The beneficial effect of Alpha-lipoic acid supplementation as a potential adjunct treatment in episodic migraines

Abstract

The current study was performed to evaluate the effects of alpha-lipoic acid (ALA) supplementation on lactate, nitric oxide (NO), vascular cell adhesion molecule-1 (VCAM-1) levels, and clinical symptoms in women with episodic migraines. Considering the inclusion and exclusion criteria , ninety-two women with episodic migraines participated in this randomized, double-blind, placebo-controlled, parallel-design trial. The participants were randomly assigned to receive either 300 mg/day ALA or placebo, twice per day for 12 weeks. The primary outcomes included headache severity, headache frequency per month, and duration of attacks and the secondary outcomes included lactate (a marker of mitochondrial function), NO, and VCAM-1 serum levels were measured at baseline and the end of the intervention. At the end of the study, there was a significant decrease in lactate serum levels (− 6.45 ± 0.82 mg/dl vs − 2.27 ± 1.17 mg/dl; P = 0.039) and VCAM-1 (− 2.02 ± 0.30 ng/ml vs − 1.21 ± 0.36 ng/ml; P = 0.025) in the ALA as compared to the placebo group. In addition, the severity (P < 0.001), frequency (P = 0.001), headache impact test (HIT-6) (P < 0.001), headache dairy results (HDR) (P = 0.003), and migraine headache index score (MHIS) (P < 0.001) had significantly decreased in the intervention as compared to the control group. No significant changes were observed for NO levels and duration of migraine pains. ALA supplementation can be considered a potential adjunct treatment in patients with migraine due to its improving mitochondrial and endothelial functions and clinical symptoms.

Full text

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The benecial eect of Alpha‑lipoic
acid supplementation as a potential
adjunct treatment in episodic
migraines
Mahnaz Rezaei Kelishadi1, Amirmansour Alavi Naeini1*, Fariborz Khorvash2,
Gholamreza Askari1 & Zahra Heidari3
The current study was performed to evaluate the eects of alpha‑lipoic acid (ALA) supplementation
on lactate, nitric oxide (NO), vascular cell adhesion molecule‑1 (VCAM‑1) levels, and clinical symptoms
in women with episodic migraines. Considering the inclusion and exclusion criteria, ninety‑two
women with episodic migraines participated in this randomized, double‑blind, placebo‑controlled,
parallel‑design trial. The participants were randomly assigned to receive either 300 mg/day ALA or
placebo, twice per day for 12 weeks. The primary outcomes included headache severity, headache
frequency per month, and duration of attacks and the secondary outcomes included lactate (a
marker of mitochondrial function), NO, and VCAM‑1 serum levels were measured at baseline and
the end of the intervention. At the end of the study, there was a signicant decrease in lactate
serum levels (− 6.45 ± 0.82 mg/dl vs − 2.27 ± 1.17 mg/dl; P = 0.039) and VCAM‑1 (− 2.02 ± 0.30 ng/ml vs
− 1.21 ± 0.36 ng/ml; P = 0.025) in the ALA as compared to the placebo group. In addition, the severity
(P < 0.001), frequency (P = 0.001), headache impact test (HIT‑6) (P < 0.001), headache dairy results
(HDR) (P = 0.003), and migraine headache index score (MHIS) (P < 0.001) had signicantly decreased in
the intervention as compared to the control group. No signicant changes were observed for NO levels
and duration of migraine pains. ALA supplementation can be considered a potential adjunct treatment
in patients with migraine due to its improving mitochondrial and endothelial functions and clinical
symptoms.
Abbreviations
ALA Alpha-lipoic acid
NO Nitric oxide
VCAM-1 Vascular cell adhesion molecule-1
HIT-6 Headache impact test-6
HDR Headache dairy results
MHIS Migraine headache index score
MA Migraine with aura
MwoA Migraine without aura
31P-MRS Phosphorus magnetic resonance spectroscopy
CBF Cerebral blood ow
FMD Flow-mediated dilation
CSD Cortical spreading depression
CAMs Cellular adhesion molecules
ICAM Intracellular adhesion molecules
HIS International Headache Society
CNS Central nervous system
OPEN
1Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical
Sciences, Isfahan, Iran. 2Department of Neurology, School of Medicine, Isfahan University of Medical Sciences,
Isfahan, Iran. 3Department of Biostatistics and Epidemiology, School of Health, Isfahan University of Medical
Sciences, Isfahan, Iran. *email: am.alavi@nutr.mui.ac.ir
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Migraine is dened as a common, chronic, throbbing, weakening neurological disease, accompanied by a seri-
ous one-sided headache, nausea, vomiting, and photophobia1,2. e prevalence of migraine worldwide and in
the United States is estimated to be 14.7%3 and 12%4, respectively. Its incidence is also reported to be about
14% among Iranian adults5. It should be noted that migraine is more common in women than in men (about
three-fold). It also occurs with higher intensity in women6. Migraine headaches are divided into episodic (with
less than 15days/month of headaches) and chronic (with more than or equal to 15days/month of headache
for > 3months, with migraine symptoms on ≥ 8days/month)7. According to the International Headache Society
(IHS) criteria, two main classes of migraine are dened: migraine with aura (MA) and migraine without aura
(MwoA)7. Patients with MA have a combination of optical, sensual, language, or motor function symptoms that
are completely reversible8. e exact pathophysiological mechanisms of migraine are not completely understood.
According to studies, several hypotheses have been proposed in the pathogenesis of migraine9,10. One of the
recognized hypotheses on migraine is hypoxia or mitochondrial dysfunction11; in addition, migraines can be
caused by factors such as nitric oxide hypersensitivity and abnormal cortical activity11.
Phosphorus magnetic resonance spectroscopy (31P-MRS) studies have displayed variations in mitochondrial
energy metabolism in the brains of people with migraine12,13. Also, a signicant reduction of adenosine triphos-
phate (ATP) has been reported in the medial occipital lobe of the brain in MwoA patients11. Mitochondrial dys-
function and decreased oxygen metabolism can be described as the cause of vascular and neuronal dysfunction in
migraine14,15. Hypoxia and mitochondrial dysfunction increase lactate levels in the brain of healthy16,17, MA and
MwoA subjects18,19. In some previous studies, elevated serum lactate levels have been reported in patients with
migraine (both MA and MwoA) compared with control groups18,20,21. In fact, elevated lactate reects mitochon-
drial dysfunction, which may play an important role in migraine19,20. When hypoxia aects tissue, endothelial
cells release nitric oxide (NO), consequently increasing the vasodilatation response and oxygen supply to tissues22.
Endothelial dysfunction has been exposed in MA and MwoA subjects22–29. Past studies have reported increased
cerebral blood ow (CBF) in migraine patients30. Following elevated CBF, NO production in endothelial cells
increases as a response to shear forces and leads to ow-mediated dilation (FMD); thus, it can increase inam-
matory responses28,31,32. Increased NO levels have been demonstrated in both migraines with and without aura33.
It has also been shown that NO supersensitivity may be a possible molecular mechanism of migraine pain34.
NO is involved in stimulating cortical spreading depression (CSD) activity and consequently increasing cellular
adhesion molecules (CAMs)35. According to previous studies, migraine is associated with an increased risk of
several vascular disorders such as ischemic stroke and coronary artery disease36–38. e CAMs present on the
surface of vascular endothelial cells, vascular smooth muscle cells, and leukocytes, mediate the early stages of
atherosclerosis, and are imperative factors in the appraisal of endothelial function27,39,40. CAMs enter the systemic
blood ow in soluble form. e soluble vascular cell adhesion molecule-1 (sVCAM-1) and soluble intracellular
adhesion molecules (sICAM-1) are members of the transmembrane immunoglobulin family and are expressed
by cytokine-activated endothelial cells41. sVCAMs are involved in inammation by mediating leukocyte adhesion
to vascular cells41. CAM serum levels show elevated levels of the intracellular adhesion molecules (ICAM) and
vascular cell adhesion molecules (VCAM) in children and young adults with migraine23,42,43.
e favorable eects of some metabolism-boosting nutrients such as magnesium, coenzyme Q10, riboa-
vin, and -Carnitine in migraine prophylaxis have been proven; these nutrients exert their eects by improv-
ing mitochondrial function44–48. Alpha-lipoic acid (ALA) is an amphipathic antioxidant, which functions as a
co-factor for complex multi-enzymes, such as pyruvate dehydrogenase and ketoglutarate dehydrogenase49,50.
Several studies have shown that ALA has antioxidant and anti-inammatory eects51,52. ALA exerts its antioxi-
dant power in several ways, which include reducing and regenerating oxidized endogenous antioxidants such
as glutathione, vitamin C, and vitamin E, purifying reactive oxygen species (ROS) and nitrogen species (RNS),
and modulating the signaling pathways for the nuclear factor kappa B (NF-κB)53,54. In addition, the protective
eect of ALA on endothelial function has been shown in previous studies55–57. Evidence conrms the safety of
ALA supplementation in various health conditions in children and adults58. One study found that about 90% of
migraine patients had abnormally low values of ALA59. Few previous studies have surveyed the eect of ALA on
the clinical symptoms of migraine60–62. To the best of our knowledge, no study has ever evaluated the eect of
alpha-lipoic acid supplementation on endothelial factors in patients with migraine. us, the existing study was
designed to assess the eects of alpha-lipoic acid supplementation on lactate serum levels, nitric oxide, VCAM-1,
and clinical symptoms in women with episodic migraines.
Materials and methods
Study design. e current study was designed as a randomized, double-blind, placebo-controlled, parallel
trial with a 3-month follow-up. is study was conducted based on the ethical guidelines of the 1975 Helsinki
Declaration63 and was approved by the ethics committee of Isfahan University of Medical Sciences, Isfahan, Iran
(IR.MUI.RESEARCH.REC.1399.436), and also registered in the Iranian Registry of Clinical Trials (http:// www.
irct. ir) as IRCT20161203031212N3. e date of the rst clinical trial registration was 9/11/2020.
Study population. is study included 92 patients with migraine recruited from outpatients referred to
Imam Mousa Sadr Clinic, belonging to Isfahan University of Medical Sciences, Isfahan, Iran, from November
2020 to March 2021. Episodic migraine (< 15 headache days/month) was detected by a neurologist on the rst
visit, in accordance with the criteria of the International Headache Society (IHS)64. All patients were female
and aged between 20 and 50years. Patients were selected based on inclusion and exclusion criteria and then
randomly allocated to the intervention or control group. Before the study commenced, all subjects had a his-
tory of migraine signs for more than 6months, with at least two attacks per month. At the beginning of the
study, informed consent was obtained from the participants. Random assignment was carried out using Per-
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muted Block Randomization (PBR) aer age matching (with a 5-year interval). Randomization was performed
by blocks of two, and random distributions were conducted by a technician cooperating with the study. During
the study, except for the randomization technician, others, including the researchers, patients, and laboratory
technicians, were blinded to the random allocations.
Inclusion criteria. Migraine patients (without aura), with at least 2 attacks per month; headaches lasting
between 4 and 72h; non-menopausal women between 20 and 50years old; non-alcoholic, non-smoker, non-
pregnant, and non-lactating patients; and patients who had been receiving xed medication for at least 4weeks
before entering the study, all of whom agreed to participate in it.
Exclusion criteria. Patients with chronic migraine; patients experiencing menopause, pregnancy or lacta-
tion; history/presence of any chronic diseases (including cardiovascular disease, diabetes, thyroid disorders,
liver diseases, kidney failure, hypertension, and other chronic disorders); malignancies, neurological disorders,
and any changes in received medication (in terms of type or dosage); intake of less than 90% supplement and
following a diet or workout program during the previous six months; taking antioxidant supplements in the
previous 4weeks and during the study; and intolerance of, or allergy to, ALA.
Sample size. e sample size was calculated according to the sample size formula recommended for similar
trials, which considers the severity of migraine as one of the main consequences of the disease, and based on the
previous study (σ equals 1.24) and considering α = 0.05, test power, and eect size were determined to be 80%
and 0.2 respectively48. A total of 45 individuals per group was required.
Intervention. Aer assessing the subjects’ eligibility based on the inclusion criteria and a meeting with a
neurologist, a total of 92 patients were included in the present study; they were randomly allocated to the ALA
(n = 47) or the placebo group (n = 45). e intervention group received 300mg/day ALA supplement (Raha
Company, Iran) twice a day, for 3months, and subjects in the control group received the placebo capsules in the
same package, dosage, color, and form to ensure a blinded design. e ALA or placebo capsules were coded as
A and B in a double-blind method. All the patients and investigators were blinded to the treatment codes. Par-
ticipants were asked to take capsules 15min before lunch and before dinner with one glass of water. e subjects
were given a list of foods containing tyramine, and they were asked not to consume any such foods during the
study. e patients were asked to return to the clinic 40days aer starting the study to receive the second sup-
plement package. Adherence was assessed based on supplement box delivery, counting the remaining capsules,
and patient self-report. Adherence to continuous supplementation was also monitored through phone calls with
the patients once a week.
Assessment of anthropometric characteristics, physical activity, and food intake. e anthro-
pometric assessments, including body weight and height, were carried out as dictated by WHO standard pro-
cesses with the least amount of clothing, and body mass index (BMI) was calculated as weight (kg) divided by
the square of height (m2). ree-day food records were documented at the beginning and end of the study, and
physical activity was recorded at the beginning of the study. Patients were also recommended to maintain their
usual physical activity and dietary pattern during the study. Aerward, the described portion sizes in the records
were converted to grams using household measures. Dietary intake was analyzed by Nutritionist IV soware
(First Databank, San Bruno, CA, USA) adapted for Iranian foods. A short form of the international physical
activity questionnaire (IPAQ) was used to compute the level of physical activity65.
Primary outcomes: clinical status assessment. A neurologist specied the symptoms of the migraine
attacks, for instance, headache severity, frequency per month, and duration. e visual analog scale (VAS) on a
0–10 numeric scale was executed to assess migraine severity66. e duration was expressed based on the mean
duration (hours) of the migraine attacks. Additionally, the migraine headache index score (MHIS) was consid-
ered as the result of headache duration (day) × headache frequency × headache severity.
e headache impact test (HIT-6) is a 6-item questionnaire, an instrument to assess the unfavorable eects of
headaches on the daily performance and wellbeing of the patient. e HIT-6 score for each patient ranges from
36 to 78, and lower scores show weaker migraine eects on the patient’s clinical status. A score above 60 points
indicates severe impact, 56–59 indicates substantial impact, 50–55 indicates intermediate impact, and 36–49
indicates slight or no impact of migraine on the patient’s life67. e validity and reliability of the questionnaires
had formerly been established for Iranians68.
Secondary outcomes: biochemical measurements. Venous blood samples were collected at the
baseline and aer the 3months of intervention, aer an overnight fast of 12h. All the patients were requested
to be present in the laboratory on a headache-free day. To separate the serum, whole blood samples were centri-
fuged at 3000rpm for 10min and were stored at − 80°C until analysis. e serum levels of lactate were measured
using Zell Bio Lactate (ELISA) kits (CAT No. ZB-LAC-96A); in this method, lactate oxidase breaks lactate into
pyruvate and hydrogen peroxide, which reacts in the presence of peroxidase with 4-aminoantipyrine and TBHB
to produce a red chinonimin dye, an increase of color in which is proportional to lactate concentration. Serum
NO levels were measured by the Griess method using a commercial kit (kiazist, Iran). Serum VCAM-1 levels
were measured on the basis of biotin double antibody sandwich technology by commercial ELISA kits (Zell Bio,
Germany; Cat. No: ZB-10203C-H9648).
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Statistical analysis. Statistical analyses were performed using SPSS for Windows version 20 (SPSS Inc.,
Chicago, IL, USA). P < 0.05 was considered statistically signicant in all the analyses. e Q–Q plots, skewness
statistics, and Shapiro–Wilk test were used to judge the normal distribution of the variables. e logarithmic
transformation approach was applied for those markers with an abnormal distribution. For accurate evaluation
of the dierences between the two groups, a two-sided, two-sample, equal variance t-test was applied. Dietary
intakes and physical activity were analyzed using a paired t-test. Numeric, normal variables were stated as means
(SE). Within-group variances pre-and post- intervention were assessed by the paired t-test. To estimate the
eects of ALA on the serum levels of the variables, covariance analysis (ANCOVA) was used, considering the
impact of possible confounders (age, physical activity, total energy intake, marital status, educational status,
economic status, and Gabapentin from drugs). All analyses were performed according to the Per-Protocol (PP)
method, so only participants who completed the 3months study period were entered into the analysis (compli-
ance rate ≥ 90%).
Results
Baseline characteristics. As displayed in Fig.1, 92 women with episodic migraine were enrolled in the
present randomized clinical trial, and 79 patients nished the study. 13 subjects (5 in the intervention and 8 in
the placebo group) dropped out. In the intervention group, 5 patients discontinued the study due to infection
with COVID-19 (n = 2), personal reasons (n = 2), and pregnancy (n = 1). In the placebo group, 8 patients were
excluded due to COVID-19 infection (n = 6), personal reasons (n = 1), and low compliance (n = 1). All partici-
pants were between 20 and 50years old. e baseline anthropometric and demographic features of the patients
included in the nal analysis are shown in Table1. ere was no signicant dierence between the ALA and
placebo groups in terms of anthropometric measurements. Moreover, physical activity levels, drugs, and total
energy intake were not signicantly dierent. Marital (p = 0.023) and economic (p = 0.001) status were signi-
cantly dierent between the two groups.
Randomized (n = 92)
Allocated to intervention group
(n=47)
Lost to follow up n = 5
• Pregnancy (n = 1)
= 2)n (19 Infection -COVID•
• Personal reasons (n = 2)
Allocated to control group (n=45)
Lost to follow up n = 8
6)= n (19 Infection -COVID•
• Personal reasons (n =1)
• Low compliance rate (n = 1)
Assessed for eligibility (n = 92)
Enrollment
Follow-up
Analyzed (n = 42) Analyzed (n = 37)
Allocation
Analysis
Figure1. Flow diagram of the study based on CONSORT statement.
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Dietary intakes. e dietary intake of the participants at baseline and post-intervention are shown in
Table2. Based on the 3-day food records, no signicant intergroup dierences were found in the dietary intakes
for energy, carbohydrates, proteins, fat, micronutrients, and antioxidants.
Clinical signs of migraine. e eects of ALA supplementation on migraine symptoms are to be seen in
Table3. e severity, frequency, duration, HDR, HIT-6, and MHIS were not signicantly dierent between the
two groups at the beginning of the study. Following supplementation with ALA for 3months, signicant reduc-
tions in severity (p < 0.001), frequency (p = 0.001), HDR (p = 0.003), HIT-6 (p < 0.001), and MHIS (p < 0.001)
were found, but duration (p = 0.303) was not signicantly dierent between the two groups. It should be noted
that in the ALA group, all clinical signs, HDR, HIT-6 and MHIS showed a signicant decrease compared with
the beginning of the study (P < 0.001, for all). Variations in the placebo group were signicant for severity, dura-
tion, and HIT6 (p = 0.023, p = 0.003, and p = 0.049 respectively), but changes in other variables were not signi-
cant in this group.
Biochemical measurements. e impacts of ALA supplementation on the biochemical variables in the
female patients with episodic migraine are summarized in Table4 and Fig.2. No signicant dierences were
observed in the baseline levels of NO and VCAM-1 between the two groups, while the baseline levels of lactate
were signicantly dierent (p = 0.018). Aer 3months of intervention, and aer adjustments for the baseline
levels of the confounder variables including age, BMI, marital status, educational status, economic status, drugs,
physical activity, and total energy intake, ALA supplementation signicantly decreased serum levels of lactate
and VCAM-1 in the ALA as compared with the placebo group (p = 0.039 and p = 0.025, respectively). Within-
group analyses showed that lactate serum levels signicantly decreased post-intervention only in the ALA group
Table 1. Baseline characteristics of participants (n = 92). e results of quantitative variables are presented as
mean ± SE. e results of qualitative variables are presented as, n (%). P resulted from independent t-test.
Variables Intervention (n = 47) Control (n = 45) p
Age (years) 40.28 ± 1.291 43.31 ± 1.15 0.084
Weight (kg) 66.771 ± 1.70 69.155 ± 1.77 0.334
Height (cm) 161.363 ± 0.93 160.077 ± 0.85 0.314
Body mass index (kg/m2)25.743 ± 0.70 27.022 ± 0.70 0.204
Physical activity (MET- min/week) 738.85 ± 81.71 676.288 ± 88.19 0.604
Marital status, n (%) 0.023
Married 36(76.6) 33 (73.3)
Single 9 (19.1) 3 (6.7)
Death of spouse or divorce 2(4.3) 9 (20)
Education status, n (%) 0.050
Under diploma 14 (29.8) 21 (46.7)
Diploma 14 (29.8) 16 (35.65)
University 19 (40.4) 8 (17.8)
Economic status, n (%) 0.001
Poor 4 (8.5) 7 (15.6)
Moderate 20 (42.6) 32 (71.1)
Good 23 (48.9) 5 (11.1)
Very good 0 (0) 1 (2.2)
Job, n (%) 0.890
Housewife 38 (78.7) 35 (77.8)
Freelance 6 (12.8) 7 (15.6)
Employee 4 (8.5) 3 (6.7)
Drugs, n (%)
Nonsteroidal anti-inammatory drug (NSAIDs) 27 (57.4) 24 (53.3) 0.692
Beta blockers 6 (12.8) 6 (13.3) 0.936
Tricyclic Antidepressants (TCAs) 11 (23.4) 12 (26.7) 0.718
Tetracyclic antidepressants (TeCAs) 1 (2.1) 0 (0) 0.245
Topiramate 1 (2.1) 0 (0) 0.245
Sodium valproate 7 (14.9) 11 (24.4) 0.248
Gabapentin 6 (12.8) 1 (2.2) 0.057
Benzodiazepine 3 (6.4) 1 (2.2) 0.317
Triptans 4 (8.5) 1 (2.2) 0.169
Selective serotonin reuptake inhibitor (SSRIs) 1 (2.1) 0 (0) 0.245
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Table 2. Dietary intakes of participants, obtained from two dietary records, throughout the study (n = 79). 1 All
values are means ± SE. P resulted by independent t-test.
Intervention (n = 42) Control (n = 37) P
Macronutrients
Energy (kcal/day) 1719.44 ± 37.91 1784.85 ± 27.47 0.164
Carbohydrate (g/day) 237.42 ± 8.74 241.78 ± 11.14 0.759
Protein (g/day) 63.52 ± 2.05 61.23 ± 1.7 0.395
Fat (g/day) 59.69 ± 2.35 67.72 ± 3.76 0.073
Micronutrients
Cholesterol (mg/day) 208.08 ± 13.93 180.22 ± 7.92 0.084
Sodium(mg/day) 2203.18 ± 86.33 2128.46 ± 110.97 0.596
Potassium (mg/day) 2544.59 ± 107.05 2413.98 ± 74.45 0.318
Calcium (mg/day) 870.84 ± 48.21 764.97 ± 34.95 0.077
Magnesium (mg/day) 217.05 ± 10.9 223.97 ± 6.49 0.587
Folate (g/day) 415.30 ± 16.29 464.17 ± 23.45 0.089
Vitamin C (mg/day) 98.26 ± 6.46 87.57 ± 4.34 0.172
Vitamin E (mg/day) 6.37 ± 0.45 6.11 ± 0.44 0.682
Table 3. e eects of Alpha-lipoic acid supplementation on migraine symptoms. P1 resulted from
independent t-test, P2 resulted from paired sample t-test, P3 resulted from analysis of covariance in the
adjusted models (adjusted for baseline level of each Variable, age, BMI, Marital status, Education status,
Economic status, Gabapentin from drugs, Physical activity and energy intake); All values are means ± SE.
1 Frequency of attacks per month. 2 Average duration of migraine attack (hr). 3 Headache dairy results: Duration
of headache (hr) × frequency of headache. 4 Headache Impact Test-6. 5 Migraine Headache Index Score:
Duration of headache (day) × frequency of headache × Severity.
Intervention (n = 42) Control (n = 37) P1 P3
Severity < 0.001
Baseline 8.202 ± 0.25 8.022 ± 0.31 0.657
End 4.72 ± 0.35 7.16 ± 0.40 < 0.001
Mean change(CI) −3.59 (−4.35, −2.83) −0.70 (−1.30, −0.104)
P2 < 0.001 0.023
Frequency10.001
Baseline 5.723 ± 0.43 5.733 ± 0.57 0.989
End 3.34 ± 0.39 5.05 ± 0.67 0.033
Mean change −2.55 (−3.24, −1.87) −0.40 (−1.61, 0.80)
P2 < 0.001 0.502
Duration (h)20.303
Baseline 36.957 ± 4.50 42.872 ± 4.40 0.351
End 15.004 ± 3.62 26.06 ± 4.74 0.064
Mean change −19.49 (−29.49, −9.49) −15.37 (−25.19, −5.54)
P2 < 0.001 0.003
HDR30.003
Baseline 205.851 ± 31.92 251.844 ± 43.98 0.397
End 48.13 ± 11.55 195.66 ± 48.90 0.005
Mean change −158.79 (−223.38, −94.20) −38.63 (−122.39, 45.12)
P2 < 0.001 0.356
HIT64 < 0.001
Baseline 70.383 ± 0.91 69.600 ± 1.37 0.633
End 50.65 ± 1.76 67.27 ± 1.71 < 0.001
Mean change −20.09 (−23.81, −16.36) −2.83 (−5.65, −0.015)
P2 < 0.001 0.049
MHIS5 < 0.001
Baseline 77.867 ± 13.03 83.32 ± 16.97 0.482
End 15.006 ± 3.37 82.99 ± 15.74 < 0.001
Mean change −65.32 (−92.61, −38.02) −0.33 (−29.61, 28.93)
P2 < 0.001 0.981
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(p < 0.001), and VCAM-1 levels decreased in both groups (p < 0.001 in the ALA and p = 0.002 in the control
group). No signicant change was observed for NO levels.
Some side eects reported by patients include stomach pain (6.3% in the intervention group versus 8.8% in
the placebo group), increased appetite (4.2% in the intervention group versus 2.2% in the placebo group), and
constipation (4.4% in the placebo group).
Discussion
e results of the present study showed that 3months of ALA supplementation in women with episodic migraines
led to a signicant reduction in serum lactate and VCAM-1 levels. Moreover, HDR, HIT6, MHIS, and migraine
symptoms, including severity and frequency, were signicantly reduced in the ALA as compared to the control
group. However, changes in serum NO levels and duration of migraine pain were not statistically signicant.
Although the mechanism of migraine pathogenesis is not completely understood, it is supposed that hypoxia
or mitochondrial dysfunction is involved in its pathogenesis11. Mitochondria play a fundamental role in the
functions of neurons through producing adequate ATP and regulating intracellular calcium levels14. MRS studies
in migraine consistently show abnormalities of mitochondrial function such as hypo-metabolism or decreased
ATP levels11,69. Numerous studies have proved that lactic acid levels are increased in migraine patients48. So,
Table 4. e eects of Alpha-lipoic acid supplementation on mitochondrial metabolic disorders marker,
and vascular markers. P1 resulted from independent t-test, P2 resulted from paired sample t-test, P3 resulted
from analysis of covariance in the adjusted models (adjusted for baseline level of each Variable, age, BMI,
Marital status, Education status, Economic status, Drugs, Physical activity and energy intake); All values are
means ± SE.
Intervention (n = 42) Control (n = 37) P1 P3
Lactate (mg/dl) 0.039
Baseline 23.02 ± 0.71 20.47 ± 0.78 0.018
End 16.87 ± 0.60 18.82 ± 0.85 0.062
Mean change(CI) −6.45 (−8.11, −4.79) −2.27 (−4.66, 0.107)
P2 < 0.001 0.061
NO (µM/ml) 0.104
Baseline 270.15 ± 14.42 256.78 ± 11.56 0.474
End 283.69 ± 20.22 243.89 ± 12.54 0.099
mean change 15.75 (−34.03, 65.54) −15.37 (−44.49, 13.75)
P2 0.526 0.292
VCAM1(ng/ml) 0.025
Baseline 6.72 ± 0.22 6.45 ± 0.30 0.480
End 4.63 ± 0.26 5.41 ± 0.37 0.088
Mean change −2.02 (−2.064, −1.40) −1.21 (−1.95, −0. 47)
P2 < 0.001 0.002
Figure2. Comparison of biochemical variables between alpha-lipoic acid and placebo groups before and
aer the intervention. P resulted from paired sample t- test. (a) Lactate, (b) Nitric oxide (NO), (c) Vascular cell
adhesion molecule-1 (VCAM-1).
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elevated levels of lactate are proposed as an indicator of defective oxidative metabolism12,14. Hypoxia is followed
by an increase in CBF, NO, and FMD in migraine22,27,32. It should be noted that NO production is one of the
mechanisms involved in the cortical spreading depression (CSD)-induced alterations of the cerebrovascular
responses35. e activation of CSD results in the increase of ICAM-1 and VCAM-1expression35. It has been
reported that the rises of ICAM-1 and VCAM-1 in the endothelial cells are positively associated with an escala-
tion in transendothelial transportation70. e release of pro-inammatory mediators via the engaged immune
cells further magnies meningeal aerent sensitization71. It is suggested that vasodilation and inammation
induced by endothelial dysfunction contribute to meningeal aerent sensitivity and migraine pain71. It is expected
that improving mitochondrial function and hypoxia status would eectively reduce migraine symptoms by
modulating endothelial function and reducing inammation. e available evidence suggests that consump-
tion of some nutrients such as riboavin44,46, coenzyme Q1047,48, magnesium45 and ALA60–62 have been shown
to improve the clinical symptoms of migraine by improving mitochondrial function.
In this study, we observed that ALA supplementation leads to a reduction in serum lactate levels. Elevated
lactate levels in migraine suerers have been shown in previous studies48,72,73; But a study by Gross etal. reported
dierent results. According to the study, only two migraine patients had high baseline lactate levels59, a result
which was in contrast with other studies18,20,21. None of the previous studies have investigated the eect of
ALA supplementation on serum lactate levels. ALA is an important cofactor for mitochondrial metabolism
and is an essential cofactor for catalysis by some mitochondrial enzymes, including pyruvate dehydrogenase,
α-ketoglutarate dehydrogenase74. Also, ALA displays a critical role in stabilizing and regulating these multi-
enzyme complexes. erefore, by increasing mitochondrial function, ALA can reduce lactate levels and increase
ATP production74.
is study indicated that supplementation with 600mg/day ALA for 3months, did not bring about signicant
changes in the mean levels of serum NO. NO is synthesized from L-arginine by three isozymes of nitric oxide
synthase (NOS), containing neuronal NOS (nNOS), endothelial NOS (eNOS), and inducible NOS (iNOS)75. e
role of NO in the pathogenesis of migraine has been proven in previous studies24. None of the previous trials
have measured serum NO levels in the evaluation of the inuence of ALA on migraine60–62. e results for ALA
supplementation are inconsistent. Badran etal. revealed that supplementation with ALA attenuates endothelial
dysfunction by averting oxidative stress and inammation and restoring NO bioavailability in mice exposed to
chronic intermittent hypoxia (CIH)76.
On the other hand, another study demonstrated that ALA in pharmacologically related doses decreases
the expression of some important inammatory mediators, such as iNOS in rat Kuper cells77. An increase in
the intake of nitrate-containing foods before the nal blood draw may be a possible explanation for the lack of
signicant changes in serum NO levels. As previously documented, serum NO levels are directly aected by
nitrate-containing foods, as NO precursors78. As one of the weaknesses of this study, we did not examine the
levels of intake of nitrate-containing foods.
In the case of the present study, the treatment of women suering episodic migraines with ALA signicantly
decreased serum VCAM-1 concentration. None of the previous studies designed to investigate the eect of ALA
intake on migraine had determined VCAM-1 levels. Neuroinammatory processes and vasomotor changes are
mediated by various neuropeptides and cytokines in migraine. A special pattern of inammatory indicators has
been detected in the systemic circulation in migraine patients, including increased levels of C-reactive proteins
(CRP)79, interleukins (ILs e.g. IL-1 and IL-6)80,81, tumor necrosis factor-alpha (TNF-α) and adhesion molecules
(ICAM and VCAM)23,82. ese inammatory markers disrupt the tendency of the blood cells to aggregate and
lead to thrombosis and endothelial dysfunction83,84. Nilsson Remahl etal. showed that compared with a healthy
control group, the mean levels of soluble adhesion molecules in Cluster Headache patients also tended to be
higher, but statistically signicantly so only for sVCAM-185. In line with our result, in 1999, Kant etal. demon-
strated that ALA decreases expression of VCAM-1 and endothelial adhesion of human monocytes aer stimula-
tion with advanced glycation end products86. e next study in 2006 showed that ALA impedes the expression of
ICAM-1 and VCAM-1 by the central nervous system (CNS), endothelial cells, and T cell migration into the spinal
cord in experimental autoimmune encephalomyelitis87. According to the results of previous studies, Ismawati
etal. in 2019 showed that treatment with ALA in diabetic rats reduces both the oxidated low-density lipoprotein
(oxLDL) levels in plasma and VCAM-1 expression on the aortas55. us, the results of our study are in line with
previous studies. Since during the intervention the use of prophylaxis drugs continued in both the intervention
and control groups, decrease in VCAM-1 levels may have been the result of reduced inammation in the control
group. However, the VCAM-1 intergroup changes are still signicant, which conrms the protective eect of
ALA on endothelial function. ALA exerts its antioxidant eects through the capture of ROS, the regeneration
of endogenous antioxidants and the restoration of oxidized proteins, and modulates the transcription of genes
and inhibits NF-κB activation55,88.
We were able to show that prophylactic ALA treatment favorably aects migraine symptoms, including
frequency (days/month) and severity of attack as well as HDR, HIT6, and MHIS, but the changes in the inter-
group attack duration were not signicant. Visual Analogue Scale (VAS) is a well-validated instrument, which
is used to assess pain intensity89. e results are also in agreement with the ndings in previous studies that
ALA supplementation can decrease migraine severity and frequency. A study in 2007 showed that treatment
with 600mg/day ALA for 3months signicantly reduces migraine attack frequency, the number of headache
days, and headache severity60. Ali etal. in 2010 showed that combined topiramate (50mg/day)/ALA (300mg/
day) therapy meaningfully decreased mean monthly migraine frequency and attack duration compared to those
receiving either topiramate or ALA only61. In another study in 2017, Cavestro etal. reported that the adminis-
tration of ALA (400mg b.i.d. for 6months) might be associated with a reduction in the number of attacks and
the days of treatment in migraineurs with insulin resistance62. Signicant changes in attack duration in both the
intervention and placebo groups following migraine medication could be a reason for the insignicance of the
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intergroup changes. HIT-6 is a short form of the Headache Impact Test questionnaire, which is widely used to
assess the adverse eects of headaches on normal daily activities. e HIT-6 questionnaire consists of 6 items:
that evaluate how oen headaches are caused by severe pain, how oen the headache limits daily activities, how
oen they makes you want to lie down, or how oen they causes fatigue, irritability, and aects concentration.
Each item can have one of 5 responses (Never, Rarely, Sometimes, Very oen, or Always). Aer assigning the
specied numerical value to each answer (6, 8, 10, 11, and 13, respectively), the sum of the scores can be a range
of 36–7890. Analysis of our study data showed that supplementation with ALA reduced HIT-6 by 20 scores in
intervention group, compared with about 3 scores in the control group. e results of the analysis show that
despite the favorable eects of medication on migraine severity and the HIT-6 score in both groups, intergroup
changes remained signicant, indicating a strong prophylactic potential for ALA in migraine. As previously
mentioned, the positive role of ALA in migraine prevention and treatment may be due to diverse mechanisms
such as its function in mitochondrial energy production, antioxidant and anti-inammatory eects55,74.
e present study has several advantages. To the best of our knowledge, this study is the rst research that was
designed to assess the eects of ALA on endothelial markers such as NO and VCAM-1. Also, proper blinding
and controlling confounder elements such as baseline values, drugs received, BMI, and total energy intake can
be noted. However, the study has some limitations. First, we did not measure the serum ALA concentration at
baseline and at the end of the study due to limited nancial resources. erefore, we were not able to determine
the extent of ALA deciency in migraine patients. In addition, the patients’ adherence was determined based on
self-report and the counting of remaining capsules. Second, we did not assess intake of nitrate-containing foods,
which could help interpret serum NO levels. erefore, further studies with a longer duration may be required
to conrm the health prots of ALA supplements in patients with migraine.
In conclusion, the ndings of this study propose that ALA has benecial eects on mitochondrial and
endothelial function as well as clinical signs of migraine. erefore, ALA may be considered as a potential
adjunctive therapy in migraine.
Data availability
e datasets generated during and/or analyzed during the current study are available from the corresponding
author on reasonable request.
Received: 28 March 2021; Accepted: 20 December 2021
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Acknowledgements
e authors would like to thank all participants and their parents. is study is a part of PhD thesis was
approved by the ethics committee of Isfahan University of Medical Sciences, Isfahan, Iran (IR.MUI.RESEARCH.
REC.1399.436).
Author contributions
M.R. designed the study, carried out the trial and wrote the manuscript, A.A. been involved in draing and
revising the manuscript, F.Kh. contributed to diagnosing and referring the patients with the episodic migraine,
Z.H. analyzed the data, Gh.A. been involved in revising the manuscript.
Funding
is study was funded by Isfahan University of Medical Sciences, Isfahan, Iran (code 399435).
Competing interests
e authors declare no competing interests.
Additional information
Correspondence and requests for materials should be addressed to A.A.N.
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