Painkillers may banish the symptoms of a headache, but they do not treat the cause. Nutritional guidance can play an integral part in headache management, and the results of a change in diet are likely to be lasting and rewarding.
Chronic daily headaches account for around 40% of patients attending headache clinics and can include migraine, chronic tension-type headache, daily persistent headache or post-traumatic headache. Although painkillers will treat the symptoms of a headache, they do not treat the cause. What’s more, dependence on these drugs affects the body’s ability to release endorphins – the body’s natural painkillers.
TYPES OF HEADACHE
In South Africa and globally a tension-type headache is the most common primary headache, and 40% of South Africans may be affected. It is a non-vascular headache and many people have one or two headaches of this type every month. Sometimes they develop more frequently, typically during times of stress. Tension-type headaches usually last only a few hours, but some people may have more persistent headaches that last for several days. They are more frequent in women than in men. Typically the symptoms include a constant ache, which affects both sides of the head with tightening of the neck muscles and a feeling of pressure behind the eyes. Relaxation of the muscles usually brings about immediate relief.
Migraines and vascular-type headaches are similar in that both are caused by the widening of the cerebral (brain) arteries. The difference is that when a migraine sufferer is exposed to a triggering factor, the arteries leading to the brain first narrow (vasoconstriction) then widen (vasodilation), and this disturbs the flow of blood. In an ordinary vascular headache, the arteries do not narrow.
Migraine affects 15 – 20% of men and 25 – 30% of women. It is a severe headache that often has a number of associated symptoms such as nausea, increased sensitivity to light and visual problems. The symptoms of a migraine may last anywhere between four hours and three days. It is thought that migraines may be caused by changes in chemicals in the brain. In particular, the levels of serotonin decrease during a migraine. Serotonin is a key neurotransmitter and a vasoconstrictor. Low levels may lead to a blood vessel spasm, and this may be implicated in the aura associated with migraines. The cause of the drop in serotonin levels is not fully understood.
Cluster headaches were once considered migraine-type because vasodilation is a key component. However, they are now separately classified and are also called histamine cephalgia, Horton’s headache or atypical facial neuralgia. They are much less common than migraine.
CAUSES OF VASCULAR-TYPE HEADACHES
Vascular-type headaches can be hereditary, but stress, bad eating and lifestyle habits, excessive drinking and smoking and lack of exercise are also predisposing risk factors. Other more specific factors are discussed below.
An increased body mass index (BMI) has been found to be associated with an increased likelihood of headache or severe headache among women. A BMI of approximately 20 is associated with the lowest risk. Relative to a BMI of 20, mild obesity (BMI of 30) is associated with roughly a 35% increase in the odds for experiencing headache, whereas severe obesity (BMI of 40) is associated with roughly an 80% increase in odds.1 Results from studies like this remain essentially unchanged when adjusted for socio-economic variables, alcohol consumption and hypertension.
Menstruation has been found to be the most important factor increasing the risk of occurrence and persistence of headache and migraine – by up to 96%.2 Just before women have their period, levels of the hormone oestrogen fall. It is not the low levels of oestrogen that cause the headache, but rather the change from one level to another.
Food allergy and intolerance play a role in many cases, and sometimes detection and removal of the food(s) will eliminate or greatly reduce symptoms. Some of the main foods that have been shown to induce vascular-type headaches include cow’s milk (57 – 65%), wheat (43 – 57%), chocolate (26 – 57%), eggs (22 – 60%) and oranges (< 52%).
More specific food reactions include the following:
- Lectins are specialised proteins found in fruits, vegetables and seafood, and especially in grains, beans and seeds. They are not degraded by stomach acid or proteolytic enzymes, making them resistant to digestion. As a result certain lectins can bind to cells in the gut and blood cells, initiating an inflammatory response and contributing to headaches in susceptible individuals.
- Sulfites (or sulfate agents) are preservatives commonly used in foods and in some medications. Intolerance to sulfites may directly stimulate the nerve cell pathways, inducing a vascular-type headache. Examples of food and drink high in sulfites include wine, vinegars, preserved fruit juices, frozen vegetables and high-fructose corn syrup.
- Tyramines are amino acid products formed naturally from the breakdown of proteins as foods age. Intolerance to tyramine may be a result of vasoconstrictive properties, leading not only to a headache but also to hypertension. Foods high in tyramine include aged cheeses, nuts, beans, yoghurt, bananas, citrus fruits and soy products.
- Histamine is a biogenic amine involved in the immune response as well as regulation of the physiological function of the gut. It also triggers an inflammatory response. A histamine intolerance may develop through both increased availability of histamine and impaired histamine degradation. Foods such as fish, cheese, preserved meat, sauerkraut, spinach, eggplant and alcohol are all high in histamines. Red wine is more problematic than white wine as it has a higher histamine content. Histamine-intolerant women often suffer from headaches that are dependent on their menstrual cycle.
- Monosodium glutamate (MSG) is a flavour enhancer widely used in fast foods. It is also used in meat tenderiser as well as many canned, prepared and packaged foods under the guise of various descriptions including ‘hydrolysed vegetable protein’, ‘yeast extract’ and ‘hydrolysed oat flour’. MSG may trigger headaches through direct vasoconstrictor effect at high doses.
Identifying the causal agent in adverse reactions to food, alcohol and drugs can be a difficult challenge. It is therefore essential to keep a food diary, as removal of foods to which the patient is allergic/intolerant can greatly reduce symptoms. The importance of eating regularly also cannot be overemphasised, as skipping meals can trigger headaches. This is not only to do with hypoglycaemia but also fluctuating levels of stress hormones.
Some supplements may be able to decrease the severity of symptoms and reduce the frequency of headaches, depending on the type of headache.
Magnesium may be beneficial because it counteracts vasospasm and inhibits platelet aggregation, both involved in the pathogenesis of vascular-type headaches. Its concentration also influences serotonin receptors, nitric oxide synthesis and release, inflammatory mediators and various other migraine-related receptors and neurotransmitters.3
Vitamin B2 (riboflavin)
Vitamin B2 is involved in the Krebs cycle, an intrinsic part of energy production. In migraines specifically, trials using vitamin B2 over a period of three months resulted in a 50% reduction in attacks.4 However, side-effects such as diarrhoea and polyuria (passing large volumes of urine) may result.
Co-enzyme Q10 (CoQ10)
CoQ10 is an endogenous enzyme cofactor made by all cells in the body. Supplementation with CoQ10 has been found to be effective in treating migraine within one month. It may work particularly well in the treatment of paediatric migraine.
Eicosapentaenoic acid (EPA)
EPA is one of the body’s natural omega-3 fatty acids. Some small studies have shown that it may be useful in reducing headache severity and frequency, possibly by lowering prostaglandin levels (thereby modulating inflammation) and normalising serotonin activity.
HEADACHES IN PREGNANCY AND LACTATION
Although migraines usually improve during pregnancy, some women find that their headaches worsen or remain the same. An increase in headaches during the first trimester, caused by fluctuating oestrogen levels, is not uncommon. However, acute and preventive migraine medications can have teratogenic effects, which means they may interfere with normal embryonic development. These include some herbal remedies such as feverfew and butterbur. For this reason, nondrug approaches are essential. Food triggers should be identified through the use of food diaries and elimination diets, preferably before pregnancy. Magnesium supplementation is an option for both acute and preventative treatment but must be done under the guidance of a qualified health professional.
Nutritional guidance plays an integral part in headache management. Food diaries are essential in determining the relationship between certain foods and headaches. Although changing one’s diet may require a great deal of motivation, the results are likely to be lasting and rewarding.
- Keith SW, et al. BMI and headache among women: results from 11 epidemiologic datasets. Obesity 2008; 16(2):377-383.
- Wöber C, et al.; PAMINA Study Group. Prospective analysis of factors related to migraine attacks: the PAMINA study. Cephalalgia 2007; 27(4): 304-314.
- Sun-Edelstein C, Mauskop A. Food and supplements in the management of migraine headaches. Clin J Pain 2009; 25(5): 446-452.
- Schoenen J, Jacquy J, Lanaerts M. Effectiveness of highdose riboflavin in migraine prophylaxis. Neurology 1998; 50: 466-470.