Controversies in Headache Medicine: Migraine Prevention Diets
Merle L. Diamond, MD and Dawn A. Marcus, MD
Perhaps the best migraine prevention diet is one that is as wholesome, fresh and unprocessed as possible, thereby eliminating many of the supposed chemical triggers for migraine. In addition, eat these foods in small portions spread throughout the day averaging 5-6 calorie controlled portions. This eating behavior assists in preventing headache due to hunger, avoids large amounts of any supposed chemical trigger at any given time and finally fires up one’s metabolism preventing weight gain, a likely factor contributing to risk of headache progression.
Patients who suffer from migraine attacks try to determine what they did wrong each time that a headache occurs—that is, they try to identify the triggers that put them at risk of having another episode. For many years, headache specialists have debated the possibility that certain foods cause the so-called "migraine threshold" to drop which allows a window of opportunity for migraine to start. Food triggers appear to be important in a minority of migraine sufferers, but other factors may be complicating an understanding of food triggers. For example, so many foods and beverages have caffeine, which has clearly been associated as a trigger for headache in individuals with high caffeine consumption.
One of the most frustrating things for migraine sufferer is the inconsistency in which different suspected and even proven triggers precipitate an attack. There are many provokers for migraine, such as hormone changes, stress, while some believe specific foods. Perhaps a better way to consider food specific triggers is the acceptance that when patients are at risk for migraine attacks, many factors may tip the scale in favor of a migraine including a particular food. Here we will specifically discuss the controversies about what is known regarding food specific migraine triggers.
What foods have been considered to trigger migraine in susceptible people?
There are multiple foods that are thought to possibly trigger a migraine attack. Nearly all foods have been generated by patient self report and almost none have any scientifically valid backing from high quality studies. The most commonly reported food triggers are alcohol (33%) and chocolate (22%). Although the majority of headache sufferers cannot identify specific food triggers, headache patients are often given a broad recommendation to monitor their headaches after eating foods that historically have been thought to contain possible headache-triggering chemicals, such as tyramine (e.g., cheeses), beta-phenylethylamine (e.g., chocolate), and nitrates (e.g., processed meats). In actuality, there have been no studies or only negative trials for headache provocation for cheeses, chocolate, dairy products, soy isoflavones and vegetables. Processed meats containing high levels of nitrites and nitrates may be highly predictable migraine triggers in some individuals. Yet, only one patient has actually been studied with the result suggesting very pure nitrates at high dose (pharmaceutical grade) induce attacks while dietary nitrates and nititrites may in susceptible individuals. Some foods can cause the blood vessels to dilate (expand) and so create the early changes seen in migraine attacks. Some foods contain a significant amount of tyramine--an amino acid that can provoke the early blood vessel changes typical of migraine. While the most heavily studied chemical trigger the majority of studies on tyramine fail to support this role. In most of these studies the placebo rates where unusually high. Medina and Diamond used diets low, median and high in tyramine with no difference between groups, although improvement in all. Foods that are high in tyramine include aged cheeses, nuts, beans, yogurt, bananas, and citrus fruits. Elimination of most of these foods long-term are likely to have a deleterious effect on health and cannot be broadly recommended. Certain alcoholic beverages, especially red wine and beer, are frequently cited migraine triggers. Two well known Italian researchers recruited 307 volunteers with migraine without aura to complete a questionnaire every time they consumed alcohol. No correlation was found between alcohol consumption and migraine attacks. Stressful events and onset of migraine were positively related.
Food additives have been linked to migraine attacks. Monosodium glutamate (MSG) is probably the best known of this group, and has been demonstrated to cause rapid cramps, diarrhea, and a horrible migraine in 10% to 15% of migraineurs. While some may consider it unnecessary it is reasonable to note that no scientific studies have actually studied MSG in migraineurs Interestingly, in self-identified MSG sensitive non-migraineurs, MSG related symptoms were only slightly more frequent in those receiving MSG than those on placebo. Some spices as well as garlic and onion have been labeled as possible triggers of migraine attacks, yet no studies support this.
Accused food triggers for migraine in susceptible individuals
Selected food triggers items may include:
- Alcohol, specifically red wine
- Aspartame sweetener
- Beans and other tyramine-containing foods
- Caffeine (often found in foods, beverages, and medicines)
- Cheeses and yogurt
- Chinese food or other soups and foods containing MSG
- Processed meats (containing sulfites-eg, bacon, sausages, salami, ham)
- Vitamins and herbal supplements (some contain caffeine or active ingredients that can make headaches worse)
Is there such a thing as a migraine prevention diet?
Diet may be important for some headache sufferers but not for others. Almost half of headache sufferers report that fasting will trigger a headache. Some patients try to eliminate from their diet anything listed as a potential trigger, but the list of foods that may trigger migraine can be exhaustive. Therefore, dietary restriction of all migraine triggers for any extended length of time is likely unhealthy.
A rational and useful approach about migraine and diet needs to focus on learning the facts and being smart. Patients should invest some time in learning about which foods are potential triggers for them, and then they can try to limit their consumption, especially during high risk times. Over time, it is possible to become skillful in identifying migraine triggers and avoiding these selected foods at those times when their risk of migraine is high. For example, at certain times in the menstrual cycle, many women experience more frequent headache attacks.
Paying attention to your diet when trying to identify potential foods that trigger migraine can also be a useful tool in understanding the importance of a healthy diet and regular meals for maintaining a healthy headache hygiene and improved lifestyle. Assessment of eating habits and identifying food triggers may be facilitated by using a headache diary, which the patient completes on a daily basis. It is much easier to find a headache trigger if you examine, within 24 hours, the events that occurred on the day of the headache. Several research studies have proven that avoiding foods thought to trigger migraine does not improve chronic headaches. A study by Drs. Diamond and Medina compared headache activity when migraine sufferers followed one of several diets. One diet restricted patients from eating supposed headache trigger foods. The other diet required patients to eat those same foods. Interestingly, headache activity improved on both diets. This suggests that a particular food is not likely to be a trigger; rather, following a scheduled diet may be therapeutic. In other words, feeling that you have control over your headaches will improve your headaches. It also suggests that no single food is a trigger for all headache sufferers.
Two common food items have been tested in several studies. An aspartame study showed only a modest worsening of headache in subjects who consumed huge amounts of aspartame (the equivalent of 12 cans of diet cola or 32 packets of sweetener daily) for one month. In another controlled trial of aspartame only those "very sure" of their aspartame sensitivity reported increased headaches despite enormous doses of aspartame. In an in-hospital study with a very tightly controlled diet, headache was experienced in 1of 3 aspartame consumers while just less than 1 of 2 experienced headache in the placebo group. In a study of chocolate as a trigger eating even large amounts of chocolate didn’t trigger headaches when patients couldn’t tell if they were eating chocolate--even for individuals who believed chocolate was a headache trigger for them.
If both clinical experience and research studies show that eating certain foods will not trigger headaches, why do patients and doctors believe that it is important to avoid eating such foods? Unfortunately, it is very difficult for both patients and doctors to determine why headaches occur at certain times and not others. In some cases, there may be a number of possible headache trigger factors. Patients then need to sort out which provoker was the important one. For example, you may have a hectic day at work and miss lunch. Late in the afternoon, you feel weak and stressed. So you grab a chocolate bar from the vending machine to eat as you race through the rest of your day. What triggered your headache? Was it the chocolate or the fasting or the stress or all or none of these? In addition, chocolate craving often occurs with menstrual periods, another common headache trigger. Finally, chocolate craving may be part of a pre-headache warning or prodrome (the first stage of the attack, before an aura or headache). When you satisfy that craving, you may falsely blame the headache on the chocolate.
How can you tell if a food is a trigger for your migraine?
- Eating a certain food should trigger a headache within 12 to at most 24 hours.
- Limit the food of concern for 4 weeks and monitor your headache frequency, severity and response to treatment using a headache diary.
- If there is no change in your headaches, then, that food alone may not be the trigger.
- Caution—do NOT restrict all possible trigger foods from your diet for an extended period of time. This is not likely to be helpful, and too much concern about avoiding foods may be another stress, as well as decrease your enjoyment of mealtime.
- Restrictive diets should not be tried or followed during pregnancy. These diets are not likely to be helpful and may prevent adequate nutrition for both mother and fetus because of the reduced consumption of calcium-rich and vitamin-rich foods.
- Restrictive diets should NOT be used in children and adolescents because of doubtful benefit and significant social disruption. Prohibiting the child from sharing a chocolate Easter basket with his siblings or the teenager from attending a pizza party can significantly add to the social stigma of having headaches.
Keeping a headache diary and following your lifestyle factors along with diet may help you identify patterns to your headache. Onset of menstrual cycles, work stress, sleep routine changes, and fasting may all be confounding what is thought to be a food trigger for headache. In a systematic and careful way, you can test these triggers one by one to see if any of them are a trigger for you. Soon you will learn that some of the foods you were concerned about are not triggers for you headaches and you can resume your normal diet and start enjoying your foods again. OR you can simply eat wholesome, fresh foods as unprocessed as possible in small amounts throughout the day.
--Merle L. Diamond, MD, FACEP, Associate Director, Diamond Headache Clinic; and Clinical Assistant Professor, Department of Medicine, Finch University of Health Sciences/The Chicago Medical School. Chicago, IL
--Dawn A. Marcus, MD, Associate Professor of Anesthesiology & Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA
Updated in May 2008 from Headache, the Newsletter of ACHE, Summer 2000, vol. 11, no. 2.
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