Functional Nutrition for Migraine

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What are migraines?

Migraine is a highly complex neurological disorder that produces moderate to severe headaches that often occur on one side of the head and are accompanied by other symptoms such as nausea, vomiting, and sensitivity to light or sound (1).

Aura refers to the series of sensory disturbances which often precede or accompany migraines (2).

How common are migraines?

Migraine affects 1 out of every 10 people worldwide (3).

In the United States, approximately 1 out of every 6 people are affected (4).

Women are twice as likely to have migraines, compared to men (34).

What are the symptoms of a migraine?

Migraine headaches can progress through four different phases, although not all patients experience every phase (5).

During the prodromal phase (24-48 hours before a migraine), the following symptoms are common (6):

  • Depression
  • Excessive yawning
  • Fatigue
  • Food cravings
  • Irritability
  • Muscle tenderness
  • Neck stiffness

After the prodromal phase, 25-30% of patients enter the aura phase, in which symptoms can last for 5-60 minutes each (57):

  • Blind spots
  • Double vision
  • Dizziness
  • Flashes of light
  • Impaired hearing
  • Incoordination
  • Loss of speech
  • Muscle weakness
  • Numbness or tingling
  • Ringing in the ears
  • Slurred speech

These are the most common symptoms that occur during the headache phase, which lasts for 4-72 hours (7):

  • Moderate or severe pain
  • Nausea and/or vomiting
  • Sensitivity to light, sound, and/or smell
  • Throbbing or pulsating pain
  • Unilateral pain (on one side of the head)

The postdromal phase (1-2 days after the headache) is sometimes accompanied by these symptoms (58):

  • Fatigue
  • Impaired concentration
  • Mood changes
  • Neck stiffness

What causes migraines?

1. Genetic predisposition

More than 38 migraine-associated genetic SNPs have been discovered (9).

In hemiplegic migraine (a rare form of migraine that causes weakness on one side of the body), single gene mutations are present (9).

However, it is thought that most migraines are caused by the interaction of multiple genes and epigenetic factors (9).

2. Precipitating factors

Typically, a precipitating factor (or trigger) initiates the migraine attack.

Common migraine triggers include (1011):

  • Alcohol
  • Diet
  • Dehydration
  • Exposure to bright lights, loud noise, or strong odors
  • Fasting (or skipping meals)
  • Hormonal changes (especially estrogen)
  • Medications
  • Sleep disturbances
  • Stress
  • Weather changes

3. Activation of the trigeminovascular system

Scientists aren’t entirely sure how migraines develop.

The current hypothesis centers around the trigeminovascular system, which refers to small sensory neurons within the trigeminal nerve (the largest nerve in the brain) that innervate cerebral blood vessels (1213).

In response to a migraine trigger, the trigeminal nerve is activated, causing it to release neurotransmitters, such as calcitonin gene-related peptide (CGRP) and substance P (14).

These neurotransmitters promote inflammation and cause blood vessels to dilate, resulting in migraine symptoms.

4. Other mechanisms involved

Migraine aura is thought to be caused by cortical spreading depression (CSD), a wave of electrical activity that spreads through the cortex of the brain (15).

Mitochondrial dysfunction is also thought to increase susceptibility to migraines by increasing neuronal excitability (the readiness of a nerve to respond to a stimulus) (16).

Abnormal serotonin metabolism resulting in low levels of serotonin (a neurotransmitter also known as 5-HT) may cause blood vessel dilation and the initiation of migraine (1718).

What conditions are linked with migraines?

1. Psychiatric disorders

Patients with migraines are 2.5 times more likely to be diagnosed with depression and up to 5 times more likely to meet the criteria for at least one anxiety disorder (19). 

Those who have migraine with aura are 3 times more likely to be diagnosed with bipolar disorder (19).

Scientists believe that possible mechanisms might include medication overuse, serotonin dysfunction, hormone fluctuations, and central sensitization (increased neuronal responsiveness to pain) (20). 

2. Stroke

Migraine with aura is associated with a twofold increased risk of ischemic stroke (21). 

It is thought that changes in vascular function related to migraines might play a role in increasing stroke risk (22).

However, it’s important to note that migraine with aura can present with symptoms that are very similar to stroke and is easily misdiagnosed (23). 

3. Gastrointestinal disorders

It is thought that chronic inflammation in the gut might contribute to migraines (24). 

Patients with inflammatory bowel disease (IBD) are twice as likely to experience migraines compared to the general population (24). 

Irritable bowel syndrome (IBS) is associated with a 60% increase in migraine risk (25). 

Approximately 30% of patients with Celiac disease and 56% of patients with gluten sensitivity report having migraines (26).

4. Fibromyalgia

The prevalence of fibromyalgia in patients with migraines has ranged from 22-66% in various studies (272829).

Scientists haven’t been able to explain the link between migraines and fibromyalgia, although they do share similar features regarding pain processing (30).

5. Epilepsy

Both epilepsy and migraines are caused by a series of electrical disturbances within the brain (31).

The link between migraines and epilepsy is controversial and inconsistent, although one recent study found that 26% of adults with epilepsy also had migraines (3233).

How are migraines diagnosed? 

The following criteria are used to diagnose the three main types of migraine headache disorders, as defined by the International Classification of Headache Disorders, 3rd Edition (ICHD-3) (7):

Migraine without aura

  1. At least five attacks fulfilling criteria 2-4.
  2. Headache attacks lasting 4-72 hours (untreated or successfully treated).
  3. Headache has at least two of the following characteristics:
    1. unilateral location (one side of the head)
    2. pulsating quality
    3. moderate or severe pain intensity
    4. aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)
  4. During headache, at least one of the following:
    1. nausea and/or vomiting
    2. photophobia and phonophobia
  5. Not better accounted for by another ICHD-3 diagnosis.

Migraine with aura

  1. At least two attacks fulfilling criteria 2 and 3.
  2. One or more of the following fully reversible aura symptoms:
    1. visual (occurring in both eyes: blind spots, flashes of light)
    2. sensory (numbness, tingling)
    3. speech and/or language (loss of speech)
    4. motor (weakness)
    5. brainstem (slurred speech, dizziness, ringing ears, incoordination, impaired hearing, double vision)
    6. retinal (occurring in only one eye: blind spots, flashes of light, or complete blindness)
  3. At least two of the following characteristics:
    1. at least one aura symptom spreads gradually over >/=5 minutes, and/or two or more symptoms occur in succession
    2. each individual aura symptom lasts 5-60 minutes
    3. at least one aura symptom is unilateral
    4. the aura is accompanied, or followed within 60 minutes, by headache
  4. Not better accounted for by another ICHD-3 diagnosis, and transient ischemic attack has been excluded.

Chronic migraine

  1. Headache (tension-type-like and/or migraine-like) on >/=15 days per month for >3 months and fulfilling criteria 2 and 3.
  2. Occurring in a patient who has had at least five attacks fulfilling criteria 2-4 for migraine without aura and/or criteria 2 and 3 for migraine with aura.
  3. On >/=8 days per month for >3 months, fulfilling any of the following:
    1. criteria 3 and 4 for migraine without aura
    2. criteria 2 and 3 for migraine with aura
    3. believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative
  4. Not better accounted for by another ICHD-3 diagnosis.

What medications are commonly used to treat and prevent migraines?

Abortive Medications

Abortive medications are used to stop (or abort) a migraine that has already started:

1. OTC painkillers

NSAIDs (ibuprofen, aspirin, naproxen sodium, etc.) and acetaminophen are the first-line treatment for migraines (34).

The combination of acetaminophen, aspirin, and caffeine (Excedrin Migraine) is also effective.

2. Triptans

If NSAIDs and acetaminophen fail or if the migraine is severe, triptans may be prescribed (34).

Triptans work by binding to serotonin receptors on blood vessels, which causes them to constrict (35).

3. Ergotamines

Similarly to triptans, ergotamines cause blood vessels to restrict by binding to serotonin receptors, relieving pain caused by vasodilation (36).

However, they are less effective than ergotamines, because they have a much lower bioavailability (3738).

4. Antiemetics 

When a patient has nausea or vomiting associated with a migraine, antiemetics such as metoclopramide can be used along with pain medications (34).

Preventative Medications

Preventive medications are used to reduce the frequency and severity of migraines:

1. Beta blockers

Certain types of beta blockers, such as metoprolol, can be effective for the prevention of migraines (34).

The mechanisms are not well understood, but they may interact with serotonin and the trigeminovascular system (39).

2. Antiepileptics

Topiramate and valproate are the two antiepileptic drugs that have been studied and proven effective for migraine prevention (34).

It’s unclear exactly how these drugs inhibit migraines, but they may be involved in reducing CGRP secretion from trigeminal neurons (39).

3. Calcium channel blockers (CCBs)

Flunarizine and verapamil are two of the most common CCBs used for the prevention of migraines (34).

These drugs may work against migraines by reducing neuronal excitability (39).

4. Antidepressants

Amitriptyline (a tricyclic antidepressant) and fluoxetine (a serotonin reuptake inhibitor) have shown efficacy for migraine prevention (40).

Fluoxetine may combat migraines by increasing serotonin levels, while amitriptyline may suppress cortical spreading depression (39).

5. Botulinum toxin (Botox)

Botulinum toxin type A (also known as Botox) is a neurotoxin produced by Clostridium botulinum, the bacteria responsible for botulism (41).

For migraines, Botox is injected near nerve fibers in the head, where it blocks the release of neurotransmitters responsible for causing pain (42).

Botox injections are approved for the treatment of chronic migraines (15 or more headache days per month) (42434445).

What are some potential diet-related triggers?

1. Tyramine?

Tyramine is a compound found naturally in foods such as aged cheese, processed meats, and fermented foods (46).

It is formed (often by bacteria) from the breakdown of the amino acid tyrosine.

A low-tyramine diet is one of the most commonly recommended dietary interventions for migraines.

It is thought that tyramine causes headaches by altering vascular function in susceptible individuals (47).

However, clinical trials examining the ability of tyramine to initiate migraines have failed to reach statistical significance (48495051).

More research is needed.

2. Histamine?

Histamine is a chemical naturally found in certain foods that is also produced by the body and has a wide range of effects (52).

An estimated 1% of the population has histamine intolerance, which can result in a variety of symptoms, including headache (53).

A 1993 study tested the effects of a histamine-free diet on symptoms in 45 patients with chronic headaches and found that headache frequency was significantly reduced after 4 weeks (54).

However, many high histamine foods also contain large amounts of other chemicals, such as tyramine, which could also play a role in causing headaches.

3. Caffeine?

The role of caffeine in migraines is complex.

Caffeine withdrawal may trigger migraine-like headaches in patients who consume caffeine on a regular basis (55).

However, caffeine can also be used to relieve migraines and is included in some OTC headache medications.

It is thought to work by causing blood vessels to restrict, but this theory is probably too simplistic.

4. Gluten?

Celiac disease and gluten sensitivity are linked with migraines, and removing gluten from the diet can help decrease or eliminate migraines in these patients (265657).

However, there is no evidence that a gluten-free diet can reduce migraines in patients without these conditions.

5. Sulfites?

Sulfites are chemicals that are commonly used as preservatives in many foods, including beer, wine, juice, nuts, wine vinegar, processed fish, fresh grapes, and dried fruits and vegetables (58596061).

During the winemaking process, sulfites are added to prevent oxidation and maintain the flavor of the wine (6263).

A small 2019 study found that people with a history of wine-induced headaches had a greater risk of getting a headache after consuming high-sulfite wine compared to low-sulfite wine (64).

However, dried fruits (especially apricots) often have significantly higher concentrations of sulfites and aren’t reported as headache triggers nearly as frequently as wine (58).

More research is needed to determine whether sulfites can trigger migraines.

6. Alcohol?

Alcohol can be considered a migraine trigger if the migraine begins within 3 hours of consumption (65).

In a recent study, 35% of participants reported alcohol, especially red wine, as a migraine trigger, but only 9% reported that alcohol consistently caused migraines (65). 

It’s unknown whether alcohol itself or components of alcohol (histamine, tannins, sulfites, etc.) are responsible for these effects.

Although sulfites found in red wine are often blamed, there is evidence that other foods (dried fruits) contain higher levels of sulfites and aren’t commonly reported as migraine triggers (58). 

PureWine is a company that sells small filters that can be placed in a glass of wine to remove histamine and sulfites.

There are anecdotal reports that headaches caused by wine are reduced or eliminated when these filters are used, but no research has been conducted.

7. Nitrates & nitrites?

Nitrates and nitrites are compounds that occur naturally but are also used as preservatives in food products, such as lunch meat, sausages, and bacon.

In the body, they are converted to nitric oxide, which acts as a signaling molecule and causes blood vessels to dilate (66).

Although nitric oxide may play a role in the development of migraines, we couldn’t find any evidence linking ingestion of nitrates or nitrites with migraines (67).

8. Artificial sweeteners?

A few studies have shown an increase in migraine frequency with aspartame consumption (>/=300 mg/day), but the evidence is mixed (686970).

Several older case reports indicate that sucralose (Splenda) may also trigger migraines in some individuals, but no trials have been performed (7172).

9. MSG?

Monosodium glutamate (MSG) is a popular flavor enhancer used most often in Asian cuisine.

Despite anecdotal reports of MSG causing migraines, research findings are inconsistent and most studies have a high risk for bias (73).

10. Chocolate?

Theobromine, a chemical found in cocoa, is similar in chemical structure to caffeine and may act as a headache trigger (74). 

A 2020 review found that chocolate was reported as a migraine trigger in 23 out of 25 studies (75).

However, clinical trials have failed to show a significant effect of chocolate on the development of migraines (767778).

11. Citrus fruits?

An older study found that 11% of patients reported having migraines triggered by citrus fruits (79).

However, there is no proposed mechanism to explain why this might occur, and no clinical trials have been performed to evaluate the effects of citrus fruit consumption on migraines.

Are elimination diets helpful for migraines?

Inflammation plays a role in the development of migraines and food sensitivities can contribute to this (8081).

Older research suggests that oligoantigenic diets can help migraine patients to identify trigger foods and reduce migraine frequency (8283).

Patients are limited to just a few foods (one meat, one grain, one vegetable, one fruit) for 3-4 weeks, then foods can be slowly reintroduced while monitoring for any symptoms (82).

Newer studies have evaluated the effects of IgG antibody-based elimination diets, which are generally less restrictive, on migraines with mixed results (84858687).

IgG-based food sensitivity testing is not recommended, because IgG may actually be a marker of food tolerance rather than sensitivity (8889).

Which nutrients might play a role in migraines?

1. Magnesium

Patients with migraines are more likely to be deficient in magnesium than healthy people (909192).

Magnesium may play a role in preventing migraines by decreasing CGRP levels and blocking pain receptors (9394).

There is evidence to suggest that magnesium supplementation (400-600 mg/day) might be effective for the prevention of migraines (9596979899100).

Magnesium citrate is a highly bioavailable form that has been widely studied and recommended for migraine prevention (100101). See our What Is the Best Magnesium Supplement for Migraines? blog post for more details.

2. Riboflavin

Riboflavin plays various roles in reducing oxidative stress, mitochondrial dysfunction, and neuroinflammation, all of which may be involved in the pathogenesis of migraine (102).

A recent review of trials found positive results for riboflavin supplementation (400 mg/day for 3 months) in the prevention of migraines in adults (103). 

The authors point out that only 27 mg of riboflavin can be absorbed at one time, so more research is needed to determine whether lower doses are similarly effective.

3. Coenzyme Q10

CoQ10 might be effective in preventing migraines due to its anti-inflammatory and antioxidant properties, as well as its role in improving mitochondrial function (104).

A 2019 meta-analysis of 5 trials showed that CoQ10 (100-400 mg/day) significantly reduces migraine frequency and severity (105).

4. Vitamin D

Patients with migraine are twice as likely to be deficient in vitamin D compared with healthy people (106).

Results from clinical trials suggest that vitamin D supplementation ranging from 2,000 IU per day to 50,000 IU per week could be effective at reducing migraine frequency (107). 

Vitamin D has anti-inflammatory properties which may be responsible for its effects on migraines (108). 

5. Omega-3 fatty acids

Omega-3 fatty acids may play a role in the treatment of migraines due to their anti-inflammatory effects (109).

A recent meta-analysis showed that omega-3 intake had no effect on frequency and severity of migraine but did reduce the duration of migraine attacks by 3.4 hours (109).

Are any supplements beneficial?

1. Butterbur

Butterbur (Petasites hybridus) is an herb that has been used to treat migraines.

The exact mechanism is unknown, but butterbur may work against migraines by lowering inflammation (110).

Two older clinical trials showed that migraine frequency was reduced by more than 50% in patients receiving butterbur supplements (50-75 mg twice a day for 3-4 months) (111112).

However, butterbur naturally contains pyrrolizidine alkaloids (PA), which may cause liver damage, so only certified “PA-free” butterbur supplements are recommended (113114).

2. Ginger

Components of ginger known as “gingerols” alleviate pain by decreasing the production of prostaglandins, a group of fat-like compounds involved in inflammatory responses (115). 

Several trials have found that ginger extract (250-400 mg) is effective for reducing migraine severity when taken after a migraine begins (115116).

However, another study found that ginger supplementation (200 mg, three times/day for 3 months) is not effective for the prevention of migraines (117).

3. Melatonin?

Melatonin is a hormone that is produced by the pineal gland and regulates the sleep-wake cycle.

It may protect against migraines due to its analgesic (pain-killing) effects and ability to regulate neurotransmitters (118).

Some studies have found a significant reduction in migraine frequency with melatonin supplementation (3 mg/day for 3 months), while other studies suggest that melatonin is no better than a placebo (118).

Higher quality research is needed.

4. Feverfew?

Feverfew (Tanacetum parthenium) is an herb that has been used to prevent and treat migraines.

It contains parthenolide, a chemical with anti-inflammatory properties that may also play a role in regulating blood vessel constriction and relaxation (119).

Smaller clinical trials evaluating the effects of feverfew on migraines have reported conflicting results (119).

However, a larger study found a significant reduction of migraine frequency by 0.6 per month in patients who received feverfew supplementation (6.25 mg, three times per day for 16 weeks) (120).

Are there any other alternative treatments?

1. Acupuncture

Acupuncture is a technique originating from traditional Chinese medicine (TCM) that involves the insertion of very small needles into the skin in certain areas of the body (121).

A recent meta-analysis of 14 trials found that acupuncture was significantly more effective at reducing migraine frequency compared to medication and had fewer side effects (122).

However, the authors noted that the overall quality of evidence was very low, so more research is needed.

2. Aromatherapy

One trial found that inhaling lavender essential oil significantly improved headache symptoms in patients with migraines (123). 

Applying peppermint oil to the forehead and temples is a popular home remedy for headaches, although the research supporting its efficacy is weak and inconsistent (124125).

3. Yoga

Several small trials suggest yoga therapy (5 days per week for 60 minutes) reduces migraine frequency and severity over a 3 month period (126127128).

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