From “Weather, food and more: The truth about triggers” (Vincent Martin MD, Director and Headache Specialist, University of Cincinnati Headache and Facial Pain Center)

Most people living with migraine have multiple triggers that can instigate their attacks— though many triggers like stress or sensory stimuli can be common,  the range and manifestation of triggers uniquely differ between individuals.¹ In a field where many myths can confuse patients, scientific evidence is starting to uncover the physiology of migraine triggers. At the recent Migraine World Summit 2020 held virtually from March 18–26, Dr. Vincent Martin (Director and Headache Specialist, University of Cincinnati Headache and Facial Pain Center) spoke in a session titled “Weather, food, and more: The truth about triggers” about his latest insights on triggers as a leading expert on migraine and weather.

The difference between a migraine trigger and migraine prodrome symptom

Migraine attacks are preceded by the migraine prodrome, which has its own symptoms including food cravings, increased fatigue, light and/or noise sensitivity, and even neck pain.^2,3 Migraine triggers, on the other hand, are factors that provoke an attack upon a patient’s exposure or withdrawal to them, which can take anywhere from 15 minutes to 24 hours to manifest.⁴ According to Dr. Martin, prodromal symptoms are often misconstrued as triggers, thereby confusing patients.

The concept of a migraine threshold has been proposed to help explain triggers.⁴ Dr. Martin pointed out that such thresholds may be sensitized by additional factors day to day, since neural circuits are constantly in flux. He stated that as a result, susceptibility to triggers—even the same trigger—could significantly vary for the same patient.

Migraine triggers: Hormonal changes and weather

One example of this effect is when those who experience menstrual migraine, influenced by hormonal changes, appear to be sensitized to other triggers before, during, and after menstruation.⁴ Another example is the effect of weather on headache and migraine, which Dr. Martin stated is his research focus. Declining or rising barometric pressure, precipitation, and humidity are some factors that could sensitize some patients to other triggers and lead to migraine attacks.⁵ Dr. Martin also mentioned a recent study published about “surprisal”—being exposed to something different from normal—being a possible trigger for an attack.¹ Along with the effect of stress as a potential trigger, he stated that these topics are actively studied in the field.

Management of migraine triggers

For patients with stress as a migraine trigger, Dr. Martin recommended biofeedback, relaxation, and lifestyle changes to alleviate the risk of headaches. To minimize menstrual migraine attacks, he endorsed oral contraceptives with low-dose estrogen, and asserted that further studies on the physiological and chemical pathways related to migraine triggers are crucial for other potential therapies.

Dr. Martin explained that there exists both a repetition theory and an avoidance theory for managing migraine triggers, and in his opinion, both apply. He stressed that some triggers may be better managed one way over the other, and it is important to find a realistic and individualized management path for each patient. Dr. Martin recommended using a diary or related app that can record triggers and headache data, and perform statistical analyses to help identify true triggers. Moreover, he mentioned that preventive therapy can be an effective aid in lowering trigger thresholds.

A focused approach

When patients hyper-focus on every potential migraine trigger, Dr. Martin stated that more harm than good may be done. In his opinion, identifying and establishing a few core triggers as definite causes of headache attacks for each patient, and encouraging practicing a healthy level of avoidance, are usually more practical strategies than exposure. Dr. Martin expressed his belief that further research will continue to reveal more connections between triggers and neural processes to expand therapy options.

References

1. Turner DP, Lebowitz AD, Chtay I, Houle TT. Headache Triggers as Surprise. Headache 2019;59(4):495–508. 
2. Dodick DW. A Phase-by-Phase Review of Migraine Pathophysiology. Headache 2018;58 Suppl 1:4–16. 
3. Schulte LH, Peng K-P. Current understanding of premonitory networks in migraine: A window to attack generation. Cephalalgia 2019;39(13):1720–7. 
4. Martin VT, Behbehani MM. Toward a rational understanding of migraine trigger factors. Med Clin North Am 2001;85(4):911–41.
5. Martin GV, Houle T, Nicholson R, Peterlin A, Martin VT. Lightning and its association with the frequency of headache in migraineurs: an observational cohort study. Cephalalgia 2013;33(6):375–83.

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