Migraine-Diet Connection: Dietary Triggers and Interventions for Migraine Management

Dietary intake may precipitate migraine attacks, with up to 60% of patients reporting exacerbations following consumption of specific foods and beverages. Chocolate, coffee, cheese, and alcohol are among the most commonly identified migraine triggers across various studies, and many patients identify multiple food-based triggers.1

More broadly, there has been growing interest in the role of dietary patterns in the pathogenesis of migraine and associated implications for potential dietary interventions. For example, multiple studies have found improvement in patients who followed diets in which commonly cited migraine triggers were eliminated.1 In a 2018 study, 50 individuals with migraine without aura who had reported migraine occurrence following the intake of certain foods were randomized to 1 of 2 groups in which the specified foods were excluded from their diet for 2 months. After the second month, group 1 relaxed the diet restriction while group 2 continued.2

At month 2, both groups showed significant reductions in the frequency, duration, and severity of migraine attacks (via visual analogue scale) compared to baseline [group 1 (P =.011, P =.041, and P =.003, respectively) and group 2 (P =.015, P =.037, and P =.003, respectively)]. These reductions persisted at month 4 in group 2 only.

“The results of the study reveal that if migraine-triggering foods are identified by migraine patients, restricting their intake can be an effective and reliable method to reduce migraine attacks,” the researchers concluded.2


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A range of other diets have demonstrated favorable results in numerous studies. A small prospective study (n=18) revealed reductions in the mean frequency and duration of migraine attacks after 1 month of adherence to a ketogenic diet compared to a regular diet (all P <.001), while patients with high adherence to the DASH (dietary approaches to stop hypertension) diet reported lower headache severity compared to those with low adherence in a cross-sectional study of 266 patients.1

While some research has found migraine improvement with low-fat diets, diets high in omega-3 fatty acids have garnered increasing evidence of benefit in this patient population, suggesting that the type of fat (saturated vs unsaturated) may be more relevant than overall fat consumption.1

In a randomized, modified double-blind controlled trial published in 2021 in BMJ (n =182), diets with increased consumption of fish high in omega-3 fatty acids, especially with a concomitant reduction in omega-6 fatty acids (as found in vegetable oils), led to reductions in headache frequency and severity and “altered blood levels of bioactive oxylipins implicated in headache pathogenesis in a manner consistent with a lowered nociceptive state,” according to the research.3

The diet that only increased omega-3 fatty acids led to 2 fewer headache days per month (95% CI, -3.3 to -0.7, respectively), while the diet that also reduced omega-6 fatty acids led to 4 fewer headache days per month (95% CI, −5.2 to −2.7).3 These results align with those of previous research showing a link between increased intake of omega-3 fatty acids and reductions in migraine prevalence and severity.1

The role of immunoglobulin G (IgG) antibodies in dietary migraine triggers is an increasing area of interest in the field, with recent findings indicating that patients with IgG antibodies may be particularly vulnerable to the effects of dietary components on migraine.4,5

In a cross-sectional study published in August 2021 in the Journal of Pain Research (n=89) patients with 1 or more food-specific IgG antibodies ≥50 U/mL demonstrated greater migraine frequency and severity and higher levels of interleukin-6 and tumor necrosis factor alpha compared to those who were IgG-negative. Patients with multiple food allergies generally experienced worse outcomes than those with fewer allergies.4

Significant positive associations were noted between IgG concentrations and Migraine Disability Assessment questionnaire (MIDAS) scores (P <0.0001) and number of days with a migraine in the previous 12 and 4 weeks (P <.0001 and P =.0001).4

A 2019 review concluded that IgG food sensitivity testing may be valuable in helping clinicians develop tailored dietary recommendations for migraine patients and could possibly lead reductions in medication use.5

While these studies point to a role for diet as a “disease-modifying agent” in migraine management, the quality of evidence in this area is highly heterogeneous due to variations in study methods and quality.6 High-quality longitudinal studies are needed to confirm associations between dietary triggers and migraine.1

For a more in-depth look at the migraine-diet connection, we interviewed Lauren R. Natbony, MD, assistant clinical professor of neurology in the division of headache and facial pain at the Icahn School of Medicine at Mount Sinai in New York.

What does the current literature suggest about the link between nutrition and dietary patterns in migraine?

There are many common and widespread suggestions for dietary interventions for migraine, but there has not been sufficient scientific evidence for any major medical organization to recommend a specific dietary intervention for migraine. However, based on the current literature, there are some diets that do show benefit for migraine and should be considered in certain patient populations.

A recent review [published in Nutrients] reported beneficial effects associated with ketogenic, modified Atkins, low-fat, and high omega-3/low omega-6 diets.6

What are some of the proposed mechanisms potentially driving the migraine-diet link?

In general, there are 5 categories of possible mechanisms of dietary triggers to headache disorders: effects on neuropeptides, neuroreceptors, and ion channels; inflammation; cortical effect; vascular effect; and activation of the sympathetic nervous system.7

Of the diets mentioned above, the proposed mechanisms of each are as follows:

It has been suggested that ketogenic and modified Atkins diets may promote neuroprotection and improve mitochondrial function, compensate for serotoninergic dysfunction, decrease levels of calcitonin gene-related peptide (CGRP) and suppress neuroinflammation.6

A low-fat diet has been proposed to lower the inflammatory state.6

A balance between omega-6 and omega-3 fatty acid intake has been proposed to reduce inflammatory responses, improve platelet function, and regulate vascular tone.6 

What are the implications for clinicians when giving advice to patients about diet and nutrition for migraine management?

The main takeaway for clinicians is that there is no one-size-fits-all diet and nutrition plan for migraine. The focus should initially be placed on keeping a general dietary account; maintaining a general food diary with simultaneous inputs of headache attacks is the first step that clinicians should recommend to patients seeking a nutritional evaluation for headache correlation.

Through this method, patterns arise that may point to particular food triggers for headache attacks. If headache attacks do occur in relation to specific food intake, then further in-depth diary accounts should be made, such as noting particular ingredients. 

If no trigger is identified, specific diets can be considered based on comorbidities. For patients with no comorbidities, the diets with the most evidence include a high omega-3/low omega-6 diet, a low-fat diet, a ketogenic/modified Atkins diet and an elimination diet of IgG positive foods. Physicians can consider recommending these diets for a specific duration to monitor for benefit.

Is there any potential role for dietary supplements in migraine management?

Dietary supplements do play a role in the prevention of migraine and have supporting evidence. The following supplements have been studied and found to be effective in the prevention of migraine regardless of dietary intake: magnesium, riboflavin, and coenzyme Q10.6

Folate may be recommended in patients with migraine with aura. It has been proposed that a polymorphism in methylenetetrahydrofolate reductase (MTHFR) may result in increased homocysteine leading to an increased risk of migraine with aura.6

Probiotics have been suggested to correct gut dysbiosis in migraine patients. However, further studies are needed before a formal recommendation can be made.6

More recent studies have demonstrated the benefit of vitamin D in migraine. It is proposed that vitamin D might exert some of its effect through lowering CGRP levels.8 Thus, adding vitamin D supplementation is reasonable.

What are the remaining needs in migraine and diet in terms of patient education and research?

Physicians need to approach dietary recommendations on an individual basis and consider the burden of various diets for patients and if any potential side effects or safety issues may occur. Patients also need to be educated on the role of diet in migraine management and that it is only one tool that may or may not be beneficial. Thus, a focus should be placed on maintenance of a consistent healthy lifestyle, in addition to nonpharmacologic and pharmacologic management of migraines.

Well-designed, systematic, and mechanism-driven dietary research is needed to provide evidence-based dietary recommendations specific for migraine. More specifically, I feel that the gut-brain axis and the role of modulation of the gut microbiota (with probiotics, diet, etc.) is an area that needs to be further explored. 

References

1. Hindiyeh NA, Zhang N, Farrar M, Banerjee P, Lombard L, Aurora SK. The role of diet and nutrition in migraine triggers and treatment: a systematic literature review. Headache. Published online May 25, 2020. doi:10.1111/head.13836

2. Özön AÖ, Karadaş Ö, Özge A. Efficacy of diet restriction on migraines. Noro Psikiyatr Ars. Published online September 20, 2016. doi:10.5152/npa.2016.15961

3. Ramsden CE, Zamora D, Faurot KR, et al. Dietary alteration of n-3 and n-6 fatty acids for headache reduction in adults with migraine: randomized controlled trial. BMJ. Published online July 1, 2021. doi:10.1136/bmj.n1448

4.  Zhao Z, Jin H, Yin Y, et al. Association of migraine with its comorbidities and food specific immunoglobulin G antibodies and inflammatory cytokines: cross-sectional clinical research. J Pain Res. Published online August 5, 2021. doi:10.2147/JPR.S316619

5. Geiselman JF. The clinical use of IgG food sensitivity testing with migraine headache patients: a literature review. Curr Pain Headache Rep. August 27, 2019. doi:10.1007/s11916-019-0819-4

6.  Gazerani P. Migraine and diet. Nutrients. Published online June 3, 2020. doi:10.3390/nu12061658

7.  Papetti L, Moavero R, Ferilli MAN, et al. Truths and myths in pediatric migraine and nutrition. Nutrients. Published online August 6, 2021. doi:10.3390/nu13082714

8.  Ghorbani Z, Rafiee P, Fotouhi A, et al. The effects of vitamin D supplementation on interictal serum levels of calcitonin gene-related peptide (CGRP) in episodic migraine patients: post hoc analysis of a randomized double-blind placebo-controlled trial. J Headache Pain. Published online February 24, 2020. doi: 10.1186/s10194-020-01090-w

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