For years, migraine and headache sufferers, at the advice of their physicians, have tried to keep track of the root triggers of their migraines and headaches. While there is no one cause for migraines or headaches, especially when it comes to diet, keeping track of what we eat can help lower the likelihood of the onset of migraine or headache. Let’s take a look at the different common food triggers for headaches and migraines, as well as some dietary tips that can help. There are a variety of different “migraine diets” that focus on a variety of known dietary triggers and tips.
How Can You Tell If a Certain Food Or Drink Is a Headache Trigger?
Typically, beverage or food that is a headache trigger will cause a headache within 10 to 12 hours, but no longer than 24 hours. One way that you can check to see if a food or beverage causes headaches and migraines is to limit your consumption of it for a period of time, such as 4 to 6 weeks. Charting your consumption of food and beverages over a month’s time frame can also help you see patterns with the onset of headaches and migraines.
How Do Sweeteners Impact Headaches and Migraines?
If you regularly drink diet soda, use sweetener in your tea or coffee, or eat foods that are sugar-free, but use sweeteners such as aspartame, you might have a slight increase in your level of headaches. In fact, monthly consumption of diet soda can contribute to an increased frequency of migraines and headaches. The mechanism behind sweetener-induced headaches is not entirely understood, but reducing it will help decrease the frequency of severe headaches.
Why Does MSG Cause Headaches?
Chinese food is a common source of MSG. MSG is a food additive that is commonly found in a wide variety of foods for added flavor. MSG has been linked with several different disorders, including obesity and metabolic disorders. MSG-triggered headaches are not totally understood, but it is believed that MSG can release nitric oxide, which dilates blood vessels within the brain. An MSG headache will be pulsing, often on both sides of the head and will frequently be agitated by physical activity, all of which fits into the criteria of migraine. If you want to avoid MSG, you can eat whole foods that have been flavored with natural herbs and spices. On food labels, MSG is often hidden as other names including glutamate, natural flavor, and partially hydrogenated vegetable protein.
What Are Some Other Foods That Will Cause Headaches?
Chocolate has been shown to cause headaches in some individuals and can also be a migraine trigger. Around 20% of people who have experienced a migraine or a headache might identify chocolate as a trigger. The headache and migraine inducing ingredient in chocolate is beta-phenylethylamine.
Cured meats, like the ham you get at the deli, can cause headaches because of the preserving agent used in them. Nitrates, the preserving agent, are used to preserve color and flavor. As with MSG, this agent can cause blood vessel dilation in the brain, which is believed to be one of the reasons cured meats can trigger headaches or migraines. Aged cheeses also have an ingredient that causes headaches. Tyramine forms in cheese as proteins break down and this agent can also cause headaches.
Additionally, salty foods, fermented foods, and pickled foods can contribute to headaches because of the preservatives they contain.
Foods That May Have a Positive Impact on Headaches and Migraines
If you are experiencing headaches or migraines, you might want to incorporate some healthier foods into your diet. Everything from leafy greens to fish can improve the headache and migraine cycle. Leafy greens contain several different ingredients, like iron, that enrich blood flow and can help with headaches. Fish contain omega 3 fatty acids, which can reduce the frequency of headaches and are discussed more here.
Why Are Headache Diets Helpful?
Keeping track of what you eat and linking it to your headache and migraine patterns can be helpful. Not only does it let you identify food and beverages that may contribute to headaches and migraines, but you are more likely able to track triggers if you can identify them within a 24 hour period.
Headache diets may also have a therapeutic effect. Identifying what causes headaches and migraines is a weapon in the arsenal that lets headache and migraine sufferers know that they have control over their headaches and migraines.
What Are Some Tips For Starting a Headache Diet?
There are some things that may help you if you wish to start a headache diet:
For a period of a few weeks, keep track of food and drink that is consumed right before the onset of a headache or migraine.
For a period of four to six weeks, eliminate the food and beverages of concern to see if they are triggering your headaches.
If no change happens or the change is minimal, the food may not be associated with your headache or migraine.
In addition to tracking foods and beverages, also track other factors in your life, such as sleep issues, your menstrual cycle, or other factors.
Once you feel as if you have identified the culprit from your headaches or migraines, eliminate that food over time.
What Are the Benefits of a Healthy Diet?
Not only will diet changes help with headaches and migraines, but they will also improve your overall health. Reducing fat intake will have a positive impact on your blood pressure and cholesterol levels. Additionally, a healthy diet can reduce the likelihood of other chronic diseases, such as diabetes, that can have headaches as a secondary effect.
IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!
FIRST, LET’S DECIDE WHERE TO START:
IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.
IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.
Do you have a bad headache along with sinus pressure, facial pressure, facial pain, sinus pain, nasal congestion, nasal drainage, postnasal drip, or sore throat? It must be a sinus headache, right? Sure, it’s possible if there is a true sinus infection going on. However, the majority of the time it isn’t.
Now if these symptoms are associated with fevers, nasty colored drainage, and other infectious symptoms, there could certainly be a sinus infection and sinus related headache. However, without these infectious types of symptoms (fever, nasty colored drainage, signs of infection), the most likely cause is actually migraine.
Yes, those several monthly headaches you get with sinus pressure and congestion are probably not recurrent sinus headaches or sinus infections. They are most likely migraine, especially if there is a recurrent pattern such as monthly occurrence. Allergies (and associated sinus symptoms) are not felt to be a common cause of headache, and most of the time those symptoms actually represent migraine. If your sinus headache has features including throbbing, pounding, pulsating pain, nausea, or sensitivity to light and sound, it easily fits criteria for migraine, and should be treated as such. However, a discussion with your doctor is always recommended to ensure there is not an associated sinus infection or other cause of the headache. Your doctor should always be the one making treatment recommendations based on their assessment.
With that said, it is still possible that allergies can cause headaches for some patients due to the inflammation involved. The second half of this blog towards the end will address the connection between allergies, headaches, and jaw pain.
Sinus Headache and Migraine Misdiagnosis and Mistreatment
The bottom line is that migraine is commonly misdiagnosed as a “sinus headache” by patients, physicians, and other medical professionals when there are sinus symptoms present. Unfortunately, what we end up seeing in the headache clinic are patients with a history of excess unnecessary antibiotics, sinus procedures, and minimal to no relief. By the time patients see us, they have often had sinus surgeries, which surprise, don’t help them. Improvement usually doesn’t begin until the headaches and sinus symptoms are treated as migraine.
Sometimes patients report their “sinus headaches” improve with these repeated courses of antibiotics, but this doesn’t confirm a sinus infection. Many antibiotics have anti-inflammatory effects, and it is often this effect on the headache that is being felt rather than an infection being treated. In addition, unnecessary excess antibiotics lead to antibiotic resistance. So, when you actually do need that antibiotic for an infection it may no longer be effective against that bacteria (and remember, most upper respiratory infections are viral, which antibiotics will have no effect on anyway). C-difficile (C-diff) infection (which can be deadly) is another complication of antibiotic use in some patients, so the less unnecessary gamble of antibiotic use the better.
There is a rare and controversial type of facial pain called mucosal contact point headache. This type of pain is typically localized to a smaller area in the face, rather than a headache elsewhere. So it is more of a facial pain than a headache. It is suspected to be caused by a severe nasal septal deviation where part of the nasal septum contacts the nasal mucosa across from it. or pressure on the nasal walls and headache. This has also been called rhinogenic headache.
How Does Migraine Cause Sinus Symptoms?
The reason for this common misdiagnosis of “sinus headache” is because the trigeminal nerve (cranial nerve 5) is the root cause and central to migraine, and it also innervates the sinuses, teeth, TMJ (temporomandibular joint) area, and the face. So if the migraine is activated and turned on, not only does the pain of the headache turn on, but so does the discomfort in the sinus areas, TMJ, teeth, along with sinus symptoms. The bottom line, if you get recurrent episodic headaches that have any throbby, pulsating or pounding pain, any nausea, or sensitivity to light and sound during a bad “sinus headache”, consider it migraine.
How Often is Migraine Misdiagnosed as Sinus Headache?
A studyof almost 3,000 patients with self-diagnosed or doctor diagnosed sinus headaches showed that 88% of the patients actually had migraine according to ICHD3 criteria, not sinus headaches! The most common sinus symptoms reported in that study were sinus pressure (84%), sinus pain (82%), and nasal congestion (63%).
Another study called the American Migraine Study II showed similar results. This was a study involving 30,000 patients. About 50% of patients who were eventually diagnosed with migraine had been previously misdiagnosed, and the most common prior misdiagnosis was sinus headache.
Yet another study that looked at 100 patients with self-diagnosed sinus headaches. After a detailed history and exam, patients were given headache diagnoses based on the ICHD3 criteria. Of the 100 patients with self-diagnosed headache, 86% were diagnosed with a migraine related headache disorder, rather than a sinus related headache.
Is There a Connection Between Allergies and Jaw Pain?
Occasionally, Virtual Headache Specialist will allow guest bloggers to write an article on a migraine related topic, or collaborate with another website or company to further disperse useful medical knowledge. Sinus headache, allergies, jaw and facial pain are very relevant migraine associated topics. So, the second half of today’s blog topic in the section below was written by a guest author, whereas I wrote the section above. I hope the following article provides additional useful information on allergies, sinuses, and how they may relate to jaw and facial pain. The article below is a collaboration with the Zyrtec website given their allergy expertise on this topic.
While many people are aware of the fact that allergies can lead to headaches and sinus pain, they may be surprised to learn that allergies can also cause jaw pain. This can present as tender cheeks, pain radiating to your jaw and teeth, or even discomfort on the top of your head, and often feels worse when you lay down and better when you’re upright.
But why?
Basically, it’s all about the sinuses. We have four pairs of sinuses (frontal, ethmoid, maxillary, and sphenoid), and sinus pressure and pain in any of them can radiate all over your face — including your jaw. That’s why keeping your sinuses healthy by using a nasal spray, treating your allergies, and rinsing your sinuses with a saline rinse can be so helpful. Eating a healthy diet, exercising, and catching some solid zzz’s each night will also benefit your sinus health. Learn more ways to show your sinuses some love in this infographic.
Can Allergies Cause Jaw Pain?**
By Kristen Stewart
When you experience jaw pain, your mind may jump to reasons such as teeth grinding or toothaches. By going for the obvious, however, you may overlook something as simple as allergies causing your jaw pain. Keep reading to uncover how allergies can cause jaw pain. First, to help you determine if you may be suffering from allergies, here’s a quick primer on what allergies are, what causes them, and who’s most at risk of getting them.
IS IT ALLERGIES OR A COLD?
Allergies affect more than 50 million people in the United States each year, with many individuals suffering from allergic rhinitis. Also known as hay fever, its symptoms are as common as they are annoying — sneezing, runny nose, and itchy, watering eyes to name a few.1
While some symptoms overlap between allergies and a cold, you may notice some key differences. Colds are contagious and people often unwittingly infect others for two days before symptoms appear. A low-grade fever and aches and pains may accompany them. This common illness may also develop gradually over a couple days.2
On the other hand, viruses don’t cause allergies, so you can’t pass allergies on to anyone else. They occur when the body initially encounters a normally harmless substance and creates antibodies to it. When the body encounters the substance again, the existing antibodies tell the immune system to send chemicals such as histamine into the bloodstream to fight the invader. The immune response causes unpleasant allergy symptoms, and they often come on suddenly rather than gradually.3 Take our allergies versus cold quiz to find out which one you have.
ALLERGY CAUSES AND RISK FACTORS
Allergic rhinitis typically comes in two forms: seasonal and perennial. As its name suggests, seasonal allergies strike at predicted times of the year, most often in the spring, summer, or early fall. The main culprits tend to be pollens from grasses, trees, and weeds as well as mold spores transported through the air.
People with perennial allergies suffer all year. Triggers tend to be exposures encountered during everyday life such as animal dander, dust mites, cockroaches, or mold spores rather than outdoor greenery or conditions.4
While allergies are more likely to strike during childhood, they can develop at any time during a person’s lifetime. Reactions can vary from minor to severe.5
Unfortunately, you can’t control most of the risk factors for developing hay fever. People with existing allergies, asthma, or eczema are more likely to have hay fever. And if a parent, sibling or other blood relative has allergies or asthma, your chance of getting hay fever increases. But you can control one risk factor by spending less time exposed to allergens like animal dander or dust mites.
ALLERGIES, SINUSES, AND HOW THEY CAN CAUSE JAW PAIN
As any sufferer knows, allergies can wreak havoc on your body. In addition to the well-known sneezing, sniffling, and red watering eyes, you may experience postnasal drip, coughing, and fatigue.6 Allergies can also clog the sinuses. Because of that, they could be the source of your nagging jaw pain.7
You probably identify sinus problems with nasal pressure. But allergies can cause lower jaw pain as well as the feeling of general pressure, especially if maxillary sinuses are obstructed. Inflamed and swollen sinuses can affect a number of areas of the face and head and result in issues ranging from headaches and earaches to facial tenderness near the eyes and nose that radiates to the jaw.8
It’s possible that seasonal allergies could cause jaw pain in other ways, although more research is needed on the subject. Frequent sneezing and coughing force the mouth open which could lead to muscle tension and overuse strain and create issues with the jaw. Similarly, a stuffy nose may make you breathe through your mouth at night. If your jaw is strained open all night, it makes sense that you could wake up with jaw discomfort.9
And for people who have a temporomandibular joint disorder (diagnosed or not), it’s possible that allergies could exacerbate it and cause increased jaw pain. However, the sinuses are the key way allergies cause jaw pain.
THE SINUSES EXPLAINED
Many parts of the body get a lot of love. We try to eat right and exercise for our hearts and stay engaged with life mentally and socially to keep our minds sharp as we age. But people often neglect their sinuses. The sinuses may only become your focus of attention if a problem occurs. But it’s worth understanding more about your sinuses, and that’s especially true if you experience jaw pain, because sinus pressure and pain can radiate all over the face.
Sinuses are also called paranasal sinuses. They’re air-filled pockets or cavities in the skull and facial bones that connect to the nose through an opening known as an ostium.
Usually when we hear about cavities, it’s when we get bad news at the dentist’s office, but sinus cavities are our allies. Check out our 6 Things to Know About Sinuses page to learn about the remarkable role they play to keep us well and healthy.
Like many parts of the body, sinuses aren’t immune from issues. Allergic sinusitis typically comes with the usual allergy symptoms such as sneezing, nasal congestion, and itchy eyes, nose, and throat.10 Allergy headaches can also occur with facial discomfort in the sinus area. Pain can be located throughout the region or sometimes located on just one side.11
KEEPING SINUSES HEALTHY
The good news is you can take steps to keep your sinuses healthy, which may help alleviate and prevent jaw pain. One action you can take is to manage allergies to keep your symptoms under control. Allergies can cause inflammation of the nose and sinuses which in turn blocks mucus from draining and may lead to an infection.
In addition, consider using nasal saline sprays to keep your nose moist. This practice ensures the cilia will work at their optimum level to clear the airways and remove debris. You may also want to irrigate your sinuses with a saline sinus wash to add moisture and flush out dust, pollen, and other intruders. 12 13
Beware of irritants such as pollution and smoke. The chlorine found in chlorinated pools may also irritate and inflame your nasal passages and sinuses. If possible, opt to swim in saltwater pools or natural bodies of water to avoid excess exposure to chlorine.14
Maintaining good health overall can also help keep sinus issues at bay. Eat a healthy diet, exercise regularly, get enough sleep, and manage stress to boost the immune system and keep colds and flus at bay. Avoid taking antibiotics or steroids if possible as they disrupt the microbiota in the sinuses and may allow pathogens to proliferate.15Finally, it may sound obvious but don’t forget to wash your hands. Handwashing can play a large role in reducing illness and sinus issues.16
FIND THE RIGHT TREATMENT TO EASE YOUR JAW PAIN
If you have severe or long-lasting jaw pain, you may want to talk to a medical professional. But if you suffer from jaw discomfort and allergies, some simple precautions may help you smile — without pain — in no time.
Kristen Stewart is a freelance writer specializing in health and lifestyle topics. She lives in New Jersey with her husband, three kids and two very needy cats.
**The “Can Allergies Cause Jaw Pain?” section above originated on the Zyrtec website, was written by Kristen Stewart, and is being reshared here for an educational collaboration. The original version can be found here:
IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!
FIRST, LET’S DECIDE WHERE TO START:
IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.
IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.
What Is Idiopathic Intracranial Hypertension (IIH) (Pseudotumor Cerebri) And What Causes It?
Idiopathic intracranial hypertension (IIH) was previously called pseudotumor cerebri. Pseudotumor cerebri was an old term which was often confusing to patients because this disorder is not because of a brain tumor. Brain tumors in strategic areas of the brain can block the flow of cerebrospinal fluid (CSF), which can cause back up and elevation of CSF pressure, called hydrocephalus. This is where the older term of pseudotumor cerebri was derived from. Benign intracranial hypertension was another previously used term which was changed because the disease can certainly be not so benign.
IIH is a completely different problem than the elevated CSF pressure from a brain tumor though, and treated much differently. The problem of IIH involves an elevation of CSF around the brain and spinal cord, without a clear reason.
CSF is continuously produced (by something called the choroid plexus inside the ventricles of the brain), absorbed, and transported out of the nervous system (by something called arachnoid villi) and into large draining veins surrounding the brain called the cerebral venous sinuses, and then into the jugular veins and blood where it is broken down.
There have been a number of theories and findings as to the causes of IIH. These include:
Overproduction of the CSF
Blockage of CSF absorption into the cerebral venous sinuses due to a faulty transport mechanism
Stenosis (narrowing) of the venous sinuses
Blot clot (thrombus) blocking the inside of venous sinuses preventing the outflow of CSF and pressure build up
Compression of the venous sinus from the outside (such as brain tumor, meningioma, etc.), causing narrowing on the inside
Sex hormones such as androgens and adipose tissue may play a potential role
Some medications have been associated with IIH including lithium, retinoids (such as excess vitamin A derivatives), oral contraceptives, and tetracycline antibiotics such as doxycycline and minocycline. Rebound IIH has also been reported from corticosteroid withdrawal.
Dural arteriovenous (AV) fistula (an artery connects to the venous sinus, allowing arterial blood flow into the venous sinus and causes much higher pressure)
Think of it like this…
Imagine the brain and spinal cord surrounded and suspended in fluid called the CSF (which cushions and keeps the brain and spinal cord afloat). To keep this fluid in place, it is surrounded by a thick lining called the dura mater. Basically, think of this arrangement like a water balloon. Now, imagine that you keep filling the water balloon with water until the pressure inside gets higher and higher. Eventually, the balloon pops. The same problem occurs in IIH. The pressure of the CSF gets higher and higher. As the pressure rises, it puts pressure on various areas of the brain and cranial nerves resulting in a variety of neurological and other symptoms. This is the basis of IIH.
Sometimes, the pressure can become high enough and you can get a CSF leak out of the surrounding membrane, similar to the balloon popping. This situation can sometimes lead to a low CSF pressure (intracranial hypotension, or CSF leak), which can cause a different type of positional headache and a different set of symptoms. We’ll discuss the problem of CSF leaks in a separate blog article and will focus here on the problem of high CSF pressure.
What Are IIH (Pseudotumor Cerebri) Symptoms?
Headache is the most common symptom of IIH. It typically involves the whole head, and is often worse in the morning (after lying down all night and pressure tends to build). It can commonly flare up by certain activities such as coughing, sneezing, straining, bending forward, and laughing.
Normal CSF pressure in adults is generally considered to be 100-200 mm CSF (10-20 cm CSF). According to criteria, IIH consists of a headache associated with CSF pressure greater than 250 mm CSF (25 cm CSF) in adults, and greater than 280 mm CSF (28 cm CSF) in children, checked by lumbar puncture (LP). The CSF pressure should be measured in the absence of treatment to lower intracranial pressure, and without sedative medications. The optimal position to check CSF pressure is lying on the left side (left lateral decubitus position) with legs extended (initially the legs/hips are flexed up towards the stomach for insertion of the LP needle to open up the spaces between the vertebrae, and then can be carefully extended out with assistance once the LP needle is in place), head in neutral position (not flexed far forwards), and the patient is breathing calmly and normally.
CSF pressure often varies through the day, so a single measurement may not be indicative of the average CSF pressure over 24 hours. In adults, if the pressure is 200-250 mm CSF (20-25 cm CSF), this can still be considered abnormal if they also have the associated signs, symptoms, and imaging findings consistent with a diagnosis of IIH. If there is uncertainty, prolonged lumbar or intraventricular pressure monitoring is occasionally considered. Temporary relief of the headache following lumbar puncture is often seen and can be supportive of the diagnosis, although it doesn’t confirm or exclude the diagnosis whether it happens or not.
IIH criteria also must have at least one of either pulsatile tinnitus (typically described as a whooshing in the ear) and/or papilledema (swelling of the optic nerve (transmits vision to the brain) in the back of the eye, seen during an eye exam).
Some patients report transient obscurations of vision (TVOs), which are brief (usually seconds) partial or complete loss of vision which rapidly returns to normal. This is suspected to be due to brief lack of blood flow (ischemia) in the swollen area of the optic nerve (from papilledema). Double vision is occasionally reported. It is usually from abducens nerve (cranial nerve 6) palsy (weakness) and can be 1 or both sides, but other reported nerve palsies can include cranial nerve 3, 4, and 7. Additional symptoms can include neck pain, pain radiating from the neck down the arm (cervical radiculopathy), back pain, ear fullness (such as high altitude), dizziness and unsteadiness.
What Tests Are Done To Diagnose IIH (Pseudotumor Cerebri)?
Dilated Eye Exam (Fundoscopy)
Irreversible progressive vision loss is the main concern with IIH if it continues untreated. The enlarged physiologic blind spot develops first followed by inferonasal visual defects, followed by progressive constriction of visual fields, and central vision is the last to be affected.
Sometimes a subtle clue of elevated CSF pressure can be picked up by observing the venous pulsations in the back of the eye on exam. If they are present, CSF pressure is likely relatively normal. If the venous pulsations are absent, this can suggest elevated CSF pressure. However, occasionally some patients can have a lack of venous pulsations normally. Another normal variant that can appear abnormal is pseudopapilledema. This looks like papilledema, but can also be normal anatomy or from causes such as optic disk drusen. With pseudopapilledema, venous pulsations are usually present, whereas in true papilledema they are absent. Additional tests to evaluate for pseudopapilledema include ultrasound and fundus autofluorescence, done with an ophthalmologist.
Every patient with suspected IIH should be referred (preferably) to neuro-ophthalmology to evaluate and monitor for evidence of elevated CSF pressure on a dilated eye exam and full visual field testing. They often do a test called optical coherence tomography (OCT) which is checked periodically to monitor for thinning (atrophy) of the optic nerve, and other structural damage from excess CSF pressure on the nerve. If a neuro-ophthalmologist is not available, than an ophthalmologist (not an optometrist) should be seen. The vision loss from IIH is usually a slow process that may or may not be noticed by the patient, and it is irreversible. Therefore, all IIH patients should have early detailed dilated eye exams and should be followed serially by a neuro-ophthalmologist or ophthalmologist.
There are a much less common (and somewhat controversial) group of patients that may have IIH without papilledema. This has been suggested to be possibly related to anatomic variations in the subarachnoid space (where CSF collects around the optic nerve) not reaching far enough to the back of the eyeball. So the part of the optic nerve that may be swollen may be further back behind the eyeball, and can’t be visualized. Another theory of this group of patients includes the episodic presence of a CSF leak, so pressure isn’t sustained long enough to cause papilledema. So, when CSF pressure reaches a certain level, the CSF leaks from a weakened area in the meninges (these keep the CSF in place around the brain and spinal cord) either in the nose (CSF rhinorrhea), the ear (CSF otorrhea), or in the spine. Rarely, some patients are felt to have alternating cycles of high pressure (IIH symptoms) and when the CSF leak reforms, cycles of low pressure (intracranial hypotension, CSF leak headache), so their complaints can vary widely between these 2 extremes of high pressure or low pressure.
Lumbar Puncture (LP)
This is really the most central piece of the IIH diagnosis as detailed above. If CSF pressure is high and the patient has signs, symptoms, and/or findings on MRI, then the diagnosis is confirmed. When the LP is done to check pressure, it is worthwhile to also send some CSF to the lab to analyze for signs of inflammation, infection, or cancerous (such as metastatic leptomeningeal disease) factors. Temporary relief of the headache following lumbar puncture is often seen and can be supportive of the diagnosis, although it doesn’t confirm or exclude the diagnosis whether it happens or not.
Brain MRI and Brain MRV
A brain MRI with contrast should be a first line test, which helps to exclude other obvious causes of papilledema and elevated CSF pressure (such as brain tumor), and results can support a diagnosis of IIH. However, a diagnosis should never be made based on MRI alone, but on the MRI in combination with a good history and clinical symptoms. Some of the supportive MRI findings include empty sella turcica, or “empty sella syndrome”. However, this is does not definitively confirm the diagnosis, and it is not uncommon to see this appearance in normal patients. Again, putting together MRI findings with the right clinical story is key. Other MRI findings that may or may not be visible include dilation/distention (due to increased CSF surrounding the optic nerves) and tortuosity of the optic nerve sheaths (more curvy and twisted appearance), flattening of the posterior sclerae (flattening of the back of the eyeball), enhancing protrusion of the swollen optic disks, pseudo-Chiari (not a true Chiari, but some cerebellar decent due to high CSF pressure pushing it down), and transverse cerebral venous sinus stenosis (narrowing).
Brain MRV should always be done with the MRI to ensure there is no blood clot (cerebral venous thrombosis) in the venous drainage pathways, or significant narrowing (stenosis) of the venous sinuses. It is preferably done with contrast for optimal imaging clarity, although contrast is not absolutely necessary. In most patients, if there is a significant finding, you’ll usually see it on noncontrast MRV. The contrast can add further definition of an area in question if there is uncertainty.
How Is IIH Treated?
Weight Loss for IIH (Pseudotumor Cerebri)
Weight loss is an absolute must for IIH if the patient is overweight. Research has suggested that losing 6-10% of initial body weight can cause IIH remission in many patients. Bariatric surgery is sometimes considered for morbidly obese patients who are unsuccessful in losing weight by more conservative ways.
What is the best IIH (Pseudotumor Cerebri) Diet?
A low-calorie, low-salt diet with mild fluid restriction generally seems to be the most helpful diet for IIH.
What Medications Are Used To Treat IIH (Pseudotumor Cerebri)?
The carbonic anhydrase inhibitors are the first line treatment for IIH. These medicines work for IIH because they decrease the production of CSF (and thus CSF pressure is lower because production has slowed). They also have a mild diuretic effect. The most common medications used for IIH are Acetazolamide (Diamox), Topiramate (Topamax), and Methazolamide.
Typical doses for Diamox start at 500 mg twice daily and can be increased to 2000 mg twice daily, although lower doses are often effective. Side effects can include tingling/numbness (paresthesias), changes in taste, and gastrointestinal symptoms such as nausea, vomiting, or diarrhea.
If there is any question of migraine mixed in with IIH, then Topiramate is my first choice because it is also FDA approved for migraine prevention, in addition to decreasing CSF production. I usually start Topamax with 25 mg at bed and is increase by 25 mg at bed each week until 100 mg at bedtime. If not improving by 4 weeks at the 100 mg dose, morning dosing is then added with 50 mg for 1 week and then 100 mg twice daily. Side effects often include weight loss, which would certainly be a desired side effect in obese patients with IIH. Other side effects can include mood changes, tinging/numbness, and cognitive complaints such as memory, word finding, and concentration.
Methazolamide is started at 25 mg twice daily and can be increased to 200 mg twice daily.
Other medicines sometimes used if the above options are not tolerated or working include furosemide and bumetanide. For sulfa allergic patients, spironolactone, triamterene, and ethacrynic acid are occasionally used.
Treating Other Headache Disorders That Occur With IIH (Pseudotumor Cerebri)
It is also very important to also treat other headache disorders that may be mixed in with the IIH headaches. For example, many patients with IIH also have headache flares that easily fit criteria for migraine headaches. They typically have chronic daily headache which looks like a mix of chronic migraine and chronic tension type headache. So, when there is IIH mixed in with these headache disorders, it sometimes becomes cloudy on which headache disorders are contributing to which symptoms as well as the overall chronic daily headache. Many times these patients are in rebound headache (medication overuse headache), and that issue must be treated and resolved before the headaches are able to improve. I typically treat these patients targeting both chronic migraine and IIH (if IIH has been confirmed as well) since they are most often intermingled.
What Are Surgical Treatments for IIH (Pseudotumor Cerebri) When Other Treatments Fail?
Optic Nerve Fenestration For IIH
Optic nerve fenestration is sometimes done for papilledema that is not improving with standard medical treatments and vision continues to worsen. This is basically a procedure which makes small slits in the optic nerve sheath, which encloses the optic nerves and keeps the CSF in place around them. By doing this, it can release the CSF pressure on the nerves (imagine it as cutting a slit in a garden hose). This procedure is only done to prevent further vision loss which isn’t responding to conservative treatment, but does not typically help the headache.
Venous Sinus Stenting For IIH
Stenoses of the transverse venous sinuses can sometimes be seen on MRV. This leads to increased venous pressures in these channels, as well as the superior sagittal sinus. Increased venous sinus pressures can be confirmed with catheter venography with manometry. Transverse venous sinus stenting is occasionally considered as a surgical treatment option for IIH in patients with pressure gradients of more than 8 mm Hg and refractory symptoms. One study found that a pressure gradient of 21 mm Hg or higher had the best outcomes.
Shunts for IIH
Ventriculoperitoneal (VP) shunts and lumboperitoneal (LP) shunts are occasionally done with a goal of surgically placing a valve and tubing device to maintain a normal pressure in the spinal fluid. VP shunting is preferred over LP shunting due to lower rates of complications. If the pressure reaches above a specific pressure setting of the valve, then CSF will drain through the tubing and into the peritoneal cavity of the body where it is then absorbed and eliminated. Shunting should always be a last resort option (outside of severe emergent cases which need rapid pressure relief) after every possible medical management option has failed. Shunts don’t tend to provide long term effectiveness for headache management and frequently require revisions. It is not uncommon for the hardware to become infected or blocked and then have to be removed. One large study found that initial improvement in headaches following shunting returned to recurrent headaches at 36 months in almost half of all patients.
How Do You Treat IIH (Pseudotumor Cerebri) In Pregnancy?
Acetazolamide can be used after the 1st trimester. Repeated LPs to drain some of the CSF pressure can be done if necessary. For women who have progressive papilledema and worsening vision, optic nerve fenestration may be necessary to preserve vision, although it will not typically help the headache.
IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!
FIRST, LET’S DECIDE WHERE TO START:
IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.
IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.
Cluster headaches are often considered the most severe type of headaches experienced by headache sufferers. It is often referred to as “suicide headache” because it is so severe, and unfortunately quite a few have committed suicide due to the extreme pain.
Cluster headache is 1 of 4 types of trigeminal autonomic cephalalgia syndromes (TACs). The headaches within this headache TACs family share some overlapping features, but have distinct differences, and are all treated much differently. So it is important to first properly confirm the diagnosis of cluster headache and clarify that it is not one of the other TACs. The ICHD3criteria classify cluster headache as a strictly one sided headache around the eye, temple, forehead which can last anywhere between 15 minutes up to 3 hours. On the same side of the headache, they must be associated with at least one “autonomic feature” which means a tearing and/or red eye, nasal congestion and/or runny nose, eyelid swelling or puffiness, forehead and/or facial sweating, small pupil and/or drooping eyelid. The patient often has a sense of restlessness or agitation and classically paces around the room, sometimes yelling out in pain (in contrast to migraine where the patient often wants to stay still and quiet in bed).
They are called cluster headaches because the headaches come in “clusters”. They may be headache free all year and then all of a sudden develop daily headaches which can occur multiple times per day (sometimes up to 8 times per day). They often occur around the same time every night or during the day, often waking the patient up from sleep around the same time nightly. These cycles of daily frequent attacks can last several weeks to several months. The majority of people who suffer from cluster headaches experience them for about 12 weeks each year, most often when the season changes (Summer to Fall and Spring to Summer). It’s one of the most painful types of headaches and is often more intense than a migraine. Let’s take a look at how cluster headaches happen during seasonal changes and what you can do about them.
Why Do Cluster Headaches Happen During the Fall and Spring?
Many people go months or years in between cluster headache cycles. When the cycles start again, they are often tied to changes in the seasons during Fall and Spring. However, cluster headaches can and do certainly come on outside of season changes as well.
Changing influences on the body’s biological clock (hypothalamus) have been a long suspected cause of cluster headache, and still felt to be the most likely culprit. Changes in seasons and daylight savings time changes are often associated with cluster headache flares. Daylight savings time changes impact our sleep patterns. When sleep patterns change, this changes the amount of natural light we are exposed to. For a headache sufferer, this can increase headache patterns. Changes in the amount of natural light that a person is exposed to during sleep-wake cycle changes can influence the body’s normal biological rhythms by influencing the hypothalamus. The result for many patients with cluster headache is that the cluster cycle can then be “turned on”.
Decreased natural light exposure during the Fall season due to a shorter duration of daylight may also impact a person’s sleep cycle. Loss of sleep may reduce endorphins (our natural pain-killers) in the body and also play a role in reducing the body’s pain tolerance threshold. A study suggested that a loss of 1 to 3 hours of sleep per night over a period of a few days could result in a headache that lasted from anywhere to 1 hour or a day. Migraine is also often very sensitive to inadequate sleep, which is a common trigger.
Why Do Seasonal Changes Cause Cluster Headaches
The change in hypothalamic circadian biological rhythms related to changes in sleep-wake cycles and exposure to natural light remain the most commonly suspected cause for cluster headache. However, the exact, true cause of cluster headaches are still not entirely known. Thus, there have been other theories of what causes cluster headaches as well, including changes in barometric pressure, and histamine release related to seasonal allergy changes.
There are a lot of headache triggers that happen during the Fall season including decreases in humidity and temperature which are associated with increases in barometric pressure. When you begin getting into Spring, Summer and warmer months, there tends to be more of a decrease in barometric pressure. These barometric pressure changes are classic migraine triggers for many patients. However, a possible relation to cluster headache has also been suggested. The exact barometric pressure that will lead to cluster headaches will vary depending on the individual. For example, a pressure of 1003 to 1007 hPa was found as a migraine trigger point in an NIH study. A specific pressure change of 6 to 10 hPa (the specific drop in air pressure) was also identified as a range in pressure drop that could cause a cluster headache or migraine.
Seasonal allergies have also been suggested to possibly play a role in migraines and cluster headaches. Increased allergies during season changes leads to increased histamine levels and sinus symptoms for some people. Deep within the nasal passageways lies some nervous system structures including the olfactory nerves (which allow you to smell), and important headache and facial pain related nerve ganglia, such as the SPG (sphenopalatine ganglia). For example, the SPG is sometimes blocked (SPG block) by numbing medications to abort various types of headache and facial pain including cluster headache, migraine, and trigeminal neuralgia.
Seasonal Affective Disorder also could be linked to various types of headaches that one experiences throughout the year. Certain people may experience a predisposition to anxiety and depression due to seasonal changes, and this may lead to headaches and insomnia.
Symptoms of Cluster Headaches
Seasonal cluster headaches can start at any age, however, most people tend to start experiencing these between the ages of 20 to 50. They tend to affect men more than women (in contrast to migraine which is the reverse). To review, some of the symptoms of a cluster headache can include:
Redness, swelling, and watering/tearing around the eye on the side of the head where the cluster headache is occurring.
A stuffed/congested and runny nose on the same side of the headache.
Pale skin and sweating.
Drooping of the eyelid and small pupil size on the side of the headache.
Sense of restlessness or agitation during the attack.
Some of the other headaches that a person might experience include anxiety, and waking up at night. Chronic cluster headache sufferers may notice an intensification of their headaches during the change to fall. If you have cluster headaches occurring for one year or longer without remission, or with remission periods lasting less than 3 months, you fall into the chronic cluster category, which is a small minority of cluster headache patients.
How To Alleviate Cluster Headaches That Are Brought On By Seasonal Changes
There are some very basic things that you can do if you suffer from cluster headaches during seasonal changes. Avoiding alcohol and smoking will help reduce the onset of cluster headaches for some. For example, alcohol is a classic trigger for cluster headache when a patient is in a susceptible cluster headache cycle. Sometimes even the smell of alcohol can trigger an attack. When the same person is outside of their cluster cycle, alcohol does not trigger the attack. So for those that drink alcohol and are unsure if their cluster cycle is done (if they are susceptible to an alcohol trigger), consuming alcohol will often let them know! The hormone melatonin can help regulate your sleep cycle, helping you rest better. Some studies have suggested melatonin levels are lower during a cluster cycle. The dose ranges from 5-15 mg taken about 2 hours before bedtime.
Otherwise, the key cluster headache treatments involve having a good abortive (as needed) treatment for when an attack happens, and a good preventive treatment to lessen the frequency and severity of attacks. The following treatments are most commonly used for cluster headaches. However, any treatment should be prescribed and discussed with your doctor because you may have other medical conditions which could make some of these treatments dangerous or life-threatening if being used inappropriately. For example, use of triptans or Dihydroergotamine (DHE) in someone with cardiac disease could cause heart attack or stroke. Use of steroids such as prednisone in someone with an ulcer could cause death by gastrointestinal bleed, or in diabetes could lead to diabetic coma and a visit to the intensive care unit due to excess glucose in the blood. Use of oxygen around smoking could cause an explosion. There are many other examples, which is why any treatment should always be provided and discussed first with your regular medical doctor. Also, you should never use treatments given by a friend if they have a similar headache disorder without first consulting with your doctor.
Abortive Treatment For Cluster Headaches
In appropriate patients, as soon as a cluster cycle starts, we often use a course of prednisone. Although this can be adjusted depending on the patient’s medical history, I typically start with 70 mg daily in the morning (since often energizing) with food for 3 days, decreasing by 10 mg every 3 days until off. This often helps to break up and shorten a cycle. Occipital nerve block on the same side of the headache for 1-3 days can also be effective in breaking up and shortening a cycle.
100% oxygen consumed by a non-rebreather facemask at cluster attack onset at 12-15 liters per minute for 10 to 15 minutes is very effective for many people.
Triptans have been a standard treatment abortively for not only migraine, but also for cluster headache. The difference is that oral triptans are not generally prescribed for cluster headache sufferers because the headache will frequently peak after the medication has had the opportunity to be absorbed by the body. Injectable triptans (Sumatriptan) is the fastest acting, often working within minutes. Nasal spray triptans (Sumatriptan, Zolmitriptan) are the next fastest options.
Dihydroergotamine (DHE) is also a good option, especially if not responding to triptans or having multiple attacks daily (DHE can last longer). Injection is the most effective, followed by the nasal spray versions).
Neuromodulatory devices can also be effective in aborting a cluster attack. GammaCore is a vagus nerve stimulator device that you can carry with you and it is FDA cleared for the abortive treatment of cluster headache. It is the only device currently with this clearance and indication. SPG (sphenopalatine ganglion) blocks can also be done in a variety of ways between the office or under sedation with pain management. There was a small surgically implantable SPG stimulator (implanted through the roof of the mouth) which could be turned on with the press of a button from a handheld device which seemed very promising and effective, but unfortunately got held up and blocked in regulatory processes and red tape. Hopefully this will be revived in the future.
Preventive Treatment For Cluster Headaches
Verapamil is often considered the gold standard of cluster headache prevention to try to stop the frequency of attacks and shorten the cluster cycle duration. It is typically started at the onset of a cluster cycle and titrated up to a higher dose depending on how the cluster attacks are responding, and how the patient is tolerating it. This is a blood pressure class of medication, so needs to be used cautiously in those with normal or low blood pressure, or if taking other blood pressure medications. Clinically, it tends to work better in the immediate release form taken three times daily as opposed to the once daily long acting version. I typically start with 40 mg or 80 mg (depending on baseline blood pressure) three times daily and increase by 40 mg every 3 days (assuming no dizziness, lightheadedness, excess fatigue, etc.) until helping or 120 mg three times daily. Although for some patients, much higher doses are required. Checking an EKG is recommended when making higher dose changes to ensure no heart block. Longer-term use of this prescription drug can be considered for chronic cluster headache or high frequency cycles through the year.
Emgality (Galcanezumab) is one of the four available CGRP monoclonal antibodies. These are all made for migraine prevention. However, Emgality is unique in that it is currently the only FDA approved medication for prevention of episodic cluster headache. Notably, Emgality dosing is different for cluster headache prevention (300 mg injection per month) compared to migraine prevention (120 mg injection per month).
Other types of preventative treatments for cluster headaches include anti-seizure medications, typically starting with Divalproex (Depakote) or Topiramate (Topamax). For more refractory cases, Lithium is sometimes used as well.
For some patients (especially chronic cluster headache), unfortunately even these options do not help them and they turn to alternative treatment options. One option that has gained a lot of exposure is the use of tryptamines at sub-hallucinogenic dosing (“microdosing”) including psilocybin (from mushrooms), lysergic acid amide (LSA), and lysergic acid diethylamide (LSD). In fact, there are also growing published studies suggesting benefits of these types of treatments. There is a group called ClusterBusters where these types of treatments are discussed further. Obviously, there are potential legal ramifications of these treatments since they are all federally illegal substances, but for some patients their cluster headache is so severe and refractory that they will do anything for relief.
Getting Help For Your Cluster Headaches
Cluster headaches can impact your ability to complete tasks at work and can require you to take more sick leave, as referenced in one study. Cluster headaches can also have an impact on your relationships with family and friends. If you develop cluster headaches your primary care physician might be able to find a viable treatment option or refer you to a headache specialist or neurologist to help you find a solution for your cluster headaches.
IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!
FIRST, LET’S DECIDE WHERE TO START:
IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.
IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.
Well first, there are many well established migraine triggers. The beverages and foods that we consume play a role in headaches and migraines for many patients. In fact, about 10% of headache and migraine sufferers can attribute at least a small part of their headaches to food and diet triggers. Often the trigger is a specific type of food or beverage. For example, in some studies (seen here and here) migraineurs reported their most common food triggers as chocolate (19-22%), cheese (9-18%), citrus fruit (11%), and alcohol (29-35%).
Certain types of diets may help reduce the likelihood and severity of headaches and migraines. Let’s take a look at some of the diets out there that may help with headaches and migraines.
How Does the Keto Diet Impact Headaches and Migraines?
The keto diet is unique in the sense that your body consumes more fat and protein while lowering the intake of carbohydrates. The idea is that your body is forced to burn fats rather than carbohydrates. Studies have shown that the keto diet was able to significantly reduce migraine frequency and abortive medication intake. It is thought that the keto diet can be particularly helpful for migraine sufferers on a twofold front:
Ketone bodies produced by the liver can provide the brain with more energy than glucose.
Additionally, ketones are thought to be anti-inflammatory. Since inflammation is a central piece of migraines, the keto diet can potentially help by reducing inflammation.
For those who are starting out fresh on the keto diet, there may be an occasional headache since the body is learning to burn fat instead of sugar. To avoid these headaches early on in the keto diet, the following suggestions will help:
Drink plenty of water.
Eat low-carb, water-rich vegetables.
Eat foods that are rich in electrolytes.
Avoid exercise on the opening days of your keto diet.
Can a Low-Histamine Diet Help With Headaches and Migraines?
Histamine can be a headache or a migraine trigger for certain individuals, even if they do not have allergies. The body makes a digestive enzyme called DAO (diamine oxidase) that processes histamine. About 25% of people have an issue with DAO production in their bodies. One study found that about 87% of people with migraines also had issues with DAO deficiencies. It was found that people who participated in a low-histamine diet had improved in their overall experiences with their migraines while a handful of people in the study had no migraines or headaches at all.
What can you eat on the low-histamine diet? You can eat fresh meat (especially chicken) and freshly caught fish. Some non-citrus fruits are low in histamine levels and include things like apples, raspberries, blueberries, melons, bananas, and kiwi. Eggs are also low in histamine. Gluten-free grains, such as rice and quinoa are also low in histamine. Fresh vegetables other than tomatoes, avocados, spinach, and eggplant are also low in histamine levels. Lastly, if you cook with oils, olive oil is low in histamine levels.
Elimination Diet, Headaches, and Migraines
From a dietary perspective, an elimination diet is any type of diet where you eliminate foods and beverages that you suspect your body does not tolerate well. On the elimination diet for headaches, there are some things that you might want to avoid:
Caffeine and alcohol: These are known to dehydrate the body and cause headaches.
Chocolate and cocoa: These are known to cause headaches. However, you may eat white chocolate.
MSG: This is a flavor enhancing substance known to trigger headaches and migraines. If you want to avoid MSG, you can eat whole foods that have been flavored with natural herbs and spices. On food labels, it is often hidden as other names including glutamate, natural flavor, and partially hydrogenated vegetable protein.
Processed meats: Anything like jerky, cold cuts, and lunch meats should be avoided. You can however eat fresh meats that you prepare yourself. Nitrates and nitrites are the migraine trigger culprits in these types of foods. These are vasodilating agents found in many foods, especially preserved and processed meats such as lunch meats, sausage, smoked foods, pork, bacon, salami, pastrami, hot dogs, corned beef, ham, and bratwurst. So if you have a child that is getting a lot of headaches and migraines, and eats lunch meat for lunch, you may want to look into nitrate and nitrite-free lunch meat options.
Dairy: You should avoid certain dairy foods like aged cheese, buttermilk, sour cream, and yogurt. However, you can eat things like cottage cheese, cream cheese, and American varieties of cheese.
Nuts: Try substituting seeds for nuts.
Fruits: Avoid citrus fruits altogether. You can eat things like apples, peaches, pears, etc.
Some vegetables, like onions, pea pods, and sauerkraut should be avoided. You can eat most leafy green vegetables and water-rich vegetables.
Condiments: You should avoid things like ketchup, mustard, vinegar-based condiments, etc.
Baked goods: Be careful to make sure that anything you eat is gluten-free while you are on the elimination diet for headaches and migraines.
Avoid any artificial sweeteners altogether, like NutraSweet.
Avoid Fermented foods such as sauerkraut, soy products, and pickled foods because they contain tyramine which is a migraine trigger for many patients. Brewer’s yeast also contains a large amount of tyramine. A low tyramine diet can be very helpful for some patients with migraine.
Overall, your doctor may advise you to try the elimination diet for a trial period to see if the foods you are eating are contributing to your headaches and migraines. When attempting to figure out what foods to try eliminating, sometimes IgG food testing against food allergens can assist in determining specific foods which may be associated with high IgG levels in the blood (meaning your immune system is reacting against them).
Inflammatory Foods, Headaches, Migraine, and the Anti-Inflammatory Diet
Another way to fight off headaches and migraines is to avoid foods that are known to cause inflammation. For example, sugar and high fructose corn syrup are found in most processed foods and sweets. In some studies, these sweet substances were known to counteract the effects of omega-3 fatty acids, which can help reduce inflammation. Artificial trans fat, vegetable oils, and seed oils can also cause inflammation, leading to headaches and migraines. Refined carbohydrates, prepared meats, and other processed foods can also cause inflammation. In addition to causing headaches and migraines, foods that cause inflammation can cause a wide variety of other issues including high cholesterol, heart disease, obesity, and diabetes.
There are other variations of the anti-inflammatory diet which focus on omega fatty acids including the high omega 3/low omega 6 (H3/L6) and low omega 6 (L6) diets. The thinking is based on the fact that omega 3 is anti-inflammatory, whereas omega 6 is more inflammatory and can increase pain. Fast food is often loaded with omega 6 fatty acids, along with many other chemical additives which are often migraine triggers. So the goal is to eat foods with a higher ratio of omega 3 as compared with omega 6. In fact, a recent study showed that eating fish with healthy omega ratios can help prevent migraines.
Fish with a healthy omega ratio include tuna (canned in water), wild salmon, swordfish, mackerel, herring, sea bass, anchovies, sardines, cod, and bluefish. Fish with a less healthy omega ratio include farm raised fish and fish canned in oil. Vegetables with a healthy omega ratio include green leafy vegetables, and those with a less healthy omega ratio include beats, carrotos, chard, and parsley. Nuts and seeds with a healthier omega ratio include walnuts, flax and chia seeds. Those with a less healthy omega ratio include almonds, pecans, cashews, and pistachios. Oils with a healthier omega ratio ratio include olive oil and canola oil, while those with a less healthy omega ratio include highly processed oils such as corn, soy, safflower, and peanut oil.
Gluten Free Diet (Celiac Sprue)
Celiac sprue is caused by inflammation in the digestive tract, caused by exposure to gluten. Gluten is a protein found in many grains, including barley, wheat, and rye. Thus it is a common ingredient in foods such as pizza, pasta, bread, and cereal. Patients often complain of abdominal bloating and pain, diarrhea, and headache when they eat these foods. Some patients can less commonly have additional neurological symptoms besides headaches, including unsteadiness/imbalance (ataxia), and peripheral neuropathy. Unexplained iron deficiency is common, and liver function tests are sometimes abnormal. 70% of patients with true gluten sensitivity and celiac sprue have been shown to have improved symptoms within 2 weeks of doing a gluten free diet. Many patients get loosely diagnosed or self diagnosed as “celiac disease” or “gluten sensitive”. However, the gold standard diagnosis is made by small bowel biopsy, along with supporting bloodwork. So if there are suspicious symptoms as discussed here, a gluten free diet for 2-4 weeks may be a good consideration to try.
Low Fat Diet
Low fat diets have been reported to decrease headache and migraines in some patients. One study looked at patients eating no more than 20 grams of fat per day. It reported significant differences in migraine frequency which went from 6 days to 1 day per month on average, along with significant decreases in migraine severity, duration, and medication intake.
Finding What Works Right For You
The various diets discussed above all have one principle in mind, eliminating certain foods from your diet that can cause headaches and migraines. Many of the foods that are mentioned in the diets above that are to be avoided contain Tyramine. This is the substance produced when the amino acid tyrosine breaks down and can cause headaches.
Not only will the right diet help you mitigate the frequency and severity of headaches and migraines, but a proper diet can also help avoid certain types of chronic health conditions. Good diet is only part of the formula that will help you reduce headaches and migraines in your daily life. Your physician will also counsel you on good diet and exercise practices to help you with your headache and migraines.
In summary, the answer to which diet is the best migraine diet is… there isn’t one. Finding dietary influences on migraine and headache will vary widely between patients and what their migraine may be susceptible to or what it responds to. However, if there are clues to when you get migraines in relation to any of the dietary factors discussed above when you eat meals, it may be worth trying that particular diet or dietary modification for at least 4 weeks. Any dietary changes should always be discussed and approved of with your regular medical doctor first though, to make sure it is safe to try depending on your particular medical history.
Regardless of dietary factors, keep in mind that having migraine means that you are wired in a way that migraines can be triggered easier as compared to someone without migraines. You may be able to identify triggers, but many times there may not be a trigger and migraines can just happen because that is the nature of the disorder, unfortunately. So you still want to ensure that you have a good migraine abortive option for when they do happen. Abortive treatments are taken at the onset of the migraine with a goal of lessening the duration and severity of the migraine attack and associated symptoms. Some of these options include NSAIDs, ergots, triptans, neuromodulatory devices, the ditans (Reyvow (Lasmiditan)) and the gepants (Ubrelvy (Ubrogepant) and Nurtec ODT (orally dissolvable tablet) (Rimegepant)).
IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!
FIRST, LET’S DECIDE WHERE TO START:
IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.
IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.
Vestibular migraine has also been called migraine-associated vertigo/dizziness, migraine-related vestibulopathy and migrainous vertigo. Vestibular migraines are not as common as other headache and migraine conditions, but they impact about 3% of the population. They happen five times more often in women than they do in men. One of the common themes among vestibular migraine sufferers is that this condition is often found in their family history, and often, these people have a history of migraines. An early clue can be that they may have gotten easily car sick as a child, and they may still as an adult.
Dizziness, lightheadedness, and wooziness are very common symptoms associated with regular migraine attacks. Vestibular migraines cause severe dizziness, vertigo, imbalance, and disequilibrium in people with migraines. The severity of these symptoms in vestibular migraine are much more severe and pronounced as compared with the more commonly associated milder dizziness type of symptoms often seen with normal migraine attacks. In addition, with vestibular migraine, you might not always have a headache with the symptoms, which can make diagnosis even more tricky. So, let’s dissect the specifics and symptoms of vestibular migraine a bit more below…
What Types of Symptoms Might I Experience With a Vestibular Migraine?
As mentioned above, vestibular migraines don’t always coincide with a headache. They include dizziness that lasts for a few moments or more, nausea, vomiting, balance problems, sensitivity to motion when you move your body, disorientation, and sensitivity to light or sound. Vestibular migraines are connected to the inner ear, so a person experiencing this type of migraine will have significant issues with their balance and equilibrium during an attack.
The International Classification of Migraine 3rd Edition (ICHD3) has specific criteria that must be met to fit the diagnosis. Other causes of vestibular symptoms such as inner ear problems and other causes must have been tested for and excluded. The person must have a history of migraine without aura or migraine with aura. They must have at least 5 episodes of moderate to severe vestibular symptoms lasting between 5 minutes to 72 hours. Vestibular symptoms can include vertigo, spinning sensation, sensation of self-motion, disequilibrium, positional vertigo such as following a change in head position or head motion, dizziness with nausea, and visually induced vertigo triggered by a moving visual stimulus. At least half of these vestibular symptom episodes must be associated with 1 of the following 3 migrainous features:
1. Headache with at least 2 of the following 4 features:
One sided location
Pulsating, throbbing, or pounding pain
Moderate to severe intensity
Worsening by physical activity
2. Sensitivity to light (photophobia) and sound (phonophobia)
3. Visual aura
Approximately 1/3rd of patients can have vestibular symptoms lasting minutes, 1/3rd can last hours, and 1/3rd can last several days. A small fraction of patients have vestibular attacks which can last seconds only, but occur repeatedly during head motion, changes in head position, or visual stimulation. In these patients, episode duration is defined as the total period during which short attacks are recurring with these triggers. An even smaller fraction of patients can have attacks that can last several weeks to a month. Overall, attacks last 72 hours or less for the vast majority of patients.
What Causes Migraines With Vertigo?
The exact cause of vestibular migraines is not clearly understood. However, many researchers believe that there is overlap and erroneous connections between pain signals and vestibular signals that come in from the inner ear and the electrical migraine pathways. Some contributing factors to vestibular migraines include many of the commonly recognized migraine triggers such as lack of sleep, consumption of MSG and certain other foods, and dehydration.
How Long Does a Vestibular Migraine Last?
Vestibular migraines can last for a period as short as 5 minutes or up to 72 hours, as detailed above. Some patients have reported this type of migraine lasting for up to 4 weeks, with the intensity of the symptoms coming and going.
What Types of Treatments Will Help Alleviate Vestibular Migraines?
Different types of abortive therapies are available for vestibular migraines. Abortive migraine medications are medications taken at the onset of the migraine with a goal of lessening the duration and severity of the migraine attack and associated symptoms. Some of these options include NSAIDs, ergots, triptans, neuromodulatory devices, and the gepants (Ubrelvy (Ubrogepant) and Nurtec ODT (orally dissolvable tablet) (Rimegepant)). Triptans and abortives are particularly helpful if they are taken at the first sign of symptoms. Your doctor might prescribe something like Ativan, Valium or another vestibular suppressant to correct the balance on your inner ear, but these should preferably not be taken frequently or daily because they can form dependency and addiction.
Some of the typical migraine pill preventive medications include antiseizure, blood pressure, and antidepressant drugs. These traditional migraine medications can also be very helpful in treating more severe occurrences of vestibular migraines.
Could My Vestibular Migraine Be Something Else?
Vestibular migraines have symptoms that overlap with other medical conditions. In fact, at least 20% of vestibular migraine cases are misdiagnosed. A condition called Meniere’s disease causes dizziness. This disease, however, will often be accompanied by a stuffed ear sensation or ear ringing. Referral to an ENT doctor (ear nose and throat) to evaluate for inner ear disorders should always be part of the evaluation plan, along with possible neuroimaging with brain MRI or CT, and possibly some blood work. A brainstem stroke can also cause dizziness before more severe symptoms set in. MRIs and other medical tests can help rule conditions like these out. Therefore, vestibular migraine should always be a “diagnosis of exclusion”, meaning it can be considered only after other causes of dizziness and vertigo have been tested for and ruled out.
How Will My Doctor Manage My Vestibular Migraines?
In addition to some of the medications suggested above, there are ways to manage your vestibular migraines. Your doctor will probably do a full medical examination to understand any comorbidities and also see what medications you are currently taking. Dizziness is one of the most commonly reported side effects of many medications, so make sure to trace onset of symptoms back to any medication adjustments as well.
Depression, lack of sleep, and anxiety are some of the issues that may be exacerbated by your vestibular migraines. If these conditions are left untreated, the vestibular migraine will not get better. Depression and anxiety do not cause vestibular migraines, but the migraines can lead to anxiety and depression and these issues can all begin to feed into and fuel one another.
Another thing to keep in mind is that traditional medicinal approaches to headaches may not be the best approach to vestibular migraines for everyone. Vestibular migraines can sometimes be sensitive to Advil, Tylenol, and other NSAIDs. However, most patients will not respond as well to these over the counter medications and will need more migraine specific therapies. If you use triptans or NSAIDs daily or with a high frequency of more than 10 days per month on average, you may be more prone to rebound vestibular migraines. Vestibular physical therapy can also be helpful for some patients if they suffer from a high frequency of symptoms.
What Is the Outlook for Vestibular Migraines?
Overall, the outlook for Vestibular migraines is good. An NIH study found that vestibular migraines in a pool of patients from a period of 10 years decreased in about 56% of cases, increased in only about 30% of people, and stayed the same in about 16 percent of cases.
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