THE ROLE OF DIET IN MIGRAINE

HEADACHES

by J. Gordon Millichap, MD, FRCP,
Pediatric Neurologist, Children's Memorial Hospital, Northwestern University
Medical Center, Chicago, Illinois; NOHA Professional Advisory Board Member.

Migraine headaches are a common neurological
disorder, and studies show that their prevalence has increased in the last
twenty years, especially in children. The cause of the increase in prevalence is
not known. The stress of a more hectic and competitive life-style is postulated
as a factor, but changes in dietary habits may be equally responsible. Other
factors known to precipitate headaches in migraine-susceptible persons
(migraineurs) include fatigue, exercise, sleep deprivation, bright lights, head
trauma, infection, menstruation, and oral contraceptives. A predisposition to
migraine headaches has a neuro-vascular and neurochemical mechanism, and the
disorder is frequently inherited. The dietary factors known to activate the
headache mechanism are called "migraine triggers."
Foods and beverages that may trigger
migraine attacksThe list of foods, food additives, and beverages that
can precipitate headaches in migraine-susceptible persons is long and includes
the following:

  • Aged or

  • strong cheese

  • Cured meats (hot dogs, bacon, ham, and salami)

  • Chocolate, nuts

  • Monosodium glutamate

  • Pickled

  • herring, chicken livers
  • Alcoholic drinks (red wine, beer)

  • Aspartame, nitrites, sulfites.

Patients with migraine may be abnormally

sensitive to one or more of these dietary items, a disorder sometimes described

as a chemical idiosyncrasy or food intolerance. A true food allergy with

positive skin testing is uncommon. The chemicals contained in foods that are

responsible for the headache triggering effect are chiefly tyramine and other

amines, including phenylethylamine and histamine. Tyramine is found in cheese,

especially aged, strong and cheddar varieties, phenylethylamine in chocolate,

octopamine in citrus fruits, and histamine in red wine and beers. Caffeine

addiction and withdrawal, common among consumers of excess coffee, can be

associated with severe throbbing headache and migraine exacerbation. Fasting or

skipping meals is also a common reason for headache recurrence in migraine

sufferers.

Tyramine-triggered migraineOne of

the first reports of the relation of tyramine to the migraine attack was that of

Dr Edda Hanington (British Medical Journal, 2:550,

1967) who observed a headache reaction to cheese eaten by patients treated for

depression with certain drugs. The drugs, monoamine oxidase (MAO) inhibitors,

inhibit an enzyme that normally metabolizes tyramine, the migraine provoking

chemical found in cheese and other foods. MAO inhibitors taken in chance

combination with a meal of cheese can also cause an acute rise in blood pressure

by releasing the neurotransmitter norepinephrine, another reason for headache

symptoms. It is postulated that patients with dietary migraine are sensitive to

tyramine-containing foods because of an inherent deficiency of MAO in their

liver and blood, and an inability to metabolize tyramine. The elimination of the

offending food and chemical from the diet should prevent or lessen the number

and severity of migraine attacks.


The elimination of the offending food and

chemical from the diet should prevent or lessen the number and severity of

migraine attacks.


Other foods known to be associated with

tyramine and migraine include beer, wine, pickled herring, chicken liver, yeast,

coffee, broad bean pods, citrus, and canned figs. Patients with depression

treated with MAO inhibitors should be given a list of foods to be avoided,

especially if they also have a predisposition to migraine.

Chocolate-induced

migrainePhenylethylamine, theobromine, and caffeine, the chemical

triggers in chocolate, may cause a headache by altering the cerebral blood flow

and releasing norepinephrine (Martin, Behbehani, 2001). When adult migraineurs

who complained that chocolate provoked their headaches were challenged with

either a chocolate bar or a closely matched placebo, 5 of 12 had a typical

migraine headache after eating chocolate while none of 8 receiving the placebo

suffered a headache (Gibb CM, et al, 1991).


When adult migraineurs who complained

that chocolate provoked their headaches were challenged with either a chocolate

bar or a closely matched placebo, 5 of 12 had a typical migraine headache after

eating chocolate while none of 8 receiving the placebo suffered a

headache


Although parental reports indicate a

frequent association between chocolate and migraine in children, controlled

studies sometimes fail to confirm a trigger effect. A subgroup of migraine

patients may be sensitive to chocolate.

Caffeine-withdrawal

headachesCaffeine concentrations contained in commonly consumed

stimulant drinks vary from a high of 150 mg in a 5 oz cup of coffee to 35 mg in

a 12 oz can of cola. Pain relievers taken for headache also contain caffeine.

Caffeine causes constriction of cerebral blood vessels.


Caffeine causes constriction of cerebral

blood vessels.


When caffeine intake is interrupted, the

blood vessels dilate, and the increase in cerebral blood flow results in

headache. Patients sometimes need to be hospitalized to manage a serious

addiction and dependency resulting from chronic caffeine overuse.

Alcoholic beverages and

migraineMany patients with migraine cannot tolerate alcoholic beverages

even in small amounts. Alcohol has a vasodilator effect on cranial blood

vessels. However, the alcohol per se is probably not the migraine-provoking

chemical, but rather, the tyramine and histamine contained in many red wines and

beers.


Grapes organically grown and wines free

of sulfites are thought by some to be less likely to trigger headaches.


Only a particular variety of grape is

responsible in some patients, and young and cheaper varieties are often less

well tolerated than aged and more expensive vintages. In some countries, the

problem of wine-induced headache has been so widespread at times that vintners

have been forced to curtail the production of red wine in favor of white, which

is better tolerated by some consumers. Grapes organically grown and wines free

of sulfites are thought by some to be less likely to trigger headaches.


Many patients with migraine cannot

tolerate alcoholic beverages even in small amounts. . . . the alcohol per se is

probably not the migraine-provoking chemical, but rather, the tyramine and

histamine contained in many red wines and beers.


A chemical effect on cranial blood vessels

by some ingredient in certain alcoholic beverages is the most plausible

explanation for the migraine response. Stress may act as a secondary trigger

mechanism in some situations. A migraineur exposed to a stressful and tiring

work environment may complain of an inability to tolerate wine, whereas the same

person on a relaxing vacation may drink and enjoy the same wine without

suffering headaches. Migraine is not primarily a psychogenic illness, but stress

and fatigue are common precipitants of attacks.

Table I.

Allergenic dietary migraine triggers and

hypoallergenic alternatives.

---------------------------------------------------------------------------

Modified from Millichap, Diet and Migraine Headaches. PNB

Publishers, with permission.

Nitrates, Nitrites, and "Hot Dog"

headacheHot dogs and other cured meats such as bacon, ham, and salami

contain nitrates. Cured meats contain about 10 per

cent of the average daily intake of nitrate in the diet, while the consumption

of beets, lettuce, celery, spinach, broccoli, cauliflower, and potatoes

contribute the largest portion of nitrate to the daily diet.


In addition to the occurrence of

headache, nitrites can cause . . . low oxygen in the blood . . .


Fruits, milk, bread, and water are

relatively small sources of the nitrate intake, in normal circumstances. Nitrites are formed by the reduction of nitrates in the

saliva or by bacterial action in the intestine. The vasodilator effect of

nitrites is responsible for the hot dog headache and flushing of the face and

neck commonly associated.

The addition of nitrite to meats has three

purposes:

1) Antibacterial effect, particularly the

inhibition of botulism spores and toxin formation;

2) Formation of pigments responsible for the

red or pink color of cured meats; without nitrites, meat would have an

unacceptable gray color;

3) Food additive responsible for the safety

and stability of cured meats. The level of nitrite permitted in cured meat

products is 200 ppm.

In addition to the occurrence of headache,

nitrites can cause methemaglobinemia (low oxygen in the blood), which imparts a

slate gray cyanotic color to the skin;

and they may act on amines in the diet to form nitrosamines, which are

carcinogenic. High levels of nitrate in the well waters of regions of Columbia

and in two village communities in rural England, where the incidence of stomach

cancer was abnormally high, have been linked to the use of sodium nitrate

fertilizer.


Nitrates and nitrites may be limited in

the diet by reducing the intake of cured meats such as hot dogs and salami and

by checking well water for nitrate contamination.


Nitrates and nitrites may be limited in the

diet by reducing the intake of cured meats such as hot dogs and salami and by

checking well water for nitrate contamination.

Aspartame-triggered migraineThe

FDA and CDC cleared aspartame for general consumption, excepting for children

with phenylketonuria (an inborn error of metabolism). Despite this clearance,

many scientists expressed caution concerning its use by patients with migraine,

epilepsy, and neuropsychiatric problems. In recent years, several studies have

demonstrated that headaches may be exacerbated in patients suffering from

migraine. (Van den Eeden, S.K., et al., Neurology ,44:1787-93,1994; Lipton, R.B., et al., Neurology,

38(Supplement 1):356,1988; Newman, L.C., Lipton, R.B., Headache, 41:899-901,2001; Millichap, J.G., Pediatric Neurology Briefs, 15:89,2001).


. . . many scientists expressed caution

concerning [aspartame/Nutrasweet] use by patients with migraine,

epilepsy, and neuropsychiatric problems.


The number and scientific standard of these

studies reported in the medical literature confirm the role of aspartame as a

significant trigger of headaches in migraineurs, and emphasize the need to

caution patients regarding the potential adverse effect of this ubiquitous sugar

substitute.

Fatty foods and migraineFatty

acids, primarily linoleic and oleic acids, may be involved in the mechanism of

migraine vascular headaches. During a migraine attack, researchers have measured

a significant rise in the blood levels of free fatty acids, which occurs

simultaneously with the release of serotonin from blood platelets, and an

abnormal distension of cranial arteries. The initial aura of a migraine attack,

characterized by visual scotomata (blind spots), is associated with cranial

artery constriction. This is followed by vasodilatation (distention of blood

vessels) as the immediate precursor of a

migraine headache. Serotonin has variable effects on cerebral blood vessels, but

especially vasodilation. It is speculated that free fatty acids are serotonin

releasing factors in the blood.

In a study of the influence of low-fat diet

on the incidence and severity of migraine headaches in 54 patients at the

University of California, Irvine, CA (Bic, Z., et al.,

Journal of Womens Health & Gender-Based

Medicine,8:623-30,1999), a decrease in dietary fat to a maximum of 20 grams

per day was associated with a significant decrease in headache frequency,

intensity, and duration (p<.0001: probability less than one in ten thousand

that the observed difference in headaches would occur by chance).


Fatty acids, primarily linoleic [omega-6]

and oleic [omega-9] acids, may be involved in the mechanism of migraine vascular

headaches. . . . Paradoxically, certain fish oils containing high quantities of

omega-3 fatty acids, as in cod and salmon, have been found to prevent migraine

attacks in certain patients.


Paradoxically, certain fish oils containing

high quantities of omega-3 fatty acids, as in cod and salmon, have been found to

prevent migraine attacks in certain patients. These fatty acids are thought to

have a stabilizing effect on nerve cell membranes, making them more resistant to

the migraine mechanism.

"Ice cream" headacheMigraineurs

may complain of headache while eating ice cream or other frozen foods. The pain

is usually located over the forehead or behind the eyes. The application of a

cold stimulus to the mouth or throat may cause a reflex constriction of blood

vessels around the head, resulting in the initiation of a headache in

susceptible individuals.

Food allergy and migraineVarious

foods, including cow's milk, egg, and wheat cereal, in addition to amine rich

chocolate, orange, and cheese, may provoke headache in migraine-susceptible

patients, especially children. In a study at Great Ormond Street Children's

Hospital, London, UK, of 88 patients treated with an "oligoantigenic diet," a

diet that eliminates all but a few sensitizing food antigens, 93 per cent with

severe frequent migraine responded and were free of headaches. (Egger, J., et al., Lancet, 2:865, 1983; Journal of Pediatrics,114:51-8, 1989).


Specific headache triggers should be

identified by carefully completed headache calendars.


The elimination diet consists of one meat

(lamb or chicken), one carbohydrate (rice or potato), one fruit (banana or

apple), one vegetable (brassica), water, and vitamin supplements. Of the 82

patients who improved on the diet, all but eight relapsed on reintroduction of

one or more foods, including chocolate. Fifty-five different foods provoked

symptoms on reintroduction. A remarkable fondness for migraine-provoking foods

was a common finding, some patients craving them and eating them in large

amounts. Cow's milk and cheese caused headaches in most of the patients in the

study, but none complained of headaches after substituting goat's-milk

cheese.


A remarkable fondness for

migraine-provoking foods was a common finding, some patients craving them and

eating them in large amounts. Cow's milk and cheese caused headaches in most of

the patients in the study, but none complained of headaches after substituting

goat's-milk cheese.


Unfortunately, the susceptibility to

diet-triggered headaches is not consistently confirmed by reactivity to the

food, skin-prick tests, and immune globulin antibody titers, and diagnosis by

the elimination diet is quite demanding. The reported relationship between food

allergy and migraine is difficult to prove, and the concept remains

controversial. Many neurologists and allergists are skeptical of the use of

restrictive diets in treatment, and a universal migraine- food elimination diet

is discouraged in practice. Specific headache triggers should be identified by

carefully completed headache calendars.

Monosodium glutamate. The Chinese

Restaurant SyndromeThe Chinese Restaurant Syndrome, now named "MSG

symptom complex," has been linked to the frequent use of monosodium glutamate

(MSG) in some asian food. Consumers, about 1 in 50 of diners in Asian

restaurants, report flushing, tingling, dizziness, and headache. Symptoms

usually appear within 15-60 minutes after ingesting relatively large amounts of

MSG on an empty stomach.


Consumers, about 1 in 50 of diners in

Asian restaurants, report flushing, tingling, dizziness, and headache.


MSG is a flavor enhancer. It is found in

frozen foods, canned soups, salad dressings, processed meats, sauces and snack

foods. Patients with migraine may have an exacerbation of headaches after

ingesting MSG, because of its effects on cranial blood vessels.

"Hunger" and hypoglycemic

headachesFasting and consequent low blood sugar (hypoglycemia) may

trigger headaches in patients with migraine. Studies have shown that 50 percent

of migraineurs have headaches after 16 hours without food.


Fasting and consequent low blood sugar

(hypoglycemia) may trigger headaches in patients with migraine.


Altered levels of serotonin and

norepinephrine and dilation of blood vessels around the brain and scalp are the

probable mechanisms of hunger-triggered headaches. Following the ingestion of an

excessive carbohydrate load, a vascular headache may also occur in response to a

rapid insulin secretion and reactive lowering of blood sugar.


To avoid these sugar intolerance,

hypoglycemic triggers, migraine sufferers should eat three well balanced meals a

day and avoid an overabundance of carbohydrate foods at any single meal.


To avoid these sugar intolerance,

hypoglycemic triggers, migraine sufferers should eat three well balanced meals a

day and avoid an overabundance of carbohydrate foods at any single meal.

Breakfast should not be neglected, especially in children.

Nonmedication therapeutic techniques in

migraine managementAlthough pain relieving and anti-inflammatory drugs

(eg. acetaminophen, Fiorinal, ibuprofen, Naproxen, or triptans) are usually

required in the treatment of an acute migraine attack, and some medications (eg.

amitriptyline, propranolol, and anticonvulsants) are effective in prevention of

headaches, other nonmedication therapies can prove valuable adjuncts in the

management of a migraine patient.


Prevention of headaches by careful

attention to known migraine triggers is preferable to frequent administration of

pain-relieving drugs.


In addition to diet, alternatives or

complements to drug treatments include biofeedback, visualization/imagery and

hypnotherapy, muscle relaxation, stretching exercises, aerobic activities,

trigger point compression, cold packs or a heating pad, electrical stimulation,

massage, acupuncture, manipulation, and psychotherapy. Magnesium and riboflavin

vitamin supplements can be beneficial, and feverfew is one of the herbal

remedies that is sometimes recommended by practitioners of alternative

medicine.


In addition to diet, alternatives or

complements to drug treatments include biofeedback, visualization/imagery and

hypnotherapy, muscle relaxation, stretching exercises, aerobic activities,

trigger point compression, cold packs or a heating pad, electrical stimulation,

massage, acupuncture, manipulation, and psychotherapy.


The therapy of migraine is multifaceted and

involves treatment of the individual as a whole (physical, nutritional,

emotional, and spiritual, or "holistic" therapy) as well as the counseling of

family members. Prevention of headaches by careful attention to known migraine

triggers is preferable to frequent administration of pain-relieving drugs.

Unfortunately, the nutritional and dietary aspects of migraine management are

most frequently neglected in favor of potentially toxic medications.

________________________________

General references:

Gibb, C.M.,

Davies, P.T., Glover, V., et al,Cephalalgia, 11:93-5,

1991.

Hockaday, J.M., Migraine in

Childhood, London, Butterworths, 1988.

Martin, V.T., Behbehani, M.M., "Headache: Toward a

rational understanding of migraine trigger factors," Medical Clinics of North America , 85: 1-20, 2001.

Millichap, J.G., Diet and Migraine

Headaches, Chicago, PNB Publishers, 2002; in press.

Millichap, J.G., Yee, M., "The diet factor in pediatric

and adolescent migraine," Pediatric Neurology 2002; in

press.

Millichap, J.G., "Aspartame," "Nitrates and Nitrites," and

"Hot Dog Headache," in Environmental Poisons in Our Food,

Chicago, PNB Publishers, 1993.

Millichap, J.G., "Migraine headaches" in Progress in Pediatric Neurology, Vols I, II, III,

Chicago, PNB Publishers, 1991, 1994, 1997.

Millichap, J.G.,

"Headaches," in Attention Deficit, Hyperactivity,

and Learning Disabilities, Chicago, PNB Publishers, 2001.

Millichap, J.G., Nutrition, Diet,

and Your Child's Behavior, Springfield, IL, Charles C. Thomas, 1986.

National Headache Foundation, Alternative Therapies & Headache Care, Chicago, 1999,

www.headaches.org

Article from NOHA NEWS, Vol. XXVII, No. 3, Summer 2002, pages 3-6.