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“Migraine on a plate”The effects of food and drink
Dr Nicholas Silver
The Walton Centre, Liverpool
2017
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Clinical Treatment Trials
• Amgen
• Novartis
• Eli Lilly
• Teva
• Electrocore
• Allergan
• ATI
Personal Fees from
• Novartis
• Teva
• Allergan
• Electrocore
• Medicolegal work
Scientific Advisor
• Electrocore
• Allergan
Disclosures
ACCME: I have no spousal/partner
conflicts, nor relationships with companies
that market, distribute or resell health care
goods or services consumed by, or used
on patients unless otherwise explicitly
stated.
I’m very brave generally, he went on in a low voice, only today I happen to have a headache
Tweedle DumLewis Carroll, Through the looking glass 1872
Third National Morbidity Survey (1989)Dr Anthony Hopkins
10% of the population consults their GP each year for neurological symptoms
Migraine is by far the commonest cause
World Health OrganisationGlobal Burden of Disease Studies
Migraine “above the radar”
• One of 3 most prevalent worldwide conditions
• 324 million people affected worldwide
• Third greatest cause of disability worldwide (WHO)
• One of the four most disabling conditions
• (equal to quadriplegia, psychosis and dementia)
• Affects adults at prime of working and child-rearing lives
• One of commonest (& most unrecognised) causes of school absence
Important concepts about migraine
1. A significant, reversible and relatively invisible cause of disability
1. Much more than “just a headache”
1. Amplifies normal bodily sensations into symptoms
1. May present with many symptoms yet little or no headache
2. Easily misdiagnosed
1. Migraine may commonly be kept going by inappropriate treatment, especially overuse of painkillers and caffeine
“A primary headache disorder characterised by central sensitisation and various combinations of neurological,
systemic and autonomic features.”
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• A systemic and multisymptomatic disorder that requires a holistic
approach to management
• A significant, reversible and relatively invisible cause of disability
• Genetic predisposition
• More common in women, due to hormonal influences
What is Migraine?
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Episodic migraine (EM):
• 90% of cases worldwide1
• < 14 headache days / month2
1National Migraine Centre. What is migraine? http://www.nationalmigrainecentre.org.uk/migraine-
and-headaches/migraine-and-headache-factsheets/what-is-migraine/. Accessed April 2017; 2Katsarava et al. Curr Pain Headache 2012: 16(1): 86–92
Only 1 in 5 patients have aura1
Patients with chronic migraine are more disabled and
demonstrate higher individual and societal burden2
Migraine is more than ‘just a headache’
Chronic migraine (CM):
• 10% of cases worldwide1
• >15 headache days / month2
Types of Migraine
Amplification
Head pain
Widespread bodily pain
- tenderness / allodynia
Stimulus Sensitivity to:
Movement
Noise (photophobia)
Light (phonophobia)
Smell (osmophobia)
Vestibular (dizziness)
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Autonomic
– Nausea + vomiting
– Postural hypotension / POTS
– Diarrhoea, increased urine
– Pallor
– Eye –red, runny, drooped
– Blocked, runny nose
– Ear fullness
– Tinnitus
– Bruising, swelling
Brain Dysfunction1
– Aura
– Mood change
– Confusion / memory
– Fatigue
– Restless legs
What Happens in Migraine?“More than just a headache”
1 Holland And Afridi, ACNR 2014:V13(7);19-21
Alcohol
Relief of stress /
weekend
Caffeine
Triggers – additive effect
headache
lifesty
le
Preventative
Hormone
fluctuation
The 4 stages of a migraine attack
Prodrome Aura Headache Postdrome
(<85%) (20%)
Hours Minutes Hours Usually 1-2 days
to days to hours* to days
Acute Migraine – Prodrome
Mental State
Fatigue
Irritability
Aggression
Depressed mood
Euphoria
Hyperactivity
Restlessness
Depersonalisation
Derealisation
Cerebral
Yawning
Phonophobia
Photophobia
Osmophobia
General
Lightheaded
Hunger (CHO)
Thirst
Dizziness
Neck pain /
stiffness
Anorexia
Frequent
micturition
Diarrhoea
RLS
Treating your migraine attack
Fluids
Food
Antisickness drugs
Painkillers
Triptans
Kitchen smells and headache
• Is Migraine headache triggered by noise, light or smells?
or
• Does this reflect increased sensitivity as amplification phenomenon, ie attack already started?
• Garlic
• Onions
• Fried cooking
• Air freshener
Characteristic gradual evolution from acute to chronic state:
1. Increasing frequency and duration1
2. Gaps “fill in” with milder migrainous headaches
1. Acute attack drugs become less effective
2. Pervasive non-headache features
Frequent headaches with migrainous features
+
< 15 days per month headache-free (CCHAF days)
Chronic Migraine
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1 http://www.headaches.org/2007/10/25/transformed-migraine-more-commonly-known-as-chronic-migraine/
Chronic Migraine: “More Than Just a Headache”
Coathangerneck pain
Mood change& irritability
Fatigue
Visual Vertigo“Migraine-associated
Dissociation” (MAD)AndVertigo
Blackouts(migraine syncope)
Frequent
(+/-severe)
Headache
Tingling and Twitching
Weakness
Restless Legs (<60%)Periodic limb movements
Autonomic symptoms(face, bowel (IBS), BP)
Fibromyalgia
Cognitive (fog, stutter, poor STM, word finding)
Panic symptoms
Distortion of reality / perception
AIWSAura
What was said in the 1920’s
“Tea and Coffee Headaches. – In the nervous, and often the
gouty and rheumatic person, the use of tea and coffee will causeviolent headaches. These luxuries of life should be discontinuedfor at least one month. An extra strong cup of black coffee, to besure, will stop the headache for the time being, but only adds fuelto the fire in the long run. We would strongly advise anyone thathas constant or periodical headaches, if he uses either tea orcoffee, and especially coffee, to leave them off entirely for threemonths. It may be the sole cause, and if caused by tea and coffee,there is no possibility of their cure by medicines while youcontinue their use”
Early 20th Century, Virtue’s Household Physician
Caffeine Overuse
“The interaction between
a therapeutic agent
and a susceptible patient”
Caffeine content in drinks12 oz drink mg
Red Bull (8oz) 80
Lucozade 46
Diet coke 46
Dr Pepper 41
Pepsi 38
Diet pepsi 36
Coca cola 34
8 oz drink mg
Coffee 70-135
Tea 40-60
Cocoa 14
Decaf coffee 2-3
Horlicks, Options decaff hot chocolate, sprite etc are caffeine free
Alcohol and Headache
• Which headache type?
• “Hangover”
• Migraine
• Cluster Headache
• Which alcohol type?
• How much do you spend?
• Champagne or Prosecco?
• Mechanism
• ? common pathogenetic mechanism at cortical, or more likely at subcortical/brainstem level
Alcohol or something else?
Probably the alcohol
Probably not the contaminants
• Histamine
• Sulphites
• Tyramine
• Phenols
• Tannins
But foods containing above in greater amounts do not
Food and Headache
Monosodium Glutamate
Tyramine
Food containing nitrites / nitrates
Citrus fruits
MSG
Chinese food
Pringles
Noodles
Flavoured chips
Tyramine
Cheeses
• Cheddar
• Stilton
• Camembert
• Swiss blue
• Gorgonzola
Alcohols
• Vermouth
• Tap beer
Preserved and other foods
• Salami
• Mortadella
• Smoked or pickled fish (lox, caviar)
• Pickled herring
• Caviar
• Sauces (e.g.bouillon, beef broth),
• Soy products,
Nitrites / Nitrates
Cured meats
Onions, pickles,
(Chocolate)
Some medications:
GTN spray (angina)
Isosorbide mononitrate (angina)
Migraine trigger – cause or effect?
Conclusions
• Migraine is common and disabling
• There are a lot of myths about migraine
• Food is a rare trigger for migraine
• Caffeine and alcohol may play a role in migraine
• Migraine may cause a craving for an innocent and falsely accused trigger
• It is hard to trigger a condition that is already switched on