A migraine is a common, chronic neurovascular disorder that remains underdiagnosed and undertreated despite advances in our understanding of its pathophysiology. One of the most fundamental questions asked by patients is what triggers a migraine headache. A migraine trigger is any factor that on exposure or withdrawal leads to the development of an acute migraine. Identification and avoidance of migraine trigger factors can be used to theoretically prevent a migraine headache, thus providing patients with a sense of control over a this chronic disorder. By avoiding known personal triggers, a small lifestyle change may have tremendous impact on the frequency of migraine attacks and substantially diminish migraine-related disability. While every patient requires an individual approach, most patients suffering from migraine headaches can utilize the following recommendations.
- Stress – emotionally charged or stressful situations can trigger migraine headaches through an effect of stress hormones on the central nervous system. Strategies that have proven effective in combating stress include the use of daily meditation sessions, biofeedback and cognitive-behavioral therapy.
- Sleep – disturbances in sleep could alter neuronal firing rates within the brainstem and worsen migraine headaches. Planning regular sleep schedules (including avoidance of oversleeping) has been shown to diminish migraine exacerbations.
- Exercise – 40 minutes of aerobic exercise performed 3 times per week has been shown to be effective for preventing headaches. Isometric neck exercises can be an effective treatment for migraines accompanied by neck pain, whether triggered by or associated with neck muscle spasm. Patients can also preform some breathing and relaxation exercises with improvement expected after about two weeks.
- Acupuncture – while definitive proof is lacking, available evidence strongly suggests that it produces benefits extending beyond placebo effect. It is widely practiced in Europe and can be effective for some patients.
- Physical stimuli – bright or flickering lights, perfumes or other strong odors can provoke headaches. Patients may wish to wear sunglasses when they are exposed to direct sunlight and avoid the use of strong perfumes.
- Weather changes – changes in barometric pressure, temperature, humidity and high winds can worsen headaches although the exact mechanism is unknown.
- Smoking – cigarette smoking is associated with greater severity of migraine headaches, although there is insufficient data to prove a causal link. Patients should reduce or cease consumption of cigarettes for possible beneficial effect on headache as well as known beneficial effects on cardiovascular health.
- Caffeine – has a variety effects on the central nervous system and its clinical effect depends on the dose and frequency of consumption. ?High daily doses of caffeine (>200 mg/day) are associated with higher incidence of headache. Patients should limit the caffeine consumption to fewer than two beverages per day. Over time, patients can also develop tolerance and physical dependence with subsequent withdrawal of caffeine causing increased headaches. Caffeine withdrawal headaches typically begin 24-48 hours after cessation of caffeine and generally last for 1 to 6 days. Patients wishing to cease the use of caffeine should decrease the dose gradually over a period of several weeks.
- Wine – both red and white wine have been implicated as possible migraine triggers. Several ingredients present in wine could provoke migraines including sulfites, histamine and phenolic flavonoids (found in skin of the grape, giving red wine its color).
- Chocolate – the role of chocolate as a migraine trigger is controversial, but several ingredients in chocolate have been implicated in headaches including phenylethylamine and theobromine (caffeine metabolite).
- Tyramine – can be found in variety of foods and beverages including cheese, smoke or pickled fish, beer, wine and dry sausage. There is good evidence from clinical trials that high-level exposure to tyramine provokes migraine-like headache in susceptible patients. Whether low or moderate level exposure (such as seen in a typical diet) can provoke headaches is controversial. It is possible that there is a subgroup of migraine patients susceptible to effects of dietary tyramine.
- Aspartame – a low-calorie sugar substitute found in a variety of beverages, snacks, desserts and sweeteners. There is some evidence to suggest that it triggers headaches when consumed in moderate-to-high doses (900-3000 mg/day) during a prolonged period (14-24 days).
- Fasting – reactive hypoglycemia is common in patients with migraine. Adherence to regular meals, small frequent meals and avoidance of foods with a high glycemic index can significantly improve migraine headaches.
- Vitamins and Supplements – magnesium deficiency is well documented in patients with migraine. 400 mg of magnesium supplements can be taken daily with food (possible side effects include loose bowel movements; sometimes oral supplements are not sufficiently absorbed and parenteral administration is needed). Supplementation with CoQ10 (300 mg/day) can also reduce headache frequency (should be administered in the morning as it can cause insomnia with at night). Riboflavin (Vitamin B2) 400 mg/day is also considered likely effective in prevention of episodic migraines. Folic Acid, Vitamin B12 and Vitamin B6 have been shown to reduce the severity of migraine auras. These three supplements are often taken together and it is important to note that 1-3 months of use may be needed before benefit is seen.
Dr. Vladimir Kramskiy is board-certified in neurology and pain medicine. As Director of the Ambulatory Recuperative Pain Medicine Program, he uses a comprehensive approach to treat acute and chronic spine and musculoskeletal pain, neuropathic pain, headaches and complex regional pain syndromes. His clinical goal is to restore optimal physical function by developing an individualized treatment plan for his patients.