The Truth About Triggers
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You and your beloved have picked an especially fine restaurant to celebrate a happy occasion in your life together. Seated at the best corner table in the softly lit dining room, you both are enjoying the spectacular view of the city lights below and the bay beyond and looking forward eagerly to a fine meal and this long-anticipated romantic evening together. To enhance your enjoyment, you splurge and order an expensive bottle of merlot.
As you toast your love for one another and raise your glass to your lips, you find the wine deliciously aromatic, and the first sip caresses your palate with its deep, smooth flavor. You sigh and look up from your glass to find your beloved regarding you with obvious adoration…and desire. What could be more perfect? You think.
Twenty minutes later that nagging pressure behind your right eye has built into a throbbing pain so severe that you find it difficult to concentrate on what your beloved is saying. You’re feeling increasingly nauseated, and the spectacular meal arrayed before you has all the gustatory appeal of a bowl of cold oatmeal. Within another ten minutes you’re in the restroom, acquainting yourself at close range with the facility’s toilet, and when you finally emerge-exhausted, sick and head pounding ever more painfully –it’s all too clear that this evening is a bust, and you’re destined for a prolonged exile (solo) to your bed within the tomb-like silence of your darkened bedroom.
Ugh. While no sane person willingly would invite such cruel punishment, who wants to give up savoring a glass of a great red wine…forever…while your migraineur kid sister can drink like a sailor and remain headache-free? Why does your migraine serve as a more accurate predictor of a change in barometric pressure than the Weather Channel? What about caffeine…Chinese food…flickering neon lights…strong perfume? Is one doomed by migraine to live like the Boy in a Bubble, insulated from all external stimuli and existing on a diet of lettuce, water and melba toast? What’s the truth about these so-called “migraine triggers”, anyway?
Individuals with migraine frequently report that their attacks may be precipitated by “triggers”. In one recent survey of 200 consecutive migraine patients referred to the University of Alabama Headache Treatment and Research Program, over 90% identified at least one migraine attack trigger; those triggers most commonly cited were physical or emotional stress (77 %), menses (72% of actively cycling females), exposure to bright or flickering light (65%) and certain (specified by the patients) odors (61%). Sleep deprivation (or “oversleeping”), fasting or skipping meals, weather changes and alcoholic drinks (especially red wine or other aromatic alcohol-containing beverages) also are commonly cited triggers.
Before we explore the more specific aspects of migraine triggers, some important general caveats deserve mention:
No single entity, however “classic” (eggs, red
wine, chocolate, “stress”), acts as a trigger in all
migraineurs.In the individual migraineur, rarely does a trigger
consistently provoke an attack.As corollary to #2, simultaneous exposure to 2 or
more triggers may be required to provoke an attack
(see below).In a given migraineur, what serves as a trigger may
also serve as a treatment (eg, caffeine).
Current theory holds that the clinical symptomotology we define as “migraine” reflects a relatively hypersensitive brain, with that hypersensitivity likely to be genetic in origin. The migrainous brain appears inherently sensitive to changes in the individual’s “internal” or “external” environment; examples of internal change include the abrupt decline in estrogen levels occurring with menses, sudden stress (or, paradoxically, release from stress) or a change in one’s usual sleep pattern (e.g., oversleeping on the weekend or vacation), whereas external changes commonly cited as triggers include weather changes, ingestion of alcohol or exposure to bright or flickering light.
Again, no single trigger - however potent – is common for all migraineurs, and an established trigger rarely triggers a migraine attack each and every time in the affected individual. Furthermore, when attacks are triggered, they may involve a spectrum of migraine symptoms that extends from no headache whatsoever (ie, aura only) to a veritable pit of physical and emotional misery. Stated at a more pragmatic level, ingestion of red wine at times may induce you to suffer a migraine, but if you maintain a passionate devotion to red wine, because the wine/attack association may not be invariable and because the attacks you do experience consequent to indulging your passion may involve only minimal headache…you may choose to play your cards and take your chances.
Or perhaps not if that glass (“or two”) of savory rioja is to be followed immediately by a sweet dessert; if that combination invariably produces annoying or even debilitating migrainous symptoms, it’s best to leave well enough alone. As another example, female migraineurs may find that ingestion of red wine invariably produces migraine only when the wine is drunk in association with another common migraine trigger: menses. As noted previously, over two-thirds of our actively cycling clinic patients report menstrual aggravation of their migraine. That what has proven to be a trigger at other points within the menstrual cycle may serve as a more consistent and potent trigger during menses is not surprising.
A word about caffeine. Finding that caffeine may trigger an attack – or learning of this potential risk from a physician, friend or another source – a migraineur may take pains to eliminate caffeine use entirely… and recoil in horror when it’s suggested that whatever oral medication is being used for acute migraine be taken with a caffeinated beverage. In reality, while caffeine can trigger migraine in some individuals, and although caffeine overuse can cause migraine progressively to worsen, caffeine can be a surprisingly effective ally in treating acute migraine. During migraine attacks the stomach’s characteristic motility may stall, and oral medications thus helplessly may linger in that organ…unable to progress down into the small intestine where they could be absorbed, into the bloodstream and exert their therapeutic effect. Caffeine can assist in restoring the stomach’s motility, and beyond simply promoting absorption of oral medications, may itself exert a more direct therapeutic effect on the migraine process. Not by coincidence is caffeine a component of so many of the preparations available for acute headache treatment, both over-the-counter and prescription (egs, Excedrin, Goody powders, Esgic, Fioricet, Fiorinal, Cafergot).
Finally, what about elimination diets? Such diets have both their diehard advocates and cold-eyed skeptics. Bottom line: (a) there are virtually no scientific data available to support an extremist position, for or against such diets; (b) by their own life experiences, most migraineurs have identified what for them are clear triggers, dietary or otherwise, and have learned to avoid those dietary components that frequently provoke attacks; (c) to maintain regular eating habits – and specifically to avoid skipping meals – is likely to be of more benefit in controlling migraine than any specific diet; and (d) adopting a migraine “elimination diet” that is inherently healthful (e.g., diets “Mediterranean” in composition) makes good sense whether it helps reduce migraine or not.
