Several clinical trials have implicated caffeine as a possible trigger or aggravating factor to migraine/headaches in certain people. it therefore makes sense to reduce, or ideally completely remove, caffeine from your diet for a trial period to see if it makes any difference to the frequency of your headaches/migraine. Sadly this means more than just giving up coffee as caffeine is found in many drinks, several Foods and some medications.
These include:
- Coffee.
- Tea.
- Many Colas and fizzy drinks.
- Most `Energy` drinks and some `Sports` drinks.
- Coffee and Chocolate flavoured drinks (including liqueurs)
- Foods containing Coffee/Chocolate/Cocoa products or flavourings.
- Some ice creams.
- Many over-the-counter medications contain caffeine (including some painkillers). Always check the label and ask the pharmacist about caffeine free alternatives.
- Several prescription drugs contain caffeine, however do not stop taking these without consulting your doctor first.
- It is worth noting that even some so-called caffeine free coffee/tea still contain some caffeine.
- As well as checking labels, there are several websites listing caffeine content of various foods/drinks.
- You should also be prepared for a possible short term worsening of your headaches and/or migraines when you first give up caffeine. This usually passes after a few weeks
There has been a lot of media attention recently regarding the use of Botox injections for the treatment of chronic migraine.
Several years ago, prior to Botox being licensed as a treatment for chronic migraine, I was invited as one of 12 migraine specialists to a presentation outlining the clinical evidence for the use of Botox injections in this way.
A couple of the consultants present were already using the procedure (off-licence) and not surprisingly were fairly convinced of its efficacy. Several others, including myself at this time, felt further more robust evidence and longer term studies were required.
Nevertheless the licence was subsequently granted and the National Institute for Health and Clinical Excellence (NICE) published its final guidance on Botox for chronic migraine in adults on 27 June 2012, recommending Botox injections “as a treatment option for those who experience chronic migraine and have not responded to taking at least three prior preventative medications, and that their condition has been appropriately managed for medication overuse headache.”
It should be pointed out that the treatment is not considered a `cure` and current evidence suggests the procedure usually needs to be repeated every few months to ensure maintained improvement.
Since the procedure currently involves 32-39 injections at various sites over the scalp (although some specialists are experimenting with fewer injections) and improvement is by no means guaranteed, my position is that this should be a `last resort` approach for severe chronic migraine only after all other treatment modalities have been tried and failed.
Botox treatment/injections are not available at Cheyham Lodge Headache and Migraine clinic however private referrals can be arranged to appropriate specialists if required.
N.b. Currently Botox injection procedures for the treatment of chronic migraine are generally not available on the NHS, although this may change over the coming months.
If only it were that simple!! There are many different Migraine triggers which vary significantly from person to person.
Identifying your personal trigger factors can take some time and experimentation on your part but the it is often well worth the effort. You may find that some changes to your diet and/or lifestyle will bring a significant improvement to the frequency and severity of your attacks.
As it happens chocolate, cheese and red wine advice have been implicated as common triggers. Research has shown that certain migraine sufferers have a biochemical condition (possibly inherited- as you may know migraine frequently runs in families), which affects their body’s ability to deal with food containing amines, for example phenylethylamine, which is found in chocolate and alcohol and tyramine, which is found in cheese, wine and citrus fruits. In one survey of over 2,000 sufferers, three quarters of them had eaten at least one amine-rich food in the 24 hours before an attack.
Amines are also absorbed more readily when combined with fat, which may explain why chocolate and cheese are particularly bad and why fried foods and dairy products may also be implicated in migraine attacks.
Common migraine trigger foods include:
- Alcohol
- Chocolate
- Cheese and other dairy products
- Seafood
- Wheat
- Citric acid (found in many drinks and prepared foods)
- Monosodium glutamate (used as a preservative in many prepared foods)
- Onions
- Pork
- Coffee and tea (caffeine)
- Marmite
- Aspartame (used as a sweetener in many drinks and prepared foods)
- Citrus fruits and fruit juices
There are many other foods to which certain individuals may have a sensitivity. It must be stressed that not all migraine sufferers will be reactive to all, or indeed any, of these foods nor will they trigger an attack in a sensitive person every time they are eaten.
Lack of food may be the problem
Fasting (defined as longer than 5 hours between food during the daytime or 13 hours overnight) has been implicated as a frequent trigger factor for migraine sufferers. Some specialists ( including myself) suggest that it is not necessarily what you eat but how often which can be just as important and recommend maximum intervals of 4 hours between food during the day and no more than 12 hours overnight. Possibly even shorter intervals if vigorous exercise is taken.
Lowered blood sugar levels are recognised as a frequent migraine trigger factor and can contribute to the onset of migraine experienced after exercise, or as a result of altered eating times at weekends (e.g. a long lie-in resulting in a late breakfast, expending more energy on activities, missing meals etc). Avoidance of dramatic variations in blood sugar levels is recommended by avoiding sugary foods( n.b many processed foods have surprising amounts of sugar added-check the labels!) and preferably eating foods containing slow-release carbohydrate such as wholemeal bread/pasta/rice or potatoes and of course -vegetables. It is also a good idea to keep some wholemeal biscuits or nuts with you to tide you over if eating times are going to be erratic .
What is the link between amines, low blood sugar levels and migraine? Basically all cells in the body need a certain amount of sugar to provide energy and this is extracted from our food. If we go a long time without food, our blood sugar level drops, when it reaches a certain level, our body responds with an outpouring of adrenaline which releases sugar stored in the liver to top up blood sugar levels. In certain people, this rapid increase in the amount of adrenaline (an amine) in the blood can trigger a migraine attack. It is also worth noting that the cells in the brain are particularly sensitive to sugar levels, requiring a steady supply for optimal functioning.
Other factors……
Obviously not all migraine is food related. There are numerous other trigger factors including hormonal influences, stress, strong emotions, environmental factors such as loud noise, bright or flickering light and strong smells, climate changes and tiredness.
For many migraine sufferers, there is not just one trigger for their attacks but a combination of factors which in isolation can be tolerated but, when several occur together, a ‘threshold’ is passed and an attack is triggered. For example, you may be able to eat cheese or chocolate, cope with a stressful lifestyle, exercise regularly and usually manage with very little sleep with no problem when any of these things occur individually. But if you have a late night followed by a stressful day without having time to eat properly before going to the gym and then have cheese for supper you may find that a migraine is inevitable.
Self help measures
It is very useful to keep a diary to help identify your own migraine triggers. The simplest way to do this is to write down everything that you ate and drank, plus a note of any unusual events, strong emotions etc., in the 24 hours before a migraine and then, when you have 3 or 4 such records, compare them to see if any similarities strike you. You may find that a pattern emerges and that a few changes to your diet and/or lifestyle can bring about an improvement. If there appears to be no linking factor, it may be beneficial to extend the diary to 48 hours prior to the attack, as some foods (such as grains) can take this amount of time to cause a reaction.
I personally advise keeping a comprehensive daily diary, as this is better at identifying the combination of factors which need to be present to trigger an attack. It will also help you to better understand the frequency and any pattern of your migraine, the effect that it has on your quality of life and will assist your GP or specialist to prescribe appropriate treatment.
The diary should include the following:
- Any special worries, overwork ,or strong emotions experienced.
- Any unusual activities, e.g. extra travelling, social occasions etc
- Everything that you have eaten or drunk and at what times. Make the record as detailed as possible and remember to include everything, even the odd sweet, chocolate or cup of coffee;
- How you are feeling, e.g. tired, full of energy, tense, confused, excitable, lethargic etc;
- Any environmental influences e.g. unusual noise (roadworks, loud music etc), strong smells (perfume, paint, petrol etc), strong or flickering light (bright sunshine, flashing advertisements or signs, disco type lighting etc);
- The weather (climate changes can affect some sufferers);
- Menstruation
- What you think triggered the attack;
Clearly trigger factors are not always within our control. We are all affected by external influences which we can do nothing about and it is important not to become too obsessive about triggers. Remember the “threshold” theory and simply try to avoid/reduce those of your known triggers over which you do have some control.
Avoidance of trigger factors may not eliminate attacks completely, so it is important to have an effective acute treatment available to treat any breakthrough attacks.
