17 Jan Self-Care & Trigger Management
Migraine attacks can happen spontaneously, but other times they are brought on by specific factors (called ‘triggers’). Some common triggers are related to your environment, physical or emotional state, or diet.
Triggers can be hard to identify, but most people will know one or two things that play a role in their migraine. This article outlines strategies to manage some of the most common triggers and to reduce your susceptibility to attacks. You can apply these principles of self-care to any other triggers you might have.
Click the headings below to jump to a specific section.
- Watch the full presentation recording
- What are triggers?
- Most common triggers:
- Take home messages
Medically reviewed by Dr Bronwyn Jenkins. Last updated January 17, 2022.
Watch the full webinar recording
This article was adapted from a webinar by Dr Bronwyn Jenkins, originally presented during Migraine & Headache Awareness Week 2021.
Dr. Bronwyn Jenkins (BMed FRACP) is a neurologist from Sydney, Australia with a subspecialist interest in headache. She is a clinician in private practice and an Honorary Medical Officer at Royal North Shore Hospital. She has participated in the Headache Master School program and written a postgraduate course in headache for the University of Sydney. She is a member of ARCH, IHS and AHS, having been a member on the International Headache Society Board from 2018 to 2020. She is President Elect and Chair of the Education subcommittee for the Australian and New Zealand Headache Society (ANZHS) which aims to improve management of headache patients in the region.
Closed captions (CC) or subtitles are available on this video. To activate CC, click on the CC icon next in the bottom right corner of the video player and select “English”. Playback speed and video quality can also be adjusted using the video settings (the icon that looks like a “cog” next to CC icon).
What are triggers?
A trigger is any factor that measurably increases your chance of experiencing a headache or migraine attack. These factors can be endogenous (in the body) or exogenous (from outside the body), and the headache could occur anywhere between two hours and three days after you encounter the trigger.
One study found that the most common trigger is stress (33%), followed by hormones (25%). Other major triggers include missed meals, sleep disturbance, odors, alcohol, heat, and dietary triggers. On average, people in the study had seven triggers each. These common triggers are quite similar to the 2021 data from Migraine Buddy (a headache diary app), which are shown below.
However, there is widespread variation in how people experience triggers. The factor that is most relevant to your friend or family member might not affect you much at all. People also often have a combination of triggers which lead to a headache or migraine attack rather than one isolated cause.
Understanding triggers can be quite complex, but it’s still useful to know the basics. Even if you don’t experience the most common triggers, practicing self-care for migraine is an important management strategy. Once you know what causes your headache or migraine attacks, you can develop your own self-care routines to help with trigger management.
Sleep disruption can be a major trigger for migraine, and it has a bi-directional relationship with migraine as well. In fact, many of the anatomical structures in the brain are significant in both migraine disorders and sleep (the cortex, thalamus, hypothalamus and brainstem).
Migraine attacks will obviously disrupt sleep, but other symptoms (including anxiety between attacks) can also contribute to insomnia. Correspondingly, insomnia can worsen someone’s migraine.
Some of the best management options in this case are strategies to improve sleep. This needs to take into account any other sleep disorders you may experience, like grinding your teeth (bruxism) or sleep apnea. If you share a bed, ask your partner to go to bed a bit after you, so they can check if you’re snoring. It is less obvious if you grind your teeth or stop breathing without snoring, but that can be investigated with a health professional if suspected.
The next step is to try sleep interventions (i.e. sleep hygiene). There are fewer high quality studies with large sample sizes that look at the psychology of sleep hygiene, but anecdotally these are some strategies to try:
- Keep to a regular sleep schedule. Go to bed and wake up at similar times each day, even on weekends, to get into a routine that can maximise sleep quality.
- Avoid daytime naps.
- Avoid caffeine after 3pm, as it stays in your system until bedtime.
- Avoid alcohol. While you may fall asleep more easily, you will tend to have fragmented, poor quality sleep.
- Consider practising a relaxation technique before bed, to help wind down.
- It can help to have a notepad by the bed to jot down any thoughts overnight. This way, you know you can address them in the morning, rather than staying up thinking about them.
- Avoid using backlit screens (TV, laptops, tablets, mobile phones) for at least 1 hour before bed.
- Make your bed and bedroom a space for sleep. Avoid reading or working in bed.
Recently, there has been some interesting research into cravings, linking them to premonitory symptoms. Premonitory symptoms appear to be associated with certain brain systems that are involved in migraine. Food cravings are thought to be related to hypothalamic dysfunction, whereas light sensitivity is connected to thalamic/cortical dysregulation. This means that some things prior to the headache phase could be part of the migraine attack, rather than being the trigger.
One study elicited migraine attacks in participants to compare their perceived triggers against their premonitory cravings. The data showed that many reported triggers were actually significant premonitory symptoms. This was statistically significant for light (trigger) & photophobia (premonitory); snacking & food cravings, and hunger & food cravings.
There’s an ongoing debate about perceived triggers and migraine symptoms, which will continue to be studied. Sometimes the difference between these becomes clear after treating the migraine disorder with preventive treatments.
Some people experience clear dietary triggers. These are very individual. Some of the most common food products that cause migraine are:
- Alcohols (particularly red wine or cheaper alcohols with lots of preservatives)
- MSG & other additives
To address this you can try an elimination diet. But it’s important to note that a food sensitivity is not the same as a food allergy. For food allergies people introduce a new food every day, but this isn’t reliable for migraine – a migraine isn’t as immediate or clear cut as an allergic rash or other reaction.
Instead, try eliminating one food for several weeks at a time then re-entering that food. You can then track if you were better or worse during those periods using a tool like a headache or migraine diary. This will allow you to make an informed decision rather than unnecessarily cutting out food groups.
The final consideration with diet is looking at specific types of diets that could be beneficial for migraine.
Omega 3 Diet
Recent and very interesting research has been about the omega 3 diet. Omega 3s (n-3 fatty acids) are primarily found in seafood and algae, as well as some high-fat plant foods (i.e. walnuts, flax seeds). The study also measured the effects of reducing omega 6 (n-6 linoleic acid) because this has been linked to inflammation.
They found that both omega 3 groups had significantly fewer headache days compared to the control group (-4 with omega 6 reduction, -2 without). The diet didn’t decrease participants’ quality of life, which can be a concern for overly restrictive or complex diets. There was also a measurable change in an anti-pain mediator called ‘17-hydroxydocosahexaenoic acid’. This showed the impact of the diet from a biological standpoint as well as the participants’ experience.
There has also been interest in the ketogenic diet – a high fat, low carbohydrate diet. This diet has been shown to alter glucose transport, mitochondrial function, oxidative stress, cerebral excitability, cortical spreading depression, inflammation and gut microbiome. All of these factors have some relevance in migraine.
The ketogenic diet has also been recommended for epilepsy, particularly for young refractory epileptic conditions. But while it is certainly of interest in migraine, keep in mind that it is quite a restrictive diet.
General Healthy Diets
The MIND diet is one example of a more simple healthy diet. It was developed specifically to focus on brain health. While it isn’t necessarily the gold standard for migraine, one study found that people with a higher MIND diet score had shorter, less severe headaches.
The DASH diet was actually developed for people with hypertension. It focuses on particular salts, fiber, and protein as the primary components. Like the MIND diet, research shows a correlation between adherence to the diet and shorter, less severe headaches.
Ultimately, the ‘best’ diet is one that you can sustain. If you don’t like fish then the omega 3 diet won’t be a good fit, and if you love pasta then the ketogenic diet could be hard. It’s about finding a balance between migraine management and dietary choices that suit your lifestyle. The Australian and New Zealand Headache Society (ANZHS) recommends the following dietary guidelines, regardless of what type of diet you follow.
- Keep blood sugars even by:
- Eat regular meals (avoid skipping meals or running late for lunch).
- Avoid excess simple sugars (cakes, biscuits, sugary drinks).
- Avoid any known dietary triggers.
Dehydration is a known trigger for migraine. Sometimes people will know they get worse migraine attacks when they exercise, which can be limiting if they want to do marathons or play a sport. Conversely, adequate hydration can reduce migraine disability, severity, frequency, and duration.
The recommended water intake for adults is 1.5 to 2 litres a day (which you should increase if it’s hot, or when exercising). If you know you experience sports-induced dehydration, it’s particularly important to drink water before, during, and after exercise.
Nausea and vomiting during a migraine attack can also cause dehydration. Increasingly, IV drips are used when people go to the emergency room for migraine treatment. At home, you can drink an oral rehydration solution (such as Hydralyte) to replace lost fluids after vomiting.
Exercise is beneficial for so many aspects of your health, and migraine is no exception.
- Biologically it suppresses inflammatory modulators (e.g. cytokines) and stress hormones (e.g. cortisol, growth hormone).
- Psychologically it improves migraine self-efficacy and internalizes the locus of control, leading to reduced migraine burden.
Studies have shown that many types of exercise can be helpful for migraine, without any single exercise being the best. There is some evidence that higher intensity training is more effective, but this is only when it can be tolerated. Running and jumping is obviously not an option during a migraine attack.
However, regular exercise can help reduce pain overall. A sufficiently rigorous aerobic exercise routine is enough to decrease migraine frequency, intensity, and duration. The ANZHS recommends that people aim for 30-40 minutes of exercise, 3-4 times a week.
Stress & Anxiety
There is a complex bi-directional relationship between anxiety, depression, and migraine. On the other hand, there’s been evidence showing the benefits of relaxation techniques, such as:
- Breathing techniques
- Progressive muscle relaxation
- Cognitive behavioural therapy
Once again, the best relaxation strategy is the one that resonates with you and suits your lifestyle. During the COVID-19 outbreak and lockdowns, some people found that the stress of sudden lifestyle changes worsened their migraine. Relaxation techniques are a powerful strategy which will be useful at any stressful time in your life.
The ANZHS recommends that people practise a relaxation technique for 20 to 30 minutes, three to five times a week.
Caffeine has an interesting relationship to migraine. It’s useful during an attack because it has analgesic properties, but regular excess use can lead to withdrawal, which can be a trigger.
There is limited evidence about an ideal daily dosage, but approximately one cup of coffee is a general guideline. Higher levels of caffeine should be limited to two days a week. This is sometimes hard to track, because the amount of caffeine varies between different products or types of coffee. The graph below is a rough guide but can help you moderate your caffeine intake – for example, you can drink more tea than coffee.
If you think caffeine is having a negative impact on your migraine, you can try to reduce or eliminate caffeinated products – similar to the food eliminations discussed previously. You should also speak to your doctor about your intake and their recommendations.
Glare or harsh lighting, certain smells, and weather changes are often reported to be migraine triggers. However, these factors are hard to measure – sensitivity to light and smells can actually be part of your premonitory symptoms. Weather changes are more clear external factors. Watch this webinar on atmospheric pressure and headache to learn more about the relationship between weather and migraine.
There are limited studies looking specifically at premonitory light sensitivity, so most discussions of light sensitivity are based on observational data. One study surveyed 711 people to ask how COVID-19 had affected their headache disorder. 54% of the participants were working from home in 2020, and they had a higher rate of headache improvement compared to the overall group. The working from home group found the flexibility of working from home beneficial, and were less bothered by light and noise.
Other environmental factors in an office could include chemical smells or ergonomics. However, the 2020 study didn’t find any significant worsening due to poor posture in home desk set-ups.
Some general tips to create a migraine-friendly environment are listed below.
- Establish good workplace ergonomics, particularly with computer use, and take regular ‘mini breaks’ to stretch and rest your eyes.
- Be aware of any repeated activities in your hobbies. Things like bending over a table or painting ceilings for prolonged periods can cause muscle strain around the head and neck and act as a trigger. Take regular breaks when possible and remember to stretch.
- Glare can be a trigger for many people. Wear sunglasses and a hat, especially in summer.
- Strong perfumes and cleaning products can be a trigger. If this is the case, try to avoid or manage environments where this would affect you.
Many women with migraine will have experienced hormonal triggers. These attacks are often more severe, more frequent, longer lasting, more likely to relapse and harder to treat compared to other episodes. They occur approximately two days before the period starts, and in the first three days of bleeding.
To accurately identify hormones as a trigger, you will need to keep a headache diary to keep track of your menstrual cycle and migraine attacks. Once you know if hormones are your main trigger, you can try to stabilise them with hormonal treatments or use “mini-prophylaxis” strategies.
Other head & neck triggers
Head pain is thought to be controlled by the trigeminocervical complex. This is a point of convergence for the main structures in the head – the eyes, sinus, teeth, nose, ears, and scalp. For people who are genetically predisposed to migraine, pain in any part of the head can worsen migraine attacks.
These imaging scans show one person with a bad neck and one with very bad sinusitis. The sinusitis is marked by the solid, bright white dots in the top and middle of the image. If you’re having symptoms of postnasal drip and nasal stuffiness you might consider testing for sinusitis. This can clarify what role your sinus problems play in your migraine – if they are a symptom of the attack, or a possible cause.
Not every person with migraine needs to have imaging done. These tests are only necessary if it’s going to change your management strategy, or if you’re considering a surgical procedure to fix the head/neck disorder. Either way, head and neck triggers are worth considering when investigating the cause of migraine attacks.
Medication overuse headache (MOH) is an important factor to consider at all stages of migraine management. It is the leading modifiable risk factor for transitioning from episodic to chronic migraine. This means that it is the leading contributor for why people slip into chronic migraine from episodic – but it is manageable and preventable.
MOH occurs when people are taking acute medications too frequently. Over the course of a month, you should have no more than:
- 5 days of codeine
- 10 days of triptans
- 15 days of paracetamol or non-steroidal anti-inflammatories (NSAIDs).
Chronic exposure to these treatments can lead to the suppression of the antinociceptive (anti-pain) systems. This causes migraine to become more frequent and often more severe. However, it can be hard to tell the difference between the primary headache disorder and MOH. A doctor can identify it because of a person’s medical history or headache diary, not from their symptoms alone.
Thankfully, some studies show that recovery can be quick. Approximately two thirds of patients improve by more than 50% just one month after they stop the overused medication. The problem is that it’s complex for people to stop taking medications that they have become dependent on. Patient education and preventing MOH entirely is the best-case scenario but there are other strategies for managing it.
Principles of managing medication overuse:
- Patient education.
- Withdrawal of overused medication.
- Bridging therapy for withdrawal headache. This allows the person to use another medication while they’re recovering from MOH. It’s a particularly helpful strategy for people that were using codeine to treat their migraine.
- Prophylactic management. There is great evidence emerging that shows triptan overusers respond well to CGRP monoclonal antibodies.
- Inpatient infusions for those failing outpatient management.
- Monitor for relapse. The rate of relapse is about 40%, so it’s important to have a support network and speak to your doctor if your medication use increases again.
Deficiencies & Natural Supplements
Deficiencies can sometimes be a trigger, which means that natural supplements have become a part of your migraine management. However, there is a big difference between correcting a deficiency and advising supplementation for all.
If you or your doctor think you might be deficient in something (i.e. vitamin D, B12, iron, or thyroid hormones), you can do a simple blood test. These are common deficiencies and your doctor will be able to help you correct them to reduce your susceptibility to migraine.
Even though these types of supplements are ‘natural’, they aren’t always safe. Some vitamins are fat soluble, which means they can accumulate in your body, and some can be neurotoxic such as B6. Others are no longer recommended and have been less available in Australia for some time (i.e. butterbur). You also should be careful with supplements during conception and pregnancy – ideally, people should only use a conception supplement at this time.
Keeping this in mind, there is still some evidence for supplements in clinical trials.
|Supplement||Why could it help?||Evidence level*|
|Magnesium||Thought to be helpful if the stress of migraine causes low magnesium levels. This then causes cortical spreading depression and neurotransmitter release, platelet aggregation and vasoconstriction. These are all processes involved in migraine attacks.||Level B|
|Riboflavin||Riboflavin has been suggested to correct mitochondrial dysfunction. Mitochondrial dysfunction would lead to reduced energy production and an imbalance in cortical excitability. Correcting this could reduce migraine attack frequency.||Level B|
|Coenzyme Q10 (CoQ10)||CoQ10 is recommended for similar reasons to riboflavin. This supplement has antioxidant and anti-inflammatory actions because it is in the mitochondrial electron transport chain. It is useful in many disorders, including showing some benefits in migraine.||Level C|
|Curcumin||This decreases a protein (Interleukin 17) that is involved in migraine.||Limited evidence|
|Vitamin D||This is definitely recommended for anyone with a deficiency. But additionally, other studies have now found that it has anti-inflammatory effects and decreases CGRP levels. CGRP is a key hormone in migraine, so future research may find more evidence for vitamin D in migraine management.||Limited evidence|
|Melatonin||Melatonin is a naturally occurring hormone involved in your circadian rhythm (sleep cycle). Improving your sleep is an important part of migraine management. There have been mixed results from trials, but it is available over the counter and is well-tolerated, so could still be worth trying.||Limited evidence|
*According to American Academy of Neurology and American Headache Society criteria
Take home messages
- We’re all on a journey to find the cause(s) of migraine.
- This is normally a number of factors rather than just one thing you’re missing.
- With increasing headache frequency, people tend to be more vulnerable to their triggers.
- Trigger management is a complex process for both you and your health practitioner because every person is different.
- Emerging knowledge suggests that some perceived ‘triggers’ are actually part of the early stages of the migraine attack.
- Potentially modifiable trigger factors are very individual.
- It’s rare for people to have the same triggers – even within families.
- Try to avoid dogmatically telling people that your trigger is going to be theirs as well.
- However, it’s certainly worth sharing experiences and knowledge so that you can make informed decisions about your personal management.
- A headache diary is useful to determine your most identifiable trigger factors.
- Use this information to pick and choose anything you’re going to avoid.
- Any changes you make should be relevant, sustainable, and worth the inconvenience to your social, work, or family life.
- Trigger management is helpful, but unlikely to completely control the underlying genetic predisposition and biology of migraine.
- Remember: it is not your fault if you can’t control your migraine attacks.
- There is a limit to how much you can control life around you.
Further information and resources
This article was adapted from Dr Bronwyn Jenkins’ presentation during Migraine & Headache Awareness Week 2021. You can view the video of this presentation, and the other presentations from the week, on our webinar recordings page.
If you’d like to learn more about specific triggers or strategies discussed in this article, you can view the following articles and webinars:
- Self-Care for Migraine – a downloadable PDF summarising the advice in this article (written by the ANZHS).
- Headache & Migraine Diaries – these diaries can help you better understand your migraine or headache disorder and inform your management strategy.
- Dehydration & Headache
- Hormonal Factors in Migraine – from Migraine & Headache Awareness Week 2019.
Here are some further resources about migraine in general.
- Migraine – a common and distressing disorder – a detailed introduction and overview of migraine
- Acute Treatments
- Natural Alternatives For Migraine & Headache – from Migraine & Headache Awareness Week 2019.
- New Preventive Treatments – from Migraine & Headache Awareness Week 2021.