Migraine and Diet

Thank you to Rashmi Halker, MD, FAHS; Jessica Ailani, MD, FAHS; Carrie Dougherty, MD, FAHS; and Margaret Slavin, PhD, RD for their contributions to this spotlight!

Nutrition 101

There are some basic concepts of nutrition that will help you to get the most out of the following ‘nutrition and migraine’ topics. Welcome to Nutrition 101!

Foods are composed of nutrients, which are used in the body to perform vital tasks. There are five types of nutrients: carbohydrates, proteins, fats, vitamins and minerals.

Carbohydrates, proteins, and fats share one big function—they provide energy to the body to perform work. In food, energy is measured in calories. Just like your car burns gasoline to drive around town, your body burns carbohydrates, proteins and fats in order to walk, talk, cook dinner, and read this page. To plan a healthy diet, it helps to know which foods contain each:

Carbohydrates are found in foods that you might think about as starchy or sweet. Starchy foods are breads, pastas, breakfast cereals, and crackers, and anything that is made with flour or corn. Sugars are also carbohydrates, and you’ll find lots of sugars in candies, baked goods, non-diet sodas, and fruit drinks. Carbohydrates travel in your blood as blood glucose, and provide a short-term supply of energy.

Fats are found in foods that you perceive as oily, fatty, or greasy. They can be liquid at room temperature, which are called oils: olive oil, vegetable oil, fish oil, and so on. These liquid oils are unsaturated fats and are generally considered to be a heart-healthy type of fat. Fats can also be solid at room temperature, like butter, shortening, and animal fats. These solid fats can be either saturated fats or trans fats, and have negative effects on heart health. Fats can be stored in the body to provide a long-term supply of energy.

Proteins have the honor of providing energy and serving many functions in the body, like forming muscles. Proteins can come from a variety of foods: meats, dairy foods, eggs, fish, beans, nuts and nut butters. Most Americans get more than enough protein. An average American adult needs to eat only five or six ounces of protein foods per day.

The vitamins and minerals help to control the body’s processes, including growth and development, but they do not provide energy. Minerals are elements found on the periodic table of elements, and our bodies have adapted to use them. For example, iron is needed to carry oxygen in our red blood cells, and calcium is the main element in our bones, along with magnesium and phosphorus (also minerals).

Vitamins have a more complex chemical structure than minerals. They have obvious names like Vitamin A, B, and C, and have essential functions in the body. Vitamin C is necessary for wound healing. The B vitamins are crucial for harnessing the energy from carbohydrates, fats and proteins.
The food label is a helpful tool to learn what’s in your food. Check out this link to learn how to use the Nutrition Facts Label.
http://www.fda.gov/downloads/Food/IngredientsPackagingLabeling/LabelingNutrition/UCM410486.pdf

Morning Pickup or Daily Grind?

Caffeine can help treat migraine headaches. Patients often report that coffee or soda helps reduce head pain. Caffeine is also a common ingredient in over-the-counter headache medicines.  Many patients note that medicines with caffeine are more helpful than those without. However, caffeine is a drug, and like many other drugs, it can cause problems when overused. Caffeine can be useful when used infrequently, but using it daily can lead to medication overuse headaches, which are also known as “rebound” headaches. Using more than 100 mg of caffeine (either in medicines or in beverages) daily (about the amount in one 8oz cup of coffee) is a known risk factor for developing daily headache.

Some suggestions for caffeine use in migraine patients:iStock_000073684747_Large-min

  • Episodic migraine patients should limit caffeine intake to one or two beverages daily (or 200mg caffeine).
  • Patients with daily headaches should consider avoiding caffeine completely.
  • Limit use of caffeine containing medications to no more than two days a week.
  • Reduce caffeine intake slowly, by 25% each week, to avoid caffeine withdrawal symptoms.
  • The amount of caffeine in different brands and types of coffee varies widely, from 133mg of caffeine in a large McDonald’s brew to 415mg in a venti Starbucks. The same is true for different medicines. Consider using an online calculator or talking to your doctor when figuring out your daily caffeine use.
  • Caffeine is probably not the only cause of frequent migraines, but reducing caffeine will often help improve headache.

Scher AI, Stewart WF, Lipton RB. Caffeine as a risk factor for chronic daily headache: a population-based study. Neurology. 2004; 63(11):2022-27.
Caffeine Content of Food & Drugs. (November 2014). Retrieved from http://www.cspinet.org/new/cafchart.html on December 7, 2015.

Hunger and Headache

Migraine sufferers often note that missing meals can trigger headache. Long periods of time between meals may trigger migraine attacks, or cause headache to be more severe because of low blood glucose levels. The risk of developing a headache increases with the amount of time between meals. Migraine patients should make time for small frequent meals. Regular daily meal times, in addition to regular sleep schedules and exercise, are associated with less frequent migraines.

Migraine Dietary Triggers

Migraine is a very common problem. It affects about 18% of all women and 6% of all men. Studies have shown migraine is a genetic disorder, however, environment, lifestyle, and diet can still play a large role in how often you get migraines.

HiResCommonly reported migraine triggers include alcohol (especially red wine and beer), chocolate, aged cheese, cured meats, smoked fish, yeast extract, food preservatives that contain nitrates and nitrites, artificial sweeteners, and monosodium glutamate (MSG). There are a few important things to remember about migraine food triggers:

  • Migraine attacks are often due to multiple factors. There are many non-dietary trigger factors for migraine. When you’re already stressed, not sleeping well, and not exercising, eating a food trigger may make it more likely to have a migraine attack. In this case, it is the combination of all of these different things that contribute to the migraine, and not just the one food.
  • Not all of these foods will trigger a migraine attack in every person with migraine. Your personal food triggers can be difficult to figure out.  Here are some suggestions:
  • Keep a food diary along with your headache diary, to help identify what you ate before migraine attacks.
  • Some foods can trigger a headache right away, while with other foods the headache can be delayed up to 24 hours.
  • If you think a specific food is triggering migraine attacks, you may try to avoid that food for a month. Monitor your symptoms to see if they improve.
  • Be careful about trying extremely strict diets. There is a risk of avoiding foods that are not necessarily migraine triggers and you may be missing out on many important nutrients.

Reference:
Sun-Edelstein C and Mauskop A. Foods and supplements in the management of migraine headaches. Clin J Pain 2009;25:446-452.

Healthy Eating for a Healthy Head

The Dietary Guidelines for Americans (DGA) make food recommendations to help you live a healthier life. Some recommendations are:

  • Aim for half of your grains to be whole grains. Whole grains have more fiber and vitamins. Try to change things like white bread, white rice, and pasta in your diet to whole grains.
  • Aim for increasing fruit and vegetable intake. Half your plate should be fruits and vegetables, every time! Eat a variety of vegetables.
  • Aim to eat healthy fats, not low fat. Limit “saturated” and “trans fats” when possible. Try to increase seafood consumption to two to three times per week to get your omega-3 fats.
  • Limit sodium to less than 2300 mg/day. Most salt in our diets comes from processed foods (heat-and-eat frozen meals, canned soups, and ready-to-eat snacks like chips and crackers). Cook “from scratch” whenever possible, or choose foods labeled as “low sodium” whenever possible.

shutterstock_132337193-minIn addition to the basics of a healthy diet, there are a few things to think about if you have migraines:

  • Don’t skip meals, especially if this triggers migraines.
  • Consider eating 5 small meals per day. Eat a carbohydrate with a protein or a good fat to stay full longer.
  • Don’t eat or drink anything that you KNOW triggers your migraine. Some common food “triggers” are alcohol, aged cheeses, caffeine, and chocolate.
  • Drink water through the day instead of sugary drinks like soda or juice.

Reference

U.S. Department of Agriculture and U.S. Department of Health and Human Services Dietary Guidelines for Americans, 2010. 7th edition, Washington, D.C.: U.S. Government Printing Office, December 2010.  http://health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf

Rockett, F. C. et al. Dietary aspects of migraine trigger factors. Nutr. Rev. 70, 337–356 (2012).

Urinary & Kidney Team. What The Color of Your Urine Says About You (Infographic). Health Essentials from Cleveland Clinic. http://health.clevelandclinic.org/2013/10/what-the-color-of-your-urine-says-about-you-infographic/. Accessed November 10, 2015

Dietary Supplements for Migraine Prevention

A majority of patients with migraine have tried using minerals, herbs, and vitamins to treat their headaches. Patients have different reasons for using supplements, including the idea that they are “more natural” or do not require a prescription. Because these complementary and alternative treatments can affect pain pathways and other body functions similar to prescription medications, it is important to be aware of the nature of these supplements, including potential side effects and the quality of evidence supporting their use for migraine prevention.

iStock_000080285009_Large

Riboflavin (vitamin B2)

Riboflavin (vitamin B2) was studied as a migraine preventive in a few small trials and found to be potentially helpful in preventing migraine in adults. However, two pediatric studies with riboflavin did not show any benefit in children. Even though the evidence from clinical trials to use riboflavin isn’t strong, both the American Academy of Neurology (AAN) and the Canadian Headache Society recommend its use in adults with migraine, because it is well tolerated and side effects are very limited and mild. Some people can experience diarrhea or frequent urination, and it’s common to see bright yellow urine. The recommended dose in adults is 400 mg of riboflavin per day, and it can take at least two to three months to see benefit.

Coenzyme Q10 (CoQ10)

Coenzyme Q10 (CoQ10) is an antioxidant important for many basic cell functions, and has been studied in migraine prevention. Based on the available studies, the AAN considers CoQ10 to be possibly helpful in migraine prevention (level C evidence). Even more, the guidelines by the Canadian Headache Society strongly recommend its use despite the low-quality evidence because it is well tolerated. Side effects of CoQ10 are rare, and can include loss of appetite, upset stomach, nausea, and diarrhea. Adults typically use 100 mg three times a day, and while the best dose in children is not clear, one to three mg/kg is frequently suggested. Similar to riboflavin, it can take three months to see benefit.

Magnesium

Magnesium is a mineral that is important for a number of body functions, and binds to specific receptors in the brain involved in migraine. Low brain magnesium has been associated with migraine aura. Studies suggest magnesium supplementation can be helpful for migraine with aura and menstrually-related migraine. Both the AAN and Canadian guidelines recommend its use for migraine prevention, either as oral magnesium citrate 400-600 mg daily or by eating more magnesium rich foods.

Petasites (Butterbur)

Petasites, an herb from the butterbur shrub, has been shown to be helpful in reducing migraine frequency in three randomized, placebo-controlled studies. In these studies, the optimal dose was 150 mg per day and it took three months to see headache improvement. For that reason, it has been deemed effective in preventing migraine by the AAN. However, because of a rare but serious risk of liver toxicity, Petasites has been removed from the market in many European countries and many headache experts in the United States have also stopped recommending its use.

Feverfew

Feverfew is an herb sometimes used in migraine prevention. There have only been a limited number of studies, however, and they have given conflicting results. The AAN guidelines give feverfew a second-line, level B recommendation for migraine prevention, supporting the idea that it is probably helpful. Side effects can include abdominal pain, nausea, vomiting, and diarrhea. Chewing raw feverfew can cause mouth sores, loss of taste, and swelling of the lips, tongue, and mouth. Feverfew can also increase the risk of bleeding, especially in individuals already on blood-thinning medications or aspirin. Feverfew should not be used during pregnancy.

In conclusion, there are many different herbs, vitamins, and minerals that can be helpful in preventing migraine. Regardless of which one is tried, patients must be upfront with their physicians about using such supplements and keep in mind that it can take two to three months of consistent use to see benefit. In addition, women who are pregnant or considering pregnancy should discuss with their physician prior to using any supplements for migraine.

Reference:

Tepper SJ. Neutraceutical and other modalities for the treatment of headache. Continnum 2015;21(4):1018-1031.

The Skinny on Weight Management for Migraine Patients

It’s important to maintain a healthy weight to reduce migraine risk. Being overweight or obese makes it more likely to have migraine or worsening migraine.

To see how your weight measures up, you can learn your body mass index (BMI) by entering your height and weight here:

http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

  • iStock_000004716692_Large-minIf your BMI is between 18.5–24.9, your weight is healthy. You should aim to keep your weight stable. Keep eating a healthy diet and exercising.
  • If your BMI is between 25.0–29.9, you are overweight. If your BMI is 30.0 or above, you are obese, and your migraines may improve if you lose weight. You should aim to lose weight to lower your BMI. You can talk with your doctor about weight loss methods that are best for you.

Many different weight loss plans have helped overweight and obese migraine patients improve their symptoms. These include low-calorie diets and exercise, low carbohydrate diets, and weight loss surgery. Weight loss surgery may be an option if your BMI is greater than 35, depending on your health. Since there is no “best” weight loss method for migraine, you can work with your doctor to find a method that best meets your needs.

Here are a few special weight loss tips if you have migraine:

  • Do not skip meals to lose weight, as this can trigger migraines. You might want to try eating five small meals per day, or adding small snacks between meals, to help you feel fuller through the day.
  • You should drink water through the day. It will help avoid headaches and also help your stomach to feel full.
  • It’s key to have social support when losing weight. Tell your family and friends why you’re trying to lose weight and ask for their support. Try to find a “weight loss buddy” to share your experiences.

Jahromi SR, Abolhasani M, Meysamie A, Togha M. The effect of body fat mass and fat free mass on migraine headache. Iran J Neurol. 2013;12(1):23.

Leidy HJ, Campbell WW. The Effect of Eating Frequency on Appetite Control and Food Intake: Brief Synopsis of Controlled Feeding Studies. J Nutr. 2011;141(1):154-157. doi:10.3945/jn.109.114389.

National Heart Lung and Blood Institute, National Institutes of Health. Calculate your Body Mass Index. http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.html

Ornello, R. et al. Migraine and body mass index categories: a systematic review and meta-analysis of observational studies. J. Headache Pain 16, (2015).

Verrotti A, Agostinelli S, D’Egidio C, et al. Impact of a weight loss program on migraine in obese adolescents. Eur J Neurol. 2013;20(2):394-397. doi:10.1111/j.1468-1331.2012.03771.x.

Eliminating the Elimination Diet

While many people feel that certain foods can cause their migraines, the proof that a special diet can stop migraines is not very strong. Diets that take out specific foods, also known as elimination diets, have been looked at in children and adults who have migraine. There is a suggestion that diet eliminations may help children who have migraines, but the same is not true in adults.  Even with little proof, many people will suggest that eating a simple, bland diet will stop migraines from happening.

Rigid diets, especially those that eliminate numerous food items, have very little to support their use in preventing migraines. Because of this, doctors will usually recommend other methods with better evidence to reduce migraine frequency. If those other methods cannot be used, elimination diets can be considered under medical supervision as part of a comprehensive approach to identify and reduce migraine triggers. These diets should only be attempted with medical and nutritional support to ensure you are getting adequate nutrition and prevent side effects.

Egger J, Carter CM, Wilson J, et al.  Is migraine food allergy? A double-blind controlled trial of oligoantigenic diet treatment.  Lancet 1983;2:865-869.

Bunner AE, Agarwal U, Gonzales JF, et al.  Nutrition intervention in migraine: a randomized cross-over trial.  The Journal of headache and pain.  2014;15:69