November 2012 Issue

Migraine Headaches — Here’s How to Identify Food Triggers and Reduce Debilitating Symptoms
By Karen Appold
Today’s Dietitian
Vol. 14 No. 11 P. 14

Once again, a migraine headache forced Kelly to leave work early. The left side of her head was throbbing, and she was feeling sick to her stomach. She couldn’t wait to get home, pull down the shades, put in earplugs, and crawl into bed.

Later, it occurred to Kelly that she didn’t experience any migraines on a recent trip to the Caribbean. Was it something about her environment or diet when traveling that made a difference? Perhaps she should consult a dietitian to further explore a change in diet, she thought.

It turns out Kelly was on to something. Her Caribbean meals of fresh seafood, salads, vegetables, and fruits were in direct contrast with the heavily processed foods she normally eats while on the run.

Who’s at Risk?
According to several studies, including the American Migraine Study II,1 21 million US women and 7 million US men over the age of 12 report having migraines. They’re most prevalent in people between the ages of 12 and 40, and they begin to decline thereafter in both sexes.1

Ninety percent of sufferers have a family history of migraines, and most people susceptible to migraines will develop one before the age of 40.2 Classic migraine symptoms include nausea, vomiting, vision or hearing disturbances, and extreme sensitivity to light and sound.

Potential Triggers
There are numerous potential migraine triggers related to food. For instance, many foods precipitate neurovascular and neurochemical effects in susceptible individuals, either through the direct effect of endogenous or artificial chemicals or by causing a release of immune mediators such as inflammatory cytokines. Examples of endogenous chemicals are the amines, including tyramine, octopamine, phenylethylamine, and histamine.

Tyramine, for instance, is a substance found naturally in foods such as aged cheese; aged, canned, cured, or processed meats; beans such as fava and broad; pickles; and canned soups. It’s formed by the breakdown of protein as foods age. “Generally, the longer a high-protein food ages, the greater the tyramine content,” explains Susan Buckley, RD, CLT, nutrition manager at South Denver Cardiology Associates in Littleton, Colorado.

Food additives such as nitrates, found in processed meats, also have been associated with migraines, along with monosodium glutamate, which is found in soy sauce, meat tenderizer, Asian foods, and a variety of packaged foods.

Other substances sometimes considered food-related triggers include tannins and phenols in black tea, bananas, apple skins, red wine, and sulfites, which are prevalent in wines. In addition, caffeine withdrawal can be a culprit.

Determining Food Triggers
Suggesting patients keep a food and symptom diary can help RDs identify common food triggers as well as screen for contributory lifestyle factors, such as dehydration or skipping meals. “Look for patterns since some reactions aren’t always immediate but can occur several days after a food is consumed,” says Susan Linke, MBA, MS, RD, LD, CLT, a dietitian in private practice in Dallas.

Tracking migraine headaches in a food diary also helps patients document migraine frequency and severity. For instance, monthly migraines might be related to a woman’s menstrual cycle instead of the foods she’s eating.

Patients also should track supplements and medications because they often contain excipients that can trigger migraines. A helpful website that lists inactive ingredients in medications is www.rxlist.com.

Obtaining a good health history is essential to identifying potential migraine contributors. Celiac disease and gluten sensitivity as well as vitamin and mineral deficiencies can instigate migraines. For example, numerous studies have established the pathogenic role of magnesium deficiency in migraines.3 Moreover, coenzyme Q10 has been found to reduce migraine frequency by as much as 48%,4 and riboflavin has been shown to be useful in migraine prophylaxis.5

After environmental and hormonal triggers have been ruled out, patients should eliminate known food triggers. If a patient continues to experience migraines, Mediator Release Testing (MRT) can identify food sensitivities that may be contributing to migraine symptoms. This testing, along with the Lifestyle Eating and Performance (LEAP) diet protocol, can be used to create an oligoantigenic diet for patients.

Diet often plays an important role in migraine pathophysiology because 60% to 80% of the immune system is in the gut, Linke says. When a susceptible individual eats a reactive food or chemical, the immune system releases mediators such as cytokines, leukotrienes, or prostaglandins, which in turn produce pathophysiologic effects such as clinical and subclinical inflammation, pain receptor activation, neurological and endocrine dysfunction, or edema. These effects are implicated in chronic inflammatory conditions such as migraines, irritable bowel syndrome, eczema, fibromyalgia, chronic fatigue, and rheumatoid arthritis, which is why these conditions are frequently comorbid, Linke explains.

What’s important to note is that certain foods trigger migraines in some people but not in others because each person has a unique immune system and physiology. Triggers also can be dose dependent, and some people may have more than one trigger, Linke says.

Testing for Triggers
Testing to identify food allergies and sensitivities can be useful for pinpointing potential triggers and constructing a patient-specific anti-inflammatory and antimigraine diet. Linke uses MRT and LEAP to accurately identify foods and food chemicals that trigger delayed-type hypersensitivity reactions and allow for the identification of a wide variety of safe foods.

“I use those safe foods to construct a patient-specific elimination diet that includes a generous amount of foods,” she says. “This increases patient compliance and satisfaction. In addition, since most guesswork is eliminated, symptoms improve significantly and quickly.”

MRT requires a simple nonfasting blood test. The patient is tested for 120 foods and 30 chemicals (natural and artificial). RDs can review results with clients and develop a nutrition plan of permissible meals, snacks, and beverages that are conducive to each patient’s lifestyle and schedule follow-up appointments to review progress.

LEAP is a patient-specific elimination diet, or “safe foods” diet, based on MRT results. The patient eats for four weeks only the foods identified as “safe” by his or her blood work. This promotes a reduction in inflammatory mediators, with consequent symptom reduction.

Elimination Diet
Research supports and encourages the use of elimination diets. These diets range from the historic three-food diet (lamb, rice, and pears, for example) to more liberal diets that eliminate major allergens. “Use the best evidence, expert opinion, and clinical judgment when constructing an elimination diet,” Linke says.

A serious flaw of traditional elimination diets is that they rely on the patient to identify adverse reactions. The problem with this method is that many immune mediators produce subclinical inflammation, which don’t create readily apparent symptoms but can collectively contribute to the patient’s poor health. Complications also stem from the fact that symptoms can be delayed for three days.

In addition, food sensitivities are dose dependent, and most patients react to multiple foods, Linke says. Therefore, a patient might eat strawberries for three days and not experience any noticeable symptoms. Consequently, the patient proceeds to add potatoes and a migraine ensues. Was the migraine triggered by the potatoes or by the cumulative effect of three days’ worth of strawberries? Or both? Likewise, did the salicylic acid in the strawberries or the solanine in the potatoes cause the migraine?

Without a good road map, such as one provided by an RD, an elimination diet can become complicated and confusing. That’s why Linke uses the LEAP protocol with her patients. “Results have been impressive,” she says.

— Karen Appold is an editorial consultant based in Royersford, Pennsylvania.

 

Most Common Migraine Triggers
• Aged cheeses (eg, blue cheese, cheddar, feta, gorgonzola, parmesan, Swiss)

• Alcohol, especially wine

• Canned soups

• Canned, cured, or processed meats

• Certain beans (eg, fava, broad, garbanzo, lima, pinto)

• Chocolate

• Nuts

• Olives

• Onions

• Overripe avocados, tomatoes, and bananas

• Raisins

• Smoked and pickled foods

• Soy sauce

 

References
1. Lipton RB, Diamond S, Reed M, Diamond ML, Stewart WF. Migraine diagnosis and treatment: results from the American Migraine Study II. Headache. 2001;41(7):638-645.

2. Migraine. Mayo Clinic website. http://www.mayoclinic.com/health/migraineheadache/DS00120/DSECTION=riskfactors. Updated June 4, 2011. Accessed August 21, 2012.

3. Mauskop A, Altura BM. Role of magnesium in the pathogenesis and treatment of migraines. Clin Neurosci. 1998;5(1):24-27.

4. Sándor PS, Di Clemente L, Coppola G, et al. Efficacy of coenzyme Q10 in migraine prophylaxis: a randomized controlled trial. Neurology. 2005;64(4):713-715.

5. Maizels M, Blumenfeld A, Burchette R. A combination of riboflavin, magnesium, and feverfew for migraine prophylaxis: a randomized trial. Headache. 2004;44(9):885-890.