When I lived in San Diego, I had a friend who was an orthopedic surgeon. Chuck was a really nice guy and excellent physician who uncomplainingly worked incredibly long hours and never seemed fazed emotionally or physically by the high level of chronic stress he endured. Once or twice a year he and his gorgeous wife with the movie star looks would fly to some exotic destination or another for some well-deserved R&R. One particular year they were off to Switzerland to spend five days at a romantic chalet in a charming alpine village. I tried with limited success to hide my envy.

When Chuck returned, however, he glumly told me that he spent the entire five days in bed – alone, he emphasized, ruefully - with the room darkened and a trashcan kept close at hand as a receptacle for his repetitive vomiting.

“You’re a neurologist,” he demanded. “Tell me why I never have a headache when I’m working 20 hour days, but then almost every vacation we go on is ruined because I have a horrible migraine for the entire time.”

In a survey of 200 consecutive migraine patients referred to a university-based headache clinic, my colleagues and I found that over 3/4ths of those patients reported “stress” as a migraine trigger. It may seem fine point, but having pondered the matter for a few years I think it may be important to distinguish between migraine “triggers” and migraine “aggravators”. Whereas chronic stress may aggravate migraine chronically and cause one to experience a heavier migraine burden over the weeks and months that pass, it is sudden stress – or, as in Chuck’s case, sudden release from stress – that may serve as an acute migraine trigger.

Sudden change - be the change good, bad or neutral - may abruptly activate the migraine circuitry and produce an acute episode of migraine that at times may persist for days. That change may involve the external environment (an abrupt change in barometric pressure, exposure to bright sunlight, a pungent odor, ingestion of red wine) or the internal environment (the drop in sex hormone levels experienced at menses, sleep deprivation, oversleeping, skipping a meal). Migraine thrives on such changes, and a holistic approach to reducing migraine burden includes eliminating or at least reducing both environmental triggers and aggravators.

For example, in the aforementioned study of a clinic-based migraine population, over 70% of actively cycling females reported menses as a migraine trigger. When medically appropriate, eliminating menses as a trigger by use of a hormone-secreting IUD or use of an active oral contraceptive throughout the month may reduce overall migraine burden. Because episodes of menstrually-associated migraine tend to be of longer duration and more difficult to treat acutely than episodes occurring at other times of the month,  eliminating the menstrual trigger may go long ways towards reducing migraine-related disability.

Be it red wine, bright lights, acute stress or acute relief from stress, no single trigger – however potent – is common to all migraineurs, and an established trigger rarely provokes a migraine attack each and every time the affected individual is exposed to the trigger. Furthermore, when migraine attacks are triggered, the spectrum of migraine symptoms experienced may span the spectrum from no headache whatsoever (aura only) to a veritable pit of physical and emotional misery… and everything in between.

Suppose you maintain a passionate devotion to red wine, but you know that ingestion of red wine at times may induce you to suffer a migraine. Because the wine>migraine 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 you may find from experience that enjoying red wine (or any other alcoholic beverage) serves as a trigger only if combined with another trigger (egs, the menstrual week, a sweet dessert, dehydration). As noted previously, the majority of actively cycling female migraineurs report menstrual aggravation of their migraine, and 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 hardly surprising.

Often my clinic patients who are using a therapy for migraine prevention will tell me that they are doing quite well… except if the weather pattern has been unstable…or there is a lot of stress at work…or there is a lot of stress outside work, etc. I live and practice medicine in metropolitan DC. The weather pattern here is always unstable, and the environment at work and elsewhere is always stressful. Along with an overall reduction in migraine burden, what one ideally receives from clinically adequate prevention therapy for migraine is increased insulation against triggers and aggravators. The barometric pressure changes and the stress are going nowhere; what can change is one’s susceptibility to having environmental factors trigger or aggravate migraine, and to decrease that susceptibility may require a combination of medical pharmacotherapy, aerobic conditioning, regular sleep and dietary habits, and any of a variety of options that fall under the big tent of “relaxation training”.

Before ending, a word about caffeine. Assuming that caffeine intake predisposes to migraine, a migraineur may recoil in horror when it is suggested that whatever oral medication is being used for acute migraine treatment be taken with a caffeinated beverage. The reality is that while caffeine occasionally can trigger migraine in some individuals, and although caffeine overuse definitely can aggravate migraine and increase migraine burden, caffeine can be a surprisingly effective ally in treating acute migraine. During migraine attacks, the stomach’s characteristic motility may stall, and oral medications may linger helplessly in the stomach…unable to progress down into the small intestine where they otherwise could be absorbed, enter the bloodstream and exert their therapeutic effect.  There is some evidence that caffeine may assist in restoring at least a portion of the stomach’s motility and thus promote more effective and rapid absorption of medication taken orally. Aside from this, caffeine itself may exert a direct therapeutic effect on the acutely activated migraine circuitry. Not by coincidence is caffeine a component of so many of the preparations available for acute headache treatment, both those available over the counter and those requiring prescription (egs, Excedrin, BC powders, Fioricet). If you are a migraineur, avoid high level chronic consumption of caffeine, avoid abrupt caffeine withdrawal, and try using caffeine as a treatment for acute migraine headache.

John F Rothrock, MD

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