“Migraine on a plate”The effects of food and drink

Dr Nicholas Silver

The Walton Centre, Liverpool

2017

1

2

Clinical Treatment Trials

• Amgen

• Novartis

• Eli Lilly

• Teva

• Electrocore

• Allergan

• ATI

Personal Fees from

• Novartis

• Teva

• Allergan

• Electrocore

• Medicolegal work

Scientific Advisor

• Electrocore

• Allergan

Disclosures

ACCME: I have no spousal/partner

conflicts, nor relationships with companies

that market, distribute or resell health care

goods or services consumed by, or used

on patients unless otherwise explicitly

stated.

I’m very brave generally, he went on in a low voice, only today I happen to have a headache

Tweedle DumLewis Carroll, Through the looking glass 1872

Third National Morbidity Survey (1989)Dr Anthony Hopkins

10% of the population consults their GP each year for neurological symptoms

Migraine is by far the commonest cause

World Health OrganisationGlobal Burden of Disease Studies

Migraine “above the radar”

• One of 3 most prevalent worldwide conditions

• 324 million people affected worldwide

• Third greatest cause of disability worldwide (WHO)

• One of the four most disabling conditions

• (equal to quadriplegia, psychosis and dementia)

• Affects adults at prime of working and child-rearing lives

• One of commonest (& most unrecognised) causes of school absence

Important concepts about migraine

1. A significant, reversible and relatively invisible cause of disability

1. Much more than “just a headache”

1. Amplifies normal bodily sensations into symptoms

1. May present with many symptoms yet little or no headache

2. Easily misdiagnosed

1. Migraine may commonly be kept going by inappropriate treatment, especially overuse of painkillers and caffeine

“A primary headache disorder characterised by central sensitisation and various combinations of neurological,

systemic and autonomic features.”

7

• A systemic and multisymptomatic disorder that requires a holistic

approach to management

• A significant, reversible and relatively invisible cause of disability

• Genetic predisposition

• More common in women, due to hormonal influences

What is Migraine?

8

Episodic migraine (EM):

• 90% of cases worldwide1

• < 14 headache days / month2

1National Migraine Centre. What is migraine? http://www.nationalmigrainecentre.org.uk/migraine-

and-headaches/migraine-and-headache-factsheets/what-is-migraine/. Accessed April 2017; 2Katsarava et al. Curr Pain Headache 2012: 16(1): 86–92

Only 1 in 5 patients have aura1

Patients with chronic migraine are more disabled and

demonstrate higher individual and societal burden2

Migraine is more than ‘just a headache’

Chronic migraine (CM):

• 10% of cases worldwide1

• >15 headache days / month2

Types of Migraine

Amplification

Head pain

Widespread bodily pain

- tenderness / allodynia

Stimulus Sensitivity to:

Movement

Noise (photophobia)

Light (phonophobia)

Smell (osmophobia)

Vestibular (dizziness)

9

Autonomic

– Nausea + vomiting

– Postural hypotension / POTS

– Diarrhoea, increased urine

– Pallor

– Eye –red, runny, drooped

– Blocked, runny nose

– Ear fullness

– Tinnitus

– Bruising, swelling

Brain Dysfunction1

– Aura

– Mood change

– Confusion / memory

– Fatigue

– Restless legs

What Happens in Migraine?“More than just a headache”

1 Holland And Afridi, ACNR 2014:V13(7);19-21

Alcohol

Relief of stress /

weekend

Caffeine

Triggers – additive effect

headache

lifesty

le

Preventative

Hormone

fluctuation

The 4 stages of a migraine attack

Prodrome Aura Headache Postdrome

(<85%) (20%)

Hours Minutes Hours Usually 1-2 days

to days to hours* to days

Acute Migraine – Prodrome

Mental State

Fatigue

Irritability

Aggression

Depressed mood

Euphoria

Hyperactivity

Restlessness

Depersonalisation

Derealisation

Cerebral

Yawning

Phonophobia

Photophobia

Osmophobia

General

Lightheaded

Hunger (CHO)

Thirst

Dizziness

Neck pain /

stiffness

Anorexia

Frequent

micturition

Diarrhoea

RLS

Treating your migraine attack

Fluids

Food

Antisickness drugs

Painkillers

Triptans

Kitchen smells and headache

• Is Migraine headache triggered by noise, light or smells?

or

• Does this reflect increased sensitivity as amplification phenomenon, ie attack already started?

• Garlic

• Onions

• Fried cooking

• Air freshener

Characteristic gradual evolution from acute to chronic state:

1. Increasing frequency and duration1

2. Gaps “fill in” with milder migrainous headaches

1. Acute attack drugs become less effective

2. Pervasive non-headache features

Frequent headaches with migrainous features

+

< 15 days per month headache-free (CCHAF days)

Chronic Migraine

15

1 http://www.headaches.org/2007/10/25/transformed-migraine-more-commonly-known-as-chronic-migraine/

Chronic Migraine: “More Than Just a Headache”

Coathangerneck pain

Mood change& irritability

Fatigue

Visual Vertigo“Migraine-associated

Dissociation” (MAD)AndVertigo

Blackouts(migraine syncope)

Frequent

(+/-severe)

Headache

Tingling and Twitching

Weakness

Restless Legs (<60%)Periodic limb movements

Autonomic symptoms(face, bowel (IBS), BP)

Fibromyalgia

Cognitive (fog, stutter, poor STM, word finding)

Panic symptoms

Distortion of reality / perception

AIWSAura

What was said in the 1920’s

“Tea and Coffee Headaches. – In the nervous, and often the

gouty and rheumatic person, the use of tea and coffee will causeviolent headaches. These luxuries of life should be discontinuedfor at least one month. An extra strong cup of black coffee, to besure, will stop the headache for the time being, but only adds fuelto the fire in the long run. We would strongly advise anyone thathas constant or periodical headaches, if he uses either tea orcoffee, and especially coffee, to leave them off entirely for threemonths. It may be the sole cause, and if caused by tea and coffee,there is no possibility of their cure by medicines while youcontinue their use”

Early 20th Century, Virtue’s Household Physician

Caffeine Overuse

“The interaction between

a therapeutic agent

and a susceptible patient”

Caffeine content in drinks12 oz drink mg

Red Bull (8oz) 80

Lucozade 46

Diet coke 46

Dr Pepper 41

Pepsi 38

Diet pepsi 36

Coca cola 34

8 oz drink mg

Coffee 70-135

Tea 40-60

Cocoa 14

Decaf coffee 2-3

Horlicks, Options decaff hot chocolate, sprite etc are caffeine free

Alcohol and Headache

• Which headache type?

• “Hangover”

• Migraine

• Cluster Headache

• Which alcohol type?

• How much do you spend?

• Champagne or Prosecco?

• Mechanism

• ? common pathogenetic mechanism at cortical, or more likely at subcortical/brainstem level

Alcohol or something else?

Probably the alcohol

Probably not the contaminants

• Histamine

• Sulphites

• Tyramine

• Phenols

• Tannins

But foods containing above in greater amounts do not

Food and Headache

Monosodium Glutamate

Tyramine

Food containing nitrites / nitrates

Citrus fruits

MSG

Chinese food

Pringles

Noodles

Flavoured chips

Tyramine

Cheeses

• Cheddar

• Stilton

• Camembert

• Swiss blue

• Gorgonzola

Alcohols

• Vermouth

• Tap beer

Preserved and other foods

• Salami

• Mortadella

• Smoked or pickled fish (lox, caviar)

• Pickled herring

• Caviar

• Sauces (e.g.bouillon, beef broth),

• Soy products,

Nitrites / Nitrates

Cured meats

Onions, pickles,

(Chocolate)

Some medications:

GTN spray (angina)

Isosorbide mononitrate (angina)

Migraine trigger – cause or effect?

Conclusions

• Migraine is common and disabling

• There are a lot of myths about migraine

• Food is a rare trigger for migraine

• Caffeine and alcohol may play a role in migraine

• Migraine may cause a craving for an innocent and falsely accused trigger

• It is hard to trigger a condition that is already switched on