Is There a Bidirectional Relationship Between Migraine and Diet?

Although the exact underlying pathogenesis of migraine remains unknown, lifestyle modifications with regard to stress, sleep, exercise, and dietary considerations have been reported as beneficial for moderate clinical features.

A targeted review published in Neuropsychiatric Disease and Treatment outlined the potential bidirectional relationship between migraine and diet based on examples from current literature.

Although the exact underlying pathogenesis of migraine remains unknown, lifestyle modifications with regard to stress, sleep, exercise, and dietary considerations have been reported as beneficial for moderate clinical features. In addition, experts still do not definitively know if mechanisms underlying migraine pathogenesis influence dietary intake.

To form testable scientific hypotheses for future investigations on the relationship’s bidirectional nature, investigator Parisa Gazerani, PhD, searched PubMed, Cochrane Library, EMBASE, and Web of Science databases for studies using the keywords diet, migraine, food, and lifestyle. However, she noted age, gender, cultural, and religious variations all impede comparisons between studies on migraine and diet.

Previous investigations on the association have focused on the content of the diet, specifically with regard to identification and elimination of certain trigger foods. Evidence also supports how mechanisms underlying migraine may alter dietary choices. Because migraine has been recognized as a disorder related to metabolic imbalance, this factor highlights the potential of functional food for migraine, Gazerani explained.

Functional food is considered so, “if it is satisfactorily demonstrated to affect beneficially one or more target functions in the body, beyond adequate nutritional effects in a way that is relevant either to an improved state of health and well-being and/or reduction of risk of disease.”

Neurotransmitters, including serotonin and orexin, hormones, and state of aura may account for differences in diet choice made by migraineurs compared with healthy individuals exhibited in some studies. As migraine seems to influence food intake, and consumed food affects the manifestations of migraine, further investigation of the gut-brain axis may be valuable, Gazerani said.

How the gut and brain interact in migraine remains unknown, but several proposed mechanisms include composition of gut microbiota or proinflammatory substances like interleukins and neuropeptides (calcitonin gene-related peptide). Studies on probiotic interventions as a prophylactic, in addition to microbiome analysis, may help shed light on this potential explanation of the relationship.

One study of prepubertal migraineurs with aura found that at baseline, food was reported as a trigger in 11% of cases but decreased to zero after 2 years. An additional study on patients over the age of 16 documented the appearance of new triggers over time, as new factors like consumption of alcohol, hormonal changes, and smoking were reported. These studies “present a valuable point that besides studying dietary factors, other daily lifestyle features, for example how a patient sleeps, makes a work-rest balance, and deals with stressful situations, are important to observe and note, because these factors are often interrelated and can influence each other directly or through indirect interactions,” the author wrote.

Migraineurs who also suffer from additional neurological, psychological, or cardiovascular disorders may be influenced by these conditions and adjust their lifestyle and diet accordingly.

A systemic review conducted in 2020 found that among 43 studies that investigated and reported dietary patterns, caffeine and alcohol were identified as major triggers for increased attack frequency. Elimination diets, low-fat diets, and ketogenic diets also yielded promising results in migraine management. However, “level of evidence was determined as low level, because the authors identified that > 50% of the studies were cross-sectional or patient surveys.”

Because dietary interventions have been mostly investigated in small populations often without control groups, results are heterogenous and definitive conclusions can’t be drawn. “No particular migraine diet exists yet to lean on a strong evidence, and hence the investigation of dietary patterns is needed to confirm efficacy before recommending for migraine prevention,” the researcher said. Although some beneficial effects of dietary interventions have been reported, individual patients may require special needs that point towards the concept of precision medicine in migraine, she explained.

When it comes to weight management, one pilot study conducted in 2019 found enhancing the quality of diet and maintaining a healthy weight helped improve some clinical features of migraine in women, as opposed to strict weight loss in isolation. Findings thus suggest weight gain might be a mitigation strategy in some underweight patients while weight reduction may yield benefits in overweight migraineurs.

According to the author, “The concept that migraine might be a response to low brain energy level or uncompensated oxidative stress, has brought the ketogenic diet back into attention.” In this diet, ketone bodies (KBs) are elevated and can be used as an alternative source of energy to correct abnormalities in glucose metabolism reported in migraineurs. But clinical research validating the effects of KBs in migraineurs is lacking.

Accumulated evidence also supports physicians advising migraineurs considered obese to lose wight, because weigh loss can improve factors increasing susceptibility for more frequent migraines like sleep and mood.

Although different conditions comorbid with migraine may affect migraineurs’ dietary intake, one study aimed to determine whether migraineurs’ food choices differ from that of healthy controls. “This study demonstrated that a migraine-specific pattern of food intake existed that was different from healthy individuals. The only exception was alcohol consumption. In addition, and based on the presence or absence of aura in migraine subtypes, the choice of certain food items was influenced,” researchers found. Future studies ought to be carried out to better understand this trend among migraineurs with aura, and those without.

“Taken together, a potential bidirectional relationship, where migraine influences food intake, and consumed food affects the manifestations of migraine, needs further investigation,” Gazerani concluded. At present, “a focus on maintenance of a consistent healthy lifestyle, in addition to nonpharmacological and pharmacological management of migraines, seems to be the key for most of migraine patients.”

Reference

Gazerani P. A bidirectional view of migraine and diet relationship. Neuropsychiatr Dis Treat. Published online February 11, 2021. doi:10.2147/NDT.S282565