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Intravenous Magnesium Sulfate to Treat Acute Headaches in the Emergency Department: A Systematic Review – A Comment

In Intravenous Magnesium Sulfate to Treat Acute Headaches in the Emergency Department: A Systematic Review, Miller and his coauthors fail to notice a major flaw in all of the reviewed studies. The trial design defies logic. It makes no sense to expect patients who are not deficient to improve with an infusion of additional magnesium. Only half of patients with an acute migraine are deficient and those who are do respond well to an infusion. Double-blind, placebo-controlled trials that include both magnesium-deficient and non-deficient patients are likely to show no benefit. No one would consider conducting a double-blind study of iron supplementation in patients with anemia without regard to their iron stores. A good example of rational design is a study by Hershey who measured CoQ10 levels in 1550 children. One third was found to be deficient and this group had a significant improvement when supplemented with CoQ10. A double-blind study involving all 1550 would have been negative, leading to the conclusion that CoQ10 is ineffective in all migraine sufferers. Measuring serum magnesium level can be problematic since less than 1% of magnesium is found in the extracellular space. Red blood cell (RBC) magnesium levels are more reliable than serum levels, but in our experience those with levels in the lowest quadrille of normal range for RBC magnesium tend to respond well to an infusion. A rationally designed study would attempt to correlate RBC magnesium levels with clinical response. Since magnesium is a very safe and inexpensive treatment, it can be argued that all patients presenting with an acute attack of migraine to an emergency department or a clinic with infusion capabilities, should first receive an infusion of magnesium sulfate before proceeding with drugs.