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Background Migraines represent a substantial burden of disease in childhood, occurring in 3–10%1 of school aged children. These are associated with increased absences from school and subsequent academic sequlae. While, the pathophysiology is not yet fully understood, it has been found that sufferers of migraines show insufficiencies in mitochondrial energy processing and thus in energy metabolism in the brain.2 Riboflavin or vitamin B2 acts as a catalyst in the action of flavoenzymes and plays a vital role in the electron transport chain.2 It has therefore been postulated that supplementing this could act to improve energy production and act as prophylaxis for migraines2. Current National Institute for Clinical Excellence (NICE) guidelines suggests Riboflavin supplement to be considered in children over 12 for migraine proplylaxis. Evidence in adult populations has been promising with a small number of studies demonstrating the reduction of migraine frequency and length. 3–7 Studies in children however are scarce with mixed result. Objectives To review the effectiveness of Riboflavin as prophylaxis for Migraines in children under 18 years. Methods Cases of migraines in children who were managed with Riboflavin at Worcester Royal Hospital were identified retrospectively. Patient notes were subsequently reviewed. Results 21 children were identified with ages ranging from 9 to 17 years (median 14). There were equal numbers of males and females. 19 (90%) patients were diagnosed with Migraine and 2 (10%) with non-migranous headaches, following appropriate investigations. The most frequent associated symptom was nausea, followed by visual disturbance/photophobia at 62% (13) and 43% (9) respectively. All patients received a 3-month course of Riboflavin 400 mg once daily, bar 1 under the age of 10 who received 200 mg once daily. 12 (57%) patients were also provided with Sumatriptan and Cyclizine for acute attacks. 8 (38%) patients had previously failed to see symptomatic improvement with other prophylactic medications. Follow up was between 4 and 28 weeks (median 13 weeks). Follow up information was not available for 2 children. 17/19 (89%) patients reported significant improvement in migraine symptoms. Of these, 7/19 (37%) patients reported complete resolution of symptoms. No adverse effects were reported. Conclusions 200–400 mg a day of Riboflavin is shown to be an effective prophylactic medication in children with Migraines in this review, with both improvement and resolution reported. Current available evidence in children is limited with mixed results. 2 randomised control trials (RCTs) with n=4210 and n=4811, both of which used doses of 50 mg/day-200 mg/day, failed to show a difference in treatment and placebo groups. 2 further RCTs with n=9813 and n=908, and a retrospective study without control (n= 41)9 showed clinical improvement in groups given 200–400 mg/day of Riboflavin. This mirrors the positive results seen in this review suggesting improvement in children may be dose related. Adverse effects reported included vomiting, diarrhoea and urinary frequency. Limitations Due to retrospective element, this review does not include a control group and it not been possible to quantify improvement. The sample size is small. Further study with randomised control trials and a larger sample size using higher doses of Riboflavin is warranted.

Certain medications have been implicated in causing acute myocardial infarctions (AMI). Sumatriptan, a medication usually prescribed for acute migraine and cluster headaches has been documented as potentially causing coronary vasospasm, thereby leading to MI. This is usually seen in patients with strong risk factors for coronary artery disease (CAD) or in those with established CAD. Most cases thus far have been reported in patients using the subcutaneous preparation of sumatriptan. Here, we present a case of a patient without prior risk factors for CAD and angiographically unremarkable coronary arteries who presented with evidence of an AMI after oral sumatriptan use for migraines.

IntroductionPostcraniotomy pain protocols use opioids, which are considered suboptimal analgesia following this procedure. Multimodal analgesia components are sparse. Our null hypothesis states that sumatriptan is not different to placebo in addition to usual intravenous opioids, for the treatment of acute postcraniotomy pain.Methods and analysisThis is a prospective single-centre randomised double-blinded placebo-controlled phase III clinical trial comparing subcutaneous sumatriptan injection in the recovery area with placebo for the treatment of postcraniotomy pain. Eligible adult patients (18 years and older) undergoing craniotomy will be identified preoperatively. Both patient groups will receive a subcutaneous injection at a point where recovery-nursing staff would initiate the usual intravenous opioid analgesia as per standardised pain management protocol. In both groups, further pain management will be followed by the usual intravenous opioid administration. Primary outcome will consist of the difference in pain experienced by the two groups of patients in recovery area 60 min after the study drug administration. Postcraniotomy pain will be measured at regular intervals using the Visual Analogue Scale (VAS) in recovery area. The minimal clinically important difference of 10 mm on the VAS between the two groups will be considered as statistically significant. We will include selected clinical and patient-reported outcomes as secondary endpoints. Univariate regression will be conducted on each one of the clinically plausible potential confounders. We will enrol a total 136 patients, with the study duration of 2 years. This trial will commence recruitment on the 1 July 2019.Ethics and disseminationThis trial protocol has achieved approval by the Austin Health Research Committee, HREC/17/Austin/596. This trial was prospectively registered with Australian New Zealand Clinical Trials Registry on the 10/05/2018 with a unique trial identifier U1111-1209-9072 and registration Number ACTRN12618000793213P. Findings of this study will be disseminated in peer-reviewed academic journals.Trial registration numberU1111-1209-9072, ACTRN12618000793213P