THE ROLE OF DIET IN MIGRAINE HEADACHES
by J. Gordon Millichap, MD, FRCP, Pediatric Neurologist, Children's Memorial Hospital, Northwestern University Medical Center, Chicago, Illinois; NOHA Professional Advisory Board Member.
Migraine headaches are a common neurological disorder, and studies show that their prevalence has increased in the last twenty years, especially in children. The cause of the increase in prevalence is not known. The stress of a more hectic and competitive life-style is postulated as a factor, but changes in dietary habits may be equally responsible. Other factors known to precipitate headaches in migraine-susceptible persons (migraineurs) include fatigue, exercise, sleep deprivation, bright lights, head trauma, infection, menstruation, and oral contraceptives. A predisposition to migraine headaches has a neuro-vascular and neurochemical mechanism, and the disorder is frequently inherited. The dietary factors known to activate the headache mechanism are called "migraine triggers."
Foods and beverages that may trigger migraine attacks
Patients with migraine may be abnormally sensitive to one or more of these dietary items, a disorder sometimes described as a chemical idiosyncrasy or food intolerance. A true food allergy with positive skin testing is uncommon. The chemicals contained in foods that are responsible for the headache triggering effect are chiefly tyramine and other amines, including phenylethylamine and histamine. Tyramine is found in cheese, especially aged, strong and cheddar varieties, phenylethylamine in chocolate, octopamine in citrus fruits, and histamine in red wine and beers. Caffeine addiction and withdrawal, common among consumers of excess coffee, can be associated with severe throbbing headache and migraine exacerbation. Fasting or skipping meals is also a common reason for headache recurrence in migraine sufferers.
Other foods known to be associated with tyramine and migraine include beer, wine, pickled herring, chicken liver, yeast, coffee, broad bean pods, citrus, and canned figs. Patients with depression treated with MAO inhibitors should be given a list of foods to be avoided, especially if they also have a predisposition to migraine.
Although parental reports indicate a frequent association between chocolate and migraine in children, controlled studies sometimes fail to confirm a trigger effect. A subgroup of migraine patients may be sensitive to chocolate.
When caffeine intake is interrupted, the blood vessels dilate, and the increase in cerebral blood flow results in headache. Patients sometimes need to be hospitalized to manage a serious addiction and dependency resulting from chronic caffeine overuse.
Alcoholic beverages and migraine
Only a particular variety of grape is responsible in some patients, and young and cheaper varieties are often less well tolerated than aged and more expensive vintages. In some countries, the problem of wine-induced headache has been so widespread at times that vintners have been forced to curtail the production of red wine in favor of white, which is better tolerated by some consumers. Grapes organically grown and wines free of sulfites are thought by some to be less likely to trigger headaches.
A chemical effect on cranial blood vessels by some ingredient in certain alcoholic beverages is the most plausible explanation for the migraine response. Stress may act as a secondary trigger mechanism in some situations. A migraineur exposed to a stressful and tiring work environment may complain of an inability to tolerate wine, whereas the same person on a relaxing vacation may drink and enjoy the same wine without suffering headaches. Migraine is not primarily a psychogenic illness, but stress and fatigue are common precipitants of attacks.
Nitrates, Nitrites, and "Hot Dog" headache
Fruits, milk, bread, and water are relatively small sources of the nitrate intake, in normal circumstances. Nitrites are formed by the reduction of nitrates in the saliva or by bacterial action in the intestine. The vasodilator effect of nitrites is responsible for the hot dog headache and flushing of the face and neck commonly associated.
The addition of nitrite to meats has three purposes:
In addition to the occurrence of headache, nitrites can cause methemaglobinemia (low oxygen in the blood), which imparts a slate gray cyanotic color to the skin; and they may act on amines in the diet to form nitrosamines, which are carcinogenic. High levels of nitrate in the well waters of regions of Columbia and in two village communities in rural England, where the incidence of stomach cancer was abnormally high, have been linked to the use of sodium nitrate fertilizer.
Nitrates and nitrites may be limited in the diet by reducing the intake of cured meats such as hot dogs and salami and by checking well water for nitrate contamination.
The number and scientific standard of these studies reported in the medical literature confirm the role of aspartame as a significant trigger of headaches in migraineurs, and emphasize the need to caution patients regarding the potential adverse effect of this ubiquitous sugar substitute.
Fatty foods and migraine
In a study of the influence of low-fat diet on the incidence and severity of migraine headaches in 54 patients at the University of California, Irvine, CA (Bic, Z., et al., Journal of Womens Health & Gender-Based Medicine,8:623-30,1999), a decrease in dietary fat to a maximum of 20 grams per day was associated with a significant decrease in headache frequency, intensity, and duration (p<.0001: probability less than one in ten thousand that the observed difference in headaches would occur by chance).
Paradoxically, certain fish oils containing high quantities of omega-3 fatty acids, as in cod and salmon, have been found to prevent migraine attacks in certain patients. These fatty acids are thought to have a stabilizing effect on nerve cell membranes, making them more resistant to the migraine mechanism.
"Ice cream" headache
Food allergy and migraine
The elimination diet consists of one meat (lamb or chicken), one carbohydrate (rice or potato), one fruit (banana or apple), one vegetable (brassica), water, and vitamin supplements. Of the 82 patients who improved on the diet, all but eight relapsed on reintroduction of one or more foods, including chocolate. Fifty-five different foods provoked symptoms on reintroduction. A remarkable fondness for migraine-provoking foods was a common finding, some patients craving them and eating them in large amounts. Cow's milk and cheese caused headaches in most of the patients in the study, but none complained of headaches after substituting goat's-milk cheese.
Unfortunately, the susceptibility to diet-triggered headaches is not consistently confirmed by reactivity to the food, skin-prick tests, and immune globulin antibody titers, and diagnosis by the elimination diet is quite demanding. The reported relationship between food allergy and migraine is difficult to prove, and the concept remains controversial. Many neurologists and allergists are skeptical of the use of restrictive diets in treatment, and a universal migraine- food elimination diet is discouraged in practice. Specific headache triggers should be identified by carefully completed headache calendars.
Monosodium glutamate. The Chinese Restaurant Syndrome
MSG is a flavor enhancer. It is found in frozen foods, canned soups, salad dressings, processed meats, sauces and snack foods. Patients with migraine may have an exacerbation of headaches after ingesting MSG, because of its effects on cranial blood vessels.
"Hunger" and hypoglycemic headaches
Altered levels of serotonin and norepinephrine and dilation of blood vessels around the brain and scalp are the probable mechanisms of hunger-triggered headaches. Following the ingestion of an excessive carbohydrate load, a vascular headache may also occur in response to a rapid insulin secretion and reactive lowering of blood sugar.
To avoid these sugar intolerance, hypoglycemic triggers, migraine sufferers should eat three well balanced meals a day and avoid an overabundance of carbohydrate foods at any single meal. Breakfast should not be neglected, especially in children.
Nonmedication therapeutic techniques in migraine
In addition to diet, alternatives or complements to drug treatments include biofeedback, visualization/imagery and hypnotherapy, muscle relaxation, stretching exercises, aerobic activities, trigger point compression, cold packs or a heating pad, electrical stimulation, massage, acupuncture, manipulation, and psychotherapy. Magnesium and riboflavin vitamin supplements can be beneficial, and feverfew is one of the herbal remedies that is sometimes recommended by practitioners of alternative medicine.
The therapy of migraine is multifaceted and involves treatment of the individual as a whole (physical, nutritional, emotional, and spiritual, or "holistic" therapy) as well as the counseling of family members. Prevention of headaches by careful attention to known migraine triggers is preferable to frequent administration of pain-relieving drugs. Unfortunately, the nutritional and dietary aspects of migraine management are most frequently neglected in favor of potentially toxic medications.
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Article from NOHA NEWS, Vol. XXVII, No. 3, Summer 2002, pages 3-6.