Nutraceuticals for the prevention of migraine in children: Do we know what the benefits and the risks are?

Children with headache have limited evidence-based preventive options. When pharmacological measures are considered, it is not surprising that children are using agents considered to be complementary and alternative in dealing with their headaches. Unfortunately, the use of many of these (and other) headache preventives has outpaced the research which may show clear evidence for their use, or, equally possibly, for their inefficacy. Recognition of the current situation should serve both as a call for more research using welldesigned, double-blind, randomized control trials in pediatric headache prophylaxis, as well as for caution until such evidence accumulates. In their review paper in this edition of Cephalalgia, ‘Nutraceuticals in the prophylaxis of pediatric migraine’, (1) Orr and Venkateswaran summarize and critically appraise observational studies and randomized controlled trials in children and adults of six different treatments for migraine prophylaxis: butterbur, riboflavin, ginkgolide B, magnesium, coenzyme Q10 and polyunsaturated fatty acids. Their review is timely and important, given the prevalence of headache in children, widespread interest in nutraceuticals, and their frequent use for a variety of pediatric and adult medical conditions. Nutraceutical use by patients is likely to be driven by several factors: incomplete efficacy of (prescription) drugs, a reluctance to use (prescription) drugs, perceived safety versus prescription drugs, perceived additional health benefits, availability and, perhaps, advertising. Disadvantages of nutraceutical use include expense if not covered by drug plans, fewer randomized control trials of these agents and so less evidence of efficacy, and increased headache burden when effective therapies are overlooked. Additionally, when individual nutraceuticals are untested or used in an unregulated setting, there is potential increased risk of harm. On the other hand, the use of nutraceuticals in the absence of good studies may cause them to be marginalized by physicians seeking such evidence before recommending them, when, if properly supported and launched, good trials might otherwise have shown those nutraceuticals to be effective. Data from the past decade from the US National Health and Nutrition Examination Survey reveal that 34% of children and adolescents routinely use vitamin and mineral supplements (2), despite the American Academy of Pediatrics not recommending supplemental vitamin use in healthy children older than 1 year who consume a varied diet. Multivitamin preparations for older children and adolescents are not regulated by the Food and Drug Administration, leading to concerns about safety and potential adverse effects. A recent analysis of linked data from the 2007 National Health Interview Survey and the 2008 Medical Expenditures Panel Survey evaluated the prevalence of complementary and alternative medicine (CAM) use among all youth in the USA, as well as youth with recurrent headaches (3). As stated by Orr and Venkateswaran, nutraceuticals are a form of CAM, making this analysis relevant. Of all youth between the ages of 10 and 17, 18.7% used at least one CAM modality (and 10.3% of all youth used specific vitamins/minerals). The estimate of youth experiencing headache was 10.6%; of these, 29.6% had used one or more types of CAM in the previous 12 months, compared with 17.4% of youth with the same diagnoses but without headache. Compared with youth with headache who did not use CAM, CAM users were more likely to be older, white, to live in homes with higher incomes, to have private health insurance and higher maternal education (3).