Headaches, particularly migraines, are a widespread and debilitating condition affecting a significant portion of the global population, including children and adolescents. Migraines not only impact the quality of life but also contribute to disability and reduced productivity. Current prophylactic therapies often fall short due to lack of specificity, tolerability issues, and limited efficacy. Consequently, there's growing interest in exploring alternative and complementary approaches, including dietary interventions.
The Migraine Landscape: Prevalence, Classification, and Pathophysiology
Headache is one of the most common disorders in the general population, frequently diagnosed in childhood. The prevalence ranges from 54.4% to 58.4% in children and adolescents. Globally, it ranks as the third biggest cause of disability. In 2019, it ranked 14th overall for global causes of disability-adjusted life years, rising to 10th place for females and ranked 2nd and 5th among individuals aged 10-24 and 25-49, respectively.
According to the International Classification of Headache Disorders 3rd edition (ICHD-3), headache is classified into primary headache, with no underlying organic causes, and secondary headache. Primary headache onset often occurs in childhood or adolescence and its prevalence grows with age, heavily impacting a child's quality of life, in particular on school performance, sports, and social activities. Tension-type headache (prevalence of 20-25%) is the most common cause of primary headache, followed by migraine. Migraine prevalence is ~15% in the general population, with a peak between 35 and 39 years. Moreover, migraine affects 7.7-9.1% of children, and girls are the most impacted.
The three main categories of migraine, according to the ICHD-3, are migraine without aura, migraine with aura, and chronic migraine. Aura consists of reversible focal neurologic symptoms (visual scintillations, scotoma, and, less often, spreading hemisensory symptoms or speech dysfunction) that develop gradually over a period of 5-60 min (or less) followed by a subsequent headache, typically unilateral, pulsatile, and aggravated by physical activity.
Migraine is recognized as a neurovascular disease with a likely genetic basis and a tendency to run in families. The most widely accepted etiopathogenetic theory is Moskowitz's trigeminovascular hypothesis. According to this theory, patients are predisposed to migraine attacks due to an over-sensitization of the trigeminal and trigemino-cervical neurons, which is associated with a lowered threshold of activation of nociceptive terminals by vasoactive peptides, the most important of which is CGRP (12). In addition, there is strong evidence to suggest that migraine is a brain energy deficit syndrome: several magnetic resonance spectroscopy studies have highlighted that the brains of migraine sufferers experience an energy deficit during attacks, likely in response to hypometabolism and increased oxidative stress in the brain.
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The Role of Nutrition in Migraine Management
Nutrition is a widely discussed environmental factor that may affect the course of migraine. While there is a debate over how certain foods can act as favorable or protective factors in relation to migraine attacks and the pro-inflammatory state, it is accepted that migraine is sensitive to diet, including food amount and meal timing, and that some dietary ingredients can trigger migraine attacks. A long list of foods involved in the mechanism of migraine has been identified, such as chocolate, citrus fruits, nuts, ice cream, tomatoes, onions, dairy products, alcoholic beverages, coffee, caffeine, monosodium glutamate, histamine, tyramine, phenylethylamine, nitrites, aspartame, sucralose, and gluten. Some foods or ingredients can trigger headaches only in subgroups of patients (e.g., celiac groups), while others can cause migraines in case of abstinence (such as caffeine). Even when these elements are correctly identified, the use of diets with certain food restrictions remains controversial. Low-fat or weight-loss dietary interventions for migraine have so far been inconclusive. The mechanisms through which nutrition could impact migraine could be related to decreasing inflammation, such as with high omega-3/low omega-6 diets, which can bring beneficial effects.
Ketogenic Diets: A Potential Therapeutic Avenue for Migraine
In recent years, the use of high-fat low-carbohydrate diets has gained popularity as a possible treatment for migraine. The International Ketogenic Diet Study Group cites migraine as one of the neurological diseases that can potentially benefit from ketogenic dietary treatment (KDT). Interestingly, the first report of using KDT for migraine appeared in 1928, only a few years after the diet's first use for epilepsy. This study obtained poor results (some relief in nine of the 23 adult patients), but the author reported being encouraged enough to continue with the high-fat method. In the last few years, several studies described in a review by Caminha et al. have investigated the potentially protective effects of ketosis-inducing diets in migraine.
Ketogenic diet therapies may affect migraine in several ways: (i) by replacing brain fuel from glucose to ketone bodies (KBs); (ii) through the positive influence of systemic ketosis on pathways of migraine pathophysiology; (iii) as signaling molecules, KBs could increase mitochondrial functioning, reduce oxidative stress, alter cerebral excitability, change cortical spreading depression, reduce systemic inflammation, and change the gut microbiome. Based on the protective effects of ketone bodies, an interesting question that has yet to be answered is whether the levels of ketosis, measured by circulating levels of beta-hydroxybutyrate (BHB), are related to the efficacy of migraine attack prevention.
To achieve high systemic ketosis, it is necessary to follow a diet that is high in fat, moderate in protein, and very low in carbohydrates, such as the classical ketogenic diet with 3:1 or 4:1 ketogenic ratios. However, there are physiological differences between children and adults, and even when treated with diets at the same ketogenic ratio, adults have much lower blood ketone levels than children. Furthermore, the classic ketogenic diet is more burdensome for patients, requiring a strict dietary plan and weighing of foods to the gram. Alternative dietary approaches, such as the medium-chain triglycerides diet, modified Atkins diet, and low glycemic index therapy, have been developed to allow for greater flexibility for patients in epilepsy treatment.
Examining the Evidence: A Systematic Review and Meta-Analysis
A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was performed in electronic databases, including PubMed/Medline, Scopus, Web of Science, LILACS, Science Direct, and the Cochrane Library. To investigate the effect of ketosis on migraine, both clinical trials and observational studies were included regardless of whether they were controlled or randomized.
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An electronic search was conducted using subject index terms such as “migraine,” “migraine disorders,” “headache,” “headache disorders,” “cephalalgia,” and “cephalalgia” in combination with keywords such as “ketones,” “3-hydroxybutyric acid,” “ketone bodies,” “acetoacetates,” “ketosis,” “ketoacidos,” “metabolic keto,” “acetonemi,” “ketonemi,” “ketoacidemi,” “ketonuri,” “ketoaciduri,“ or “acetonuri”. In addition, gray literature was searched using Google Scholar. Some newer references from more up-to-date studies or references found in previous review articles were included manually. The populations of interest were adults, adolescents, and children, and the comparison group was any control diet or placebo group.
The research and study selection were carried out independently by two authors using Rayyan software in two steps: (1) reading the titles and abstracts, and (2) evaluating the complete articles selected in the previous stage and including other studies present in the references of the selected articles. The decision to include the articles was based on the PICOS strategy [Population (P), children and adults; Intervention (I), ketosis/ketone bodies; Control (C), placebo; Outcome (O), relief in migraine symptoms; Study type (S), clinical trials]. In cases of disagreement, a third author reviewed the full-text articles to decide. The articles found in the electronic databases were organized using the Mendeley reference manager. Google Scholar was used to search for gray literature.
The risk of bias was assessed using the RoB 2.0 Cochrane tool, which checked five domains: randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. After selecting articles, the quality of evidence was checked using the Mixed Methods Appraisal Tool system (MMAT system). Data tables were constructed based on article details, and data for generating the meta-analysis were exported to Review Manager (RevMan) 5.4 software.
Findings from the Literature: Types of Ketogenic Therapies and Study Characteristics
A total of 2,582 articles were identified from all databases. After a systematic selection of articles that excluded duplicates (carried out by two authors), only 10 articles remained (eight conducted in Italy, one in Switzerland, and one in Australia). All studies were conducted on adults affected by migraine, except for one that concerned the treatment of cluster headaches. Half of the selected articles used an interventional open-label trial design, and only one article used retrospective observational data.
The ketogenic therapies tested in migraine treatments included the very low-calorie ketogenic diet (VLCKD, n = 4), modified Atkins diet (MAD, n = 3), classic ketogenic diet (cKDT, n = 2), and the administration of an exogenous source of beta-hydroxybutyrate (BHB).
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Most articles (four out of 10) used a Very Low-Calorie Ketogenic Diet (VLCKD). Patients were instructed to avoid rice, grains, cereals and derivatives (bread, pasta, crackers, cookies, etc.), legumes, starchy vegetables (potatoes, corn, and green peas), fruits, and dairy products other than cheese, cream, or butter. The diet plans of the studies included Italian dietary products developed by industries. Owing to dietary restrictions, nutraceutical integrators were prescribed. Salads were allowed ad libitum, dressed with a spoonful of olive oil.
The Carnivore Diet: An Extreme Approach
The carnivore diet, also known as the "zero carb" diet, is a restrictive eating plan that advises the consumption of only animal products and a few other items. The carnivore diet is very restrictive. Avid fans of the carnivore diet say it has a range of benefits. “Unfortunately, there are no controlled studies to confirm the safety of the diet,” Lisa said. Another area of concern is the lack of dietary fiber in the carnivore diet. “The higher the consumption of fiber, the lower the risk of colon cancer,” Lisa said. If you are trying the carnivore diet, you may also experience vitamin and mineral deficiencies due to the restrictive nature of what you are eating. Consuming a large amount of animal protein can lead to unwanted stress on the kidneys, especially if you already experience kidney issues. With all the various diet trends promoted today, it can be difficult to know what is the safest or healthiest. “The best diet is the one you can sustain the longest. A gradual lifestyle change approach is more manageable than tackling a trendy diet that is drastically different than your usual diet.
Ketogenic Diet vs. Carnivore Diet
A ketogenic diet is defined by its ability to induce nutritional ketosis, typically through a macronutrient ratio of: 70-80% fat, 10-20% protein, 5-10% carbohydrates (usually 20-50 grams of net carbs* per day). In contrast, a carnivore diet is an extreme form of keto that includes: 60-90% fat, 10-40% protein, 0% carbohydrates (no fiber, no plant foods, no polyphenols). The diet is primarily meat, organ meats, animal fats, eggs, and sometimes dairy. While both diets can promote nutritional ketosis, carnivore excludes all plant-based foods, which are essential in a therapeutic keto approach. Eliminating these foods, as the carnivore diet does, risks undermining the very systems that need the most support in post-viral recovery.
One of the most concerning effects of the carnivore diet is the complete elimination of fermentable fiber. Butyrate isn’t just a byproduct of fiber fermentation-it’s a critical postbiotic that helps maintain gut barrier integrity, reduce neuroinflammation, and regulate immune tolerance. Butyrate helps modulate the immune system by reducing excessive inflammation and promoting tolerance, supports the integrity of the gut lining by nourishing intestinal cells, and acts as a fuel source for colonocytes. A 2023 paper found that individuals with ME/CFS had a significantly diminished capacity for microbial butyrate synthesis, as well as altered bacterial network structure and correlations between low butyrate-producing capacity and fatigue severity (Guo et al, 2023). Butyrate deficiency also impairs deep sleep and contributes to unrefreshing rest. Butyrate is not just a gut metabolite; it crosses into circulation and interacts with sleep-regulating centers in the brain. Fermentation isn’t just a digestive nuisance, it’s essential to host-microbe symbiosis.
Loss of microbial diversity is a consistent finding in both ME/CFS and long COVID. Low levels of healthy gut bacteria such a F. Rebuilding a healthy and resilient microbiome is a foundational goal. Polyphenols, for example, act as selective prebiotics. They feed beneficial microbes while actively suppressing pathogenic strains. These compounds, combined with resistant starch and low-FODMAP vegetables, help restore microbial diversity. A carnivore diet, by excluding all plant foods, removes the very tools needed to restore gut health.
While some proponents argue that meat provides all essential nutrients, research suggests this isn’t the case for most real-world carnivore diets. Vitamin K - important for coagulation balance and is synthesized by gut microbes. A 2020 review noted that a long-term carnivore diet may require supplementation to meet micronutrient needs-something many followers don’t realize (O’Hearn, 2020). On average, about 20% of daily water intake comes from food, primarily fruits and vegetables. Carnivore diets also tend to promote fluid and sodium loss, especially in the first few weeks, due to glycogen depletion (which releases stored water). For individuals with autonomic dysfunction, this can worsen symptoms.
Potential Benefits and Considerations
Despite all of this, some people report dramatic symptom relief on a carnivore diet. What’s going on here? A positive response provides a useful clinical clue: it reflects underlying gut dysfunction, not a biological need for meat-only eating. These individuals often have multiple food intolerances, digestive sluggishness, or microbial imbalance that make plant foods harder to tolerate in the short term. These effects offer a gut rest, not a fix. They temporarily reduce symptom burden by limiting exposure to compounds that irritate an already sensitive digestive system. A low-FODMAP ketogenic approach or carefully structured elimination diet could achieve similar benefits without sacrificing long-term gut and metabolic health.
Another reason some people report symptom relief on a carnivore diet may involve lectins-a class of carbohydrate-binding proteins found in many plant foods, especially legumes, grains, and nightshades. Lectins (found in beans, legumes and other foods) can irritate the stomach lining in some people. No high-quality studies, though, have connected them with chronic illnesses. In those with increased intestinal permeability, a feature observed in both ME/CFS and long COVID (Su et al, 2022; Giloteaux et al, 2016), lectins may have a greater opportunity to interact with the immune system. Despite popular claims, there are currently no high-quality human clinical trials linking lectin consumption to chronic disease symptoms in the general population. In fact, many lectin-rich foods, when cooked, are associated with positive health outcomes, including improved metabolic and cardiovascular markers (Becerra-Tomás et al, 2022). In these individuals, removing high-lectin foods may temporarily reduce symptom burden. But much like with FODMAPs, the goal isn’t lifelong avoidance. With time and targeted support for the gut barrier, many people can reintroduce cooked lectin-containing foods without issue.
A short carnivore stint may serve as a functional elimination diet for some. Carnivore might offer temporary reprieve, but it’s not a sustainable or safe solution for most with post-viral syndromes. The long-term health impacts of such a restrictive, plant-free diet have not been thoroughly studied in ancestral populations or clinical settings. A short-term carnivore diet may serve as a brief elimination phase for identifying intolerances, but it must be followed by a structured reintroduction of plant-based foods to support long-term gut and immune health.
A Recent Study: Ketogenic Diet Protocols and Migraine
A recent study published in the journal Nutrients explored the link between three ketogenic diets (KD) and migraine symptoms. Preliminary results suggested that all the three diets are associated with reductions in the frequency and intensity of migraines.
The diets also reduced the frequency of migraine days per month from 18 to 8 days and the intensity of attacks from 8.1 to 5.3. MIDAS scores also declined from 76 to 37, while the HIT-6 score decreased from 65 to 54. Fat mass and BMI decreased while free-fat mass was preserved. In this pilot study, researchers found promising evidence that KD therapies can effectively prevent migraine frequency and intensity while also reducing fatigue and improving quality of life. However, the team noted that further studies with larger sample sizes are required to validate these findings. They also acknowledged that the study was not a double-blinded study; they could, therefore, not exclude the possibility that their results were due to the placebo effect.
Alternative Dietary Approaches and Considerations
In today’s fast-paced world, where dietary trends abound, it’s essential to understand the relationship between what we eat and our health. The Ketogenic diet, known for its high-fat, low-carb approach, has gained popularity for weight loss and potential health benefits. Some proponents believe it might help reduce migraines, although the evidence is still inconclusive. The key principle of the Ketogenic diet is to induce a state of ketosis, where the body primarily uses fats for energy instead of carbohydrates. The Mediterranean diet, rich in fruits, vegetables, whole grains, and healthy fats, has been associated with various health benefits. It’s known for its potential to reduce inflammation and improve heart health. Veganism, which excludes all animal products, has gained traction for ethical, environmental, and health reasons. Some migraine sufferers have reported reduced symptoms after adopting a vegan lifestyle, likely due to the anti-inflammatory nature of plant-based diets. A gluten-free diet is crucial for individuals with celiac disease or gluten sensitivity. Some migraine sufferers have also opted for this diet, speculating that gluten might trigger their attacks. Intermittent fasting involves cycling between periods of eating and fasting. Although not primarily designed for migraine relief, some people have reported fewer headaches while practicing intermittent fasting. The raw food diet focuses on consuming uncooked, whole, and unprocessed foods, typically plant-based. While this diet is associated with increased nutrient intake and reduced inflammation, its effects on migraines are not well-studied. The Paleolithic (Paleo) diet mimics the diet of our hunter-gatherer ancestors, emphasizing whole foods, lean proteins, fruits, and vegetables. Some individuals believe this diet can reduce migraines by eliminating processed foods and potential triggers. A plant-based diet centers around consuming plant-derived foods while limiting or avoiding animal products. Rich in nutrients and antioxidants, this diet can promote overall health. Low-carbohydrate diets, like the Atkins diet and the South Beach Diet, restrict carb intake to induce weight loss and potentially offer other health benefits. Some individuals with migraines have reported fewer attacks on low-carb diets. Weight Watchers, now known as WW, focuses on portion control and balanced eating. While it’s not specifically designed for migraine relief, losing weight through healthier eating habits can lead to reduced migraine frequency for some individuals. Vegetarianism involves abstaining from consuming meat but may still include other animal products like dairy and eggs. A vegetarian diet rich in plant foods can be beneficial for overall health, but its direct impact on migraines may vary among individuals. A low-fat diet aims to limit dietary fat, often focusing on heart health. Some individuals believe that reducing fat intake may help with migraine prevention. The South Beach Diet emphasizes lean proteins, healthy fats, and good carbohydrates. While not specifically designed for migraines, its focus on balanced eating can contribute to a healthier lifestyle. The Dukan Diet, a high-protein, low-carb approach, has gained popularity for its weight loss potential. While it’s not directly aimed at migraines, some individuals have reported fewer headache episodes while following this diet. The Mayo Clinic Diet focuses on making healthy choices and promoting sustainable weight loss. The Whole30 diet involves a 30-day reset, eliminating certain foods that could be potential irritants or triggers. Nutrisystem offers portion-controlled meals and snacks, aiming for weight loss and healthy eating habits. The Carnivore diet consists of eating exclusively animal products. It’s a controversial and restrictive diet, with limited evidence on its health effects, especially concerning migraines. The Cabbage Soup diet is a short-term, low-calorie diet designed for rapid weight loss. The DASH (Dietary Approaches to Stop Hypertension) diet aims to lower blood pressure through a balanced eating plan. The Zone Diet focuses on a balanced intake of carbohydrates, proteins, and fats. While it’s not directly aimed at migraines, a balanced macronutrient distribution can support overall health. The Alkaline diet aims to maintain a slightly alkaline pH in the body, primarily through plant-based foods. The Blood Type diet suggests that individuals should eat specific foods based on their blood type. While not directly targeted at migraines, following this diet may lead to healthier food choices. Certain foods can trigger migraines in susceptible individuals. Identifying and avoiding these trigger foods is crucial for managing migraine frequency.