SEEDS for success: Lifestyle management in migraine
Release date: November 1, 2019
Expiration date: October 31, 2020
Estimated time of completion: 1 hour
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ABSTRACT
Primary care physicians can help their patients with migraine modify their triggers, and thereby mitigate the severity and frequency of their symptoms, by offering lifestyle modification counseling based on the mnemonic SEEDS (sleep, exercise, eat, diary, and stress). The authors review evidence associated with each of these factors and provide best-practice recommendations.
KEY POINTS
- Sleep: Standard sleep hygiene recommendations to maximize sleep quantity and quality.
- Exercise: 30 to 60 minutes 3 to 5 times a week.
- Eat: Regular healthy meals, adequate hydration, and low or stable caffeine intake.
- Diary: Establish a baseline pattern, assess response to treatment, and monitor analgesia to improve accuracy of migraine diagnosis.
- Stress: Cognitive behavioral therapy, mindfulness, relaxation, biofeedback, and provider-patient trust to minimize anxiety.
THE SECOND E IS FOR EAT (FOOD AND DRINK)
Many patients believe that some foods trigger migraine attacks, but further study is needed. The most consistent food triggers appear to be red wine and caffeine (withdrawal).18,19 Interestingly, patients with migraine report low levels of alcohol consumption,20 but it is unclear if that is because alcohol has a protective effect or if patients avoid it.
Some patients may crave certain foods in the prodromal phase of an attack, eat the food, experience the attack, and falsely conclude that the food caused the attack.21 Premonitory symptoms include fatigue, cognitive changes, homeostatic changes, sensory hyperresponsiveness, and food cravings.21 It is difficult to distinguish between premonitory phase food cravings and true triggers because premonitory symptoms can precede headache by 48 to 72 hours, and the timing for a trigger to be considered causal is not known.22
Chocolate is often thought to be a migraine trigger, but the evidence argues against this and even suggests that sweet cravings are a part of the premonitory phase.23 Monosodium glutamate is often identified as a trigger as well, but the literature is inconsistent and does not support a causal relationship.24 Identifying true food triggers in migraine is difficult, and patients with migraine may have poor quality diets, with some foods acting as true triggers for certain patients.25 These possibilities have led to the development of many “migraine diets,” including elimination diets.
Elimination diets
Elimination diets involve avoiding specific food items over a period of time and then adding them back in one at a time to gauge whether they cause a reaction in the body. A number of these diets have been studied for their effects on headache and migraine:
Gluten-free diets restrict foods that contain wheat, rye, and barley. A systematic review of gluten-free diets in patients with celiac disease found that headache or migraine frequency decreased by 51.6% to 100% based on multiple cohort studies (N = 42,388).26 There are no studies on the use of a gluten-free diet for migraine in patients without celiac disease.
Immunoglobulin G-elimination diets restrict foods that serve as antigens for IgG. However, data supporting these diets are inconsistent. Two small randomized controlled trials found that the diets improved migraine symptoms, but a larger study found no improvement in the number of migraine days at 12 weeks, although there was an initially significant effect at 4 weeks.27–29
Antihistamine diets restrict foods that have high levels of histamines, including fermented dairy, vegetables, soy products, wine, beer, alcohol, and those that cause histamine release regardless of IgE testing results. A prospective single-arm study of antihistamine diets in patients with chronic headache reported symptom improvement, which could be applied to certain comorbidities such as mast cell activation syndrome.30 Another prospective nonrandomized controlled study eliminated foods based on positive IgE skin-prick testing for allergy in patients with recurrent migraine and found that it reduced headache frequency.31
Tyramine-free diets are often recommended due to the presumption that tyramine-containing foods (eg, aged cheese, cured or smoked meats and fish, and beer) are triggers. However, multiple studies have reviewed this theory with inconsistent results,32 and the only study of a tyramine-free diet was negative.33 In addition, commonly purported high-tyramine foods have lower tyramine levels than previously thought.34
Low-fat diets in migraine are supported by 2 small randomized controlled trials and a prospective study showing a decrease in symptom severity; the results for frequency are inconsistent.35–37
Low-glycemic index diets are supported in migraine by 1 randomized controlled trial that showed improvement in migraine frequency in a diet group and in a control group of patients who took a standard migraine-preventive medication to manage their symptoms.38
