‘Trigger’ is the term used to describe what started the cascade of events that ends in a migraine attack.
It may not be easy to identify what your triggers are if your attacks are linked to a number of different things. A trigger may not cause an attack every time, and not every attack may have a trigger, which can be confusing.
One way to identify your triggers is to keep a trigger diary. This is a very detailed migraine diary, including what time you got up, everything you ate, drank and did in your day, what the weather was like, if you have a migraine attack all your symptoms and medications, through to what time you went to sleep. You can do this just in a diary or notebook, or there are apps like Migraine Buddy that track things like barometric pressure, and produce reports for you. You will need to keep a trigger diary for a while to be able to identify your likely triggers. However, keeping a diary long term can be detrimental to your mental health, so try to limit using diaries to when there are some changes in your migraine patterns.
Changes in routine (eg. Saturday or weekend migraine)
Some people find that changes in their routine can contribute to a migraine. For example changing sleep patterns or changes caused by long journeys can precede an attack. Many people complain that they get migraines at the weekend, or when they go on holiday. Without the daily grind of getting up and going to work, or getting the kids off to school, you may have a lie in, not have your usual morning coffee, eat at different times, or you may go out and do something you wouldn’t normally do. Alternatively, it may that you have relaxed from your normal stressful life, and it is the relaxing that triggers the migraine attack.
There’s nothing wrong with enjoying or weekends or holidays! If you are finding your migraine attacks strike just as you start to unwind for the weekend, you may want to consider still getting up and having breakfast at your normal weekday time to ensure you start the day right. Or, if going on a big holiday, you might want to transition or taper your routine into the holiday by allowing yourself to sleep in a little more each day. If it is relaxing that triggers your migraine attacks, consider some lifestyle changes to relax more during the week, or consider exercising in the morning of your weekends to get the heart rate up just like work would. Finding consistency is the key.
Migraine and stress are strongly linked. Just as noted above that relaxing can trigger a migraine attack, so too can anxiety, excitement and any form of tension and shock. In most cases, this will be unavoidable, as we don’t ask other people to upset us. If there is something stressful in your life, whether it is work, or family, or anything else, try and deal with the problem as soon as possible so you can more effectively manage your migraine. There’s no point in ‘sucking it up’ and making yourself really sick in the process.
Stress triggered migraine is particularly troublesome when dealing with migraine related anxiety. People with migraine are often trying to regulate their lives, avoiding triggers, and are constantly on the lookout for the first signs of the next attack. Being ‘on guard’ like this all the time leads to anxiety. So, if anxiety is a trigger for you, it can lead to an endless cycle of migraine attacks and anxiety. Get help from a psychologist (you can get a mental health care plan from your GP to see a psychologist under Medicare), acknowledge your anxiety for what it is – part of migraine, and have a plan to deal with it when the over-thinking and unreasonable fears start to creep in.
Too much, too little, and broken sleep can all be a migraine trigger. Going to bed late, getting up early or late, even if you have a good night’s sleep, can also trigger a migraine attack. Again, the key here is routine: have a set bedtime, and get up at the same time.
Check if your phone or watch has a bedtime function that will tell you when to go to bed, when to get up, and automatically put your devices into ‘do not disturb’ mode in between.
Hormonal changes (menstrual migraine)
Migraine is closely associated with hormones. Some women find their migraine attacks start at puberty, and are linked to their menstrual cycle. The additional hormonal trigger for women may explain why more women than men experience migraine during their reproductive years. Menopause is often the most difficult time for women with migraine. Post menopause many women find their migraine eases, while men of a similar age find their migraine gets worse.
If you get menstrual migraine, a low dose or estrogen free birth control option (including long acting reversible contraceptive solutions that can stop periods altogether like Mirena IUDs, and Depo Provera shots) may be a good option. However, if you have migraine aura, you should discuss this carefully with your neurologist (and gynaecologist or GP), as your risk of stroke is higher, and some hormonal birth control options can significantly increase the risk of stroke.
Exercise (exercise induced migraine)
Exercise is helpful in preventing migraine, but for about a third of people living with migraine, exercise is also a trigger. The best theory is that the sudden increase in cardiac activity causes a spasm in blood vessels in the brain, which is one of the things that can start an attack. Beta blockers can be an effective preventative for people with exercise induced migraine.
If you live with exercise induced migraine, you probably did not have much difficulty identifying this trigger. However, you don’t have to avoid exercise entirely. Here’s some tips to help you to exercise without triggering an attack:
- Avoid high impact activity, or anything that needs a great or sudden burst of physical exertion.
- Do long warm ups and and cool downs to smooth the cardiac activity.
- Consider smoother sports, like yoga and swimming, over higher intensity sports like boxing or football.
- Stay well hydrated and if possible cool – exercising indoors in an airconditioned environment may be best.
Food related triggers occur in about 10-20% of people with migraine. Many people will crave snack food such as chocolate or chips in the early stages of a migraine attack which leads them to conclude that particular food is a trigger. However, if the craving for a particular food is a symptom of the beginning of the attack, it probably is not a trigger, and you need to find out what you did or ate before that.
Some food products contain chemicals or additives which may also be implicated in an attack. Ones which are frequently mentioned by people with migraine are monosodium glutamate, nitrates and aspartame. Tyramine is a chemical found in red wine and soft cheeses like camembert and brie that is often indicated as a migraine trigger.
If you think you have food triggers, particularly the more difficult to identify chemicals or additives, you are best to do a full elimination diet with the help of a dietician (you can get access to a dietician under Medicare through your GP with a chronic condition health care plan, and there are also dieticians in the public health system you may be able to access). The RPAH Allergy Clinic in Sydney, who developed the elimination diet, have the handbook and recipe books you can buy, as well as some basic information, available on their website. Note: an elimination diet is a diagnostic tool to find your triggers, not an eating plan to avoid migraine attacks. Living on an elimination diet will mean you are not getting enough nutrients.
Missing meals or insufficient food is one of the most significant dietary triggers. Try eating 5-6 small meals a day, or having healthy snacks between meals. If you are vomiting a lot or unable to eat during a significant attack, it is ok to keep the blood sugar up with soft drink or whatever you are craving, just try not to make that an everyday occurrence.
There are many diets sold to people living with migraine. While some of these may be based in science, most are just selling yet another miracle cure to those in our community desperate to try anything. Of course, if you want to try a diet you should do so, but avoid diets or programs with any level of fasting, that eliminate carbohydrates completely (low carb is fine), or that have any expensive supplements or meal replacements.
Too much caffeine can contribute to the onset of a migraine attack. Some people find that suddenly stopping caffeine altogether can also be a trigger. If you suspect this, you may wish to cut down on caffeine gradually. Caffeine can also be helpful in managing migraine, which is why there is caffeine in some migraine medications (for example, panadol extra). Be aware of the ingredients of the medications you take, and any foods that may also contain caffeine, to ensure you are not overdosing.
Too much caffeine can also cause medicine overuse headache. Try not to exceed 200mg of caffeine a day from any source to avoid medicine overuse headache. That’s about 2-3 cups of tea, coffee or cola (Coke, Pepsi etc).
Mild dehydration can have an impact on people who have migraine. It is recommended that you should drink at least 8 glasses of water per day. This is in addition to any other drinks you may have. Increasing your water intake during an attack helps about 10% of people who live with migraine.
There are certain trigger factors which can be related to environmental issues such as dust, smoke, high altitude, weather changes, heat, humidity, loud noises, strong smells, exposure to glare or flickering lights. Sitting in front of a computer at home or work for long periods of time can cause problems if you experience migraine.
The simple rules OH&S recommends for everyone such as taking regular breaks, using anti glare screens and good lighting, can help avoid migraine attacks. Sitting comfortably is very important when you use a computer to avoid muscle tension building up in the head, neck and shoulders, which can be a trigger for some people, so make sure your workstation is properly set up. Migraine is an invisible disability, so you can ask for reasonable adjustments in your workplace, such as a glare filter on your monitor, or moving your desk so a light that is bothering you is not in your eyeline.
Remember: your migraine triggers are unique to you – what triggers an attack for someone else will not necessarily be a trigger for you, and what works for someone else may not work for you. The above information is a guide to the most common triggers, but you need to do the homework to identify your own triggers and how you can avoid them.