How Diet Affects HeadacheManagement of Headache Triggers

Bridgette Linehan, APRNNeurology Nurse Practioner

Norton Headache and Concussion Center

If I change my diet, will I cure my headaches?

• There is no cure for migraine• However, you can potentially reduce some

headache frequency and severity by avoiding headache triggers

• Discovering and eliminating headache triggers can help adopt a healthy lifestyle with less burden of headaches

Migraine Triggers

If summation of triggers are greater than threshold – a headache happens

Migraine Triggers

• Most frequently reported triggers– Stress– Menstruation– Changes in sleep– Skipping meals– Changes in weather– Diet

• Time from trigger to onset of headache can be up to 72 hours - hard to track

Migraine Triggers

• Can be difficult to track• Sometimes the “perfect storm” of triggers not

just one single item– Explains why sometimes can have a glass of wine

and sometimes not– Weather change + menstruation + sleep

deprivation + glass of wine = migraine– Glass of wine alone = no migraine

Stress

• Stress – When we are stressed, our bodies react physically: Muscles tense and hormones become elevated — two physiological changes that can lead to migraines.

• Coming up soon will discuss some strategies to control stress — and discover other lifestyle changes you can make.

Hormones

• Hormonal changes. Because estrogen and progesterone are such potent migraine triggers, women are nearly three times more likely than men to experience migraines.

• Will be discussed later

Physical Exertion or Abrupt Lifestyle Changes

• Physical exertion or abrupt lifestyle changes. Jumping into an extreme exercise program can cause migraines, as can changing sleep patterns, alternating work shifts, or any other sudden deviation from your normal routine that disrupts or alters your body’s physiology.

Intense Sensory Stimuli

• Intense sensory stimuli. Bright light, loud noises, and strong smells — such as cleaning chemicals, cigarette smoke, raw onions, scented candles

Environmental Factors

• Environmental factors. Some people get migraines when there are changes in the atmosphere: sudden thunderstorms, abrupt changes in altitude or barometric pressure, windstorms, seasonal changes, even increased pollen levels. Others are sensitive to the switch to daylight savings time or travel across time zones.

The Top 10 Diet Related Migraine Triggers

• 1. Tyramine• 2. Alcohol• 3. Leftovers• 4. Nitrates• 5. Tannins• 6. Sulfates• 7. Common Additives• 8. Artificial Sweeteners• 9. Caffeine • 10. Dehydration & Low Blood Sugar

Lower triggers Raise threshold

Ways to reduce headache

Trigger Modification

• Non-modifiable– Genetics– Gender– Weather– Some stressors– Menstruation

(somewhat)– Air pollution

• Modifiable– Lack of sleep– Missing meals– How stress is handled

• Stressors are there, but the way it is handled can be modified

– Foods

Diet and Migraine

• Regular meals• Normalize blood sugar• Reduction in Omega-6 fatty acids– Red meats, fast foods

• Increase in Omega-3 fatty acids– Fish oil

Prehistoric 1900 2000

1:1 4:1 25:1

Omega-6 FA

Omega-3 FA

Changes in fatty acid intake over time

MSG

• Flavor enhancer commonly added to Chinese food, canned vegetables, soups and processed meats

• MSG occurs naturally in ingredients such as hydrolyzed vegetable protein, autolyzed yeast, hydrolyzed yeast, yeast extract, soy extracts, and protein isolate, as well as in tomatoes and cheeses

• The FDA requires that these products be listed on the ingredient panel, the agency does not require the label to also specify that they naturally contain MSG

• Take home message – MSG is hidden in foods

Tyramine

• Here are examples of tyramine-rich foods:– Aged cheese– Beer on tap– Meats that have been fermented or air-dried, such as summer

sausage– Red wine– Sauerkraut– Soy sauce

• Other foods that may contain tyramine include:– Sauces containing fish or shrimp– Miso soup– Yeast extract

Leftovers

• Tyramine content increases over time• Especially if stored improperly• Frequently foods at work / parties• Be careful with airtight containers and proper

refrigeration

Alcohol

• Alone or with congeners (in wine / liquor) can induce headache in certain individuals

• Red wine probably most implicated• Distilled vodka probably least causative• Migraineurs more susceptible to hangover

headaches• Alcohol leads to dehydration– Can trigger migraine

Nitrates and nitrites

• Mostly used as a preservative for added flavor• Have vasodilatory effects on the body• Commonly found in– Hot dogs– Deli meats– Pepperoni– Sausage– Cured, smoked, canned meats

Sulfites

• Sulfites are another type of preservative• Commonly found in most dried fruits

(including prunes, figs, and apricots)• Wine (white and red)• Many processed foods• Check labels carefully to avoid this sneaky

migraine trigger.

Artificial Sweeteners

• Inconsistent reports– As with all of this, depends on the individual

• Aspartame (NutraSweet)• Sucralose• Various others

Caffeine

• Overuse of caffeine can lead to more frequent headaches– Check medicines: Excedrin, Fioricet

• Abrupt withdrawal of caffeine often times leads to more headaches

• Some physicians say zero caffeine, probably around 100mg/day is ok

Caffeine

• Soda 12oz (Regular and sugar-free) • 30–50mg

• Coffee 6oz• 103mg

• Decaffeinated coffee• 6oz=2mg

• Tea• 6oz=30mg

Caffeine

• Starbucks “grande” coffee• 330mg of caffeine

Chocolate

• Frequently reported migraine trigger• Evidence in inconsistent• Some believe that “craving” chocolate is a

premonitory symptom of migraine– ie. headache was inevitable

• Some evidence of blood sugar dip after chocolate causes headache

Missing Meals / Dieting

• Low blood sugar• Fluctuations in blood sugar• Dehydration

Plan of attack

• Frequent, small meals– Normal blood sugar– Avoid dehydration• 2.5 Liters of water per day (about 80oz)

– Elimination diet

Elimination Diet

• Eliminate common triggers from diet– Caffeine, cheese, nuts, chocolate, shellfish,

artificial sweeteners, onions, alcohol, dairy, processed meats

– After elimination from diet (4+ weeks) begin to reinstate items in to diet one at a time• 4 weeks each item and record headache frequency

– If having more headaches, remove this item

7 Healthy Habits to Reduce Migraines

• Eat regularly• Maintain a healthy weight• Quit smoking• Exercise gently but regularly• Practice relaxation• Get enough sleep (yet not too much)• Consider physical therapy along with

acupuncture, biofeedback, or massage

A Quick Eating Out Survival Guide

• Avoid buffets: They may leave food sitting too long or use suspect ingredients.

• Chinese food: Possible triggers are MSG and soy sauce. Japanese food: Possible triggers are soy sauce, tofu, and miso.

• Mexican food: Possible triggers are beans (fava, navy, broad), cheese, sour cream, guacamole, and (in rare instances) tomato-based

Quick Survival Guide

• Restaurants to enjoy include:• High-Quality American: order the chicken (grilled, baked,

roasted, steamed, boiled, or broiled -- request no MSG, vinegar, or citrus juice); vegetables (steamed or sautéed in olive oil and garlic); rice or potatoes, plain (baked, boiled, or roasted),

• Seafood: have any fish (grilled, baked, roasted, steamed, poached, or broiled — request no MSG, vinegar, or citrus juice); vegetables (steamed or sautéed in olive oil and garlic); rice or potatoes, plain (baked, boiled, or roasted),

• Italian: order pasta with broccoli and grilled chicken or seafood tossed in an olive oil–based sauce

Quick Survival Guide

• Desserts:• Treat yourself to strawberries with whipped

cream; rice pudding; or herbal tea with plain biscotti.

• Avoid chocolate, unless you have confirmed that chocolate is not a personal migraine trigger.

• Keep in mind these suggested meals are free from all of the most common migraine triggers.

Quick Survival Guide

• After keeping a migraine diary, you’ll probably find that you are sensitive to only a handful of foods. Once you’ve identified your personal triggers, it will be much easier to order a wide variety of dishes in most ethnic cuisines.

Dietary Supplements

• Coenzyme Q10• Feverfew• Omega fatty acids• Vitamin B2 (Riboflavin)• Magnesium

Coenzyme Q10

• Coenzyme Q10 (CoQ10) is a vitamin-like substance that helps enzymes create energy at the cellular level. Without it, cells can’t work properly.

• Daily dose of 300-400milligrams daily. • Few side effects, can be costly

Feverfew

• Feverfew is a traditional medicinal herb• It relaxing blood vessels and decreasing

inflammation to improve circulation in the brain. • Feverfew is also found in combination with riboflavin

and magnesium in supplements formulated specifically for migraine prevention. Women who are pregnant or trying to become pregnant and individuals taking blood thinners should not take feverfew due to undetermined safety in these populations.

Omega 3 Fatty Acids

• Inconsistent reports on effectiveness in migraine

• Natural anti-inflammatory effects• Reduce Omega-6 FA (fast foods, red meat)• Increase Omega-3 FA (fish or fish oil

supplements)

Riboflavin (B2)

• Mitochondrial defect in migraine leading to impaired oxygen utilization

• Riboflavin used in mitochondria• 200mg twice per day

• May take 3 months to see difference

• Will turn urine yellow

Magnesium

• Blood levels do not adequately measure magnesium stores in the body

• Migraine patients often deficient in magnesium

• Lack of magnesium leads to more hyperexcitability of the brain (more migraine attacks)

Magnesium

• Used IV for severe migraine attacks in hospital or outpatient infusions

• Oral magnesium readily available• At least 400mg per day• Can lead to diarrhea / upset stomach

Take Home Message

• Trigger awareness to change the balance of threshold vs triggers leading to migraine attacks

• Foods may play an important role in trigger management of migraine

• Elimination and slow reintroduction is the best strategy to really identify triggers

• Dietary supplements may improve migraine frequency and severity

Take Home Message

• Remember, there is no cure for migraine• Management is the key to success

• Reduce triggers• Raise threshold• Do not overuse rescue medications

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