What are Migraine Triggers? 2023
Many conditions are listed as causing a Migraine attack. This is not exactly true. Why? Because Migraine is an inherited genetic/familial condition and the “causation of Migraine” is that one is born with it.
Also, many of the triggers discussed casually or listed on the internet are not recognized by Migraine experts.
Who would be a good expert or reference for this type of information? Try the International Classification of Headache Disorders 3 (ICDH 3), the so called “Bible” for headache. They should know.
This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, the American Headache Society, migraine textbook author, podcaster, YouTube video producer, and blogger.
Migraine Triggers are scientifically researched conditions that predispose to developing a Migraine attack.
A list of the precipitating factors of Migraine (from epidemiological studies) include the following:
• Psychological factors: stress, mental strain, fatigue, sleep (too much or too little)
• Endogenous factors: menstrual cycle
• Environmental factors: weather change, temperature change, frequent travels, odors
• Dietary factors: hunger and alcohol. For other food groups, since response differs individually, there is no need to restrict intake.
These terms require definition. The International Classification of Headache Disorders differentiates between a migraine trigger which is something that causes an attack within 24 hours, like red wine inducing a migraine minutes after it is consumed, and an "aggravating factor" like stress which builds up over weeks to produce migraine.
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Related questions.
How should individual migraine patients deal with precipitating or aggravating factors in their daily lives?
With time and experience migraine patients need to learn that an attack occurs easily under specific conditions.
Therefore, migraine attacks may be prevented by avoiding the precipitating/aggravating factors that set off their migraines.
It is important that individual patients know what factors precipitate or aggravate their own migraine.
What did the authors of the ICDH 3 find by searching the literature to identify the precipitating/aggravating factors that affect migraineurs?
Approximately 75% of migraine patients have some kind of precipitating factors.
The common migraine precipitating/aggravating factors identified in various epidemiological studies include:
Stress
Mental strain
Fatigue
Sleep
Menstrual cycle
Weather change
Temperature change
Frequent travels
Odor
Hunger
Alcohol
Does stress have a significant place as a factor for headache?
Apart from alcohol, the other factors listed above are also precipitating factors of tension-type headache.
Stress is one of the most prominent precipitating factors of migraine.
Stress triggers migraine in approximately 60% of the patients, and 25% of these patients feel that headache occurs when they are relieved from stress (the let-down headache).
How strong are sleep issues?
Lack of sleep is perceived as the trigger in approximately 30% of the migraine patients.
Too much sleep is implicated in 25%.
What about weather issues?
Weather is cited as the precipitating factor in 53% of the migraine patients.
11% of the patients felt that weather is the precipitant in two-thirds of the headache attacks.
What about red wine?
Among alcoholic beverages, red wine is a famous precipitating/aggravating factor.
Histamine that is related to pain, and alcohol and polyphenol that possess vasodilating effect are probably involved in the precipitating/aggravating effect.
In a study of a group of migraine patients who believed that red wine provoked migraine and a group who did not, migraine was triggered by red wine only in the group that believed that red wine provoked migraine.
What about food aggravating Migraine?
Findings regarding food suggest that the precipitating factors may differ depending on individual patients with migraine.
Even from the old days, foods containing amines represented by tyramine, such as cheese, chocolate, citrus fruits, and nuts are well known to precipitate migraine.
In a survey conducted in England, 16 to 18% of respondents cited chocolate or cheese as precipitating factor.
A double-blind placebo controlled study in 20 patients who believed that chocolate provoked migraine found that chocolate ingestion triggered migraine attacks in many patients.
On the other hand, a double-blind study using chocolate and placebo in patients with chronic headache (including migraine and tension-type headache) found no difference in the rate of migraine provocation between chocolate and control even in patients who believed that chocolate was a precipitating factor.
While a large number of foods have been implicated as precipitating/aggravating factors, they do not apply to all the patients.
Even in the same patient, a given food does not always provoke headache. Few patients mention specific foods apart from alcohol.
Therefore, unnecessary dietary restriction may have the opposite effect of lowering patients’ Quality Of Life.
The American Headache Society publishes views on triggers of migraine on its website.
According to a survey conducted by Takeshima persons with migraine consume more fatty/oily foods, coffee, and tea than persons without headache. From these data, regular consumption of a well balanced diet is recommended.
What about Migraine and obesity?
Although there is no correlation between obesity and the prevalence of migraine, study has shown that obesity is associated with chronic progression of migraine.
Despite recent advances in the treatment of migraine, many patients still do not achieve symptomatic relief. However, even in such patients, lifestyle improvement, for example through sleep and dietary guidance and stress management, may mitigate symptoms, and maintenance of appropriate weight may present chronification of migraine.
Chabriat, et al,[i] wrote in 1999 in Headache on “Precipitating factors of headache. A prospective study in a national control-matched survey in migraineurs and non-migraineurs.” They screened prospective factors in a migraine and non-migraine group of patients who kept a diary for a 3-month period. The most frequent precipitating factors in both groups were:
“fatigue and/or sleep, stress, food and/or drinks, menstruation, heat/cold weather, and infections in both groups.”
Kelman[ii] writing in Cephalalgia in 2007 on “The triggers or precipitants of the acute migraine attack” listed stress at a frequency of 79 % and food at 26.9 %. The table of frequency of individual migraine triggers from his article was:
Trigger Frequency
Stress 79.7%
Hormones (in women) 65.1%
Not eating 57.3%
Weather 53.2%
Sleep disturbance 49.8%
Perfume or odor 43.7%
Neck pain 38.4%
Light (s) 38.1%
Alcohol 37.8%
Smoke 35.7%
Sleeping late 32.0%
Heat 30.3%
Food 26.9%
Exercise 22.1%
Sexual activity 5.2%
Kelman is not going by ICDH here which refers to stress as an “aggravating factor,” not a “trigger.” However, his list is interesting and I keep a copy of this article in my office to hand out.
Another observation here is that many patients will focus on the different foods that may aggravate migraine and not recognize stress in their lives which is the most aggravating feature of migraine.
I guess one’s diet is an easy thing to consider and look up and avoid, and everybody needs to watch what they eat, but food as a trigger for migraine is not the big issue.
What about Migraine and menstruation?
This is clearly another big trigger for Migraine and probably the main reason shy women, who menstruate, have 3X as many Migraine attacks than men, who do not.
The big issue is stress. Look at the Kelman's table above which lists various triggers and their frequency. Stress is at the top and food is near the bottom. All migraine studies of frequency of migraine triggers are like this.
Stress concerns personal insight, work/family relationships, time, travel, eating, exercise, faith, getting along. It’s a tough series of issues that need to worked out, sometimes requiring counselling, with migraine patients.
Check out my big Migraine book.
• References
Chabriat H, Danchot J, MIchel P, Joire JE, Henry P, Precipitating factors of headache. A prospective study in a nation control-matched survey in migraineurs and nonmigraineurs. Headache. 1999;39(5):335-338.
1) Kelman L: The triggers or precipitants of the acute migraine attack. Cephalalgia 2007; 27(5): 394-402.
2) Robbins L: Precipitating factors in migraine: a retrospective review of 494 patients. Headache 1994; 34(4): 214-216.
3) Takeshima T, Ishizaki K, Fukuhara Y, Ijiri T, Kusumi M, Wakutani Y, Mori M, Kawashima M, Kowa H, Adachi Y, Urakami K, Nakashima K: Population-based door-to-door survey of migraine in Japan: the Daisen study. Headache 2004; 44(1): 8-19.
4) Rasmussen BK: Migraine and tension-type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle. Pain 1993; 53(1): 65-72.
5) Zivadinov R, Willheim K, Sepic-Grahovac D, Jurjevic A, Bucuk M, Brnabic-Razmilic O, Relja G, Zorzon M: Migraine and tension-type headache in Croatia: a population-based survey of precipitating factors. Cephalalgia 2003; 23(5): 336-343.
6) Turner LC, Molgaard CA, Gardner CH, Rothrock JF, Stang PE: Migraine trigger factors in non-clinical Mexican-American population in San Diego county: implications for etiology. Cephalalgia 1995; 15(6): 523-530.
7) Spierings EL, Ranke AH, Honkoop PC: Precipitating and aggravating factors of migraine versus tension-type headache. Headache 2001; 41(6): 554-558.
8) Chabriat H, Danchot J, Michel P, Joire JE, Henry P: Precipitating factors of headache. A prospective study in a national control-matched survey in migraineurs and nonmigraineurs. Headache 1999; 39(5): 335-338.
9) Littlewood JT, Gibb C, Glover V, Sandler M, Davies PT, Rose FC: Red wine as a cause of migraine. Lancet 1988; 1(8585): 558-559.
10) Peatfield RC, Glover V, Littlewood JT, Sandler M, Clifford Rose F: The prevalence of diet-induced migraine. Cephalalgia 1984; 4(3): 179-183.
11) Peatfield RC: Relationships between food, wine, and beer-precipitated migrainous headaches. Headache 1995; 35(6): 355-357.
12) Gibb CM, Davies PT, Glover V, Steiner TJ, Clifford Rose F, Sandler M: Chocolate is a migraine-provoking agent. Cephalalgia 1991; 11(2): 93-95.
13) Marcus DA, Scharff L, Turk D, Gourley LM: A double-blind provocative study of chocolate as a trigger of headache. Cephalalgia 1997; 17(8): 855-862.
14) Wber C, Holzhammer J, Zeitlhofer J, Wessely P, Wber-Bingl C: Trigger factors of migraine and tension-type headache: experience and knowledge of the patients. J Headache Pain 2006; 7(4): 188-195.
15) HEADACHE: The Journal of Head and Face Pain (website): The American Headache
16) Bigal ME, Lipton RB: Obesity is a risk factor for transformed migraine but not chronic tension-type headache.
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All the best.
Britt Talley Daniel MD