Headache
Nutrition and Headaches
By: Christina Sun-Edelstein, MD and Alexander Mauskop, MD
Migraine is a disabling disorder that affects millions of Americans. While the traditional treatment of headaches has focused on prescription medications for acute and preventive treatment, the role of nutritional issues in preventing headaches cannot be overemphasized. Also, since many medications have side effects or contraindications, migraine sufferers often seek alternative options for headache treatment. In recent years there has been an increasing demand for natural therapies for common problems such as headaches. This review covers some food-related tips for avoiding headaches and the use of some vitamins and herbal supplements that may help to prevent headaches.
An awareness of nutritional issues that may affect migraines can be very helpful in decreasing the occurrence of headaches. People who suffer from migraines should know which foods can potentially trigger headaches, and what types of eating patterns are best for avoiding headaches. Some people know exactly what foods consistently trigger their headaches, but others may not be able to accurately pinpoint their food triggers. Often a food diary is helpful in determining which foods are linked to your migraines.
The importance of eating regularly cannot be overstated, since skipping meals can trigger headaches. Skipped meals and fasting were reported migraine triggers in more than half of patients surveyed in several studies. Low blood sugar can trigger headaches so it is important to eat breakfast, lunch and dinner everyday. Many people skip breakfast, which puts them at risk for having headaches in the morning. Snacks in the mid-morning and mid-afternoon might also be helpful for people who find that their headaches are often triggered by hunger.
Also, spikes and falls in your blood sugar can trigger headaches. Eating protein and fiber with each meal can help to stabilize the way the food is broken down by your body, thus preventing large fluctuations in blood sugar. For example, having cereal with milk (which has protein) is a better breakfast choice than a big muffin, which is generally high in sugar and low in protein. Protein-rich foods include: meat, fish, poultry, eggs, dairy, beans and nuts. High-fiber foods include wholegrain breads, whole wheat pastas, bran, fruit (especially dried fruit), green leafy vegetables and nuts and seeds.
Staying well-hydrated throughout the day is also important, since dehydration can trigger headaches. We recommend drinking plenty of water daily to prevent headaches. Caffeinated drinks (coffee, tea, soda) can actually have a dehydrating effect by causing increased urination so these should be limited as much as possible. This is especially important since caffeine also has a role in increasing headaches (see Caffeine section under Identifying Your Triggers).
Many migraineurs appear to be very sensitive to certain foods, although the scientific basis for food triggers is controversial. Though the foods and substances discussed below are often identified by patients as headache triggers, not all of the foods will trigger a migraine in any one person. Headaches are generally triggered by a combination of substances, during a time of particular vulnerability (such as just before or during menstruation). Food diaries are helpful in sorting out which ones are problematic for each patient.
Alcohol
Alcohol, especially red wine, is commonly identified as a headache trigger by migraine sufferers. It can either trigger a headache shortly after drinking, or it can cause a hangover headache the next morning. Headaches that occur within several hours after drinking alcohol are probably the result of blood vessel dilation and constriction. Wine also contains substances such as tyramine, histamine and sulfites, all of which can trigger headaches.
On the other hand, hangover headaches are thought to be due to impurities called congeners that are formed as the alcohol is metabolized by the body and possibly magnesium depletion. Darker colored beverages such as red wine, whiskey and bourbon have higher levels of congeners than clear drinks such as gin or vodka, and are therefore more likely to cause a hangover headache. Though the severity of the hangover headache generally increases with larger amounts of alcohol consumed, hangover headaches actually occur more often in light or moderate drinkers than in regular heavy drinkers. Drinking in moderation and eating greasy foods prior to drinking may help to decrease the severity of the headache.
Caffeine
Caffeine is a substance found in coffee, tea, soda and chocolate. The relationship between caffeine and headaches is a tricky one. When used infrequently in small amounts, caffeine can be very helpful in treating headaches. This is because caffeine has some pain-killing properties, gets to the brain quickly, and helps in the absorption of other medications. That’s why it’s included in over-the-counter headache medications such as Excedrin, and prescription drugs such as Fioricet. However, too much caffeine (usually two to three cups of coffee per day) on a regular basis can actually give you more headaches. Even one cup of coffee on a daily basis can worsen headaches in some people. If you have a “withdrawal headache” after skipping your usual amount of coffee, then you’re probably drinking too much every day, whether it’s one cup or three cups.
Food Additives
Food additives that are commonly identified as headache triggers include nitrites and monosodium glutamate (MSG). Nitrates and nitrites are preservatives that are used for food coloring, prevention of food poisoning and to add a cured or smoked flavor. After eating foods with nitrites, such as sausages or other cured meats and fish including hot dogs, bacon, ham, salami, pepperoni, corned beef, pastrami and lox, some people develop headaches within minutes to hours. Nitrates and nitrites probably trigger headaches by dilating blood vessels. People who are sensitive to these substances should read food labels and avoid foods with sodium nitrite, sodium nitrate, potassium nitrite, or potassium nitrate.
MSG is a flavor enhancer that is most commonly associated with Chinese food. It is also used in meat tenderizer (Accent) and many canned, prepared and packaged foods. MSG is often disguised on food labels as “hydrolyzed vegetable protein (HVP),” “autolyzed yeast,” “sodium caseinate,” “yeast extract,” “hydrolyzed oat flour,” “texturized protein,” or “calcium casinate.” In sensitive patients, MSG can trigger a headache within 30 minutes. Other symptoms may include a hot flush in the chest, neck, and shoulders, dizziness, and abdominal discomfort.
Artificial Sweeteners
Aspartame (NutraSweet) is an artificial sweetener that is 180 to 200 times sweeter than regular sugar. Since it became available in 1981, there have been many reports of headaches in connection with its use. The scientific evidence suggests that aspartame may be a headache trigger in people who ingest moderate to high doses (900 to 3000 mg per day). As a frame of reference, one packet of NutraSweet contains about 36 mg of aspartame. Sucralose is the active component of Splenda, another common artificial sweetener. Some case reports have suggested that it may also be a headache trigger. Though many people add artificial sweeteners directly to their coffee or tea, they are actually included in many different foods, such as cereals, breath mints and even yogurt. People who think they are sensitive to aspartame or sucralose should check food labels for these substances.
Chocolate
The role of chocolate as a headache trigger is a controversial issue. Chocolate and cacao contain phenylethylamine, a substance which may trigger headaches in some migraineurs by altering the size of blood vessels. Chocolate also contains some caffeine, which may trigger headaches. However, some people have cravings for certain foods such as chocolate during a very early stage of migraine called the “prodrome,” which may start up to 48 hours before headache pain begins. In these people, eating chocolate does not trigger the headache- the migraine mechanism has already begun.
Tyramine-containing Foods
Tyramine is a substance that is found in aged cheese, cured meats, smoked fish, beer, fermented food and yeast extract (including freshly baked bread or cake), among other foods. It probably triggers headaches by constricting blood vessels or by activating some biochemicals in the body that can then set a migraine in motion.
Some scientific studies have shown that the use of herbal and nutritional supplements can be effective in the prevention of migraine. In some patients, these supplements may be helpful in decreasing headache frequency and severity alone. However, in others, they may be most useful when combined with traditional prescription medications. Before starting treatment with any of these supplements, you should consult your doctor or health care provider.
Magnesium
Magnesium is a mineral that is essential for the normal functioning of the human body. Its deficiency has been associated with serotonin and nitric oxide release, changes in blood vessel size, and inflammation, all of which may play a role causing the pain of migraine. Some studies have suggested that migraine sufferers, especially those with menstrually-related migraines, have low brain and body levels of magnesium. Symptoms of magnesium deficiency include premenstrual syndrome (PMS), leg muscle cramps, cold hands and feet, weakness, anorexia, nausea, digestive disorders, lack of coordination and confusion. Low magnesium can be seen in any chronic medical illness, including cardiovascular disease, diabetes, pre-eclampsia, eclampsia, sickle cell disease and chronic alcoholism.
Given that many migraineurs have low magnesium levels, supplementation with oral magnesium can be very helpful in preventing headaches in some patients, as shown in several scientific studies. Chelated magnesium, magnesium oxide and slow-release magnesium are likely to be the best absorbed in the gastrointestinal system. Other forms of magnesium are poorly absorbed and can cause diarrhea. The daily dose is 400 mg. Another way of increasing your magnesium level is by increasing your intake of magnesium-rich foods such as nuts, legumes, dark green leafy vegetables, wholegrain breads and cereals and seafood.
Riboflavin
Riboflavin, also known as vitamin B2, is important in maintaining many of the body’s energy-related processes at the cell level. One study showed that daily supplementation with 400 mg of riboflavin resulted in a significant decrease in headache attacks. The most common side effect of treatment is an orange discoloration of the urine, which is harmless. Rare side effects include diarrhea and frequent urination.
Coenzyme Q10
Coenzyme Q10 is a compound that is produced by the body and is important for the basic functioning of cells. It also boosts energy, strengthens the immune system, and acts as an antioxidant. Supplementation with 300 mg daily was show in one study to decrease headache frequency, and was effective within one month of treatment. Another study showed that treatment with CoQ10 might also be effective in treating pediatric migraine. Treatment is generally very well-tolerated, although some patients experience gastrointestinal side effects.
Alpha Lipoic Acid
Like riboflavin and CoQ10, alpha lipoic acid is another compound that is important in the energy-related functions of the body’s cells. Some preliminary studies have suggested that it may be helpful in reducing headache frequency. The proposed dosage is 600 mg daily.
Herbal treatment and remedies appeal to many people because they appear to be more “natural” than traditional medications. Although this may be the case to some degree, herbal treatments can still be dangerous when used incorrectly, or in high doses. Some of them can even cause serious side effects. Treatment with herbal remedies should be avoided in pregnant women because of possible harmful effects on the developing fetus. We also recommend avoiding these remedies in young children or the elderly.
Feverfew
Feverfew is an herbal preparation that is available as the dried leaves of the weed plant tanacetum parthenium. It was used to treat headache, inflammation, and fever several centuries ago, and rediscovered in the late 20th century. Some studies and case reports have suggested that it may be helpful in preventing and treating migraine headaches. The effective dose is controversial, since dried feverfew leaves can lose some of their strength over time. However, researchers generally recommend taking 125 mg of a dried feverfew-leaf preparation that contains at least 0.2 percent parthenolide. Potential side effects include stomach upset, mouth ulcers, and a “post-feverfew syndrome” of joint aches.
Butterbur (Petasites hybridus)
The butterbur plant is a perennial shrub that was used in ancient times for its medicinal qualities. Recently, some well-designed studies have shown that it is effective in the prevention of migraine headaches. It probably works by decreasing the inflammation associated with migraine. Butterbur is sold as Petadolex and the recommended dose is 150 mg daily. Side effects include gastrointestinal disturbances, especially burping.
Ginger
Ginger has been used in China for centuries, in the treatment of pain, inflammation, and musculoskeletal symptoms. It can have some effects on reducing inflammation and may be helpful in the treatment of migraine, especially for people that have nausea with their headaches. Ginger can be added to meals or brewed as a tea (one ounce of freshly grated gingerroot to two cups water). However, the evidence for its use in migraine treatment is only anecdotal; there haven’t been any good scientific studies showing that it is effective.
Valerian Root
Valerian root can be useful as a sedative, especially in insomniacs. It may also be helpful for migraine patients with anxiety, since it doesn’t have the “hangover effect” caused by some prescription sedatives. The suggested dose for insomnia is 300 to 600 mg, which is equivalent to 2 to 3 grams of dried herbal valerian root soaked in one cup of hot water for 10 to 15 minutes. At higher doses, valerian root is associated with headaches and muscle spasm.
Although we can’t cure migraines, there are many ways that we can decrease the frequency and severity of headaches without taking more and more prescription medications. Eating well and avoiding possible headache triggers can have a major impact on your headache pattern. Vitamins and herbal supplements are also potentially good options for decreasing headaches without many side effects. Always talk to your health care provider before starting any of these treatments.
Nutritional Issues That Affect Migraines
An awareness of nutritional issues that may affect migraines can be very helpful in decreasing the occurrence of headaches. People who suffer from migraines should know which foods can potentially trigger headaches, and what types of eating patterns are best for avoiding headaches. Some people know exactly what foods consistently trigger their headaches, but others may not be able to accurately pinpoint their food triggers. Often a food diary is helpful in determining which foods are linked to your migraines.
Eating To Prevent Headaches
The importance of eating regularly cannot be overstated, since skipping meals can trigger headaches. Skipped meals and fasting were reported migraine triggers in more than half of patients surveyed in several studies. Low blood sugar can trigger headaches so it is important to eat breakfast, lunch and dinner everyday. Many people skip breakfast, which puts them at risk for having headaches in the morning. Snacks in the mid-morning and mid-afternoon might also be helpful for people who find that their headaches are often triggered by hunger.
Also, spikes and falls in your blood sugar can trigger headaches. Eating protein and fiber with each meal can help to stabilize the way the food is broken down by your body, thus preventing large fluctuations in blood sugar. For example, having cereal with milk (which has protein) is a better breakfast choice than a big muffin, which is generally high in sugar and low in protein. Protein-rich foods include: meat, fish, poultry, eggs, dairy, beans and nuts. High-fiber foods include wholegrain breads, whole wheat pastas, bran, fruit (especially dried fruit), green leafy vegetables and nuts and seeds.
Staying well-hydrated throughout the day is also important, since dehydration can trigger headaches. We recommend drinking plenty of water daily to prevent headaches. Caffeinated drinks (coffee, tea, soda) can actually have a dehydrating effect by causing increased urination so these should be limited as much as possible. This is especially important since caffeine also has a role in increasing headaches (see Caffeine section under Identifying Your Triggers).
Identifying Your Triggers
Many migraineurs appear to be very sensitive to certain foods, although the scientific basis for food triggers is controversial. Though the foods and substances discussed below are often identified by patients as headache triggers, not all of the foods will trigger a migraine in any one person. Headaches are generally triggered by a combination of substances, during a time of particular vulnerability (such as just before or during menstruation). Food diaries are helpful in sorting out which ones are problematic for each patient.
Alcohol
Alcohol, especially red wine, is commonly identified as a headache trigger by migraine sufferers. It can either trigger a headache shortly after drinking, or it can cause a hangover headache the next morning. Headaches that occur within several hours after drinking alcohol are probably the result of blood vessel dilation and constriction. Wine also contains substances such as tyramine, histamine and sulfites, all of which can trigger headaches.
On the other hand, hangover headaches are thought to be due to impurities called congeners that are formed as the alcohol is metabolized by the body and possibly magnesium depletion. Darker colored beverages such as red wine, whiskey and bourbon have higher levels of congeners than clear drinks such as gin or vodka, and are therefore more likely to cause a hangover headache. Though the severity of the hangover headache generally increases with larger amounts of alcohol consumed, hangover headaches actually occur more often in light or moderate drinkers than in regular heavy drinkers. Drinking in moderation and eating greasy foods prior to drinking may help to decrease the severity of the headache.
Caffeine
Caffeine is a substance found in coffee, tea, soda and chocolate. The relationship between caffeine and headaches is a tricky one. When used infrequently in small amounts, caffeine can be very helpful in treating headaches. This is because caffeine has some pain-killing properties, gets to the brain quickly, and helps in the absorption of other medications. That’s why it’s included in over-the-counter headache medications such as Excedrin, and prescription drugs such as Fioricet. However, too much caffeine (usually two to three cups of coffee per day) on a regular basis can actually give you more headaches. Even one cup of coffee on a daily basis can worsen headaches in some people. If you have a “withdrawal headache” after skipping your usual amount of coffee, then you’re probably drinking too much every day, whether it’s one cup or three cups.
Food Additives
Food additives that are commonly identified as headache triggers include nitrites and monosodium glutamate (MSG). Nitrates and nitrites are preservatives that are used for food coloring, prevention of food poisoning and to add a cured or smoked flavor. After eating foods with nitrites, such as sausages or other cured meats and fish including hot dogs, bacon, ham, salami, pepperoni, corned beef, pastrami and lox, some people develop headaches within minutes to hours. Nitrates and nitrites probably trigger headaches by dilating blood vessels. People who are sensitive to these substances should read food labels and avoid foods with sodium nitrite, sodium nitrate, potassium nitrite, or potassium nitrate.
MSG is a flavor enhancer that is most commonly associated with Chinese food. It is also used in meat tenderizer (Accent) and many canned, prepared and packaged foods. MSG is often disguised on food labels as “hydrolyzed vegetable protein (HVP),” “autolyzed yeast,” “sodium caseinate,” “yeast extract,” “hydrolyzed oat flour,” “texturized protein,” or “calcium casinate.” In sensitive patients, MSG can trigger a headache within 30 minutes. Other symptoms may include a hot flush in the chest, neck, and shoulders, dizziness, and abdominal discomfort.
Artificial Sweeteners
Aspartame (NutraSweet) is an artificial sweetener that is 180 to 200 times sweeter than regular sugar. Since it became available in 1981, there have been many reports of headaches in connection with its use. The scientific evidence suggests that aspartame may be a headache trigger in people who ingest moderate to high doses (900 to 3000 mg per day). As a frame of reference, one packet of NutraSweet contains about 36 mg of aspartame. Sucralose is the active component of Splenda, another common artificial sweetener. Some case reports have suggested that it may also be a headache trigger. Though many people add artificial sweeteners directly to their coffee or tea, they are actually included in many different foods, such as cereals, breath mints and even yogurt. People who think they are sensitive to aspartame or sucralose should check food labels for these substances.
Chocolate
The role of chocolate as a headache trigger is a controversial issue. Chocolate and cacao contain phenylethylamine, a substance which may trigger headaches in some migraineurs by altering the size of blood vessels. Chocolate also contains some caffeine, which may trigger headaches. However, some people have cravings for certain foods such as chocolate during a very early stage of migraine called the “prodrome,” which may start up to 48 hours before headache pain begins. In these people, eating chocolate does not trigger the headache- the migraine mechanism has already begun.
Tyramine-containing Foods
Tyramine is a substance that is found in aged cheese, cured meats, smoked fish, beer, fermented food and yeast extract (including freshly baked bread or cake), among other foods. It probably triggers headaches by constricting blood vessels or by activating some biochemicals in the body that can then set a migraine in motion.
Vitamins and Herbal Supplements in Headache Prevention
Some scientific studies have shown that the use of herbal and nutritional supplements can be effective in the prevention of migraine. In some patients, these supplements may be helpful in decreasing headache frequency and severity alone. However, in others, they may be most useful when combined with traditional prescription medications. Before starting treatment with any of these supplements, you should consult your doctor or health care provider.
Vitamins and Minerals
Magnesium
Magnesium is a mineral that is essential for the normal functioning of the human body. Its deficiency has been associated with serotonin and nitric oxide release, changes in blood vessel size, and inflammation, all of which may play a role causing the pain of migraine. Some studies have suggested that migraine sufferers, especially those with menstrually-related migraines, have low brain and body levels of magnesium. Symptoms of magnesium deficiency include premenstrual syndrome (PMS), leg muscle cramps, cold hands and feet, weakness, anorexia, nausea, digestive disorders, lack of coordination and confusion. Low magnesium can be seen in any chronic medical illness, including cardiovascular disease, diabetes, pre-eclampsia, eclampsia, sickle cell disease and chronic alcoholism.
Given that many migraineurs have low magnesium levels, supplementation with oral magnesium can be very helpful in preventing headaches in some patients, as shown in several scientific studies. Chelated magnesium, magnesium oxide and slow-release magnesium are likely to be the best absorbed in the gastrointestinal system. Other forms of magnesium are poorly absorbed and can cause diarrhea. The daily dose is 400 mg. Another way of increasing your magnesium level is by increasing your intake of magnesium-rich foods such as nuts, legumes, dark green leafy vegetables, wholegrain breads and cereals and seafood.
Riboflavin
Riboflavin, also known as vitamin B2, is important in maintaining many of the body’s energy-related processes at the cell level. One study showed that daily supplementation with 400 mg of riboflavin resulted in a significant decrease in headache attacks. The most common side effect of treatment is an orange discoloration of the urine, which is harmless. Rare side effects include diarrhea and frequent urination.
Coenzyme Q10
Coenzyme Q10 is a compound that is produced by the body and is important for the basic functioning of cells. It also boosts energy, strengthens the immune system, and acts as an antioxidant. Supplementation with 300 mg daily was show in one study to decrease headache frequency, and was effective within one month of treatment. Another study showed that treatment with CoQ10 might also be effective in treating pediatric migraine. Treatment is generally very well-tolerated, although some patients experience gastrointestinal side effects.
Alpha Lipoic Acid
Like riboflavin and CoQ10, alpha lipoic acid is another compound that is important in the energy-related functions of the body’s cells. Some preliminary studies have suggested that it may be helpful in reducing headache frequency. The proposed dosage is 600 mg daily.
Herbal Supplements
Herbal treatment and remedies appeal to many people because they appear to be more “natural” than traditional medications. Although this may be the case to some degree, herbal treatments can still be dangerous when used incorrectly, or in high doses. Some of them can even cause serious side effects. Treatment with herbal remedies should be avoided in pregnant women because of possible harmful effects on the developing fetus. We also recommend avoiding these remedies in young children or the elderly.
Feverfew
Feverfew is an herbal preparation that is available as the dried leaves of the weed plant tanacetum parthenium. It was used to treat headache, inflammation, and fever several centuries ago, and rediscovered in the late 20th century. Some studies and case reports have suggested that it may be helpful in preventing and treating migraine headaches. The effective dose is controversial, since dried feverfew leaves can lose some of their strength over time. However, researchers generally recommend taking 125 mg of a dried feverfew-leaf preparation that contains at least 0.2 percent parthenolide. Potential side effects include stomach upset, mouth ulcers, and a “post-feverfew syndrome” of joint aches.
Butterbur (Petasites hybridus)
The butterbur plant is a perennial shrub that was used in ancient times for its medicinal qualities. Recently, some well-designed studies have shown that it is effective in the prevention of migraine headaches. It probably works by decreasing the inflammation associated with migraine. Butterbur is sold as Petadolex and the recommended dose is 150 mg daily. Side effects include gastrointestinal disturbances, especially burping.
Ginger
Ginger has been used in China for centuries, in the treatment of pain, inflammation, and musculoskeletal symptoms. It can have some effects on reducing inflammation and may be helpful in the treatment of migraine, especially for people that have nausea with their headaches. Ginger can be added to meals or brewed as a tea (one ounce of freshly grated gingerroot to two cups water). However, the evidence for its use in migraine treatment is only anecdotal; there haven’t been any good scientific studies showing that it is effective.
Valerian Root
Valerian root can be useful as a sedative, especially in insomniacs. It may also be helpful for migraine patients with anxiety, since it doesn’t have the “hangover effect” caused by some prescription sedatives. The suggested dose for insomnia is 300 to 600 mg, which is equivalent to 2 to 3 grams of dried herbal valerian root soaked in one cup of hot water for 10 to 15 minutes. At higher doses, valerian root is associated with headaches and muscle spasm.
Conclusion
Although we can’t cure migraines, there are many ways that we can decrease the frequency and severity of headaches without taking more and more prescription medications. Eating well and avoiding possible headache triggers can have a major impact on your headache pattern. Vitamins and herbal supplements are also potentially good options for decreasing headaches without many side effects. Always talk to your health care provider before starting any of these treatments.