By Louise M. Klebanoff, MD
Assistant Professor of Clinical Neurology, Weill Cornell Medical College
Dr. Klebanoff reports no financial relationships relevant to this field of study.
Ginger extract has a long anecdotal history as a treatment for migraine headaches in traditional Chinese medicine. This well-designed study provides evidence that adding ginger to a standard nonsteroidal anti-inflammatory medication improves outcomes of migraine treatment by all measured parameters.
Martins LB, Rodrigues AMDS, Rodrigues DF, et al. Double-blind placebo-controlled randomized clinical trial of ginger (Zingiber officinale Rosc.) addition in migraine acute treatment. Cephalgia 2018; doi: 10.1177/0333102418776016. [Epub ahead of print].
Migraine is a common disabling primary headache disorder, affecting 12% of the population of the Western world. Although many medications are available for both the acute treatment and prevention of migraine, side effects and incomplete treatment relief lead to low satisfaction with current therapies. Increasingly, patients are turning to integrative treatment approaches, including nutraceuticals. Ginger (Zingiber officinale Rosc.) is a medicinal plant used for treating multiple conditions in China and India. The ginger rhizome contains several bioactive compounds. Volatile compounds are responsible for its aroma and flavor, and nonvolatile compounds, including gingerols and shogaols, are present in ginger extracts. The pharmacological activity of the nonvolatile compounds includes significant antiemetic, anti-inflammatory, antithrombotic, and analgesic effects, all of which could be helpful in the treatment of acute migraine. Several mechanisms have been proposed to explain the analgesic actions of ginger, including the inhibition of arachnoid acid metabolism via the cyclooxygenase (COX) pathways and blocking lipoxygenase (LOX). In addition, shogaols may modulate the neuroinflammatory response through the down-regulation of inflammatory markers on microglial cells, and gingerols may act as agonists of the capsaicin-activated vanilloid receptors.
Martins et al performed a double-blind, placebo-controlled, randomized clinical trial with 60 participants comparing ginger to standard medical treatment in acute migraine. Patients experiencing a migraine attack of moderate or severe pain intensity were recruited through the emergency department of the Vera Cruz Hospital in Belo Horizonte, Brazil. Patients were between 18 and 60 years of age, had a diagnosis of migraine with or without aura for at least one year, and had one to six migraine attacks a month. The investigators evaluated headache impact using the Headache Impact Test version 6 (HIT-6) and the Migraine Disability Test (MIDAS). All patients with a migraine attack of moderate or severe intensity received ketoprofen 100 mg intravenously. Patients were randomized to receive 400 mg ginger extract or placebo. The primary endpoint was the proportion of patients who responded to treatment two hours after drug intake. Multiple secondary endpoints also were assessed.
Patients who received ginger reported lower pain intensity at one and two hours after drug intake. The proportion of patients who were pain free after two hours was higher in patients receiving ginger (56.7 vs. 33.3; P = 0.03) and more patients reported “no disability.” Photophobia was reported less frequently in patients who took ginger. In both groups, no patient had vomiting after treatment. Most patients (73.1%) who received ginger extract reported being fully satisfied with treatment vs. 28.1% of patients receiving placebo (P < 0.01). Rescue medications were used by 13.3% of patients who received placebo compared to 8.7% of patients who received ginger. Side effects were not different between groups.
COMMENTARY
This well-designed, albeit small, double-blind, placebo-controlled, randomized clinical study found that ginger extract provided improved treatment response when added to standard therapy with ketoprofen. Ginger extract was well-tolerated. Patients receiving ginger had improved pain scores, disability scores, and treatment satisfaction when compared with placebo. There is historical anecdotal support for using ginger in multiple medical conditions, as well as experimental evidence of the mechanism of action of ginger as an anti-inflammatory and analgesic. Considering the frequency of migraine in the general population, the dissatisfaction with current treatment options, and the potential benefits of ginger extract with minimal side effects, ginger extract needs additional evaluation as both an acute and preventive treatment option for migraine.
