Nutritional Neuroscience

An International Journal on Nutrition, Diet and Nervous System

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Mechanisms of action of vitamin B1 (thiamine),

B6 (pyridoxine), and B12 (cobalamin) in pain: a
narrative review

A. M. Paez-Hurtado, C. A. Calderon-Ospina & M. O. Nava-Mesa

To cite this article: A. M. Paez-Hurtado, C. A. Calderon-Ospina & M. O. Nava-Mesa

(2023) Mechanisms of action of vitamin B1 (thiamine), B6 (pyridoxine), and B12
(cobalamin) in pain: a narrative review, Nutritional Neuroscience, 26:3, 235-253, DOI:
10.1080/1028415X.2022.2034242

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Published online: 14 Feb 2022.

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NUTRITIONAL NEUROSCIENCE
2023, VOL. 26, NO. 3, 235–253
https://doi.org/10.1080/1028415X.2022.2034242

REVIEW

Mechanisms of action of vitamin B1 (thiamine), B6 (pyridoxine), and B12

(cobalamin) in pain: a narrative review
a b a
A. M. Paez-Hurtado *, C. A. Calderon-Ospina * and M. O. Nava-Mesa
a
Neuroscience Research Group (NEUROS)-Centro Neurovitae, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá,
Colombia; bCenter for Research in Genetics and Genomics (CIGGUR), GENIUROS Research Group, School of Medicine and Health Sciences,
Universidad del Rosario, Bogotá, Colombia

ABSTRACT KEYWORDS
Pain is a complex sensory and emotional experience with nociceptive, nociplastic, and neuropathic Inflammation; nociception;
components. An involvement of neurotropic B vitamins (B1 – thiamine, B6 – pyridoxine, and B12 – neuropathic pain; vitamin
cyanocobalamin) as modulators of inflammation and pain has been long discussed. New evidence B1; vitamin B6; vitamin B12
suggests their therapeutic potential in different pain conditions. In this review, we discuss the main
role of neurotropic B vitamins on different nociceptive pathways in the nervous system and to
describe their analgesic action mechanisms. The performed literature review showed that, through
different mechanisms, these vitamins regulate several inflammatory and neural mediators in
nociceptive and neuropathic pain. Some of these processes include aiming the activation of the
descending pain modulatory system and in specific intracellular pathways, anti-inflammatory,
antioxidative and nerve regenerative effects. Moreover, recent data shows the antinociceptive,
antiallodynic, and anti-hyperalgesic effects of the combination of these vitamins, as well as their
synergistic effects with known analgesics. Understanding how vitamins B1, B6, and B12 affect several
nociceptive mechanisms can therefore be of significance in the treatment of various pain conditions.

1. Introduction at any point of time. Mixed pain can be acute or chronic

Pain is a serious and widespread public health problem
affecting around 10%–20% of adults worldwide [1–5].
There are three different types of pain subcategorized
according to their pathophysiological mechanisms by
the International Association for the Study of Pain.
Nociceptive pain is a pain sensation caused by ‘an actual
or threatened damage to non-neural tissue and is due to
activation of nociceptors’ [6]. Pain initiated or caused by
a lesion or a disease of the somatosensory system is
referred to as neuropathic pain. Nociplastic pain is
defined as ‘pain that arises from altered nociception
despite no clear evidence of actual or threatened tissue
damage causing the activation of peripheral nociceptors
or evidence for disease or lesion of the somatosensory
system causing the pain’ [6]. Inflammatory pain is a
type of nociceptive pain which results from hypersensi-
bility of nociceptors by inflammatory mediators [7].
Nociceptive, neuropathic, and nociplastic pain result
from diverse mechanisms. In recent years, the term
‘mixed pain’ has become established to describe a mixture
of different pain components [8]. Different pain types can
overlap in any combination and can act simultaneously
and/or concurrently to cause pain in the same body area.
Either mechanism may be more clinically predominant
[9]. Thus, mixed pain management requires a combination
of agents targeting all the underlying mechanisms.
Vitamin B1, B6, and B12 belong to the hydrosoluble
group of vitamins. They are vital to axonal transport,
neuron excitability, and the synthesis of neurotransmitters
[10–16]. Vitamin B1, B6, and B12 are also important for
nucleic acid and proteins synthesis, as well as for phospha-
tidylcholine synthesis [17–19]. Mammals do not have the
ability to synthesize B vitamins by themselves. Thus, its
intake must be done through microbial or dietary sources
[20–22]. Most of these vitamins are found in plant-based
foods, with the exception of B12, which is found in animal-
derived products synthesized by bacteria in the digestive
tract of mammals. Despite this, humans cannot assimilate
this form of the vitamin, due to its absorption in the ileal
mucosa through an intrinsic factor-mediated mechanism
[21,22]. From a biochemical point of view, vitamin B6 and
B12 interact in the methionine cycle and indirectly in the
citric acid cycle, together with other B vitamins such as
thiamine. This emphasizes the importance of a balanced
diet in order to supply the necessary amounts of these vita-
mins for a proper metabolic functioning.
Deficiencies of B vitamins have been related to per-
ipheral neuropathy, and therefore with neuropathic

CONTACT M. O. Nava-Mesa mauricio.nava@urosario.edu.co EMCS- Universidad del Rosario, sede Quinta Mutis, Bogotá, Colombia
*A. M. Paez-Hurtado and C. A. Calderon-Ospina contributed equally to this work.
© 2022 Informa UK Limited, trading as Taylor & Francis Group
236 A. M. PAEZ-HURTADO ET AL.
pain [23,24]. Several inflammatory conditions have been
associated with B vitamins deficiency. For instance, in
active arthritis, excessive hydrolysis of pyridoxal 5’-
phosphate during inflammation due to a reduction in
albumin levels and elevated alkaline phosphatase
activity has been reported [25]. In addition, in different
neoplastic and autoimmune disorders (e.g. rheumatoid
arthritis) the use of methotrexate is quite common.
This drug may reduce serum levels of folic acid and vita-
min B12 [26]. It is well known that these conditions are
usually associated with nociceptive and neuropathic
pain, therefore it is plausible that these deficiencies
could increase pain scores and then facilitate the pro-
gression to a chronic pain condition.
Several experimental animals and in vitro models
have shown that B vitamins (including thiamine, pyri-
doxine, riboflavin and cobalamin) produce antinocicep-
tive, anti-hyperalgesic, and anti-inflammatory effects
and reduce mechanic allodynia [12,27–31]. Similarly,
it has been described that B vitamins can enhance the
therapeutic effects of analgesics [32–48]. Considering
that the mechanisms involved in the pathophysiology
of pain are diverse, the combined use of different agents,
each with own mechanisms of action, can be more effec-
tive in reducing pain in a synergistic way with lower
doses and with fewer adverse effects.
B vitamins can be used both, prophylactically and thera-
peutically. New experimental and clinical evidence points
toward their therapeutic potential in different pain con-
ditions, even when there is no demonstrated B vitamin
deficiency (Table 1). In a systematic review and meta-analy-
sis, it was showed that B1, B6 and B12 shorten the duration
of analgesic treatment with diclofenac in patients with acute
low back pain, compared with diclofenac as monotherapy
[49]. Another recently meta-analysis [50] suggested that B
vitamins could improve the symptoms of peripheral neuro-
pathy according to the etiology. In the case of diabetic neu-
ropathic pain, their efficacy is plausible but is necessary to
conduct high-quality further studies [51].
In the present work, we review the mechanisms of action
of neurotropic B vitamins as modulators of inflammation
and pain. In addition, we present their potential involve-
ment in different pain pathways focusing on the antinoci-
ceptive, antiallodynic, and anti-hyperalgesic mechanisms,
as well as their synergic effects with known analgesics.
2. Antinociceptive, anti-inflammatory, and
nerve protecting mechanisms of B vitamins
2.1. Vitamin B1 – thiamine
Vitamin B1 (thiamine, B1) functions in the body as a
coenzyme named thiamine pyrophosphate, which is
involved in important functions in carbohydrate metab-
olism, especially in nerve cells. It is the coenzyme of pyr-
uvate decarboxylase, transketolase, and alpha⍰
ketoglutarate dehydrogenase and participates in the for-
mation of acetylcholine. Moreover, blocking voltage-
gated sodium channels, it regulates neural excitability
in injured neurons in the dorsal root ganglion (DRG),
suppressing thermal hyperalgesia and improving analge-
sia [68]. Details are given in the subchapters below.
2.1.1. Neural excitability and sodium currents in
DRG neurons
Moallem et al. demonstrated that thiamine prolongs the
reaction time of mice in the hot-plate test, with and
without sciatic nerve ligation, in a dose-dependent man-
ner. In this way, it has been established that this vitamin
has an antinociceptive effect for the control of nocicep-
tive pain as well as neuropathic pain [30].
Later, Song et al. demonstrated that intraperitoneal
(IP) administration of vitamin B1 significantly inhib-
ited neural hyperexcitability due to compression of
the DRG in rats, as well as repressing thermal hyper-
algesia. A dose-dependent inhibition of DRG neuron
hyperexcitability was achieved using in vitro DRG per-
fusion with different doses of vitamin B1. Further-
more, DRG neurons showed differential sensitivity to
B1 treatment, depending on their size (smaller neur-
ons were more sensitive). Authors concluded that thia-
mine could modulate Na+ currents, and reduce
hyperexcitability and thermal hyperalgesia in harmed
DRG neurons [12].
An earlier study conducted by Itokawa and Cooper
in rats revealed that vitamin B1 is involved in ionic
transport through the cell membrane. It has been
suggested that thiamine triphosphate (or thiamine pyr-
ophosphate) binds to a specific site on the cellular mem-
brane of nerve fibers that is a Na+ channel or is adjacent
to it [69]. In addition, thiamine has shown to reduce
capsaicin-induced calcium currents in cells which
express TRPV1 receptors [70,71]. This receptor is a
cation channel expressed in nociceptive neurons
which mediate thermal and chemical noxious stimuli
in peripheral tissues.
Zylka et al. found that the thiamine monophospha-
tase (TMPase) is molecularly equivalent to the trans-
membrane isoform of prostatic acid phosphatase
(PAP) in DRG sensory neurons. This enzyme partici-
pates in the conversion of ATP to adenosine, which is
an antinociceptive molecule in mammals [72]. It is
also involved in the interconversion of biologically
active forms of thiamine [73]. PAP is also highly
expressed in the dorsal horn of the spinal cord, so its
role in controlling ATP-mediated pain transmission is
 NUTRITIONAL NEUROSCIENCE 237

Table 1. Analgesic effects of the combination of B vitamins in clinical conditions.

Number and type of the
Reference Pain condition studies included Type of pain Intervention Control Main results
[52] Acute low back pain Six randomized, double- Mixed pain Diclofenac plus Diclofenac PO Seven studies found a
[53] blind controlled cyanocobalamin (or or IM reduction in recovery
[54] clinical trials. methylcobalamin) and/or time (complete pain
[55] Two randomized thiamine (or relief) to half the usual
[40] clinical trials. benfothiamine) plus time in the intervention
[56] pyridoxine, PO or IM group, and eight studies
[57] depending on the study reported a greater
[35] reduction in pain scores
in the diclofenac plus B
vitamins in favor of the
intervention group
versus the monotherapy
control group with
diclofenac
[58] Chronic low back One randomized open- Mixed pain Diclofenac plus Diclofenac Reduction in pain intensity
[59] pain label clinical trial. benfothiamine, pyridoxine Placebo and in the number of
One prospective and cyanocobalamin, PO recurrent episodes of low
observational, Thiamine plus pyridoxine back pain
randomized, double- plus cyanocobalamin, PO
blind study.
[37] Lower limb fracture One low-quality Nociceptive Diclofenac plus thiamine, Diclofenac IM One of the two studies
[19] and surgery preliminary clinical pyridoxine and found a significant
trial and one cyanocobalamin, IM reduction of pain
randomized double- intensity in the
blind controlled combination therapy
clinical trial group compared to
control group at different
time points (p <0.05).
[60] Postoperative pain One high-quality Nociceptive Diclofenac plus thiamine, Diclofenac IV All the studies found
[61] randomized controlled pyridoxine and Diclofenac IV statistically significant
[62] trial and three low cyanocobalamin IV Paracetamol differences in pain scored
[63] quality randomized, infusion over a 12h period PO in favor of the
double-blind prior to surgery. Gabapentin intervention group
controlled clinical Diclofenac plus thiamine, PO All documented a
trials pyridoxine and reduction in the amount
cyanocobalamin, IV of analgesic consumption
Paracetamol plus thiamine, within the first 12 h
pyridoxine and postoperative following
cyanocobalamin, PO caesarean section.
Gabapentin plus thiamine,
riboflavin, pyridoxine and
nicotinamide, PO
[39] Severe knee One randomized Nociceptive Diclofenac plus thiamine, Diclofenac IM Significant differences were
osteoarthritis double-blind pyridoxine, found in favor of
controlled clinical trial cyanocobalamin, IM combination therapy for
both VAS measurements
(p < 0.05), and the Likert
scale (p < 0.05) with 12
patients (50%) who
reported complete pain
relief in the combination
therapy group vs. 3
(12.5%) in the
monotherapy group (p <
0.05).
[64] Painful Diabetic One low quality Neuropathic Gabapentin plus thiamine, Pregabalin PO Combination therapy was
[65] Neuropathy randomized double- cyanocobalamin, PO NA as effective as pregabalin.
[66] blind controlled Combination of thiamine, Thioctic acid Nonetheless, pain
clinical trial. pyridoxine and IV intensity reduction was
One descriptive case cyanocobalamin, PO achieved with 50% of the
series and one Thioctic acid plus thiamine minimum required
prospective, (B1), pyridoxine gabapentin dose alone
observational study (B6) and cyanocobalamin (800–1600 mg/d) in the
(B12) IV intervention group.
Combination of B1, B6
and B12 vitamins was
found to be efficacious in
271 patients (87.4%)
according to NRS
Combination therapy of B

(Continued)
238 A. M. PAEZ-HURTADO ET AL.
Table 1. Continued.
Number and type of the
Reference Pain condition studies included
[67] Peripheral One prospective, open-
neuropathy of label, multicenter,
different observational study
aetiologies’ i.e.
diabetic PN, carpal
tunnel syndrome
and idiopathic
IM: intramuscular; IV: intravenous; MNSI: the Michigan neuropathic screening instrument; NA: not applicable; NRS: numeric pain rating scale; PO: per oral.
Note: We included only clinical studies in which therapy was based on B vitamins combination but not in isolated B vitamins.
undeniable. The pain control effect of thiamine is highly
dependent on PAP in such a way that in the thermal
sensitivity test by heating the hind paw, the knockout
mice for this enzyme did not have antinociceptive
effect to the administration of thiamine, while wild
type mice had an increase in the withdrawal latency
time [73–75]. It has been proposed that PAP could
transform thiamine into an active molecule through a
new catalytic reaction or work as a thiamine/thiamine
analog receptor. Another alternative explanation is
that PAP is an important subunit of this thiamine/thia-
mine analog receptor or that it aids thiamine analogs to
bind such receptor [73].
2.1.2. Regulation of inflammatory mediators
Moallem et al. analyzed the anti-inflammatory and anti-
nociceptive effects of vitamin B1 in mice using granu-
loma caused by compressed cotton implantation and
xylene-induced edema in ears, respectively. It was
shown that thiamine prevented the inflammation
(acute and chronic) induced by xylene [30]. It has
been proposed that this anti-inflammatory effect could
be explained at least partially due to a lower production
of pro-inflammatory cytokines such as interleukins 6
(IL-6) and tumor necrosis factor (TNF)-alpha [27].
In summary, thiamine has been shown to have anti-
inflammatory and antinociceptive properties in murine
models of nociceptive and neuropathic pain. This effect,
dependent on PAP, is also explained by the blockade of
voltage-gated sodium channels. However, the exact
mechanism by which thiamine (or its metabolites)
interact with PAP at the molecular level remains to be
clarified. It is also necessary to delve more into the
mechanisms underlying the anti-inflammatory effects
of vitamin B1. Similarly, it is important to establish-
whether the analgesic/anti-inflammatory effect is pre-
sent in experimental pain models other than mice and
those that have already been mentioned.
Type of pain Intervention Control Main results
vitamins plus thioctic
acid was superior to
thioctic acid alone
according to MNSI
Neuropathic Combination of thiamine, NA Progressive relief of
pyridoxine and different neuropathic
cyanocobalamin, PO symptoms such as
stabbing and burning
pain, paraesthesia and
numbness
2.2. Vitamin B6 – pyridoxine
Vitamin B6 (pyridoxine) exists in three different forms in
nature: pyridoxine, pyridoxal, and pyridoxamine. These
compounds function as prodrugs in the sense that they
must be metabolized to produce the active metabolite
called pyridoxal 5’-phosphate (PLP), which is responsible
for the biological functions of the vitamin [20].
PLP participates as a coenzyme in many biochemical
reactions involved in different physiological processes
such as: fatty acid metabolism, neurotransmitter synthesis,
immune function, gluconeogenesis, folate metabolism,
synthesis of coenzyme Q, and heme synthesis [20]. Folic
acid metabolism in turn favors the conversion of homocys-
teine to S-adenosylmethionine, which acts as a methyl
group donor to produce nucleic acids, myelin, and cat-
echolamines among other compounds [21].
PLP works as a coenzyme in several reactions includ-
ing conversion of tryptophan to niacin, transamination
and decarboxylation of amino acids, deamination of
cysteine and hydroxyamino acids, and metabolism of
fatty acids [20]. In this way, PLP is necessary for the syn-
thesis of neurotransmitters such as serotonin, dopamine,
norepinephrine, and gamma-aminobutyric acid (GABA).
This promoting effect of the synthesis of neurotransmit-
ters, along with promoting the synthesis of myelin and
other essential compounds for nerve fibers, make pyri-
doxin considered a neurotropic B vitamin [20].
Regarding antinociceptive properties, early studies in
rats have documented that pyridoxine is able of inhibiting
somatogenic nociceptive pain in the hot-plate model, as
well as visceral nociceptive pain in the writhing test in a
dose-dependent manner [76] and in a model of neuro-
pathic pain due to compression of the dorsal root
ganglion (DRG) or ligation of the sciatic nerve in rats
[10]. This effect could be explained, at least in part, by a
lower pain impulse propagation through inhibiting the
effect of two cation channels expressed in nerve fibers,
operated by glutamate or by ATP as explained below.

2.2.1. Inhibition of protein glycosylation final
products: decrease of oxidative stress
It has been postulated that pyridoxine and pyridoxamine
remarkably lower lipid peroxidation and the generation of
glycosylated hemoglobin in red blood cells exposed to a
glucose-enriched environment. Thus, vitamin B6 can
impede oxygen radical production, avoiding the lipid per-
oxidation and protein glycosylation related with hypergly-
cemia [77]. Moreover, in a preclinical model of U937
monocytes the three biological forms of vitamin B6 pre-
vented the synthesis of oxygen-derived free radicals and
lipid peroxidation produced by hydrogen peroxide [78].
These findings suggest that vitamin B6 has antioxidant
properties and could have an important role avoiding
the nerve damage related with diabetic neuropathy,
which in turn can lead to neuropathic pain [79,80].
2.2.2. Decrease of intracellular glutamate levels
and cellular surface of calcium channels
Central sensitization is a key mechanism in chronic pain,
allodynia, and secondary hyperalgesia. It is caused by a
growing reactivity to noxious or non-noxious sensory
stimulation due to hyperresponsiveness of neurons
located at the central nervous system (CNS) [81]. Periph-
eral inflammation and the following continuous nocicep-
tive stimulus lead to a higher release of neurotransmitters
(e.g. substance P and glutamate) from the primary afferent
central terminals in the spinal cord and trigeminal
nucleus. The high concentration of these neurotransmit-
ters leads to a state of neuronal hyperexcitability known
as central sensitization. Activation of the postsynaptic
N-methyl-D-aspartate receptor (NMDA) receptor for
glutamate is a critical process for the initiation and main-
tenance of central sensitization [82,83].
From in vitro models, it has been proposed that pyr-
idoxine could decrease the intracellular levels of gluta-
mate, inducing the enzyme glutamate decarboxylase
which converts glutamate into GABA which is the
counterregulatory neurotransmitter of glutamate, thus
interfering with one of the most important mechanisms
of central sensitization [84].
Moreover, it has been documented that pyridoxine
inhibits the release of glutamate caused by depolariz-
ation in the glutamatergic nerve endings of the rat cer-
ebral cortex [85]. This mechanism not only supports a
central sensitization control effect for vitamin B6 of
importance in pain management but also a possible
neuroprotective effect [21].
2.2.3. Antagonistic effect on various isoforms of
P2X receptors
Several studies suggest that the anti-inflammatory and
analgesic effect of pyridoxine might be mediated by
NUTRITIONAL NEUROSCIENCE 239
the P2X receptor. It can be found in the vascular
smooth muscles, the heart and in the central and per-
ipheral nervous system [31]. P2X and its homomeric
(P2X (3)) and heteromeric (P2X (2/3)) forms belong
to the family of purinergic membrane P2 receptors.
They are located on the primary afferent neurons of
the DRG that activate the nociceptive effect. Its acti-
vation together with the action of inflammatory
mediators and direct agonists contribute to the appear-
ance of acute pain and its chronicity [86,87]. Vitamin
B6 and its derivatives have been shown to have an
antagonistic effect on various isoforms of P2X recep-
tors such as P2X1, P2X2 and P2X3, thus explaining
their antinociceptive properties, as well as selectivity
on the afferent system of pain and reduction of the
central hyperexcitability [31,88,89].
In summary, vitamin B6 modulates glutamate
levels, thus controlling neural excitability. Moreover,
an antagonistic effect on various isoforms of P2X
receptors has been described. The combination of
these mechanisms suggests a preponderant role for
this vitamin in inhibiting central sensitization which
is the pathophysiological hallmark of chronic pain.
From a clinical point of view, pyridoxine as monother-
apy has been used in certain painful neuropathies
[90,91]. Paradoxically, higher doses of pyridoxine itself
may also induce neural injury through Bax and cas-
pase-8 induction [92]. However, this neurotoxic
effect is rare and only occurs with high daily doses
(>500 mg/day) and/or longer treatment duration (>6
months) [93]. Therefore, a clear indication of its thera-
peutic use is recommended, as well as plasma levels
monitoring, especially when using high doses.
2.3. Cyanocobalamin
Several studies have shown that vitamin B12 has mul-
tiple mechanisms of action involving an antinocicep-
tive effect in processes of neuronal regeneration and
myelin synthesis, inducing axonal growth and differen-
tiation of Schwann cells [94–97]. Similarly, it partici-
pates in DNA methylation and gene transcription
that contributes to an increase in the synthesis of pro-
teins required for neuronal regeneration [97,98].
Additionally, it exerts an essential role in cell replica-
tion during purine and pyrimidine synthesis, and in
the upregulation of the expression of brain-derived
neurotrophic factor. Vitamin B12 mechanisms of
action related to decrease nervous fiber damage are
derived from reducing the final protein glycosylation
products, inhibition of the diacylglycerol–protein
kinase C (DAG–PKC) pathway and regulation of hex-
osamine and pentose pathways [14,68].
240 A. M. PAEZ-HURTADO ET AL.
2.3.1. Nerve regeneration and conduction velocity
Histological and morphological evidence from patients
with diabetic neuropathy, and acrylamide-induced neu-
ropathy and streptozotocin-induced diabetes animal
models, have shown an improvement of neuronal func-
tion and myelin regeneration at high cyanocobalamin
doses for extended treatment periods [95,99–102].
Specifically, vitamin B12 may induce regeneration of
damaged nerves by incorporation of leucine into the
protein fraction of the damaged sciatic nerve [97,102].
Moreover, after a high-dose vitamin B12 adminis-
tration, a significant increase in the number of motor
fiber regenerations was evidenced in sciatic nerve injury
and acrylamide neuropathy models [97,102], additional
to an increase in neuronal density in the calf muscle sur-
face, when combined with L-methylfolate and pyridox-
ine 5-phosphate [103]. Some of those effects could also
be explained by neurotrophic effects of cobalamin. For
instance, epithelial growth factor is involved in vitamin
B12 signaling pathway in the CNS of rats, showing that
the lack of this neurotrophic factor, in relation to coba-
lamin deficiency, is in part responsible for the develop-
ment of neurodegenerative central neuropathy
(interstitial and intramyelinic edema in the white matter
of the spinal cord) [104]. Finally, it has also been shown
that cyanocobalamin has the ability to increase the sen-
sory and motor nerve conduction velocities, resulting in
the improvement of regenerative processes of peripheral
nerves [97,105,106].
2.3.2. Regulation of inflammatory mediators
Reduction in COX-mediated second inflammatory
phase have been reported in mice pain models with
B12 administration, suggesting central and peripheral
inhibitory properties associated with this enzyme [29].
The evaluated anti-inflammatory and antinociceptive
effects of cyanocobalamin in acute and chronic pain,
assessed by hot-plate and writhing tests, as well as
xylene-induced ear edema and cotton pellet-induced
granuloma, showed a dose-dependent inhibition of
pain and a reduction in granuloma formation. With
these results, authors suggest that prostaglandins
(PGE2 and PGF2) and COX, histamine and/or leuko-
triene may play an important role as nociceptive
mediators inhibited by B12, besides its relation to cen-
tral serotonergic inhibitory activity [29].
Regarding the effect on neuropathic and inflamma-
tory pain, a prospective experimental study performed
in rats by Imtiaz et al. [107] evaluated the efficacy of
vitamin B12 and folic acid in reducing these variables.
By performing formalin and tail flick tests, results
showed that the administration of these supplements
has a positive impact on the reduction of neuropathic
pain and significantly decreasing inflammatory pain.
Similarly, authors suggested that low production of
(TNF-α), IL-6 and IL-8, C-reactive protein, free radicals
and/or nuclear factor κB (NF-κB), may explain those
anti-inflammatory effects [107]. Related to this, Xu
et al. [14] conducted a study that assessed the efficacy
of IP administration of methylcobalamin in the treat-
ment of vincristine-induced mechanical allodynia and
thermal hyperalgesia in rats. The results showed that
this vitamin inhibited NADPH oxidase and NF-kB
pathway, therefore prevented overproduction of TNF-
α and also enhances the expression of IL-10 in the dorsal
spinal horn, which can regulate several pro-inflamma-
tory mediators [14].
2.3.3. Neural excitability and sodium currents in
DRG neurons
In a chronic compression of the DRG model in rats,
inhibition of spontaneous ectopic discharges of dorsal
root fibers associated with cyanocobalamin were also
reported [11,108,109]. Ectopic discharges in primary
afferent neurons play an essential role in the develop-
ment of neuropathic pain. It is suggested that axons
with injured terminal arbors may lead to abnormal
spontaneous discharges. The possible inhibitory action
of vitamin B12 on NADPH oxidase activation and the
downstream regulation of NFκB pathway may contrib-
ute to the modulation of anti-inflammatory and pro-
inflammatory cytokines in the spinal DRG [14]. The
potentiation of the antiallodynic and analgesic effect of
peripheral pain signals may also be related to the inhi-
bition of hyperpolarization of activated cationic cur-
rents and hyperexcitability of injured DGR neurons
[97,108]. The possible modulation of HCN1 and
HCN2 channels of DRG may result in a pain-relieving
effect of this vitamin [11].
In summary, vitamin B12 plays major roles in differ-
ent mechanisms of action that improve nerve regener-
ation reducing allodynia and hyperalgesia, modulating
neural excitability and conduction velocity, inhibiting
ectopic spontaneous discharges in peripheral nerves,
and regulating inflammatory mediations responsible
for pain signaling. The clinical beneficial effects of coba-
lamin are depending of the type of painful condition.
For instance, although cobalamin may reduce severity
in chemotherapy induced peripheral neuropathy, it
did not decrease total pain score and pain interference
in that pathology [110]. However, it has been shown
some evidence (level II and III) of cobalamin in post-
herpetic neuralgia and painful peripheral neuropathy
[111]. Evidence of vitamin B12 as a monotherapy in
other types of pain conditions and diabetic neuropathy
is still limited [71,112].

3. Antinociceptive intracellular pathways
induced by B vitamins
In addition to the aforedescribed mechanisms, it is poss-
ible that the B vitamins modulate excitatory activity at
the CNS level through multiple intracellular signaling
pathways.
There is evidence of the role of the NO/cyclic guano-
sine monophosphate (cGMP) in hyperalgesia and allo-
dynia phenomena at the spinal cord level in several
models of pain [113]. Modulation of this intracellular
cascade has antinociceptive effects after stimulation of
type C fibers in inflammatory pain in rats [114]. Consid-
ering that the B-complex vitamins regulate the activity
of NO/cGMP pathway at levels of tissue GMP [15], an
antiallodynic effect of these vitamins through this mech-
anism is feasible. Indeed, it has been found that different
B vitamins (in particular pyridoxine) have antinocicep-
tive effects mediated by activation of guanylyl cyclase in
visceral pain models (writhing test) [115], and this
mechanism has been also suggested on inflammatory
pain [116]. Accordingly, several studies have reported
that activation of guanylyl cyclase with the subsequent
increase in cGMP may lead to antinociception
[12,68,79,117,118]. In addition, cGMP–protein kinase
G (PKG) signaling pathway also contributes to modu-
late hyperexcitability states in compression models of
DRG neurons [119]. Song et al. (2003) investigated
the possible involvement of cGMP–PKG pathway in
inhibition of hyperalgesia in rats with chronic com-
pression of DRG after treatment with thiamine. In
that study, intrathecal administration of thiamine inhib-
ited thermal hyperalgesia through activation of cGMP–
PKG and potassium channels [118].
Some authors suggest that B-complex vitamins and
derivatives (e.g. benfotiamine) induces the inhibition
of the PKC signaling pathway and the DAG pathway
[117,120]. Central and peripheral administration of
PKC blockers produces antiallodynic and antinocicep-
tive effects in neuropathic and inflammatory pain
models [121,122]. It has been found that B1 vitamin
inhibit the DAG–PKC pathway [120,123]. Moreover,
it has been shown that thiamine is able to block three
major pathways related to metabolic and oxidative
stress in diabetic polyneuropathy models: the DAG–
PKC pathway, the hexosamine pathway, and the
advanced glycation end-product pathway [117,124,125].
Antinociceptive effects of vitamins B combination
(B1, B6 and B12) in the spinal cord dorsal horn of
anesthetized cats have been showed [126]. In that
study, vitamins B produced a dose-dependent signifi-
cant reduction of electrical responses at spinal cord
level after heat stimuli of the skin. Deng et al. showed
NUTRITIONAL NEUROSCIENCE 241
in a study in mice that co-administration of vitamins
B1, B6, and B12 potentiated the acute antinociceptive
effect of morphine and attenuate opiate tolerance, an
effect that is probably mediated by phosphorylation of
the NMDA-NR1 subunit (p-NR1) at the spinal cord
level. Indeed, P-NR1 phosphorylation is increased by
morphine exposure. In addition to the effects of p-
NR1 in neural plasticity, it is also associated with the
phosphorylation level of PKC. Such increased phos-
phorylations induced by chronic morphine in the spinal
cord were suppressed with repeated daily adminis-
tration of B vitamins. The microglial activations
induced by morphine (increased p38 MAPK phos-
phorylation, IBA1, and IL-1b in the spinal cord) were
also inhibited by the B vitamins [127].
The role of cGMP on pain control is complex and
depends on specific neurons implicated in the nocicep-
tive pathway. For instance, guanylate cyclase activity in
the primary afferent neurons has antinociceptive effects,
meanwhile in inhibitory and projection neurons at the
dorsal horn level may induce nociception [113]. B vita-
mins participate in the modulation of several intracellu-
lar pathways and it is possible that analgesic effects of B
vitamins at the spinal cord level could be explained by
regulation of these signaling cascades (Figure 1).
4. Supraspinal antinociceptive effects
Descending pain modulatory system involves structures
such as the periaqueductal grey matter in the midbrain,
as well as structures at the pons (i.e. locus coeruleus)
and medulla oblongata (i.e. rostral ventromedial medulla
– RVM) [128–130]. The analgesic effects of vitamin B, as
well as its derivatives and active forms that were described
previously, may be related to changes in the synthesis of
neurotransmitters that participate in pain modulatory sys-
tems and in the peripheral nervous system (Figure 2
modified from [131]). For instance, vitamin B12 may
increase availability and effectiveness of norepinephrine
and 5-hydroxytryptamine at CNS [132,133]. Those neuro-
transmitters are part of the descending inhibitory system
from the brainstem to the spinal cord.
Monotherapy with pyridoxine as well as the com-
bined with vitamins B12 participate in the synthesis of
different monoamines such as serotonin, as well as reg-
ulating the expression of serotonin (5HT) receptors
[13]. 5HT is known to play an important role in the des-
cending pain modulatory systems, specifically from the
RVM to the posterior horn of the spinal cord [130].
Studies performed by neuroimaging with positron emis-
sion tomography in monkeys showed that treatment
with pyridoxine increases the synthesis of 5HT in the
242 A. M. PAEZ-HURTADO ET AL.

Figure 1. This scheme represents a plausible model about intracellular action mechanisms of B vitamins in nociceptive pathways. The
first synapsis between the primary afferent neuron and the second-order cell (projection neuron), as well as inhibitory control from a
GABAergic interneuron at the spinal cord is shown. Thiamine and cobalamin may lower excitability through GMPc-PKC-K+ pathway in
nociceptive afferent neurons. This mechanism may reduce the probability of peripheral sensitization after tissue or nerve injury. Coba-
lamin is also involved in modulation of neuroinflammation acting on glial cells (i.e. astrocytes and microglia) and blocking PKC activity
and phosphorylation of NMDA receptors in projection neurons. Together, those mechanisms may be involved in reducing central
sensitization and chronic pain. Abbreviations: α-amino-3-hydroxy-5-methyl-4-isoxazoleproprionic acid receptor (AMPA); cyclic guano-
sine monophosphate (cGMP); diacylglycerol (DAG); guanylate cyclase (GC); G-protein-coupled receptors (GCR); glutamate (Glu); inter-
leukin (IL); neurokinin receptor (NK); N-methyl-D-aspartate receptor (NMDA); nitric oxide (NO); nitric oxide synthase (NOS); nuclear
factor kappa B (NF-kB); protein kinase C (PKC); protein kinase G (PKG); phospholipase C (PLC); substance P (SP); tumor necrosis factor
(TNF); transient receptor potential cation channel (TRP).

brain [134]. Similarly, pyridoxine deficiency is associ-
ated with a reduction in the levels of 5HT and GABA
in the hypothalamus [135,136], as well as norepi-
nephrine in plasma and at the brainstem level
[135,137]. These deficiencies, as well as changes in var-
ious physiological variables, can be reversed even by
administering a single dose of pyridoxine. Some authors
suggest that analgesic effects of B vitamins in models of
neuropathic pain could be explained by interaction with
intra-supraspinal receptors, such as both endogenous
opioids tonically released and non-opioid inhibitory
neurotransmitters, such as serotoninergic systems and
GABA [10]. In a classic study, the interaction between
B vitamins and both, the serotonergic and opioid system
in brain structures, which are involved in the nocicep-
tive processing (i.e. thalamus and reticular formation)
was described in an in vivo model [138].
Pyridoxal 5-phosphate participates in L-Dopa to dopa-
mine conversion and allows conversion of glutamate to
GABA, preventing excitotoxicity. In addition, it can alter
intracellular glutamate levels and cell surface calcium
channels which are factors associated with hyperalgesia
[10,13,68]. Like 5HT, norepinephrine is an important
neurotransmitter as a central modulator of pain. The acti-
vation of descending noradrenergic pathways activates
presynaptic α2A receptors and reduces the activation of
nociceptive neurons in lamina I of the spinal posterior
horn [130,139]. Vitamin B12 has also therapeutic effects
by activating the central noradrenergic system [140].
Inhibitory control in central circuits under basal con-
ditions is necessary for modulate pain transmission and
control excitability. Correspondingly, in an in vivo
study, the effect of intracortical microinjection of vita-
min B12 was investigated on penicillin-induced epilep-
tiform activity in rats. Combined treatments with
vitamin B12 and diazepam resulted in better antiepilep-
tiform effects. The antiepileptic effects of vitamin B12
and diazepam were prevented by flumazenil (GABA-A
receptor blocker). Therefore, this result suggests that
antiepileptiform effects of vitamin B12 is mediated by
GABA-benzodiazepine receptor complex [96]. More-
over, epilepsy secondary to pyridoxine deficiency also
indicate that B vitamins are involved in control of glu-
tamate effects in the CNS [141]. Indeed, in vitro studies
 NUTRITIONAL NEUROSCIENCE 243

Figure 2. Summary of main antinociceptive mechanisms of B vitamins in the nervous system. Illustration shows the first order neuron
(nociceptive primary afferent), the transmission to the second-order neuron (located in the posterior horn of the spinal cord), and the
descending pain modulatory system from the brainstem nuclei (PAG, LC and RVM) to the spinal cord. The antinociceptive effects of B
vitamins are presented at each level of that pathway where it may reduce the nociceptive transmission mechanisms, meanwhile
increase the activity of the descending modulatory pain system through several neurotransmitter systems. Abbreviations: voltage-
gated sodium channels (NAv); locus coeruleus (LC); dorsal root ganglion (DRG); prostatic acid phosphatase (PAP); norepinephrine
(NE); rostral ventromedial medulla (RVM); periaqueductal grey (PAG); transient receptor potential cation channel V1 (TRPV1), P2X-
type ATP-dependent purinergic receptor (P2X); serotonin (5HT).

have shown that combination of B vitamins has protec-
tive effects from glutamate induced NMDA-excitotoxi-
city in neuronal cultures [142,143].
For all these reasons, the combined administration of
the B-complex vitamins may play a very important role
in the activation of the descending pain modulatory sys-
tems by improving the central availability of these
neurotransmission systems and also to modulate hyper-
excitability states in the CNS.
5. The role of the combination of vitamins B1,
B6, and B12 in different pain pathways and
synergy with analgesics
As described previously, vitamin B1, B6, and B12 have
individual effects on several pain pathways and have
shown antiallodynic, anti-hyperalgesic, and antinoci-
ceptive effects. A synergistic antinociceptive effect
between these vitamins have been described in animal
pain models according to their pathophysiological
mechanism (Table 2). In a recent study, it was shown
that combination of B vitamins (B1, B6, and B12) can
attenuate the activity of P2X3, TRPV1, IL-1β, and
TNFα in a model of diabetic neuropathic pain [144].
Because methylcobalamin inhibited NF-kB pathway,
reduce TNFα and increase IL-10 (anti-inflammatory
cytokine) [14], it is possible that the effects on P2X
and TRPV1 are attributed to thiamine and pyridoxine,
stressing the rational of this combination.
In addition, some studies have also shown that B
vitamins may potentiate the analgesic effect in combi-
nation with opioids, anticonvulsant, or anti-
244 A. M. PAEZ-HURTADO ET AL.

Table 2. Analgesic effects of the combination of B vitamins in animal models of pain.

Pain model (animal strain,
Reference age)
[126] Noxious radiant heat stimuli
applied to the sole of the
cat’s hindfoot (NS, 1–2 y/o)
[145] Carrageenin-induced
hyperalgesia in the tail
Benzoquinone-induced
writhing test in rats
Hot-plate test, Heat-coil
test, Tail pressure test in
rat (Wistar rats-WI-AF/Han,
10–12 w/o)
[132] Supramaximal electrical
stimulation of afferent C
fibers in the sural nerve of
rats (Sprague-Dawley/SIV,
7–15 w/o)
[146] Writhing test in mice (NMRI,
3.5 – 4 w/o)
[147] Acetic acid induced
abdominal constrictions
(writhing test) in mice
Hot-plate test in mice
Formaldehyde-induced
hind paw oedema in mice
(Swiss, 3–8 w/o)
[10] Spinal ganglia compression
or loose ligation of the
sciatic nerve in rats
(Sprague-Dawley, 5.5-7 w/
o)
[148] Formalin test in rats with
streptozotocin-induced
diabetes mellitus and
diabetic neuropathy
(Sprague-Dawley, 6–8 w/o)
[144] Mechanical and thermal
stimulation in rats with
streptozotocin- induced
diabetic neuropathic pain
(Sprague-Dawley, 5.5-7 w/
o)
IP: intraperitoneal; IT: intrathecal; NA: not applicable; NS: not specified; PO: per oral; SC: subcutaneous; w/o: weeks old; y/o: years old.
Type of pain Intervention
Nociceptive Combination of thiamine
(100 mg), pyridoxine
(100 mg) and
cyanocobalamin (1 mg), IV or
IT (diluted 1:10 or 1:100)
superfusion
Nociceptive Combination of thiamine and
(including a pyridoxine (167–667 mg/kg),
specific model for and cyanocobalamin (33–
inflammatory 167 mg/kg s.c and 0,3–
visceral pain) 1.7 mg/kg), IP
Nociceptive and Combination of thiamine,
neuropathic pyridoxine and
cyanocobalamin (ED50 was
4.6 ml/kg at 100 min after
injection), IP
Inflammatory Combination of thiamine,
(visceral) pyridoxine and
cyanocobalamin (reported as
high dose levels for 7 days),
PO
Nociceptive and Combination of thiamine,
inflammatory pyridoxine and
cyanocobalamin (20–200 mg/
kg, i.p. or per os) and
monotherapy of each vitamin:
B1 and B6 (50–200 mg/kg, i.p)
and riboflavin (3–100 mg/kg,
i.p), IP, SC or PO
Neuropathic Combination of thiamine (5, 10,
33 and 100 mg/kg),
pyridoxine (33 and 100 mg/
kg) and cyanocobalamin (0.5
and 2 mg/kg) for 1 and 2
weeks, IP
Neuropathic and Combination of thiamine,
inflammatory pyridoxine and
cyanocobalamin for 7–9 days,
(high dose was B1:B6:B12 at
180:180:1.8 mg/kg), SC
Neuropathic Combination of thiamine,
pyridoxine and
cyanocobalamin (B1/B6/B12
= 100/100/2 mg/kg), IP daily
for 7 days.
Control Main results
Saline solution Significant dose-dependent
depression in the
electrophysiological responses
evoked in dorsal horn neurons
NA (no control Combination of B vitamins
mentioned) produced antinociceptive effects
at the highest dosage and dose-
dependent reductions of the
number of writhes
Pyridoxine, IP B vitamins combination and B6 in
injection monotherapy reduce the
nociceptive response in neurons
of the thalamus
Combination Addition of cyanocobalamin on the
thiamine and thiamine and pyridoxine
pyridoxine, PO combination leading to an
increased antinociceptive effect
Saline solution, Combination of B vitamins, as well
naloxone (10 as B1 and B6 alone produced an
mg/kg, i.p.). antinociceptive effect in the
writhing test. Combination of B
vitamins partially reduced
formaldehyde-induced oedema,
but did not inhibit response in
the hot-plate model
Saline solution Vitamins B1, B6 and B12 at high
doses reduce pain scores and
thermal hyperalgesia. Not effects
on mechanical hyperalgesia
NA (no control B vitamins reduced tactile allodynia
mentioned) and formalin-evoked
hyperalgesia in a dose-
dependent manner and
improved sensory nerve
conduction velocity
Sham group B vitamins reduced mechanical
received allodynia and/or thermal
citrate buffer hyperalgesia. Reduction in spinal
pro-inflammatory cytokines and
activity of P2X3 and TRPV1 in
DRG.

inflammatory drugs [10,12,15,16,49,116,146,147,149– in the SNC, as well as reduction of pro-inflammatory

151] (Table 3). B vitamins can interact with known
analgesics through several mechanisms. For instance,
in a muscle pain model induced by formalin in rats,
antinociceptive effects of intracerebroventricular
(ICV) injection of cobalamin and their analgesic
synergy with diclofenac is partially prevented by nalox-
one (opioid receptor antagonist). Therefore, this
analgesic effect of vitamin B12 is depending on opioid
receptors (probably on µ receptors) and its interaction
on anti-inflammatory pathways [152]. As we described
before, synergy of B vitamins with morphine involves
phosphorylation of NMDA receptors and p38 MAPK
cytokines and microglial activation [127]. This effect
not only have implications in analgesic potentiation
but also reduction of several side effects induced by
opiates. Finally, combination of molecules with differ-
ent mechanisms of action and neuronal targets yields
better analgesic efficacy. For instance, vitamin B1
increases analgesic efficacy of pregabaline in models
of neuropathic pain [153]. This effect is probably
explained because thiamine reduces sodium channels
conductance, meanwhile gabapentinoids blocks α2δ
subunit of calcium channels in sensory neurons sub-
jected to hyperexcitability states.
 NUTRITIONAL NEUROSCIENCE 245

Table 3. Synergistic effects of B vitamins with known analgesics in animal models of pain.
Pain model (strain,
Ref. age) Type of pain Intervention Control Main results
[154] IART injection of Inflammatory Combination of thiamine Saline solution, diclofenac Combination of B vitamins as
50 ml of 30% uric (100 mg/kg), pyridoxine alone, thiamine plus well as B12 alone
acid to the right (100 mg/kg) and diclofenac, pyridoxine plus significantly potentiated
hind limb of rats by cyanocobalamin (1 mg/ diclofenac the antinociceptive effect
pain-induced kg) with and diclofenac of diclofenac in a dose-
functional- (1.8 mg/kg), PO dependent manner.
impairment model No antinociceptive effect
(PIFIR) (Wistar rats, when using B vitamins
4.8–5.5 w/o) without diclofenac
[155] 50 µl1% Formalin- Inflammatory Combination of B1 + B6 + Saline solution, diclofenac Combination of B vitamins
induced flinching B12 (32–178 mg/kg) of alone yielded a dose-dependent
behavior in the thiamine (100 mg/kg), reduction of flinching
right hind paws of pyridoxine (100 mg/kg) Co-administration of B
rats (Wistar rats, 6– and cyanocobalamin vitamins and diclofenac
7 w/o) (1 mg/kg) with diclofenac increased the
(0.31–316 mg/kg), PO antinociceptive effect of
diclofenac alone
[156] Crushed tibial nerve Neuropathic Cyanocobalamin (50, 100 Saline solution, diclofenac B12 and diclofenac in
in rats and 200 µg/kg) with alone monotherapy both
Cold allodynia diclofenac (2 mg/kg), IP showed antiallodynic
model in rats for 10 consecutive days effects, effects more
Mechanical after surgery pronounced when co-
allodynia model in administering B12 and
rats (Wistar rats, diclofenac.
5.2-5.8 w/o)
[48] 50 µl1% Formalin- Inflammatory Combination of thiamine Saline solution (4 ml/kg), Combination of B vitamins
induced flinching (100 mg/kg), pyridoxine ketorolac alone yielded dose-dependent
behavior in the (100 mg/kg) and reduction of flinching
hind paws of rats cyanocobalamin (1 or Pronounced, synergistic
(Wistar rats, 7–8 w/ 5 mg/kg) with ketorolac effect in co-administration
o) (32–10 mg/kg), PO with thiamine, pyridoxine
and cyanocobalamin and
ketorolac
[157] Tight ligation of the Neuropathic Combination of thiamine, Saline solution, gabapentin Combination of B vitamins
left L5 and L6 spinal pyridoxine and alone reduced tactile allodynia in
nerve in rats (Wistar cyanocobalamin (75– a dose-dependent manner,
rats, 6–7 w/o) 600 mg/kg 100:100:1, effect more pronounced in
respectively) with and co-administration B
without gabapentin (30– vitamins and gabapentin
300 mg/kg), PO
[158] Tight ligation of the Neuropathic Combination of thiamine (75 Saline solution (4 ml/kg), B1, B6, and B12 in
left L5 and L6 spinal –600 mg/kg), pyridoxine morphine (1–3 mg/kg SC) monotherapy reduced
nerve in rats (Wistar (75–600 mg/kg) and and diclofenac (1–10 mg/ tactile allodynia in a dose-
rats, 6–7 w/o) cyanocobalamin (0.75– kg SC) as negative dependent manner.
6 mg/kg) alone or controls, gabapentin (10– Better effect in co-
thiamine and 300 mg/kg PO) as positive administration with B1 and
cyanocobalamin in control, dexamethasone B12 or B1, B12 and
combination with and alone dexamethasone
without dexamethasone
(4–32 mg/kg), SC
[70] Constriction of the Neuropathic Combination of thiamine, Carbamazepine alone B Vitamins combination
infraorbital nerve in pyridoxine and prevented heat
rats (Wistar rats, cyanocobalamin at low- hyperalgesia. B6 and B12
4.8–5.2 w/o) doses (18, 18 and attenuated mechanical
1.8 mg/kg, respectively) or and cold hyperalgesia,
high doses (180, 180 and respectively. Better effect
18 mg/kg, respectively), in co-administration with
with or without carbamazepine.
carbamazepine (3 or
10 mg/kg), SC on day four
after surgery
[159] 20 µg 2% Formalin- Nociceptive and inflammatory Combination of B1 + B6 + Vehicle (0,5% Tween 80 in Combination of B vitamins
induced licking B12 (30–562 mg/kg) of 0,9% saline solution)., showed a dose-dependent
behavior in the thiamine (30–707 mg/kg), Rhodiola rosea extract antinociceptive effect in
hind paws of mice, pyridoxine (30–707 mg/ alone; B1, B6 and B12 as the abdominal constriction
SC (female ICR kg) and cyanocobalamin monotherapy and the licking behavior
mice, 5–8 w/o) (1–177 mg/kg) or as model
monotherapy with and No effect of B vitamins in
without Rhodiola rosea hot-plate model
extract (10–177 mg/kg), IP

(Continued)
246 A. M. PAEZ-HURTADO ET AL.

Table 3. Continued.
Pain model (strain,
Ref. age) Type of pain Intervention Control Main results
or PO 15 min before
formalin injection
[127] Hot water tail flick Nociceptive Combinations of thiamine, Morphine (10 mg/kg) SC Vitamin B combination
test in mice (ICR pyridoxine and injection daily for seven potentiated acute
mice, 3–3.5 w/o) cyanocobalamin (132/132/ days morphine antinociception
2 mg/kg) (66/66/1 mg/kg) and reduced
and (33/33/ antinociceptive tolerance
0.5 mg/kg), IP daily, 15 to morphine administered
min before morphine chronically
injection
[152] IM injection of 50 µl Nociceptive and inflammatory Cyanocobalamin (1.25, 2.50, Control groups were ICV Significant antinociceptive
2.50% formalin in 5.00 and 10.00 µg per rat) injected with normal effects (number of paw
the right with and without saline flinching) after combined
gastrocnemius diclofenac (12.50 and treatments of diclofenac
muscle in rats 25.00 µg per rat), ICV with vitamin B12
(Wistar rats, 5.5-6.5 injection
w/o)
IART: intra-articular; ICV: intracerebroventricular; IM: intramuscular; IP: intraperitoneal; NA: not applicable; PO: per oral; SC: subcutaneous; w/o: weeks old.

6. Conclusions and further clinical directions Several preclinical studies have shed light on the
specific mechanisms by which they exert their protective
Considering the emerging concept of mixed pain, it is
and therapeutic effects on the nociceptors and on the
necessary to establish new therapeutically approaches
various inflammatory mediators. It was also postulated
that involve several targets, synergism between analge-
in several studies that if these three vitamins (vitamin
sics and multiple action mechanisms to control nocicep-
B1, B6, and B12) are used in combination with other
tion. In that case, clinical and animal models (in vivo
analgesic therapies, and they may produce an additive/
and in vitro) provide evidence for the significant role
synergistic effect and also may aid in reducing the over-
of B vitamins when used alone or in combination in
all dose of analgesic which can reduce the side effects. In
different pain conditions.
conclusion, it can be said that these vitamins (B1, B6,
Thiamine, pyridoxine, and cobalamin have shown to
and B12) affect several physiopathological pain mechan-
regulate several inflammatory mediators in nociceptive
isms and hence they can be of significance in the treat-
pain models. In addition, there is also evidence for a
ment of various pain conditions.
role of these vitamins in promoting nerve repair and
Taking into account that some effects of B vitamins
recovery of nerve function. Indeed, it has been described
on specific intracellular pathways have been described
that this recovery is associated with improvement in
in models of tissue damage or metabolic stress and
nerve conduction and reducing ectopic discharges in
not directly in pain models, it is important to perform
peripheral nerves after injury (a mechanism specially
future studies in order to evaluate the possible effect
related with cobalamin).
of B vitamins on nociceptive pathways and/or in specific
Each one of these vitamins (vitamin B1, B6, and B12)
types of neurons. It is essential to emphasize the impor-
has individual effects on several pain pathways and
tance of understanding the mechanisms of action of
metabolic functions. Particularly, vitamin B1 is
these vitamins in order to have a better approach to
especially useful due to its function as a cofactor in ener-
pain management.
getic metabolism and antioxidative properties, and
Currently, there is high-quality evidence to rec-
therefore indirectly affecting the synthesis of myelin,
ommend the combination of thiamine, pyridoxine
nucleic acids, and neurotransmitters, key factors for
and cyanocobalamin as analgesic adjuvant in patients
antinociceptive neural function. On the other hand,
with acute low back pain. However, there is a need
vitamin B6 acts as a coenzyme in the synthesis of neuro-
for further large-scale clinical trials to establish what
transmitters such as GABA, dopamine and serotonin,
type of B vitamins combination is more useful in con-
necessary for inhibitory control in the CNS. In addition,
ditions frequently associated with mixed pain (i.e. can-
it shows a neuroprotective effect given its relation to the
cer pain, osteoarthritis, chronic postsurgical pain, and
glutamatergic system. Finally, vitamin B12 is essential in
so on.) according to their specific action mechanisms
the synthesis of myelin fundamental for nerve regener-
and interaction with other known analgesics, as well
ation and therefore could have an important role in
as doses, duration of treatment, and routes of
neuropathic pain.
administration.

Acknowledgements
Medical writing and editing were supported by Kerstin Eckart
(Munich, Germany) and sponsored by P&G Health Germany
GmbH. .
Disclosure statement
Carlos Calderon-Ospina has carried out consulting activities
for P&G Health International.
Data availability statement
Data sharing is not applicable to this article as no new data
were created or analyzed in this review article.
ORCID
A. M. Paez-Hurtado http://orcid.org/0000-0002-4961-974X
C. A. Calderon-Ospina http://orcid.org/0000-0002-7305-
8727
M. O. Nava-Mesa http://orcid.org/0000-0001-8458-7862
References
[1] Nahin RL. Estimates of pain prevalence and severity in
adults: United States, 2012. J Pain. 2015;16(8):769–80.
doi:10.1016/j.jpain.2015.05.002.
[2] Breivik H, Collett B, Ventafridda V, Cohen R,
Gallacher D. Survey of chronic pain in Europe: preva-
lence, impact on daily life, and treatment. Eur J Pain.
2006;10(4):287–33. doi:10.1016/j.ejpain.2005.06.009.
[3] Dahlhamer J, Lucas J, Zelaya C, Nahin R, Mackey S,
DeBar L, et al. Prevalence of chronic pain and high-
impact chronic pain among adults – United States,
2016. MMWR Morb Mortal Wkly Rep. 2018;67
(36):1001–06. doi:10.15585/mmwr.mm6736a2.
[4] Blyth FM, March LM, Brnabic AJ, Jorm LR,
Williamson M, Cousins MJ. Chronic pain in
Australia: a prevalence study. Pain. 2001;89(2–
3):127–34. doi:10.1016/s0304-3959(00)00355-9.
[5] McQueen KA. Pain management: a global perspective. Br
J Anaesth. 2013;111(5):843–44. doi:10.1093/bja/aet363.
[6] Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H,
Gibson S, et al. The revised international sssociation
for the study of pain definition of pain: concepts, chal-
lenges, and compromises. Pain. 2020;161(9):1976–82.
doi:10.1097/j.pain.0000000000001939.
[7] Vardeh D, Mannion RJ, Woolf CJ. Toward a mechan-
ism-based approach to pain diagnosis. J Pain. 2016;17
(Suppl. 9):T50–69. doi:10.1016/j.jpain.2016.03.001.
[8] Junker U. Chronic pain: the “mixed pain concept” as a
new rational. Dtsch Arztebl. 2004;101(20):A-1393.
[9] Freynhagen R, Parada HA, Calderon-Ospina CA, Chen
J, Rakhmawati Emril D, Fernandez-Villacorta FJ, et al.
Current understanding of the mixed pain concept: a
brief narrative review. Curr Med Res Opin. 2019;35
(6):1011–1018. doi:10.1080/03007995.2018.1552042.
[10] Wang Z-B, Gan Q, Rupert RL, Zeng Y-M, Song X-J.
Thiamine, pyridoxine, cyanocobalamin and their
NUTRITIONAL NEUROSCIENCE 247
combination inhibit thermal, but not mechanical
hyperalgesia in rats with primary sensory neuron
injury. Pain. 2005;114(1–2):266–77.
[11] Zhang M, Han W, Zheng J, Meng F, Jiao X, Hu S, et al.
Inhibition of hyperpolarization-activated cation
current in medium-sized DRG neurons contributed
to the antiallodynic effect of methylcobalamin in
the rat of a chronic compression of the DRG.
Neural Plast. 2015;2015:197392. doi:10.1155/2015/
197392.
[12] Song X-S, Huang Z-J, Song X-J. Thiamine suppresses
thermal hyperalgesia, inhibits hyperexcitability, and
lessens alterations of sodium currents in injured, dorsal
root ganglion neurons in rats. Anesthesiology. 2009;110
(2):387–400. doi:10.1097/ALN.0b013e3181942f1e.
[13] Dakshinamurti K, Sharma SK, Bonke D. Influence of B
vitamins on binding properties of serotonin receptors
in the CNS of rats. Klin Wochenschr. 1990;68
(2):142–45. doi:10.1007/BF01646863.
[14] Xu J, Wang W, Zhong XX, Feng Y, Wei X, Liu XG.
EXPRESS: methylcobalamin ameliorates neuropathic
pain induced by vincristine in rats: effect on loss of per-
ipheral nerve fibers and imbalance of cytokines in the
spinal dorsal horn. Mol Pain. 2016;12. https://www.
ncbi.nlm.nih.gov/pubmed/27306413. doi:10.1177/
1744806916657089.
[15] Vesely DL. B complex vitamins activate rat guanylate
cyclase and increase cyclic GMP levels. Eur J Clin
Invest. 1985;15(5):258–62. doi:10.1111/j.1365-2362.
1985.tb00180.x.
[16] Yu CZ, Liu YP, Liu S, Yan M, Hu SJ, Song XJ.
Systematic administration of B vitamins attenuates
neuropathic hyperalgesia and reduces spinal neuron
injury following temporary spinal cord ischaemia in
rats. Eur J Pain. 2014;18(1):76–85. doi:10.1002/j.1532-
2149.2013.00390.x.
[17] Geller M, Oliveira L, Nigri R, Mezitis S, Ribeiro M,
Fonseca A, et al. B vitamins for neuropathy and neuro-
pathic pain. Vitam Miner. 2017;6(2):161.
[18] Gazoni FM, Malezan WR, Santos FC. B complex vita-
mins for analgesic therapy. Rev Dor. São Paulo.
2016;17(1):52–56. doi:10.5935/1806-0013.20160.
[19] Ponce-Monter HA, Ortiz MI, Garza-Hernandez AF,
Monroy-Maya R, Soto-Rios M, Carrillo-Alarcon L,
et al. Effect of diclofenac with B vitamins on the treat-
ment of acute pain originated by lower-limb fracture
and surgery. Pain Res Treat. 2012;2012:104782.
doi:10.1155/2012/104782.
[20] Calderon-Ospina CA, Nava-Mesa MO. B vitamins in
the nervous system: current knowledge of the bio-
chemical modes of action and synergies of thiamine,
pyridoxine, and cobalamin. CNS Neurosci Ther.
2020;26(1):5–13. doi:10.1111/cns.13207.
[21] Kennedy DO. B vitamins and the brain: mechanisms,
dose and efficacy – a review. Nutrients. 2016;8(2):68.
[22] Zempleni J, Suttie JW, Gregory III JF, Stover PJ.
Handbook of vitamins. Boca Raton, FL: CRC Press;
2013.
[23] Staff NP, Windebank AJ. Peripheral neuropathy due to
vitamin deficiency, toxins, and medications.
Continuum. 2014;20(5):1293–306. doi:10.1212/01.CO
N.0000455880.06675.5a.
248 A. M. PAEZ-HURTADO ET AL.
[24] Koike H, Takahashi M, Ohyama K, Hashimoto R,
Kawagashira Y, Iijima M, et al. Clinicopathologic features
of folate-deficiency neuropathy. Neurology. 2015;84
(10):1026–33. doi:10.1212/WNL.0000000000001343.
[25] Chiang EP, Smith DE, Selhub J, Dallal G, Wang YC,
Roubenoff R. Inflammation causes tissue-specific
depletion of vitamin B6. Arthr Res Ther. 2005;7(6):
R1254–62. doi:10.1186/ar1821.
[26] Forster VJ, van Delft FW, Baird SF, Mair S, Skinner R,
Halsey C. Drug interactions may be important risk fac-
tors for methotrexate neurotoxicity, particularly in
pediatric leukemia patients. Cancer Chemother
Pharmacol. 2016;78(5):1093–96. doi:10.1007/s00280-
016-3153-0.
[27] Menezes RR, Godin AM, Rodrigues FF, Coura GME,
Melo ISF, Brito AMS, et al. Thiamine and riboflavin
inhibit production of cytokines and increase the anti-
inflammatory activity of a corticosteroid in a chronic
model of inflammation induced by complete
Freund’s adjuvant. Pharmacol Rep. 2017;69(5):1036–
43. doi:10.1016/j.pharep.2017.04.011.
[28] Onk D, Mammadov R, Suleyman B, Cimen FK,
Cankaya M, Gul V, et al. The effect of thiamine and
its metabolites on peripheral neuropathic pain induced
by cisplatin in rats. Exp Anim. 2018;67(2):259–69.
doi:10.1538/expanim.17-0090.
[29] Hosseinzadeh H, Moallem SA, Moshiri M, Sarnavazi
MS, Etemad L. Anti-nociceptive and anti-inflamma-
tory effects of cyanocobalamin (vitamin B12) against
acute and chronic pain and inflammation in mice.
Arzneim Forsch. 2012;62(7):324–29. doi:10.1055/s-
0032-1311635.
[30] Moallem SA, Hosseinzadeh H, Farahi S. A study of
acute and chronic anti-nociceptive and anti-inflamma-
tory effects of thiamine in mice. Iran Biomed J. 2008;12
(3):173–78.
[31] Theriault O, Poulin H, Thomas GR, Friesen AD, Al-
Shaqha WA, Chahine M. Pyridoxal-5’-phosphate
(MC-1), a vitamin B6 derivative, inhibits expressed
P2X receptors. Can J Physiol Pharmacol. 2014;92
(3):189–96. doi:10.1139/cjpp-2013-0404.
[32] Alemanno F, Ghisi D, Westermann B, Bettoni A,
Fanelli A, La Colla L, et al. The use of vitamin B1 as
a perineural adjuvant to middle interscalene block for
postoperative analgesia after shoulder surgery. Acta
Biomed. 2016;87(1):22–27.
[33] Barroso AB, Lima V, Guzzo GC, Moraes RA,
Vasconcellos MC, Bezerra MM, et al. Efficacy and
safety of combined piroxicam, dexamethasone, orphe-
nadrine, and cyanocobalamin treatment in mandibular
molar surgery. Braz J Med Biol Res. 2006;39(9):1241–
47. doi:10.1590/s0100-879 ( 2006000900012.
[34] Bernstein AL, Dinesen JS. Brief communication: effect
of pharmacologic doses of vitamin B6 on carpal tunnel
syndrome, electroencephalographic results, and pain. J
Am Coll Nutr. 1993;12(1):73–76. doi:10.1080/073157
24.1993.10718286.
[35] Chiu CK, Low TH, Tey YS, Singh VA, Shong HK. The
efficacy and safety of intramuscular injections of
methylcobalamin in patients with chronic nonspecific
low back pain: a randomised controlled trial. Sing
Med J. 2011;52(12):868–73.
[36] Dongre YU, Swami OC. Sustained-release pregabalin
with methylcobalamin in neuropathic pain: an Indian
real-life experience. Int J Gen Med. 2013;6:413–17.
doi:10.2147/IJGM.S45271.
[37] Garza AF, Monroy-Maya R, Soto-Rios M, Reyes-
Garcia G, Carrillo-Alarcon L, Ponce-Monter H, et al.
A pilot study of the effect of diclofenac with B vitamins
for the treatment of acute pain following lower-limb
fracture and surgery. Proc West Pharmacol Soc.
2008;51:70–72.
[38] Hedaya R. Five herbs plus thiamine reduce pain and
improve functional mobility in patients with pain: a
pilot study. Altern Ther Health Med. 2017;23(1):14–19.
[39] Magana-Villa MC, Rocha-Gonzalez HI, Fernandez del
Valle-Laisequilla C, Granados-Soto V, Rodriguez-
Silverio J, Flores-Murrieta FJ, et al. B-vitamin mixture
improves the analgesic effect of diclofenac in patients
with osteoarthritis: a double blind study. Drug Res.
2013;63(6):289–92. doi:10.1055/s-0033-1334963.
[40] Mauro GL, Martorana U, Cataldo P, Brancato G,
Letizia G. Vitamin B12 in low back pain: a randomised,
double-blind, placebo-controlled study. Eur Rev Med
Pharmacol Sci. 2000;4(3):53–58.
[41] Talebi M, Andalib S, Bakhti S, Ayromlou H, Aghili A,
Talebi A. Effect of vitamin b6 on clinical symptoms and
electrodiagnostic results of patients with carpal tunnel
syndrome. Adv Pharm Bull. 2013;3(2):283–88. doi:10.
5681/apb.2013.046.
[42] Xŭ G, Xu S, Cheng C, Xu G, Tang WZ, Xu J. Local
administration of methylcobalamin and lidocaine for
acute ophthalmic herpetic neuralgia: a single-center
randomized controlled trial. Pain Pract. 2016;16
(7):869–81. doi:10.1111/papr.12328.
[43] Maladkar M, Tekchandani C, Dave U. Post-marketing
surveillance of fixed dose combination of methylcoba-
lamin, alpha lipoic acid, folic acid, biotin, benfotiamine
& vitamin B6-nutripathy for the management of per-
ipheral neuropathy. J Diabetes Mellitus. 2014;4
(02):124.
[44] Xu G, Lv ZW, Xu GX, Tang WZ. Thiamine, cobalamin,
locally injected alone or combination for herpetic itch-
ing: a single-center randomized controlled trial. Clin
J Pain. 2014;30(3):269–78. doi:10.1097/AJP.0b013e318
2a0e085.
[45] Xu G, Xu G, Feng Y, Tang WZ, Lv ZW.
Transcutaneous electrical nerve stimulation in combi-
nation with cobalamin injection for postherpetic neur-
algia: a single-center randomized controlled trial. Am
J Phys Med Rehabil. 2014;93(4):287–98. doi:10.1097/
PHM.0000000000000002.
[46] Xu G, Xu S, Tang WZ, Xu G, Cheng C, Xu J. Local
injection of methylcobalamin combined with lidocaine
for acute herpetic neuralgia. Pain Med. 2016;17
(3):572–81. doi:10.1093/pm/pnv005.
[47] Nunes CP, De Oliveira JM, Mibielli MA, Cohen JC,
Nunes FP, Ribeiro M, et al. A double-blind, compara-
tive, placebo-controlled study in two arms of the safety
and efficacy of the anti-inflammatory and analgesic
action of the association of cyanocobalamin, pyridox-
ine chlorihydrate, thiamine mononitrate and diclofe-
nac sodium in tablets, in patients with osteoarthritis.
Rev Bras Med. 2005;62(11):486–91.

[48] Medina-Santillan R, Reyes-Garcia G, Rocha-Gonzalez
HI, Granados-Soto V. B vitamins increase the analgesic
effect of ketorolac in the formalin test in the rat. Proc
West Pharmacol Soc. 2004;47:95–99.
[49] Calderon-Ospina C-A, Nava-Mesa MO, Arbeláez
Ariza CE. Effect of combined diclofenac and B vita-
mins (thiamine, pyridoxine, and cyanocobalamin) for
low back pain management: systematic review and
meta-analysis. Pain Med. 2020;21(4):766–81.
[50] Stein J, Geisel J, Obeid R. Association between neuro-
pathy and B-vitamins: a systematic review and meta-
analysis. Eur J Neurol. 2021 Feb 22. doi:10.1111/ene.
14786.
[51] Karaganis S, Song X-J. B vitamins as a treatment for
diabetic pain and neuropathy. J Clin Pharm Ther.
2021 Feb 9. doi:10.1111/jcpt.13375.
[52] Vetter G, Brüggemann G, Lettko M, Schwieger G,
Asbach H, Biermann W, et al. Shortening diclofenac
therapy by B vitamins. results of a randomized
double-blind study, diclofenac 50 mg versus diclofenac
50 mg plus B vitamins, in painful spinal diseases
with degenerative changes. Z Rheumatol. 1988;47
(5):351–62.
[53] Kuhlwein A, Meyer H, Koehler C. Reduced diclofenac
administration by B vitamins: results of a randomized
double-blind study with reduced daily doses of diclofe-
nac (75 mg diclofenac versus 75 mg diclofenac plus B
vitamins) in acute lumbar vertebral syndromes. Klin
Wochenschr. 1990;68(2):107–15.
[54] Brüggemann G, Koehler C, Koch E. Results of a
double-blind study of diclofenac+ vitamin B1, B6,
B12 versus diclofenac in patients with acute pain of
the lumbar vertebrae. A multicenter study. Klin
Wochenschr. 1990;68(2):116–20.
[55] Lettko M, Bartoszyk GD. Reduced need for diclofenac
with concomitant administration of pyridoxine and
other B vitamins: clinical and experimental studies.
Ann N Y Acad Sci. 1990;585:510–12.
[56] Tahir Ahmad K, Asher A, Irfan Zafar H. Treatment of
acute lumbago; low dose diclofenac sodium with vita-
min-B complex compared with diclofenac alone. 2008.
[57] Mibielli M, Geller M, Cohen J, Goldberg S, Cohen M,
Nunes C, et al. Diclofenac plus B vitamins versus diclo-
fenac monotherapy in lumbago: the DOLOR study.
Curr Med Res Opin. 2009;25(11):2589–99.
[58] Levin O, Moseĭkin I. Vitamin B complex (milgamma)
in the treatment of vertebrogenic lumbosacral radicu-
lopathy. Zhurnal Nevrol Psikhiatrii Imeni SS
Korsakova. 2009;109(10):30–35.
[59] Schwieger G, Karl H, Schönhaber E. Relapse preven-
tion of painful vertebralo syndrome in follow-up treat-
ment with a combination of vitamins B1, B6, and B12.
Ann N Y Acad Sci. 1990;585:540–42.
[60] Pérez-Flores E, Medina-Santillán R, Reyes-García G,
Mateos-García E. Combination of diclofenac plus B
vitamins in acute pain after tonsillectomy: a pilot
study. Proc West Pharmacol Soc. 2003;46:88–90.
[61] Medina-Santillán R, Pérez-Flores E, Mateos-García E,
Reyes-García G, Granados-Soto V, Flores-Murrieta
FJ. AB-vitamin mixture reduces the requirements of
diclofenac after tonsillectomy: a double-blind study.
Drug Dev Res. 2005;66(1):36–39.
NUTRITIONAL NEUROSCIENCE 249
[62] Galván-Montaño A, Reyes-García G, Suárez-Roa
MdL, Asbun-Bojalil J. Effective analgesic between
acetominophen+B vitamins vs. acetominophen in
pediatric ambulatory surgery. Cir Cir. 2010;78
(5):400–09.
[63] Khezri MB, Nasseh N, Soltanian G. The comparative
preemptive analgesic efficacy of addition of vitamin B
complex to gabapentin versus gabapentin alone in
women undergoing cesarean section under spinal
anesthesia: a prospective randomized double-blind
study. Medicine. 2017;96(15):e6545. doi:10.1097/MD.
0000000000006545.
[64] Mimenza Alvarado A, Aguilar Navarro S. Clinical trial
assessing the efficacy of gabapentin plus B complex
(B1/B12) versus pregabalin for treating painful diabetic
neuropathy. J Diabetes Res. 2016;(6):1–8.
[65] Rizvi A, Ahmad A, Rizvi Z. Efficacy of combination of
vitamin B1, B6 and B12 in management of diabetic per-
ipheral neuropathy. PJMHS. 2013;7(3):801–04.
[66] Rotaru A, Albu CV, Tudorascu DR, Catalin B,
Gheonea M, Udristoiu I, et al. Thioctic acid and vita-
min B complex improves clinical sings in diabetic per-
ipheral neuropathy. Rev Chim. 2019;70:3614–17.
[67] Hakim M, Kurniani N, Pinzon RT, Tugasworo D,
Basuki M, Haddani H, et al. Management of peripheral
neuropathy symptoms with a fixed dose combination
of high-dose vitamin B1, B6 and B12: a 12-week pro-
spective non-interventional study in Indonesia. Asian
J Med Sci. 2018;9(1):32–40.
[68] Alvarado AM, Navarro SA. Complex B vitamins:
physiology and therapeutic effect on pain. Am J
Pharmacol Sci. 2016;4(2):20–27.
[69] Itokawa Y, Cooper JR. Ion movements and thiamine.
II. The release of the vitamin from membrane frag-
ments. Biochim Biophys Acta. 1970;196(2):274–84.
doi:10.1016/0005-2736(70)90015-5.
[70] Kopruszinski CM, Reis RC, Bressan E, Reeh PW,
Chichorro JG. Vitamin B complex attenuated heat
hyperalgesia following infraorbital nerve constriction
in rats and reduced capsaicin in vivo and in vitro
effects. Eur J Pharmacol. 2015;762:326–32. doi:10.
1016/j.ejphar.2015.05.063.
[71] Buesing S, Costa M, Schilling JM, Moeller-Bertram T.
Vitamin B12 as a treatment for pain. Pain Phys.
2019;22(1):E45–E52.
[72] Zylka MJ. Pain-relieving prospects for adenosine
receptors and ectonucleotidases. Trends Mol Med.
2011;17(4):188–96. doi:10.1016/j.molmed.2010.12.006.
[73] Hurt JK, Coleman JL, Fitzpatrick BJ, Taylor-Blake B,
Bridges AS, Vihko P, et al. Prostatic acid phosphatase
is required for the antinociceptive effects of thiamine
and benfotiamine. PLoS One. 2012;7(10):e48562.
doi:10.1371/journal.pone.0048562.
[74] Taylor-Blake B, Zylka MJ. Prostatic acid phosphatase is
expressed in peptidergic and nonpeptidergic nocicep-
tive neurons of mice and rats. PLoS One. 2010;5(1):
e8674. doi:10.1371/journal.pone.0008674.
[75] Zylka MJ, Sowa NA, Taylor-Blake B, Twomey MA,
Herrala A, Voikar V, et al. Prostatic acid phosphatase
is an ectonucleotidase and suppresses pain by generat-
ing adenosine. Neuron. 2008;60(1):111–22. doi:10.
1016/j.neuron.2008.08.024.
250 A. M. PAEZ-HURTADO ET AL.
[76] Zimmerman M, Bartoszyk GD, Bonke D, Jurna I, Wild
A. Antinociceptive properties of pyridoxine.
Neurophysiological and behavioral findings. Ann N Y
Acad Sci. 1990;585:219–30. doi:10.1111/j.1749-6632.
1990.tb28055.x.
[77] Jain SK, Lim G. Pyridoxine and pyridoxamine inhibits
superoxide radicals and prevents lipid peroxidation,
protein glycosylation, and (Na++K+)-ATPase activity
reduction in high glucose-treated human erythrocytes.
Free Radic Biol Med. 2001;30(3):232–37. doi:10.1016/
s0891-5849(00)00462-7.
[78] Kannan K, Jain SK. Effect of vitamin B6 on oxygen rad-
icals, mitochondrial membrane potential, and lipid
peroxidation in H2O2-treated U937 monocytes. Free
Radic Biol Med. 2004;36(4):423–28. doi:10.1016/j.
freeradbiomed.2003.09.012.
[79] Reyes-Garcia JG, Medina-Santillan R, Flores-Murrieta
FJ, Caram-Salas NL, Granados-Soto V. Analgesic
effects of B vitamins. Curr Top Pharmacol. 2006;10
(1):1–31.
[80] Mascolo E, Verni F. Vitamin B6 and diabetes: relation-
ship and molecular mechanisms. Int J Mol Sci.
2020;21:10. https://www.ncbi.nlm.nih.gov/pubmed/
32456137. doi:10.3390/ijms21103669.
[81] Pietrobon D, Moskowitz MA. Pathophysiology of
migraine. Annu Rev Physiol. 2013;75:365–91. doi:10.
1146/annurev-physiol-030212-183717.
[82] Bennett GJ. Update on the neurophysiology of pain
transmission and modulation: focus on the NMDA-
receptor. J Pain Symp Manage. 2000;19(Suppl. 1):S2–
S6. doi:10.1016/s0885-3924(99)00120-7.
[83] Ji RR, Nackley A, Huh Y, Terrando N, Maixner W.
Neuroinflammation and central sensitization in chronic
and widespread pain. Anesthesiology. 2018;129(2):343–
66. doi:10.1097/ALN.0000000000002130.
[84] Huang Y, Su L, Wu J. Pyridoxine supplementation
improves the activity of recombinant glutamate decar-
boxylase and the enzymatic production of gama-ami-
nobutyric acid. PLoS One. 2016;11(7):e0157466.
doi:10.1371/journal.pone.0157466.
[85] Yang TT, Wang SJ. Pyridoxine inhibits depolarization-
evoked glutamate release in nerve terminals from rat
cerebral cortex: a possible neuroprotective mechan-
ism? J Pharmacol Exp Ther. 2009;331(1):244–54.
doi:10.1124/jpet.109.155176.
[86] Jarvis MF. Contributions of P2X3 homomeric and het-
eromeric channels to acute and chronic pain. Expert
Opin Ther Targets. 2003;7(4):513–22. doi:10.1517/
14728222.7.4.513.
[87] Zheng JH, Chen J. Modulatory roles of the adenosine
triphosphate P2x-purinoceptor in generation of the
persistent nociception induced by subcutaneous bee
venom injection in the conscious rat. Neurosci Lett.
2000;278(1–2):41–44. doi:10.1016/s0304-3940
(99)00896-4.
[88] Brown SG, Kim YC, Kim SA, Jacobson KA, Burnstock
G, King BF. Actions of a series of PPADS analogs at
P2X1 and P2X3 receptors. Drug Dev Res. 2001;53
(4):281–91. doi:10.1002/ddr.1197.
[89] North RA, Jarvis MF. P2x receptors as drug targets.
Mol Pharmacol. 2013;83(4):759–69. doi:10.1124/mol.
112.083758.
[90] Aufiero E, Stitik TP, Foye PM, Chen B. Pyridoxine
hydrochloride treatment of carpal tunnel syndrome: a
review. Nutr Rev. 2004;62(3):96–104. doi:10.1111/j.
1753-4887.2004.tb00030.x.
[91] Aydin Köker S, Gözmen S, Demirağ B, Ünalp A,
Karapinar TH, Oymak Y, et al. Effect of pyridoxine
plus pyridostigmine treatment on vincristine-induced
peripheral neuropathy in pediatric patients with
acute lymphoblastic leukemia: a single-center experi-
ence. Neurol Sci. 2021;42(9):3681–86. doi:10.1007/
s10072-020-04970-w.
[92] Vrolijk MF, Opperhuizen A, Jansen EHJM, Hageman
GJ, Bast A, Haenen GRMM. The vitamin B6 paradox:
supplementation with high concentrations of pyridox-
ine leads to decreased vitamin B6 function. Toxicology.
2017;44:206–12. doi:10.1016/j.tiv.2017.07.009.
[93] Calderon-Ospina C-A, Nava-Mesa MO, Paez-Hurtado
AM. Update on safety profiles of vitamins B1, B6, and
B12: a narrative review. Ther Clin Risk Manag.
2020;16:1275–88. doi:10.2147/TCRM.S274122.
[94] Suzuki K, Tanaka H, Ebara M, Uto K, Matsuoka H,
Nishimoto S, et al. Electrospun nanofiber sheets incor-
porating methylcobalamin promote nerve regeneration
and functional recovery in a rat sciatic nerve crush
injury model. Acta Biomater. 2017;53:250–59. doi:10.
1016/j.actbio.2017.02.004.
[95] Okada K, Tanaka H, Temporin K, Okamoto M,
Kuroda Y, Moritomo H, et al. Methylcobalamin
increases Erk1/2 and Akt activities through the methyl-
ation cycle and promotes nerve regeneration in a rat
sciatic nerve injury model. Exp Neurol. 2010;222
(2):191–203. doi:10.1016/j.expneurol.2009.12.017.
[96] Tamaddonfard E, Farshid AA, Samadi F, Eghdami K.
Effect of vitamin B12 on functional recovery and histo-
pathologic changes of tibial nerve-crushed rats. Drug
Res. 2014;64(9):470–5. doi:10.1055/s-0033-1363219.
[97] Zhang M, Han W, Hu S, Xu H. Methylcobalamin: a
potential vitamin of pain killer. Neural Plast.
2013;2013:424651. doi:10.1155/2013/424651.
[98] Pfohl-Leszkowicz A, Keith G, Dirheimer G. Effect of
cobalamin derivatives on in vitro enzymatic DNA
methylation: methylcobalamin can act as a methyl
donor. Biochemistry. 1991;30(32):8045–51. doi:10.
1021/bi00246a024.
[99] Sonobe M, Yasuda H, Hatanaka I, Terada M,
Yamashita M, Kikkawa R, et al. Methylcobalamin
improves nerve conduction in streptozotocin-diabetic
rats without affecting sorbitol and myo-inositol con-
tents of sciatic nerve. Horm Metab Res. 1988;20
(11):717–18. doi:10.1055/s-2007-1010925.
[100] Ishihara H, Yoneda M, Yamamoto W. Efficacy of intra-
venous administration of methycobalamin for diabetic
peripheral neuropathy. Med Consult Remed. 1992;29
(1):1720–25.
[101] Kuwabara S, Nakazawa R, Azuma N, Suzuki M,
Miyajima K, Fukutake T, et al. Intravenous methylco-
balamin treatment for uremic and diabetic neuropathy
in chronic hemodialysis patients. Int Med. 1999;38
(6):472–75. doi:10.2169/internalmedicine.38.472.
[102] Watanabe T, Kaji R, Oka N, Bara W, Kimura J. Ultra-
high dose methylcobalamin promotes nerve regener-
ation in experimental acrylamide neuropathy. J

Neurol Sci. 1994;122(2):140–43. doi:10.1016/0022-
510x(94)90290-9.
[103] Jacobs AM, Cheng D. Management of diabetic small-
fiber neuropathy with combination L-methylfolate,
methylcobalamin, and pyridoxal 5’-phosphate. Rev
Neurol Dis. 2011;8(1–2):39–47.
[104] Scalabrino G, Tredici G, Buccellato FR, Manfridi A.
Further evidence for the involvement of epidermal
growth factor in the signaling pathway of vitamin
B12 (cobalamin) in the rat central nervous system. J
Neuropathol Exp Neurol. 2000;59(9):808–14. doi:10.
1093/jnen/59.9.808.
[105] Hong L, Zhang J, Shen J. Clinical efficacy of different
doses of lipo-prostaglandin E1 in the treatment of
painful diabetic peripheral neuropathy. J Diabetes
Compl. 2015;29(8):1283–86. doi:10.1016/j.jdiacomp.
2015.08.001.
[106] Sun H, Yang T, Li Q, Zhu Z, Wang L, Bai G, et al.
Dexamethasone and vitamin B(12) synergistically pro-
mote peripheral nerve regeneration in rats by upregu-
lating the expression of brain-derived neurotrophic
factor. Arch Med Sci. 2012;8(5):924–30. doi:10.5114/
aoms.2012.31623.
[107] Imtiaz M, Begum N, Ali T, Gomes RR, Saha S, Tasfi RF,
et al. Pain & inflammation: effects of short term daily
adminstration of vitamin B12 & folic acid in long
evans rats. Bangl Crit Care J. 2016;4(1):33–37.
[108] Atsuta Y. The study of generating and suppressive fac-
tors of ectopic firing in the lumbar dorsal root using an
in vitro model. Rinsho Seikei Geka. 1994;29(4):441–48.
[109] Chaplan SR, Guo HQ, Lee DH, Luo L, Liu C, Kuei C,
et al. Neuronal hyperpolarization-activated pacemaker
channels drive neuropathic pain. J Neurosci. 2003;23
(4):1169–78.
[110] Schloss J, Colosimo M. B vitamin complex and che-
motherapy-induced peripheral neuropathy. Curr
Oncol Rep. 2017;19(12):76. doi:10.1007/s11912-017-
0636-z.
[111] Julian T, Syeed R, Glascow N, Angelopoulou E, Zis P.
B12 as a treatment for peripheral neuropathic pain: a
systematic review. Nutrients. 2020;12(8):E2221.
doi:10.3390/nu12082221.
[112] Jayabalan B, Low LL. Vitamin B supplementation for
diabetic peripheral neuropathy. Singap Med J.
2016;57(2):55–59. doi:10.11622/smedj.2016027.
[113] Schmidtko A, Tegeder I, Geisslinger G. No NO, no
pain? The role of nitric oxide and cGMP in spinal
pain processing. Trends Neurosci. 2009;32(6):339–46.
doi:10.1016/j.tins.2009.01.010.
[114] Laurido C, Hernandez A, Constandil L, Pelissier T.
Nitric oxide synthase and soluble guanylate cyclase
are involved in spinal cord wind-up activity of mono-
arthritic, but not of normal rats. Neurosci Lett.
2003;352(1):64–66. doi:10.1016/j.neulet.2003.08.014.
[115] Abacioglu N, Tunctan B, Cakici I, Akbulut E, Uludag
O, Kanzik I. The role of L-arginine/nitric oxide path-
way in the antinociceptive activity of pyridoxine in
mouse. Arzneimittelforschung. 2001;51(10):832–38.
doi:10.1055/s-0031-1300122.
[116] Reyes-Garcia G, Medina-Santillan R, Teran-Rosales F,
Castillo-Henkel C, Vidal-Cantu GC, Caram-Salas NL,
et al. B vitamins increase the anti-hyperalgesic effect
NUTRITIONAL NEUROSCIENCE 251
of diclofenac in the rat. Proc West Pharmacol Soc.
2002;45:147–49.
[117] Sanchez-Ramirez GM, Caram-Salas NL, Rocha-
Gonzalez HI, Vidal-Cantu GC, Medina-Santillan R,
Reyes-Garcia G, et al. Benfotiamine relieves inflamma-
tory and neuropathic pain in rats. Eur J Pharmacol.
2006;530(1–2):48–53. doi:10.1016/j.ejphar.2005.11.016.
[118] Song XJ, Wang ZB. Activation of cGMP-PKG signaling
pathway mediates thiamine induced-inhibition of ther-
mal hiperalgesia in rats with primary sensory neuron
injury. Ann Meet Profess Res Sci Exp Biol. 2003;439:7.
[119] Huang ZJ, Li HC, Liu S, Song XJ. Activation of cGMP-
PKG signaling pathway contributes to neuronal hyperex-
citability and hyperalgesia after in vivo prolonged com-
pression or in vitro acute dissociation of dorsal root
ganglion in rats. Sheng Li Xue Bao. 2012;64(5):563–76.
[120] Hammes HP, Du X, Edelstein D, Taguchi T,
Matsumura T, Ju Q, et al. Benfotiamine blocks three
major pathways of hyperglycemic damage and pre-
vents experimental diabetic retinopathy. Nat Med.
2003;9(3):294–99. doi:10.1038/nm834.
[121] Souza AL, Moreira FA, Almeida KR, Bertollo CM,
Costa KA, Coelho MM. In vivo evidence for a role of
protein kinase C in peripheral nociceptive processing.
Br J Pharmacol. 2002;135(1):239–47. doi:10.1038/sj.
bjp.0704434.
[122] Yajima Y, Narita M, Shimamura M, Narita M, Kubota
C, Suzuki T. Differential involvement of spinal protein
kinase C and protein kinase A in neuropathic and
inflammatory pain in mice. Brain Res. 2003;992
(2):288–93. doi:10.1016/j.brainres.2003.08.042.
[123] Babaei-Jadidi R, Karachalias N, Ahmed N, Battah S,
Thornalley PJ. Prevention of incipient diabetic nephro-
pathy by high-dose thiamine and benfotiamine.
Diabetes. 2003;52(8):2110–20. doi:10.2337/diabetes.
52.8.2110.
[124] Haupt E, Ledermann H, Köpcke W. Benfotiamine in
the treatment of diabetic polyneuropathy – a three-
week randomized, controlled pilot study (BEDIP
study). Int J Clin Pharm Ther. 2005;43(2):71–77.
doi:10.5414/cpp43071.
[125] Winkler G, Pal B, Nagybeganyi E, Ory I, Porochnavec
M, Kempler P. Effectiveness of different benfotiamine
dosage regimens in the treatment of painful diabetic
neuropathy. Arzneimittelforschung. 1999;49(3):220–
24. doi:10.1055/s-0031-1300405.
[126] Fu QG, Carstens E, Stelzer B, Zimmermann M. B vita-
mins suppress spinal dorsal horn nociceptive neurons
in the cat. Neurosci Lett. 1988;95(1–3):192–97.
doi:10.1016/0304-3940(88)90655-6.
[127] Deng XT, Han Y, Liu WT, Song XJ. B vitamins potenti-
ate acute morphine antinociception and attenuate the
development of tolerance to chronic morphine in
mice. Pain Med. 2017;18(10):1961–74. doi:10.1093/pm/
pnw358.
[128] Reynolds DV. Surgery in the rat during electrical analge-
sia induced by focal brain stimulation. Science. 1969;164
(3878):444–45. doi:10.1126/science.164.3878.444.
[129] Fields HL, Bry J, Hentall I, Zorman G. The activity of
neurons in the rostral medulla of the rat during with-
drawal from noxious heat. J Neurosci. 1983;3
(12):2545–52.
252 A. M. PAEZ-HURTADO ET AL.
[130] Ossipov MH, Dussor GO, Porreca F. Central modu-
lation of pain. J Clin Invest. 2010;120(11):3779–87.
doi:10.1172/JCI43766.
[131] Nava-Mesa MO, Aispuru Lanche GR. [Role of B vita-
mins, thiamine, pyridoxine, and cyanocobalamin in
back pain and other musculoskeletal conditions: a nar-
rative review]. Semergen. 2021 Apr 14. doi:10.1016/j.
semerg.2021.01.010.
[132] Jurna I, Carlsson KH, Komen W, Bonke D. Acute effects
of vitamin B6 and fixed combinations of vitamin B1, B6
and B12 on nociceptive activity evoked in the rat thala-
mus: dose-response relationship and combinations with
morphine and paracetamol. Klin Wochenschr. 1990;68
(2):129–35. doi:10.1007/BF01646861.
[133] Jurna I. [Analgesic and analgesia-potentiating action of
B vitamins]. Schmerz. 1998;12(2):136–41. doi:10.1007/
s004829800054.
[134] Hartvig P, Lindner KJ, Bjurling P, Laengstrom B,
Tedroff J. Pyridoxine effect on synthesis rate of seroto-
nin in the monkey brain measured with positron emis-
sion tomography. J Neural Transm Gen Sect. 1995;102
(2):91–97. doi:10.1007/BF01276505.
[135] Paulose CS, Dakshinamurti K, Packer S, Stephens NL.
Sympathetic stimulation and hypertension in the pyri-
doxine-deficient adult rat. Hypertension. 1988;11
(4):387–91. doi:10.1161/01.hyp.11.4.387.
[136] Dakshinamurti K, Singer WD, Paterson JA. Effect of
pyridoxine deficiency in the neuronally mature rat.
Int J Vitam Nutr Res. 1987;57(2):161–67.
[137] Viswanathan M, Paulose CS, Lal KJ, Sharma SK,
Dakshinamurti K. Alterations in brainstem alpha 2
adrenoreceptor activity in pyridoxine-deficient rat
model of hypertension. Neurosci Lett. 1990;111(1–
2):201–205. doi:10.1016/0304-3940(90)90368-j.
[138] Dimpfel W, Spuler M, Bonke D. Influence of repeated
vitamin B administration on the frequency pattern
analysed from rat brain electrical activity (Tele-
Stereo-EEG). Klin Wochenschr. 1990;68(2):136–41.
doi:10.1007/BF01646862.
[139] Pertovaara A. Noradrenergic pain modulation. Prog
Neurobiol. 2006;80(2):53–83. doi:10.1016/j.pneurobio.
2006.08.001.
[140] Loder C, Allawi J, Horrobin DF. Treatment of multiple
sclerosis with lofepramine, L-phenylalanine and vita-
min B(12): mechanism of action and clinical impor-
tance: roles of the locus coeruleus and central
noradrenergic systems. Med Hypotheses. 2002;59
(5):594–602. doi:10.1016/s0306-9877(02)00261-x.
[141] Baumeister FA, Gsell W, Shin YS, Egger J. Glutamate
in pyridoxine-dependent epilepsy: neurotoxic gluta-
mate concentration in the cerebrospinal fluid and its
normalization by pyridoxine. Pediatrics. 1994;94
(3):318–21.
[142] Lin Y, Desbois A, Jiang S, Hou ST. Group B vitamins
protect murine cerebellar granule cells from gluta-
mate/NMDA toxicity. Neuroreport. 2004;15(14):2241–
44. doi:10.1097/00001756-200410050-00020.
[143] Kaneda K, Kikuchi M, Kashii S, Honda Y, Maeda T,
Kaneko S, et al. Effects of B vitamins on glutamate-
induced neurotoxicity in retinal cultures. Eur J
Pharmacol. 1997;322(2–3):259–64. doi:10.1016/s0014-
2999(96)00997-1.
[144] He D-D, Gao Y, Wang S, Xie Z, Song X-J. Systematic
administration of B vitamins alleviates diabetic pain
and inhibits associated expression of P2X3 and
TRPV1 in dorsal root ganglion neurons and proinflam-
matory cytokines in spinal cord in rats. Pain Res Manag.
2020;2020:3740162. doi:10.1155/2020/3740162.
[145] Bartoszyk GD, Wild A. Antinociceptive effects of pyr-
idoxine, thiamine, and cyanocobalamin in rats. Ann N
Y Acad Sci. 1990;585(1):473–76. doi:10.1111/j.1749-
6632.1990.tb28079.x.
[146] Leuschner J. Antinociceptive properties of thiamine,
pyridoxine and cyanocobalamin following repeated
oral administration to mice. Arzneim Forsch. 1992;42
(2):114–15.
[147] Franca DS, Souza AL, Almeida KR, Dolabella SS,
Martinelli C, Coelho MM. B vitamins induce an antinoci-
ceptive effect in the acetic acid and formaldehyde models
of nociception in mice. Eur J Pharmacol. 2001;421(3):157–
64. doi:10.1016/s0014-2999(01)01038-x.
[148] Jolivalt CG, Mizisin LM, Nelson A, Cunha JM, Ramos
KM, Bonke D, et al. B vitamins alleviate indices of neu-
ropathic pain in diabetic rats. Eur J Pharmacol. 2009;612
(1–3):41–47. doi:10.1016/j.ejphar.2009.04.028.
[149] Dakshinamurti K, Sharma SK, Geiger JD.
Neuroprotective actions of pyridoxine. Biochim
Biophys Acta. 2003;1647(1–2):225–29. doi:10.1016/
s1570-9639(03)00054-2.
[150] Altun I, Kurutaş EB. Vitamin B complex and vitamin
B12 levels after peripheral nerve injury. Neural Regen
Res. 2016;11(5):842–45. doi:10.4103/1673-5374.177150.
[151] Fujii A, Matsumoto H, Yamamoto H. Effect of vitamin
B complex on neurotransmission and neurite out-
growth. Gen Pharmacol. 1996;27(6):995–1000. doi:10.
1016/0306-3623(95)02072-1.
[152] Tamaddonfard E, Tamaddonfard S, Cheraghiyan S.
Effects of intracerebroventricular injection of vitamin
B12 on formalin-induced muscle pain in rats: role of
cyclooxygenase pathway and opioid receptors. Vet
Res Forum. 2018;9(4):329–35. doi:10.30466/vrf.2018.
33104.
[153] Liu L, Ma S-H, Xia L-J. The influence of thiamin on the
efficacy of pregabalin in rats with spinal nerve ligation
(SNL)-induced neuropathic pain. Neurol Res. 2016;38
(8):717–24. doi:10.1080/01616412.2016.1188550.
[154] Reyes-Garcia G, Medina-Santillan R, Teran-Rosales F,
Mateos-Garcia E, Castillo-Henkel C. Characterization
of the potentiation of the antinociceptive effect of
diclofenac by vitamin B complex in the rat. J
Pharmacol Toxicol Methods. 1999;42(2):73–77.
doi:10.1016/s1056-8719(00)00045-9.
[155] Rocha-Gonzalez HI, Teran-Rosales F, Reyes-Garcia G,
Medina-Santillan R, Granados-Soto V. B vitamins
increase the analgesic effect of diclofenac in the rat.
Proc West Pharmacol Soc. 2004;47:84–87.
[156] Tamaddonfard E, Samadi F, Egdami K. The effects of
vitamin B12 and diclofenac and their combination on
cold and mechanical allodynia in a neuropathic pain
model in rats. Vet Res Forum. 2013;4(1):19–24.
[157] Reyes-Garcia G, Caram-Salas NL, Medina-Santillan R,
Granados-Soto V. Oral administration of B vitamins
increases the antiallodynic effect of gabapentin in the
rat. Proc West Pharmacol Soc. 2004;47:76–79.

[158] Caram-Salas NL, Reyes-Garcia G, Medina-Santillan R,
Granados-Soto V. Thiamine and cyanocobalamin
relieve neuropathic pain in rats: synergy with dexa-
methasone. Pharmacology. 2006;77(2):53–62. doi:10.
1159/000092643.
NUTRITIONAL NEUROSCIENCE 253
[159] Montiel-Ruiz RM, Gonzalez-Trujano ME, Deciga-
Campos M. Synergistic interactions between the antino-
ciceptive effect of Rhodiola rosea extract and B vitamins
in the mouse formalin test. Phytomedicine. 2013;20
(14):1280–87. doi:10.1016/j.phymed.2013.07.006.