Let's Work On Those Weekend Migraines 2023
Let’s Work On Those Weekend Migraines.
Migraine headaches come and they go, many times they just come out of the blue for no reason at all, but at other times it is that dinner you missed the night before when you came home exhausted from a draining work schedule and you just went to bed, or those 2 margaritas you had for supper at that new Mexican food restaurant to celebrate the end of the week.
Or maybe it was the late breakfast and mid-morning jogging you did on a sunny Saturday morning straight out of bed, and the hot shower you took after your exercise.
Many headaches all have well known triggers that set them off, and the same is true for your weekend Migraines.
Read my Mini Book on Migraine Here.
This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, migraine textbook author, podcaster, YouTube video producer, and blogger.
Weekend Migraine headaches. What causes them? The cause is multifactorial, like a hit list of Migraine triggers.
Possible causes are:
1.Oversleeping.
2.Alcohol.
3.Withdrawal from stress.
4.Heat/Sun/Work out headache.
5.Not eating regularly.
6.Caffeine withdrawal.
7.Humidity and Dehydration.
1.Oversleeping.
Why does oversleeping result in a Migraine headache?
Migraine is intimately related to our inner biologic cycle, especially our diurnal sleep/wake cycle. Sleep experts advise 7-8 hours of sleep every night for most persons. If someone has a job and needs to be in the office working by 9 A.M., they will need to be up at a daily set time of 7-8 A.M. Then if that person normally goes to sleep by 10 or 11 P.M. they may obtain the required amount of sleep.
If this sleep allowance is not kept then there will be problems, especially for the unfortunate Migraine brain person who has inherited a very special, sensitive brain that reacts to changes in sleep, heat, stress, estrogen levels, all sorts of medications, like caffeine, and degree of hydration.
Oversleeping several hours on Saturday or Sunday morning distorts the Migraine brain sleep cycle and can set off the start of a Migraine headache. It is to be avoided if possible. There are many articles on missed sleep aggravating Migraine.
Standard textbooks on headache have traditionally noted a relationship between sleep and migraine. Diamond and Dalessio writing in their textbook, The Practicing Physician’s Approach To Headache in 1982 list “over-sleeping” as a factor for migraine. Likewise, Saper, et al, writing the textbook, Handbook of Headache Management in 1999 state that “Sleep (too much or too little)” is a “potential provoking factor of migraine.”
Matthew writing on “Headache And Sleep” in Headache in 1987 stated, “patients with chronic, intractable, predominantly nocturnal headaches appear to have a high incidence of sleep abnormalities compared with normal persons.”
Pearlman writing in 2002 in The Spectrum Of Migraine stated:
“Sleep patterns are often variable in an adolescent lifestyle, and sleep pattern changes often trigger or exacerbate migraine. Sleep deprivation, as in this case, is a frequent trigger in children and adolescents. Regular sleep routines can often reduce headache frequency.”
Calhoun and Ford writing in 2007 on “Behavioral Sleep Modification May Revert Transformed Migraine to Episodic Migraine” stated that:
“Sleep problems have been linked with headaches for more than a century, but whether the headaches are the cause, or the result of the disrupted sleep is unknown.”
Sleep has a powerful effect on Migraine and the rules for living with it are:
Patients should set their sleep cycle to get up in the morning and go to bed every day at the same time, even through the weekend. Bedtime and rise time should not vary more than half an hour from day to day. Do not keep two sleep schedules—one for the week and one for the weekend.
Try to get 7 to 8 hours of sleep every night and stay in bed at least, but not more than, 8 hours. Patients should not watch television, read, work, or listen to music or the radio in bed.
Avoid oversleeping Saturday morning or falling asleep for that seductive two-hour nap on Sunday afternoon. This may incubate a migraine.
If you get an early morning migraine close to the time you normally awaken, try to stay up, and do not go back to sleep.
Patients should eat dinner at least 4 hours before bedtime and to limit fluids within 2 hours of bedtime.
Patients should stop all naps even if they feel tired or drowsy during the day to help consolidate the next night’s sleep.
Use an alarm clock to wake up in the morning for short 10-15 minute power naps in the afternoon.
Careful attention to these sleep ideas will help with oversleeping Migraines.
Clinical Pearl: Get up at the same time every day.
I woke up Saturday morning late!!!
2.Alcohol
Alcohol is well known to aggravate a Migraine headache.
I previously wrote in a different blog article on “Is Alcohol A Migraine Trigger?”
“Alcohol is commonly stated to be a trigger by many patients and accepted by many doctors. Controlled studies regarding consumption of alcohol triggering migraine are mostly positive for red wine. There are confusing results that limit the relationship with other forms of alcohol.
Older personal, non-scientific statements are not to be trusted as much as newer, more carefully constructed scientific research studies. One of the earliest references connecting migraine and alcohol was made by Celsus (25 B.C.-50 A.D.) “the pain…is contracted…by drinking wine.”
Another earlier statement was made by Paul of Aegina (625-690 A.D.) who commented on the relationship between drinking wine and the occurrence of migraine. Paulus Aeginata described migraine from “drinking of wine.”
It has been thought that certain chemicals in alcohol such as tyramine and histamine act in the brain to set off a migraine headache.
Who educates and writes about Migraine and Alcohol? The National Headache Foundation, the American Headache Society, and many migraine websites and doctors write on migraine advocate attention to alcohol factors to avoid migraine and often provide a list of foods and chemicals that are suspected of doing this. However, the whole question of migraine worsened by various foods is controversial and confusing.
What do expert neurologists who write about migraine say? Lance, the famous Australian neurologist who first wrote about “ice pick headache” wrote in 1995: “…my patients with special food triggers have the same number of migraine attacks when they avoid triggers as before. The only thing on which they agreed is that alcohol precipitates attacks, specifically red wine. Otherwise, I think the question of dietary migraine is very suspect.”
Clinical Pearl: If you get a headache from alcohol, watch out, especially red wine.
Why did I….?
3.Withdrawal from stress
Freedom from stress-the Letdown/Weekend/Holiday/Vacation headache—Migraines that come after stress.
Withdrawal from stress is a migraine activating factor which is just the opposite of applied stress and is paradoxical in many ways. The reaction is poorly understood and likely related to multiple neurochemical changes in the brain relating to stress. One possible mechanism is that the stress hormone, adrenalin, is secreted in our bodies when we are stressed whether we want it or know it. A cue to adrenalin secretion might be slight increase in the resting pulse or blood pressure.
All week long during the daily stress of work and family adrenalin is secreted, secretly in the body and one of the things it does is cause cerebral arterial vasoconstriction. Then, on the weekend, when there may be more unstructured time and a different schedule, the patient may stay up late on Saturday night-getting their sleep/wake cycle out of synch, and they may eat irregularly or have an alcoholic beverage with dinner Saturday night.
On Sunday, the patient oversleeps, and the pituitary/adrenal axis slows down resulting in a bad migraine Sunday morning because of adrenalin withdrawal, alcohol, and oversleeping.
Also, for many Americans Sunday may be a stressful time even though there may be no active type work. The lack of structure in the weekend days can result in arguments in the family over issues that could not be approached during the busy week. And then Sunday evening the mind unconsciously anticipates the return to the regular work week schedule and tension may arise.
Clinical Pearl: Keep stress levels steady and constant.
My Multitask world
4.Heat/Sun/Work out headache.
The relationship of heat, sun, and working out with migraine has not been studied statistically but mostly surveys of migraine patients mention it. None of the headache textbooks I consulted discussed it, but it is all over the internet if one Goggles “migraine and heat” or “migraine and the sun.”
Consider that exposure to heat, sun, or working out makes the individual red in the face or somewhat flushed. All the tiny blood vessels in the face are vasodilated following exposure to heat, the sun, or working out and the same thing happens inside the skull to the cerebral arteries. Cerebral vasodilation and trigeminal activation are the heart of migraine and clues to our understanding of what is going on in the brain with headache. There may be more subtle changes in the brain from small increases in core body temperature which promotes Migraine.
Other conditions to watch out for are a hot shower or bright sunlight, glancing off the surface of water, a mirror, or the surface of a car hood insignia which may start a Migraine.
Some migraine patients get a “work out headache” if they get hot. If this happens with exercise, then change to work out in a cool environment so you do not get so hot. Exercise inside in front of a fan or in air conditioning to jog on a treadmill rather than out in the hot July sun. Take ibuprofen, Excedrin, or a half of a Triptan drug before you work out while limiting painkillers to no more than 2 treatment days a week.
If you still get a work-out headache, then try a sport that does not raise the body temperature like swimming. A general rule regarding exercise is that if a migraine has already started then exercise should be avoided. However, in some patients, migraine may be stopped by exercise.
Aerobic exercise is good for migraine, anxiety disorders, panic attacks, depression, tension-type headache, and sleep problems. There are many articles in the last 30 years on the value of aerobic exercise for migraine.
Clinical pearls: Do not get too hot, avoid the sun, get good sunglasses, take a lukewarm bath.
Dang sun gave me a Migraine.
5.Eating regularly
The pituitary gland is the “master gland” at the base of the brain which in response to brain signals monitors all the endocrine glands in the human body. That is, the pituitary gland controls the production of insulin in the pancreas, the production of adrenalin and cortisone in the adrenal gland, and the production of thyroid hormone in the thyroid gland.
The pituitary gland is well served by arteries and veins so it can sense the flow of the chemicals in the blood stream coursing through the body. The pituitary gland continuously monitors the amount of glucose in the blood stream and then either shuts off insulin production if the blood sugar is too low or turns on insulin production if the blood sugar is too high.
The pituitary gland, in response to a low blood sugar, usually less than 50, sends out a hormonal signal that can cause vasodilation of the cerebral arteries and the start of a “hungry headache” which is usually a dull, throbbing headache in the temples or a full-blown migraine.
Because of this fact and because one of the problems with migraine patients is that they have a sensitive brain to numerous triggers and because a low blood sugar is a reliable and frequent migraine trigger, migraine patients should eat regularly.
Where I grew up that meant one ate three meals a day but interviewing many migraine patients has convinced me that not everyone heard that message, particularly young girls, or teenagers. They do not like to hear me say that “Breakfast means to break the fasting of sleep.”
When I suggest they eat three meals a day, these young ladies look at me with a shock of disbelief as if I had asked them if they like to listen to the Kingston Trio—my favorite folk group in the sixties.
Yet I persist with my advice. If they do not eat anything for breakfast, I find it helpful to then document when they do eat. When is lunch, what time is dinner? If the evening meal is 6:00 P.M. and they eat lunch at 12:00 noon I calculate out loud that they have gone 18 hours without eating so they may consider the number of hours they routinely go with no food in their stomachs. “Can you drive your car with an empty tank?”
When they sneer and suggest that they miss a meal a day to lose weight, I point out that none of the successful weight loss organizations such as Jenny Craig and Weight Watchers recommend missing meals. I look them in the eye and tell them that persons who miss meals tend to max, or one may say, pig out when they do eat.
I rarely hear a reply to that statement. Everyone knows it is true in their hearts. When they tell me, they do not have time to eat in the morning, because missing breakfast is the main meal missed, I respond that Migraine patients need to organize their lives carefully the night before so that they are prepared in the morning to live their lives in a slower, calmer fashion, rather than rushing everywhere. The Boy Scout motto is “Be Prepared.”
Aurelius Cornelius Celsus (25 B.C.-50 A.D.) was an advisor to Emperor Tiberius and Caligula who became a Roman encylopedist. He lived in Gallia Narbonensis and his only surviving work, the De Re Medicina was probably part of a much larger encyclopedia, and was a source of information regarding diet, pharmacy, and surgery.
Pearce stated that: “It is sometimes said that there was only one great Roman book on medicine: De Re Medicina.”
Celsus recognized migraine and some of its causes:
“A long weakness of the head, but neither severe nor dangerous, through the whole life. Sometimes the pain is more violent, but short, not fatal, which is contracted by drinking wine, or crudity, or cold, or heat of a fire, or the sun. And all these pains are sometimes accompanied by a fever, and sometimes not; sometimes they afflict the whole head, at other times a part of it.”
It is generally accepted that fasting can produce a migraine attack. Livening described fasting as an aggravating factor for migraine in 1793. Pearce induced moderately severe hypoglycemia (20mg/100ml) by insulin in patients with migraine and only 2 developed an attack. Rose, writing on “Food and Headache” in Headache Quarterly in 1997 stated:
“There is a slight decrease in the level of serum glucose a few hours after beginning a fast (3.3 to 3.9 mmol/L =60 to 70 mg/dl). However, because of gluconeogenesis, decrease in glycogen synthesis, and less hepatic glycolysis there is no hypoglycemia (below 2.2 mmol/L). This result occurs because of a fall in insulin level, rise in glucagon level, and increased sympathetic activity. These findings indicate that while missing meals may be a trigger for migraine attacks, it is not simply the fall in serum glucose level that is responsible.”
Clinical pearl: Eat three meals every day. Eat something for breakfast.
I’m dieting…here comes your 19th Migraine breakdown.
6.Caffeine withdrawal.
Caffeine is a drug. It is addictive. It is the number one drug that causes medication overuse headache in America.
If caffeine is not consumed at the same time, rebound headache occurs. Most people like to drink it. This is an important thought to be considered and remembered. Caffeine is in our coffee, our tea, our cola, our over-the-counter headache medicine, and our chocolate. Caffeine is ubiquitous.
The grocery store in Dallas where I live has a Starbucks outlet inside the store and then another big stand-alone Starbucks restaurant down the street in the same block. Eight oz of regular coffee has 135mg of caffeine, but one Starbucks 8 oz latte has 250 mg.
In my office I have a question on the patient registration form that asks how many caffeine drinks a day the patient takes. Doing quick simple math, I can estimate total caffeine content. Four brewed coffees (4X135=540) and 3 cokes (3X35=135) add up to 675 mg of caffeine a day which is usually for dietary, recreational, social, “I can’t get going in the morning without it,” “I get a headache if I don’t do it” reasons in the patients that I am seeing.
Caffeine is absorbed within 30 to 60 minutes after drinking a cup of coffee and its effects last from 4 to 6 hours. Pharmacologically, caffeine acts as a central nervous system stimulator, a point that is well made by the coffee ad on TV which calls it “the think drink.” “Caffeine speeds up reaction time and improves automatic processing skills like doing arithmetic problems and proofreading,” says author Stephen Braun. “But for more complicated tasks, like complex word problems, caffeine has also been shown to worsen performance.”
John J. Barone, who tracks caffeine consumption at The Coca-Cola Company in Atlanta, reports that the average American adult drinks about 200 mg of caffeine a day, while the top ten percent take in an average of 400 mg/day.
The typical American drinks about two cups of coffee a day, although at the peak of caffeine intake in 1962, three cups of coffee a day was typical. Smoking cigarettes removes caffeine from the blood twice as fast as those who do not smoke and this fact may account for why smokers drink more coffee.
The approximate breakdown in terms of the source of caffeine is coffee-75%, tea-10%, colas-10%, and chocolate-2%. Many persons feel nervous or anxious with as little as 200 mg of caffeine. Since the duration of the effect of the drug is 4 to 6 hours, if one goes to bed at 11 P.M. then the last drink of coffee should be no later than 5 P.M.
Caffeine also acts as a constrictor of smooth muscle, which is found in arteries, the bladder, and the colon. It is the arterial vasoconstrictive action which helps with mild migraine (Excedrin, Anacin, BC Powders) and may lead to rebound vasodilatation headache when one withdraws from caffeine too quickly.
The smooth muscle effect also acts as a mild stimulant on the bladder, promoting urination and in the colon, a bowel movement. Caffeine can aggravate migraine, anxiety, panic disorder, tremor, cardiac palpitations, gastric reflux, and insomnia.
Caffeine can make you sick if you stop it after taking too much or just by taking too much. The headache patients that see are commonly confused by the effects of caffeine, thinking it either treats or causes headache. Caffeine can do both but in general I suggest virgin, unadulterated cerebral arteries not getting their daily hit of caffeine.
Caffeine is a drug and after prolonged daily use if caffeine is abruptly stopped or reduced in amount significantly then the patient suffers headache followed by one or more of the following symptoms:
Fatigue, drowsiness, anxiety, depression, nausea, vomiting, clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The diagnostic criteria for caffeine intoxication are recent consumption of caffeine in excess of 250 mg a day and the development of five or more the following signs during, or shortly after caffeine use:
Restlessness, nervousness, excitement, insomnia, flushed face, diuresis, gastrointestinal disturbance, muscle twitching, rambling flow of thought and speech, tachycardia or cardiac arrhythmia, periods of inexhaustibility, or psychomotor agitation.
Caffeine may delay sleep onset, which means that it takes a person on caffeine longer to fall asleep. It also may interfere with rapid eye movement (REM) sleep and dreaming. Patients routinely taking caffeine containing medications have more trouble falling asleep at night than those who take no caffeine.
Caffeine helps absorb other drugs in the stomach and is the reason why Excedrin has caffeine and aspirin in it. Caffeine alone may act as a mild pain killer, but together with aspirin, acetaminophen, or ibuprofen may potentiate the analgesic effect. The old pre-triptan era acute migraine treatment, Cafergot, had caffeine and ergotamine in it for the same reason.
Another problem with caffeine is that the companies that sell it do not put the amount of caffeine on the label, so the unwitting consumer does not know how much he is consuming. Americans finally know the amounts of cholesterol, fat, trans fat, and salt in most foods, but the amount of caffeine is still a hidden trade secret.
Even caffeinated water--incredible that there is such a thing-- does not say how much caffeine is in it. The following table lists the amount of caffeine in some over the counter analgesics, colas, and tea.
Approximate amounts of caffeine in common drinks are:
Coffee, grande 16 oz Starbucks 550
Coffee, tall 12 oz Starbucks 375
Coffee, short 8 oz Starbucks 250
Redline RTD 250
NoDoz, max strength or Vivarin 200
7-Eleven Big Gulp cola 64 oz 190
Coffee non-gourmet 8 oz 135
Excedrin 2 130
Coffee instant 8 oz 95
Jolt 711
Anacin 65
Cola 12 oz 35
Mt. Dew 55
Dr. Pepper 39
Pepsi 37
Tab 46
Cappuchino, 8 or 12 oz 35
Expresso Starbucks 1 oz 35
Tea, green or instant 8 oz 30
Chocolate dark, semisweet 1 oz 20
Coffee decaf Starbucks 8 or 12 oz 10
Coffee decaf non-gourmet 8 oz 5
Hot chocolate or cocoa 8 oz 5
Chocolate milk 1 oz 5
Liquid Speed (amount concealed within a proprietary formula)
Caffeinated water ?
Note that gourmet decaf coffees such as Starbucks have twice as much caffeine as non-gourmet coffees so even drinking decaf drinks will still expose many persons to a considerable amount of caffeine. Migraine patients should decaffeinate themselves either quickly, in which case they likely will suffer headache and other withdrawal symptoms, or by slowly tapering down, such as decreasing by one cup of coffee or one cola every three days. Patients with medication overuse headache should generally decaf quickly.
Sadly, I must also report the sad fact that chocolate contains caffeine. The chemistry of chocolate is complicated as it also contains tyramine, theobromine, and phenylethylamine which may have a mild effect on the brain.
Clinical Pearl: Caffeine is addictive; it commonly drives Migraine headaches.
Out of COFFEE!!!!!!
7.Humidity and hydration.
Humidity is defined by the amount of water in the environment. I remember well the sticky, hot, humid summer mornings in Galveston, Texas where I lived 5 years during medical school and internship. Humidity can be sensed in our bodies and may be a Migraine trigger for some.
Hydration refers to imbibing water or fluid into out bodies. Infants and seniors are especially sensitive to this. Think of watch football or tennis players pausing to drink Gatorade or their favorite sport drink on the side lines before getting back into the game. We all need to consider proper hydration, but especially Migraineurs.
Clinical Pearls: Do not exercise or do yard work when it is too humid and keep that water bottle nearby to avoid dehydration.
Never should have jogged in the sun with no water bottle,
Check out my Big Book on Migraine Here.
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All the best.
Britt Talley Daniel MD
