Triggers, co-morbidities and premonitory symptoms of migraines.

Migraine triggers and premonitory symptoms are reported by the vast majority of patients with migraine. The interaction of environmental triggers and a susceptible brain is what is thought to initiate migraines.

Kelman (Cephalalgia 2007;27:394-402), studying a sample of 1750 patients with migraines found that 76% of migraineurs reported triggered attacks of migraine and that triggers were very frequent in 9%, frequent in 27%, and occasional in 40%. The most common trigger factors (occurring at least occasionally) included stress (80%), hormones (65% of women), missed meals (57%), weather (53%), sleep disturbance (50%), odors (44%), alcohol (38%), heat (30%), and foods (27%). Subjects reported an average of 7 triggers.

Patients with migraine and triggers seem to have more severe headache profiles (longer attacks, more pronounced symptoms, higher recurrence rates, and more associated sleep and mood disturbances), longer lifetime duration of migraine, and more family members with migraine. Migraine with aura (MA) and chronic migraine were more frequently associated with triggers than migraine without aura (MO) and episodic migraine.

A number of studies have shown that stress and sleep significantly triggered headaches in patients with MA.

The most common migraine trigger is stress. Migraine sufferers are thought to be highly responsive emotionally. Anxiety, worry, shock, and sadness can all release certain brain chemicals that lead to a migraine headache. Paradoxically, the sense of release after a stressful period can trigger migraines (let-down headaches).

For many women, menstruation is a major trigger. Attacks may occur before or during menstrual period or at ovulation. The abrupt fall in estrogens is believed to be the cause. High levels of estrogens may explain why two thirds of women during pregnancy have less migraine attacks. Fluctuating estrogen levels around menopause may cause an increase in migraines attacks.

Sensory stimuli such as bright lights and sun glare can induce migraines, as can loud sounds. Unusual smells (perfume, paint thinner, secondhand smoke etc) can also be a trigger. Strong perfumes may be an immediate trigger for some patients as well as flickering lights such as TVs and movie screens or sunshine flashing through trees on a road.

A change of weather can prompt a migraine. The relationship between weather and migraines is poorly understood.  Variations in barometric pressure, temperature and humidity can be the cause. It also has been hypothesized that changes in the ionic composition of the air that precede storms may also be a factor.

Missing sleep or getting too much sleep may trigger migraines in some people, as can jet lag.

Oral contraceptives and vasodilators, such as nitroglycerin, can aggravate migraines

Intense physical exertion, including sexual activity, may provoke migraines.

Aged cheeses, salty foods and processed foods may trigger migraines. Skipping meals or fasting also can trigger attacks.

• Ripened cheeses that contain tyramine (such as cheddar, emmental, stilton, brie, and camembert).
• Chocolate
• Sugar in excess.
• Marinated, pickled, or fermented foods
• Foods that contain nitrites or nitrates (bacon, hot dogs) or MSG (soy sauce, meat tenderizers, seasoned salt), sweeteners (aspartame).
• Sour cream
• Nuts, peanut butter
• Sourdough bread
• Broad beans, lima beans, fava beans, snow peas
• Figs, raisins, papayas, avocados, red plums, bananas, citrus fruits, pineapple etc.
• Alcohol (including red wine and beer)
• Excessive amounts (more than 300mg) of caffeinated beverages such as tea, coffee, or cola.

Starbucks brewed coffee caffeine content: Short (8 floz) 180mg, Tall (12 floz) 260mg, Grande (16 floz) 330mg and Venti (20 floz) 415mg.

While caffeine can trigger migraine and cause rebound headaches (Medication Overuse Headaches) in some individuals, caffeine may be an effective ally in treating acute migraines. Caffeine can assist in restoring the stomach’s motility that may be reduced during a migraine attack and beyond simply promoting absorption of oral medications caffeine may itself exert a more direct therapeutic effect on the migraine process. For that reason caffeine is a component of many preparations available for acute headache treatment.

Kelman (Headache 2004; 44:865-872), evaluated 893 patients found that nearly one third of the patients fulfilling diagnostic criteria for migraine had premonitory symptoms. The median duration of premonitory symptoms was 2 hours (mean 6.8 hours). The most common premonitory symptoms were fatigue (25.6%), changes in mood (23.4%), and gastrointestinal (GI) symptoms (22%). Less common symptoms included head pain, aching and twitching, eye symptoms, cognitive changes, temperature changes, yawning, food craving, etc.