WO2011042701A1 - Compositions for the prevention or treatment of migraine - Google Patents

Abstract

Compositions for the prevention or treatment of migraine are described based on the use of the low doses of particular combinations of safe natural products and the administration of different compositions in the morning and evening that contain components designed to take into account the natural circadian variation of the nutrients in the body and thereby to obtain an increase in effect with lower dosage than currently believed to be efficacious.

Description

Compositions for the Prevention or Treatment of Migraine

FIELD OF THE INVENTION

The present invention relates to compositions for use in the prevention and treatment of migraine, and more particularly to a dietary supplement or kit comprising two compositions for morning and evening administration.

BACKGROUND OF THE INVENTION

Headache, which encompasses migraines, tension type headaches, and cluster headache, is a common and debilitating condition affecting predominantly women with a prevalence between 5 to 25% and in men 2 to 10 %. Migraine is twice as prevalent in the American population than is diabetes with 12% prevalence for migraine compared to a 6% prevalence for diabetes. Migraine, according to the world federation of neurology, can be defined as a familial disorder characterized by recurrent attacks of headache widely variable in intensity, frequency, and duration. The attacks are commonly unilateral and are usually associated with anorexia, nausea and vomiting. It can be divided into two major subtypes: migraine with aura and migraine without aura. A migraine with aura is characterized by the aura, a reversible neurological symptom, that can be a blurred vision or hallucination usually preceding the actual crisis, whereas a migraine without aura does not precede with the aura and usually last for 4 to 72 hours, a large sub-group of which are the menstrual migraines occurring during the menses. Migraine without aura is the most common type representing 80% of the migraine cases.

Not only migraine affects significantly quality of life: among adults of all ages, migraine is 19^th among all causes of disability expressed as years of healthy life lost to disability, but it also presents a significant economical burden on society costing over 40 billion dollars per year in the US and Europe. Moreover, comorbidity of other diseases adds to the burden of healthcare cost as it has been noted that depression is three times more common in people with migraine than in healthy individuals. Two types of treatment are currently available to the migraine sufferer: an acute or an abortive treatment based on relieving the symptoms of the migraine itself and a prophylactic treatment to reduce the frequency and intensity of the attacks. The majority of the acute treatments available such as triptans , ergotamines, analgesics such as acetaminophen, and combination medications have provided some relief, however they all have significant side effects and if frequently used there is substantial evidence that they may cause medication overuse headache, leaving patients without any effective treatment to ease their pain and with a worsening condition than when they started the treatment. Many patients opt out of those treatments for their lack of efficacy over time and or side effects. The costs of those treatments are also very high while potentially providing only a temporary solution to the problem with the risk of significant side effects. Moreover given that 54% of migraine patients experience one or more attacks per month, and 13% claim one or more attacks per week, a prophylactic treatment would be more appropriate being more cost effective (less sick leave from work), but also could relieve the anxiety associated with the patient dreading the next migraine attack. However, the prevention treatments currently available like anticonvulsant drugs (divalproex sodium), beta blockers ( propanolol), calcium channel blockers (flunarizine) , methysergide and antidepressants (selective serotonin re-uptake inhibitors) are essentially the same drugs as the acute treatment drugs, albeit at lower doses, and retain their significant side effects especially over long term usage.

In order to identify the suitable prevention treatment migraine patients often have to test the various options for a number of months until they find one that might help them reduce their frequency of migraine. Moreover, the long term

consequences of their usage is still unknown and there is a need for a usage over a period of 25 years or more as prevalence varies with age, but is the highest between 25 and 50 for both men and women. Some alternative prophylactic treatments with fewer side effects have shown efficacy such as riboflavin, coenzyme Q10, butterbur, magnesium, feverfew, B12 and folic acid, tryptophan, 5 hydroxytryptophan, melatonin , foreverwell™ mix addressing the gutbrain theory (US Patent No: 6517832).

US 2008206360 discloses formulations for the prevention and treatment of headaches, particularly migraine headaches, based on a single composition containing high doses of a combination of minerals, vitamins and plants.

The ones with most noted side effects among them albeit fewer than the

pharmaceutical drugs are the plant based extracts. In particular feverfew can result in an increased tendency to bleed, gastrointestinal disturbances and withdrawal syndrome when stopped suddenly and the active ingredient of butterbur: S-petasin has been shown to have an impact on the reproductive system by inhibiting the production of testosterone in rat testicular cells. Moreover the long term use of the plant based prevention therapy is questionable as side effects might appear over time like in the case of feverfew with minor ulcerations of the mouth appearing in 12% of people treated with feverfew leaves. Mouth ulceration may be a systemic effect and not due to contact dermatitis as consumption of encapsulated product did not reduce the incidence of minor ulcerations.

A number of mixes of the above natural therapies are available, the majority of which consist of a mix of plant extract like feverfew and vitamins using high doses of the ingredients, which questions their suitability for long-term usage. Although the mixes such as feverfew, riboflavin and magnesium have also shown some efficacy in trials, the results were disappointing and did not show a significant improvement over 25 mg of riboflavin which was the placebo whereas feverfew, magnesium and riboflavin all showed significant improvement at the same doses as the doses used in the mix.

SUMMARY OF INVENTION

Broadly, in some aspects, the present invention is based on the recognition that in order to achieve a synergistic effect between the combination of ingredients known to be active in migraine prevention, the timing of administration and specific combination of ingredients and formulations are critical. Accordingly, the present invention addresses the need for an effective prophylactic treatment of migraine that is based on the use of the low doses of particular combinations of safe natural products, thereby helping to provide a treatment that can be employed over a long period of time, and preferably at a low cost compared to currently used prescription drugs. In particular, in some aspects, the present invention is based on the administration of different compositions in the morning and evening that contain components designed to take into account the natural circadian variation of the nutrients in the body and thereby to obtain an increase in effect with lower dosage than currently believed to be efficacious.

Accordingly, in a first aspect, the present invention provides a dietary supplement for use in a method of preventing or treating migraine, wherein the supplement comprises two compositions, (i) a morning composition comprising

methylcobalamin, riboflavin or F N, zinc, and thiamine or benfotiamine for administration to a subject in the morning; and (if) an evening composition comprising melatonin, methylfolate, pyridoxine or pyridoxal 5 phosphate, and magnesium for administration to a subject in the evening.

Preferably, the morning composition comprises between 10-1000 meg of methylcobalamin, between 25 and 200 mg riboflavin or FMN, between 5 and 50 mg zinc, between 5 and 100 mg thiamine or benfotiamine and/or the evening composition comprises between 0.1 and 1 mg melatonin, between 0.5 mg and 0.8mg methylfolate, between 5mg and 100 mg pyridoxine or pyridoxal 5 phosphate, between 50mg and 400 mg of magnesium. In some embodiments, the morning and evening compositions consist of the stated components, i.e. further active components are not present. However, in this case, the compositions may contain in addition to the stated active components, any excipients or carriers required for the formulations.

It is also preferred that the effect of the morning or evening pills is synergistic as compared to the administration of the components of the pill. In combination with the components of the pills, taking into account the natural circadian variation of the nutrients in the body enables the pills to contain relatively low doses of the components as compared to treatments proposed in the prior art using the individual components, thereby providing a beneficial effect to the patient while helping to minimize some of the side effects, such gastrointestinal disturbances, observed when higher doses are used. It is also preferred that in contrast to many prior art formulation, the compositions of the present invention do not contain any whole plant components or plants extracts in them.

In preferred embodiments, the present invention may result in one or more of the following additional advantages:

• In order to overcome the issues of absorption seen in migraine patients due to their gastrointestinal status, the specific combinations of the different components take into account the interactions between the components and the specific form of the components, thus further contributing to the activity seen at lower dosage than the treatments proposed in the prior art.

• The components of the pills might provide "positive side effects" by

preventing the occurrence of other diseases due to a dysregulation of the biological clock, inappropriate diets creating vitamin and mineral deficiencies as well as preventing migraine.

• The lack of phytotherapy, such as feverfew or butterbur, in the composition further reduces the risk of rebound effects when stopping the treatment and of side effects in the long term.

• The low dosages and low toxicity of the prophylactic treatment might further allow for the use of the treatment in the prevention of migraine in children for whom there is very little choice of treatment available.

The compositions may each be in the form of a pill, a tablet, a capsule, a powder, a patch or a liquid. Preferably, the morning composition is a sublingual tablet and/or the evening composition is a slow release tablet. The preferred sublingual and slow release formulations used are specifically designed to take into account the unusual gastro-intestinal disturbances migraine patients suffer from in order to optimize the absorption of the components.

In a further aspect, the present invention provides a kit comprising two

compositions,(i) a morning composition comprising methylcobalamin , riboflavin or FMN, zinc, and thiamine or benfotiamine; and (ii) an evening composition comprising melatonin, methylfolate, pyridoxine or pyridoxal 5 phosphate, and magnesium.

In a further aspect, the present invention provides a dietary supplement or kit according to the present invention for use in a method of preventing or treating migraine.

In a further aspect, the present invention provides use of (i) methylcobalamin , riboflavin or FMN, zinc, and thiamine or benfotiamine; and (ii) melatonin, methylfolate, pyridoxine or pyridoxal 5 phosphate, and magnesium in the manufacture of a medicament for preventing or treating migraine, wherein the medicament comprises a first composition comprising components (i) for morning administration and the second composition comprising components (ii) for evening administration.

In a further aspect, the present invention provides a method of preventing or treating migraine, the method comprising administering to a patient in need of treatment thereof a prophylactically or therapeutically effective amount of the dietary supplement or kit according to the present invention thereby to prevent or treat migraine. In the present invention, references to the treatment or prevention of migraine include migraine with aura and migraine without aura (including but not limited to menstrual migraine), and tension headache whereby symptoms to be relieved are selected from but not limited to the group consisting of unilateral head pain, nausea dizziness, throbbing pain, worsening of pain by light, physical activity and sound.

Embodiments of the present invention will now be described by way of example and not limitation.

DETAILED DESCRIPTION OF INVENTION

The mechanisms underlying migraine are complex and incompletely understood. It is a genetically based disease with so far at least 3 genes involved. Migraine is usually initiated by a trigger, which is either endogenous (such as stress or estrogen fluctuation during menses) or exogenous (such as changes in weather and bright sunlight).

Many theories have been proposed to explain the etiology of migraine. The vasodilatory theory suggests that the extracranial arterial dilation during an attack is related to migraine pain. However, it has been shown that there was no vasodilatation of meningeal and blood vessels in the brain during migraine attacks (Migraine headache is not associated with cerebral or meningeal vasodilatation-a 3T magnetic resonance angiography study, Schoonman GG, van der Grond ], Kortmann C, van der Geest RJ, Terwindt GM, Ferrari MD Journal of Neurology 2008 Aug Volume 131 Issue Pt 8 Pages 2192-200).

The more recent theories consider migraine as a primary disorder of the brain whereby the trigeminovascular system activation plays a major role as it is involved in the nociceptive process resulting in a neurogenic inflammation provoking the release of a number of inflammatory factors leading to pain. Increased neurone excitability, decreased inhibition or decreased pre-activation levels have all been proposed as initial events that might trigger the trigeminovascular activation.

A deficit of mitochondrial energy metabolism has also been shown to play a role in the pathogenesis of migraine (Tepper SJ, Rapoport A, Sheftell F. The pathophysiology of migraine. Neurologist 2001;7:279-86.).

Alterations in the tryptophan pathways are thought to play a major role in migraine. Tryptophan is a precursor on the one side to serotonin and melatonin and via the kynurenic pathway to nicotinamide on the other side. Dysregulation of the tryptophan pathways in migraine may lead to an accumulation of homocysteine on one side and to quinolinic acid on the other as a deficit in cofactors essential to shifting the balance towards the production of serotonin and melatonin as been shown in migraine.

In migraine patients, low melatonin and high homocysteine levels have been noted. A dysregulation of the biological clock, which can be visible through a dysregulation of the tryptophan pathway can lead to an increase in homocysteine as a reduction in melatonin can result in an increase in homocysteine fj Pineal Res. 2002

Jan;32(l):63-4.Homocysteine levels are increased due to lack of melatonin in pinealectomized rats: is there a link between melatonin and homocysteine? Baydas G, Gursu F, Cikim G, Canatan H.).

A number of neuromediators, that are key players in the regulation of the biological clock, have been implicated in migraine, in particular melatonin, serotonin and dopamine but also recently glutamate an excitatory mediator (Vikelis M, Mitsikostas DD The role of glutamate and its receptors in migraine.CNS Neurol Disord Drug Targets. 2007 Aug;6(4):251-7.) Moreover, migraine is exacerbated by light and might even be triggered by intense bright light. Serotonin turnover in the central nervous system undergoes marked circadian and seasonal rhythmicity (Acta Psychiatr Scand Suppl. 1980; 280:75-85. Seasonal and circadian monoamine variations in human brains examined post mortem.Carlsson A, Svennerholm L, Winblad B.), and is rapidly stimulated by light exposure (Lancet. 2002 Dec

7;360(9348):1840-2] Effect of sunlight and season on serotonin turnover in the brain. Lambert GW, Reid C, Kaye DM, Jennings GL, Esler MD). Serotonergic innervation of the suprachiasmatic nucleus (SCN), a key player in the regulation of the biological clock, serves to modulate light-induced glutaminergic input whereby 5 hydroxy-tryptophan, the precursor of serotonin inhibits the light-input pathway to the SCN (Neurotransmitters of the suprachiasmatic nuclei Vallath Reghunandanan and Rajalaxmy Reghunandanan Journal of Circadian Rhythms 2006, 4:2). If there would be an unbalance of the tryptophan pathway due to a dysregulation of the biological clock, intense light might result in an increase in glutamate and thus trigger a migraine and correcting this dysregulation might therefore prevent migraines. Moreover, a deficiency of pineal melatonin has also been proposed as a cause for migraine (Ital J Neurol Sci 1986 Jun;7(3):319-23. Is migraine due to a deficiency of pineal melatonin? Toglia JU), which in effect might be caused by a dysregulation of the biological clock.

The present invention aims at correcting the dysregulation of the biological clock believed to be a root cause of migraine, by providing sufficient building blocks through cofactors and enzymes which are either deficient in migraine patients or in excess because of genetical mutations or lack of absorption, and which are essential for the functioning of the different chemical pathways influencing the regulation of the internal clocks, leading to a prevention of migraines.

In preferred embodiments of the present invention, the specific formulations of the morning composition and evening composition take into account the interactions between minerals and vitamins, the pharmacodynamics and pharmacokinetics of each active ingredient in relation to the specific characteristic of a migrainous digestive system which is often slower with gastric stasis and presents other gastrointestinal disturbances (/ones R, Lydeard S. Irritable bowel syndrome in the general population. BMJ 1992;304:87-90 ; Kurth T, Holtmann G, Neufang-Huber J, Gerken G, Diener HC. Prevalence of 46 unexplained upper abdominal symptoms in patients with migraine. Cephalalgia 2005;26:506-10 ; Chen TC, Leviton A, Edelstein S, Ellenberg JH. Migraine and other diseases in women of productive age. The influence of smoking on observed association. Arch Neurol 1987;44:1024-8) in order to optimize the absorption and distribution of the ingredients allowing for the synergistic activity. To our knowledge, no migraine prevention treatment using supplements has taken these combined points into account. Alternatively or additionally, the low doses of the components and the lack of phytotherapy in the compositions allow for a reduced risk of long term side effects, and might even lead to general health benefits by preventing the negative evolution of other chronic diseases, given that it has been shown that a large portion of the population are deficient in a number of the active ingredients detailed in the invention through their diet and life style leading to an increase risk of a number of diseases such as cardiovascular disease and diabetes. The present invention would thus provide a formulation of supplements that are conducive to good health while providing a prophylactic treatment for migraine.

The components were chosen on the basis of their clinical evidence in migraine treatment while playing a role in the regulation of the internal biological clock either directly of indirectly, for their positive interaction and for their activity shown in the case study. The active ingredients of the present invention are listed below.

MAGNESIUM

Magnesium deficiency is wide spread. Magnesium is extremely important for the metabolism of Ca, K, P, Zn, Cu, Fe, Na, Pb, Cd, HC1, acetylcholine, for many enzymes, for the intracellular homeostasis and for activation of thiamine. Magnesium depletion may be due to dysregulation of biorhythms (New perspectives in magnesium research, Nutrition and Health springer London 10.1007/978-1-84628- 483-0JL0 Yoshiki Nishizawa, Hirotoshi Morii and Jean Durlach). Migraine may be considered as a type of chronophathological form of magnesium depletion with hypofunction of the biological clock [Importance of magnesium depletion with hypofunction of the biological clock in the pathophysiology of headhaches with photophobia, sudden infant death and some clinical forms of multiple sclerosis Magnesium Research. Volume 17, Number 4, 314-26, December 2004 Jean Durlach, Nicole Pages, Pierre Bac, Michel Bara, Andree Guiet-Bara)..Magnesium depletion has been shown in migraine patients, in particular, headache has been linked to photosensitive magnesium depletion (Headache due to photosensitive magnesium depletion Magnesium Research. Volume 18, Numero 2, 109-22, June 2005, Original article Auteur(s) : j Durlach, Nicole Pages, Pierre Bac, Michel Bara, Andree Guiet- Bara) and levels of magnesium in serum, salivary secretions and red blood cells are reduced in migraine patients with and without aura as well as brain magnesium (Headache. 1992 Mar;32(3):132-5. Serum and salivary magnesium levels in migraine. Results in a group of juvenile patients. Gallai V, Sarchielli P, Coata G, Firenze C, Morucci P, Abbritti G). Magnesium has shown efficacy in the clinic in migraine prophylaxis at high doses, with mixed results. In a double blind randomized placebo controlled study of patients with migraine without aura taking 600 mg/day of magnesium, the attack frequency, and severity decreased significantly (The effects of magnesium

prophylaxis in migraine without aura Magnesium Research. Volume 21, Number 2, 101-8, June 2008, Emel Koseoglu, Abdullah Talaslioglu, Ali Saffet Gonul, Mustafa Kula]. In another trial, the attack frequency was reduced by 41.6% in the

magnesium group and by 15.8% in the placebo group compared to the baseline (p < 0.05) (Cephalalgia. 1996 Jun;16(4):257-63. Prophylaxis of migraine with oral magnesium: results from a prospective, multi-center, placebo-controlled and double-blind randomized study. Peikert A, Wilimzig C, Kohne-Vo!land R).

Magnesium absorption depends on a wide range of factors and might be the cause of the conflicting clinical trial results whereby no efficacy was seen in some trials (Med Hypotheses. 2001 Feb;56(2):163-70 The multifaceted and widespread pathology of magnesium deficiency ; Johnson S, ; Headache. 2004 May;44(5):445-6. Oral magnesium oxide prophylaxis of frequent migrainous headache in children: a randomized, double-blind, placebo-controlled trial.Wang F, Van Den Eeden SK, Ackerson LM, Salk SE, Reince RH, Elin RJ). In preferred embodiments, the present invention uses specific forms of magnesium in order to overcome at least some of these absorption difficulties.

Moreover, Magnesium interacts with a number of vitamins and minerals preventing their absorptions, which might be the reason for the lack of efficacy in the clinic of certain mixes combining riboflavin, feverfew and magnesium (A combination of riboflavin, magnesium, and feverfew for migraine prophylaxis: a randomized trial.

Headache, 2004 Oct;44(9):885-90 Maizels M, Blumenfeld A, Burchette R.)

The present invention takes into account those interactions further optimizing the absorption.

Organic forms of magnesium (MgJ, in particular Mg gluconate are more absorbable than inorganic salts (Study of magnesium bioavailability from ten organic and inorganic g salts in Mg-depleted rats using a stable isotope approach, Magnesium Research. Volume 18, Numero 4, 215-23, december 2005, C Coudray, Rambeau, C Feillet-Coudray, E Gueux, JC Tressol, A Mazur, Y Rayssiguier). Magnesium citrate, also an organic form of Mg was found to be more bioavailable than other forms in a double blind study (Mg citrate found more bioavailable than other Mg preparations in a randomised, double-blind study Magnesium Research. Volume 16, Number 3, 183-91, September 2003, Ann F Walker, Georgios Marakis, Samantha Christie, Martyn Byng , Hugh Sinclair.) In the preferred embodiment of the invention, magnesium is in the form of magnesium citrate. Although other forms such as magnesium gluconate and magnesium taurate are also included as alternatives in the present invention, magnesium taurate presenting advantages in migraine prevention due to the role of taurine. Taurine participates in melatonin production and action (Brain Res. 1979 Apr 20; 166(1) :65-74. Taurine: stimulation of pineal N-acetyltransferase activity and melatonin production via a beta-adrenergic mechanism. Wheler GH, Weller JL, Klein DC.) and is considered a darkness mimicking agent. Taurine plays a role in the maintenance of homeostasis in the central nervous system during hyperexcitability. An increase in taurine may therefore act as a protective inhibitory neuromodulator and be effective in the prevention of migraine.

Magnesium is well tolerated and may occasionally result in abdominal cramps and diarrhea, especially at high doses and with poor bioavailable forms.

Magnesium has a clear circadian variation with a peak in the first hours of the day increasing during the night (Clin Ter. 2008 Sep-Oct;159(5):329-46 Kanabrocki EL, Sothern RB, Ryan MD, Kahn S, Augustine G, Johnson C, Foley S, Gathing A, Eastman G, Friedman N, Nemchausky BA, Kaplan E., Circadian characteristics of serum calcium, magnesium and eight trace elements and of their metallo-moieties in urine of healthy middle-aged men ; Clin Chim Acta. 1978 Jul 1;87(1):35-41. Serum

magnesium circadian rhythm in human adults with respect to age, sex and mental status; Touitou Y, Touitou C, Bogdan A, Beck H, Reinberg A.). In the prior art, the administration of magnesium in the migraine treatments has never taken into account the circadian variation.

Magnesium is one of the components used in the formulations of the present invention. The preferred formulation for the magnesium is a slow release formulation of magnesium citrate, magnesium gluconate or magnesium taurate that mimics the circadian progressive increase of magnesium during the night which is added to other components with which it may have a synergistic activity and administered before going to bed. Adding it to the evening pill contributed to the reduction in migraine seen in the case study.

MELATONIN

Substantial evidence points to melatonin as playing a role in the regulation of circadian rhythms, sleep and headache disorders (Cephalalgia_^ 2005 Jun;25(6):403- 11. Melatonin, the pineal gland and their implications for headache disorders. Peres MF). A deficit in nocturnal melatonin levels was seen in menstrual migraine, chronic and episodic headaches and during migraine crisis (Cephalalgia. 1995

Apr;15(2):136-9; discussion 7 Nocturnal melatonin excretion is decreased in patients with migraine without aura attacks associated with menses ) Brun , B Claustrat , P Saddier , G Chazot ; Funct Neurol. 2008 Apr-Jun;23(2):77-81. Plasma melatonin pattern in chronic and episodic headaches: evaluation during sleep and waking. Bruera O, Sances G, Leston J, Levin G, Cristina S, Medina C, Barontini M, Nappi G, Figuerola MA; The Journal of Headache and Pain Volume 9, Number 4 / August, Z008 Low urinary 6-sulphatoxymeIatonin concentrations in acute migraine Marcelo Rodrigues Masruha, Domingos Savio de Souza Vieira, Thais Soares

CianciaruUo Minett, Jose Cipolla-Neto, Eliova Zukerman, Luiz Celso Pereira Viianova and Mario Fernando Prieto Peres.)

Melatonin has shown efficacy in the prevention of migraine at 3mg doses in a double blind placebo trial (Neurology. 2004 Aug 24;63(4):757.Melatonin, 3 mg, is effective for migraine prevention. Peres MF, Zukerman E, da Cunha Tanuri F, Moreira FR, Cipolla-Neto J]; and 14 out of 21 children reported that the headache attacks had decreased by more than 50% compared to baseline and 4 of them reported having no attacks (Neurol Sci. 2008 Sep;29(4):285-7. Epub 2008 Sep 20.Melatonin to prevent migraine or tension-type headache in children. Miano S, Parisi P, Pelliccia A, Luchetti A, Paolino MC, Villa MP). A double-blind placebo- controlled, cross-over study investigated the effects of melatonin on varying headaches and their relation to delayed sleep phase syndrome (DSPS) with 30 patients receiving 5mg melatonin for 14 days, after which they were crossed-over for an additional 14 days, showed a significant reduction in frequency of the headaches and in every DSPS patient the sleep-wake rhythm was advanced after melatonin treatment thus synchronizing their biological clocks (Nagtegaal JE, Smits MG, Swart AC, et al. Melatonin-responsive headache in delayed sleep phase syndrome: preliminary observations. Headache 1998;38:303-307.) All the dosages used in the above clinical trials are higher than the dosage used in the preferred embodiments of the present invention. Melatonin has been classified as a hormone, however growing evidence suggests that it might be classified as a vitamin as it is an ingested micronutrient important for life processes and it is present in plants and food. (Journal of Pineal Research: Volume 34(l)January 2003p 75-78 Melatonin: a hormone, a tissue factor, an autocoid, a paracoid, and an antioxidant vitamin Tan, Dun-Xian, Manchester, Lucien C, Hardeland, Rudiger, Lopez-Burillo, Silvia, Mayo, Juan C, Sainz, Rosa M., Reiter, Russel). As there is no real storage mechanism a need for sufficient

supplementation is required if the internal production system does not function correctly as seen in migraine. Melatonin might prevent migraine via its role as a free radical and NO scavenger, broad spectrum antioxidant but also by reducing neurotoxicity due to quinolinic acid (Neuropharmacology. 2000 Jan 28;39(3):507-14 Melatonin reduces oxidative neurotoxicity due to quinolinic acid: in vitro and in vivo findings Javier Cabrera, Russel J. Reiter, Dun-Xian Tan, Wenbo Qi, Rosa M. Sainz- Juan Carlos Mayo, Joaquin J. Garcia, Seok Joong Kim and Gamal El-Sokkary). Moreover melatonin shows anti- oxidative properties at the mitochondrial level and can prevent energy failure and mitochrondria impairment similar to the role riboflavin is thought to have in the prevention of migraine (Front BioscL 2007 Jan l;12:947-63. Melatonin role in the mitochondrial function. Acuna-Castroviejo D, Escames G, Rodriguez Ml, Lopez LC; Life Sci. 2004 Jul 2;75(7):765-90 Melatonin and mitochondrial function Leon J, Acuna-Castroviejo D, Sainz RM, Mayo JC, Tan DX, Reiter RJ.) Melatonin may also play a role in protecting cells from oxidative damage due to homocysteine (Pharmacol Toxicol. 2002 Jan;90(l):32-7.Inhibitory effect of melatonin on homocysteine-induced lipid peroxidation in rat brain homogenates. Osuna C, Reiter Rj, Garcia JJ, Karbownik M, Tan DX, Calvo JR, Manchester LC) and therefore might be protective versus the toxic effect of homocysteine which is usually elevated in migraine patients.

There is a comorbidity between migraine and other gastrointestinal disorders. Low levels of melatonin have been associated with an increase in ulcers, and melatonin has shown efficacy in the prevention of ulcers (Journal of Pineal Research:Volume 33(l)August 2002p 1-7 Melatonin protects against gastric ulceration and increases the efficacy of ranitidine and omeprazole in reducing gastric damage

Bandyopadhyay, Debashis; Bandyopadhyay, Arun; Das, Pratap K.; Reiter, Russel J.) Therefore adding the component melatonin to the mix might improve the GI disorders in migraine patients.

Long-term exogenous melatonin administration from 0.5 to 50mg/day does not induce feedback reactions leading to diminished or enhanced endogenous melatonin formation. (Melatonin administration to blind people: phase advances and entrainment. J BiolRhythms 1991; 6:249-261. ; Matsumoto M, Sack RL, Blood ML et al. The amplitude of endogenous melatonin production is not affected by melatonin treatment in humans. J Pineal Res 1997; 22:42-44.). This is important for the migraine prophylactic treatment as it needs to be administered over long periods in order for it to show efficacy and the invention aims at providing a prevention treatment with few or no side effects over the long term.

There are few side adverse effects of melatonin and it is generally considered safe in recommended doses. Although one might expect the need for high dosages of melatonin to prevent migraine following the doses used in trials and in the treatment of other diseases in order to have a pharmacological effect, thanks to the combination of components used in the invention, timing of administration and formulations, the present invention allows for lower doses of melatonin to be used. Melatonin is included in the present invention in a preferred slow release

formulation at low doses administered before going to bed in order to take into account the natural circadian rhythm of melatonin. Melatonin contributed to the reduction in migraine in the case study.

ZINC

Zinc has anti-oxidative properties and is essential for the production of melatonin and serotonin as it involves zinc enzymes and a zinc deficiency can lead to low levels of both neuromediators, both decreased in migraine patients (Med Hypotheses. 2001 May;56(5):641-5. Micronutrient accumulation and depletion in schizophrenia, epilepsy, autism and Parkinson's disease Johnson S.) Zinc acts as a glutamate NMDA receptor antagonist in the brain. The adjunction of zinc might also provide a protective effect against quinolinic induced neurotoxicity (Neuroscience.

1990;37(2):347-52. Prevention of quinolinic acid neurotoxicity in rat hippocampus in vitro by zinc. Ultrastructural observations. Kida E, Matyja E.) Zinc has never been used per se as a preventative treatment for migraine, however it is included in the present invention for its synergistic role with the other

components of the invention in preventing migraines.

Zinc has a circadian variation with a morning peak. Timing of meals can alter daily variation in plasma zinc concentration.fj Nutr. 1994 Apr;124(4):508-1 Daily

Variation in Plasma Zinc Concentrations in Women Fed Meals at Six-Hour Intervals King JC, Hambidge KM, Westcott JL, Kern DL, Marshall G. ; Clin Ter, 2008 Sep- Oct;159(5):329-46). Circadian characteristics of serum calcium, magnesium and eight trace elements and of their metallo-moieties in urine of healthy middle-aged men. Kanabrocki EL, Sothern RB, Ryan MD, Kahn S, Augustine G, Johnson C, Foley S, Gathing A, Eastman G, Friedman N, Nemchausky BA, Kaplan E.)

Low doses of zinc are used in the invention in order to restore but not alter the balance of copper and iron status as higher doses may affect the balance (British Journal of Nutrition (2001), 85:S181-S185 Micronutrient interactions: effects on absorption and bioavailability Brittmarie Sandstroma). Other than the impact on the balance of iron and copper, zinc is well tolerated at the low dosages used in the invention.

Zinc is administered in the present invention at a different time as melatonin in order to prevent a risk of interaction and a decrease of efficacy of melatonin in reducing nitric oxide (Biol Trace Elem Res. 1999 Sep;69(3):261-8. Zinc

coadministration attenuates melatonin's effect on nitric oxide production in mice. Chen MD, Lin PY, Sheu WH.) Moreover, Zinc can bind to melatonin and tryptophan forming a complex which could decrease both melatonin and zinc absorption (J Pineal Res. 1998 Jan;24(l):15-21. The interaction of melatonin and its precursors with aluminium, cadmium, copper, iron, lead, and zinc: an adsorptive voltammetric study. Limson J, Nyokong T, Daya S.) Zinc is also administered in the present invention at a different time as folic acid (or its active forms) as folate influences zinc homeostasis (American Journal of Clinical Nutrition, Vol 39, 535-539, Effect of oral folic acid supplements on zinc, copper, and iron absorption and excretion DB Milne, WK Canfield, JR Mahaiko and HH Sandstead) Zinc is also administered in the present invention at a different time as magnesium to avoid an inhibitory effect of zinc on magnesium balance and absorption (Prasad A: Zinc bioavailability in Cunnane SC Zinc: Clinical and Biochemical Significance. Boca Raton, FL: CRC Press,1988 ; p652: Herb, nutrient, and drug interactions: clinical implications and therapeutic strategies Mitchell Bebel Stargrove, Jonathan Treasure, Dwight L. McKee Elsevier Health Sciences, 2007.)

Zinc picolinate is better absorbed than zinc citrate or zinc gluconate in humans (Agents Actions. 1987 Jun;21(l-2):223-8. Comparative absorption of zinc picolinate, zinc citrate and zinc gluconate in humans.Barrie SA, Wright JV, Pizzorno JE, Kutter E, Barron PC.)

The preferred form of zinc is zinc picolinate, both because it is more bioavailable than other forms of zinc but also because the liberation of picolinic acid, an endogenous metabolite of L-tryptophan, might provide added benefit as it has been suggested to protects against quinolinic acid induced neurotoxicity in the brain (Picolinic acid blocks the neurotoxic but not the neuroexcitant properties of quinolinic acid in the rat brain: evidence from turning behaviour and tyrosine hydroxylase immunohistochemistry. Neurosci Res. 1994;61:603-12. ; Cockhill J, Jhamandas , Boegman RJ, Beninger RJ. Action of picolinic acid and structurally related pyridine carboxylic acids on quinolinic acid-induced cortical cholinergic damage. Brain Res. 1992;599: 57-63.) However, alternatively or additionally, a number of forms of zinc such as zinc acetate may be used in the present invention.

Zinc has been added to the morning mix as it has shown in the case study to contribute to the prevention of migraines.

Vitamin B12

Methylcobalamin is one of the two active forms of vitamin B12. Cyanocobalamin is the most commonly supplemented form of vitamin B12 and the form used in the migraine prevention clinical trial together with folic acid with a view of lowering homocysteine levels (Pharmacogenet. Genomics. 2009 Jun;19(6):422-8. The effects of vitamin supplementation and MTHFR (C677T) genotype on homocysteine- lowering and migraine disability. Lea R, Colson N, Quinlan S, Macmillan J, Griffiths L).

The other active form, hydroxycobalamin has been used in clinical trials for migraine prophylaxis. In a preliminary trial, administration of 1 mg of hydroxycobalamin per day for 3 months reduced the frequency of migraine attacks by at least 50% in 10 of 19 people with recurrent migraines (Cephalalgia. 2002 Sep;22(7):513-

9.Hydroxocobalamin, a nitric oxide scavenger, in the prophylaxis of migraine: an open, pilot study P-HM van der Kuy , FWHM Merkus , JJHM Lohman , JWM ter Berg , & PM Hooymans). In patients with migraine without aura, although levels of B12 were no different from controls, there was a functional vitamin B12 deficiency represented by elevated urine methylmalonic acid, a metabolite of

hydroxycobalamin, in this case it is claimed that only the hydroxycobalamin form of B12 would work in migraine prevention (Turk J Med Sci 2008; 38 (5): 409-414 Osman Metin IP iOGLUl Omer OZCANl Mustafa GLJLTEPE1 Hakan TEKELI2 Mehmet Guney SENOL2 Functional Vitamin B12 Deficiency Represented by Elevated Urine Methylmalonic Acid Levels in Patients with Migraine). Following the above studies on hydroxycobalamin, one would conclude that the methylcobalamin would not show efficacy in migraine prevention.

However in the present invention, methylcobalamin is the form of choice over cyanocobalamin and hydroxycobalamin for the biological, pharmacological and bioavailability reasons detailed below and for its efficacy in the case study. Although the amount of cyanide is considered toxicologically insignificant, humans must remove and detoxify the cyanide molecule then reduce the cobalamin to its usable oxidation state, and then enzymatically convert the cobalamin into one of two metabolically active coenzyme forms (methylcobalamin and 5

deoxyadenosylcobalamin). Each step of the process requires optimum metabolism and gastrointestinal functioning, which is an issue for migraine patients who show gastric stasis even outside of their migraine crisis (Headache. 2007 Nov- Dec;47(10):1443-6. Gastric stasis occurs in spontaneous, visually induced, and interictal migraine. Aurora S, Kori S, Barrodale P, Nelsen A, McDonald S.; Headache. 2006 Jan;46(l):57-63. Gastric stasis in migraine: more than just a paroxysmal abnormality during a migraine attack. Aurora SK, Kori SH, Barrodale P, McDonald SA, Haseley D]). Cyanocobalamin might therefore not be effective in a number of migraine patients due to the likelihood of a malfunction in the steps leading to the active form apart from the risk of a accumulation of the cyanide over a long period of time .

An increase in excitatory amino acid neurotransmitters such as glutamate may lead to excessive activity of the NMDA receptors, with a result of reinforcing migraine pain. Chronic exposure to methylcobalamin protected cultured cortical neurons against glutamate neurotoxicity (Akaike A, Tamura Y, Sato Y, el al. Protective effects of a vitamin B12 analog, methylcobalamin, against glutamate cytotoxicity in cultured cortical neurons. Eur J Pharmacol. 1993;241:1-6.). Moreover evidence suggests that the combination of a number of B vitamins has a protective role against

excitotoxicity mediated by glutamate (Neuroreport. 2004 Oct 5;15(14):2241-4. Group B vitamins protect murine cerebellar granule cells from glutamate/NMDA toxicity.Lin Y, Desbois A, Jiang S, Hou ST). S-adenosylmethionine (SAM) has been reported to have a protective action against ischemia-induced neuronal death in the central nervous system by administering methylcobalamin (Yamamoto Y, Shibata S, Hara C, et al. Methylcobalamin attenuates the hypoxia/hypoglycemia- or glutamate- induced reduction in hippocampal fiber spikes in vitro. EurJPharmacol.

1995;281:335-340. ; Trovarelli G, de Medio GE, Porcellati S, et al. Neuro-chem Res. 1983;8:1597-1609). This could mean that the preventative properties of

methylcobalamin (methylB12) might not only be by lowering the levels of homocysteine but also by preventing the excitatory effect of glutamate thus preventing migraines while reducing the impact of the temporary hypoperfusion of the brain seen in migraine with aura.

Moreover, methylcobalamin has shown efficacy in treating circadian rhythm disturbances (Brain Dev. 1995 Nov-Dec;17(6):428-31. Circadian rhythm

abnormalities in adrenoleukodystrophy and methyl B12 treatment. Tomoda A, Miike T, Matsukura M.) Methylcobalamin is effective in suppressing melatonin rhythm disturbances induced by transient light stimulation (Transient fluctuation of serum melatonin rhythm is suppressed centrally by vitamin B12. T Nakamura, K Uchida, Y Moriguchi, N Okamoto, Y Morita Chronobiology International The Journal of

Biological and Medical Rhythm Research 1997; 14(6):549-560) therefore one might suggest that part of the efficacy of the combination of melatonin and

methylcobalamin in the present invention in preventing migraines could be due to a decrease of sensitivity to light which is often a trigger for migraine patients.

There are suggestions that B12 might have a circadian variation with a peak 2 hours after dark and a trough 2 h before light in rats (Neurosci Lett. 1997 Jun

6;228(2):131-4. Circadian rhythms in vitamin B12 content of the rat brain. Ikeda M, Inoue S.),. In a small study in the elderly a nocturnal decrease in plasma cobalamin and transcobalamin was noted (Circadian variation of plasma cobalamin,

transcobalamin-bound cobalamin and unsaturated binding capacity of

transcobalamin and haptocorrin in healthy elderly Karin Sparring Bjorksten³-, Lars- Hakan Thorell³ and Ebba Nex0^b Journal of Affective Disorders Volume 36, Issues 1-2, 24 December 1995, Pages 37-42). This data suggests that there might be a circadian variation of B12 levels with a decrease early in the evening and an increase in the morning. ethylcobalamin is well tolerated and without any side effects at the doses recommended in the preferred embodiments of the present invention.

The focus is to ensure a sufficient storage of B12 in the liver while timing the administration so that it mimics as much as possible the circadian variation. In the present invention, the administration of methylcobalamin will therefore take place in the morning. In order to ensure adequate stocks in the liver, methylcobalamin is the preferred form used, as significantly more cobalamin accumulates in the liver tissue following administration of MetCbl, with significantly greater tissue retention (Okuda K, Yashima K, Kitazaki T, Takara I. Intestinal absorption and concurrent chemical changes of methylcobalamin. J Lab Clin Med 1973;81:557-567).

As free methylcobalamin is not very stable in the gastrointestinal tract and migraine patients are likely to suffer from gastrointestinal disturbances, a sublingual formulation is the preferred formulation for methylcobalamin, administered in the morning. Methylcobalamin has been added to the morning mix as it has shown in the case study to contribute to the prevention of migraines.

Riboflavin (Vitamin B2)

Riboflavin is the precursor to flavin adenine mononucleotide (FMN), synthesized from adenosine triphosphate (ATP) and riboflavin by riboflavin kinase which in turn is the precursor of flavin adenine dinucleotide (FAD), by the adenylation of FMN by FAD synthetase, the latter two coenzymes being the active forms of riboflavin.

Riboflavin has shown efficacy in the prevention of migraine at high doses of 400mg per day (Cephalalgia. 1994 Oct;14(5):328-9. High-dose riboflavin as a prophylactic treatment of migraine: results of an open pilot study. Schoenen J, Lenaerts M, Bastings E.) Its role has been attributed to its help in enhancing the activity of the electron-transport chain in the mitochondria, thought to be defective in migraine. Riboflavin is required as a cofactor for the MTHFR enzyme. Riboflavin has also been shown to lower levels of plasma homocysteine in Individuals homozygous for the methylenetetrahydrofolate reductase [MTHFR) 677CT polymorphism, which might be another explanation of the protective role riboflavin has in migraine [Riboflavin Lowers Homocysteine in Individuals Homozygous for the MTHFR 677CT

Polymorphism Helene McNulty, PhD; Le Roy C. Dowey, PhD; J.J. Strain, PhD; Adrian Dunne, PhD; Mary Ward, PhD; Anne M. Molloy, PhD; Liadhan B. McAnena, PhD; Joan P. Hughes, MSc; Mary Hannon-Fletcher, PhD; John M. Scott, ScD (Circulation.

2006; 113:74-80.)

Riboflavin is not only active at the mitochondria level but also plays a role as a cofactor of a cytochrome for entrainment of the circadian clock located in a subset of ganglion cells with direct projectins to the suprachiasmtic nucleus (SCN), at the origin of the retinohypothalamic tract that transmits the light signal to the master circadian clock in the SCN. (Vitamin B₂-based blue-light photoreceptors in the retinohypothalamic tract as the photoactive pigments for setting the circadian clock in mammals Yasuhide Miyamoto and Aziz Sancar). Riboflavin is also necessary for the activation of vitamin B6 . It is also necessary for the synthesis of the active form of folate.

As seen above, Riboflavin has a number of roles for which a deficit would increase the risk of migraines, it has therefore been incorporated as one of the components in the present invention.

Either riboflavin, or its active form FMN, is used in the present invention, as they are mutually convertible. In the case of an oral administration in the form of a tablet, riboflavin is the preferred form whereas in the case of a sublingual tablet in order to avoid lower absorption due to gastro intestinal disturbances seen in migraine patients, FMN is the preferred form.

No circadian variations of FMN and FAD coenzymes were observed whereas riboflavin in plasma and urine showed a slight decrease in the afternoon. 9Zempleni J, Galloway J, McCormick D. Pharmacokinetics of orally and intravenously

administered riboflavin in healthy humans Am J Clin Nutr 1996; 63:54-66).)

In the present invention, riboflavin is generally not be administered together with magnesium, which has been the basis of the majority of migraine prevention treatments so far in order to avoid possible chelation between the two and a reduction in absorption of riboflavin.

Riboflavin and zinc are administered at the same time in the present invention in order to benefit from their synergistic effect whereby riboflavin supplementation might have a beneficial effect on zinc utilization with an increased absorption of zinc with riboflavin supplementation (Biol Trace Elem Res. 1998 Nov;65(2):109-15. Effect of riboflavin supplementation on zinc and iron absorption and growth performance in mice. Agte W, Paknikar KM, Chiplonkar SA.O

Riboflavin intake many times higher than the RDA is apparently without

demonstrable toxicity. Nevertheless, the photosensitizing (sensitivity to light) properties of riboflavin raise the possibility of some potential risks. Other possible reactions to very high doses include itching, numbness, burning/prickling sensations, and yellow discoloration of the urine. Low doses of riboflavin are therefore desirable if used as a prevention treatment over a long period of time.

In the present invention, low doses of riboflavin are effective in the case study thanks to the formulation, timing of intake and other components present in contrast to the need of high doses to be effective in migraine prevention if used on its own.

VITAMIN B6

Vitamin B6 is involved in the regulation of mental function and mood. There are six forms of vitamin B6: pyridoxal (PL), pyridoxine (PN), pyridoxamine (PM), and their phosphate derivatives: pyridoxal 5'-phosphate (PLP), pyridoxine 5'-phosphate (PNP), and pridoxamine 5'-phospate (PNP). PLP is the active coenzyme form, and has the most importance in human metabolism. Vitamin B6 is involved in numerous pathways and in particular in the tryptophan pathway metabolism towards melatonin where it is an essential homocysteine re-methylation cofactor, and deficiency in B6 is associated with increase in blood homocysteine levels. Vitamin B6 was administered together with folic acid and B12 in the prevention of migraine with a view to reduce the levels of homocysteine. The combination showed efficacy in the double blind placebo controlled trial in reducing the prevalence of migraine disability from 60% at baseline to 30% after 6 months (P=0.01), whereas no reduction was observed for the placebo group (P>0.1) (Pharmacogenet Genomics. 2009 Jun;19(6):422-8. The effects of vitamin

supplementation and MTHFR (C677T) genotype on homocysteine-lowering and migraine disability. Lea R, Colson N, Quinlan S, acmillan J, Griffiths L)

Pyridoxine can raise serotonine levels. Pyridoxine in the form of pyridoxal phosphate is also involved in the transformation of tryptophan into niacin.

Moreover, pyridoxine has shown in animal models protection in neurons against neurotoxicity from excessive release of glutamate (J Pharmacol Exp Ther. 2009 Jul 23. Pyridoxine inhibits depolarization-evoked glutamate release in nerve terminals from rat cerebral cortex: a possible neuroprotective mechanism? Yang TT, Wang SJ; Int J Vitam Nutr Res. 2007 Sep;77(5):336-40. Pyridoxine may protect the cerebellar granular cells against glutamate-induced toxicity. Buyukokuroglu ME, Gepdiremen A, Tastekin A, Ors R.)

Although vitamin B6 has to our knowledge not been tested on its own for the prevention of migraine, its key role in the tryptophan pathway and potential neuroprotective effect are supportive to its addition to the present invention.

Toxic effects such as ataxia, severe sensory-nervous system dysfunction have been described for chronic consumptions of doses from 150-200mg/day and higher of pyridoxine (Schaumburg H, Kaplan J, Windebank A, Vick N, Rasmus S, Pleasure 0, Brown MJ: Sensory neuropathy from pyridoxine abuse. A new megavitamin syndrome. N Engl J Med 309:445-448, 1983.; Nisar M, Watkin SW, Bucknall RC, Agner RAL: Exacerbation of isoniazid induced peripheral neuropathy by pyridoxine. Thorax 45 :419-420, ] 990. Parry GJ, Bredesen DE: Sensory neuropathy with low- dose pyridoxine. Neurology 35:1466-1468, 1985.) As pyridoxine is associated with the other components of the present invention, low doses are possible which would allow for a lower risk of side effects.

As, so far no circadian variation was noted for B6 J Am Coll Nutr. 1995

Dec;14(6):579-86. Pharmacokinetics of vitamin B6 supplements in humans.

Zempleni J, Vitamin B6 is administered in the evening although it would also be possible to administer it in the morning.

The form of pyridoxine in the preferred embodiment is the pyridoxal-5'-phosphate (PLP) as it is the active form of the vitamin B6. It is readily absorbed by the intestine.

Pyridoxine has been added to the evening mix as it has shown in the case study to contribute to the prevention of migraines.

FOLIC ACID (L METHYL- FOLATE)

Folic acid is a prodrug that needs to undergo an enzymatic conversion into the biologically active L-methylfolate, via dihydrofolate to tetrahydrofolate (THF) into 5,10 methylene THF and then into L-methylfolate also called 5- methyltetrahydrofolate ([6S]-5-MTHF). Its primary function is the transfer of methyl and formyl groups, essential for cell growth and reproduction, breakdown of proteins, formation of nucleic acids, red blood cell maturation and in particular plays a key role in the tryptophan pathway towards the synthesis of serotonin and melatonin where it allows homocysteine re-methylate to methylcysteine. A deficiency might result in both a decrease of serotonin and melatonin synthesis, but also an increase in homocysteine (Nutr. 2002 Sep;132(9):2781-4. Folate deficiency alters melatonin secretion in rats.Fournier I, Ploye F, Cottet-Emard JM, Brun J, Claustrat B.).

Folic acid has been used in migraine prevention in few trials on its own (Headache. 1969 Jan;8(4):167-70.The use of folic acid in vascular headache of the migraine type.Kopjas TL) and more recently in combination with B12 and B6 with a view to lowering homocysteine levels, folic acid supplementation resulting in a decrease of homocysteine levels. Supplementation of folic acid to 16 children with

hyperhomocysteinemia and MTHFR polymorphism resulted in a decrease in migraine attacks (Headache. 2007 Oct;47(9):1342-4.Efficacy of folic acid in children with migraine, hyperhomocysteinemia and MTHFR polymorphisms.Di Rosa G, Attina S, Spano M, Ingegneri G, Sgro DL, Pustorino G, Bonsignore M, Trapani-Lombardo V, Tortorella G.)

Only high doses of folic acid of 3 mg together with B12 have been used in the prevention of migraine with a view of lowering homocysteine levels (American Journal of Clinical Nutrition, Vol. 82, No. 4, 717-718, October 2005 Do low doses of folic acid result in maximum lowering of homocysteine? Lynn B Bailey). Folate has been used in the treatment of migraine in combination with feverfew and riboflavin as well as other vitamins with a preferred dose of 1 to 5 mg of folic acid in one formulation , and always with the presence of feverfew the plant based migraine prevention (Folate based migraine treatment US2008206360 (Al)).

In the present invention, it is preferred that phytotherapy is not introduced and lower doses than the ones used in trials has shown efficacy in combination with the other components of the invention.

There is a concern that unmetabolised folic acid might accumulate which has been shown to be associated with a decrease in cytotoxicity of circulating natural killer cells (Troen AM, Mitchell B, Sorensen B, et al. Unmetabolized folic acid in plasma is associated with reduced natural killer cell cytotoxicity among postmenopausal women. J Nutr. 2006;136:189-194.), whereas this is not the case with L-methylfolate (Hasselwander 0, Honlein W, Schweillert L, Kro ^" mer K. 5 Methyltetrahydrofolate— the active form of folic acid. Functional Foods 2000, Conference Proceedings; pp 48- 59. ; Kelly P, McPartlin I, Goggins M, Weir DG, Scott IM. Unmetabolized folic acid in serum: acute studies in subjects consuming fortified food and supplements. Am J Clin Nutr. 1997;65:1790-1795).

Oral L-methylfolate in its crystalline form avoids problems with synthetic folic acid. it has a higher bioavailability and can cross the blood brain barrier approximately 7 times higher concentrations than folic acid, it is the only form crossing the blood brain barrier whereas folic acid blocks the transport of the active methylfolate to the brain (Wu D and Pardridge WM. Blood-brain barrier transport of reduced folic acid. Pharmaceutical Research. 1999;16(3):415-419. Spector R and Lorenzo AV. Folate transport in the central nervous system. Am J Physiol. 1975;229(3):777-82.) Moreover, as there is evidence of a correlation between migraine with aura and C677T polymorphism (Association of the C677T polymorphism in the MTHFR gene with migraine: a meta-analysis. Cephalalgia. 29(8):818-825, August 2009.Rubino, E; Ferrero, M; Rainero, I; Binello, E; Vaula, G; Pinessi, L), 40% to 50% of the general population is heterozygous for this polymorphism and enzyme activity is decreased by more than 70% in those who are homozygous (Bezold G, Lange M, Peter RU. Homozygous methylene- tetrahydrofolate reductase C677T mutation and male infertility. NEJM. 2001;344:1172-1173. Frosst P, Blom H], Milos R, et al. A candidate genetic risk factor for vascular disease: a common mutation in methylene- tetrahydrofolate reductase. Nat Genet. 1995;10:111-113.0), it is likely that most migraine sufferers would not be able to convert folic acid to its active form which it turn results in an increase in homocysteine. 5-MTHF is considered non-toxic. In doses up to 50 mg per day, gastrointestinal complaints, insomnia, irritability, and fatigue have been mentioned as occasional side effects. Therefore, the L-methylfolate is a better form to use in migraine prevention and is the form used in the preferred embodiment of the present invention.

L-methylfolate is administered in the evening in order to prevent any risk of a decrease in zinc absorption in the presence of folic acid, (Eur J Nutr. 2009 Aug 13. Effect of water soluble vitamins on Zn transport of Caco-2 cells and their

implications under oxidative stress conditions. Tupe RS, Agte W.].

Migraine most often occurs following a circadian pattern early morning (Headache. 1998 Jun;38(6):436-41.Migraine chronobiology. Fox AW, Davis RL.), the

accumulation of homocysteine during the night might therefore be a trigger of a migraine. Folate is administered in the evening in order to take into account the circadian variation of homocysteine levels that significantly increase at night and decrease during the day in order to prevent the increase to trigger a migraine in the morning (Am ] Cardiol. 2000 Nov 15;86(10]:1153-6, A9-10. Circadian rhythm of serum total homocysteine in men. Bremner WF, Holmes EW, anabrocki EL,

Hermida RC, Ayala D, Garbincius J, Third JL, Ryan MD, Johnson M, Foley S, Shirazi P, Nemchausky BA, Scheving LE.)

Methylfolate has been added to the evening mix as it has shown in the case study to contribute to the prevention of migraines.

THIAMINE: VITAMIN Bl

The central nervous system is almost entirely dependent on glucose for its energy requirements. Thiamine functions as the coenzyme thiamin pyrophosphate (TPP) in several steps of glucose utilization and carbohydrate and branch chain amino acids metabolism. Hence, thiamine deficiency will result in overall decrease in

carbohydrate metabolism and its inter-connection with amino acid metabolism (via oc-keto acids). Migraine might be considered as a neuropathic pain (Is migraine a neuropathic pain syndrome? Current Pain and Headache Reports David M. Biondi ). Thiamine together with Cyanocobalamin has shown efficacy in relieving neuropathic pain in rats (Caram-Salas NL, Reyes-Garcia G, Medina-Santillan R, Granados-Soto V: Thiamine and Cyanocobalamin Relieve Neuropathic Pain in Rats: Synergy with

Dexamethasone. Pharmacology 2006;77:53-62) . Benfotiamine (a synthetic form of thiamine) has shown effect on relieving inflammatory and neuropathic pain in rats (Eur 1 Pharmacol. 2006 Jan 13;530(l-2):48-53. Epub 2005 Dec 15.Benfotiamine relieves inflammatory and neuropathic pain in rats.Sanchez-Ramirez GM, Caram- Salas NL, Rocha-Gonzalez HI, Vidal-Cantu GC, Medina-Santillan R, Reyes-Garcia G₍ Granados-Soto V).

Thiamine plays a role in the regulation of the biological clock as it can phase shift circadian rythms (Front Neuroendocrinol. 2007 Aug-Sep;28(2-3):61-71. Epub 2007 Mar 24. The relationship between nutrition and circadian rhythms in mammals. Froy 0.). Low body temperatures can result in recurrent migraines. Thiamine deficiency can effect the circadian clock function and body temperature in animal models by reducing the body temperature (J Neurol Sci. 1999 Feb 1; 163(1):6-10. Altered circadian rhythmicity is an early sign of murine dietary thiamine deficiency. Bennett MR, Schwartz WJ. Thiamine deficiency-induced disruptions in the diurnal rhythm and regulation of body temperature in the rat LANGLA1S P. ). w ; HALL T. « ;Metabolic brain disease 1998, vol. 13, n°3, pp. 225-239 (1 p.1/2).). Moreover, thiamine is closely associated to magnesium, and magnesium deficits may lead to thiamine deficits (Zieve L. Influence of magnesium deficiency on the utilization of thiamine. Ann N Y Acad Sci. 1969;162[2):732 -743.) Magnesium serves as a cofactor required for normal functioning of several key thiamine-dependent enzymes of carbohydrate metabolism and neurochemical transmission. In order to correct a thiamine deficiency magnesium needs to be provided as well [Dyckner T., Ek B., Byhlin H., Wester P. 0. Aggravation of thiamine deficiency by magnesium depletion. Acta Med Scand 1985; 218(1): 129-131). Magnesium levels have been shown to be low in migraine patients, it might therefore be likely that thiamin levels are also low in migraine patients.

While not wishing to be bound by any particular theory, and although there is to our knowledge no convincing data for the use of thiamine in migraine prevention, and no data on the use of benfotiamine in migraine prevention, adding it to the components in the present invention is preferred and believed to significantly contribute to the synergistic action of the components and it has contributed to the reduction of migraines in our case study.

There are no reports of adverse effects of oral thiamine, even at dosages of several hundred milligrams a day.

Benfotiamine has shown better bioavailability than regular thiamine producing high and durable increase in thiamine levels. Maximum plasma levels of thiamine are about 5-fold higher after benfotiamine intake and the bioavailability is about 3.6 times as high as that of thiamine hydrochloride and better than that of other lipophilic thiamine derivatives (US Patent No :3064000) Benfotiamine metabolizes rapidly into thiamine pyrophosphate (TPP, the active form of thiamine), which then continues to metabolize in the body as usual. Benfotiamine itself does not accumulate in the body.

Benfotiamine has never been used in the prevention of migraine however it has been used in other disease treatments where it has shown efficacy in the prevention of a wide variety of oxidative-stress induced conditions, including diabetic nephropathy, neuropathy and retinopathy.

Benfotiamine has a very good safety record. Moreover the LD50 in mice for benfotiamine is 15000mg/kg and that of thiamine hydrochloride is 3710 mg/kg (US Patent No: 3064000). And thiamine hydrochloride is deemed safe at doses of several hundred mg/day.

No circadian variation was noted for thiamine so far ( J Pharm Sci. 1993

Jan;82 (l) :56-9. High-performance liquid chromatographic determination of total thiamine in human plasma for oral bioavailability studies. Mascher H, Kikuta C.) In the preferred embodiment of the invention, thiamine is administered in the morning, in the preferred form of benfotiamine, however thiamine hydrochloride may also be used. Benfotiamine has been added to the morning mix as it has shown in the case study to contribute to the prevention of migraines. PREFERRED FORMULATION

The present invention is based on a particular combination of compounds, each in a particular dosage range, formulation and timing of administration. Clinical use of this combination of two pills one in the morning and one in the evening has shown unique efficacy in preventing migraine headaches, the compounds on their own requiring higher doses in order to show efficacy. All the components of this invention mentioned above are available commercially. It will be appreciated that the formulations of the present invention may further include, in addition to the active components, one or more pharmaceutically acceptable carriers, excipients, buffers, adjuvants, stabilisers, or other materials, as described herein. Such carriers, excipients, etc. must be "acceptable" in the sense of being compatible with the other ingredients of the formulation. Suitable carriers, excipients, etc. can be found in standard pharmaceutical texts, for example,

'Remington's Pharmaceutical Sciences', 18th edition, Mack Publishing Company, Easton, Pa., 1990, and can be chosen by the those skilled in the art.

The preferred embodiment of the invention is a two units dosage form that could be in a tablet, capsule, powder, patch, or liquid form. The first one, "the morning mix" is administered in the morning and contains the following components:

1. 500 meg of methylcobalamin

2. lOO mg FMN

3. 20 mg zinc picolinate

4. 100 mg benfotiamine

The second one, "the evening mix", is administered in the evening before going to bed and contains the following components:

1. 0.5 mg melatonin

2. 0.5 mg 5 methyltetrahydrofolate

3. 50 mg B6 in the form of pyridoxine HCL

4. 200 mg magnesium citrate

In a preferred embodiment, the timing of administration of the two units has been optimised to take into account the natural circadian variation of the nutrients in the body and obtain an increase in effect with lower dosage. In the preferred embodiment, the morning mix is administered in the form of a sublingual tablet and the evening mix in the form of a slow release tablet. The two specific formulation types have been selected in order to take into account the natural circadian variations of the minerals and vitamins in the body, the gastro- intestinal disturbances migraine patients often suffer from, and the pharmacokinetics and interactions of the different compounds. All formulations are done using industry standard methods of production. It has been shown that the mix of compounds administered following the specific timing of the preferred embodiment showed a significantly greater percentage of symptomatic relief compared to the compounds at higher doses on their own and administered with a different timing. CASE HISTORY

A 36 year old female patient with a family history of migraines and a history of menstrual migraine since her puberty had a frequency of migraine ranging from 3 to 6 per month lasting for 24 hours each. The patient has tried a number of abortive treatments among which sumatriptan, which caused side effects leading her to stop their usage. Subsequently she tried exercise, specific diets, biofeedback techniques without any avail. She then took daily tablets of magnesium citrate at doses of 600 mg, which reduced the frequency of the migraines from 6 to 4 per month but not the intensity of the attacks. She then added riboflavin at 400 mg to magnesium she was already taking, which reduced the migraines a little further without a significant difference from magnesium on its own and with no effect on the intensity of the migraines. After testing different combinations of ingredients, doses and timing of administration, the use of the combination product of the present invention described in the preferred embodiment led to a significant reduction of both the number of migraines down to 1 every other month with periods of several months without any migraine but also significantly reduced the severity of the migraines when they did occur. There was also a reduction in the use of acetaminophen when the migraines did occur and a complete disappearance of the peptic ulcers she used to suffer from every other month.

Claims

Claims:

1. A dietary supplement for use in a method of preventing or treating migraine, wherein the supplement comprises two compositions, (i) a morning composition comprising methylcobalamin, riboflavin or FMN, zinc, and thiamine or benfotiamine for administration to a subject in the morning; and (ii) an evening composition comprising melatonin, methylfolate, pyridoxine or pyridoxal 5 phosphate, and magnesium for administration to a subject in the evening.

2. The dietary supplement for use in a method of treatment of claim 1, wherein the morning composition comprises between 10-1000 meg of methylcobalamin , between 25 and 200 mg riboflavin or FMN, between 5 and 50 mg zinc, between 5 and 100 mg thiamine or benfotiamine.

3. The dietary supplement for use in a method of treatment of claim 1 or claim 2, wherein the evening composition comprises between 0.1 and 1 mg melatonin, between 0.5 mg and 0.8mg methylfolate, between 5mg and 100 mg pyridoxine, between 50mg and 400 mg of magnesium.

4. The dietary supplement for use in a method of treatment of any one of claims 1 to 3, wherein the morning and evening compositions consist of the stated components and optionally one or more carriers.

5. The dietary supplement for use in a method of treatment of any one of claims 1 to 4, wherein the magnesium is provided as magnesium citrate, magnesium gluconate or magnesium taurate; and/or the zinc is provided as zinc picolinate or zinc acetate

6. The dietary supplement for use in a method of treatment of any one of the preceding claims , wherein the compositions are in the form of a pill, a tablet, a capsule, a powder, patch or a liquid.

7. The dietary supplement for use in a method of treatment of any one of the preceding claims, wherein the morning composition is a sublingual tablet and/or the evening composition is a slow release tablet

8. The dietary supplement for use in a method of treatment of any one of the preceding claims, wherein the effect of the morning or evening pills is synergistic as compared to the administration of the components of the pill.

9. The dietary supplement for use in a method of treatment of any one of the preceding claims, wherein the timing of administration of the two compositions takes account of the natural circadian variation of the components of compositions in the body of a patient.

10. The dietary supplement for use in a method of treatment of any one of the preceding claims, wherein the migraine is a migraine with aura or without aura.

11. The dietary supplement for use in a method of treatment of any one of the preceding claims, wherein the prevention or treatment reduces the frequency and/or intensity of the migraine.

12. The dietary supplement for use in a method of treatment of any one of the preceding claims, wherein the morning and evening compositions do not contain any whole plant components or plants extracts.

13. A kit for use in a method of preventing or treating migraine comprising two compositions,(i) a morning composition comprising methylcobalamin , riboflavin or FMN, zinc, and thiamine or benfotiamine for administration to a subject in the morning; and (ii) an evening composition comprising melatonin, methylfolate, pyridoxine or pyridoxal 5 phosphate, and magnesium for administration to a subject in the evening.

14. The kit of claim 13, wherein the morning composition comprises between 10- 1000 meg of methylcobalamin , between 25 and 200 mg riboflavin or FMN, between 5 and 50 mg zinc, between 5 and 100 mg thiamine or benfotiamine.

15. The kit of claim 13 or claim 14, wherein the evening composition comprises between 0.1 and 1 mg melatonin, between 0.5 mg and 0.8mg methylfolate, between 5mg and 100 mg pyridoxine or pyridoxal 5 phosphate, between 50mg and 400 mg of magnesium.

16. The kit of any one of claims 13 to 15, wherein the magnesium is provided as magnesium citrate, magnesium gluconate or magnesium taurate; and/or the zinc is provided as zinc picolinate or zinc acetate.

17. The kit of any one of claims 13 to 16, wherein the compositions are in the form of a pill, a tablet, a capsule, a powder, patch or a liquid.

18. The kit of any one of claims 13 to 17, wherein the morning composition is a sublingual tablet and/or the evening composition is a slow release tablet

19. The kit of any one of claims 13 to 18, wherein the effect of the morning or evening pills is synergistic as compared to the administration of the components of the pill.

20. The kit of any one of claims 13 to 19, wherein the timing of administration of the two compositions takes account of the natural circadian variation of the components of compositions in the body of a patient.

21. The kit of any one of claims 13 to 20, wherein the migraine is a migraine with aura or without aura.

22. The kit of any one of claims 13 to 21, wherein the prevention or treatment reduces the frequency and/or intensity of the migraine.

23. The kit of any one of claims 13 to 22, wherein the morning and evening compositions do not contain any whole plant components or plants extracts.

24. Use of fj) methylcobalamin , riboflavin or FMN, zinc, and thiamine or benfotiamine; and (if) melatonin, methylfolate, pyridoxine or pyridoxal 5 phosphate, and magnesium in the manufacture of a medicament for preventing or treating migraine, wherein medicament comprises a first composition comprising

components (i) for morning administration and the second composition comprising components (ii) for evening administration.

25. The use of claim 24, wherein the morning composition comprises between 10-1000 meg of methylcobalamin , between 25 and 200 mg riboflavin or FMN, between 5 and 50 mg zinc, between 5 and 100 mg thiamine or benfotiamine.

26. The use of claim 24 or claim 25, wherein the evening composition comprises between 0.1 and 1 mg melatonin, between 0.5 mg and 0.8mg methylfolate, between 5mg and 100 mg pyridoxine or pyridoxal 5 phosphate, between 50mg and 400 mg of magnesium.

27. The use of any one of claims 24 to 26, wherein the magnesium is provided as magnesium citrate, magnesium gluconate or magnesium taurate; and/or the zinc is provided as zinc picolinate or zinc acetate

28. The use of any one of claims 24 to 27, wherein the compositions are in the form of a pill, a tablet, a capsule, a powder, patch or a liquid.

29. The use of any one of claims 24 to 28, wherein the morning composition is a sublingual tablet and/or the evening composition is a slow release tablet

30. The use of any one of claims 24 to 29, wherein the effect of the morning or evening pills is synergistic as compared to the administration of the components of the pill.

31. The use of any one of claims 24 to 30, wherein the timing of administration of the two compositions takes account of the natural circadian variation of the components of compositions in the body of a patient.

32. The use of any one of claims 24 to 31, wherein the migraine is migraine with aura and without aura.

33. The use of any one of claims 24 to 32, wherein the prevention or treatment reduces the frequency and/or intensity of the migraine.

34. The use of any one of claims 24 to 33, wherein the morning and evening compositions do not contain any whole plant components or plants extracts.

35. A method of preventing or treating migraine, the method comprising administering to a patient in need to treatment thereof a prophylactically or therapeutically effective amount of the dietary supplement or kit according to any one of claims 1 to 12 thereby to prevent or treat migraine.

36. The method of claim 35, wherein the migraine is a migraine with aura or without aura.

37. The method of claim 35 or claim 36, wherein the prevention or treatment reduces the frequency and/or intensity of the migraine.