Caffeine and Migraine
This is a review of an article on caffeine and migraine.
The relationship between severe headache or migraine has always been controversial, yet it has been thought that caffeine is one of the common everyday type drugs like acetaminophen or ibuprofen that can aggravate headache if too much is taken.
I have written a lot about the relationship between migraine and caffeine. My blog, podcast, and YouTube articles are entitled:
Caffeine is a drug
Migraine and Caffeine
Does Caffeine withdrawal help Migraine?
This is an article by Britt Talley Daniel MD, retired member of the American Academy of Neurology, Migraine textbook author, Podcaster, YouTube video producer, and Blogger.
Check out my mini eBook on Migraine.
Do caffeine and aspirin over-the-counter (otc) drugs work?
All of the caffeine and aspirin otc drugs for headache are mildly helpful for most people. For some persons with mild migraine one of these drugs may be all they need and they work very well. The majority of migraineurs need a prescription drug from a doctor for acute onset treatment of their migraine.
The other real problem in this treatment scenario is that about 50% of persons with migraine have never been given a diagnosis of migraine by their doctor and have never been given an effective acute treatment drug, like a triptan, which are still currently the most effective drugs for acute therapy.
Where do people get their caffeine?
Approximate amounts of caffeine in various beverages:
Coffee, grande 16 oz Starbucks 550 mg
Coffee, tall 12 oz Starbucks 375 mg
NoDoz or Vivarin 200 mg
7-11 Big Gulp cola 61 oz 190 mg
Coffee non-gourmet 8 oz 135 mg
Excedrin 2 tabs 130 mg
Coffee instant 8 oz 95 mg
Jolt Cola 16 oz 160 mg
Anacin 65 mg
Coke Cola 12oz 35 mg
Mt. Dew 55 mg
Dr. Pepper 39 mg
Pepsi 37 mg
Tab 46 mg
Cappuccino 8 oz 35 mg
Expresso Starbucks 1 oz 35 mg
Tea, green or instant 8 oz 30 mg
Chocolate dark semisweet 1 oz 20 mg
Coffee decaf non-gourmet 8 oz 5 mg
Coffee decaf Starbucks 8 oz 10 mg
Hot chocolate or cocoa 8 oz 5 mg
Chocolate milk 1 oz 5 mg
Pharmacological effects of caffeine.
Caffeine blocks adenosine receptors, which accelerate physiological effects to occur. Adenosine is a neurochemical that impacts the sleep-wake cycle. Since caffeine blocks adenosine receptors, it promotes alertness. Adenosine is involved with calcium channels in muscle. When caffeine blocks adenosine receptors, there is increased strength and endurance of muscles. Adenosine causes dilation of cerebral arteries, so if this effect is blocked by caffeine, vasoconstriction occurs. Vasoconstriction of cerebral arteries treats migraine.
Caffeine is 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 caffeine is 6-8 hours, but even one drink in the morning will interrupt sleep in some persons. Caffeine constricts smooth muscle found in arteries, the bladder, and the colon. It is the arterial vasoconstrictive action which helps with mild migraine (Excedrin, B.C. Powder, and Vanquish). The smooth muscle effect also acts as a mild stimulant on the bladder, promoting urination and in the colon, a bowel movement.
Too much caffeine can cause and aggravate medication overuse headache.
The International Classification of Headache Disorders recommends that over the counter drugs like Excedrin, Vanquish, and Equate may give a person with migraine medication overuse headache if one of these drugs is taken more than 15 days a month. However, the rate of occurrence of medication overuse headache is low-somewhere about 0.5-2%. But if you are a headache doctor it will be 90% of all new patients that you see.
The same limitation exists for ibuprofen, naproxen, and acetaminophen. How many migraineurs know this fact? Not very many would be my assumption. Therefore, since the over-the-counter drugs help a little, they reduce the pain some, but they do not completely rid the patient of headache so the migraineur keeps taking the drug that helped. This often goes on for days, sometimes weeks, months, or even very rarely for years.
I saw a patient in her sixties who had been taking 2 Advil twice a day since she was a child. On top of that she used an admixture of barbiturate drugs, opioid narcotics, and daily caffeine as coffee. Her diagnosis was migraine without aura and medication overuse headache. She did better with education and limiting headache medication use, taking a triptan at onset for her migraine with good treatment effect.
I live in a large metropolitan city and she told me she had seen over 10 doctors for her headaches and that no one had ever discussed drug limitation to 2 days a week or tried a triptan.
The limit of acute headache medicine to only 2 days a week.
Headache doctors counsel their migraine patients that they must limit their use of acute therapy drugs to no more that 2 days per week. Why is this? During a migraine the trigeminal cranial nerve supplying the face and eye is innervated and three chemicals are released-Substance P, Neurokinan, and CGRP.
These drugs inflame the cranial arteries and the trigeminal nerve in ways that are not completely understood. The continued use of pain killers, triptans, opioid narcotics, and barbiturate headache drugs keeps this outflowing of the inflammatory chemicals occurring. The ganglia of the arteries and nerve in the brain stem release Substance P:, Neurokinan, and CGRP.
As long as the patient keeps overtreating with Advil, Tylenol, Fiorinal, or sumatriptan, these neurochemicals are released and the headache continues. It was not unusual in a headache practice for me to see persons who had experienced daily headache mixed with frequent times of sever headache for 20-30 years.
This is an article by Britt Talley Daniel MD, retired member of the American Academy of Neurology, Migraine textbook author, Podcaster, YouTube video producer, and Blogger.
The problem with advising headache patients to stop their caffeine.
They don’t want to do it. They’ll whine and beg and negotiate in the office and then often cheat at home. They’ll say “Oh, I don’t mind stopping my Fiorinal, or my Tylenol #3 tabs, but not my morning coffee. I would die.” But if they are able to take this advice, they will do better.
The recidivism (means fall back, fail) rate for patients with chronic medication overuse headache varies according to whom you reference. Google chrome reports:
According to a guideline published in Neurological Research and Practice, the success rate of therapy for medication overuse headache is about 50–70% after 6–12 months. However, there is a high relapse rate, especially in patients with opioid overuse.
I have never seen a published rate for success with stopping caffeine alone. I think it would be lower. That is the beauty of the neurological article I am citing in this blog which reports on the relationship between caffeine intake and sever headache or migraine.
The reference article for this report is:
Lu Zhang # 1, Jiahui Yin # 2, Jinling Li writing in Sci Rep. 2023 Jun 23;13(1):10220 on
“Association between dietary caffeine intake and severe headache or migraine in US adults.”
Abstract
The relationship between current dietary caffeine intake and severe headache or migraine is controversial. Therefore, we investigated the association between dietary caffeine intake and severe headaches or migraines among American adults. This cross-sectional study included 8993 adults (aged ≥ 20 years) with a dietary caffeine intake from the National Health and Nutrition Examination Surveys of America from 1999 to 2004.
Covariates, including age, race/ethnicity, body mass index, poverty-income ratio, educational level, marital status, hypertension, cancer, energy intake, protein intake, calcium intake, magnesium intake, iron intake, sodium intake, alcohol status, smoking status, and triglycerides, were adjusted in multivariate logistic regression models.
In US adults, after adjusting for potential confounders, a 100 mg/day increase in dietary caffeine intake was associated with a 5% increase in the prevalence of severe headache or migraine (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.02–1.07). Further, the prevalence of severe headache or migraine was 42% higher with caffeine intake of ≥ 400 mg/day than with caffeine intake of ≥ 0 to < 40 mg/day (OR 1.42, 95% CI 1.16–1.75). Conclusively, dietary caffeine intake is positively associated with severe headaches or migraines in US adults.
Introduction
Severe headache or migraine is a common neurological disorder that can seriously affect people's daily lives and heavily burden individuals and society. Globally, severe headache or migraine ranks second among the causes of years lived with disability, with the greatest age-standardized prevalence in 1990 and 2017. It is three times more common in women than men, with a lifetime prevalence of 43% and 18%, respectively. It remains a serious public health issue in the United States (US), with an age-adjusted prevalence of 15.9% across all adults in 20184.
The financial strain of migraine is enormous; approximately 40% of US adults with migraine were unemployed in 2018, and a similar percentage were classified as poor or “near poor”. Therefore, effective preventive measures and modifiable risk factors for severe headaches or migraines should be investigated.
Recent studies have shown that genetics, sleep, and diet are contributing factors to headaches. Caffeine is an important area of concern in diet, and it occurs naturally in various foods, such as coffee beans, tea, kola nuts, mate leaves, and cocoa nuts. Caffeine is an antagonist of adenosine, inhibiting the release of excitatory neurotransmitters, resulting in decreased cortical excitability.
Additionally, caffeine has psychostimulant effects via the modulation of dopaminergic neurons, and dopamine plays a role in the pathogenesis of migraine. Headache attacks are related to changes in cerebral blood flow, and caffeine intake or withdrawal can change the speed of cerebral blood flow and aggravate headaches since it significantly affects the central nervous system.
Previous studies have reported the wide use of caffeine for patients with headaches, either alone or in combination with other treatments. The American Headache Society recommends over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs) and combinations such as acetaminophen, aspirin, and caffeine as Level A recommendations for reducing migraine and other symptoms.
Derry et al. reported in a randomized double-blinded study that the addition of caffeine (≥ 100 mg) to standard doses of commonly used analgesics improved pain relief; however, this finding varies among studies. Shirlow et al. conducted a study on Australians and reported that the proportion of participants with headaches increased significantly with average caffeine intake. However, Boardman et al. found no clear relationship between caffeine intake and headache in a cross-sectional study in the United Kingdom (UK).
In another study, Hoy et al. reported that caffeine preparations were effective and generally well tolerated in treating migraine and episodic tension-type headache (TTH) in adult patients enrolled in a randomized, multicenter, active-comparison study. Most previous studies are based on surveys of small samples, and studies on adults are insufficient.
Therefore, it is necessary to further investigate the relationship between dietary caffeine and severe headaches or migraines and explore the underlying mechanisms. Ultimately, we used data from the National Health and Nutrition Examination Survey (NHANES) database to explore the association of dietary caffeine intake with severe headaches or migraine in adults.
Methods
Study design and participants
The data on study participants were obtained from the NHANES, a major program conducted by the Centers for Disease Control and Prevention (CDC) to assess the health and nutritional status of adults and children in the US28. The NHANES database contains demographic, dietary, examination, laboratory, and questionnaire data. Study protocols for NHANES were approved by the National Center for Health Statistics (NCHS) Ethics Review Board (Protocol #98-12, https://www.cdc.gov/nchs/nhanes/irba98.htm). All the participants signed the informed consent before participating in the study. This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). All information from the NHANES program is available and free to the public; therefore, the agreement of the medical ethics committee board was not necessary.
Participants in our study were screened according to the following inclusion criteria: (1) aged 20 years or above, (2) caffeine intake was obtained through at least one 24-h recall, and (3) information on whether they had severe headaches or migraines.
Assessment of severe headache or migraine
Severe headache or migraine was assessed using a questionnaire that consisted of one question: “During the past 3 months, did you have severe headaches or migraines?” Participants who answered yes were considered to have severe headaches or migraine, and participants who answered no were considered not to have severe headaches or migraine.
Assessment of dietary caffeine
Dietary caffeine intake was collected through two 24-h dietary recall interviews. The first 24-h dietary recall was conducted in person, and the second was conducted 3–10 days later via telephone.
The in-person interview was conducted in a private room in the NHANES mobile examination centre using a computer-assisted dietary interview system, which an NHANES interviewer administered. The amount of caffeine consumed (mg/day) was estimated from all caffeine-containing foods and beverages, including coffee, tea, soda, and chocolate.
The caffeine content of all foods consumed by participants was estimated using the United States Department of Agriculture’s Food and Nutrient Database. We obtained the daily caffeine intake based on the sum of the caffeine content of all foods consumed in a single 24-h dietary review. Detailed information on the assessment of caffeine intake can be found at: https://wwwn.cdc.gov/Nchs/Nhanes/1999-2000/DRXIFF.htm#DRXICAFF.
In this study, we extracted the mean caffeine intake between the first and second dietary recalls as participants’ dietary caffeine intake. For participants who only attended one 24-h dietary recall, caffeine intake was defined as the day's caffeine intake.
Results
Participant characteristics
In this study, 8993 participants were included (Figure S1). Table 1 shows the characteristics of the participants according to their dietary caffeine intake. We grouped the participants according to their caffeine intake based on previous literature. Walter’s study defined 40–200 mg of caffeine per day as a "moderate" amount. Further, Nawrot and van Dam RM research pointed out that more than 400 mg of caffeine daily is harmful to health. Accordingly, we divided caffeine intake into four groups: ≥ 0 to < 40 mg/day, ≥ 40 to < 200 mg/day, ≥ 200 to < 400 mg/day, and ≥ 400 mg/day.
Statistically significant differences were observed in age, educational level, race/ethnicity, marital status, PIR, BMI, smoking status, alcohol status, cancer, TG, energy intake, protein intake, calcium intake, magnesium intake, iron intake, and sodium intake in the different dietary caffeine intake groups (P < 0.05).
Participants with the lowest dietary caffeine intake in group 1 (≥ 0 to < 40 mg/day) were likely to be younger, non-Hispanic white, less educated, living alone, poorer, and underweight, with less smoking, less drinking, no cancer, no hypertension, lower TG, and lower energy, protein, calcium, magnesium, iron, and sodium intake.
Association between dietary caffeine intake and severe headache or migraine
We investigated the individual effects of each covariate on severe headaches or migraine using univariate analyses separately for the males and females in Table 2. In males, the incidence of severe headaches or migraines was likely to be with higher education, married/living with a partner, relatively wealthy, with greater BMI, drinking, hypertension, and cancer patients. Also, the higher incidence of severe headaches or migraines in females may be higher education, those who lived alone, were relatively wealthy, with less BMI, drinking, hypertension, and cancer patients.
Discussion
The results of this cross-sectional study of adult males in the US showed the association between dietary caffeine intake and severe headaches or migraine for the first time in a nationally representative sample. After adjusting for other variables, we found a linear relationship between dietary caffeine intake and severe headaches or migraines from 1999 to 2004. We also found that age modified the association.
Age may affect the relationship between dietary caffeine intake and severe headaches or migraine; in the subgroup analysis, we found a stronger relationship in age < 60 years, and the interaction is significant among females. Hormones, such as menarche, oral contraceptive use, pregnancy, menopause, etc., greatly influence females’ migraines, mainly involving young and middle-aged people ≥ 20 to < 60 years. Studies also have shown that caffeine intake affects the levels of luteal progesterone levels, luteal total, and free estradiol in premenopausal women; in postmenopausal females, no significant associations were detected with these hormones, which may have implications for the relationship between dietary caffeine intake and severe headaches or migraine in adults non-elderly. However, its impact mechanism is still unclear, and it is necessary to conduct further studies to explore this conclusively.
This study had some limitations. First, this was a cross-sectional study; thus, we could not determine a causal relationship between dietary caffeine intake and severe headaches or migraine. Second, the data were obtained from questionnaires; therefore, there could be significant recall bias. Third, severe headache or migraine is based on self-reports and cannot be distinguished by type. Fourth, the caffeine intake calculated by food conversion may be inaccurate.
However, the data used in this study came from the NHANES database, a research program designed to assess the health and nutritional status of adults and children in the US, and is intended to be accurate. Fifth, the results may have been influenced by uncontrolled confounding, such as non-alcoholic fatty liver disease (NAFLD). Sixth, the data is nearly 20 years old at this point and may not be reflective of the current population, so our next study will include more recent data.
Conclusions
Our study showed that higher dietary caffeine intake is positively associated with a higher prevalence of severe headaches or migraines in US adults. However, further prospective studies are needed to clarify whether increased dietary caffeine intake increases the risk of severe headaches or migraine.
Dr. Daniel-So, the association of caffeine and severe migraine is valid and that is why headache doctors advise their patients to get off caffeine.
Check out my big book on Migraine.
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