More than ‘just a headache’, migraines can be debilitating and seriously affect wellbeing for sufferers. In this article, Dr Danielle Crida answers some common questions about migraines, with a deep dive into the triggers and theories of why migraines occur, and how implementing dietary and lifestyle changes may significantly improve quality of life.

A common neurological condition, best known for its main symptom of intermittent, severe headaches, migraine has a strong genetic predisposition and affects more women (incidence 5-25% with a lifetime prevalence of up to 50%) than men (2-10% incidence). (1) It often begins during puberty and peaks in middle age during the most productive and stressful phase of life. (2) Attacks vary in frequency from daily to less than one per year, and have 4 distinct phases:

• Prodrome: Hours or days before an attack, some sufferers (migraineurs) experience warning symptoms such as tiredness and yawning, neck stiffness and food cravings (2)
• Aura: 20% of migraineurs experience sensory symptoms - visual (e.g. flashing lights), auditory (e.g. tinnitus) or tactile (e.g. skin tingling), or motor symptoms (e.g. clumsiness), which usually last for less than 1 hour
• Pain phase: Headache and associated symptoms lasting 4-72 hours
• Postdrome: Many feel fatigued and depressed, whereas others experience a euphoric feeling for up to 2 days after an episode

Tension headaches, the most common type of headache, are dull and steady with no associated symptoms and can feel like a tight band around the head. They are usually caused by tight muscles in the neck and scalp due to stress, anxiety or bad posture.

In contrast, a migraine headache is often intense and throbbing, sometimes felt on only one side of the head, and usually accompanied by other symptoms such as nausea and vomiting, and light, sound or smell sensitivity. Pain worsens with simple activity such as walking or bending over and when severe, necessitates lying still in a quiet, dark room.

An area of the brain becomes overexcited, triggering ‘cortical spreading depression’ (CSD) - a slow wave of electrical activity and blood vessel narrowing that passes through the brain. During CSD, cell membranes become unstable, allowing changes to the usual chemical balance within cells, and causing the aura that some migraineurs experience. Upon arrival at the trigeminal nerve neurovascular bundle, chemicals are released that cause inflammation and blood vessel expansion, which leads to a throbbing headache. 

While the cause is poorly understood, there are three main theories:

The impaired brain energy production theory:The energy needed for brain function is greater than that being produced by the mitochondria, due to overactive brain cells or suboptimal mitochondrial function. Mitochondria are small organelles within each cell which generate energy, and contribute to oxidative stress and calcium balance. Lending plausibility to this theory, migraines have strong maternal inheritance, and mitochondrial DNA is inherited solely from mothers. Migraines are also a common symptom in those with mitochondrial disorders, and there is a genetic link between mitochondrial function and common migraine. Mitochondria are vital for normal nerve cell function due to their role in calcium homeostasis, with constriction of blood vessels at migraine onset caused by increased calcium concentrations within certain brain cells. (2-4) 

The oxidative stress/inflammation theory:Throughout the body there is a constant flux between pro-oxidant and antioxidant chemical reactions and nutrients. A migraine can be seen as an adaptive response of the brain to flood itself with a healing wave of antioxidant and anti-inflammatory nutrients from increased blood flow and blood vessel dilation, to combat oxidative stress. (4) 

The oversensitive brain theory:The brain is a complex organ that hates change and craves constantness. This theory describes a brain struggling to maintain perfect homeostasis and overly sensitive to changes in biochemical and environmental conditions, e.g. alterations in blood sugar, nutrient and hormone levels, and even weather conditions. (5)

The diagnosis is clinical, based on a typical history and lack of symptoms between attacks.

Each migraineur has a variety of triggers which may act as a precipitant under certain circumstances. These include foods (e.g. allergies, intolerances, food chemicals, unhealthy food choices, red wine); skipping meals; caffeine - excess or withdrawal; dehydration; sleep - less/more than usual; hormonal changes; strong smells; bright lights; loud noise; emotions such as stress, anxiety or anger; exercise - lack of, or excess; a change in the weather. There is no cure for migraine, but avoiding triggers and implementing lifestyle strategies can significantly decrease the frequency of episodes. 

While true food allergies are easier to recognise, it is helpful to identify trigger foods (e.g. MSG, alcohol) and intolerances (e.g. gluten, dairy) by keeping a migraine diary and considering an elimination diet under the guidance of a nutritional therapist. Caffeine intake should be kept consistent as both excess and withdrawal can be triggers. One reason that a migraine may strike during weekend lie-ins is that the brain has missed out on its early morning caffeine fix!

A blood sugar-balancing, anti-inflammatory diet is beneficial for a number of reasons, being high in healthy fats and quality protein, vegetables and fibre, and low in sugars, processed and high glycaemic foods. Some migraineurs have suboptimal glucose regulation, with exaggerated glucose and insulin spikes seen after high glycaemic meals, which can be followed by low blood glucose, triggering a migraine. (7) Anti-inflammatory diets are high in antioxidants, reducing oxidative stress, with a high omega 3:6 ratio, decreasing inflammation. 

Metabolism of carbohydrates can be pro-inflammatory, so even lowering carbohydrates in the diet can be helpful. (8) Some have obtained relief from migraine with the ketogenic diet, which is very low carbohydrate and supplies the brain with an alternative source of fuel - ketone bodies. Ketosis improves mitochondrial functioning and reduces brain excitability, oxidative stress and inflammation. Migraineurs following this diet for 1 month had an 80% reduction in migraine frequency, severity and medication use. (4)

Magnesium: Often lacking in Western diets and depleted by stress, magnesium may help in migraine prevention due to its role in communication between nerve cells, serotonin metabolism and in decreasing inflammation. Dietary intake surveys have linked inadequate magnesium consumption with migraine, and clinical trials have demonstrated magnesium supplementation is effective for prophylactic treatment of migraine, at doses of 600mg elemental magnesium daily. (13-15) As this is a higher than usual supplementation dose, please discuss with your doctor. If using a bioavailable, fully reacted magnesium supplement, the required dose may be less.

The following nutrients are also worth considering:

Omega-3: Suboptimal levels are usually seen in those not eating oily fish several times weekly; increasing the omega-3:6 ratio may reduce migraine duration and severity, and medication use. (16) Adding 1.5g EPA and DHA per day to migraineurs’ medication doubled migraine prevention efficacy in a study.

Homocysteine-lowering vitamins B6, folate and B12: Homocysteine is an amino acid, broken down by vitamins B6, folate and B12, which if raised increases the risk of cardiovascular disease and dementia. It can also trigger migraine through blood vessel dysfunction, and is associated with migraine with aura. (2) These 3 vitamins can be taken in a vitamin B-complex. B12 deficiency is more common among migraineurs, and supplementation may reduce migraine attack frequency, duration and the need for medication. (17)

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