A 12-week randomized double-blind clinical trial of eicosapentaenoic acid intervention in episodic migraine

Omega-3 polyunsaturated fatty acids (PUFAs) may benefit migraine improvement, though prior studies are inconclusive. This study evaluated the effect of eicosapentaenoic acid (EPA) on episodic migraine (EM) prevention. Seventy individuals with EM participated in a 12-week randomized, double-blind, placebo-controlled trial from March 2020 and May 2022. They were randomly assigned to either the EPA (N = 35, 2 g fish oil with 1.8 g of EPA as a stand-alone treatment daily), or the placebo group (N = 35, 2 g soybean oil daily). Migraine frequency and headache severity were assessed using the monthly migraine days, visual analog scale (VAS), Migraine Disability Assessment (MIDAS), Hospital Anxiety and Depression Scale (HADS), Migraine-Specific Quality-of-Life Questionnaire (MSQ), and Pittsburgh Sleep Quality Index (PSQI) in comparison to baseline measurements. The EPA group significantly outperformed the placebo in reducing monthly migraine days ( (cid:0) 4.4 ± 5.1 days vs. (cid:0) 0.6 ± 3.5 days, p = 0.001), days using acute headache medication ( (cid:0) 1.3 ± 3.0 days vs. 0.1 ± 2.3 days, p = 0.035), improving scores for headache severity ( Δ VAS score: (cid:0) 1.3 ± 2.4 vs. 0.0 ± 2.2, p = 0.030), disability ( Δ MIDAS score: (cid:0) 13.1 ± 16.2 vs. 2.6 ± 20.2, p = 0.001), anxiety and depression ( Δ HADS score: (cid:0) 3.9 ± 9.4 vs. 1.1 ± 9.1, p = 0.025), and quality of life ( Δ MSQ score: (cid:0) 11.4 ± 19.0 vs. 3.1 ± 24.6, p = 0.007). Notably, female particularly benefited from EPA, underscoring its potential in migraine management. In conclusion, high-dose EPA has significantly reduced migraine frequency and severity, improved psychological symptoms and quality of life in EM patients, and shown no major adverse events, suggesting its potential as a prophylactic for EM.


Introduction
Migraine, a prevalent global neurological disorder, is associated with significant disability (Ashina et al., 2021;Cheng, 1990;Disease et al., 2017;Sakai and Igarashi, 1997;Wong et al., 1995;Zhao et al., 1988).According to the third edition of the International Classification of Headache Disorders (ICHD-3), migraine is characterized by recurrent episodes of moderate-to-severe headache that lasts 4 to 72 h, most often unilateral and associated with nausea and/or vomiting, photophobia, and phonophobia.In terms of frequency, migraine can be differentiated as episodic migraine (EM) or chronic migraine (CM).EM is defined as experiencing migraines with or without aura on fewer than 15 days per month.In contrast, CM is characterized by migraine occurrences on at least 15 days per month, of which at least 8 headache days meet the criteria for migraine or respond to migraine-specific treatment (IHS, 2018).
Numerous investigations have documented the beneficial effects of omega-3 polyunsaturated fatty acids (PUFAs) in mitigating psychiatric, neurological and neurodegenerative disorders (Deyama et al., 2021;Li and Song, 2022;Lin et al., 2023;Zailani et al., 2023;Zhou et al., 2022) and no conclusive reports of serious adverse events related to omega-3 PUFA have been documented (Chang et al., 2023).Omega-3 PUFAs, specifically eicosapentaenoic acid (EPA), exhibit anti-inflammatory properties by competing with arachidonic acid (AA) as a substrate for cyclooxygenases and 5-lipoxygenase, as discussed in a previous study (De Caterina et al., 2004).A study involving rat models demonstrated that resolvin derived from EPA effectively reduces inflammation and pain by suppressing the expression of inflammatory cytokines like TNFα, IL-6, and IL-1β (Laye, 2010).Moreover, it can alleviate pain by targeting the transient receptor potential cation channel subfamily V member 1 (TrpV1), a pivotal factor in the generation of inflammatory pain (Lin et al., 2020;Xu et al., 2010).As a result, PUFAs, which operate through mechanisms resembling those of anti-inflammatory medications, have significant relevance in evaluating the severity of inflammatory disorders and mitigating neurogenic pain (Abdolahi et al., 2017;Calder, 2006).However, only a limited number of studies have explored their potential impact on migraine.Previous studies have explored the use of PUFAs in migraine prevention, either as a monotherapy or as an augmentation to conventional antimigraine agents such as sodium valproate, amitriptyline, and nutraceuticals like nanocurcumin (Abdolahi et al., 2021;Fayyazi et al., 2016;Harel et al., 2002;Pradalier et al., 2001;Soares et al., 2018b).As a stand-alone treatment for migraine prevention, omega-3 PUFAs administered at 6 g/d (EPA 180 mg, DHA 120 mg) for 16 weeks did not show significant difference in mean intensity, mean duration of the attacks, and rescue medication usage compared to a placebo group (Pradalier et al., 2001).This finding contrasts with their own previous two small double-blind cross-over studies reporting a decrease in migraine attacks (Glueck et al., 1986;Mccarren et al., 1985).Similar results, which showed no difference in frequency, duration, and severity of headaches, were observed in a crossover study carried out on recurrent migraines in adolescents treated for 2 months with omega-3 PUFAs 2 g/d (EPA 378 mg, DHA 249 mg) and 2 months of olive oil as placebo (Harel et al., 2002).Interestingly, sodium valproate, amitriptyline, and nanocurcumin with a combination of omega-3 PUFAs (1 g/d: 180 mg EPA and 120 mg; 1.5 g/d: 400 mg EPA and 350 mg DHA; 2 g/d: 600 mg EPA and 300 mg DHA, respectively) experienced better improvement either in the reduction in headache duration, frequency, and severity compared to the group receiving medication or nanocurcumin alone (Abdolahi et al., 2021;Fayyazi et al., 2016;Soares et al., 2018b).Consequently, the outcomes of these interventions have demonstrated inconsistency, with previous research predominantly focusing on mixed types of PUFAs (EPA combined with DHA) rather than examining EPA or DHA individually.This underscores the critical necessity for establishing precise dosages and formulations of omega-3 PUFAs, specifically tailored for patients with EM.
Furthermore, various studies, including clinical trials, network metaanalysis (NMA), and practice guidelines, have demonstrated the effectiveness of high-dose EPA in several contexts: doses of 1.8 to 4 g EPA daily for primary and secondary prevention of cardiovascular events (Bhatt et al., 2019;Yokoyama et al., 2007), 1.5 to 2 g EPA daily to enhance cognition, quality of life, and behavioral disturbances in Alzheimer's participants (Tseng et al., 2023), and 1 to 2 g of net EPA daily from pure EPA or an EPA/DHA formula with a ratio greater than 2:1 for major depression (Guu et al., 2019).EPA, but not DHA, appears to be more responsible for cardiovascular and neuropsychiatric functions.However, no robust trial has evaluated the efficacy and safety of highdose EPA for migraine prevention.In our current placebo-controlled, double-blind, randomized study, we administered a high dose of EPA (1.8 g/day) to determine its therapeutic potential for EM prevention.Consequently, we assessed the association between daily high-dose EPA supplementation and its impact on migraine symptoms, encompassing headache frequency and severity, as well as comorbid symptoms such as depression, anxiety, sleep quality, and overall quality of life.

Study participants
Participants diagnosed with episodic migraine (EM) were recruited from the neurology clinic of Kuang Tien General Hospital between March 2020 and March 2022.Out of the 70 eligible patients, this doubleblind randomized controlled trial enrolled 15 men and 55 women.The participants were adults aged between 20 and 65 years and had a confirmed diagnosis of EM as per the third edition of the International Headache Society diagnostic criteria (ICHD-3), exhibiting migraines with or without aura on fewer than 15 days per month and possessing a documented migraine history of at least one year (IHS, 2018).We have also incorporated generalized anxiety disorder (GAD) and major depressive disorder (MDD), which were confirmed by medical professionals according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).Participants were excluded if they met the following criteria: (1) CM (>15 days per month); (2) headaches other than migraine; (3) recent use of specific medications within the past 4 weeks, including migraine prophylactic agents, antidepressants, calcium channel blockers, antiepileptic drugs, cycle-modulating hormonal medications, onabotulinum toxin A, or CGRP monoclonal antibody injections; (4) migraine onset occurring after the age of 50 years which often indicates a high risk of secondary headaches; (5) the emergence of abnormal laboratory parameters (ex.elevation of serum hepatic enzymes, increased ESR or CRP level, leukocytosis.)or physical examination findings (ex.neck stiffness, papilledema, focal weakness.);(6) documented allergy or hypersensitivity to fish or omega-3 PUFAs; (7) a history of bleeding diathesis or current use of anticoagulant agents; and (8) current pregnancy or lactation status.

Study design
The study was designed as a 12-week randomized, double-blind, placebo-controlled clinical trial with the objective of assessing the efficacy of EPA as a stand-alone treatment in patients with EM (Cardia et al., 2020;Ramsden et al., 2013;Tajmirriahi et al., 2012).This research obtained approval from the Ethics Committee and Institutional Review Board of Kuang Tien General Hospital (KTGH10844) and was registered on ClinicalTrials.gov(NCT04572789).

Randomization and intervention
Initially, 85 patients underwent eligibility assessment, of which only 70 met the criteria for study inclusion.These 70 participants were then randomly assigned in a 1:1 ratio to either the EPA or placebo groups using computer-generated randomization with block randomization and were subsequently monitored for a duration of 12 weeks.Over the course of the 12-week study, each participant ingested two capsules of the test substance daily, with one taken after breakfast and the other following dinner (Nishizaki et al., 2023).In the EPA group, the test substance consisted of 1 g fish oil per capsule, delivering 900 mg of EPA.The EPA product utilized ethyl EPA in its ethyl ester form for this research.The soft capsule formulation we employed contained only ethyl EPA, with less than 0.3 % Vitamin E added as an antioxidant.In terms of composition, the capsule comprised less than 1 % DHA and less than 9 % of other fatty acids.The product, crafted by CNC GELCAPS CORPORATION-an entity accredited with ISO 22000, HACCP, and GMP standards-incorporates an orange flavoring agent to conceal the taste of EPA.Conversely, in the placebo group, each capsule contained 1 g of 100 % soybean oil.We employed a method for monitoring medication adherence, wherein we assessed adherence by counting the remaining pills in the medication container during study visits.All participants demonstrated full compliance, achieving a 100 % adherence rate.Fig. 1. illustrates the study design.

Characteristics of participants
Table 1 summarizes the clinical and demographic characteristics of the participants.No significant differences were observed between the groups in terms of age, sex, Body Mass Index (BMI), GAD, MDD, monthly migraine frequency, and frequency of acute headache medication use, including acetaminophen, nonsteroidal anti-inflammatory drugs, triptans, ergots, and dihydroergotamine.In terms of migraine frequency and headache severity, the majority of patients in both groups exhibited similar baseline characteristics, including moderate pain (VAS score of 4-5), poorer sleep quality (PSQI score > 5), moderate disability (MIDAS score, Grade III ranging from 11 to 20), normal or borderline HADS scores, and lower MSQ scores.This indicates that migraines substantially affect various aspects of the patients' daily living.

Outcome measurements
All participants underwent the administration of specific questionnaires and the collection of relevant data both at the baseline and at the week-12.
The primary outcome was the decrease in migraine attacks over a 12week period, assessed by the change in the frequency of migraine days per month from the baseline to the 12th week.
To monitor their condition, participants were instructed to maintain headache diaries for at least 4 weeks prior to the intervention (Diary 1, during the pre-intervention run-in period) and throughout the 12-week treatment duration (Diaries 2-4, each covering a 4-week timeframe).These daily calendar entries aimed to capture information regarding the frequency, location, duration, and severity of headache, the presence of aura, menstruation, concomitant symptoms, number of days with acute headache medication intake (including the amount and frequency of analgesic intake for each migraine attack), and any substances provided during the study.All patients received adequate training from an experienced and skilled study coordinator, who ensured they were given sufficient time to understand the process.They were also encouraged to directly contact the study coordinator with any queries regarding headache diary recording.This approach enabled our study team to ensure the accuracy and quality of the self-reported headache diaries.
To maintain consistency, the evaluating physician was blinded to the treatment, and the participants were evaluated by the same physician at  Note: For continuous variables, data is expressed as the mean ± SD (standard deviation) and analyzed using an independent sample t-test.For categorical variables, data is presented as the number of participants or percentage and examined using a Chi-square test.Abbreviations: VAS, visual analog scale, scoring from 1 to 10; PSQI, Pittsburgh Sleep Quality Index, scoring from 0 to 21; MIDAS, Migraine Disability Assessment; HADS, Hospital Anxiety and Depression Scale; MSQ, Migraine-Specific Quality; GAD, Generalised Anxiety Disorder; MDD, Major Depressive Disorder.
each visit.Details information about the intervention can be found in Fig. 1, adhering to the Consolidated Standards of Reporting Trials (CONSORT) guidelines (Schulz et al., 2010).

Statistical analysis
The determination of sample size relied on a prior study (Soares et al., 2018b).To achieve an 80 % test power for detecting differences in improvement proportions between groups, the anticipated sample size was set at 34 per group.Following a post-hoc power analysis, it was revealed that a sample size of 35 per group provided a robust statistical power of 95 % to identify between-group differences in the mean reduction of migraine frequency, specifically a minimum difference of 3.8 days per month.The data were analyzed based on the intention-totreat principle.No interim analysis was conducted.
Table 1 displays baseline characteristics such as age, monthly migraine days, frequency of acute headache medication intake, VAS score, PSQI score, MIDAS score, HADS score, and MSQ score, which were assessed between the two groups using independent sample t tests.The distribution of sex difference was examined using a Chi-square test.
Table 2 illustrates the comparison of study outcomes before and after supplementation within each study group.Data is presented as the mean ± standard deviation (SD).The difference between baseline and week 12, denoted as delta (△), was calculated by subtracting the before frequency/scores from the after frequency/scores.To assess treatment effects within each group, a paired t-test was utilized to compare Note: Data is expressed as the mean ± SD (standard deviation).Within-group differences from baseline (Before) to week 12 (After) were assessed using a paired sample t test (for all) and Wilcoxon sign rank test (conducted separately for males and females), while between-group differences in changes (After-Before) were compared using the independent sample t test (for all) and Wilcoxon rank sum test (conducted separately for males and females baseline (Before) and week 12 (After) measurements.Additionally, we explored the effects of treatment-induced alterations between groups through independent sample t-tests.A stratified analysis based on sex was conducted to explore potential interactions between sex, PUFAs, and migraine.Due to a limited number of participants in each sex category, a non-parametric approach was adopted.The assessment of treatment effects within each group involved a Wilcoxon sign rank test to compare baseline (Before) and week 12 (After) measurements.Furthermore, the impact of treatment-induced changes between groups was examined using Wilcoxon rank sum tests.
Significance was determined at a two-sided p-value of < 0.05.All statistical analyses were performed using SAS 9.4 (SAS Institute, Cary, NC, USA).

Adverse events
During each visit, the participants were asked specifically about the following adverse events (AEs): rash, diarrhea, shortness of breath, swollen tongue, fatigue, any new or worsening symptoms.Details of any reported event were requested, and the participant was followed up until the event was resolved.All potential AEs were reported to the study coordinator, and the principal investigator reviewed all potential AEs.In addition, the headache diary comments were monitored by the study team.The study coordinator or research assistant followed up on the diary comments that could be interpreted as an AE, including all headache symptoms that were unusual for the participant.

Discussion
To the best of our knowledge, this is the first study to investigate the impact of high-dose EPA monotherapy on preventing EM.The main findings of this study indicate that a daily dosage of 1800 mg of EPA over a 12-weeks period exhibited greater effectiveness compared to a placebo, resulting in reduction of monthly migraine days, decreased headache severity, a reduction in the frequency of acute headache medication usage, the amelioration of headache-related disability, a decrease in psychological distress, and an enhancement in overall health-related quality of life.
Previous randomized controlled trials, reviews, and meta-analyses have not demonstrated consistent improvements in migraine (Abdolahi et al., 2018;Fayyazi et al., 2016;Harel et al., 2002;Pradalier et al., 2001;Soares et al., 2018a).The discrepancies in previous results may be attributed to the following reasons: (1) PUFA selection, which involved differing dosages and formulations of omega-3 PUFAs, some used in conjunction with guideline-recommended medications, resulting in differing levels of efficacy; (2) methodological differences, such as not all trials adopting a placebo-controlled design, make their results more susceptible to influences from other factors, including natural disease progression, placebo effects, selection bias, and more.These elements are more prone to positive findings; (3) participant characteristics, including age, sex, physical and mental health conditions, ethnicity, and environmental influences, which can impact the overall clinical effects of omega-3 PUFAs (Gazerani, 2020).Nonetheless, a large cohort study demonstrated that a dietary regimen rich in omega-3 EPA + DHA, with or without concurrent reduction of omega-6 linoleic acid intake, could alter nociceptive oxylipins (Ramsden et al., 2021).These molecules are enriched in trigeminal nerve endings and central pain processing pathways and can lead to significant reductions in both the frequency and severity of migraine compared to the control diet.This observation implies a direct connection between omega-3 and omega-6 PUFAs and migraine pathogenesis (Ramsden et al., 2021).In their post hoc analysis, a diet high in omega-3 (with EPA + DHA increased to 1.5 g/day) and a diet high in omega-3 but low in omega-6 (EPA + DHA increased to 1.5 g/ day and linoleic acids reduced to ≤ 1.8 % of energy) were shown to be effective in reducing monthly headache days among participants.Specifically, reductions of 1.8 and 4.4 days were observed for those with CM, and 2.7 and 3.6 days for those with EM.This analysis indicates that such dietary interventions could potentially match or exceed the effectiveness of approved CGRP monoclonal antibodies, which have shown to reduce headache days by about 2-2.5 days per month) (Lattanzi et al., 2019;Nagaraj et al., 2021;Tfelt-Hansen et al., 2020).In our study, the supplementation of EPA resulted in a significant reduction in the average monthly migraine frequency, decreasing from 7.4 to 3.0 days compared to the baseline superior to the placebo group, where the frequency changed from 6.7 days to 6.1 days per month (Table 2).Together, these findings indicate that omega-3 PUFA supplementation may offer clinical effectiveness in the management of migraine.
The pathophysiology of migraine has yet to be fully elucidated, but the most widely acknowledged biological pathway associated with migraine include: (1) the trigeminovascular theory, which involves nociceptive transmission and migraine-associated symptoms (Noseda and Burstein, 2013); (2) the vasodilation theory, involving the release of CGRP and other vasoactive peptides (Mason and Russo, 2018;Russo, 2015); and (3) the neuroinflammation theory, noted for significantly increased microglial activation, neuroinflammation, and neuropathic pain in the brain (Kursun et al., 2021).In this context, various cytokines, including tumor necrosis factor (TNF), interleukin 1 (IL-1), and adiponectin, have been implicated in inflammation, modulation of the pain threshold, sensitization of trigeminal nerve fibers, and ultimately in the precipitation of migraines (Kursun et al., 2021).EPA and DHA have been identified to exert beneficial effects through anti-inflammatory mechanisms (Abdolahi et al., 2021), reduction of nociceptive responses (Satyanarayanan et al., 2019), and inhibition of vasodilation in migraine patients (Ramsden et al., 2021).Moreover, SPMs and other omega-3derived metabolites regulate pro-inflammatory and resolution pathways and thus play a significant neurological and anti-inflammatory role, which in turn may be beneficial in reducing the symptomatology of migraine (Giacobbe et al., 2020;Hennebelle et al., 2017).In line with these findings, our data revealed that high-dose EPA supplementation was effective for EM prevention.Taken together, these findings suggested that omega-3 PUFAs, particularly EPA, may contribute, at least in part, to the prevention of migraines through their anti-inflammatory effects.However, further research is required to elucidate the precise molecular mechanisms underlying the effects of omega-3 PUFAs, specifically EPA on migraine pathophysiology and progression.
In the present study, we found that in addition to decreasing the frequency and severity of migraine, EPA supplementation ameliorated the associated emotional burden, such as anxiety and depression.To our surprise, previous studies did not assess the effect of omega-3 PUFAs EMinduced mood disorders, which makes our study the first in this regard.Our finding largely agrees with the findings on the role of omega-3 PUFAs in neuropsychiatric disorders (Lin et al., 2012;Sadeghi et al., 2015).Psychiatric disorders such as depression or anxiety disorders may be either a comorbidity, a trigger, a risk factor for the nonresponse for migraine to treatment and may exhibit a bidirectional relationship with migraine (Antonaci et al., 2011;Baskin and Smitherman, 2009;Breslau et al., 1991;Breslau et al., 2000;Minen et al., 2016;Radat and Swendsen, 2005).Neuroinflammatory pathways may be promising treatment targets and biomarkers of migraine (Kursun et al., 2021).A recent study reported that supplementation with omega-3 PUFAs for 8 weeks resulted in a significant increase in circulating anti-inflammatory cytokine (IL-4) as well as a significant decrease in pro-inflammatory cytokine IFN-γ in patients with migraines (Djalali et al., 2023).EPA exerts its anti-inflammatory properties by antagonizing arachidonic acid formation in the plasma membrane and inhibiting phospholipase A2 activity to reduce the secretion of eicosanoids, such as prostaglandin, and proinflammatory cytokines (Su, 2009;Su et al., 2018).Furthermore, high-purity EPA may be more effective than DHA in reducing inflammatory cytokines and alleviating depressive symptoms, which are linked to inflammation as one important mechanism of MDD (Guu et al., 2019;Su et al., 2014;Tu et al., 2020).In agreement with these findings, our data revealed that high-dose EPA supplementation was effective for patients with EM who have emotional comorbidities.
Regarding current migraine prevention treatments, the widespread adoption of CGRP monoclonal antibodies or antagonists is hindered by their high cost and the substantial side effects associated with oral prophylaxis approaches (Simioni, 2022).In contrast, omega-3 PUFAs have demonstrated excellent tolerability in patients with psychiatric disorders (Lin et al., 2012;Lin and Su, 2007;Su, 2009), and medical illnesses, with AEs being infrequent (Bays, 2006).Our data also affirm the safety and tolerability of high-dose EPA intake.Few AEs occurred, and most were mild severity, resulting in no patients withdrew from this study due to AEs.Participants in this trial demonstrated good tolerance to omega-3 PUFAs, with no discovery of previously unrecognized AEs associated with the supplements.Therefore, EPA may represent a promising therapeutic alternative for migraine prevention owing to its high tolerability, safety and cost-effectiveness.
The strengths of our prospective study are that the interventions, assessments, and outcome measures were based on recommendations in the guidelines from trials on migraine; therefore, our study results are reproducible (Abu-Arafeh et al., 2019).Our study employed a high dose of EPA (1.8 g/day), which surpasses the dosages used in the majority of other trials investigating omega-3 PUFAs for migraine prevention.This higher dose has been validated as more effective in managing depression, anxiety, and cardiovascular outcomes (Bhatt et al., 2019;Chang et al., 2018;Chang et al., 2023;Yokoyama et al., 2007).On the other hand, focusing on EPA alone could be seen as an innovation, since previous research predominantly examined mixed types of PUFAs (EPA with DHA) rather than examining EPA individually, in patients with migraine.Furthermore, the lower risk of AEs from nutraceuticals that contributed to the high adherence, the provision of acute headache medications for headache relief that encouraged continued participation in the trial, even if the nutraceutical intervention was not immediately effective, and our hospital's strong rapport with patients and proactive patient engagement.These elements collectively contributed to none of the participants dropping out, thereby enhancing the validity of our findings.
However, there are some limitations to the present study.First, this was a single-center study with a relatively small sample size and a short treatment duration, which may impact the interpretation and generalizability of the study results.In addition, the follow-up period was limited, making it challenging to ascertain the long-term effectiveness of this treatment.Future larger-scale multicenter studies with longer treatment and follow-up durations should be performed, with high-dose EPA provided as monotherapy and as adjunctive treatment to standard treatment.Secondly, additional controls for confounding variables such as medical comorbidities, genetic polymorphisms, and psychosocial factors should be included to determine the independent association between EPA supplementation and migraine attacks.Thirdly, despite advising participants not to consume additional omega-3 PUFA supplements, we were unable to control this factor in free-living populations who may include omega-3 PUFA-rich foods in their diet to alleviate headaches.Fourthly, this study primarily focused on EM prevention.Future clinical trials should evaluate the effects of EPA on CM, a condition that is more debilitating and challenging to manage than EM (Katsarava et al., 2012).Fifthly, there is a large body of evidence related to inflammatory processes in migraine pathophysiology.However, the present trial did not measure any biomarkers to understand whether the improvement is associated with changes in inflammatory levels, which should be regarded as a future direction.Sixthly, our study's female participant percentage (78.57%) closely reflects the global epidemiological trends of migraines, which show a higher prevalence in women (18 %) compared to men (6 %) (Burch et al., 2019).Due to the limited male population in our study, statistical significance might not be achievable, even if it might be effective.With women being at an increased risk of developing migraines, our study also offers further insight into whether female patients might particularly benefit from omega-3 PUFAs intervention.Further research is needed to evaluate the interaction between biological sex, PUFAs, and migraine.

Conclusion
Our study has shown that 12 weeks of high-dose EPA monotherapy demonstrates favorable effects on the frequency and severity of migraines, as well as on the psychological symptoms and quality of life of EM patients, with a high degree of tolerability and safety.Nutraceutical EPAs could play a role in alleviating migraines, potentially relieving patients of their burden and leading to an improvement in their quality of life.The findings from this randomized placebo-controlled trial revealed that omega-3 PUFAs could offer a novel avenue for addressing the challenges posed by migraines.Consequently, the results of this study may not only serve as a valuable reference for future large-scale RCTs to investigate the optimal dosing and components of omega-3 PUFAs for migraine prevention but also underscore the need for replication of these findings in adequately powered and controlled studies.

Statement of Ethics
The study was approved by the Institutional Review Board of Kuang Tien General Hospital, Taichung, Taiwan (NCT04572789).Written informed consent was obtained from all patients.

Table 1
Baseline demographic characteristics of participants.

Table 2
Comparison of study outcomes between study groups before and after supplementation in each group.