Invest Clin 61(1): 19 - 27, 2020 https://doi.org/10.22209/IC.v61n1a02

Investigation of dietary factors in migraineurs.

Hongjin Li, Yingbo Zhang, Qiang Li, Yingying Li, Xiaojun Diao and Chunfu Chen

Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China.

Key words: migraine; tension-type headache; eating habits; food-induced factors.

Abstract. We conducted the current study to investigate migraine-related dietary factors in migraine patients. Seventy patients with migraine and 30 patients with tension-type headache were enrolled in the study, recruited from the headache outpatient department of the Shandong Provincial Hospital from June 2014 to May 2016. The average age of the migraine group was 15 to 60 years with an average of 35.5 ± 13.8 years, including 23 males and 47 females (1: 2.04 male to female ratio). The age of patients with tension-type headache ranged from 18 to 60 years-old with an average of 35.4 ± 14.4 years, includ- ing 13 males and 17 females (1: 1.31 male to female ratio). The headache was graded based on the severity and frequency of the episodes, according to the ICHD-II diagnostic criteria, during symptom intermission. The results were analyzed with the SPSS 21.0 software. Thirty migraine patients (42.9%) and three tension-type headache patients (10.0%) presented diet-induced factors. There was a significant difference (p<0.05). The difference in rates of food- induced factors between migraine patients with aura and migraine patients without aura was statistically significant (p<0.05), and food-induced factors are more common in migraine patients with aura. The most common food- induced factor in males was alcohol while the food-induced factors in female varied more. Both, the headache frequency and severity in migraine patients with food-induced factors, were higher than those in migraine patients without food-induced factors (p<0.05), but the difference in the headache duration was not statistically significant (p>0.05).

Corresponding Author: Chunfu Chen, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China. Tel:+86-053168776354; Email: chenchunfu_1@aliyun.com

Investigación de factores dietéticos en personas con migraña.

Invest Clin 2020; 61 (1): 21-29

Palabras clave: migrañas; migrañas nerviosas; hábitos alimentarios; incentivos alimen- tarios.

Resumen. El estudio se realizó para investigar los factores alimentarios relacionados con la migraña en los pacientes que sufren este trastorno. Se es- cogieron 70 casos de migrañas y 30 casos de cefaleas de tipo tensional, entre junio de 2014 y mayo de 2016, reclutados de la Clínica de Jaqueca del hospital provincial de Shandong. La edad media de los grupos de migrañas osciló entre los 15 y los 60 años, con un promedio de 35,5 ± 13,8 años, de los cuales 23 fueron hombres y 47 mujeres (1: 2,04 ratio). Los casos de cefalea de tipo ten- sional tenían entre 18 y 60 años, con un promedio de 35,4 ± 14,4 años, de los cuales 13 eran hombres y 17 mujeres (1: 1,31 ratio). Los dolores de cabeza se clasificaron en función de la gravedad y la frecuencia con arreglo a los criterios de diagnóstico del ICHD - II para el intervalo sintomático. Los resultados se analizaron con el programa informático SPSS 21.0. Se encontraron factores alimentarios inductores en 30 casos de migraña (42,9%) y en tres casos de ce- falea de tipo tensional (10,0%). La diferencia fue significativa (p<0,05). Hubo una diferencia estadísticamente significativa entre la incidencia de los factores inductores alimentarios entre las personas con migrañas con aura y las perso- nas con migrañas sin aura (p<0,05). Estos factores fueron más comunes entre las personas que presentaban migrañas con aura. El factor alimentario induc- tor más común entre los hombres fue el alcohol, mientras que en las mujeres fue más variable. Tanto la frecuencia de la cefalea como su severidad, fueron mayores en pacientes con migraña con factores alimentarios inductores que en pacientes sin estos factores inductores (p<0,05), pero la diferencia en la duración de la cefalea no fue estadísticamente significativa (p>0,05).

Received: 18-02-2019 Accepted: 06-02-2020

INTRODUCTION

Studies have shown that about 85% of migraineurs have spoken about its precipi- tating factors. Common aggravating factors include mental stress, weather change, anxi- ety and depression, mood swing, insomnia, overwork, stimulation by sound, light and taste, hunger and diet (1), etc. Among these aggravating factors, dietary factors are very common. The major reported diet-induced factors in clinical practice include irregular eating and food-induced factors, that is, if

migraine occurs within a particular period of time (often within 24h and generally no more than 48h) after food intake, all these particular foods are called food-induced fac- tors (2). In previous studies, the rates of all kinds of diet-induced factors had a wide range, from 12% to 60% (3-7), but signifi- cantly higher than in other types of head- ache. For patients with diet-induced factors, if they can effectively identify and prevent such factors, it may help to improve the con- trol of migraine.

Migraine is defined as the recurring headaches usually involving one side of the head, which are often accompanied by nau- sea and visual disturbances, and can be di- vided into two major sub-types, migraine without aura and migraine with aura. The tension-type headache is characterized by a diffuse, mild to moderate pain in your head and is often described as feeling a tight band around your head, and is the most common type of primary headache (4). The char- acters of tension-type headache are blunt ache, tenderness on your scalp, neck and shoulder muscles, blurred vision and tinni- tus. Its pathogenesis is realated to psycho- logical stress, anxiety, depression, mental factors, muscle tension and abuse of anal- gesic drugs (5). However, the relationship between the common primary headache and dietary induced factors has not been report- ed. We mainly investigated the food-induced factors such as drinks, staple food, fruits and vegetables, seasoning in daily diet of local patients. In addition, dietary regularity was also investigated. The irregular eating refers to poor eating habits, such as fasting, over- eating, abuse and withdrawal. Therefore, we conducted an epidemiological investigation to research the effect of diet-induced factors on different types of headache and the two sexes, which will provide a theoretical basis for non-drug prevention of migraine.

STUDY SUBJECTS AND METHODS

Research Subjects

All headache patients in this study were selected from patients who were confirmed, treated and enrolled in the headache outpa- tient department of the Shandong Provin- cial Hospital from June 2014 to May 2016, including 70 migraine patients and 30 ten- sion-type headache patients, with half a year course of this disease. All of the patients in- volved in our study voluntarily agreed and signed an informed consent form, which was approved by the ethics committee.

In the migraine group, the age ranged from 15 to 60 years with an average of 35.5

± 13.8 years, including 23 males and 47 fe- males (1: 2.04 male to female ratio). There were 15 migraine patients with aura and 55 migraine patients without aura. The age of the tension-type headache patients ranged from 18 to 60 years-old with an average of

35.4 ± 14.4 years, including 13 males and

17 females (1: 1.31 male to female ratio).

Inclusion and Exclusion Criteria

Inclusion Criteria

Positively diagnosed based on the di- agnostic criteria about migraine without aura, migraine with aura, chronic migraine and tension-type headache of the Interna- tional Classification of Headache Disorders 2nd Edition, ICHD-II issued by International Headache Society in 2004 (9, 10).

Exclusion Criteria

1. Menstruation-related migraine, co- existence of various types of headaches, sec- ondary headaches and neuralgia.

2. Patients with serious systemic dis- eases or suffering from other chronic dis- eases.

3. Patients with a history of intracra- nial infection, craniocerebral trauma and/or other craniocerebral organic diseases.

4. Drug addicts or drug abusers.

5. Patients taking oral contraceptives, pregnant or lactating women.

6. Patients who declined to participate and patients who still cannot complete rel- evant questionnaires under the guidance.

Data Collection

A questionnaire (8) was used to collect general information and detailed conditions of patients in line with the criteria. The in- formation of patient was provided by the patients themselves and/or their families. All of the patients kept headache diaries and were then followed up at 3 and 6 months. All information was collected and collated in the process of initial or follow-up visits,

and the proportion of patients with irregular eating was collected. The questionnaire was open-ended, and the possible food-induced factors in the questionnaire included drinks, grains, meat, fruits, vegetables, condiments and other products. Irregular eating includ- ed fasting, withdrawal and overeating. All foods should have been taken as main meals between 6 am and 8 pm. All the physical objects are purchased in the regular super- market market. In addition, all food was not special. All information was collected and collated in the process of initial or follow up visits every 2 months.

Headache Grading

Grading was performed on headache severity by combing the patients’ clinical manifestations, characteristics of headache and the score of Visual Analogue Scale (VAS) and referring to 1995 Migraine Diagnostic Efficacy Evaluation Standard Opinions (9).

Statistical Analysis

Statistical analysis was performed in SPSS 21.0 (IBM, White Plains, New York, USA). Parametric data was expressed as mean ± standard deviation (x̄ ± s). The com- parison of enumeration data between the migraine group and tension-type headache group was conducted used chi-square test; the comparison of enumeration data within the migraine group used nonparametric in- dependent sample rank-sum test and that of measurement data adopted two independent sample t-test. Statistical significance was de- fined as p<0.05.

RESULTS

General Data

This study included 70 patients with mi- graine and the ratio of male and female ratio was 23:47, which is in line with the ratio of in- cidence rate of our country’s male and female patients with migraine. The study group in- cluded 15 migraine patients with aura and 55 migraine patients without aura. Among them,

there were two patients with mild headache (2.9%), 25 patients with moderate headache (35.7%) and 43 patients with severe headache (61.4%). Their ages were 35.5 ± 13.8 (15 ~

60) years and their course of disease duration was 10.9 ± 8.2 (2 ~ 35) years. There were

30 tension-type headache patients in total and the ratio of male to female was 13/17; their ages were 35.4 ± 14.3 (18 ~ 60) years and their course of the disease was 11.7 ±

9.9 (0.5 ~ 33) years. The comparative differ- ence of the migraine group and tension-type headache group in gender, age and course of the disease was of no statistical significance (p>0.05). The two groups of patients were comparable.

Irregular Eating

The rates of irregular eating of migraine group and tension-type headache group were 31.4% (22/70) and 10.0% (3/30), respec- tively. The rate of migraine patients with ir- regular eating habits was significantly high- er than that of patients with tension-type headache (p = 0.025).

The rates of irregular eating of male and female in migraine group were 30.4% (7/23) and 31.9% (15/47), respectively, and the difference was not statistically signifi- cant (p = 1.000).

The rates of irregular eating in mi- graine patients with aura and migraine pa- tients without aura were 46.7% (7/15) and 27.3% (15/55), and the difference was not statistically significant (p = 0.210).

The rates of food-induced factors in migraine group and tension-type headache group were 17.1% (12/70) and 0 (0/30) and the difference was statistically significant (p

= 0.016), which indicates that food-induced factors are fairly common in migraine pa- tients but rare in tension-type headache pa- tients.

The rates of food-induced factors in male and female patients of migraine group were 21.7 (5/23) and 14.9% (7/47), respec- tively, and the difference was not statistically significant (p = 0.511).

The rates of food-induced factors in migraine patients with aura and migraine patients without aura were 40.0% (6/15) and 10.9% (6/55), respectively, and the difference was statistically significant (p

= 0.016), which indicates that migraine patients with aura are prone to have food- induced factors.

Reported food-induced factors in mi- graine group include: alcohol (n= 6), co- ffee (n=2), chocolate(n=2), salt (n=1), banana (n=1), fat meat (n=1), soy sauce (n=1), cake (n=1), corn (n=1) (including 1 female patient simultaneously had two ty- pes of food-induced factors: coffee and cho- colate; 1 female patient simultaneously had 4 types of food-induced factors: banana, fat meat, soy sauce and cake). The most com- mon food-induced factor in male patients was alcohol, while the food-induced factors in female patients were diverse, including coffee, chocolate, banana, fat meat, soy sauce, cake and corn. The composition of food-induced factors is shown in Fig. 1 and

Fig. 2.

Relationship between Irregular Eat- ing and Migraine Indexes

Among the 70 migraine patients, 48 had regular eating and the other 22 had ir- regular eating habits. Rank sum test for the attack frequency, duration and pain sever- ity was performed in these two groups of patients, and the test results are shown in Table I. The difference in attack frequency between two groups of patients was statis- tically significant (p<0.001), but the differ- ences in the headache duration (p = 0.334) and in the severity of pain (p = 0.609) were not statistically significant. This indicates that compared with migraine patients with regular eating, migraine patients with irreg- ular eating are more vulnerable to suffer mi- graine attacks, but there was no difference in migraine duration and pain severity be- tween the two groups. However, among the 22 migraine patients with irregular eating in this study, no patient reported that the mi- graine attack had a close temporal relation- ship with irregular eating (including fasting, dieting, long intervals between meals, etc.).

A B

Fig. 1. Food-induced Factors of Migraine Patients and their Incidence Rates.

Fig. 2. Composition Ratio of Different Food-induced Factors. The most common food-induced factor in male patients was alcohol, while the food-induced factors in female patients were diverse, including coffee, chocolate, banana, fat meat, soy sauce, cake and corn.

TABLE I

INFLUENCE OF REGULAR EATING ON MIGRAINE INDEXES (x̄±s)

Headache Indexes Irregular Eating Group (n=22)

Regular Eating Group

(n=48) Z P

Attack Times per Month 15.82 ± 10.81 9.36 ± 11.77 -3.488 <0.001

Duration (h) 17.00 ± 15.52 17.64 ± 18.95 -0.966 0.334

Headache Severity 6.95 ± 2.34 5.55 ± 1.68 -0.512 0.609

Relationship between Food-induced Factors and Migraine Indexes

Migraine patients were divided into two subgroups: one subgroup migraine pa- tients with food-induced factors and another migraine patient without food-induced fac- tors. Rank sum test for the attack frequency, duration and pain severity was performed in these two subgroups of patients, and the results are shown in Table II. The difference in the headache attack frequency between these two subgroups of patients was statisti- cally significant (p = 0.048); the difference in duration was not statistically significant (p = 0.651); the difference in pain sever- ity was statistically significant (p = 0.033). This indicates that migraine patients with food-induced factors are more likely to have migraine attacks than those without food- induced factors, and experience more severe attacks than those without food-induced fac- tors, but these two subgroups have no signif- icant differences in the duration of migraine attacks.

Diet-induced Factors and Headache Severity

Migraine patients were divided into two groups according to migraine diagnosis and efficacy scoring criteria for assessment, patients with diet-induced factors and pa- tients without diet-induced factors by grade in accordance with the headache severity. Rank-sum test were performed for head- ache patients with different severity. There was obvious difference in migraine sever- ity between two groups (p<0.001) and the patients with diet-induced factors are more likely to have severer headache. The results are shown in Table III.

Diet-induced Factors and Migraine Chronification

Among patients in the migraine group, there were 43 paroxysmal migraine patients and 27 chronic migraine patients. The dif- ferences in the rate of eating habits (c2 = 1.769, p = 0.199), food-induced factors (c2

= 0.059, p = 1.000) of these two types of

TABLE II

INFLUENCE OF FOOD-INDUCED FACTORS ON MIGRAINE INDEXES (x̄±s)

TABLE III

HEADACHE SEVERITY OF MIGRAINE PATIENTS WITH AND WITHOUT DIET-INDUCED FACTORS (n)

TABLE IV

RELATIONSHIP OF DIET-INDUCED FACTORS AND THEIR ANOREXIA SYMPTOMS WITH MIGRAINE MODERATION TRANSFORMATION

patients were not statistically significant, which indicates that diet-induced factors may not play a role in migraine moderation. The results are shown in Table IV.

DISCUSSION

Dietary factors in migraine is a complex topic. About 55 years ago, Selby and Lance observed that migraine attacks in a propor- tion of patients were usually precipitated by dietary items (10). Subsequently, studies re- ported the percentage of patients reporting foods as a trigger for migraine ranged from

12 to 60%, with many subjects reporting more than one factor (11-14). Avoidance of

specific foods (e.g., alcohol, cheese, choco- late, sauce, monosodium glutamate, aspar- tame, some fruits and milk) may be helpful, but it is difficult to completely avoid them because they are widely used in restaurants and home cooking. Such factors are not well studied in China. The diet-induced factors of migraine and their characteristics of “can be found, can be controlled, economically and safely” have become an entry point of current studies of environmental factors of migraine as well as the prevention and thera- peutic research of migraine (14). A number of clinical studies have shown that conduct- ing diet control for patients with migraine can significantly help relieve migraine pa-

tients’ condition (4,7,10,12), which makes diet control for migraine patients an impor- tant component in non-drug therapy.

The mechanism by which dietary fac- tors induce migraine attacks is not clear, but it may be related to the following pos- sibilities: (a) some dietary factors, such as alcohol and coffee, directly cause intracere- bral vasodilation. (b) By changing some neu- rotransmitters, such as the contents of cate- cholamines, 5-HT, glutamic acid, etc., in the central nervous system, or by affecting nitric oxide (NO) synthetic system in vivo and then causing dysfunction in vasoconstriction (1).

1. Certain eating habits or diets can cause the imbalance of nutrients, such as lack of Mg2+, riboflavin and coenzyme-Q10, thereby causing metabolic dysfunction, affecting the information processing of neurons and low- ering the threshold of migraine attack (15).

2. Some studies suggest that food intoler- ance is also involved in the diet mechanism of migraine. It can lead to vasodilation and induce migraine by inducing mast cell de- granulation to release histamine or activate complements, etc.; it also can produce a se- ries of inflammatory reactions by activating

other countries, there are several methods to identifying food-induced factors (1,5,18- 20), but none of these methods can effective- ly recognize diet-induced factors of migraine with simplicity, thus reducing the accuracy;

(c) other environmental factors are often in- volved in migraine, which increases the dif- ficulty of identifying dietary factors; (d) the sample size of this study is relatively small, and the quantitative classification adopted for all indexes of migraine lacks much stan- dard references. And the present study can- not exclude the implications that dietary factors avoidance list brings for patients.

Our data show that there is a relevant as- sociation between the onset of the headache and diet in China. The results suggest the need to conduct a much larger study to produce more conclusive findings on the relationship between dietary factors and migraine. Consid- ering the small sample size of this study, it is not enough to further explore the influence of more aspects of food and the relationship be- tween specific food triggers/dietary patterns and migraine occurrence in a broader area.

FUNDING

T

h

and B lymphocytes, and thus triggers mi-

graine (16). (e) Some foods, such as salm- on\bean products, may affect the hormonal status of the patients, especially estrogen homeostasis, which may be associated with menstrual-related headaches (17).

Studies and data from China regard- ing dietary factors in migraine are sparse. The rate of migraine-related dietary factors in this study is lower than those reported in other countries. In addition, in studies conducted in other countries, there are also many patients simultaneously with a vari- ety of diet-induced factors, which may be considered to be related to the following factors: (a) differences in geography, eco- nomic status and education level will have an impact on the dietary structure; (b) the identification of food-induced factors is very complex. At present, in various studies from

Scientific Development Plan Project of Shandong Province (2014GSF118005).

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