Integrative nutrition treatment considerations for migraines

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By Kellie Blake, RDN, LD, IFNCP

I recently had a patient who reported several migraine headaches per month. She was prescribed several pharmaceuticals and ibuprofen as needed and reported good symptom control during migraine episodes, but she desired a more natural, preventative approach.

Migraine headaches can be debilitating for many people leading to poor quality of life and lost work productivity. It is estimated that 28 million Americans suffer from migraine symptoms including moderate to severe throbbing headache pain with nausea, vomiting, light sensitivity, and/or aversion to loud sounds.

As reported in American Family Physician, migraines are the fourth most common cause of emergency room visits in the United States, yet the etiology remains unclear. It is thought to involve vasoconstriction followed by reactive vasodilation, but an energy deficit to the brain and increased oxidative stress are also considerations.

Traditional treatment includes pharmaceuticals, but medication over-use is a concern in this population and long-term side effects like rebound headache, drug dependence, and heart attack can occur. Considering these possible side effects and that migraine frequency is reduced by less than 50 percent with these medications, the investigation of healthier alternatives for prevention and treatment is indicated.

As is the case in many health conditions, adverse food reactions can be a culprit leading to negative symptoms. In the absence of a serious allergic reaction though, many patients may not make the connection between what they are eating and migraine attacks. While there are some known triggers of migraine headaches, such as caffeine, chocolate, cheese, citrus fruits, alcohol, nitrates, and monosodium glutamate, each patient can have unique food allergies, sensitivities, and/or intolerances to address as well. 

A full elimination diet can provide very helpful information when it comes to determining trigger foods. For a period of eight weeks, I have patients eliminate gluten, corn, soy, dairy, pork, beef, processed meats, shellfish, peanuts, caffeine, eggs, alcohol, sugar, soda, and chocolate. In addition, inflammatory oils, food additives, and artificial sweeteners are excluded.

Patients often experience significant relief when stripping away these potential triggers. To determine problematic foods once the elimination period is completed, I have patients reintroduce an eliminated food by consuming two to three servings of that single food in the unprocessed form on one day. Patients are encouraged to avoid that food for days two and three and to keep track of any negative symptoms. If symptoms occur, I educate patients to again remove that food and wait three to six months before attempting to reintroduce the food again. This systematic reintroduction allows for pin-pointing foods or additives that may be causing symptoms.

In addition to sensitive foods, I consider blood sugar control. Impaired blood glucose regulation is a common cause of migraine headache and improving blood sugar control and normalizing insulin secretion can decrease the frequency and severity of migraines. Patients with type 2 diabetes who have more frequent hypoglycemic episodes have increased prevalence of migraine. In addition, skipping meals and fasting are associated with migraine attacks likely related to the high energy demands of the brain and limited available glycogen stores. Targeting blood sugar with the meal plan and lifestyle can be very helpful for migraine patients.

The long-term meal plan for migraine sufferers should be personalized, but some options to consider include a low-fat, vegan diet with the restriction of trigger foods, which has been shown in a randomized, cross-over trial to improve reported headache pain possibly related to decreased neurogenic inflammation and vasodilation, lower tyramine intake, weight loss, and the high antioxidant and anti-inflammatory properties of plant foods.

In addition, as reported in Nutritional Medicine, a high protein, low carbohydrate meal plan elicited complete relief of symptoms in patients with chronic migraines. Diabetic patients and those with reactive hypoglycemia who followed a meal plan low in refined sugar with six small meals per day experienced a 75 percent improvement in frequency and severity of migraines.

Furthermore, a review in Nutrients, describes the possible beneficial effects of ketosis for migraine sufferers. Ketones are produced mostly by the liver to provide energy in the absence of adequate glycogen storage. The ketogenic diet, which is high in fat, low in carbohydrate, and moderate in protein, increases ketone production and has been shown in an observational study to reduce migraine frequency, severity, and medication use by 80 percent, possibly related to the effect on glucose control and the ability of the brain to utilize ketones for fuel.

Finally, a meal plan that focuses on supporting mitochondrial health can also be helpful for the prevention and treatment of migraines. As reported in Nutrients, mitochondrial dysfunction is common in migraine sufferers and providing therapeutic foods that support healthy mitochondrial function can possibly decrease migraine frequency and severity. A mitochondrial food plan is anti-inflammatory, gluten-free, low in refined grains, and moderate in high-quality fats to help support energy production and protect the mitochondria from damage.

In addition to the personalized meal plan, I add nutritional supplements as a supportive tactic in the prevention and management of migraines. Magnesium deficiency is common, with 68 percent of Americans falling short of the recommended daily intake. Magnesium is important for hundreds of reactions in the body including mitochondrial energy production. Migraine sufferers have lower magnesium concentrations in the brain and are known to have altered mitochondrial function. The meal plan will ideally contain a variety of high magnesium foods such as leafy greens, nuts, and beans, but I also recommend magnesium supplements based on magnesium intake.

Coenzyme Q10 (CoQ10) is another important supplement to consider as it is involved in mitochondrial energy production and CoQ10 serum concentrations are lower than normal in migraine sufferers. As reported in Nutritional Medicine CoQ10 supplementation has been shown to decrease migraine days per month. In addition, a randomized, placebo-controlled trial published in Current Pain and Headache Reports concluded that, while a combination supplement of CoQ10, magnesium, and riboflavin did not reduce migraine days per month, it did decrease pain intensity.

Riboflavin supplementation has also been shown to significantly reduce migraine frequency, possibly related to its role in mitochondrial energy production. As reported in Nutritional Medicine, patients receiving as little as 5 milligrams of riboflavin three times per day experienced complete resolution of migraine attacks.

My patient reported several migraine attacks per month. She had followed a vegan diet for two years at one point and avoided gluten and dairy for a few weeks without any noticeable effect. She did endorse very healthy eating habits throughout the day but admitted to consuming chocolate and sugar prior to bedtime each night. She also lacked adequate water intake and described stress as problematic.

My initial recommendation included increasing water intake to at least 64 ounces per day based on her weight, stress management techniques, and a full elimination diet as described above for eight weeks. I also added 100 milligrams of CoQ10 and 300 milligrams of magnesium per day.

Over the past two months, my patient has experienced complete cessation of her migraines and she has also been able to avoid migraine medication for this time. She admits to being nervous to begin the reintroduction phase due to the possibility of a migraine recurrence, but she is interested in learning her trigger foods. Once the reintroduction is completed, she will transition to a mitochondrial food plan excluding her trigger foods for maintenance.

A personalized approach utilizing strategies to determine sensitive and allergic foods, improve blood sugar control, and providing targeted nutrient supplementation can be formidable when it comes to thwarting migraines.

References:

Bunner, A.E., Agarwal, U., Gonzales, J.F., Valente, F., and Barnard, N.D. (2014)Nutrition intervention for migraine: a randomized crossover trial. Journal of Headache and Pain. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4227630/

Gaby, Alan. (2017) Nutritional Medicine, 2^nd Edition. Retrieved from: https://bookshelf.vitalsource.com/books/9781532322009

Gross, E.C., Klement, R.J., Schoenen, J., D’Agostino, D.P., and Fischer, D. (2019) Potential Protective Mechanisms of Ketone Bodies in Migraine Prevention. Nutrients. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6520671/

Leonardi, M., Steiner, T.J., Scher, A.T., and Lipton, R.B. (2005) The global burden of migraine: measuring disability in headache disorders with WHO’s Classification of Functioning, Disability and Health (ICF). Journal of Headache and PainRetrieved from: https://pubmed.ncbi.nlm.nih.gov/16388337/

Mayans, L. and Walling, A. (2018) Acute Migraine Headache: Treatment Strategies. American Family Physician. Retrieved from: https://www.aafp.org/afp/2018/0215/p243.html

Wells, R.E., Beuthin, J., and Granetzke, L. (2019) Complementary and Integrative Medicine for Episodic Migraine: an Update of Evidence from the Last 3 Years. Current Pain and Headache Reports. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6559232/