We who have been around headache treatment for a while often find ourselves in this strange dilemma. There are many so-called “truths” about headache that are promoted in pop-culture, repeated by some physicians or other practitioners, but was somewhat dis-proven a long time ago. When a new patient comes to see us and they have seen in popular books (not written by headache scientists) or seen on shows like Dr. Oz, certain information about headaches, and we don’t teach the same, they assume we are the idiots. Right before my eyes I see their trust start to fade. So we are stuck with either agreeing with false information or loosing the patient’s trust.
One of these touchy areas is in regards to migraine triggers. The Headache journal, which came out today, they had a great research article about that. I will get back to that in a minute.
Back in the 1980s we heavily promoted finding and avoiding triggers as a major way of treating migraine. When it came to foods, we had a dietitian on staff who trained our patients in a strict elimination diet (including gluten-free). Patients suffered through these intense diets for months and even years.
But that was a long time ago. Since then there was a lot of water under the bridge and research. Now, the only thing we know for sure is that the following can be triggers for some patients;
Direct injuries to the head or neck
Sleep disturbance and,
Possibly, stress let-down (not the stress itself).
There are some triggers that are hard to study such as barometric pressure change.
However, you will notice that foods are not mentioned at all. That is because the studies have never shown food . . . any food . . . to be a migraine trigger. This means the idea of food allergies or even the foods mentioned in pop-culture for triggering migraine, chocolate, red wine, cheese, gluten and etc.
In this last study published today, the conclusion was that patient reported triggers have no evidence of being a real trigger. For example, if a patient says that cheddar cheese always triggers their headaches, then they put them in a study and for so many months they get a ton of hidden cheddar cheese and for several months they get absolutely no cheddar cheese, their migraine rate is exactly the same.
The reason why many patients identify triggers appears to be psychological. Any time you have a random event, be it migraine or winning at the slot machine, you can become very superstitious. I know that when I woke up with a horrible migraine on Thanksgiving Day that I racked my brain to try and figure out what had triggered it. I had all kinds of ideas. I love Indian food and had eaten it the night before . . . but not since. I think it is part of my superstition.
I think another part of this trigger focus is a bit of Puritan thinking. It goes like this, anything that brings pleasure, must be bad for you. So, it is believed that red wine, chocolate, caffeine and etc. must be triggers. To get a bid Freudian here, it is on a deep psychological level that some people feel that the migraine is punishment for enjoying that quiet evening with a glass of wonderful wine and a bite of dark chocolate.
The latest fad is gluten-free diets. While there is a real disease state, Celiac Sprue, which is aggravated by dietary gluten, the role of gluten in causing disease is grossly overstated in America at this time and is just another passing pop-health fad. The science of looking at the role of gluten in aggravating headaches is simply not there. But I think it goes back to that Puritan mentality. Bread is wonderful. I’ve eaten gluten-free bread and honestly, it taste like crap to me. I’m sure there are bakers out there who could make palatable gluten-free bread. But why punish myself like that when I don’t have Celiac Sprue?
But my point is, that when you look at the science, there is no evidence that these things make migraine worse. If you feel better about yourself for following these strict diets, then by all means do it.
The problem often happens when I have a new patient sitting in my office and they are greatly disappointed that I’m not putting them on fad diets. They seem to always interpret this as either I don’t really care about them, or I’m really dumb when it comes to headaches. After all, “The Doctors” on TV suggested these diets. But these doctors on TV have never read a headache study, never attended a headache scientific meeting and get their information from the same place patients to. Their producers read it on the Internet and write them as script to say. Sometimes advertisers (supplement makers, book authors) pay them to promote certain ideas.
But there are many things that patients can do that make a big difference. Here are some of them;
1) Aerobic exercise,
2) Avoiding stress let down, by avoid stress (and learning to think through it better),
3) Sleeping well,
4) Not taking too many pain medications or too many triptans,
5) Taking your preventative medications faithfully
6) Avoid (easier said than done) head or neck injuries.