A migraine is not just a regular headache. It is usually a very debilitating pathology that significantly affects our quality of life. It requires a careful and individualized assessment and treatment.
There is a wide range of pharmacological treatments available (but the side effects must also be considered). There is evidence that the type of diet and use of supplements are worth considering in the prevention of migraine attacks.
Dr. Celia Gonzalo Gleyzes – Neolife Medical Team
A migraine is a disorder that affects more than 12% of the general population. It occurs most often in women. There are three major types: migraine without aura (the most common), migraine with aura, and chronic migraine (15 or more headaches a month for more than three months). Each category encompasses numerous subtypes.
There are families with several affected individuals, suggesting there is some genetic basis involved.
Suffering from migraine means having recurrent attacks. In each episode, four phases are identified: the prodrome, the aura, the headache (in this case, a throbbing in one side of the head), and the postdrome. Symptoms will vary from person to person (visual, somatosensory, verbal, etc.).
Common triggers in order of frequency are: stress, hormones in women, not eating, weather, sleep disorders including sleep apnea, perfumes or smells, neck pain, light, alcohol, smoke, going to bed late, heat, some foods, exercise, and sexual activity.
A brain imaging test may be requested by a neurologist at the initial assessment to rule out other pathologies. The proposed treatments may be indicated for the prevention and reduction of the frequency of attacks or for controlling the acute phase of pain (1).
As a recent development, we may cite the drug galcanezumab (Emgality®). It is a humanized monoclonal antibody that inhibits the physiological activity of calcitonin gene-related peptide (CGRP). In phase 3 trials, the recommended doses of subcutaneous galcanezumab once a month were significantly more effective than a placebo in preventive therapy in adults with episodic or chronic migraine, even in patients for whom several migraine prevention medications had failed. The beneficial effects of the galcanezumab preventive treatment were maintained for up to one year, reducing the number of month headache days (MHD) and improving health-related quality of life (HR-QOL). Although more clinical testing is required to determine its long-term safety profile, monthly doses of galcanezumab represent an important future option for the prevention of episodic and chronic migraine (aura) and cluster headache (another type of headache) (2).
Among the non-pharmacological measures, we find the avoidance of triggers such as lack of sleep, tiredness, stress, and some foods. Other specialists even use cognitive behavioral therapy techniques.
This “diet” consists of eliminating foods that may trigger migraine attacks. Some of these foods may be: chocolate, citrus fruits, nuts, ice cream, tomato, onion, dairy products, alcohol, coffee, caffeine, monosodium glutamate (flavor enhancer most commonly used in Asian food), histamine, tyramine, phenylethylamine, nitrites, aspartame, sucralose, and gluten.
The list is long and other factors such as individual susceptibility (genetics), quantity, time of exposure to substance, etc. should be considered.
The patient has to prepare a careful record of their migraine attacks and try to establish links/associations with some of these foods in order to anticipate and thus avoid/limit the consumption of these substances.
A recent review of the literature found that diets such as the ketogenic, folate-rich, low-fat, modified Atkins, high in omega-3, and low in omega-6 may have beneficial effects. The Mediterranean diet has also been cited, but with less evidence.
The ketogenic diet and the modified Atkins seem to have neuroprotective effects, improve mitochondrial function, compensate for Serotonin dysfunction, decrease CGRP levels, and lower neuroinflammation.
Low glycemic index diets are useful in cases of migraine, decreasing the inflammatory state.
The interest in diets that are rich in omega-3 lies in reducing inflammatory response and regulating vascular tone.
Sodium intake should be considered depending on the population type, i.e. a low sodium diet may benefit elderly patients with high blood pressure, and a diet with a higher sodium content would be appropriate in patients with comorbidities like postural tachycardia syndrome or in patients with low blood pressure and low body mass index.
There are diets whose therapeutic targets are cellular structures (e.g. mitochondria) and molecules (DNA). Hardy and Tollefsbol introduced the concept of “epigenetic diet” to explain which environmental factors, such as the diet, could have an effect on the expression of the patient’s genes (epigenetics). It has been found that methylation of certain genes was associated with migraines.
Folate (vitamin B9), involved in DNA methylation, seems beneficial in the prevention of migraines.
Ketosis alters cellular functions through epigenetic mechanisms, therefore this diet is considered effective in cases of migraine. In the publications available so far, high levels of homocysteine are linked to an increased risk of migraines. Homocysteine production requires folate and vitamins (B6 and B12). A deficit of these elements leads to DNA hypomethylation, and the hypothesis is that this may trigger the appearance of migraines.
The gut-brain axis and probiotics
Migraines are often accompanied by gastrointestinal symptoms (nausea, vomiting, dyspepsia, and intestinal motility problems). Some studies associate migraines with inflammatory bowel disease and celiac disease.
If we focus on the gut-brain axis and its bidirectional relationship, we may suggest that there are neurological conditions and behaviors that depend on the microbiota.
As for migraines, relying on the hypothesis of increased intestinal permeability, pro-inflammatory substances would reach the trigeminovascular system and act as trigger. Current studies are not sufficiently conclusive and homogeneous to be able to claim that probiotics are effective in migraine patients.
Some dietary modifications will have a beneficial effect on the gut microbiota: proper fiber consumption, low glycemic index diets, vitamin D and omega-3 supplements, low-fat vegan diets, gluten-free diets, probiotics, and weight loss diets. Researchers have shown the link between migraines and obesity, reporting clinical improvement after weight loss.
Precautions with nutraceuticals
A number of nutraceuticals have always been used in migraines: 5-HTP, vitamins, magnesium, coenzyme Q10, and herbal preparations (mayweed and butterbur).
However, the use of supplements should be monitored by a doctor; cases of liver damage have been reported after butterbur consumption.
In cases of migraine, we must keep in mind that the doctor should always apply the SEEDS protocol (Sleep, Exercise, Eat, Diary, and Stress), that is, help the patient improve their quality of sleep, promote physical activity, propose the proper diet, explain that keeping a record of events and triggers is crucial, and propose measures to combat stress (3).
(1) Pathophysiology, clinical manifestations, and diagnosis of migraine in adults UpToDate
(2) A Review in the Prevention of Migraine and Treatment of Episodic Cluster Headache. Scott, L.J. Drugs (2020). https://doi.org/10.1007/s40265-020-01329-5
(3) Migraine and Diet. Parisa Gazerani, Laboratory of Molecular Pharmacology, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, 9220 Aalborg East, Denmark Nutrients2020, 12(6), 1658; https://doi.org/10.3390/nu12061658 Published: 3 June 2020