What are the best supplements for migraine management?

0:00 my name is Thilinie Rajapaks.  I am a
0:02 neurologist I’m trained in adult and
0:05 pediatric neurology I actually work with
0:06 children at the Stollery Children’s
0:08 Hospital in Alberta Edmonton and I
0:12 wanted to speak to you today I was asked
0:14 to speak to you today about how you can
0:15 incorporate supplements in the treatment
0:17 of migraine
0:18 um I’ll briefly comment on cluster as
0:20 well
0:21 um as always cluster does not have as
0:23 much information as it deserves but we
)0:26 will try to do our Justice to it towards
0:29 the end as well so I’m hopeful that what
0:32 we talk about today can be of assistance
0:35 and help and feel free to put questions
0:37 into
0:39 the Q a I’m not sure if the chat is up
0:41 working at Alex but she’ll take a look
0:44 at it and I’m happy to pause whenever to
0:48 answer questions
0:52 so for today
0:54 um I was asked to comment on how
0:57 patients can assess what are safe and
1:00 effective natural supplement products or
1:03 use in Canada to treat migraine and
1:06 other headache disorders and so what I
1:08 wanted to go over with you all today was
1:10 just some information I think all
1:12 patients should have in an understanding
1:14 in Canada how drugs and in particular
1:18 Natural Health products are regulated so
1:21 to understand what is a safe Natural
1:22 Health product not just for migraine but
1:24 for any health condition that you might
1:26 buy in Canada
1:28 and you know there’s this question of
1:30 can I use supplements to replace drugs
1:32 people are always wanting to find more
1:34 natural ways of treating chronic health
1:37 conditions including migraine or are
1:40 supplements just going to be a
1:41 complementary side therapy to the you
1:44 know stronger medications that I’ll have
1:45 to take for the rest of my life I want
1:48 to briefly talk about drug nutraceutical
1:50 interactions that is how your supplement
1:52 choices might interact with
1:54 pharmacologic or prescription
1:55 medications that you’re already on and
1:58 to understand how to discuss that with
2:00 your doctor or even look into it on your
2:02 own
2:03 um to make sure that you’re not mixing
2:05 and matching potentially dangerous
2:07 combinations
2:09 and then again we’ll talk about health
2:11 Canada’s regulation of Natural Health
2:13 Products I’ll go over a few recommended
2:16 supplements for the treatment of
2:17 migraine there are so so many
2:20 um out there and what I’m going to talk
2:22 about are the ones that
2:24 have the most medical evidence
2:27 for them in terms of research but that
2:30 doesn’t mean we can’t talk about things
2:32 um you know off the cuff in the Q a I
2:35 might not know answers about all of them
2:36 because you all seem to know a lot about
2:39 what’s out there and I try to keep up on
2:41 the science and what’s published but
2:43 um it’s really nice to hear from
2:44 patients about what they are learning
2:46 about also so we can share the
2:47 information together
2:49 um of the ones that I will speak about
2:50 we’ll talk about how they work how to
2:52 start and also how to stop because
2:54 sometimes I think patients feel like
2:56 they get put on medications put on
2:58 things and then put on them for life and
3:00 never told what to do with it how to
3:02 stop how do I know when I’m better
3:05 um we’ll talk about ingredients
3:07 um and in particular just some to be
3:10 aware of or stay away from and um in
3:13 terms of choosing Brands we don’t
3:14 advocate for any particular brand but
3:17 there are some ways to understand what
3:19 might be a safer Choice than others and
3:21 then we’ll go to q a
3:22 um I don’t have anything to disclose and
3:24 in particular I’m not affiliated with
3:26 any companies that make
3:28 um any of the products that I speak
3:30 about I do sit on the American Academy
3:33 of Neurology natural and complementary
3:36 Health
3:37 guideline panel for migrate management
3:39 so that’s really the only thing I do
3:41 that’s related to supplements and
3:44 migraine
3:46 so a bit about me uh I’m a neurologist I
3:49 trained at the University of Calgary and
3:51 I did my fellowship with Dr Werner
3:53 Becker in Calgary and I think he’s very
3:56 well known and loved in the headache
3:57 community and I had an excellent
3:59 experience training with him
4:02 I currently work in Edmonton I’m The
4:04 Clinical Director of the stullery
4:06 headache program at the astrology
4:07 Children’s Hospital in Edmonton Alberta
4:09 so I’m also an assistant professor here
4:11 at the University of Alberta and so I
4:14 have a care and research interest in
4:19 novel treatments for migraine not just
4:22 medications or you know although they
4:25 have their place and their benefits but
4:27 looking at other ways to treat headache
4:29 outside of um
4:32 drug prescriptions
4:34 um I’m also a mom of two boys and so
4:37 that keeps me busy outside of work in
4:39 the hospital and I also experience
4:41 migraine myself so I hope that I can
4:43 come to you with
4:45 um some personal and professional
4:47 experience
4:48 um that might you know make things a
4:50 little more relevant as we are all um
4:53 experiencing the same condition together
4:55 in different ways I just put up a couple
4:57 examples of some of the Publications
5:00 that I’ve had over the years
5:01 and I do have an interest in particular
5:04 in um in sort of nutraceutical or
5:07 natural treatments for migraine
5:09 so I think that’s part of why I was
5:11 asked to speak today as well
5:14 um so Alexandra this is the part I said
5:16 might be a little tricky I’m going to
5:18 exit out of the talk to try to show just
5:19 a quick video I mean let’s be honest we
5:22 all have migraine we all experience it
5:24 so I don’t have to tell you what it is I
5:26 don’t have to tell you the criteria we
5:28 all know what it is
5:29 um but what I thought I’d do is if this
5:31 works I’ll share this video
5:33 just to
5:36 um
5:37 just kind of remind us all what’s
5:38 happening in the brain when we get
5:40 migraine
5:41 um Alexandria is this showing this
5:43 Roblox
5:44 migraine headache video
5:47 it is not um it is not that’s okay I can
5:52 maybe do stop and we share uh let’s see
5:56 how about this
5:57 otherwise okay
5:59 is that one sharing there we are yeah
6:01 okay I will apologize for the commercial
6:04 and play this it’ll take about three
6:06 minutes
6:07 works as a brand new one for you they’re
6:09 a digital gift card
6:12 it’s brought to you by the Association
6:23 to learn more about migraine at
6:25 www.vibratingdisorders.org
6:29 foreign
6:33 all right we’ll stop it there
6:37 and switch back to
6:41 foreign
6:54 can we see back to the slide okay
6:57 perfect so
6:59 [Music]
7:00 um
7:00 I just wanted to go over that because I
7:02 think it’s a nice video that explains
7:04 what we’re all going through in a bit of
7:05 a scientific manner but in speaking
7:08 about what
7:11 um
7:12 and I’m seeing quite a few pop-ups in
7:14 the chat and Q a Alexandra will you let
7:16 me know if there’s something in there
7:17 that we need to
7:19 I think some were just experiencing the
7:21 video a little bit lower volume
7:23 um but I think it gave a great Visual
7:27 and we will provide the link later on so
7:29 don’t worry
7:31 oh and I did not see that while it was
7:33 playing but
7:35 um
7:35 you can share that with you at the end
7:37 of the talk as well the link for that
7:40 um in terms of moving on to
7:42 nutraceuticals or supplements I’m not
7:44 sure if everyone has heard this term but
7:46 it’s coming out in at least the medical
7:49 literature as a word to describe a food
7:52 or dietary supplement that is used to
7:54 provide a health or medicinal benefit
7:56 and so the reason I use this term with
7:58 you all is you know supplement to spine
8:00 too it might be a vitamin it might be a
8:02 mineral what have you
8:04 um doctors are using the term
8:06 nutraceutical and so for us to all speak
8:08 the same language I think is a good
8:09 start in in terms of better health care
8:12 for everyone so this is this is kind of
8:15 a term that’s out in the literature as
8:18 far as Physicians are concerned
8:21 and so this can represent a multitude of
8:23 things dietary regimens
8:26 um
8:26 vitamins minerals
8:30 a whole host of you know plant-based
8:32 vital medicines so the nutraceutical
8:36 industry or area is is quite
8:39 um alive and thriving in many uh disease
8:42 spheres but especially in migraine
8:45 and a lot of people with headache use
8:47 supplements
8:48 um a study in the U.S estimates up to a
8:52 third of children with sort of primary
8:54 headache disorders like tension type or
8:55 migraine use some type of supplement or
8:59 supplement or a complementary
9:01 alternative therapy for their headaches
9:02 and this increases to 84 percent of
9:04 adult headache patients so I’m sure many
9:06 of you here today already have quite a
9:08 bit of experience with supplements in
9:11 the treatment of headache unfortunately
9:13 not everyone thinks to tell their doctor
9:15 that they’re using these um substances
9:18 and as as a physician I really would
9:20 encourage you to share sometimes it’s
9:23 not on purpose it’s an oversight or it’s
9:25 thought oh it’s natural nobody would
9:27 want to know it’s you know it’s like
9:29 mint tea what’s the big deal
9:32 um but we’ll as we’ll talk about later
9:35 some of these supplements are not
9:37 without their own risks and they can
9:40 interact with other medications your
9:42 doctor is prescribing you so I’d always
9:43 encourage
9:45 um you to have a list of what
9:47 supplements you might be taking and
9:48 share them with your doctor again your
9:50 doctor might not be aware of all the I
9:52 certainly I’m sure I’m not aware of all
9:54 the supplements and nutraceuticals that
9:56 are out there for use in migraine but it
9:58 can be something you learn about
9:59 together it can be something you educate
10:00 your doctor about and most Physicians
10:03 now are aware and open to learning more
10:06 about different supplements and I
10:09 certainly learn a lot from my patients
10:13 so
10:15 um I was asked to sort of talk about how
10:17 do we know if a product is safe and and
10:19 whether to use it
10:21 um and in Canada a natural health
10:23 product is a term used to refer to a
10:26 range of products including vitamin and
10:28 mineral supplements Herbal Remedies
10:30 traditional Chinese medicine homeopathic
10:32 medicines
10:33 probiotics and even consumer products
10:37 like toothpaste deodorants shampoos they
10:40 can also be classified as Natural Health
10:42 Products because they may contain
10:44 medicinal ingredients and might be
10:46 intended to be used for a medicinal
10:48 purpose purpose and so if you’re selling
10:50 something like that in Canada
10:53 you need to sort of follow these
10:57 regulatory practices that the government
10:58 has set out and
11:01 um I wanted to briefly talk about what
11:03 happens in Canada again I’m not an
11:04 expert in regulation I just have had the
11:06 opportunity to learn a little bit about
11:07 it and wanted to share with you all so
11:09 that you can understand what happens in
11:11 our country
11:14 so in Canada
11:17 um the commercial sale of Natural Health
11:20 Products is subject to
11:22 um Natural Health Products regulations
11:24 and that’s been this version’s been in
11:27 for since January 2004 and really the
11:30 regulations are to help ensure that
11:32 Canadians have access to Safe effective
11:34 high quality Natural Health Products and
11:37 this is you know a particular passion of
11:39 mine because I I know that around the
11:41 world many governments don’t
11:45 um have this same sort of objective in
11:47 mind and that means that what comes to
11:49 the consumer and the Canadian or other
11:51 sort not Canadian but other citizens
11:53 around the world in terms of what’s able
11:55 to be purchased is sometimes not safe
11:57 um and we certainly wouldn’t want
11:59 um our patients or citizens of our
12:01 country to become ill consuming
12:03 substances
12:04 um they were trying to use to get better
12:07 um and so in Canada to be legally sold
12:09 all natural Health Products have to have
12:12 a product license and the sites have to
12:14 follow very specific manufacturing
12:16 packaging labeling um
12:18 sort of rules and regulations and and
12:21 something that’s called good
12:22 manufacturing practices that are very
12:25 strict regulations that are followed
12:28 between the companies and enforced by
12:30 the government to help sort of obtain a
12:33 product and site license and create that
12:35 product and sell it in the country
12:37 but this is the biggest thing I wanted
12:39 everyone to be aware of and maybe you
12:40 already know about it if you do that’s
12:42 great the natural product number is
12:45 something that Natural Health Products
12:47 that have been licensed for sale in
12:48 Canada will have and it’s often on the
12:51 label as an npn with a number
12:53 um
12:54 but as you can see the eight digit
12:55 number for example on this little
12:57 vitamin C picture if you’re buying a
13:00 product in Canada
13:01 um it should of a natural health product
13:04 it should have an npn and and so if it’s
13:06 there it means that the product has been
13:07 authorized for sale in Canada and it is
13:09 safe and effective when you use it in
13:12 accordance with what is instructed on
13:14 the label and so
13:16 um you know I think if there’s one thing
13:18 I want you to take away from this is
13:19 when you pick up something on the Shelf
13:21 in Canada look for the npn and
13:24 um
13:25 and just understand that that means it’s
13:27 gone through quite a rigorous regulatory
13:30 process to get there this is quite a lot
13:33 of detail but again I want to share with
13:34 you because I was interested to learn
13:36 and I think like everyone would be
13:37 interested to know these things so in
13:39 terms of product licensing
13:41 um all nhps that are sold in Canada need
13:43 to have a license and the license is
13:45 only issued once they’ve decided that
13:48 the product that is being sold is safe
13:50 effective and of high quality and really
13:53 the companies need to provide safety and
13:55 efficacy of Health claims to obtain this
13:58 npn and that can be various types of
14:01 evidence
14:03 ranging from clinical trial data to
14:06 other resources
14:09 to make decisions about um
14:12 sort of efficacy and safety
14:16 and then in terms of labeling
14:18 um they’re really quite strict labeling
14:20 rules that manufacturers have to follow
14:23 in terms of product names doses how it’s
14:26 administered
14:27 and its recommended use or health claim
14:30 lists of ingredients have to be provided
14:33 and then any contraindications or
14:35 Warnings and adverse reactions also need
14:37 to be put on the label and then as I
14:39 said good manufacturing processes or
14:42 practices are just measures designed and
14:44 enforced to make sure that what
14:46 companies are selling
14:47 um
14:48 are of good quality
14:50 and um
14:52 they follow set standards for testing
14:54 manufacturing handling and distribution
14:58 so that was a lot but I was interested
15:00 to learn that so I thought I would share
15:01 that with you too
15:03 um on a more personal level how my
15:05 patient’s always ask me how can I decide
15:07 if supplements are right for me and I
15:09 think it’s a very personal decision
15:11 because it’s one that you make yourself
15:13 you don’t need a doctor to be involved
15:16 you talk to a friend you look something
15:19 up on the internet you decide you’re
15:21 going to go somewhere and find it so
15:22 it’s a very personal decision and I
15:25 think I mean I often feel like you guys
15:27 can answer this question better than I
15:29 can but I feel like my patients are
15:30 looking for alternatives to what’s out
15:32 there right now either medications are
15:35 too expensive they don’t work or they
15:36 have too many side effects
15:39 um and so my patients at least say that
15:42 they’re looking for alternatives to what
15:44 what their
15:46 receiving in care right now and that’s
15:49 no you know
15:52 um negative against uh the industry that
15:55 works very hard to provide effective
15:57 safe treatments for migraine but
15:59 sometimes we just need more and you know
16:02 personal preference and belief can also
16:04 factor into the choice of the
16:06 nutraceuticals or supplements some
16:08 people just want that um sort of natural
16:10 approach and that’s often something I
16:13 see in Pediatrics as well parents go you
16:16 know this isn’t such a big deal is there
16:17 something natural I can try
16:19 um and so that’s you know a decision we
16:21 make together
16:23 and you might also be looking to
16:24 complement like what you’re doing with
16:26 your doctor with prescribed medication
16:30 this is a bigger sort of theoretical
16:33 question of why try any migraine
16:34 preventative and again it’s a shared
16:36 decision between yourself and your
16:37 physician
16:38 um but really
16:40 um there are some criteria but it’s
16:41 really a personal choice usually to my
16:43 patients I’ll say if you have three or
16:45 more severe headache days a month where
16:46 you’re functionally impaired you can’t
16:48 go to school you can’t go to work and it
16:51 does not respond to a usual acute
16:54 treatment you should consider
16:55 preventative or if you’re having six or
16:58 eight days per month and your acute
17:00 medicines are working probably consider
17:02 preventative so you don’t become one of
17:04 those patients that might progress into
17:05 chronic migraine over time
17:07 maybe you don’t have access to good
17:09 acute treatments
17:11 um because they don’t work or you don’t
17:12 like the side effects maybe you have
17:14 very severe symptoms so you might not
17:16 have a migraine very often but when you
17:19 do you can’t move one side of your body
17:20 and that is um very sort of scary and
17:24 disabling and you might want to do
17:25 anything to prevent that even if it only
17:27 happens a couple times a year
17:29 certainly if you feel like migraines
17:30 having an impact on your life
17:33 um and despite your best efforts at
17:35 trying different lifestyle modifications
17:37 avoiding triggers and acute treatments
17:39 you’re just not where you want to be
17:40 that’s another reason to consider and
17:43 obviously we don’t want our patients to
17:44 develop medication overuse headache so
17:46 another reason to consider preventing
17:49 them rather than treating them when they
17:50 come on
17:53 um I hope this Project’s okay I took
17:55 this out of the um
17:58 Canadian Journal of neurological
17:59 Sciences
18:00 um guidelines which are now 10 years old
18:03 uh surprisingly and they’re still very
18:05 good but um need updating for sure I
18:08 wanted to show you all in their summary
18:10 of recommendations here
18:12 um where things like butterbur
18:15 riboflavin coenzyme Q10 Q10 and
18:17 magnesium sit in relation to medications
18:21 from pharmacologic medications that we
18:23 often use for the treatment of migraine
18:26 and I’ll go over what all these
18:27 recommendations and quality of evidence
18:29 means but basically if something is
18:32 strongly recommended in this case by the
18:34 Canadian Headache Society it’s because
18:35 the evidence
18:37 um suggests that its benefits of use
18:41 outweigh its risks and it should be
18:43 um of use to patients in reducing
18:46 migraine frequency and what I wanted to
18:48 show you all is
18:50 supplements now all the studies for all
18:53 these medications and supplements are
18:55 very different in their design and the
18:56 patients that were enrolled in the
18:58 products that were used in the countries
19:00 they were carried out in so it’s
19:01 definitely not like a one-to-one
19:02 comparison but supplements do have a
19:04 role and some evidence
19:07 um in in how they’re used in the
19:11 management of migraine and this is just
19:12 one example of episodic migraine
19:15 um
19:15 so again this is just also another
19:18 summary I can share the resource with
19:20 you
19:21 um later but just to show you where in
19:24 comparison to all the medications that
19:26 your doctor will typically
19:29 um think about prescribing for
19:31 medication where the supplements fit and
19:34 these are a few of the
19:36 um more commonly recommended supplements
19:40 or more commonly studied supplements in
19:42 migraine
19:44 um and the reason I’m showing this to
19:45 you is I know they’re busy slides but
19:47 this is what your doctor looks at when
19:48 you ask a question so it’s good to see
19:50 the other side of things of
19:52 um you know I come to my doctor and I
19:54 have a question what are they going to
19:55 do they’re going to pull up these
19:56 guidelines
19:57 um and these are the guideline
19:59 guidelines that I work on and they’re in
20:02 a update process right now but
20:05 um yeah I think that there is a place
20:08 for supplements in in addition to the
20:10 medications that we use so I just wanted
20:11 to show you how we as Physicians go
20:13 about making these recommendations to
20:15 you based on all the research that’s
20:17 been done
20:18 foreign in general
20:22 um
20:22 supplements work in very different ways
20:24 in migraine it really depends on each
20:27 individual product
20:28 but like medications like prescription
20:30 medications they can be targeted towards
20:33 reducing
20:35 excitability of neurons they can be
20:38 targeted to improve energy metabolism in
20:40 our mitochondria in the low battery
20:41 packs of cells and so things like
20:45 magnesium or coenzyme Q10 or riboflavin
20:48 sort of work more along those lines and
20:52 and some agents can be targeted more
20:54 towards inflammation and
20:57 anti-inflammatory processes so really
21:01 different supplements work in different
21:02 ways but the thing I wanted to share was
21:04 they work quite similarly to some
21:06 medications so
21:08 there even though they’re natural they
21:11 have some very similar Pathways to
21:12 medications that we prescribe
21:16 and I always liked this quote because
21:20 I think sometimes we have this
21:22 misconception that supplements are safe
21:24 that natural products are okay I can
21:26 take as much as I want and it doesn’t
21:27 really matter I can’t overdose but
21:30 really all substances are poisons and
21:33 really what differentiates a poison from
21:35 a remedy is a dose so I think together
21:39 patients and doctors need to be careful
21:41 about any type of supplement you use
21:44 just because it’s natural it doesn’t
21:46 always mean that it’s not without risk
21:51 we sort of talked about this already but
21:54 um I just really want to reiterate that
21:55 sometimes there are no intrinsic
21:56 differences between prescription drugs
21:58 and supplements I treat them all like a
22:00 medication in the sense that they need
22:01 to be noted
22:04 um and in the health record of the
22:06 patient and and just monitor to make
22:10 sure that um
22:11 they are not at risk of interacting with
22:14 any other regimens that the patient is
22:17 uh
22:18 using for their care sometimes people
22:21 like natural cheaper options supplements
22:23 aren’t always cheaper sometimes they are
22:26 um and they can be easier to access you
22:27 can walk into a store and buy them over
22:29 the counter order them online and that
22:31 is often easier than trying to get into
22:33 your doctor’s office
22:37 I got a question of can I take both
22:39 prescription and supplements together
22:40 and
22:42 I’ll talk to you about drug supplement
22:43 interactions and a little interaction
22:45 Checker that you can try on your own at
22:48 home but it can take quite a while for
22:50 some prescription medications to work we
22:53 do advise our patients to try something
22:55 for at least you know six to eight weeks
22:57 preferably even three months is the
23:00 standard um
23:01 time of a trial for a treatment and so
23:04 some patients feel like they would like
23:06 to add a supplement on during this time
23:08 period to sort of augment or provide a
23:11 synergistic approach where the two work
23:13 together Better Together rather than
23:15 alone so that might be a situation in
23:18 which if you tell your doctor look like
23:19 I’d like to try this and this at the
23:21 same time see if things move along
23:23 faster or better that might be something
23:26 worth considering
23:27 if you do that
23:29 um I always do this as a physician I
23:32 think patients can help too in running
23:35 running interaction Checkers on their
23:38 own medications and I think it’s this is
23:41 one example you can go to this website
23:43 um type in your whatever medications you
23:46 might be on and it does have a good
23:49 comprehensive list of supplements also
23:51 and so I can talk to you about whether
23:53 one might alter levels of the other
23:56 um and and I really do like to put this
23:59 information in the hands of patients
24:00 because you guys know your body and your
24:05 medications and your migrating best and
24:07 so it’s nice when a patient comes to me
24:10 and says hey I noticed I’m on these two
24:12 medications is that okay or I’ve noticed
24:14 this combination makes me feel a bit
24:15 strange could we look into that it jogs
24:18 my memory to go oh yeah you know what
24:19 these are two that you know you can
24:21 prescribe together but one might
24:23 increase the level of the other and so
24:24 we should uh be mindful of that
24:29 so the big question which supplements
24:31 are recommended again there’s so many
24:33 out there the ones that I will talk
24:35 about are the ones that have the most
24:37 um scientific randomized control
24:40 um randomized controlled evidence but
24:42 um
24:43 really uh every day I learn about
24:46 something new in terms of what
24:48 supplements are available for the
24:51 treatment of migraine this was
24:54 um a nice little table of
24:57 again this is the doctor version so I’ll
24:59 tell I’ll walk you through this it’s
25:01 just what we look at when you guys ask
25:02 us questions about what to use and what
25:05 might work so um you can see here I
25:08 don’t have my arrows showing Alexandra
25:10 but
25:12 um
25:13 the American Academy of Neurology has
25:15 these levels of evidence Canadian
25:17 Headache Society also has
25:19 um recommendations and levels of
25:21 efficacy all this means is every
25:23 organization is looking out for you and
25:25 trying to analyze the thousands of
25:27 studies that are put out every year
25:30 um to say you know what we as an
25:32 organization organization think this one
25:34 is the best option in terms of efficacy
25:36 this one is the safest option you know
25:37 this one might not be so good this one
25:39 has safety concerns and so
25:42 um the ones that keep coming up in terms
25:44 of worthwhile trying are coenzyme Q10
25:46 magnesium citrate and riboflavin
25:50 um see for a few I wasn’t going to talk
25:51 about just because
25:53 um there was a recommendation against
25:55 its use by the Cana Headache Society not
25:57 for any reason other than it they just
25:59 didn’t feel like the evidence supported
26:00 its efficacy and people might
26:03 individually have uh experience that is
26:06 different from that but we’ll just go
26:08 through a few supplements now and
26:10 hopefully get the conversation moving
26:13 um riboflavin vitamin B2 is a supplement
26:15 I recommend very often to both um
26:18 pediatric and adult patients it’s very
26:20 well tolerated
26:21 in children it’s interesting one of the
26:23 studies showed that it was effective but
26:25 not when used long term over three
26:27 months I think there’s a bit of a
26:30 um a sort of not resistance but you can
26:32 sort of
26:33 get used to it over time and so if you
26:35 want to try it I would suggest trying it
26:37 for three months maybe six months and
26:40 continuing it if it helps but not you
26:43 know just continuing it in three to six
26:45 months if it doesn’t do much for you
26:47 it helps in those mitochondrial energy
26:51 metabolism cells in your body and really
26:55 comes with a strong recommendation by
26:57 the Canadian Headache Society where they
26:58 feel like the benefits outweigh the
27:00 risks even though the quality of
27:02 evidence is low that means maybe it was
27:04 not studied in this
27:06 10 000 person trial where they compared
27:09 5000 people with riboslavin to 5000
27:11 people with Placebo that’s all that
27:13 that’s all that low quality evidence
27:15 means but
27:17 um it doesn’t mean you shouldn’t try it
27:19 and this is one that I’m comfortable
27:21 recommending to patients um both
27:23 pediatric and adult the doses I have
27:26 here are 400 milligrams a day for adults
27:28 and 200 milligrams a day for kids under
27:30 40 kilograms and really there hasn’t um
27:32 been much significant side effects or
27:36 contraindications that I’m aware of
27:37 because it’s metabolized and excreted in
27:40 your urine it will change your urine to
27:42 kind of like a highlighter yellow which
27:44 is just a thing to be aware of nothing
27:46 dangerous but sometimes a bit funny when
27:48 you see it otherwise it shouldn’t
27:50 significantly interact with other
27:51 medications so it’s a nice option to try
27:54 if you are on other dermacologic
27:58 medications and are concerned about
28:00 interactions
28:01 again I have no affiliation with any
28:04 company that sells um medications that
28:06 my patients always tell me like it’s
28:09 hard to find this stuff and so I went on
28:11 Amazon and whale.ca last night and got
28:14 these screenshots and it looks like
28:17 it looks like they’re available
28:19 um certainly I know that when people go
28:21 to buy these items um sometimes it’s
28:23 sold out or the prices can vary but this
28:26 is just an example of two places again
28:27 I’m not affiliated with them at all but
28:29 two places you can find them at as well
28:31 as I’m sure most natural sort of um food
28:35 stores would carry rub a slaven as well
28:38 I just want to be clear it should just
28:40 be vitamin B2 a lot of my patients
28:43 um hopefully you know they take a b
28:45 complex and and tell me yeah I’m going
28:47 to be complex and I’m like oh that’s
28:49 better than nothing but it’s not going
28:50 to Target your mitochondria or your
28:53 battery packs as specifically as vitamin
28:55 B2
28:56 so make sure when you’re at the store
28:58 look from B2 on the bottom
29:01 uh coenzyme Q10 is another sort of
29:04 related it’s different but it’s a
29:07 cofactor that’s also required for
29:08 mitochondrial function and again
29:10 mitochondria are those battery packs in
29:11 your cells that give your cells energy
29:13 and some of the studies were interesting
29:15 in that they found that if you had a
29:17 coenzyme Q10 deficiency you might
29:19 respond better to supplementation you
29:21 don’t have to have a deficiency but
29:24 um
29:24 it’s something you might want to look
29:26 into with your doctor if you’re wanting
29:28 to try this for yourself a typical adult
29:31 dose is 100 milligrams three times a day
29:33 and in terms of side effects um
29:36 certainly I think if you have
29:37 gallbladder or liver issues I would
29:39 maybe not go towards this one it can
29:42 cause some nausea and diarrhea but
29:44 generally it’s considered effective and
29:46 safe in children and adults and again
29:49 gets that strong recommendation from the
29:51 Canadian Canadian Headache Society and
29:54 again this low quality evidence you will
29:56 keep seeing it don’t be saddened by it
29:58 it’s just the state of research in uh
30:01 migraine and research in medicine is
30:04 um sometimes we have to make
30:05 recommendations based on what we have
30:07 and we don’t always have those nice big
30:09 expensive studies like we do at some of
30:12 the pharmacologic medications when it
30:15 comes to supplements
30:18 again I was able to find in on Amazon
30:20 and well.ca so it should be accessible
30:23 again price can sometimes be a limiting
30:26 factor but uh it is is able to be
30:30 purchased
30:32 magnesium is another supplement that
30:35 um
30:36 is very sort of commonly taken by my
30:40 patients and I’m asked about it quite a
30:42 bit when you’re deficient in magnesium
30:44 and there have been studies that have
30:45 shown that many migraine patients
30:47 children and adults are naturally
30:49 deficient in migrant and magnesium and
30:51 then when they take magnesium their
30:53 headaches get better it might be
30:55 worthwhile checking your magnesium
30:57 levels with your family doctor before
30:59 trying magnesium
31:01 um you’re more likely to have a positive
31:02 response if you’re a little bit
31:04 deficient already but that doesn’t mean
31:06 you have to have a deficiency to
31:07 experience benefit from magnesium as a
31:09 supplement
31:11 um the typical dose of the citrate
31:13 formulation is the one that I usually
31:15 use there are many different types it’s
31:16 400 to 600 milligrams a day and
31:19 certainly patients do tell me it can be
31:21 hard on the stomach it can cause
31:23 diarrhea and um sometimes we’re mean and
31:25 we say they say what dough should I take
31:27 and they say basically until until
31:29 you’re going to the bathroom
31:31 um and not too much but that’s how you
31:35 know it’s at a right level in your
31:36 bloodstream so there’s a sweet spot to
31:38 find with your doctor and you can work
31:39 on the doses
31:41 um we don’t recommend its use in
31:43 patients with neuromuscular disease
31:45 because magnesium can affect
31:46 transmission of signals to your muscles
31:48 and kidney disease as well but again it
31:51 got that kind of strong recommendation
31:53 from a Canadian Headache Society so this
31:55 is one that I like to use
31:58 foreign
31:59 give it a green light
32:01 it’s a pretty safe good bet
32:04 and then again it’s available in
32:05 different forms at different locations
32:10 um so this is an interesting topic or um
32:14 product I wanted to bring up with you
32:16 um the pedicities hybridist plant or
32:19 root in particular
32:21 creates butterbur which is a
32:25 um
32:25 spider medicine and plant-based medicine
32:27 that is used to treat migraine it has
32:30 anti-inflammatory properties it
32:31 modulates cgrp which is that
32:34 neuropeptide we’re all excited about in
32:36 migraine now it’s a pain signaling
32:38 neuropeptide the issue with butterbur is
32:41 it actually works quite well in terms of
32:43 preventing migraine and in adults its
32:45 dose is 75 milligrams twice a day but
32:48 the current guidelines are being updated
32:50 and there were some concerns about its
32:52 safety with respect to
32:54 um formulations outside of Canada
32:57 very rarely causing liver disease or in
33:01 some cases liver failure and quite quite
33:03 rare in in terms of the number of events
33:07 but that led to many regulatory agencies
33:11 and then guideline panels afterwards
33:13 saying that we needed to sort of put a
33:16 pause on recommending it however I’ll
33:18 talk about what’s changed in Canada
33:20 recently that might reassure patients in
33:24 Canada
33:26 um but before that we’ll just comment
33:27 briefly on its side effects um burping
33:29 can be an issue which is a funny but
33:31 somewhat frequent side effect of this
33:32 medication and then if you have
33:34 allergies to
33:36 um the daisy family of flowers uh you
33:39 would not want to use this medication
33:40 certainly if you have any liver disease
33:42 or chronic alcohol
33:44 um
33:45 use or abuse because of the very very
33:48 low risk that it could affect your liver
33:50 we advise against its use for those
33:54 particular patients
33:55 currently we’re not recommending its use
33:57 in Pediatrics and pregnancy and that is
33:59 also on the health Canada
34:02 sort of approval that they just received
34:04 in January of last year
34:06 but right now the guidelines are a bit
34:09 tricky and so your doctor May say don’t
34:11 use it but the guidelines are being
34:13 updated and in particular in Canada the
34:17 only formulation that I’m aware of right
34:19 now
34:20 that is safe and does not have the
34:23 presence of these um parallelicity and
34:25 alkaloids or PAs that were found to be
34:28 associated with liver failure in the
34:30 other products worldwide is petadolics
34:33 so again I’m not affiliated with the
34:35 company I’m not saying you know run out
34:38 and buy this particular brand but in
34:40 Canada this is the the brand that
34:43 um
34:44 is
34:46 um a special extract from the parasites
34:48 hybridis plant it has guaranteed 15
34:50 extract a person extract and is free of
34:53 the Pas that we are worried about when
34:55 it comes to risk of liver failure
34:56 outside of Canada
34:59 um and so it can be quite effective for
35:01 the prevention of migraine if you do
35:03 decide to take it talk to your doctor
35:05 let them know you’re taking it you may
35:07 want to monitor your liver enzymes with
35:09 your doctor as an additional safety
35:11 feature and I’m speaking a little bit
35:14 outside of current evidence and
35:17 guideline practices so really just make
35:20 sure if you want to try it that it’s an
35:21 informed decision that you make with
35:23 your doctor and just make sure to follow
35:25 your liver Health closely while you are
35:28 taking it of notes this particular
35:30 product has had no serious Adverse
35:31 Events in Canada for over 20 years so I
35:34 think if you were wanting to try one
35:35 this would be the one to try it foreign
35:40 so next I’m just wanting to make sure
35:43 I’m on time if I get I have about five
35:45 minutes left to talk so
35:47 um with melatonin melatonin is a really
35:49 cool
35:51 um substance in that it it is the clock
35:53 factor that comes from our pineal gland
35:55 deep inside our brain and helps regulate
35:57 our circadian rhythms but it also has
35:59 lots of effects on nitric oxide
36:02 um the opioid system Gaba which is sort
36:05 of an inhibitory neurotransmitter and
36:07 serotonin systems as well
36:09 in one study they found that its use of
36:11 three milligrams nightly was equivalent
36:13 to 25 milligrams of Elavil every evening
36:15 in the prevention of migraine and so it
36:17 was quite effective if you’re looking to
36:19 try a migraine preventative that’s not
36:21 medication and you’re having issues with
36:24 sleep this would be something nice to
36:26 try of course it side effects at higher
36:29 doses is that people get sleepy in the
36:30 daytime so you wouldn’t want to take it
36:33 if you’re waking up at 2 am I wouldn’t
36:35 take it at 2 am I usually tell my
36:37 patients to take in an hour before
36:38 bedtime
36:40 um and it doesn’t
36:41 seem to have adverse effects that are
36:43 quite serious or significant
36:45 interactions with other medications but
36:47 of course you can always put it in that
36:49 interaction Checker if you want to be
36:51 sure
36:52 and so it is recommended as safe and
36:54 effective for kids and adults
36:57 in a lower dose of about three
36:59 milligrams every night
37:02 this one I put up just because I thought
37:04 it might we might want to talk about it
37:06 later there really isn’t a lot to say
37:09 unfortunately because
37:11 state of cannabis research and migraine
37:14 is it’s still a controlled substance in
37:16 the states and so where a lot of our
37:18 studies come out of they’re not really
37:21 studying it in a rigorous manner however
37:23 I know everyone’s talking about it here
37:25 in Canada many people are using it and
37:27 many patients find anecdotal
37:29 or report you know anecdotal benefit
37:32 um so I didn’t want to ignore it I I
37:35 Never Say Never I think
37:37 um in children we’re a little bit more
37:38 strict with it we know that cannabis use
37:40 in adolescence can affect brain
37:42 development
37:43 um decision making impulse control
37:46 um over time and so we don’t recommend
37:48 its use and the Canadian Pediatric
37:50 Association the American Academy of
37:52 Pediatrics have statements cautioning
37:53 against its use in children
37:56 um but certainly maybe we can talk about
37:57 it in the Q a
38:00 I find in in the medical sense
38:03 um cannabis sort of is a washout in
38:07 terms of it sometimes activates some
38:08 pain receptors and deactivate some pain
38:11 receptors in the science so you kind of
38:13 get not a lot of great pain control but
38:15 you might get treatment of anxiety or
38:17 help with sleep
38:18 which can help your headaches
38:21 um in the long run
38:23 so last but not least
38:26 um cluster
38:28 and and supplement use is really a very
38:30 understudied area and so I came across
38:35 some small little surveys that were done
38:38 of cluster patients and one that was
38:40 interesting to me was this 10 000
38:43 international units a day of vitamin D3
38:45 where 80 of the patients there were
38:48 about 110 of them found that it
38:50 significantly reduced their cluster
38:52 symptoms
38:53 um and so vitamin D3 was the one that
38:55 came up for me in my search in addition
38:57 to these other supplements that have
38:59 been tried or studied in small um
39:02 small studies but unfortunately as
39:05 always with cluster the studies are
39:07 small there’s not enough evidence to
39:09 help us understand you know the role of
39:12 supplements in managing cluster headache
39:13 but vitamin D3 is something I would
39:15 consider if you’re not using it and you
39:17 experience clustered
39:19 um we shouldn’t really all be on it for
39:21 different reasons but this particular
39:22 dose was one that was
39:24 published in neurology
39:27 and found to be effective
39:29 or the subset of patients
39:32 this is a super tiny and I’m now seeing
39:36 quite poor quality image and I’m sorry I
39:39 just wanted to show it to you guys
39:40 because this was a survey of almost 500
39:43 cluster patients when they talk about it
39:46 was a qualitative study so they were
39:47 sort of asking them their opinions about
39:48 how do you manage your cluster headaches
39:51 and what do you use many of them
39:53 um you know admitted that illicit
39:56 substances like
39:57 magic mushrooms LSD cocaine ecstasy
40:01 helped
40:02 um again not not saying that that’s the
40:05 way we should go but this is what people
40:07 are doing and so when in the supplement
40:09 section here a large proportion of them
40:11 are saying they found vitamin D omega-3
40:13 fish oils calcium magnesium silk zinc
40:16 taurine and ginger quite quite a lot of
40:20 um varied supplements with varied
40:22 mechanisms of action they found them
40:23 helpful in addition to um
40:27 cannabis wasn’t super helpful for most
40:29 cluster patients in this study but I
40:32 just wanted to bring bring that up to
40:35 you and I can give you the paper or
40:36 reference if anyone wants to look at it
40:38 but it was the just an interesting note
40:41 that we really don’t have enough
40:43 information on cluster patients to make
40:45 a good recommendation right now except
40:47 for maybe vitamin D3 is something I
40:49 would try
40:51 um briefly towards the end how do I
40:52 choose which brand to buy again we don’t
40:55 um support any particular brand
40:57 um through this Society or myself
40:58 personally but just be assured now that
41:01 you’ve learned about the regulatory
41:03 process that any product sold in Canada
41:05 with its own npn is a good start it’s
41:07 gone through quite a tough process to
41:09 get to the show
41:11 um ask your doctor ask your friends and
41:13 family Check reviews on websites
41:16 um but really you might even need to try
41:19 between Brands if you find a riboflavin
41:21 that you like and it works stick with it
41:24 if you want to try and switch between a
41:26 couple of companies I’d recommend that
41:28 before giving up on the supplement
41:29 completely
41:31 um because there is such variation in
41:33 manufacturing processes
41:36 and the question of when to stop
41:38 obviously if you have an immediate
41:39 allergic reaction stop right away
41:42 um difficulty breathing rash swelling
41:45 and as with any medication or treatment
41:47 I tell my patients if the side effects
41:49 are very uncomfortable
41:51 obviously stop but most side effects if
41:54 you can bear with a medication and go up
41:56 slowly on the dose we’ll recede in about
41:58 two weeks
42:00 um we advise to stop after about three
42:03 to six months of effective headache
42:04 treatment that is this supplement should
42:06 have reduced your headaches by 50 or
42:08 more
42:10 um I treat supplements like medications
42:11 if you don’t reduce headaches by 50 or
42:13 more I don’t really consider it
42:15 effective
42:16 um and I know there are some of us out
42:17 there that are struggling with
42:19 very refractory headache that doesn’t
42:21 respond to anything but
42:23 um the sort of general rule of thumb is
42:26 if it’s not doing getting rid of 50 of
42:28 your headaches it’s not doing what it’s
42:30 supposed to
42:31 so when you meet with your doctor always
42:33 ask them
42:34 um do I still need the supplement or
42:36 this medication
42:37 um are there any side effects I should
42:39 be aware of am I able to tolerate it and
42:43 are we using the lowest effective dose
42:47 and so in conclusion I just wanted to
42:49 share with you that I think supplements
42:50 can offer migraine relief either on
42:53 their own or as a complementary therapy
42:55 to whatever you’re doing drug-wise
42:57 medication-wise with your doctor
42:59 supplements do work similarly to
43:01 medications and so I want everyone to
43:03 think of them as such and think about
43:05 how they might interact with the other
43:07 Medical Treatments you’re receiving
43:11 um you know you now understand a bit
43:13 more about Natural Health Products and
43:15 how they’re licensed in Canada and I
43:16 hope that gives you a little more
43:17 Comfort look for that npn when you pick
43:19 up a bottle on the shelf and consider
43:22 trialing a few different supplements
43:24 with your doctor on board and make sure
43:26 it’s a shared decision
43:28 um certainly if you’re doing this on
43:29 your own
43:30 do seek medical assistance uh if you’re
43:34 if you’re feeling kind of lost or
43:35 confused or not sure but I always like
43:37 when my patients tell me what they’re
43:38 trying I learn they learn and we all um
43:41 treat migraine safely together
43:44 that way
43:46 um and that’s it for me