Migraine triggers – real or not?

Most people with migraine will find that certain conditions seemed to be linked with an increased likelihood of getting a migraine. These are called migraine triggers. Common triggers include stress, fasting, sleep deprivation, and hormonal changes. Specific migraine triggers can sometimes be difficult to identify. In general, a trigger should precipitate a migraine within about 12 hours of exposure. A new article published this month in the journal Neurology from Dr. Olesen’s research group reported that they were generally unsuccessful triggering migraine in people with migraine with aura who had reported flickering lights or strenuous exercise could trigger a migraine attack. This small study tested 27 people. After flickering light and/or exercise exposure, migraine occurred in only about 20 percent of people. The authors concluded that it’s important to directly test identified triggers to verify that they really do trigger migraines.

Does this mean people really can’t identify migraine triggers? Absolutely not. An earlier report of people migraine with aura in the journal Cephalagia also from Dr. Olesen’s group reported that 80 percent of people reported having migraine triggers, most commonly stress. Only 54 percent of people, however, reported that their trigger would at least often precipitate their migraine with aura and only 26 percent reported their migraine was always triggered by the identified trigger. This means that, for most people, triggers don’t precipitate a headache all or even most of the time.

Why don’t triggers consistently trigger attacks? Several years ago, we did a study showing that chocolate did not consistently trigger migraines, even in people reporting chocolate to be a frequent migraine trigger.  Why was our research different from people’s normal migraine experiences?  I like to think of triggers like they are weighing down a scale and when the scale gets heavy enough, a migraine occurs. Using chocolate as an example, you can see how this can happen. This week, you may have a migraine on Monday at 4 PM and you remember you ate a chocolate bar at 3 PM. Two weeks later, you have a chocolate bar with your lunch at noon, and don’t get a migraine later that day. Is chocolate a trigger or not? What might be happening? Triggers are often additive. The Monday you got the migraine after eating chocolate, you’d had a busy weekend and stayed up late on Sunday. Monday morning, you slept through your alarm, skipped breakfast, and rushed to work.  You were assigned a big project in the morning, and decided to have a cola and chips at your desk while you worked instead of going to the cafeteria for soup and a sandwich. At 3 PM you were famished and grabbed a chocolate bar from the vending machine. So what triggered the 4 PM migraine? Was it the chocolate or not? The chocolate may have been a factor, but there were lots of other strong triggers also in play – change in sleep pattern, fasting, and stress. When you had the chocolate bar with lunch a couple weeks later, those other triggers may not have also been present. This may help explain why triggers don't always result in a migraine.

So the take home message is not that people can’t really identify triggers or that you should ignore potential triggers. It means that identifying migraine triggers can be challenging. Keeping track of a range of potential triggers, including stress, eating and sleeping cycles, menstrual periods, etc., in a migraine diary can be helpful when determining your unique circumstances when certain triggers are most likely to trigger your migraines. Perhaps you can get away with that piece of chocolate cake or glass of wine when your life is otherwise on an even keel, but when you’re premenstrual and skipped breakfast, you will need to pass on the chocolate or wine.

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