Fredrick R. Taylor, MD

  1. Nearly everyone believes their headaches have one or more causes or triggers.
  2. Managing triggers is widely recommended.
  3. Trigger coping may be better than an emphasis on avoidance.
  4. The A through G of headache management balance these concerns.

Introduction to Headache Triggers

We all want our headaches to have a defined cause. Even more so, a cause we can avoid. Most often the cause is found in a good family history. The actual cause involves our genes, while any given headache has one or more possible triggers. When in acute pain, we think about what triggered it. We normally connect the pain to the closest negative event. This may be a bad night’s sleep, stress from that next test, a menstrual period, or a weather front moving through. We, in conjunction with our health care providers, want to find the triggers so we can avoid them. Too often everyone thinks: “remove the “cause” and stop the attacks.” Sometimes, we go to the Internet to learn about the “cause.” We may obtain lists of “known” triggers for headache. The lists are endless, and this process is a problem when there is little to no truth to the trigger. Many “known” triggers have no proof.

Creating trigger lists

An early study on triggers involved a newspaper ad and questionnaire. It asked 500 “food-sensitive” migraineurs to report on food and headache beliefs. Seventy-five percent of responders reported chocolate as a trigger, nearly fifty percent cheese, less than one in three citrus, and alcoholic drinks by twenty-five percent. For providers, food sensitivity or allergy became a significant belief following a study in which patients were placed on a minimal diet of lamb, pears and spring water. After five days, one to three foods believed by the patient to trigger headaches were added back and a very large list of physical symptoms were surveyed and headache assessed.

With elimination on average of ten foods believed by the patient to cause headache 85% of subjects reported being headache free. The study reported food as an allergen for and significant cause of headache. The method of the study severely limited any ability to reach a valid answer. Patients added back foods believed to cause headache. No one was blinded or unaware of the process or results. Follow-up was limited or at least never listed. The study was invalid due to withdrawal of overused medications, smoking, oral contraceptives and other important factors triggering headache. However, foods became known as a major trigger of headache. In an effort to solve headache, food elimination diets were off and running. Books, the internet, and other promoters keep food elimination alive and well today. Even an ACHE website article was written on this topic.

Recent studies on patient triggers exist, and the recorded triggers are a collection of patient beliefs. The trigger list closely follows those listed in the introduction above. The most common triggers are sleep changes, stresses in everyday life, menstrual periods for women, changes in weather and travel. It turns out that research has not consistently found food to be a common, predictable or proven headache trigger.

Trigger avoidance or trigger coping

The World Health Organization states good headache management requires “identification of predisposing and/or trigger factors and their avoidance through appropriate lifestyle change.” Despite this, avoiding a trigger may not be possible. An example is the weather. Select studies suggest that headache triggers act to produce an anxiety response. With infrequent, short-duration exposure, a trigger increases the pain response. With regular and prolonged exposure, something different occurs. The pain response to the anxiety promoting trigger decreases over time.

Based on this science, patients and providers need to manage triggers in several ways. One approach is to control exposure with a “learning to cope with the trigger.” This style of trigger management rather than avoidance leads to successful headache management for many. This “learn to cope strategy” may be best for all but those impossible to manage in this manner. The ABCs of triggers combines these steps.

ABC’s through “G” of headache management

The ABC concept derives from important steps in cardiac resuscitation. Consider these our critical steps in preventing or recovering from disabling headache. While the A in this list is priority number one, the other letters are each important, but requires each of us to prioritize what fits our life. This list is set up to help us remember. We need information to know what to manage. We should then label or rank what is most important for our success. Put another way, what can we start and continue for success? What matters most is that we think about the ABCs, rank their importance, and then act on one and then another.

A—for assessing sleep

Sleep is our most important priority to control pain. Inability to sleep is known as insomnia. Inability to fall asleep is very common, and not being able to fall asleep is often due to a racing mind. This is often referred to as sleep-onset insomnia. This results from an inability to let our mind relax. We fail to let today’s thoughts and tomorrow’s concerns rest on a tablet on the vanity overnight. Instead, they rumble about in our head causing trouble. This trouble includes tomorrow’s headache, especially with less than six and more than nine hours of sleep.

Inability to maintain sleep has additional causes and is more complex than one might think. The ability to return to sleep immediately after going to the bathroom during the night is normal. Having to check on young “sleeping” kids in the middle of the night is not normal. Anxiety is a very critical factor in all types of insomnia. Snoring may be one factor causing sleep difficulty. Our snoring partner may disturb an hour on average of sleep. Or, it may be our own breathing habit.

A formal sleep assessment is warranted when headaches are frequently present on awakening that resolve after getting up. If waking in the morning not feeling refreshed or restored is a problem, than a sleep study may well be worthwhile. If dozing often during the day is a problem, get on the Internet and take the Epworth Sleepiness Scale test. Always try to allow ideally eight hours of sleep or more based on younger age. If sleep fails to improve over time, make this an even bigger priority seek help. See achenet.org including another article in this edition for additional information. The commandment or mantra is: sleep restores health.

B—for biofeedback, breath work and behaviors

We must lead for best success. Be a best cheerleader, collect a team, then cheer and lead the team to forever fewer headaches. Behaviors matter, and thoughts in our head change results. Later parts of this ABC list are loaded with options for behaviors. Specific efforts at biofeedback, deep breathing, cognitive-behavioral therapy (CBT), guided imagery, meditation, progressive relaxation, tai chi, yoga are considered a short list. Talk with a health care provider to learn more. More and more health care systems have an Integrative Health Care team. If none is available seek benefit from such an approach, perhaps from a headache specialist.

C—for chemicals and caffeine

Caffeine is put into medication because it can help headache, however, regular caffeine use can cause headache. Only 100mg caffeine daily increases possible daily headache by three fold. There are other chemicals that can cause headache, although proof for triggering migraine is often lacking. Aspartame is a known trigger and it may lead to daily headache. MSG causes Chinese restaurant syndrome headache. Nitrates and nitrites cause hot dog headache. There is a lesson here: the susceptible brain may find some dose of chemical okay, but another dose a problem, and any substance of benefit can also harm. Some chemicals aren’t ever helpful. Manage letter “C” by a combination of reduce, cope and avoid. See letter “F” for more details. The key in all things is moderation.

D—for diet

When food is eaten may matter more to headache than what is eaten. Avoid hunger and delays or skips in meals. Eat small, frequent amounts, and control appetite and waist management.

What you eat matters to your waist. The larger this gets beyond normal, the more likely headache will follow headache. Don’t eat junk food. Don’t use processed foods with long lists of difficult to understand ingredients. Eat as many fresh foods of all kinds as possible. Think a rainbow of colors.

E—for exercise

Exercise for good health and fewer headaches. Five to six days a week is ideal, but a few days are better than none. Exercise refers to a heart rate at 50-65% of maximum (our heart rate maximum is 205 minus half our age). For aerobic heart rate, take this number and multiple by 50-65%. Set this as the goal.

Talking in full sentences is another way to measure this level of activity. Any difficulty with your breath or heart rate higher than this is not necessary for heart, brain, mind and spirit health. Days per week and time spent are equally important for a headache sufferer. Exercise intensity beyond the goal heart rate is not necessary. Aerobic level activity leads to an increase in natural body joy and pain control chemicals. These natural opioids are reduced by chronic pain and narcotic use. Exercise to fight headache triggers such as anxiety, poor sleep, sadness, stress, and waist and weight gain.

Non-exercise is generally any activity like walking that is done as part of a normal day. Any movement is better than none. Standing is better than sitting to manage the waist.

F—for fluids

Fluids prevent dehydration, and dehydration is a risk for headache. Certain drugs increase the risk for kidney stones, and are best prevented by lots of fluids. Eight, eight-ounce glasses per day are a good start. The ideal drink is water. For waist management, avoid sugared water and remember to avoid diet products. These might trigger headache. Recent data suggests they also might increase risk for stroke and heart attack. Migraine with aura may make it very important to avoid these to reduce risk. Remember letter “C” and don’t increase coffee.

G—for groups

Healthy groups reduce loneliness and stress. Connection to other people is critical for health, and the most important connections are family. Repair of family relations can be critical, as loneliness is associated with poor health. Numerous studies define the need for a support network. Being alone does not mean being lonely. However, being in a group without support is like being alone and lonely. Seek a good social support network and actively participate in it. For peace of mind, body and spirit make family ties a priority.

H—for habits and happiness

When able to act regularly on and make A, B, C, D, E, F, G work, habits may develop for a lifetime of happiness.

Summary
Go ahead and identify real headache triggers. Then set a plan in motion to manage them, use knowledge of A–G. By use of A–G, we can control and “learn to cope” with any headache trigger.

Frederick R. Taylor, MD, ACHE Newsletter Editor, Director of the Park Nicollet Headache Center and Adjunct Professor of Neurology, University of Minnesota School of Medicine, Minneapolis, MN.