Lifestyle Treatments to Prevent or Reduce the Frequency of Migraine Headaches

Migraine headaches are among the most common reasons for visits to neurologists worldwide. The headaches can be severe and recurrent and related symptoms (for example, nausea, fatigue and light and sound sensitivity) can lead to substantial disability.[1] Acutely, migraines often are treated with acetaminophen (TYLENOL) or nonsteroidal anti-inflammatory (NSAID) drugs such as ibuprofen (ADVIL, MIDOL, MOTRIN and generics). Other classes of drugs have been approved for acute migraine pain, including triptans (also known as serotonin receptor agonists). Public Citizen’s Health Research Group has classified triptans as Limited Use, to be taken only if acetaminophen and NSAIDs fail to provide relief.[2] Importantly, opioids should not be used to treat or prevent migraines, as they may exacerbate or promote such headaches.[3]

Prevention is as important as the acute treatment of migraine headaches. Several drugs are available to prevent or reduce the frequency of migraines. They include the antiseizure drug topiramate (EPRONTIA, QSYMIA, QUDEXY XR, TOPAMAX, TROKENDI XR). Public Citizen’s Health Research Group has classified topiramate as Do Not Use for migraine prevention because of its many serious adverse effects.[4] Other seizure medications, valproic acid (generic only) and divalproex (DEPAKOTE), also are used to prevent migraines. However, because of concerns that such drugs cause birth defects, Public Citizen’s Health Research Group recommends that women of childbearing age avoid using them for migraine prevention.[5] Lifestyle changes that do not involve medications appear to offer some relief for people with recurrent migraine headaches. A 2022 review article in The Lancet Neurology[6] describes the potential and limitations of such preventive strategies.

Background on migraines

The exact cause of migraines is not known; limited, irregular brain activity (electrical and chemical) and blood flow are thought to be involved. In adults, the prevalence of any migraine headache is approximately 17% in women and 6% in men; chronic migraines effect 2% of the global population.[7] Long-term migraine headaches that prompt consideration of preventive therapy are sometimes divided into two categories: episodic, which involve at least four, multi-hour headache days per month; and chronic, which involve 15 or more headaches per month.[8] Each year, about 3% of people with episodic migraines develop chronic migraines.[9] Over time, however, many individuals with chronic migraines revert to episodic migraines. The goals of prevention include reducing headache days and decreasing the frequency of progression from episodic to chronic migraines.

The Lancet Neurology review article[10]

The Lancet Neurology article reviewed observational studies and clinical trials that assessed the association between lifestyle factors and migraines, and that were published between 2015 and 2022. The review focused on studies that could be of practical use, especially studies that used patient-maintained diaries as key sources of data about factors that may influence the frequency of migraine episodes, such as stress management, sleep, nutrition and exercise.

Stress

In the observational studies, stress was determined to be the strongest factor associated with migraines. Not all studies, however, found that stress was a trigger for migraines, and the time lag between experiencing stress and experiencing a migraine was variable; sometimes stress was an instantaneous trigger, other times the “let down” of moving from high to low stress was the trigger and sometimes stress had no effect on the occurrence of a migraine. One study found that the more surprising or novel the stress, the more likely it would trigger a migraine.

Behavioral interventions for presumed stress-related migraines include those characterized as relaxation or mindfulness therapies. Cognitive behavioral therapies (CBT) targeting maladaptive thoughts and conduct that might trigger migraines were also considered. Only two of eight recent trials indicated that such behavioral interventions might be effective. The largest of these two trials included 98 migraine patients randomized to either mindfulness or other stress management approaches for headaches; this study found that mindfulness was slightly superior, resulting in an average of 4.6 versus 6 monthly headache days. The smaller trial included just 35 migraine patients randomized to either a muscle-relaxation protocol or a waitlist and found a significantly reduced frequency of migraines in the relaxation group, by an average of approximately 2 monthly migraine headache days. Overall, the evidence for stress-reducing behavioral therapies for migraines was very limited, and offered little support for these interventions.

Sleep

Sleep-related issues were the only consistent lifestyle factor associated with migraine frequency. In one study, 326 patients used a sleep diary and were followed for three months. The study found the risk of next-day migraine attacks increased an average of 21% on a day patients experienced noticeable tiredness, and by 11% on days following a “restless” night’s sleep.

Two small trials of cognitive behavioral therapy suggested that this approach may have potential as a strategy to reduce the frequency of migraines. One trial included 42 women with chronic migraines who received six weeks of digital CBT for their insomnia. That trial found that the subjects randomized to CBT had an average reduction of 2.6 monthly headache days compared to those who did not receive this therapy. Another trial of 74 adults with migraines found that subjects randomized to CBT for insomnia had an average of 6.2 fewer monthly migraine headache days compared with placebo (sham lifestyle changes) or less formal behavioral therapy (sleep hygiene).

Diet

People with migraines may attribute some of their headaches to specific foods or beverages. The available evidence, however, does not support these apparent triggers, except for the consumption of relatively large quantities of alcohol (at least 5 servings, with a serving defined as 12 ounces of regular beer, 5 ounces of wine or 1.5 ounces of distilled spirits) or large quantities of caffeine. There is some evidence that “improbable use” (for example, drinking a lot at a party when you do not regularly drink) may trigger migraines, that cravings for food may precede (though not necessarily cause) a migraine and that water in-take may reduce headache frequency and duration.

Eleven trials of dietary interventions for migraine were reviewed; the evidence for effectiveness was minimal at best and frequently negative. Several studies suggested opportunities for further research. Diets designed to reduce hypertension were found helpful in one study, as were ketogenic diets (low carbohydrates and high fats) in two other studies. A low-glycemic (sugar) diet study with a total of 350 adults found that such a diet may be as useful for migraine-prevention as commonly used medications, such as propranolol (HEMANGEOL, INDERAL, INNOPRAN and generics), amitriptyline (generic only), flunarizine (not available in the United States) or topiramate. Voluntary caffeine elimination was not found to reduce migraines, but other studies suggested that diets enriched with omega-3 (fatty fish) and omega-6 (nut oils) might be helpful.

Physical activity

Only one small observational study of physical activity was identified involving 28 migraine patients. The study found no significant difference in pedometer-measured steps on days with or without migraines. Three small, randomized trials suggested that regular exercise may reduce the frequency of migraines in women. One trial involved 32 women who were assigned to either a yoga-plus-medication group or medication-only group. After 12 weeks, the yoga group reported average declines in migraine headache days of roughly 2.8 per month, whereas the medication-only group reported increases of 1.4 migraine headache days per month.

What You Can Do

To control episodic or chronic migraine headaches, consider addressing the following behaviors: sleep, exercise, nutrition and stress. As sleep issues were the only consistent lifestyle factor associated with migraine frequency that was identified in the review, they may be especially important to address. It may also be useful to keep a date-and-time-stamped diary of behaviors and migraines to help you work with clinicians (such as nutritionists, behavioral therapists or neurologists) to develop an individualized, nonpharmaceutical approach to migraine headaches.
 

References

[1] National Institute of Neurologic Disorders and Stroke. Migraine. July 11, 2023. https://www.ninds.nih.gov/health-information/disorders/migraine. Accessed September 1, 2023.

[2] Worst Pills, Best Pills News. Review of the triptan drugs for treating migraines. June 2022. https://www.worstpills.org/newsletters/view/1468. Accessed September 1, 2023.

[3] Schwedt TJ, Garza I. Preventive treatment of episodic migraine in adults. UpToDate. June 22, 2023.

[4] Worst Pills, Best Pills News. Topiramate: limit use to treatment of seizures, do not use for other conditions. https://www.worstpills.org/newsletters/view/1188. Accessed September 6, 2023. April, 2018.

[5] Worst Pills, Best Pills News. Valproic acid and divalproex: high risk of birth defects. November 2018. https://www.worstpills.org/newsletters/view/1232. Accessed September 1, 2023.

[6] Seng EK, Martin PR, Houle TT. Lifestyle factors and migraine. Lancet Neurol. 2022 Oct;21(10):911-921.

[7] Garza I, Schwedt TJ. Chronic Migraine. UpToDate. July, 2023.

[8] Schwedt TJ, Garza I. Preventive treatment of episodic migraine in adults. UpToDate. June 22, 2023.

[9] Garza I, Schwedt TJ. Chronic Migraine. UpToDate. July, 2023.

[10] Seng EK, Martin PR, Houle TT. Lifestyle factors and migraine. Lancet Neurol. 2022 Oct;21(10):911-921.