The Role of Avoiding Known Triggers, Embracing Protectors, and Adhering to Healthy Lifestyle Recommendations in Migraine Prophylaxis

Insights From a Prospective Cohort of 1125 People With Episodic Migraine

Amparo Casanova MD, PhD; Marina Vives-Mestres PhD; Stephen Donoghue PhD; Alec Mian PhD; Christian Wöber MD

Headache. 2023;63(1):51-61.

Abstract and Introduction

Abstract

Objectives/Background: Until recently, guidelines for migraine prevention recommended avoiding known migraine headache triggers. Adhering to healthy lifestyle behaviors is also recommended. In a recent cohort study many triggers were found to decrease the probability of migraine attacks in some individuals. The extent to which people with migraine adhere to healthy lifestyle recommendations is unknown. We set out to determine if known migraine trigger factors and daily adherence to healthy lifestyle recommendations are associated with decreased probability of migraine attacks in some individuals.

Methods: This was an observational longitudinal cohort study of individuals with episodic migraine who registered to track their headache symptoms and daily exposure to trigger factors prospectively using a migraine-headache electronic diary during 90 days. We assessed whether triggers increased or decreased migraine attack risk in each individual. In addition, we calculated the proportion of days in which the individual adhered to lifestyle recommendations.

Results: We analyzed a total of 1125 individuals contributing 14,080 migraine attacks. Out of 47 triggers, 24 were more often associated with decreased rather than with increased migraine attack risk. Most pronouncedly this was true for caffeine, alcohol, and chocolate; happiness; relaxedness; sleep factors (longer duration, higher quality, and waking up refreshed); and physical activity. People who were more compliant with healthy behaviors, especially keeping good hydration and regular meals, were significantly older and had been diagnosed with migraine disease for a longer period, compared to those who were less compliant. Overall, exercising ≥3 times a week was the least followed recommendation.

Conclusion: Many triggers behaved as protectors in a non-negligible proportion of individuals with episodic migraine, challenging the recommendation of avoiding known triggers. Low adherence to healthy lifestyle recommendations demonstrates an opportunity to increase awareness among people with migraine.

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Next Section

Abstract and Introduction
Background
Methods
Results
Discussion
References

Table 1. Triggers, their units, and variable types
Emotional (8)	Stress^a, anxiety^a, irritability^a, happiness^a, sadness^a, angriness^a, boredom^a, relaxedness^a
Sleep (3)	Sleep duration^b, sleep quality^a, feeling refreshed after sleep^a
Activity (2)	Physical activity^c, travel^b
Dietary (11)	Missed meals^c, dehydration^c, chocolate^d, tyramine^d, nitrates^d, monosodium glutamate (MSG)^d, citrus fruits^d, artificial sweetener^d, salty foods^d, nuts^d, onions^d
Environmental/weather (9)	Exposure to bright lights^c, exposure to loud noise^c, exposure to strong odors^c, humidity (mean)^e, barometric pressure (mean)^f, air temperature (mean)^g, wind gusts (peak)^h, wind speed (mean)^h, time outside (outdoors)^b
Physical (4)	Tiredness/fatigue^c, eyestrain^c, neck pain^c, (head/neck) skin sensitivity^c
Medication (2)	Missed migraine medication^c, missed other medication^c
Person-specific
Hormonal/female (3)	Menstruation (menstrual bleeding)^c, menopause symptoms^c, sexual activity^c
Other (5)	Alcohol^c, caffeine^c, nicotine (cigarettes, cigars, pipe)ⁱ, nicotine (other—e.g., patches)ⁱ, illicit drugsⁱ

^aLikert scale: 0–10.
^bContinuous variable: hours.
^cBinary variable: yes/no.
^dCategorical variable: none/some/a lot.
^eContinuous variable: %.
^fContinuous variable: KPa.
^gContinuous variable: °C.
^hContinuous variable: km/h.
ⁱContinuous variable: number of cigarettes or drug units.

Table 2. Demographic and migraine characteristics ( n = 1125)
	Mean (SD) or no. (%)	Range
Age (years)	43.1 (12.7)	18–79
Country
United States	454 (40.4)
Great Britain	368 (32.7)
Other	303 (26.9)
Sex—female (n = 989)^a	990 (88.0)	–
Regular menstrual cycles	548 (55.4)	–
Menopausal	153 (15.5)	–
Postmenopausal	151 (15.3)
No menstruation	137 (13.9)
Employment status (n = 795)		–
Employed	538 (67.7)
Self-employed	77 (9.7)
Homemaker	54 (6.8)
Student	46 (5.8)
Retired	36 (4.5)
Other	30 (3.9)
Migraine diagnosed by doctor^b (n = 1124)	1012 (90.0)	–
Years with migraine^c (n = 911)	21.8 (13.9)	0–62
Most troublesome type of headache^c (n = 624)
Migraine	554 (88.8)
Tension-type	41 (6.6)
Other	29 (4.6)
Disability (n = 1122)
MIDAS Grade I	45 (4.0)
MIDAS Grade II	67 (6.0)
MIDAS Grade II	176 (15.7)
MIDAS Grade IV	834 (74.3)
Data from 90 days of app use
Headache days (monthly average)	11.0 (4.5)	2.0–30.0
Migraine days (monthly average)	7.5 (3.6)	1.3–22.7
Migraine attacks (monthly average)	3.2 (0.9)	0.7–5.7

Abbreviations: MIDAS, Migraine Disability Assessment Scale; SD, standard deviation.
^a(n=) indicates available data for a specific variable, if smaller than n = 1125.
^bSelf-reported at registration.
^cThis question was added at the end of 2015.

Table 3. Individual trigger–migraine attack onset associations
Trigger/symptom	Valid estimates—Results			No valid estimates—Reasons
Trigger/symptom	Protector (HR < 1) n (%)	Trigger (HR > 1) n (%)	No association found (HR = 1) n (%)	Constant factor n (%)	Low variability n (%)	Model did not converge n (%)
Emotional
Stress	12 (1.1)	177 (15.7)	913 (81.2)	4 (0.4)	8 (0.7)	11 (1.0)
Anxiety	7 (0.6)	176 (15.6)	888 (78.9)	11 (1.0)	27 (2.4)	16 (1.4)
Irritability	12 (1.1)	154 (13.7)	914 (81.2)	4 (0.4)	27 (2.4)	14 (1.2)
Happiness	285 (25.3)	9 (0.8)	795 (70.7)	1 (0.1)	31 (2.8)	4 (0.4)
Sadness	5 (0.4)	142 (12.6)	842 (74.8)	20 (1.8)	74 (6.6)	42 (3.7)
Angriness	9 (0.8)	85 (7.6)	875 (77.8)	18 (1.6)	92 (8.2)	46 (4.1)
Boredom	18 (1.6)	48 (4.3)	764 (67.9)	79 (7.0)	152 (13.5)	64 (5.7)
Relaxedness	167 (14.8)	15 (1.3)	924 (82.1)	1 (0.1)	15 (1.3)	3 (0.3)
Sleep
Sleep duration	75 (6.7)	39 (3.5)	1006 (89.4)	0 (0.0)	2 (0.2)	3 (0.3)
Sleep quality	201 (17.9)	20 (1.8)	888 (78.9)	0 (0.0)	14 (1.2)	2 (0.2)
Sleep refreshed	380 (33.8)	5 (0.4)	727 (64.6)	0 (0.0)	9 (0.8)	4 (0.4)
Activity
Physical activity	123 (10.9)	13 (1.2)	838 (74.5)	29 (2.6)	55 (4.9)	67 (6.0)
Travel	19 (1.7)	23 (2.0)	582 (51.7)	138 (12.3)	264 (23.5)	99 (8.8)
Dietary
Missed meals	8 (0.7)	80 (7.1)	559 (49.7)	97 (8.6)	290 (25.8)	91 (8.1)
Dehydration	8 (0.7)	83 (7.4)	556 (49.4)	134 (11.9)	268 (23.8)	76 (6.8)
Chocolate	74 (6.6)	21 (1.9)	898 (79.8)	31 (2.8)	40 (3.6)	61 (5.4)
Tyramine	30 (2.7)	25 (2.2)	618 (54.9)	193 (17.2)	171 (15.2)	88 (7.8)
Nitrates	24 (2.1)	15 (1.3)	584 (51.9)	227 (20.2)	195 (17.3)	80 (7.1)
MSG	8 (0.7)	6 (0.5)	341 (30.3)	324 (28.8)	336 (29.9)	110 (9.8)
Citrus fruits	30 (2.7)	24 (2.1)	670 (59.6)	110 (9.8)	185 (16.4)	106 (9.4)
Artificial sweetener	24 (2.1)	14 (1.2)	365 (32.4)	382 (34.0)	228 (20.3)	112 (10.0)
Salty foods	46 (4.1)	17 (1.5)	826 (73.4)	39 (3.5)	66 (5.9)	131 (11.6)
Nuts	33 (2.9)	16 (1.4)	783 (69.6)	77 (6.8)	121 (10.8)	95 (8.4)
Onions	32 (2.8)	12 (1.1)	871 (77.4)	38 (3.4)	91 (8.1)	81 (7.2)
Environmental/weather
Exposure to bright lights	12 (1.1)	149 (13.2)	562 (50.0)	106 (9.4)	188 (16.7)	108 (9.6)
Exposure to loud noise	5 (0.4)	148 (13.2)	470 (41.8)	123 (10.9)	275 (24.4)	104 (9.2)
Exposure to strong odors	10 (0.9)	98 (8.7)	436 (38.8)	209 (18.6)	274 (24.4)	98 (8.7)
Humidity^a	46 (4.1)	43 (3.8)	956 (85.0)	74 (6.6)	6 (0.5)	0 (0.0)
Barometric pressure^a	41 (3.6)	39 (3.5)	955 (84.9)	78 (6.9)	12 (1.1)	0 (0.0)
Temperature^a	68 (6.0)	66 (5.9)	915 (81.3)	72 (6.4)	4 (0.4)	0 (0.0)
Wind gust^a	26 (2.3)	35 (3.1)	1023 (90.9)	11 (1.0)	19 (1.7)	11 (1.0)
Wind speed^a	31 (2.8)	31 (2.8)	971 (86.3)	75 (6.7)	16 (1.4)	1 (0.1)
Time outside	58 (5.2)	48 (4.3)	993 (88.3)	2 (0.2)	7 (0.6)	17 (1.5)
Physical
Tiredness/fatigue	0 (0.0)	252 (22.4)	727 (64.6)	21 (1.9)	20 (1.8)	105 (9.3)
Eyestrain	0 (0.0)	268 (23.8)	481 (42.8)	122 (10.8)	182 (16.2)	72 (6.4)
Neck pain	0 (0.0)	409 (36.4)	441 (39.2)	50 (4.4)	91 (8.1)	134 (11.9)
Allodynia	3 (0.3)	158 (14.0)	281 (25.0)	341 (30.3)	246 (21.9)	96 (8.5)
Medication
Missed migraine medication (n = 688)^a,b	5 (0.7)	6 (0.9)	65 (9.5)	440 (64.0)	133 (19.3)	39 (5.7)
Missed other medication^a (n = 688)	1 (0.2)	9 (1.3)	75 (10.9)	470 (68.3)	87 (12.7)	46 (6.7)
Person-specific triggers
Hormonal/female
Menstruation (n = 704)	1 (0.1)	97 (13.8)	427 (60.7)	114 (16.2)	23 (3.3)	42 (6.0)
Menopause symptoms (n = 153)	5 (3.3)	12 (7.8)	60 (39.2)	40 (26.1)	17 (11.1)	19 (12.4)
Sexual activity (n = 904)	7 (0.8)	5 (0.6)	499 (55.2)	100 (11.1)	165 (18.3)	128 (14.2)
Other
Alcohol (n = 817)	55 (6.7)	7 (0.9)	518 (63.4)	26 (3.2)	105 (12.9)	106 (13.0)
Caffeine (n = 1004)	100 (10.0)	10 (1.0)	420 (41.8)	308 (30.7)	16 (1.6)	150 (14.9)
Nicotine^a (n = 69)	5 (7.3)	2 (2.9)	28 (40.6)	13 (18.8)	16 (23.2)	5 (7.3)
Nicotine other^a (n = 69)	2 (2.9)	0 (0.0)	8 (11.6)	48 (69.6)	6 (8.7)	5 (7.3)
Illicit drugs^a (n = 61)	3 (4.9)	2 (3.3)	29 (47.5)	11 (18.0)	13 (21.3)	3 (4.9)

Note: Results of 46,782 models in 1125 individuals and up to 47 triggers.
Abbreviations: HR, hazard ratio; MSG, monosodium glutamate.
^aMissing >5%: weather variables 10.5%–15.3% missing (collected automatically, app error; missing values replaced by mean); missed -medication 7.8% missing (no replacement); nicotine 7.4% missing (19 individuals with >5% missing; missing values replaced by 0); illicit drugs 9.14% missing (12 individuals with >5% missing; missing values replaced by 0).
^b(n=) indicates the number of individuals for whom a specific variable applies, if smaller than n = 1125.

Table 4. Adherence to healthy lifestyle recommendations
Healthy headache lifestyle	≥Proportion of time being compliant≥
Healthy headache lifestyle	Never n (%)	(0%–20%) n (%)	(20%–40%) n (%)	(40%–60%) n (%)	(60%–80%) n (%)	>80% n (%)
Regular sleep	8 (0.7)	41 (3.6)	126 (11.2)	248 (22.0)	412 (36.6)	290 (25.8)
Regular meals	0 (0.0)	25 (2.2)	33 (2.9)	79 (7.0)	213 (18.9)	775 (68.9)
Adequate hydration	2 (0.2)	30 (2.7)	36 (3.2)	99 (8.8)	221 (19.6)	737 (65.5)
Regular exercise	113 (10.0)	180 (16.0)	147 (13.1)	147 (13.1)	212 (18.8)	326 (29.0)
All healthy lifestyle	161 (14.3)	368 (32.7)	257 (22.8)	204 (18.1)	113 (10.0)	22 (2.0)

Note: Number and proportion (N[%]) of individuals who complied with recommendations at different frequencies during 90 days (n = 1125). Regular sleep is defined as sleep duration between 7 and 9 h; regular meals is defined as avoiding skipping meals; adequate hydration is defined as dehydration not present; regular exercise is defined as exercising at least three times a week.

Table 5. Individual healthy lifestyle–migraine attack onset associations
Healthy headache lifestyle	Valid estimates—Results			No valid estimates—Reasons
Healthy headache lifestyle	Protector (HR < 1) n (%)	Trigger (HR > 1) n (%)	No association found (HR = 1) n (%)	Constant factor n (%)	Low variability n (%)	Model did not converge n (%)
Regular sleep	80 (7.1)	7 (0.6)	966 (85.9)	9 (0.8)	6 (0.5)	57 (5.1)
Regular meals	93 (8.2)	7 (0.6)	718 (63.8)	97 (8.6)	4 (0.4)	206 (18.3)
Adequate hydration	102 (9.1)	8 (0.7)	700 (62.2)	134 (11.9)	7 (0.6)	174 (15.5)
Regular exercise	46 (4.1)	20 (1.8)	535 (47.6)	355 (31.6)	15 (1.3)	154 (13.7)
All healthy lifestyle	68 (6.0)	7 (0.6)	712 (63.3)	161 (14.3)	77 (6.8)	100 (8.9)

Note: Results of 5625 models in 1125 individuals and four recommendations, and their combination. Abbreviation: HR, hazard ratio.

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The Role of Avoiding Known Triggers, Embracing Protectors, and Adhering to Healthy Lifestyle Recommendations in Migraine Prophylaxis

Insights From a Prospective Cohort of 1125 People With Episodic Migraine

Abstract and Introduction

Abstract

Tables

Tables

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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