Individuals with migraine who see a new physician almost always want to talk about their triggers, as Michael Marmura, MD, associate professor of neurology at Thomas Jefferson University and Jefferson Health in Philadelphia, knows all too well. While much is still unknown and debated about triggers, most people tend to list around five triggers, he said.
Knowing the common triggers can be helpful. According to Dr. Marmura and another expert, Deena Kuruvilla, MD, FAHS, medical director of the Westport Headache Institute in Westport, CT, these include:
- stress and ‘’letdown” after stress
- menstrual cycle changes, including the premenstrual period
- weather changes, such as low barometric pressure
- sleep disturbances
- alcohol and certain foods
There are also triggers that are not as obvious, and some symptoms that are mistaken for triggers can actually be premonitory symptoms (more on this below), Dr. Marmura explained. For instance, neck pain, fatigue, and sensitivity to light, sound, or odor may mimic triggers but actually may signal the start of the attack. “Light sensitivity is a common premonitory symptom of migraine,” Dr. Marmura said. However, “light or stimuli like strobe lights or 3D movies can trigger migraine in susceptible people.”
As part of his conversations with patients about triggers, Dr. Marmura always discusses the unpredictability of triggers, that is, the most common ones that occur in episodic migraine, and the need for strategies to help patients cope (see also his literature recent review1 ).
Both Dr. Marmura and Dr. Kuruvilla take a practical approach to helping patients understand, monitor and manage triggers. Some of their suggestions:
- Focus on triggers that can be modified or eliminated. “If there’s an obvious trigger, for example, every time you smell a specific fragrance, you have a migraine, stay away from just that,” Dr. Kuruvilla said. Also important to realize, she said: Avoiding triggers does not guarantee you won’t have a migraine.
- Build up their threshold. In other words, Dr. Marmura tells patients: “Focus on your overall health instead of worrying about whether onions are causing your migraine.” That threshold building means handling stress, getting enough sleep, eating a healthful diet – all the usual healthy lifestyle habits.
- Find ways to cope with everyday situations. For instance, light is often a trigger, as patients who work in offices with harsh overhead lights know. When a special workstation is not possible, ask to use a green light lamp.
- Educate others about migraine. Stigma about migraine can be stressful. Coworkers, friends, and family who have never had a migraine often have no concept of the pain level. Explain that taking medicine does not always work and that the pain can continue for hours or days.
- Try journaling. Journaling can help provide clues about triggers and stresses. Patients can write symptoms and what was happening on that date, including what they ate. Sometimes, people discover previously unrecognized triggers, such as caffeine withdrawal on weekends.
Clinicians should also be aware of cephalgia phobia – the fear of having attacks between attacks, Dr. Marmura said. Focusing on that too much, he reported in his review, has been linked with chronification and medication overuse headache.2
Therefore, it’s important to encourage patients to do the things they want to do, even if those events involve triggers. For instance, someone may wish to attend a baseball game but fear that the crowds, distance traveled to get there, food smells, and other potential triggers might be overwhelming. For that patient, suggest starting out with a trip to a nephew’s game, traveling a shorter distance, and gracefully exiting if a migraine attack occurs. For someone hesitant to go to a party that might get loud and stressful, Dr. Marmura suggests accepting the invitation and reminding the host you cannot stay the entire time.
Many times, migraine triggers remain unknown, such as a reaction to an uncommon or unexpected exposure. Trying to pinpoint a single, specific trigger and differentiating it from a premonitory symptom, can be difficult.3 According to Dr. Marmura, a premonitory symptoms can occur 2 to 48 hours before an attack. For instance, many people may blame the chocolate they ate as a trigger, but eating the chocolate might have simply quelled a food craving, and then an unrelated attack followed. He cited studies failing to show chocolate as a migraine trigger.4
And of course, it’s important to never blame the patient. “I think a big mistake is blaming patients and saying, ‘You are getting migraines because you don’t avoid your triggers,’’’ Dr. Marmura said.
- Marmura MJ. Triggers, protectors, and predictors in episodic migraine. Curr Pain Headache Rep. 2018;22(12):81. Published 2018 Oct 5. doi:10.1007/s11916-018-0734-0
- Giannini G, Zanigni S, Grimaldi D, et al. Cephalalgiaphobia as a feature of high-frequency migraine: a pilot study. J Headache Pain. 2013;14(1):49. Published 2013 Jun 10. doi:10.1186/1129-2377-14-49
- Turner DP, Lebowitz AD, Chtay I. Houle TT. Headache triggers as surprise. Headache. 2019 Apr;59(4)495-508. doi:10.1111/head.13507
- Marcus DA, Scharff L, Turk D, Gourley LM. A double-blind provocative study of chocolate as a trigger of headache. Cephalalgia. 1997;17(8):855-800.