The Role of Diet and Nutrition in Migraine Triggers and Treatment

A Systematic Literature Review

Nada Ahmad Hindiyeh, MD; Niushen Zhang, MD; Mallory Farrar, PharmD; Pixy Banerjee, MPharm; Louise Lombard, MNutr; Sheena K. Aurora, MD

Disclosures

Headache. 2020;60(7):1300-1316. 

In This Article

Abstract and Introduction

Abstract

Background: Migraine is a disabling primary headache disorder often associated with triggers. Diet-related triggers are a common cause of migraine and certain diets have been reported to decrease the frequency of migraine attacks if dietary triggers or patterns are adjusted.

Objective: The systematic literature review was conducted to qualitatively summarize evidence from the published literature regarding the role of diet patterns, diet-related triggers, and diet interventions in people with migraine.

Methods: A literature search was carried out on diet patterns, diet-related triggers, and diet interventions used to treat and/or prevent migraine attacks, using an a priori protocol. MEDLINE and EMBASE databases were searched to identify studies assessing the effect of diet, food, and nutrition in people with migraine aged ≥18 years. Only primary literature sources (randomized controlled trials or observational studies) were included and searches were conducted from January 2000 to March 2019. The NICE checklist was used to assess the quality of the included studies of randomized controlled trials and the Downs and Black checklist was used for the assessment of observational studies.

Results: A total of 43 studies were included in this review, of which 11 assessed diet patterns, 12 assessed diet interventions, and 20 assessed diet-related triggers. The overall quality of evidence was low, as most of the (68%) studies assessing diet patterns and diet-related triggers were cross-sectional studies or patient surveys. The studies regarding diet interventions assessed a variety of diets, such as ketogenic diet, elimination diets, and low-fat diets. Alcohol and caffeine uses were the most common diet patterns and diet-related triggers associated with increased frequency of migraine attacks. Most of the diet interventions, such as low-fat and elimination diets, were related to a decrease in the frequency of migraine attacks.

Conclusions: There is limited high-quality randomized controlled trial data on diet patterns or diet-related triggers. A few small randomized controlled trials have assessed diet interventions in preventing migraine attacks without strong results. Although many patients already reported avoiding personal diet-related triggers in their migraine management, high-quality research is needed to confirm the effect of diet in people with migraine.

Introduction

Migraine is a disabling primary headache disorder with 2 major subtypes: migraine without aura and migraine with aura.[1] The clinical presentation of a migraine attack varies widely among patients, including the intensity of pain and the pattern of associated symptoms, such as photophobia, phonophobia, osmophobia, nausea, vomiting and movement sensitivity.[2] Migraine is associated with a number of comorbidities, including psychiatric disorders (eg, depression and anxiety), sleep disorders, fatigue, cardiovascular risk factors (eg, hypertension, diabetes, high cholesterol, and obesity), and cardiovascular and cerebrovascular diseases.[3–5]

While the pathophysiology of migraine is not completely understood, evidence suggests that dietary factors may play a role in several possible mechanisms. Diet may have an effect on the modulation of neuropeptides, neuroreceptors and ion channels, sympathetic nervous system and cerebral glucose metabolism, and/or by causing inflammation, release of nitric oxide, and vasodilation.[6]

Certain foods, such as chocolate, caffeine, milk, cheese and alcoholic beverages, have been identified as common triggers of migraine attacks.[7–9] Hoffmann and Recober (2013) stated in their review that foods and drinks are the most commonly reported triggers for migraine and these often include chocolate, cheese, nuts, citrus fruits, processed meats, monosodium glutamate, aspartame, fatty foods, coffee, and alcohol.[10] A systematic review revealed fasting and alcohol as triggers in 44% and 27% of people with migraine, respectively.[11] Patients with triggers have been reported to be more prone to have a functional disability compared to those without trigger (2.41 ± 0.68 vs 2.04 ± 0.72, on a 0–4 scale, with a higher score indicating higher impairment, P = .03). The number of triggers also correlates with functional disability in people with migraine, with an increase in the number of triggers leading to higher disability (r = 0.23, P = .002).[12]

Despite not being part of the current diagnostic criteria for headache disorders, triggers form an important component in the characterization of the migraine phenotypes.[13] There is often difficulty in reliably identifying migraine triggers. Studies have aimed at identifying triggers in people with migraine using natural experimentation, which involves the covariation assessment of presence or absence of triggers with headache attacks, and formal experimentation or diary studies which use advanced statistical modeling techniques.[14,15] Paper diaries have been included traditionally, and although electronic diaries may reduce recall bias and improve compliance, only a few headache diary studies have used smartphones or handheld devices to evaluate the association between triggers and migraine attacks.[14]

Limited evidence suggests that different kinds of diet interventions may offer a promising approach in the management of migraine. Diet interventions, such as high folate diet, low-fat diet, high omega-3, and low omega-6 fatty acid diets, ketogenic diet, Atkins diet, and low sodium diet, have been reported to reduce migraine attacks.[6,16] Therefore, it is important to increase the awareness of existing evidence to aid the optimal use of dietary interventions in the management of migraine.

The aim of the present systematic literature review was to qualitatively summarize data from randomized controlled trials (RCTs) or observational studies on the role of diet patterns, diet-related triggers, and dietary interventions in adults with migraine. Evidence from published literature on the correlation or association of dietary patterns with migraine, the effect of diet as triggers, and the effect of diet interventions on migraine-related outcomes (frequency, intensity, duration, and pain) were assessed in efforts to aid providers in integrating dietary considerations in the migraine management.

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