by J. Gordon Millichap, MD, FRCP, Pediatric Neurologist, Children's Memorial Hospital, Northwestern University Medical Center, Chicago, Illinois; NOHA Professional Advisory Board Member.

Migraine headaches are a common neurological disorder, and studies show that their prevalence has increased in the last twenty years, especially in children. The cause of the increase in prevalence is not known. The stress of a more hectic and competitive life-style is postulated as a factor, but changes in dietary habits may be equally responsible. Other factors known to precipitate headaches in migraine-susceptible persons (migraineurs) include fatigue, exercise, sleep deprivation, bright lights, head trauma, infection, menstruation, and oral contraceptives. A predisposition to migraine headaches has a neuro-vascular and neurochemical mechanism, and the disorder is frequently inherited. The dietary factors known to activate the headache mechanism are called "migraine triggers."

Foods and beverages that may trigger migraine attacks
The list of foods, food additives, and beverages that can precipitate headaches in migraine-susceptible persons is long and includes the following:

• Aged or strong cheese
• Cured meats (hot dogs, bacon, ham, and salami)
• Citrus fruits
• Fatty or fried foods
• Chocolate, nuts
• Monosodium glutamate
• Food dyes, additives
• Pickled herring, chicken livers
• Ice cream
• Yogurt, sour cream
• Meat and vegetable extracts
• Pork and seafood
• Canned figs, broad beans, tomatoes
• Caffeine-containing drinks (coffee, tea, all "cola" soft drinks)
• Caffeine withdrawal
• Alcoholic drinks (red wine, beer)
• Aspartame, nitrites, sulfites.

Patients with migraine may be abnormally sensitive to one or more of these dietary items, a disorder sometimes described as a chemical idiosyncrasy or food intolerance. A true food allergy with positive skin testing is uncommon. The chemicals contained in foods that are responsible for the headache triggering effect are chiefly tyramine and other amines, including phenylethylamine and histamine. Tyramine is found in cheese, especially aged, strong and cheddar varieties, phenylethylamine in chocolate, octopamine in citrus fruits, and histamine in red wine and beers. Caffeine addiction and withdrawal, common among consumers of excess coffee, can be associated with severe throbbing headache and migraine exacerbation. Fasting or skipping meals is also a common reason for headache recurrence in migraine sufferers.

Tyramine-triggered migraine
One of the first reports of the relation of tyramine to the migraine attack was that of Dr Edda Hanington (British Medical Journal, 2:550, 1967) who observed a headache reaction to cheese eaten by patients treated for depression with certain drugs. The drugs, monoamine oxidase (MAO) inhibitors, inhibit an enzyme that normally metabolizes tyramine, the migraine provoking chemical found in cheese and other foods. MAO inhibitors taken in chance combination with a meal of cheese can also cause an acute rise in blood pressure by releasing the neurotransmitter norepinephrine, another reason for headache symptoms. It is postulated that patients with dietary migraine are sensitive to tyramine-containing foods because of an inherent deficiency of MAO in their liver and blood, and an inability to metabolize tyramine. The elimination of the offending food and chemical from the diet should prevent or lessen the number and severity of migraine attacks.

The elimination of the offending food and chemical from the diet should prevent or lessen the number and severity of migraine attacks.

Other foods known to be associated with tyramine and migraine include beer, wine, pickled herring, chicken liver, yeast, coffee, broad bean pods, citrus, and canned figs. Patients with depression treated with MAO inhibitors should be given a list of foods to be avoided, especially if they also have a predisposition to migraine.

Chocolate-induced migraine
Phenylethylamine, theobromine, and caffeine, the chemical triggers in chocolate, may cause a headache by altering the cerebral blood flow and releasing norepinephrine (Martin, Behbehani, 2001). When adult migraineurs who complained that chocolate provoked their headaches were challenged with either a chocolate bar or a closely matched placebo, 5 of 12 had a typical migraine headache after eating chocolate while none of 8 receiving the placebo suffered a headache (Gibb CM, et al, 1991).

When adult migraineurs who complained that chocolate provoked their headaches were challenged with either a chocolate bar or a closely matched placebo, 5 of 12 had a typical migraine headache after eating chocolate while none of 8 receiving the placebo suffered a headache

Although parental reports indicate a frequent association between chocolate and migraine in children, controlled studies sometimes fail to confirm a trigger effect. A subgroup of migraine patients may be sensitive to chocolate.

Caffeine-withdrawal headaches
Caffeine concentrations contained in commonly consumed stimulant drinks vary from a high of 150 mg in a 5 oz cup of coffee to 35 mg in a 12 oz can of cola. Pain relievers taken for headache also contain caffeine. Caffeine causes constriction of cerebral blood vessels. 

Caffeine causes constriction of cerebral blood vessels. 

When caffeine intake is interrupted, the blood vessels dilate, and the increase in cerebral blood flow results in headache. Patients sometimes need to be hospitalized to manage a serious addiction and dependency resulting from chronic caffeine overuse.

Alcoholic beverages and migraine
Many patients with migraine cannot tolerate alcoholic beverages even in small amounts. Alcohol has a vasodilator effect on cranial blood vessels. However, the alcohol per se is probably not the migraine-provoking chemical, but rather, the tyramine and histamine contained in many red wines and beers.

Grapes organically grown and wines free of sulfites are thought by some to be less likely to trigger headaches.

Only a particular variety of grape is responsible in some patients, and young and cheaper varieties are often less well tolerated than aged and more expensive vintages. In some countries, the problem of wine-induced headache has been so widespread at times that vintners have been forced to curtail the production of red wine in favor of white, which is better tolerated by some consumers. Grapes organically grown and wines free of sulfites are thought by some to be less likely to trigger headaches.

Many patients with migraine cannot tolerate alcoholic beverages even in small amounts… the alcohol per se is probably not the migraine-provoking chemical, but rather, the tyramine and histamine contained in many red wines and beers.

A chemical effect on cranial blood vessels by some ingredient in certain alcoholic beverages is the most plausible explanation for the migraine response. Stress may act as a secondary trigger mechanism in some situations. A migraineur exposed to a stressful and tiring work environment may complain of an inability to tolerate wine, whereas the same person on a relaxing vacation may drink and enjoy the same wine without suffering headaches. Migraine is not primarily a psychogenic illness, but stress and fatigue are common precipitants of attacks.

Table I. 
Allergenic dietary migraine triggers and hypoallergenic alternatives.

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Modified from Millichap, Diet and Migraine Headaches. PNB Publishers, with permission.

Nitrates, Nitrites, and "Hot Dog" headache
Hot dogs and other cured meats such as bacon, ham and salami contain nitrates. Cured meats contain about 10 per cent of the average daily intake of nitrate in the diet, while the consumption of beets, lettuce, celery, spinach, broccoli, cauliflower and potatoes contribute the largest portion of nitrate to the daily diet. 

In addition to the occurrence of headache, nitrites can cause…low oxygen in the blood…

Fruits, milk, bread, and water are relatively small sources of the nitrate intake, in normal circumstances. Nitrites are formed by the reduction of nitrates in the saliva or by bacterial action in the intestine. The vasodilator effect of nitrites is responsible for the hot dog headache and flushing of the face and neck commonly associated.

The addition of nitrite to meats has three purposes:

1. Antibacterial effect, particularly the inhibition of botulism spores and toxin formation;
2. Formation of pigments responsible for the red or pink color of cured meats; without nitrites, meat would have an unacceptable gray color;
3. Food additive responsible for the safety and stability of cured meats. The level of nitrite permitted in cured meat products is 200 ppm.

In addition to the occurrence of headache, nitrites can cause methemaglobinemia (low oxygen in the blood), which imparts a slate gray cyanotic color to the skin; and they may act on amines in the diet to form nitrosamines, which are carcinogenic. High levels of nitrate in the well waters of regions of Columbia and in two village communities in rural England, where the incidence of stomach cancer was abnormally high, have been linked to the use of sodium nitrate fertilizer.

Nitrates and nitrites may be limited in the diet by reducing the intake of cured meats such as hot dogs and salami and by checking well water for nitrate contamination.

Nitrates and nitrites may be limited in the diet by reducing the intake of cured meats such as hot dogs and salami and by checking well water for nitrate contamination.

Aspartame-triggered migraine
The FDA and CDC cleared aspartame for general consumption, excepting for children with phenylketonuria (an inborn error of metabolism). Despite this clearance, many scientists expressed caution concerning its use by patients with migraine, epilepsy, and neuropsychiatric problems. In recent years, several studies have demonstrated that headaches may be exacerbated in patients suffering from migraine. (Van den Eeden, S.K., et al., Neurology ,44:1787-93,1994; Lipton, R.B., et al., Neurology, 38(Supplement 1):356,1988; Newman, L.C., Lipton, R.B., Headache, 41:899-901,2001; Millichap, J.G., Pediatric Neurology Briefs, 15:89,2001).

…many scientists expressed caution concerning [aspartame/Nutrasweet^®] use by patients with migraine, epilepsy, and neuropsychiatric problems.

The number and scientific standard of these studies reported in the medical literature confirm the role of aspartame as a significant trigger of headaches in migraineurs, and emphasize the need to caution patients regarding the potential adverse effect of this ubiquitous sugar substitute.

Fatty foods and migraine
Fatty acids, primarily linoleic and oleic acids, may be involved in the mechanism of migraine vascular headaches. During a migraine attack, researchers have measured a significant rise in the blood levels of free fatty acids, which occurs simultaneously with the release of serotonin from blood platelets, and an abnormal distension of cranial arteries. The initial aura of a migraine attack, characterized by visual scotomata (blind spots), is associated with cranial artery constriction. This is followed by vasodilatation (distention of blood vessels) as the immediate precursor of a migraine headache. Serotonin has variable effects on cerebral blood vessels, but especially vasodilation. It is speculated that free fatty acids are serotonin releasing factors in the blood.

In a study of the influence of low-fat diet on the incidence and severity of migraine headaches in 54 patients at the University of California, Irvine, CA (Bic, Z., et al., Journal of Womens Health & Gender-Based Medicine,8:623-30,1999), a decrease in dietary fat to a maximum of 20 grams per day was associated with a significant decrease in headache frequency, intensity, and duration (p<.0001: probability less than one in ten thousand that the observed difference in headaches would occur by chance).

Fatty acids, primarily linoleic [omega-6] and oleic [omega-9] acids, may be involved in the mechanism of migraine vascular headaches…Paradoxically, certain fish oils containing high quantities of omega-3 fatty acids, as in cod and salmon, have been found to prevent migraine attacks in certain patients.

Paradoxically, certain fish oils containing high quantities of omega-3 fatty acids, as in cod and salmon, have been found to prevent migraine attacks in certain patients. These fatty acids are thought to have a stabilizing effect on nerve cell membranes, making them more resistant to the migraine mechanism.

"Ice cream" headache
Migraineurs may complain of headache while eating ice cream or other frozen foods. The pain is usually located over the forehead or behind the eyes. The application of a cold stimulus to the mouth or throat may cause a reflex constriction of blood vessels around the head, resulting in the initiation of a headache in susceptible individuals.

Food allergy and migraine
Various foods, including cow's milk, egg, and wheat cereal, in addition to amine rich chocolate, orange, and cheese, may provoke headache in migraine-susceptible patients, especially children. In a study at Great Ormond Street Children's Hospital, London, UK, of 88 patients treated with an "oligoantigenic diet," a diet that eliminates all but a few sensitizing food antigens, 93 per cent with severe frequent migraine responded and were free of headaches. (Egger, J., et al., Lancet, 2:865, 1983; Journal of Pediatrics,114:51-8, 1989).

Specific headache triggers should be identified by carefully completed headache calendars.

The elimination diet consists of one meat (lamb or chicken), one carbohydrate (rice or potato), one fruit (banana or apple), one vegetable (brassica), water, and vitamin supplements. Of the 82 patients who improved on the diet, all but eight relapsed on reintroduction of one or more foods, including chocolate. Fifty-five different foods provoked symptoms on reintroduction. A remarkable fondness for migraine-provoking foods was a common finding, some patients craving them and eating them in large amounts. Cow's milk and cheese caused headaches in most of the patients in the study, but none complained of headaches after substituting goat's-milk cheese.

A remarkable fondness for migraine-provoking foods was a common finding, some patients craving them and eating them in large amounts. Cow's milk and cheese caused headaches in most of the patients in the study, but none complained of headaches after substituting goat's-milk cheese.

Unfortunately, the susceptibility to diet-triggered headaches is not consistently confirmed by reactivity to the food, skin-prick tests, and immune globulin antibody titers, and diagnosis by the elimination diet is quite demanding. The reported relationship between food allergy and migraine is difficult to prove, and the concept remains controversial. Many neurologists and allergists are skeptical of the use of restrictive diets in treatment, and a universal migraine- food elimination diet is discouraged in practice. Specific headache triggers should be identified by carefully completed headache calendars.

Monosodium glutamate. The Chinese Restaurant Syndrome
The Chinese Restaurant Syndrome, now named "MSG symptom complex," has been linked to the frequent use of monosodium glutamate (MSG) in some asian food. Consumers, about 1 in 50 of diners in Asian restaurants, report flushing, tingling, dizziness, and headache. Symptoms usually appear within 15-60 minutes after ingesting relatively large amounts of MSG on an empty stomach.

Consumers, about 1 in 50 of diners in Asian restaurants, report flushing, tingling, dizziness, and headache.

MSG is a flavor enhancer. It is found in frozen foods, canned soups, salad dressings, processed meats, sauces and snack foods. Patients with migraine may have an exacerbation of headaches after ingesting MSG, because of its effects on cranial blood vessels.

"Hunger" and hypoglycemic headaches
Fasting and consequent low blood sugar (hypoglycemia) may trigger headaches in patients with migraine. Studies have shown that 50 percent of migraineurs have headaches after 16 hours without food. 

Fasting and consequent low blood sugar (hypoglycemia) may trigger headaches in patients with migraine.

Altered levels of serotonin and norepinephrine and dilation of blood vessels around the brain and scalp are the probable mechanisms of hunger-triggered headaches. Following the ingestion of an excessive carbohydrate load, a vascular headache may also occur in response to a rapid insulin secretion and reactive lowering of blood sugar. 

To avoid these sugar intolerance, hypoglycemic triggers, migraine sufferers should eat three well balanced meals a day and avoid an overabundance of carbohydrate foods at any single meal.

To avoid these sugar intolerance, hypoglycemic triggers, migraine sufferers should eat three well balanced meals a day and avoid an overabundance of carbohydrate foods at any single meal. Breakfast should not be neglected, especially in children.

Nonmedication therapeutic techniques in migraine management
Although pain relieving and anti-inflammatory drugs (eg. acetaminophen, Fiorinal, ibuprofen, Naproxen, or triptans) are usually required in the treatment of an acute migraine attack, and some medications (eg. amitriptyline, propranolol, and anticonvulsants) are effective in prevention of headaches, other nonmedication therapies can prove valuable adjuncts in the management of a migraine patient. 

Prevention of headaches by careful attention to known migraine triggers is preferable to frequent administration of pain-relieving drugs.

In addition to diet, alternatives or complements to drug treatments include biofeedback, visualization/imagery and hypnotherapy, muscle relaxation, stretching exercises, aerobic activities, trigger point compression, cold packs or a heating pad, electrical stimulation, massage, acupuncture, manipulation, and psychotherapy. Magnesium and riboflavin vitamin supplements can be beneficial, and feverfew is one of the herbal remedies that is sometimes recommended by practitioners of alternative medicine.

In addition to diet, alternatives or complements to drug treatments include biofeedback, visualization/imagery and hypnotherapy, muscle relaxation, stretching exercises, aerobic activities, trigger point compression, cold packs or a heating pad, electrical stimulation, massage, acupuncture, manipulation, and psychotherapy.

The therapy of migraine is multifaceted and involves treatment of the individual as a whole (physical, nutritional, emotional, and spiritual, or "holistic" therapy) as well as the counseling of family members. Prevention of headaches by careful attention to known migraine triggers is preferable to frequent administration of pain-relieving drugs. Unfortunately, the nutritional and dietary aspects of migraine management are most frequently neglected in favor of potentially toxic medications.

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General references:

Gibb, C.M., Davies, P.T., Glover, V., et al, Cephalalgia, 11:93-5, 1991.

Hockaday, J.M., Migraine in Childhood, London, Butterworths, 1988.

Martin, V.T., Behbehani, M.M., "Headache: Toward a rational understanding of migraine trigger factors," Medical Clinics of North America , 85: 1-20, 2001.

Millichap, J.G., Diet and Migraine Headaches, Chicago, PNB Publishers, 2002; in press.

Millichap, J.G., Yee, M., "The diet factor in pediatric and adolescent migraine," Pediatric Neurology 2002; in press.

Millichap, J.G., "Aspartame," "Nitrates and Nitrites," and "Hot Dog Headache," in Environmental Poisons in Our Food, Chicago, PNB Publishers, 1993.

Millichap, J.G., "Migraine headaches" in Progress in Pediatric Neurology, Vols I, II, III, Chicago, PNB Publishers, 1991, 1994, 1997.

Millichap, J.G., "Headaches," in Attention Deficit, Hyperactivity, and Learning Disabilities, Chicago, PNB Publishers, 2001.

Millichap, J.G., Nutrition, Diet, and Your Child's Behavior, Springfield, IL, Charles C. Thomas, 1986.

National Headache Foundation, Alternative Therapies & Headache Care, Chicago, 1999, www.headaches.org

Article from NOHA NEWS, Vol. XXVII, No. 3, Summer 2002, pages 3-6.

LIST III: FOODS WITH HIGH SODIUM CONTENT - These foods should be avoided.

MILK

• Buttermilk

CHEESE

• All excepting special low sodium cheese or low sodium cottage cheese

MEAT/FISH/FOWL

• Bacon, ham, hot dogs, sausages, bologna, luncheon meat; canned, salted, dried, smoked or pickled meat, fish or poultry. Herring caviar, regular canned tuna and salmon, anchovies, sardines and salted cod. Canned crab, shrimp, lobster and oysters. Salt pork, chipped or corned beef, brain, kidney, meats koshered by salting. Regular peanut butter.

CONDIMENTS

• Most seasonings, sauces, marinades with salt.

VEGETABLES

• Sauerkraut, olives, pickles, regular canned vegetables and canned vegetable juices. Any vegetable prepared in brine.

FATS

• Salted butter or margarine, commercial salad dressings and regular mayonnaise, bacon fat, salted nuts, canned gravies.

SOUPS

• All regular canned soups, soup mixes, broth, bouillon, consommé, commercial bouillon cubes, powders or liquids.

BREADS & CEREALS

• Regular and yeast breads and rolls prepared with salt, dry cereals other than those listed in LIST I, regular pancakes, muffins, biscuits, cornbread, crackers and mixes. Potato chips, corn chips, pretzels, salted popcorn. Corn meal and self-rising flour.

DESSERTS

• Instant pudding, pie crust unless prepared without salt, desserts in excess of the amount allowed in LIST II.

BEVERAGES

• Dutch process cocoa, soft drinks or beer which have been boiled in areas high in sodium content in their water supplies.
  
  
  

LIST II: FOODS WITH MODERATE SODIUM CONTENT - These foods must be limited in amounts as specified.

MILK

• (Whole, Carnation Instant Nonfat, diluted evaporated, skim, low fat) - Limit to 2 cups daily.

EGGS

• Limit 1 per day

MEAT/FISH/FOWL
(Other than those in LIST III) - Limit to 6 oz. cooked weight daily.

• Fresh crab, lobster, shrimp, scallops, brains, kidneys, and frozen fish which have been cooked in brine contain higher amounts of sodium than other fresh meats. These foods should be chosen infrequently.

DESSERTS
Limit to one choice per day - serving portion as indicated

• Cake - 1 1/2 oz.
• Cookies, assorted - 1 oz
• Gelatin - 1/2 cup
• Ice cream - 1/2 cup
• Regular cooked puddings such as tapioca, rice, etc. - 1/2 cup
• Sherbet - 1/2 cup

VEGETABLES
Limit to one choice per day - 1/2 cup serving only (fresh, frozen or salt-free canned)

• Beets
• Collard Greens
• Carrots
• Chard
• Dandelion Greens
• Celery
• Frozen Lima Beans
• Frozen Peas
• Kale
• Mustard Greens
• Turnips, white