Consider melatonin for migraine prevention
This affordable, over-the-counter hormone is as effective as amitriptyline, causes fewer adverse effects, and may have a surprising added benefit.
PRACTICE CHANGER
Recommend nightly melatonin 3 mg to your patients with chronic migraines, as it appears to be as effective as amitriptyline in reducing headaches and causes fewer adverse effects.
STRENGTH OF RECOMMENDATION
B: Based on a single, good quality randomized controlled trial.
Gonçalves AL, Martini Ferreira A, Ribeiro RT, et al. Randomised clinical trial comparing melatonin 3 mg, amitriptyline 25 mg and placebo for migraine prevention. J Neurol Neurosurg Psychiatry. 2016;87:1127-1132.1
WHAT’S NEW
An effective migraine prevention alternative with minimal adverse effects
Melatonin is an accessible and affordable option for preventing migraine headaches in chronic sufferers. The 3-mg dosing reduces headache frequency—both in terms of the number of migraine headache days per month and in terms of the percentage of patients with a >50% reduction in headache events—as well as headache intensity, with minimal adverse effects.
CAVEATS
Product consistency, missing study data
This trial used 3-mg dosing, so it is not clear if other doses are also effective. In addition, because melatonin is available over-the-counter, the quality/actual doses may be less well regulated, and thus, there may be a lack of consistency between brands. Unlike clinical practice, neither the amitriptyline nor the melatonin dose was titrated according to patient response or adverse effects. As a result, we are not sure of the actual lowest effective dose, or if greater effect (with continued minimal adverse effects) could be achieved with higher doses.
Lastly, 69% to 75% of patients in the treatment groups completed the 16-week trial, but the authors of the study reported using 3 different analytic techniques to estimate missing data. The primary outcome included 178 of 196 randomized patients (90.8%). For the primary endpoint, the authors treated all missing data as non-headache days. It is unclear how these missing data would affect the outcome, although an analysis like this would tend towards a null effect.
CHALLENGES TO IMPLEMENTATION
Challenges are negligible
There are really no challenges to implementing this practice changer; melatonin is readily available over-the-counter and it is affordable.
ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.
