The role of vitamin B12 is underappreciated by many doctors. This week, The Wall Street Journal published a full-page article on vitamin B12 deficiency, which can be of great help to many of the two million readers of this newspaper. The survey quoted in the article shows that only one third of patients with this deficiency are diagnosed within a year, 22% within 1-2 years, 20% within 2-5 years 10% within 5-10 years and 14% after more than 10 years. It took several years for the author of the WSJ article to be diagnosed.

A confounding problem is that even if the doctor orders a vitamin B12 level, the widely used blood test is inaccurate. While the normal range is from 200 to 1,200 (depending on the laboratory), cases of severe deficiency have been described with levels of up to 700. You may have a good amount of vitamin B12 circulating in the blood, but it may not be getting into the cells where it is needed for the normal functioning of the nervous system, blood formation, and other functions. Many patients with a level above 200 are told by their doctors that their level is normal, but it should be at least over 400 and even better if it is above 500. We do have two additional blood tests that can confirm if the body needs additional vitamin B12 – homocysteine and methylmalonic acid levels but they are rarely utilized.

It is well worth your time to read the entire WSJ article.

I’ve written several times about the dangers of long-term treatment with PPIs, acid reducing drugs, such as Prilosec and Nexium. Among other side effects, they interfere with the absorption of vitamin B12 and other vitamins and minerals.

As far as headaches, vitamin B12 deficiency can be a contributing factor and taking vitamin B12 along with other B vitamins can relieve migraines.

Pain of facial neuralgia was found to be due to vitamin B12 deficiency in case studies of 17 patients and their pain resolved with vitamin B12 injections.

As the WSJ article suggests, many patients with neurological symptoms require regular injections rather than taking vitamin B12 pills. A couple of hundred of our patients come for monthly vitamin B12 injections, often along with an infusion of magnesium – another very common and highly underdiagnosed deficiency. It is not only migraines and other headaches that improve, but also fatigue, dizziness, and other symptoms.

Here is an old article from the Educational Materials section of our website.

Yet another study shows that low vitamin D level predisposes to neurological problems. A report just published in a leading neurology journal, Neurology by British and American researchers shows that low levels of vitamin D are associated with a higher risk of delirium in hospitalized patients.

This study looked at 313,121 participants, 544 of whom were hospitalized with delirium. The researchers proved that there is genetic evidence supporting connection between vitamin D levels and delirium. They called for trials of correction of low vitamin D levels for the prevention of delirium.

It is a strange call to action because we already know from other large studies that vitamin D deficiency predisposes to several neurological problems. These include not only migraines, but also multiple sclerosis, stroke, and other major diseases  Why not just make sure that nobody has a deficiency? Well, one reason is that insurance companies do not want to pay for the test because we do not have proof that correcting this deficiency will prevent these neurological problems. As we know, correlation does not mean causation. However, conducting large scale studies is very expensive and it takes many years to obtain the results. And why was a normal range for vitamin D was established if not to make sure that people are not deficient.

As I mentioned in my last post on vitamin D in 2015 everyone should have their vitamin D level checked and if you are deficient, get your level up to the middle of normal range. The normal range is 30 to 100, so below 40 is definitely not optimal.

Ginger is not only a popular spice, but a truly remarkable medicinal plant. Ginger’s proven anti-inflammatory properties may be responsible for its beneficial effects in migraine patients. Ginger may be effective for the treatment of seasickness, morning sickness of pregnancy and I recommend it for nausea of migraine as well.

A study published in the journal of the International Headache Society, Cephalalgia examined the effect of ginger, when added to an intravenous pain medication.

Another double-blind study involving 100 patients compared the efficacy of ginger with sumatriptan in the treatment of an acute migraine attack. Patient satisfaction and their willingness to continue treatment was also evaluated after 1 month following intervention. Two hours after using either drug, mean headaches severity decreased significantly. Efficacy of ginger powder and sumatriptan was similar. Adverse effects of ginger powder were less than sumatriptan. Patient satisfaction was similar in two groups.

Considering that ginger has anti-inflammatory properties, it is possible taking it daily may also prevent migraines, although no preventive trials have been conducted to date.

Cefaly is a transcutaneous electrical nerve stimulation (TENS) device designed to treat migraine headaches by stimulating supraorbital nerves. The device was cleared by the FDA in 2014 for both acute and preventive treatment of migraine headaches. The preventive indication was based on a double-blind trial involving only 67 patients, while the use of Cefaly for acute migraines was based only on an open-label trial. A study recently published in Cephalalgia examined the efficacy of this device for acute treatment of migraines in a double-blind trial of 106 patients.

The trial confirmed that Cefaly is indeed effective for abortive therapy of migraine attacks. For prevention, it is recommended to use the device for 20 minutes every day, while to treat an acute attack the device should be used for an hour. The primary outcome measure was the mean change in pain intensity at 1 hour compared to baseline. This primary outcome measure was significantly more reduced in the stimulation group compared to the sham group: 60% versus 30% reduction. No serious adverse events were reported and five minor adverse events occurred in the stimulation group. I’ve had one or two patients report that the device actually triggered a migraine, but this can also happen with any oral migraine drug.

The main reason I offer Cefaly before any other device (eNeura TMS or gammaCore) is that it is the most affordable. The price has gone up since it’s introduction and ranges from $350 to $500, however the manufacturer offers a 60-day return policy. This is long enough to see if it is effective. Cefaly is sold only with a doctor’s prescription, which is uploaded to the Cefaly website (Cefaly.us for US patients and Cefaly.com for the rest of the world).

Several older reports have suggested an association between dry eye disease (DED) and migraine headaches. Researchers at the Univercity of North Carolina at Chapel Hill just published a large and convincing study confirming this comorbidity.

This was a retrospective study which included 72,969 patients older than 18 years seen over a period of 10 years. The study included 41,764 men and 31,205 women. Of these, 5,352 patients (7.3%) were diagnosed to have migraine headaches and 9,638 (13.2%) had the diagnosis of DED. The odds of having DED and migraine headaches was 1.4 times higher than that of patients without migraine headaches. This association was true for men and women older than 65 and women of all ages. Older age and female sex are both risk factors for the development of DED, probably due to hormonal and age-related changes.

The incidence of migraines and DED in the general population are reversed – about 12% suffer from migraines and 7% from DED, which is probably due to the fact that the study included only patients see at ophthalmology clinics.

The authors conclude that patients with migraine headaches are more likely to have comorbid DED compared with the general population, but this association may not reflect cause and effect. Both conditions do share inflammation as one of the underlying processes.

It is very likely that the eye discomfort from DED can be making migraines more frequent and severe. The diagnosis of DED should be considered in all migraine sufferers, especially in those with difficult to control attacks because effective treatment of DED could lead to an improvement in migraines.

Having conducted and published research on magnesium and seeing dramatic improvement from magnesium in many of my patients, I try to write about magnesium at least once a year. Up to half of migraine sufferers are deficient in magnesium and could greatly benefit from it.

Magnesium supplements are considered “probably effective” for the prevention of migraine headaches, according to the American Headache Society and American Academy of Neurology guidelines. The reason magnesium is listed as only probably effective is poor design of most clinical trials. There was no selection of patients – magnesium was given to all without any regard to their magnesium status. Obviously, those who did not have a deficiency did not benefit from taking magnesium and they diluted positive results seen in those who were deficient.

A study conducted by researchers at George Mason University looked at the dietary and supplement data of 2,820 American adults between 20 and 50 years old. They found that higher dietary intake of magnesium led to lower risk of migraines in both men and women. This relationship was even stronger in women, but not men who took magnesium supplements.

They also found that the average consumption of magnesium in these 2,820 Americans was only 70%-75% of the Recommended Dietary Allowance. Obviously, it is better to get your magnesium from food, such as whole grains, dark leafy vegetables, avocados, legumes, and other. However, changing your diet is not easy, so the second best choice is to take a supplement. I recommend 400 mg of magnesium glycinate, but other magnesium salts can also help.

About 10%-20% of our patients who are deficient in magnesium either do not absorb magnesium (we check their RBC magnesium levels) or do not tolerate it and get diarrhea. They do very well with a monthly intravenous infusion of magnesium.

Magnesium has many benefits besides relieving migraines, including possibly preventing Alzheimer’s disease, reducing the size of a stroke, post-concussion syndrome, fibromyalgia, palpitations, asthma, muscle cramps, “brain fog”, and other symptoms.