Homocysteine and migraine

High homocysteine levels increase the risk of cardiovascular disease (strokes and heart attacks) and can be reduced by folic acid and vitamin B12 (cyanocobalamine).   A study by Spanish doctors published in Headache found elevated homocysteine levels in patients who have migraines with aura.  Patients who have migraine with aura are known to have increased risk of cardiovascular disease and it is possible that elevated homocysteine levels are at least in part responsible for this risk.  I routinely check homocysteine, vitamin B12 and folic acid levels in all of my patients.  One caveat is that vitamin B12 levels are not very reliable – you may have a normal level, but still be deficient.  While laboratories consider a level of over 200 to be normal, clinical deficiency is often present at levels below 400.  A single case report has been published of a severe deficiency with neurological symptoms and a vitamin B12 level of over 700.  This patient lacked the ability to transport vitamin B12 from his blood into the cells.  Injections of high doses of vitamin B12 corrected the problem.  Oral magnesium supplementation is not as effective as injections because vitamin B12 is poorly absorbed in the stomach.   Other ways to get vitamin B12 is by taking it sublingually (under your tongue) or by a nasal spray (it requires a prescription and is fairly expensive).  Many of my patients a willing to self-inject vitamin B12, which they do anywhere fro once a week to once a month.   Vegetarians are more likely to be deficient since meat (and liver) are the main sources of vitamin B12.  Smokers are also at a high risk because cyanide in smoke binds to vitamin B12.

  1. Dr. Mauskop says: 10/17/20155:29 pm

    MTHFR is a mutation that is accompanied by high homocysteine level, so it is a good idea to check homocysteine level. However, high homocysteine is treated with vitamins B12, B6 and folic acid and if you are already taking B12 and folic acid, this may be enough. Magnesium is a good idea for the prevention of migraine headaches.
    There is some evidence that high doses of oral vitamin B12 (2,000 mcg a day) are as good as injections. A prescription supplement, Metanx contains well-absorbed forms of B6, B12, and folic acid, but it is more expensive than what you buy over the counter.

  2. Kate Bergman says: 10/15/20157:37 am

    Ii just found out I tested positive for the MTHFR gene. The strange thing is that I get a B12 injection already every week for pernicious anemia and am on folic acid and also take magnesium. Doc’s out of town and am wondering how or if what I am already taking is making things better or worse. Thanks for your response.

  3. Dr. Mauskop says: 04/21/20154:37 pm

    We check homocysteine levels only in people who have migraine with aura. Actually, it is very unlikely that the doctor gets any kind of kickbacks for Botox and Botox is the only treatment approved by the FDA for chronic migraines. It is also the most effective and the safest treatment. For people with low vitamin B12 level I usually recommend vitamin B12 in a sublingual form (the tablet that melts in your mouth) or a monthly injection, which patients can give to themselves. If homocysteine is high, in addition to vitamin B12 you need to take a B complex as well. B complex usually includes folic acid, vitamins B1, B2, and B6. It takes a few weeks to notice a difference in headaches.

  4. Kristine says: 04/21/201510:14 am

    I have had migraines that have gotten progressively worse for 13 years. Ever since I had my son actually. Every neurologist I have seen have said we don’t know why, I have tried Triptans, changed foods to find triggers, and I am now on Fiorcet. It helps but I know it can cause rebound headaches. Never have I seen Homocysteine Levels or have them mentioned. My current job is on hold temporarily due to massive migraines…I am trying to find another Neurologist since my current one just wants to push other drugs like botox that she gets kickbacks from..how do I know or how can I mention to a new neurologist what I need? I have had clean CTs and was told levels are fine..I am stressed from this problem please give me as much information that I can use so that I can get these under control. With the B12 you recommend( I take MagOx 400 for Mitral Valve Prolapse) is there a long time to notice any good changes?

  5. Dr. Mauskop says: 11/16/20122:53 pm

    The usual dose of magnesium is 400 mg a day and some people need more or they need monthly infusions if they have absorption problems. The recommended dose of vitamin B2 is also 400 mg a day. Other supplements found to be effective for migraine headaches include, 300 mg of CoQ10, feverfew, Boswellia, and other. Botox injections can provide more and more relief with each subsequent treatment, but it is important not to wait more than 3 months between Botox treatments.

  6. Lisa says: 11/16/201211:29 am

    I am 44 and developed severe migraines at age 40. I was diagnosed at around the same time with autoimmune pernicious anemia. I have been receiving b12 shots for 4 years but my migraines have persisted. I was also on the birth control pill for many years, but stopped 2 months ago. I have been taking 200mg magnesium and 200 mg B2 per day. I now have migraines 3 days per week & receive botox shots. I cannot tolerate any of the usual preventatives such as tomomax, notritptyline. I do not smoke & am slim and otherwise in good health. However, could any additional vitamin deficiencies (folic acid, b6 etc.) be causing these migraines?

  7. Dr. Mauskop says: 01/22/20128:18 pm

    In people without kidney disease, the usual starting dose is 400 mg a day, taken with food. The dose can be increased to 400 or 500 mg two times a day, as long as it does not cause diarrhea or stomach pains. There are different types of magnesium – magnesium oxide, citrate, chelated forms, such as gluconate, aspartate, diglycinate. If these are not tolerated, a slow release form, Mag Tab SR can be tried, although it is much more expensive.

  8. Carole says: 01/22/20127:35 am

    you mention taking magnesium supplements, what dosage would you recommend ??

  9. Dr. Mauskop says: 09/26/201110:04 pm

    I would suggest seeing an internist or a neurologist. We do not test for this gene, but only measure vitamin B12, folate, homocysteine, and at times methylmalonic acid – another indirect indicator of vitamin B12 deficiency.

  10. Ruth says: 09/23/20114:23 pm

    To confirm MTHFR and pursue treatment, which of the following would you suggest seeing, a geneticist, hematologist, or endocrinologist?

  11. Ruth says: 09/22/201112:34 pm

    Thank you, Dr. Mauskop.

  12. Dr. Mauskop says: 09/12/20112:21 pm

    A homocysteine level of 21 is very high. I would strongly urge you asking your doctor for vitamin B12 injections since taking it by mouth is often ineffective due to poor absorption. Other B vitamins, including folate, can be taken by mouth. You should also ask your doctor about taking a magnesium supplement.

  13. Ruth Kissner says: 09/12/20112:04 pm

    My daughter has had a continual migraine headache for more than 10 months. The headache literally never leavers her. Her pain level is typically a 7 or 8. She has had approximately 8 days in the past year where she would label the pain as a low 5. She has had extensive testing which has not revealed the cause of the headache nor have the treatments alleviated the headache. We have a strong history of MTHFR gene mutation homozygous in our family. At my request the doctor checked her homocysteine level last week. She has tested with a higher than normal homocysteine level of 21. I have purchased B6, B12, and Folate vitamins but she has not taken them. Do you have any suggestions?

  14. Dr. Mauskop says: 07/14/20119:56 pm

    Ideally, you should have your doctor order and vitamin B12 and homocysteine levels. If B12 is low and/or homocysteine is high, then B12 injections are likely to help. Since the blood tests are expensive and the shot is cheap and safe, you can also ask your doctor to give you a shot to see if it helps.

  15. dana says: 07/14/20116:23 pm

    I have had migraines for over 20 years, gradually getting worse over the years. Two years ago I had 2 of my parathyroid glands taken out because of parathyroid tumors, I am starting to feel a little better over time, but my migraines aren’t any better. I also have fibromyalgia, which seems to be getting worse over the years. Lately, I am very, very tired and have been experiencing a lot of tingling on the left side of my body, from the top of my head to my toes, but only on my left side. I have looked on the internet and everything I read say it is just a sign of worsening fibro, but I was just wondering if I would benefit from B-12 injections. Would it help both my migraines and my fibro, or would I just be wasting my time? I used to take injections when I was pregnant with my second child for nausea because I couldn’t hold anything down at all and it helped considerably for the nausea and gave me some energy.

  16. Dr. Mauskop says: 04/11/201010:35 am

    Treatment of elevated homocysteine usually consists of taking folic acid (also known as vitamin B9) and vitamin B12. B complex might contain these two vitamins, but usually not in sufficient amounts.

  17. Rebecca says: 04/10/201011:56 pm

    I get severe migraines with visual aura. My Homocysteine level is 12.3. My doctor recommends my taking B2 (riboflavin) and B complex, but your site indicates B12. I am confused.

  18. kimberly says: 09/24/20099:36 am

    a severe and traumatic migraine sufferer, i began a weekly dose of b12 shots. no migraines for 4 months. then the doctor stopped it and made me take one a month. migraines every two weeks.

    did the doctor resume weekly b12 shots?


    because. my levels were above average.

    sleep..is one of the most important remedies and preventions to my migraines.

  19. Dr. Mauskop says: 09/08/20099:40 pm

    Sublingual vitamin B12 can be sufficient for many people, but for those with a serious deficiency I usually recommend, at least for the first few months, a weekly injection of vitamin B12.

  20. Toni says: 09/08/20097:30 pm

    I have been diagnosed with migraine with an auro (smell, no visual) and recently diagnosed with B12 deficency, mostlikely due to stomach problems in the last 20 years (and being on acid reduction medicine for long period of time).

    My main question is would sublingual b12 vitamins 3,000 micrograms help – or should i really reconsider the daily shots?

  21. Dr. Mauskop says: 07/27/200911:16 pm

    I checked the LpVitamins and their vitamin B12 is more expensive than a monthly or even a weekly injection of vitamin B12. There are many significantly cheaper versions of the sublingual vitamin B12 and for many people they do work, but for a small number of patients injections are required to maintain normal levels of vitamin B12. Most of my patients are happy to self-inject vitamin B12 and avoid visiting doctor’s office. The only proven alternative to injections is a nasal spray, Nascobal. It is a prescription product and is fairly expensive.

  22. LpVitamins says: 07/27/200910:57 pm

    Sublinqual Vitamin B12 is the easy way to avoid vitamin B12 deficiency and get the B12 vitamins and other B Vitamins your body requires for so many bodily functions. You can listen to the radio interview with Dr. Libby at http://www.lpvitamins.com/vitamin_b12.htm Sublingual is as effective as B12 shots, but there’s no needle or pain.

  23. Dr. Mauskop says: 07/24/20093:07 pm

    If you are otherwise in good health, don’t feel tired or have any other symptoms and don’t have family history of early heart attacks and strokes there is no need to check. Vitamin B12 deficiency can make headaches worse, so taking a supplement may help.

  24. Helen says: 07/24/20092:54 pm

    I don’t have aura, I do have migraine. I s it worth checking hymocysteine, b12 and folic acid anyway? Do the supplements give an relief from migraine?

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