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

Discussion

In this systematic literature review for the effect of diet on migraine, limited high-quality evidence was found. Evidence regarding the effect of general diet patterns in people with migraine varied in the studies identified. One study reported no unfavorable impact of any nutritional factor;[21] whereas a few studies observed an association between eating behaviors and a reduction in headache occurrence.[23,25] Some studies suggest that there may be a relationship between meal timing and migraine attacks. A study identified in this review showed that night time snacking and eating a late dinner could reduce the odds of headache.[22] Although the data quality was generally low to medium, these studies suggest that maintaining steady glucose levels by eating more frequent, small meals and snacks could be a strategy that might prevent headaches triggered by fasting.[62]

Earlier reviews have mentioned that about 12% to 60% of subjects in different studies have reported foods as trigger for migraine, with many subjects reporting more than 1 dietary trigger.[63] Avoiding triggers is a general recommendation to people with migraine; however, there is a lack of scientific evidence to support this therapeutic recommendation. Several studies identified in this review suggest that diets containing less fried foods, dairy products, caffeine, and processed foods, such as white bread and processed meat, may be beneficial in reducing migraine symptoms or frequency.[24,28–30] Diets high in fats, carbohydrates or caffeine cause activation of the sympathetic nervous system or parasympathetic withdrawal, which might contribute to the precipitation of migraine.[64]

Alcohol consumption had conflicting associations with migraine.[14,27,36] Alcohol was one of the most frequently reported triggers identified in this review[14,32] and in a vast majority of prior studies.[65] However, some studies also reported an inverse correlation between alcohol consumption and risk of migraine.[21,27] The inconsistent findings suggest that some individuals or people from specific cultures may be more susceptible to alcoholic triggers. The inconsistencies may also be attributable to the fact that people with migraine have generally limited their intake of alcohol because they know it is a trigger. People with migraine may benefit from limiting alcohol, particularly red wine, if this is identified as a trigger for an individual.

Overall, many patients reported multiple dietary triggers and relatively inconsistent associations were observed, which suggest some dietary factors may not precipitate a migraine attack in isolation or that the association between food and migraine attacks is multifactorial and complex. The lifetime benefit would be substantial in people with migraine if an understanding of their own triggers leads to even a small effect on the severity, duration or frequency of attacks. The usage of migraine diaries in future studies may be a useful tool in identifying individual triggers.

Several studies identified in this review showed that dietary interventions can have a statistically significant effect on decreasing migraine attack frequency, severity or both. Data from most of the observational studies and RCTs showed no statistical significance in the number of headache days; however, a trend toward the reduction in the number of headache days was observed.

Low-fat or low-lipid vegan diets were reported to be beneficial in improving outcomes in people with migraine.[51,52] An omega-3 polyunsaturated fatty acid and eicosapentaenoic acid-rich diet resulted in lower prevalence of severe headache or migraine.[55] An earlier RCT also reported that a high omega-3 and low omega-6 fatty acid diet leads to the reduction of headache days, frequency and pain in people with chronic headaches.[66] Ketogenic[54] and low-glycemic index[50] diets have also been reported to be beneficial in certain people with migraine.[67] The benefit of these diets was expected given that earlier studies have reported a significant correlation between obesity and migraine headache[68,69] and avoiding unhealthy food has led to better outcomes in people with migraine. Data do not support the use of one of these diets over another in people with migraine, but comorbidities such as diabetes, hypertension, and cardiovascular diseases may be considered, while recommending a specific diet. Also, physicians may consider recommending these diets for a specific duration to enable optimal benefit, while avoiding nutritional deficiencies. Furthermore, compliance with the dietary recommendations would be crucial to achieve better outcomes.

Elimination of specific foods, such as wheat, orange, egg, caffeine, cheese, chocolates, and milk, from a person's diet was found to be associated with a reduction in the frequency, onset, and severity of migraine attacks.[60] The findings were similar to a prior study which reported a decrease in headache frequency in people with migraine who had an elimination diet based on positive skin prick test for food allergens.[9] However, an earlier review reported that the widespread belief of avoiding chocolates and cocoa products in migraine is not supported by robust scientific literature.[70] The IgG-based elimination diet was associated with a significant reduction in attack duration and number and severity of attacks, and the number of headache days in some people with migraine.[57,58,61]

Overall, preliminary evidence from some RCTs suggest that people with migraine may benefit from low-fat, low-lipid diet, ketogenic diet, or elimination diet of IgG-positive foods; however, an individualized approach to these dietary interventions may be needed. Furthermore, more long-term studies involving large samples examining the effect of diet interventions are needed to see if there is a place for diet in migraine management guidelines.

The studies included in this review were conducted on varied patient populations with different study designs. Most studies were cross-sectional and therefore, not designed for identifying causal relationships between migraine and possible diet-related triggers or diet patterns. The overall study quality of the observational studies was poor to medium. Most studies were point-in-time patient surveys or questionnaires with limited conclusions and were susceptible to recall bias. In addition, none of the observational studies involved blinding and very few discussed power or confounding. There is limited evidence from high-quality RCTs that assessed the effect of diet intervention on migraine. Overall, there were very few studies that lasted longer than 12 weeks, so the long-term effectiveness of the diet interventions included in the review remains unknown. Furthermore, the studies were completed in a wide variety of countries from Europe, Asia, and the United States. This made comparisons between studies difficult due to cultural and religious variations among different countries. Our review included adults with migraine and was focused on studies published in or after the year 2000; however, reviews assessing data in migraine and other types of headaches have reported similar findings.[6,71] Despite these limitations, the individual studies identified in this review suggest that certain dietary factors can act as triggers. The review presents a body of evidence on the beneficial effect of diet interventions, which may aid clinicians in developing a holistic management plan for people with migraine. Longitudinal and high-quality RCTs and longer-term studies are needed to confirm the preliminary results reported by various studies on the effect of diet in migraine.

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