Migraine Triggers Tricky for Patients to Pinpoint

Most patients with migraine have a sophisticated idea of what causes their headaches, but the chances of this information being wrong are higher than desirable unless the patient formally experimented with triggers, new research shows.

“It is commonly believed that each headache sufferer has a unique pattern of triggers,” lead author Timothy T. Houle, PhD, Associate Professor of anesthesia and neurology at Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, told ConsultantLive. “Physicians may not have all the information they need to determine what is causing a patient’s headaches if the only available information was collected by the patient using natural experiments.”

For the study, 9 women who had regular menstrual cycles and had a diagnosis of migraine with or without aura provided data for 3 months by completing a daily diary and tracking stress with the Daily Stress Inventory, a self-administered questionnaire to measure the number and impact of common stressors experienced in everyday life. Morning urine was collected daily for hormone level testing, and the researchers reviewed 3 years’ worth of weather data from a local weather station.

Dr Houle and coauthor Dana Turner, MSPH, chose to examine weather, stress, and ovarian hormones because they are 3 of the most commonly reported headache triggers. “These triggers are always present to some degree for female headache sufferers and must be accounted for when thinking about the effects of an additional trigger, for example, drinking wine,” Dr Houle said.

Considering fluctuations in these variables, there were only about 2 days each month in terms of stress and ovarian hormones and 2 days each year in weather patterns that were similar enough for patients to test these conditions on their own.

Physicians often have a wealth of clinical experiences to assist headache sufferers in deducing their triggers, Dr Houle noted. “For example, a physician could help a patient create a random list of days where he or she will approach a trigger (for instance, cheese) and compare these to a randomly selected group of days where the patient will avoid the trigger,” he said.

Dr Houle is creating a group of online tools to help physicians do experiments like this with their patients who have headache.

Physicians need to rethink what their patients know about migraine triggers while respecting their patients’ beliefs, he said. “The beliefs about the triggers are as important as the truth about them. I suggest gently exploring the idea of testing these beliefs, especially if the trigger belief system is interfering with the patient's quality of life, that is, the patient avoids many foods or activities he or she enjoys.”

These beliefs quite possibly are based on limited experiences-one headache that resulted from a single exposure. “A patient’s beliefs could be changed by evaluating more evidence,” Dr Houle suggested.

“Physicians should be careful, though, because these belief systems also might reflect an underlying anxiety disorder where the patient is keeping safe from fearful stimuli.” In such a case, bringing in a behavioral specialist would be of great help, he said.

The researchers reported their results online on March 27, 2013, in the journal Headache.