Migraine: Nutritional Considerations

Nutritional approaches to migraine can be particularly attractive when treating pregnant women, where pharmacologic interventions are generally contraindicated.

Foods containing tyramine and other biogenic amines have long been suspected of triggering migraine. Although a review of randomized, double–blind, placebo–controlled studies failed to establish these as a cause of either headache or migraine,²² other studies (see below) indicate that dietary treatment may still be helpful for preventing migraine in certain individuals. Additional controlled clinical trials are required to firmly establish a role for diet in the causation or prevention of migraine; nevertheless, dietary treatment may be considered first as a low–cost, low–risk treatment before medication is used or in patients who either do not respond to or tolerate medication well.

Avoidance of foods found to trigger migraine can reduce or eliminate headache in approximately 20% to 50% of patients.^23,24 Foods commonly identified as migraine triggers include (in order of importance): dairy products (eg, cheese), chocolate, eggs, citrus fruits, meat, wheat, nuts and peanuts, tomatoes, onions, corn, apples, and bananas.²⁵ Tyramine– and phenylalanine–containing foods, such as aged cheese, beer, and red wine, have also been implicated in migraine.^24,25 Although evidence is limited, dietary treatment of pediatric migraine with an allergen–free diet was effective in over 90% of subjects.²⁶ Elimination of certain food additives, including MSG, aspartame, and sodium nitrate, may also be helpful.^27,28

To identify trigger foods, an elimination diet may be conducted on an outpatient basis if the patient can control his or her diet for several weeks.

The procedure is as follows: Start with a baseline diet including only those foods not implicated in migraine:

1. Brown rice.
2. Cooked or dried fruits, other than citrus fruits (cherries, cranberries, pears, prunes).
3. Cooked green, yellow, and orange vegetables (artichokes, asparagus, broccoli, chard, collards, lettuce, spinach, string beans, squash, sweet potatoes, tapioca, and taro).
4. Plain or carbonated water.
5. Condiments (modest amounts of salt, maple syrup, and vanilla extract).

Wean from caffeine–containing beverages gradually, or avoid caffeine if not habitually consumed.

When migraines have stopped or diminished (usually within a week or so), the patient should keep a food diary and add in foods one at a time in generous amounts every other day to observe which cause migraine recurrence.

Foods listed above that are the most common triggers of migraine attacks should be added last. If the food is associated with a migraine attack, it should be removed from the diet for 1 to 2 weeks and then reintroduced to see if the same reaction occurs. If no symptoms are experienced, that food can remain in the diet.

Some evidence suggests that reducing total and omega–6 fat in the diet may reduce migraine occurrence in some patients. In an open trial including 54 migraine patients, reducing total fat intake from 66 grams to 28 grams per day resulted in a significant decrease in headache frequency, intensity, duration, and medication intake.²⁹ It is not clear if the effect was due to reduced fat intake or to the exclusion of specific high–fat foods.

One suggested mechanism relates to arachidonic acid. This omega–6 fatty acid, found in animal products and derived to a lesser degree from the intake of the polyunsaturated fat linoleic acid, is a precursor for both prostaglandin E2 (PGE2) and leukotriene B4 (LTB4), levels of which are elevated during migraine attacks.^30,31 Although inhibition of the production of these eicosanoids by NSAID’s (see Migraine Treatment section) and by antileukotriene drugs³² has been found effective for migraine prevention, changes in diet that limit the intake of omega–6 fats may have a similar biological action.

Studies with supplemental fatty acids that are known to reduce the production of PGE2 and LTB4 (eg, EPA, DHA, and GLA) have also been found to reduce the frequency, duration, and severity of migraine attacks in a limited number of clinical trials.^33,34 As with diets that eliminate biogenic amines or allergens, further study of the potential for low–fat diets and fatty acid supplements is required to establish a role in migraine prevention.

Supplements

A particular complication of research into therapy of migraine is the very strong placebo effect that requires sound experimental design. The following nutriceuticals have some experimental evidence although some have been investigated with greater rigor than others.

Vitamin B₂. Studies have found significant reductions in headache frequency and headache days with pharmacologic doses (400 mg) of riboflavin per day.^35,36

Magnesium. Magnesium deficiency is a common finding in patients with menstrual migraine.³⁷ Migraine patients retain more magnesium after an oral load than control patients, also suggesting systemic magnesium deficiency.38 Magnesium therapy has been found to improve migraine symptoms when given intravenously³⁹ and to reduce the number of headache days in children given oral magnesium.⁴⁰ Magnesium has also been used intravenously to abort severe migraine attacks in the emergency room. Whether this is by a different mechanism than its prophylactic effect is not known.

Omega–3 fatty acids. Evidence of efficacy of omega–3 fatty acids for migraine prophylaxis has been mixed. The rationale for their use was based on anti–inflammatory effects as well as platelet stabilizing effects. However, two earlier promising reports^41,42 were followed by a later negative report.⁴³ The latter report suggested the presence of a strong placebo effect that may influence research findings, as noted above.

Coenzyme Q10. Coenzyme Q10 is being investigated for the treatment of several neurologic disorders. There is some evidence from randomized clinical trials that this is effective in migraine prophylaxis, although most studies have been small and some have been unblinded. ⁴⁴

5–Hydroxytryptophan. Small studies have suggested a benefit for supplementation with 5–hydroxytryptophan.⁴⁵ Its role as an intermediary in the metabolic pathway of serotonin production has provided some theoretical underpinning for these studies. However, evidence of efficacy at this point is weak.

Caffeine. Some patients report anecdotally that 1 to 2 cups of strong black coffee may stop an evolving migraine. Caffeine withdrawal appears to trigger headache46 that is abated by coffee drinking.⁴⁷ However, daily use may contribute to development of frequent and resistant headaches.⁴⁸

Orders

Nutrition consultation to help identify food triggers, prescribe elimination diet as described above, and formulate meal plans.

Consider allergist referral on an outpatient basis.

What to Tell the Family

The patient’s family should be taught about the possible role of dietary and environmental triggers and how family members can assist the patient in avoiding them. Among individuals with identified triggers, even minor exposures can cause migraines. The family can assist and encourage the patient to keep a headache and diet diary to better identify headache–provoking foods and substances. The whole family can use the elimination diet short–term. This will help the patient comply with the diet. Riboflavin and magnesium supplements may also be considered.