Why Eating Can Help Your Migraine

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Imagine you’re having a migraine attack. Sure, there’s the severe throbbing pain like someone took a massage gun to your head. And there’s the sensitivity to light and sound that drives you to cocoon up in your bed. But for many people with migraine, there’s another symptom that can be unbearably disruptive: waves and waves of nausea.

Nausea is such a prominent symptom of migraine that anti-nausea medications are considered a critical component of evidenced-based migraine care. Drugs have also been developed to bypass the mouth and gut, in part because people suffering from a migraine attack may just throw up an oral medication. In the most widely used primary care screener for migraine, the disease is basically defined as a severe headache with nausea.

This brings us to the relationship between migraine and food. Most of the time, people with migraine come to me and ask, what should I eat to prevent migraine attacks? And there are few clear answers. Although the consumption of caffeine and alcohol seems to be at least cross-sectionally associated with migraine onset and have plausible mechanisms, evidence for other specific foods is less clear. This relationship is further muddied by the fact that migraine attacks actually begin in your brain hours before you feel the pain (called the “prodrome”). For example, there’s a hypothesis that the common belief that chocolate triggers migraine attacks may actually be describing food cravings for chocolate that appear during prodrome.

This has led some of us to focus more on how you eat than what you eat. For example, fasting is a well-recognized dietary pattern that is associated with migraine attack onset. So many times, behavioral migraine providers will give advice to eat consistently. But do we know that advice works?

“Not yet,” said Dr. Margaret Slavin, Associate Professor of Nutrition and Food Science at the University of Maryland. “In fact, our intuitive assumptions about exactly what dietary interventions will reduce migraine frequency are being challenged by new data.” Dr. Slavin, a Ph.D. food scientist and registered dietitian, has been challenging these assumptions and making us think in new ways about the relationship between diet and migraine.

Dr. Slavin also highlights how migraine may interfere with eating, either directly or indirectly through nausea. “It is pretty hard to eat much of anything, especially a healthy diet with small frequent meals, when you are having severe nausea.” And some people may not even feel nauseous but may just feel less hungry during a migraine attack. This is because calcitonin gene-related peptide—a signaling molecule that increases in the body during migraine attacks—is capable of decreasing food intake when studied in animal models.

I often highlight to my own patients that we have to eat. Eating is not optional, it is a foundational part of living as a human being. So given the current state of the evidence, what does Dr. Slavin recommend to her own patients?

“Clinical trials of a variety of healthy diets have shown reductions in migraine frequency. As for which diet to choose, the best healthy diet is a diet you can stick to. These research studies are conducted in a very different environment, where the research participants are often given much or all of their food for months at a time, and sometimes nutrition counseling. It’s harder for someone who’s not part of a study to eat the same rigorous diet. So, I really do encourage people to give themselves permission to not feel like they have to change their whole diet, all at once. It’s ok to make one small change at a time. Keep doing it until it sticks (or doesn’t), and then look around for something else you could change” Dr. Slavin said. “For most people, a good place to start would be to increase the amount or variety of vegetables and fruits, or to swap whole grains for refined grains (like brown rice for white rice) because these are often the most lacking in our diets.”

Ideally, patients with migraine would also want to avoid long periods of fasting, and stay hydrated. For overweight patients with migraine, a focus on a healthy diet that can lead to weight reduction may also confer benefit. “But to be clear, these recommendations are based on a relatively small number of trials, none of which we would consider a primary efficacy trial.”

I look forward to seeing the new evidence coming down the diet and migraine science pipeline. In the meantime, we can stop blaming ourselves for triggering migraine attacks with this or that food. My conversations with Dr. Slaving have just emphasized to me how the migraine-diet relationship is complex and nuanced, and that the best advice is advice everyone would do well to follow: find a healthy diet you enjoy, and stick to it.