Headache — Preventative Treatment — Clinical Pathway: Primary Care

Headache Clinical Pathway — Primary Care

Preventative Treatment

The goals of preventative treatments are to reduce migraine headache frequency, duration, and intensity, and to increase responsiveness to acute medications. It can take two months to see the positive effects of preventative treatment. Nutraceuticals are a reasonable choice to start with. Consider starting for frequently occurring migraine headaches.

Start with riboflavin and/or magnesium. Consider CoEnzyme Q10 if patient is vegetarian, or melatonin if there are problems with sleep.

Medication Dosing Comments
Riboflavin
(Vitamin B2)
  • 4-7 yrs
    • Start at 50 mg
    • If necessary, titrate to 50 mg BID or 100 mg daily
  • 8-12 yrs
    • Start at 100 mg
    • If necessary, titrate to 100 mg BID or 200 mg daily
  • > 12 yrs
    • Start at 200 mg
    • If necessary, titrate to 200 mg BID
  • Consider increasing dose after 2-4 wks of initial tx if inadequate response
  • Turns urine bright yellow, infrequent belly upset, take with food
Magnesium
  • Increase weekly if tolerated – watch for diarrhea
  • Doses as magnesium salt
  • Magnesium oxide and magnesium citrate
    • Doses > 400 mg or 10 mg/kg/dose should be divided BID or TID for better tolerability
  • 15-25 kg
    • 100 mg nightly
    • May titrate by 100 mg per week up to 200 mg per day
  • 25-40 kg
    • 200-250 mg nightly
    • May titrate by 100-200 mg per week up to 400 mg per day
  • > 40 kg
    • 200-250 mg nightly
    • May titrate by 200 mg per week up to 600 mg per day
  • May help with constipation, menstrual migraine, migraine with aura, MSK pains, or anxiety
  • Consider if there is a history of positive response to
    IV magnesium
  • Do not use in children with renal insufficiency
  • Formulations
    • Magnesium oxide
      • 200, 250, 400 and 500 mg forms
      • Poorly absorbed, may cause diarrhea
        with initiation
      • May be covered by insurance
    • Magnesium citrate
      • Gummy forms available
Coenzyme Q10
or CoQ10
  • 1-3 mg/kg/dose (max 100 mg)
    • Morning, daily
  • Available in 100 mg tabs, can be quartered
  • Children who are vegetarian/vegan may be deficient in CoQ10, consider supplementation
  • Can cause upset stomach and difficulty sleeping
Vitamin D3
  • If level < 30 ng/mL
    • 1250 mcg (50,000 units) weekly for 8 wks, then 50 mcg (2,000 units) daily
  • If level > 30 ng/mL
    • Ensure at least 25 mcg (1,000 units) daily through diet or supplement
  • Vitamin D levels are not standardly checked for headache. However, if result available or relevant risk factors, consider this dosing.
Melatonin
  • Start between 0.5 mg and 3 mg
  • Take 30 mins before bedtime
  • Consider for sleep issues

Supplements and Over-the-counter Vitamins

Supplements are not regulated in the same way as pharmaceutical drugs. Some companies voluntarily undergo inspection for the quality of their products. Look for seals such as: USP, NSF, NPA, and GMP to ensure higher-quality ingredients.