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.

Conclusion

Migraine is a disabling primary headache disorder with high societal impact. Several studies have reported a link between diet triggers and migraine, but the associations need to be confirmed by high-quality longitudinal studies. Certain dietary interventions may help to improve clinical outcomes in some people with migraine, but these findings still need to be supported with robust evidence before being recommended for use in clinical practice.

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Abbreviations
BMI body mass index, CI confidence interval, DASH dietary approaches to stop hypertension, HR hazard ratio, IgG immunoglobulin G, IRR incident rate ratio, NHANES National Health and Nutrition Examination Survey, NICE National Institutes for Health and Care Excellence, OR odds ratio, PRISMA Preferred Reporting Items for Systematic reviews and Meta-analyses, RCT randomized controlled trial, SD standard deviation, VAS visual analog scale

Funding
Support for this publication was provided by Eli Lilly and Company.

Acknowledgment
The authors would like to thank Ananya Biswas, a former employee of Eli Lilly Services India Pvt. Ltd., India, for assistance in writing the manuscript.

Table 1. PICOS and Eligibility Criteria
Study Characteristic	Inclusion Criteria	Exclusion Criteria
Patient population (P)	People with migraine aged ≥18 years	Pediatric patients (≤18 years), any other disease condition, studies not reporting data specifically for people with migraine
Intervention (I)	Diet, food, and nutrition	–
Comparators (C)	All interventions, placebo or usual care	–
Outcomes (O)	Diet, food, and nutrition: • As triggers or predisposing factors for migraine • Used for the prevention or treatment of migraine	Supplements, nutritional supplements, natural medications, vitamins
Study design/publication type (S)	Randomized controlled trial (RCT) or pragmatic trials, non-RCT, prospective or retrospective observational studies, systematic literature reviews (SLRs)†	Editorial, letter, note, comment, book chapter or case reports
Time frame	January 1, 2000-March 5, 2019	–
Language	English	Non-English

†Bibliographic searching of SLRs was conducted to identify additional relevant articles.

Table 2. Diet Patterns
Topic Author, year	Study Design, N	Outcome Summary
General Diet Patterns
Overall dietary pattern	Prospective analysis of factors related to migraine attacks study, N = 327	There was limited evidence with regard to nutrition in the precipitation of migraine. Risk of migraine, headache, and headache persistence was lowered with consumption of beer on days before headache onset
Wober, 2007²¹
Eating habits	Case-control study, randomly selected, N = 170	More people with migraine had no regular diet, did not eat meals on a regular schedule, and ate less than 3 meals per day than the control group without migraine
Nazari, 2010²³	Case-control study, randomly selected, N = 170
Night-time snacking	Daily diary data analysis from NIH observational study, N = 34	Night-time snacking and eating a late dinner were associated with reduction in the odds of headache
Turner, 2014²²
Overall dietary pattern	NHANES cross-sectional survey, N = 3023	Women with or without migraine did not have any significant difference in dietary intake patterns, including total energy intake, percent of energy from macronutrients, sodium, caffeine, omega-3 fatty acids, omega-6 to omega-3 fatty acid ratio and eating frequency. However, women with migraine have higher odds of being alcohol consumers. Women of normal weight without migraine had significantly higher diet quality§ than women of normal weight with migraine
Evans, 2015²⁶	NHANES cross-sectional survey, N = 3023
Dietary patterns,	Cross-sectional survey in the Women's Health Study, N = 7042	People with migraine reported low intake of total alcohol compared to those without any headache history. People with migraine with aura were more likely to have a low intake of chocolate, cheese, ice cream, hot dogs and processed meats compared to those with migraine without aura
Rist, 2015²⁴
Overall dietary pattern	Population-based survey, N = 1782	Increased prevalence of RH/M was found among women who often or sometimes drank heavily and those who skipped breakfast
Molarius, 2008²⁵	Population-based survey, N = 1782
Specific Diet Patterns
"Healthy Eating Plate" diet	Cohort study, N = 101	There was a statistically significant decrease in migraine frequency and rescue drugs per month with increased consumption of whole-grain bread and whole-grain pasta and decreased consumption of white bread
Altamura, 2018²⁸	Cohort study, N = 101
Smoking and alcohol	Retrospective data analysis of the National Statistics Institute of Spain database, NR	Migraine prevalence was positively associated with daily smoking and negatively associated with alcohol consumption (in the preceding 12 months
Matias-Guiu, 2014²⁷
Dietary patterns	Cross-sectional study, N = 285	Subjects with high adherence to western† eating pattern had more attack frequency, whereas subjects with high adherence to healthy‡ eating pattern had lower attack frequency
Hajjarzadeh, 2018³⁰	Cross-sectional study, N = 285
Dietary Sodium intake	National cross-sectional study, N = 8819	Probable migraine history decreased with an increasing dietary sodium intake; however, it was found only in women with lower BMI
Pogoda, 2016³¹	National cross-sectional study, N = 8819
Dietary risk factors	Cross-sectional study, N = 750	Consumption of fried food has a significant positive association with migraine headache
Najaf Zare, 2012²⁹	Cross-sectional study, N = 750

BMI = body mass index; N = number of patients; NHANES = National Health and Nutrition Examination Survey; NIH = National Institutes of Health; NR = not reported; RH/M = recurrent headache/migraine.
†Western diet consists of high consumption of cola, salted nuts, processed meat, and fast foods and snacks.
‡Healthy diet consists of high consumption of fruits, fish, vegetable pickles, vegetables, and legumes.
§Diet quality was measured using Healthy Eating Index 2005 [HEI-2005] total scores, where higher scores reflect higher consumption of fruits, vegetables, legumes, grains, milk, meat, beans, and oils, and lesser intake of saturated fat, sodium, and energy from solid fat, alcohol, and added sugars as per the standards specified by HEI-2005.

Table 3. Diet-Related Triggers
Author, year	Study Design, N	Outcome Summary
Alcohol
Park, 2016¹⁴	Prospective observational study, N = 62	Alcohol use was significantly associated with migraine
Mollaoglu, 2013³²	Prospective cohort study, N = 126	Triggers for migraine included alcohol
Onderwater, 2019³³	Cross-sectional, questionnaire study, N = 2197	The most common alcohol-related trigger was red wine
Panconesi, 2013³⁸	Cross-sectional study, N = 448	Very few patients indicated alcohol as a trigger
Wang, 2013³⁶	Cross-sectional study, N = 394	Alcohol drinking was associated with migraine. Alcohol as a trigger was less common in females than males
Yokoyama, 2012⁴⁹	Cross-sectional study, N = 419	People with migraine drank less alcohol than those with TTH
Hauge, 2011³⁵	Questionnaire survey, N = 126	Alcohol triggers were red wine, liquor, champagne or sparkling wine, white wine, and beer
Andress-Rothrock, 2010³⁴	Questionnaire survey, N = 200	Triggers included alcohol. Specific types of alcohol (e.g., red wine) may trigger attacks
Takeshima, 2004³⁷	Population-based survey, N = 5740	Risk for migraine or TTH was not influenced by the consumption of alcohol, after age and gender adjustment
Fasting
Abu-Salameh, 2010³⁹	Cohort cross-over migraine diary study, N = 30	During Ramadan, fasting was associated with an increase in migraine headache
Yadav, 2010¹²	Prospective questionnaire study, N = 182	Fasting was one of the most commonly reported triggers
Al-Shimmery, 2010⁴⁰	Patient interview/survey, N = 200	Fasting during Ramadan and other days of the year were significantly associated with migraine
Food allergens
Bektas, 2017⁴¹	Prospective observational study, N = 49	Food allergen frequency did not differ between migraine and control groups (not exposed to allergens); however, an allergy to pollen was frequently found in the migraine group compared to the control group
Caffeine
Mollaoglu, 2013³²	Prospective cohort study, N = 126	Triggers for migraine included coffee
Omer Saglam, 2015⁴²	Retrospective observational study, N = 23	Excessive caffeine intake (all forms) was reported by patients as one of the food triggers.
Tai, 2018⁴³	Prospective observational, cross-sectional study, N = 684 (migraine = 319)	Coffee was one of the most common dietary factor associated with migraine
Dietary triggers
Park, 2016¹⁴	Prospective observational study, N = 62	Overeating was significantly associated with migraine
Mollaoglu, 2013³²	Prospective cohort study, N = 126	Triggers for migraine included dietary factor, hunger, milk and cheese, and chocolate
Omer Saglam, 2015⁴²	Prospective cohort study, N = 23	Patients reported the following food triggers: Cheese/cheese products, excessive nuts intake, excessive fresh/dry fruits intake, high dairy products consumption, more processed food consumption, and high baked food consumption
Kelman, 2007⁴⁴	Retrospective observational analysis, N = 1750	Food was a very frequently observed trigger in people with migraine
Tai, 2018⁴³	Prospective observational, cross-sectional study, N = 684 (migraine = 319)	Some dietary factors including chocolate and foods rich in monosodium glutamate were most commonly associated with migraine
Hauge, 2011³⁵	Questionnaire survey, N = 126	Food and seasoning† usage was associated with migraine
Andress-Rothrock, 2010³⁴	Questionnaire survey, N = 200	Missing meals and use of specific foods including chocolate, cheese, and hot dogs was associated with migraine
Baldacci, 2013⁴⁷	Prospective observational, cross-sectional study, N = 120	People with migraine seemed to better recognize triggers like particular food and stress
Camboim Rockett, 2012⁴⁶	Cross-sectional survey, N = 123	Only few patients reported no susceptibility to any dietary trigger
Hauge, 2010⁴⁵	Questionnaire survey, N = 629	Hunger/missing a meal, dehydration, and use of food/seasoning was associated with migraine
Zivadinov, 2003⁴⁸	Population-based survey, N = 2039 (migraine = 720)	Significant positive association of food items noted in people with migraine with aura compared to migraine without aura

N = number of patients; TTH = tension-type headache.
†Seasoning was not defined by the article.

Table 4. Diet Interventions
Author, year	Study Design, N	Intervention-Comparator	Outcome Summary
Specific diets
Evcili, 2018⁵⁰	RCT, N = 350	Low glycemic index diet vs. Control (medication group)	In the first month after dietary restriction, the number of monthly attacks significantly decreased in both groups but not in severity, based on a VAS score. The mean scores of VAS significantly decreased later in the diet group compared with those in the medication group (after 3 months)
Ferrara, 2015⁵¹	Randomized cross-over N = 83	Low-lipid diet vs. Habitual diet (normal-lipid diet)	People with migraine on a low-lipid diet had a significant reduction in the number of migraine attacks, as well as the severity of attack compared to those on a normal-lipid die
Bunner, 2014⁵²	Randomized cross-over interventional trial, N = 42	Low-fat vegan diet vs. Placebo supplement (a capsule containing alpha-linolenic acid and vitamin E)	The Patient's Global Impression of Change showed significantly greater improvement in pain reduction during the diet period. The frequency of pain relief medication use fell significantly during the diet period compared to the supplement period
Spigt, 2005⁵³	Pilot-RCT, N = 18	Increased water intake (1.5 L) vs. Placebo (normal water intake)	Water seemed to have an effect on the total number of hours of headache and headache intensity, although the effects were not statistically significan
Di Lorenzo, 2016⁵⁴	Prospective observational study, N = 18	Ketogenic diet vs. Normal diet	After 1-month of the ketogenic diet, the mean attack frequency and duration significantly reduced
Sanders, 2018⁵⁵	Cross-sectional observational, N = 12317	Measured daily intake of EPA/DHA	Greater intake of omega-3 PUFAs was associated with a lower prevalence of severe headache or migrain
Mirzababaei, 2018⁵⁶	Questionnaire, cross-sectional, N = 266	Level of adherence to the DASH diet (high intake of fruits, vegetables, whole grains, poultry, fish, and nuts, restricting saturated fat, red meat, sweet beverages, and refined grains)	The results of analysis in the crude model showed that individuals with the greatest adherence to the DASH diet displayed lower prevalence in severe headaches, compared to those with the lowest adherence
Elimination diets
Ozon, 2018⁶⁰	Randomized cross-over study (Using headache diary), N = 50	Diet strict with trigger removal vs. Diet relaxed with trigger removal	Monthly attack frequency, attack duration, and attack severity were found to have decreased to a statistically significant extent compared to those in the period before diet implementation in patients with diet restriction (removal of triggers from diet)
Aydinlar, 2013⁵⁷	RCT, Double-blind, randomized, cross-over trial, N = 21	IgG-based elimination vs. Baseline (usual diet)	Compared with baseline (usual diet), the elimination diet was associated with significant reductions in attack count, attack duration, attack severity, and acute medication use during attacks
Alpay, 2010⁵⁹	RCT, double-blind, cross-over, N = 30	Excluding (Elimination diet) or including (Provocation diet) foods with high IgG antibody level	Number of headache days reduced from baseline in the elimination diet group. Elimination diet was also superior in terms of attack count, number of attacks with acute medication, and total medication intake
Mitchell, 2011⁵⁸	RCT, single blind, N = 167	True diet (n = 84) vs. Sham diet (n = 83) based on IgG antibodies reactivity-related elimination	There were significant differences in median number of headache days between true diet and sham diet at week 4 but not at week 12
Arroyave Hernandez, 2007⁶¹	Prospective cohort study, N = 56	Elimination diet based on IgG food allergy positive reactivity vs. Control group without migraine	After 6 months on the elimination diet, the majority of patients had remission of migraine (no migraine) and only a few observe a decreased in intensity and frequency. There was statistically significant difference between patients and the control group regarding level IgG food reactivity

DASH = dietary approaches to stop hypertension; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; IgG = immunoglobulin G; N = number of patients; PUFA = polyunsaturated fatty acid; RCT = randomized controlled trial; VAS = visual analog scale.

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The Role of Diet and Nutrition in Migraine Triggers and Treatment

A Systematic Literature Review

Conclusion

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