausea and functioned near 50% of her capacity. Oral magnesium supplementation provided no help, but an injection of 1 g of magnesium sulfate during an attack produced dramatic relief without any side effects. She tried increasing the dose of oral magnesium but developed diarrhea. Chelated and slow-release forms of magnesium were better tolerated, but also did not prevent her menstrual migraine. The patient went on to receive monthly premenstrual infusions of 1 g of magnesium sulfate with complete prevention of her migraine attacks. When she traveled and was unable to receive her infusion, severe headache returned. Comment. Magnesium deficiency is common in patients with migraine, but it is often not detectable by measuring serum levels. In patients with other clinical symptoms of magnesium deficiency, a therapeutic trial with an oral magnesium supplement is indicated. If a patient with frequent and severe migraines does not tolerate or respond to oral magnesium, an IV infusion may be highly effective. [end of case] COENZYME Q10 Deficiency of CoQ10, a mitochondrial cofactor, was found in 33% of children with migraines.25 Supplementation with CoQ10 significantly reduced disability and headache frequency. A DBPC trial in 42 adults using 100 mg 3 times a day of CoQ10 was also positive.26 The only side effect that patients are likely to experience is insomnia, or dyspepsia if CoQ10 is taken at night. A dose-ranging study of CoQ10 in Parkinson disease established that only the highest dose, 1200 mg/d, was effective. It is possible that a dose higher than 300 mg/d, usually recommended for migraine, may be even more beneficial. However, in the absence of any data and because of the relatively high cost, the author recommends that migraine patients take 300 mg daily. The American Academy of Neurology guideline update (13A) places CoQ10 in category C possibly effective. [KP 8] [KP 9] RIBOFLAVIN Riboflavin, or vitamin B2, is another mitochondrial cofactor involved in energy generation, also shown to be effective in the prophylaxis of migraine headaches. A single DBPC study was conducted in 55 patients using 400 mg of riboflavin daily for 3 months.27 While the results were positive, a significant difference between riboflavin and placebo was noted only in the third month. Therefore, when using riboflavin for migraine prophylaxis, patients should be advised to take it for at least 3 months. Understandably, patients are reluctant to wait that long to see whether the treatment is successful, and this is a reason to use a combination of riboflavin with magnesium, CoQ10, and at times herbal supplements. Riboflavin is considered probably effective, according to the evidence-based guideline for the prevention of episodic migraines (13A). BUTTERBUR Butterbur (Petasites hybridus) is a common plant that was shown to be effective for the prevention of migraine headaches in a DBPC three-arm study that involved 245 patients.28 A daily dose of 150 mg of butterbur was significantly more effective than placebo, while 100 mg was not. However, butterbur is a toxic plant with teratogenic, carcinogenic, and hepatotoxic properties. The recently updated guideline (13A) considers butterbur effective in the prevention of episodic migraine headaches. [KP 10] FEVERFEW Feverfew (Tanacetum parthenium) is a safe plant that can be ingested raw or in any form a patient desires. Most patients opt for a processed and encapsulated formulation, but the amount of active ingredients (parthenolides) in these products varies widely. The best DBPC study, which was conducted by German researchers, used standardized extract in 170 patients and showed statistically significant improvement.29 This extract is considered probably effective by the updated guideline (13A), but it is not available in the United States. Feverfew products that are available may not be of the same quality and consistency as they lack the regulation of the nutraceutical industry. FOLIC ACID, VITAMIN B12, AND VITAMIN B6 The methylenetetrahydrofolate reductase (MTHFR) gene variant C677T has been implicated as a genetic risk factor in the susceptibility to migraine with aura. The C677T polymorphism reduces enzymatic capability and causes elevated homocysteine levels. It is speculated that disruption of neurovascular endothelium by elevated homocysteine levels is a possible trigger for migraine with aura. It is also possible that this is the cause of white matter lesions and strokes seen in patients having migraine with aura. In a DBPC study, 52 patients experiencing migraines with aura were administered either placebo or 2 mg of folic acid, 400 g of cyanocobalamin (vitamin B12), and 25 mg of pyridoxine (vitamin B6).30 Vitamin supplementation reduced homocysteine by 39% compared with baseline, a reduction that was significantly greater than in the placebo group. Vitamin supplementation also significantly reduced migraine disability, headache frequency, and pain severity. It seems reasonable to check homocysteine level in all patients with migraine with aura.31 [KP 11] ACUPUNCTURE Definitive proof is lacking to show that acupuncture relieves headaches; however, the available evidence from randomized controlled trials strongly suggests that acupuncture produces a benefit extending beyond the placebo effect. A difficulty of conducting blinded trials is that insertion of a needle produces a strong placebo effect, and acupuncture is performed differently in different regions. Placing needles into nonacupuncture spots appears to be as effective. Acupuncture may be as effective as prophylactic drugs at times, however, while causing significantly fewer side effects. The largest study of acupuncture conducted in Germany enrolled 15,056 patients, of whom 11,874 were treated with acupuncture in addition to standard care and the remaining 3182 were randomized to acupuncture or control groups (standard care alone, no acupuncture).32,33 The group of 11,874 patients and those randomized to acupuncture showed a 45% reduction in headache days per month over the course of 6 months as compared to the control group. The study groups included patients with migraine, tension-type headache, and a combination of both, and did not differentiate between the headache types when reporting the results. Acupuncture is widely practiced in Germany, and one study addressed the efficacy of this treatment performed by different specialists. The study revealed that acupuncture was equally effective when performed by all specialists with the exception of orthopedic surgeons, whose results were inferior. [KP 12] OXYGEN Oxygen is an excellent abortive treatment for about 70% to 80% of patients with cluster headache.34,35 It is crucial to use oxygen under high flow (10 L to12 L per minute) through a nonrebreathing mask. (Ten Lpm concentrators are available.) Patients with cluster headache require a large tank of 100% oxygen or a 10-Lpm concentrator. Complete relief is often achieved within 5 to 15 minutes, particularly when the treatment is initiated early in the attack. This treatment is practical for attacks that occur at home, although some patients have a tank of oxygen at home and another at work. Oxygen is devoid of side effects, and the only hazard is an explosion from an open flame. Patients who smoke should be warned about this risk. Oxygen is ineffective for other types of headaches. CAPSAICIN Application of capsaicin into the nostril on the side of cluster headache attacks has been the subject of several small studies. One study was double-blind36 while another compared instillation of capsaicin into the ipsilateral versus contralateral nostril.37 In both studies capsaicin was applied for 7 days; in the double-blind study capsaicin was applied twice daily into the ipsilateral nostril, while in the second study it was applied once a day. Both studies were positive, but because of small sample size the results are suggestive rather than conclusive. SUMMARY While every patient requires an individual approach, these recommendations are applicable to most patients with migraine. Planning regular sleep schedules, regular meals, avoidance of high simple-carbohydrate foods, adequate hydration, restriction and consistency of caffeine intake, regular aerobic exercise, and biofeedback or meditation are reasonable. Many patients also benefit from taking magnesium, CoQ10, riboflavin, butterbur, or feverfew. Patients having migraine with aura and also an elevated homocysteine level should be treated with cyanocobalamin, folic acid, and pyridoxine. Isometric neck exercise strengthens neck muscles and may improve cervicogenic and migraine headaches. Acupuncture is an option for the prevention of headaches. Oxygen can be effective for aborting cluster headache attacks, while intranasal capsaicin might shorten the cluster period. It is important to write down these options for patients to take home as most people will have difficulty remembering them. It is best not to preprint this list, as patients are much more likely to follow advice when it appears to be specifically tailored to and discussed with them. REFERENCES 1. Coughlin AM, Badura AS, Fleischer TD, Guck TP. Multidisciplinary treatment of chronic pain patients: its efficacy in changing patient locus of control. Arch Phys Med Rehabil 2000;81(6):739740. 2. Holroyd K, Drew JB, Cottrell CK, et al. 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Mauskop A, Altura BT, Cracco RQ, Altura BM. Intravenous magnesium sulfate relieves cluster headaches in patients with low serum ionized magnesium levels. Headache 1995;35(10):597600. 25. Hershey AD, Powers SW, Vockell A-LB, et al. Coenzyme Q10 deficiency and response to supplementation in pediatric and adolescent migraine. Headache 2007;47(1):7380. 26. Sndor PS, Di Clemente L, Coppola G. Efficacy of coenzyme Q10 in migraine prophylaxis: a randomized controlled trial. Neurology 2005;64(4):713715. 27. Schoenen J, Jacquy J, Lanaerts M. Effectiveness of high-dose riboflavin in migraine prophylaxis. A randomized controlled trial. Neurology 1998;50(2):466470. 28. Lipton RB, Gobel H, Einhaupl KM, et al. Petasites hybridus root (butterbur) is an effective preventive treatment for migraine. Neurology 2004;63(12):22402244. 29. Diener HC, Pfaffenrath V, Schnitker J, et al. 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High-flow oxygen for treatment of cluster headache: a randomized trial. JAMA 2009;302(22):24512457. 36. Fusco BM, Marabini S, Maggi CA, et al. Preventative effect of repeated nasal applications of capsaicin in cluster headache. Pain 1994;59(3):321325. 37. Marks DR, Rapoport A, Padla R, et al. A double-blind placebo-controlled trial of intranasal capsaicin for cluster headache. Cephalalgia 1993;13(2):114116. KEY POINTS [KP 1] Forty minutes of aerobic exercise performed 3 times a week is effective in preventing headaches. [KP 2] Frequent isometric neck exercise can relieve cervicogenic headaches and improve migraine headaches in patients with associated neck pain or muscle spasm. [KP 3] Caffeine is a major contributor in the transformation of headaches from episodic to chronic. Daily consumption of as little as two cups of coffee or caffeine drinks plus analgesic products containing caffeine can worsen headaches. [KP 4] Reactive hypoglycemia is common in patients with migraine. Adherence to regular mealtimes, small frequent meals, and avoidance of foods with high glycemic index can significantly improve migraine headaches. [KP 5] Serum magnesium levels are unreliable in predicting brain magnesium levels; the commercially available red blood cell magnesium levels are more indicative of the true magnesium status but are not entirely accurate. Magnesium levels in the lower half of normal range should be considered deficient. Serum levels are helpful only when they are low. [KP 6] Clinical symptoms of magnesium deficiency, in addition to headaches, are leg muscle cramps; feeling cold or having cold extremities; and, in women, premenstrual syndrome symptoms. [KP 7] Oral magnesium supplements can cause diarrhea or fail to be absorbed. If there is a strong suspicion of magnesium deficiency or if serum or red blood cell magnesium levels are low, an IV infusion of 1 g of magnesium sulfate can be beneficial. Parenteral treatment of migraine should begin with a magnesium infusion. [KP 8] Supplementation with 300 mg of CoQ10 can be effective in preventing migraines in adults and adolescents. It should be administered in the morning because if taken at night it can cause insomnia. [KP 9] Daily intake of 400 mg of riboflavin can prevent migraine headaches, although in some patients the benefit may appear only after 3 months. [KP 10] Butterbur and feverfew can be effective for the prevention of migraine headaches in some patients. Pregnant women, however, should not take these herbal preparations. Butterbur is associated with several serious potential risks. [KP 11] Patients with migraine with aura should have their homocysteine level checked. If it is high, supplementation with folic acid, cyanocobalamin, and pyridoxine may reduce the homocysteine level and migraine disability. [KP 12] Acupuncture can be effective for some patients with migraine and tension-type headaches, although it can be a time-consuming and expensive treatment. Table 4-1 Acceptance Commitment Therapya (1) The limits of control (short- and long-term costs and benefits), focus on experience (body scan) (2) Values (what you care about, how you want to live your life) (3) Cognitive defusion (observing thoughts without trying to evaluate or change them) (4) Mindfulness (being in the moment) (5) Committed action (road map connecting values, goals, actions, obstacles, and strategies) (6) Review and continued action in support of values (7) Moving forward a Modified from Wetherell JL, Afari N, Rutledge T, et al. A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain 2011;152(9):20982107.3 Table 4-2 Cognitive Behavioral Therapya (1) Three-component cognitive-behavioral therapy model (thoughts, feelings, behaviors), pain monitoring (2) Relaxation training (diaphragmatic breathing, progressive muscle relaxation, guided imagery) (3) Pain-fatigue cycle, activity pacing, and pleasant-event scheduling (4) Identifying and challenging negative thoughts (activity, belief, consequences, dispute model) (5) Problem-solving skills training and assertive communication (6) Review and practice (7) Relapse prevention a Modified from Wetherell JL, Afari N, Rutledge T, et al. A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. 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