Triggers, Protectors, and Predictors in Episodic Migraine

DOI: https://doi.org/10.1007/s11916- 018- 0734- 0

Abstract-Summary A wide variety of triggers prompt attacks in episodic migraine.

This review describes the most common triggers in episodic migraine and pro-

vides strategies for managing them in clinical practice.

Multiple migraine attack triggers have been established based on patient surveys,

diary studies, and clinical trials.

Clinical studies have verified that fasting, premenstrual periods in women, “let- down” after stress, and most likely low barometric pressures are migraine triggers. Multiple studies clearly demonstrate triggers in episodic migraine, often related

to change in homeostasis or environment.

Many common migraine triggers are not easily modifiable, and avoiding triggers

may not be realistic.

Introduction Patients with migraine are keen to learn about factors activating migraine and report a number of triggers.

Exogenous compounds such as glyceryl trinitrate [571] and prostaglandin E2

[572] trigger migraine attacks in susceptible subjects.

Lower-intensity “natural” triggers such as stress or bright lights do not reliably

produce migraine [570].

Many patients with episodic migraine experience a wide variability of attacks

month-to-month.

Prodromal symptoms in migraine such as mood changes or food cravings are

also common and may be confused for triggers [179].

This may explain why most patients cannot find triggers which invariably pro-

duce a migraine.

This review focuses on the evidence for specific triggers for migraine including

toxicity or withdrawal, changes in homeostasis and other stressors.

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2 Mechanisms

Head trauma or overuse of medication may also precipitate or worsen migraine

attacks but will not be considered a triggers for the purposes of this assessment.

Which Triggers Are Most Prevalent in Episodic Migraine? Large systematic reviews have confirmed the most common triggers for migraine attacks, with stress, auditory stimuli, fatigue, fasting, and menses the most com- monly implicated respectively [573].

Kelman and others reviewed triggers in 1750 patients with migraine and found

them in 76% of respondents, with an average of 7 each.

Combining multiple factors is probably more potent and in patients with infre-

quent migraine may be necessary to trigger an attack.

It is not clear if triggers are more or less important in those with and without aura or if triggers are specific for patients with migraine compared to tension-type headache.

One study suggested food triggers are more common in migraine than tension-

type headache [574].

The Curelator Headache web-based platform, for example, attempts to deter- mine associations between one or many combinations of factors and triggers to predict migraine attacks in individuals based on their data [575].

How Accurate Are Patients in Reporting Triggers? It can be challenging to distinguish between migraine triggers and premonitory symptoms which occur 2–48 h prior to migraine.

Placebo-controlled studies have failed to show chocolate triggers migraine [576]. While many have an inaccurate perception of their actual triggers, on the day of

an attack, patients are fairly good at predicting migraine.

The suggestion that a specific trigger will cause migraine attacks may contribute to expectancy mechanisms that have been established as a cause of increased symp- toms in other pain disorders [577].

Dietary Triggers in Migraine Dietary studies which attempt to link specific foods to migraine are limited by the lack of placebo, the difficulty in distinguishing between premonitory food cravings and triggers, and the fact that the foods are more likely to be contributory than the sole cause of a migraine attack [578].

Fasting and caffeine withdrawal are two of the most common migraine triggers, but several studies have evaluated the role of diets and specific foods or additives as triggers of migraine.

Fasting is among the best studied and most reliable natural migraine triggers and

becomes more common with longer fasts [579].

Alcohol is one of the most commonly cited migraine triggers, but population- and clinic-based studies suggest people with migraine are less likely to drink, and that alcohol is not linked to migraine based on diary studies [580].

Multiple studies have attempted to explore the role of specific foods and addi-

tives in triggering migraine.

2.4 Lifestyle

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Menstrual Changes as a Migraine Trigger Menses are perhaps the most common migraine trigger in women.

In one population-based study, over half of women with migraine reported an increased rate of migraine related to menses, although only a small minority (3.9%) had migraine during menstruation [581].

Diary studies confirm that menstruation can trigger migraine, perhaps more so in

those with aura [582].

Estrogen withdrawal prior to menses is likely the cause of menstrual migraine and explains why migraine onset often commences prior to menstruation onset or on the first day [583].

Weather Triggers in Migraine Hoffman and others reviewed the 12-month calendar data of 20 subjects with migraine and found 6/20 were significantly sensitive to weather changes, with lower temperature and higher humidity being associated with increased headache inten- sity [584].

A 1-year calendar study in Japan found 18 of 28 patients had migraines related

to weather changes, most commonly related to low barometric pressure [585].

A non-clinic web or smartphone study of volunteers in Germany found an increased rate of migraine reports on days of significant weather changes, in par- ticular a 5 °C rise in temperature [586].

A few studies have attempted to find correlations between weather data and

emergency department (ED) visits for headache or migraine.

ED visits for headache or migraine were more frequent during days of higher mean temperatures in the 24 h before the visit, and there was a weaker correlation between low barometric pressures 48–72 h before hospitalization [587].

Sensory Stimuli as a Migraine Trigger It can be difficult to sort out if sensory stimuli are triggers or if patients with migraine simply become more sensitive to stimuli in the premonitory phase prior to an attack [588].

Multiple types of visual stimuli have been cited as a trigger for migraine. Light exacerbates migraine in patients without visual perception as perceived in

the thalamus [589].

Odors are among the most common reported triggers of migraine in surveys with

70% of patients in one study reporting odors trigger attacks [590].

Patients with migraine report multiple types of odors as triggers for migraine

such as perfumes, paints, gasoline, bleach, and rancid smells [591].

Stress as a Migraine Trigger Stress is perhaps the most common self-reported trigger of migraine, and many studies have been able to demonstrate a link between chronic stress, pain, migraine, and catastrophic thinking [592, 593].

Retrospective and prospective diary studies, however, are not typically able to

confirm the association between stressful days and acute migraine attacks.

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2 Mechanisms

Poor sleep quality is commonly cited as a trigger for migraine, and in many

patients with migraine, sleep helps treat an attack [594].

While sleep disturbances are a commonly reported trigger, diary studies do not

consistently demonstrate it as a risk factor for migraine.

Seidel and others found that while sleep quality is reduced in migraine, rates of fatigue and daytime sleepiness are similar to controls, suggesting poor sleep is caused by migraine, not the other way around [595].

Advising Patients on Triggers and Protectors: a Practical Approach Focusing on triggers as a way to prevent migraine appeals to patients and clinicians wanting to promote wellness and reduce medication use.

A recent study by Martin and others found the standard advice to avoid triggers was not effective in reducing migraine compared to a waitlist control group and less effective than cognitive therapy or a “learning to cope with triggers” approach [596]. Here are a few strategies to utilize when advising patients with migraine on

triggers.

While it is worthwhile to screen for some dietary triggers such as excessive alco- hol or aspartame consumption, it is probably better to avoid recommending a spe- cific diet for migraine as dietary factors vary from person to person.

For patients with very frequent migraine, it may be impossible to identify dis-

tinctive triggers.

While positive health behaviors should be encouraged, it is probably also worth offering effective preventive medication for patient patients with frequent or severe migraine attacks.

Conclusions Multiple factors are verified triggers in chronic migraine including stress, fasting, weather changes, and menses.

Strategies for managing migraine triggers include keeping a headache diary,

focusing on healthy lifestyle choices, and using prevention.

Acknowledgement A machine generated summary based on the work of Marmura, Michael J. 2018 in Current Pain and Headache Reports.

A Clinical Approach to Addressing Diet with Migraine Patients