List of 24 Common Migraine Triggers
List of 24 Common Migraine Triggers
Migraine is a genetic condition that is inherited through your DNA. The genes that transmit migraine have been found and published in the medical literature. Migraine occurs in 25 % of women and 6 % of men. For women migraine is their most common chronic medical problem and more prevalent than diabetes, heart disease, or arthritis. Migraine is one of the main causes of disability worldwide in men and women. Migraine causes more than a million ER visits every year.
An attack of migraine lasts 4-72 hours and may be called episodic migraine if it occurs less than 14 days per month, or chronic migraine if more than 15 headache days a month occur, 8 of which have migraine features. Researchers have discovered so-called “Migraine Triggers” which may set off an attack within 24 hours. “Aggravating features” are more chronic occurring factors, lasting weeks to months that may set off a migraine headache.
This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, the American Headache Society, migraine textbook author, and blogger.
List of Common Migraine Triggers and Aggravating Features. The list is as follows:
Freedom from stress—letdown/weekend/holiday headache
Menstruation with fluctuating estrogen levels
Elevated estrogen level from birth control pill or treatment of postmenopausal women
Hypoglycemia from fasting
Barometric weather change
Mountain sickness/decompression illness
Over-sleeping or napping
Nocturnal end of a dream headache
Overuse of analgesics
Brain freeze/ice cream headache
Toothache/grinding with TMJ syndrome
Discussion of individual issues
1.Stress/nervous excitement. Stress is always the number one driver of migraine. Stress is outside pressure in life, work, family that is upsetting. Humans used mental mechanisms of “denial” “projection” “suppression” to deal with unsettling situations. It could be working 2 extra hours a day, caring for a sick child or family member, interoffice conflict, monetary pressure, an overbearing, critical boss, or many other things. Whatever it may be the stressful event occupies our minds, and if unhealthy we brood, or bury it and don’t talk about it. If we are healthier, we discuss the problem with our spouse, co-worker, friend, family member, priest, rabbi, or preacher. We get it out and deal with it. Then we feel better and we find a way to make it through.
Stress can cause acute nervous excitement, sometimes with symptoms from altered normal physiology of our bodies, like the rapid heartbeat, trembling hands, and trouble breathing that may come with a panic attack. Whatever the stress is, it can set off migraine headaches.
2.Freedom from stress—letdown/weekend/holiday headache. Some people reliably get a migraine not at the time of stress, but when they are free of stress. Examples of this may be the “letdown” migraine that occurs after completing exams at school, or a mother who finally finishes everything she must do on Thanksgiving to buy and prepare the turkey and fix up her home for 14 family members. She sits down, puts her feet up, and soon an awful migraine starts in her left temple. Part of this may be caused by withdrawal from the constant vasoconstrictive effect of the stress hormone, adrenalin. Contracted arteries are suddenly released into vasodilation and a severe migraine starts.
3.Menstruation with fluctuating estrogen levels. Liveing, the great British cataloguer and writer of migraine in the late eighteenth century described “catamenial” (menstrual related) migraine in 1873. It is known that about 60-70 % of women with migraine develop a migraine around the end of the third week of their menstrual cycle when estrogen levels fall. This is called menstrually related migraine without aura. Thirty percent of women have no menstrual cycle related migraine. The first 6 months of pregnancy are a high estrogen time for mothers and migraines rarely come then.
It is not well understood exactly how falling levels of estrogen produce migraine.
4.Elevated estrogen level from birth control pill or treatment of postmenopausal women. The FDA has warned that all estrogen-based birth control pills are “contraindicated” with migraine. This means they shouldn’t be taken by migraineurs. Also, postmenopausal women may develop more frequent and severe migraines taking estrogen.
The general rule here is that both fluctuating levels of estrogen, such as occurs with the normal menstrual cycle of 3 weeks of estrogen and then a week of progesterone, or estrogen levels that are too high, may worsen migraine.
5.Hypoglycemia from fasting. It is well accepted that fasting can produce a migraine attack in persons with migraine. Liveing described fasting as an aggravating factor for migraine in 1873. Everybody gets hypoglycemia if they don’t eat. Your car won’t go if it doesn’t have any gas either. Breakfast means “break the fasting of sleep.” Migraine patients should eat three meals a day and carry extra snacks or power bars if they get hungry.
6.Barometric pressure change. Migraine patients commonly report when seen back on regular visits about the effect of weather change or cold fronts or barometric pressure aggravating their headaches. I hear it all the time. It’s like persons sometimes say they can “feel a storm coming” in their bones. Liveing reported the influence of the atmosphere on migraine in his big book on migraine in 1873.
It may be due to the pressure difference between the atmosphere and air-filled sinuses. I never learned about barometric pressure sensors in the brain while studying neuroanatomy. Some say the reaction comes from barometric sensors in the carotid arteries, or traction on cranial dural veins, or cranial sinuses.
Certain barometric changes set off migraine headaches. It happens with mountain sickness, scuba diving, high altitude jet travel, decompression illness, altitude changes, and with dry wind sweeping down from the mountains.
A study in a Journal of Internal Medicine article reported on migraine patients who kept a headache diary for one year. After comparing these diaries with the barometric pressure changes noted at a nearby weather station, a direct correlation between lower atmospheric pressure and the onset and duration of migraine attacks was found. The report concluded that “barometric pressure change can be one of the exacerbating factors of migraine headaches.”
Prince, et al, writing in 2004 in Headache on “The Effect of Weather on Headache” on 77 patients in a migraine clinic. Thirty-nine or 5.6 % were found to be sensitive to weather but 48 (62.3 %) thought they were sensitive. The authors concluded:
Our study supports the influence of weather variables on headache. We showed that patients are susceptible to multiple weather variables and that more patients thought weather was a trigger than was the case.
I instruct patients to monitor barometric pressure daily on their cell phone or computer and to treat early with a triptan, even before the migraine starts, if they usually get an attack with pressure change.
7.Motion sickness. Motion sickness is also comorbid 60 % with migraine. Motion sickness is car sickness when a child, inability to read in the car, especially in the back seat, air sickness, sea sickness. Migraine inflames all the sensory cranial nerves and the eighth cranial nerve carries audition and motion sensitivity from the inner ear into the brain. The migraine process inflames this nerve. Many patients with an acute migraine get car sick when driving which may not bother them when they don’t have a migraine headache.
A new classification of migraine from the International Classification of Headache Disorders is Vestibular Migraine. This may be attacks of vertigo with or without migraine headache at the same time that comes with nausea, vomiting, and prostration. The word vertigo comes from the Latin meaning “to turn or spin.” In its broadest application vertigo may mean perception of movement of their environment by an affected patient.
As an ex-Navy neurologist, I know that the US Navy has a medical restriction regarding motion sickness that may drive an unfortunate, promising, and willing recruit to a medical board for dismissal. Reason would imply that motion sickness is potentially a medical limiting problem for any sailor.
Motion sickness can be experienced riding in the car, while reading in the car, in a boat, or on an airplane. Migraine patients get motion sickness more than the normal population and the existence of motion sickness is often queried on headache history inventories in the office of the neurologist. Patients with motion sickness report symptoms also at the fair on whirling rides or roller coasters. Sometimes after the motion induced vertigo and nausea, the patient with motion sickness will get a headache as a migraine may be activated by the experience. Gradually they learn to avoid such rides. They know they can’t read in the car and that it’s better to drive or sit in the front seat and with time they adjust to the problem.
8.Insomnia. Poor sleeping habits have a powerful effect on migraine headaches. Insomnia is a core diagnostic feature of depression, which is 50 % comorbid with migraine, and with generalized anxiety disorder, GAD, which is 40 % comorbid with migraine. Using an electroencephalogram, EEG, sleep has four stages, with stage 1 being light sleep and stage 4 being deep sleep. All the sleep studies on migraine patients find they only get to light, stage 2 sleep. Trouble sleeping could be taking a long time to fall asleep or trouble staying asleep, or sometimes both problems.
Then during dreaming rapid eye movement, REM, sleep occurs, and migraine patients may experience an “end of the dream” wake up migraine headache. Migraine patients also may have early morning “wake up“ headaches. Oversleeping on a non-working Saturday or Sunday morning may trigger a migraine.
9.Fragrances. Migraine inflames all the brain sensory nerves and the olfactory nerve is the first of 12 cranial nerves. The odors or fragrances that aggravate migraine are cigarrete or cigar smoke, perfumes, paint, and mildew. This is called osmophobia. Migraine patients have sensitive brains.
Kelman in Headache wrote on osmophobia and taste abnormality in a large (727) group of migraine patients. Kelman reported:
Osmophobia and taste abnormality occur in one quarter of migraineurs during an acute migraine attack while perfume or odor trigger migraine in almost 50 % of patients. Osmophobia and taste abnormality in the acute migraine attack, as well as perfumes or odor as a migraine trigger, are more common in females than in males.
11.Flashing/flickering/fluorescent light. Sensitivity to light or photophobia is one of the necessary diagnostic features of migraine according to the International Classification of Headache Disorders. Many different types of light may aggravate the sensitive brain of a migraine patient. Patients may state that they have experienced the start of a migraine after seeing “light glance off the shiny chrome of a car or water.” Others may state that their migraine started after watching the sunshine through “lines of trees while driving.” Migraine patients who go to bars where there is loud rock music and flashing strobe lights may get a headache.3
Fluorescent lights will flicker when they are turned on, particularly if they are old or need to be replaced. If this light is located in the workplace, it may aggravate certain sensitive migraine patients. I have written notes for patients to give to their boss requesting these fluorescent lights be replaced. I have also had some patients who wore dark glasses at work because they couldn’t get the light changed. Many migraine patients wear hats with bills or sunglasses when outside. They avoid the light.
12.Fever. Someone with fever has a flushed, red face. In this condition all the superficial arteries in the skin of the face are vasodilated. During an attack of migraine, the cranial arteries are also vasodilated. Persons without migraine may get a “vasodilating headache” with fever but migraine patients are more commonly affected.
13.Dietary factors. This is a complicated, controversial subject in the migraine literature. I have a list of possible foods that may aggravate migraine on my webpage, www.doctormigraine.com under the general migraine category and a chapter in Migraine called Migraine Aggravating Events. The usual foods discussed are hot dogs, foods with monosodium glutamate MSG, chocolate, and yellow cheeses.
14.Heat/sun/workout 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 also which promotes migraine.
15.Intercourse/Orgasm. The occurrence of a sudden, quick, high-intensity, onset to peak level 10 headache with orgasm is a well know and reported occurrence with migraine. These headaches have been described as “they come on in seconds, like a flash, like a bolt from the blue, like I was hit on the head with a hammer.” After neurologic workup these headaches are usually considered benign.
Hippocrates described headache “from immoderate venery.” Venery is excessive sexual activity. Napoleon’s wife reportedly stated, “Not tonight; I have a headache.” This is a common somewhat humorous cliché reflecting the socially assumed but inaccurate gender differences in sex drive and the perceived role of women regarding controlling and sometimes avoiding sexual activity which exists in modern culture.
Lance, a famous Australian headache neurologist first wrote about it in 1969 in his article “Coital Cephalalgia.” Lance later stated:
Since foods and wines are often incriminated as sources of headache, it seemed only a matter of time before sexual intercourse was added to the list of pleasurable activities which may be responsible for headache, the most common of kill-joys.”
However, Couch and Bearss reported in 1987 that some individuals have noted relief from migraine headache with sexual activity and orgasm, so go figure. For a thorough discussion of this subject go to Chapter 12 in my book, Migraine. ICHD calls this “Primary headache associated with sexual activity.”
15.Overuse of analgesics. This is the most common reason for a headache patient to see a headache doctor. The syndrome was first called “rebound headache” a basketball term indicating return of headache after initial successful treatment. This is now called medication overuse headache and affects 3-4 % of the world population. ICHD says taking triptans or over the counter drugs (caffeine, Tylenol, Advil, or Naprosyn” over 15 days a month or opioid narcotics or butalbital more than 10 days/month may produce chronic migraine (15 of more headache days a month,8 of which have migraine features). See Chapter 5 in Migraine for a thorough discussion.
16.Head injury/concussion/post-concussion. All of the following entities may worsen migraine-- a mild non-concussive head injury for several days, concussion for weeks to a month, and post-concussion syndrome for several months. None of the injures cause headache every day for a long time, like a year without medication overtreatment. The doctor and the patient must be careful with the judicious use of treatment for headache in this situation. Opioid narcotics and butalbital have no place here. Caution also with using over the counter drugs like caffeine, Tylenol, Advil, or Aleve because they can produce daily medication overuse headaches.
In general patients with head injury should be scanned at the ER with CT and be examined by a doctor.
Head injures may release neurochemicals into the brain that aggravate headache. There is a head injury migraine syndrome called “Post-traumatic Migraine.”
Caffeine is the most commonly used over the counter vasoactive drug in the world used to treat headache. The popular soft drink, Coca Cola, was invented by a pharmacist for the purpose of treating headache.
Caffeine has been combined with aspirin as Excedrin for treatment of migraine and it is all that a number of mild migraine patients need to get rid of their headache. In recent years the Starbucks chain has placed their ubiquitous logo and coffee houses all over America selling very high caffeine content coffee which has moved the American caffeine addiction problem to higher levels.
Medical articles declaring addiction to caffeine and predictable withdrawal symptoms following cessation occurred in the early 1990’s and probably influenced the inclusion of caffeine as an addictive drug in the 1994 edition of the DSM-IV, the American Psychiatric Association’s fourth Diagnostic and Statistical Manual.
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.” The duration of the effect of the drug is 4-6 hours. This means that if one goes to bed at eleven PM, then the last drink of coffee should be no later than three PM so that caffeine doesn’t affect sleep, although many persons will sleep better with no caffeine at all.
Caffeine also acts as a constrictor of the smooth muscle, found in arteries, the bladder, and the colon. It is the arterial vasoconstrictive action of Excedrin which helps mild migraine and may lead to medication overuse headache when one withdraws from caffeine. The smooth muscle effect also acts as a mild stimulant on the bladder, promoting urination and in the colon, a bowel movement.
Withdrawal symptoms are: headache, fatigue, restlessness, nervousness, insomnia, exhaustion, and psychomotor agitation and they may last 2-4 weeks.
See my webpage articles on “Caffeine is a drug.” And “How does caffeine worsen migraine,” at www.doctormigrine.com.
18.Wine/beer/alcohol/hangover headache. Paulus Aeginata in the seventh century described migraine from “drinking of wine.” Gallagher writing in Headache in 1988 on “Diet and Migraine” stated:
Alcohol is a nonspecific vasodilator that is thought to provoke migraine attacks in susceptible persons by depressing or altering the function of central vasomotor centers, since the direct effect of alcohol on blood vessels is insignificant. Of all the known precipitating agents, alcohol is the most consistent provoker of headache in the largest number of migraine patients.
As time has gone on and more research has been done, the relationship of alcohol to headache has become more complicated. Alcohol may cause an immediate headache, like 30 minutes after drinking a glass of red wine, or a delayed headache, called “a hangover” that comes on the next morning.
Some persons drink to excess to have a next morning hangover, while the migraine patient may awaken with a headache following only a small amount of alcohol.
See my blog article on “Is alcohol a migraine trigger?” at www.doctormigraine.com. and the chapter in Migraine on “Migraine Aggravating Events.”
19.Brain freeze/ice cream headache. Raskin wrote that the most common cause of head pain is ice cream, occurring in one third of a randomly selected population. Most people are familiar with this problem. They eat something very cold and when that cold substance touches the roof of their palate, many times and very soon they experience an intense, dagger like pain extending from the palate and throat through their head that stops them from doing anything for a few moments.
Hulihan in his 1997 British Medical Journal editorial in 1997 entitled “Ice Cream Headache. No need for abstinence,” described the problem as follows:
The pain begins a few seconds after the rapid ingestion of cold foods or beverages and peaks in 30-60 seconds. The pain is usually located in the midfrontal area, but can be unilateral in the temporal, frontal, or retro-orbital region. It is a stabbing or aching type of pain that recedes 10-20 seconds after its onset. Rarely, it persists for two to five minutes.
The cold substance, which could be rocky road ice cream or a 711 slushy, provokes the sensitive temperature fibers of the second, maxillary division of the trigeminal nerve and the glossopharyngeal nerve in the throat so that certain persons develop this predictable, short lived, but disturbing experience. Pain and temperature fibers travel together through the same neuronal pathway and then “cold” can become “pain” very quickly.
The question is whether many normal non-migraineurs get brain freeze headaches or if it is a specific migraine trigger? As with many modern myths that are carefully studied “the devil is in the statistics.” The Migraine book has more to say about this.
No treatment is usually required, and sufferers rarely seek medical attention. Since the posterior aspect of the palate is most likely to produce the referred pain of ice cream headache, avoiding contact of the cold food with this area can effectively eliminate the symptoms. Most people arrive at such preventive measures without the advice of doctors. Ice cream abstinence is not indicated.
20.Toothache/grinding with TMJ syndrome. All teeth and the temporomandibular joint (TMJ) are innervated by the trigeminal nerve. Pain from dental or joint disease can aggravate brain pathways that lead to migraine.
21.Prolonged overexertion. Overexertion turns on the autonomic nervous system and the pituitary-adrenal system much like stress or the “flight and fight response.” Cerebral neurochemicals are produced also. The problem for the patient is that their bodies do all these things naturally and without their will so that when the exertion is over the patient collapses and tries to get some rest. Subsequent withdrawal of adrenalin or cerebral neurochemicals can produce a “let down headache” at a time of rest following exertion. This may be the weekend, a vacation to the beach, the end of school when the kids are out, or the downside migraine attack that follows a major national or religious holiday.
1.Which of the list are triggers and which are aggravating factors?
It depends upon time and which ones result in a migraine within 24 hours or following an accumulation of problems.
Triggers would be: menstruation, hypoglycemia, barometric weather change, motion sickness, mountain sickness, over sleeping, end of dream, fragrances, flashing light, dietary factors, heat, orgasm, head injury, fever, caffeine withdrawal, alcohol, brain freeze, and toothache.
Aggravating factors would be: stress, freedom from stress, elevated estrogen, insomnia, overuse of analgesics, and over exertion.
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Britt Talley Daniel MD