Migraine headaches are a prevalent and debilitating neurological disorder that significantly impacts the quality of life of affected individuals. Affecting over 1 billion individuals globally across all geographical regions, migraine poses a serious burden on individuals and society. Characterized by recurrent, throbbing, often unilateral, severe, and pulsating headaches, migraines can also present with phonophobia, photophobia, vomiting, and nausea. Some patients may experience transient visual disturbances, including blurry vision, zigzag lines, or flashing lights either before or during an attack. Migraine is categorized into two primary subtypes: migraine without aura (MwoA) and migraine with aura (MwA), differentiated by the presence or absence of aura symptoms preceding the pain phase.
Dietary patterns have been increasingly recognized as potential factors in the prevention and management of migraines. While individual food components and nutrients have been linked to migraine, research examining the correlation between migraine and overall dietary patterns is growing. Investigating the interrelationships, interactions, and cumulative effects of different nutrients and food items may be more appropriate to examine the relationship between chronic disorders and diet. Among the various dietary approaches, the Mediterranean diet has garnered attention for its potential benefits in mitigating migraine symptoms.
Understanding Migraine: A Complex Condition
Migraine is a multifaceted and intricate condition shaped by both genetic predispositions and environmental influences. Although various elements are involved in its pathogenesis, the primary source of the condition remains inadequately elucidated. The mechanisms involved encompass neural damage within the brain, modifications in cerebral blood circulation, neuroinflammatory processes, mitochondrial impairment, hormonal fluctuations, elevated homocysteine levels, obesity, and genetic predispositions. Furthermore, additional contributing factors consist of increased concentrations of specific neuropeptides, particularly calcitonin gene‐related peptides (CGRPs) and nitric oxide (NO), deficiencies in vitamin D, serotonin synthesis by platelets, disruptions in the gut-brain axis, and enhanced production of norepinephrine. An essential genetic factor may also contribute significantly to the occurrence of migraines.
Kowalska et al. emphasize the significant involvement of various ion channels, particularly those within the transient receptor potential ankyrin 1 (TRPA1) family, in the pathophysiology of migraine. The TRPA1 channel is notably responsive to a range of exogenous irritants, which can activate nociceptive pathways that are integral to headache mechanisms. This activation plays a pivotal role in the sensitization of trigeminal neurons, a fundamental characteristic in the onset of migraine episodes. Moreover, other genetic factors linked to migraine, such as mutations in the SCN1A and KCNK18 genes, are also associated with channelopathies relevant to migraine. The discovery of these genetic variants sheds light on the potential mechanisms that contribute to migraine susceptibility and underscores the intricate nature of its genetic framework.
Migraine has also been linked to various other health issues such as obesity, cardiovascular events, respiratory conditions like asthma, and mental health disorders like anxiety and depression. This constellation of comorbidities complicates the clinical management and the outcomes of primary headaches, especially in chronic forms, where symptoms overlap. The mechanisms through which conditions become comorbid remain challenging to elucidate. Comorbidity may serve as a risk factor for the persistence of chronic conditions or act as a precipitating factor for headaches. Additionally, comorbidity could arise as a result of recurrent headache episodes, the effects of headache treatments, or as a consequence of other shared factors associated with headaches.
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Dietary Patterns and Migraine: An Emerging Link
Recent studies have focused on the analysis of dietary patterns to explore the association between dietary intake and the occurrence of disorders. Rist et al. (2015) found that the frequency of migraine attacks varies across different dietary patterns in women with migraine. Another cross‐sectional research indicated that a greater dietary acid load score is inversely linked to migraine headache features among women.
Determining food patterns or indexes relies on understanding individuals' total usual consumption of foods, beverages, nutrients, or a combination thereof. Dietary patterns consider the interactive and cumulative impacts between multiple dietary components, reflecting the complexity and totality of real‐world eating behaviors. Food intake data are obtained from interviewer-administered, self‐reported questionnaires, dietary records, or recalls. Most epidemiological research on food patterns has relied on self-reported food frequency questionnaires (FFQs) to evaluate participants' usual past diets. These questionnaires can include almost 60-200 drink or food items along with portion sizes. Dietary assessment methods are associated with measurement error, which has been discussed in many studies. However, the capacity to rank subjects according to their relative intake of dietary items using the FFQs is commonly considered acceptable.
There exist two primary methodologies for conducting dietary pattern analysis, which hinges on whether the dietary pattern is empirically defined or based on predetermined criteria established by the researcher. An a priori dietary pattern is constructed upon different nutritional variables that can be scored according to dietary guidelines, established scientific correlations between diet and health conditions, or a food tradition. Examples of a priori dietary patterns are the Mediterranean Diet (MedDiet), Healthy Eating Index (HEI), and Dietary Approaches to Stop Hypertension (DASH) score. Their advantages are ease of calculation and interpretation. Limitations include subjectivity in choosing dietary components and may not fully encompass the diet. An a posteriori dietary pattern is empirically extracted from data using mathematical and statistical methodologies such as factor analysis or cluster analysis. Its benefits are patterns that reflect how people eat and discoveries that are not limited by current knowledge. Limitations in analysis choices are subjective, and patterns may not be reproducible across populations. Overall, food pattern analysis is a beneficial strategy in nutrition research to assess the complex synergistic impacts of whole diets on health and disease outcomes. However, traditional single‐food and nutrient analyses are still essential and complementary.
The Mediterranean Diet: An Overview
In 2010, the United Nations Educational, Scientific, and Cultural Organization (UNESCO) identified the MedDiet as an “intangible cultural heritage” of Greece, France, Italy, Spain, and Morocco. This dietary pattern aimed to preserve the characteristics of local diversity and culinary traditions unique to Mediterranean countries to promote health benefits. For the first time, it was introduced as a dietary pattern low in saturated fatty acids that was capable of protecting the cardiovascular system. Later, it was identified as a dietary pattern consisting of foods rich in highly protective nutrients that can prevent several diseases.
The Mediterranean diet consists of traditional eating habits in the countries bordering the Mediterranean Sea, including Spain, France, Monaco, Italy, and Greece. The Mediterranean diet has a lot of different forms, as the eating styles vary among these bordering countries. In addition, the culture, ethnic background, religion, economy, geography, and agricultural production contribute to the differences between these countries and the various forms of the Mediterranean diet.
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The MedDiet is defined by high consumption of plant‐derived food items, such as fresh fruits, vegetables, legumes, seeds, nuts, whole grains, and olive oils, accompanied by moderate consumption of low‐fat dairy items, fish, and red wine (consumed during main meals), as well as limited intake of red meat and sweets. It provides a combination of healthy and diverse foods and many nutritional benefits, such as minerals, vitamins, fibers, and other protective nutrients and compounds.
The primary components of the Mediterranean diet are fruits, vegetables, breads, grains, potatoes, beans, nuts, seeds, and olive oil. Olive oil is considered the primary fat source, and dairy products and eggs are recommended to be consumed in low amounts. The goal is to replace unhealthy fats with healthy ones; for example, olive oil and fatty fish (high in omega-3). Wine is recommended to be consumed in moderation. Some examples of fatty fish are mackerel, herring, sardines, albacore tuna, and salmon. These fish are high in omega-3 fatty acids, which are known to help fight inflammation in the body.
In general, some types of foods have cardioprotective effects, which means they have the capacity to protect against cardiovascular disease. When discussing the cardioprotective effects of food, the goal is improved cardiovascular health and reduced cardiovascular morbidity (having disease) and mortality (death). Some other factors of improved cardiovascular health include reduced blood pressure, reduced inflammation, improvement in exercise capacity, and improvement in lipid levels in the blood.
Mediterranean Diet and Migraine: Evidence and Mechanisms
Extensive research efforts have revealed that the MedDiet exerts beneficial effects on numerous disorders, such as obesity, diabetes, cancer, neurological disorders, and cardiovascular diseases. Several investigations have established a correlation between the MedDiet and the clinical aspects of migraine.
In a cross‐sectional study on 262 migraine patients aged 20-50 years old, a validated 168-item, food frequency questionnaire was used to assess the dietary intakes of participants. The Mediterranean diet score was calculated for each subject using nine pre-defined dietary components and ranged from 0-9. After controlling for potential confounders, Mediterranean diet tended to be associated with lower headache frequency (β = -1.74, 95% CI: -3.53, 0.03) and duration (β = -0.28, 95% CI: -0.59, -0.02) and was significantly associated with lower MHIS (β = -29.32, 95% CI: -51.22, -7.42), and HIT-6 score (β = -2.86, 95% CI: -5.40, -0.32) for those in the highest category of Mediterranean diet scores compared to the lowest category. Enhanced compliance with the MedDiet was related to lower headache duration, frequency, migraine headache index score, and Headache Impact Test‐6 (Arab et al. 2023). Consistently, another study found that patients suffering from episodic migraines with low adherence to the MedDiet had more frequent and more severe migraine attacks. Moreover, a remarkable negative relationship was found between following the MedDiet and attack severity (Bakırhan et al. 2022). Marchetti et al. investigated the effects of modified MedDiet (MMD) with a 1.5:1 ω‐6/ω‐3 ratio to a 4:1 ω‐6/ω‐3 ratio on morning headaches.
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A study conducted in 2021 researched the association between diet quality, Mediterranean dietary patterns, and migraine characteristics. The subjects of the study were individuals between the ages of 18-64 and were being seen at a headache outpatient clinic. The study found that individuals who adhered less to the Mediterranean diet, had more severe disability and more severe and frequent migraine attacks.
Eating a Mediterranean diet containing lots of oily fish could help to reduce the frequency of migraines in people who suffer from them, data suggests. Roughly 10 million adults in the UK suffer from migraines, with women three times more likely to be affected than men. Although several new treatments have become available in recent years, many people continue to experience pain.
Both Omega-3 fatty acids, found in oily fish and certain nuts and seeds, and Omega-6 fatty acids, found in refined vegetable oils, are precursors to pain-regulating molecules called oxylipins, with those derived from the former having pain-reducing effects, and the latter having pain-amplifying effects. Dr Christopher Ramsden at the National Institute on Aging in Baltimore, US, and colleagues decided to test whether altering the relative ratio of these fats in people’s diets had any impact on the frequency or severity of their migraines. They recruited 182 patients who suffered from migraine headaches between five and 20 days a month, and randomly assigned them to eat one of three diets for 16 weeks: one that raised Omega-3 but kept Omega-6 fatty acids the same; another which raised Omega-3 and lowered Omega-6; and a control diet that included typical levels of both fatty acids. The diets were designed to be as similar to one another as possible, with the main difference being the type of oil or butter, and the main protein source (eg. oily fish v low-fat fish or poultry), that the participants were provided with. The research, published in the British Medical Journal, found that both of the interventional diets increased levels of a pain-reducing oxylipin, compared with the control diet.
Incorporating the Mediterranean Diet into Your Migraine Management Plan
People with migraine are always looking for ways to prevent attacks, including using nondrug approaches like dietary changes. Diets rich in several nutrients can help reduce the frequency and severity of your attacks. "There are many more ways that diet can be therapeutic as opposed to triggering for migraine," says Robert Bonakdar, MD, a certified headache specialist and integrative medicine expert with the Scripps Center for Integrative Medicine in San Diego. "This concept in general can be helpful in ‘de-villainizing’ nutrition and diet.
It’s important for doctors to understand your lifestyle and what you eat. This helps them find a plan that works best for you. One of the best things a patient can do for their doctor is to identify foods you believe are triggers. Bring these suspicions to your doctor so you can work together to figure out you options and alternatives. When working in migraine and headache medicine, patients often explain what they consider possible triggers or influences over how their migraine occurs.
Here are some practical tips for incorporating the Mediterranean Diet into your life:
- Prioritize Plant-Based Foods: Emphasize fruits, vegetables, legumes, nuts, and whole grains in your daily meals.
- Use Olive Oil as Your Primary Fat Source: Replace unhealthy fats with olive oil in cooking and dressings.
- Include Fish Regularly: Aim to consume oily fish like salmon, mackerel, and sardines at least twice a week.
- Limit Red Meat and Sweets: Reduce your intake of red meat and sugary treats.
- Stay Hydrated: Drink plenty of water throughout the day.
- Eat Regularly: Avoid skipping meals and maintain consistent eating times.
Beyond the Mediterranean Diet: Other Important Considerations
While the Mediterranean Diet shows promise for migraine prevention, it's essential to remember that it's just one piece of the puzzle. Here are some other factors to consider:
- Identify Your Triggers: Certain foods, stress, and environmental factors can trigger migraines. Keeping a headache diary can help you identify your personal triggers.
- Maintain a Healthy Lifestyle: Regular exercise, adequate sleep, and stress management techniques can all contribute to migraine relief.
- Consult with a Healthcare Professional: A doctor or registered dietitian can help you develop a personalized migraine management plan that includes dietary recommendations and other strategies.
"We know that simple but profound steps such as meal consistency and hydration are steps that are often overlooked but can by themselves have a profound ability to reduce migraine frequency and intensity," says Dr. "I have seen improvement just with increasing fiber or omega-3 intake, as we know that most Americans have a suboptimal intake, and higher intake has been shown to reduce migraine burden," says Bonakdar.
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