What role do triggers play in migraines?
The word "trigger" means something that initiates a migraine. It's like a rifle. When you pull the trigger, the shot goes off. A small event sets off a complex chain of events. The bullet "waits" in the gun, but only when the trigger is activated is the kinetic energy released. The word derives from the earlier notion that something directly causes migraines. But that's not the case. A trigger isn't causal; it merely sets something off, as the word itself suggests. Triggers are effective at certain times and not at others. I might be stressed today, and again next week, but only the week after next will stress trigger a migraine attack. So, it's not primarily the trigger itself that matters, but rather the susceptibility and the circumstances that allow a trigger to act at all. Triggers, in and of themselves, are not decisive in triggering a migraine attack.
Is there a tendency to overestimate the issue?
Many patients panic about certain triggers. We know people who can no longer even go to a restaurant because they fear certain food ingredients. For decades, it was thought that cheese, coffee, citrus fruits, or chocolate promoted migraine attacks—this is not the case. On the contrary: cravings for certain foods are themselves a symptom of migraines. Just as cravings for pickled herring and raspberry ice cream are not the cause of pregnancy, but rather a symptom of the specific situation, cravings for chocolate are not the cause of migraines, but also a symptom. Unfortunately, this is still not widely known, and old myths persist. Many people still believe these earlier explanations, but they are long outdated.
Why do we react sensitively to certain triggers?
Certain risk genes in our genetic makeup are responsible for a high predisposition to migraines. In the largest migraine study ever conducted, involving over 375,000 participants and carried out at the world's leading migraine centers, 38 risk genes and 44 gene variants were discovered. These are responsible for two key regulatory mechanisms in our bodies: Firstly, they affect the cardiovascular system. This also means that the risk of developing high blood pressure, heart attack, or stroke is almost twice as high in migraine sufferers as in non-sufferers. Secondly, they involve psychological and sensory mechanisms controlled by our nervous system, including perception, thought, cognition, and emotions. Migraine sufferers perceive and react more quickly to stimuli. They continuously absorb recurring stimuli and find it difficult to block them out. Anything that happens too quickly, too suddenly, or too frequently can trigger migraine attacks. This is the common thread running through many triggers. The nervous system, which already operates very quickly due to genetic predisposition, reaches its limit, creating an energy deficit in the nerve cells. The brain then attempts to compensate for this deficit through a protective mechanism: intense cravings for high-calorie foods. This is why many people report experiencing uncontrollable cravings before a migraine. They might eat chocolate or a cheese sandwich, for example, and then think the next day: "Aha, I ate this or that, and that triggered it." However, these cravings are actually a protective mechanism. It's important to give in to these carbohydrate cravings and replenish the nervous system regularly. The brain essentially needs three things: carbohydrates, water, and oxygen. If one of these resources is insufficient or depleted too quickly—for example, due to stress, overactivity, skipping meals, insufficient fluid intake, or being in poorly ventilated rooms—a deficiency can occur, potentially leading to migraine attacks caused by an insufficient energy supply to the nerve cells.
How can I explain the fact that sometimes something throws me off track and sometimes it doesn't?
What matters is not any single factor, but the cumulative effect of events over the past few days. It's not about what happened today, but rather the overall state of my body. If I've had five days of stress, the problem isn't the first day, when the stress was at its worst, but the fifth or sixth day, because by then the nervous system is exhausted. Incidentally, Saturday is the most common day for migraines, followed by Sunday. The reason can be deduced directly from this knowledge.
So, if triggers accumulate, that's not good. You shouldn't overreact to them, but you should still pay some attention to them, right? What triggers do migraine patients report most often?
The common denominator of all these factors is change. Anything that changes too quickly, too impulsively, too suddenly puts a strain on the nervous system. We've developed a checklist of migraine triggers. Stress tops the list. However, stress is experienced very individually. Overactivation of the nervous system, for example, when something is worrying, is a typical trigger and a condition for an energy deficit in the nervous system. Second on the list is anxiety. Many patients suffer more from the fear of the next attack than from the pain itself. They perceive more things as threatening—for example, the fear of the next migraine attack and then not being able to go to work, not being able to be there for their children or partner, having to take medication. This constant anxiety leads to the body being in a perpetual state of alert and ready to flee. This, in turn, creates stress and anxiety. This presents an opportunity to change these conditions through specific psychological and behavioral medicine techniques. You can get annoyed about anything, but you don't have to. Other important triggers are negative or positive emotions such as worry, sadness, or emotion.
What about physical triggers?
This includes, for example, physical overexertion. The body uses up energy that is no longer available for the nervous system. Anything irregular, such as going to bed too late, rushing off on vacation, traveling, jogging before breakfast, skipping meals, etc., can trigger attacks. Physical factors, such as the proverbial change in weather, also play a role. The weather itself isn't the problem, but rather the body's adjustment to a new weather condition, which in turn requires energy. If all other factors are stable, the weather won't affect you. You can't change the weather, but you can change yourself by generally avoiding an energy deficit. This includes, for example, eating regularly, relaxing, and planning for rest and recovery. After a night's sleep, a carbohydrate-rich breakfast is particularly important so that nerve cells can quickly regain energy and thus their ability to function.
Is there anything else one can do to counteract this and reduce the overload on the brain?
It's like a bank account. You shouldn't withdraw more than you deposit to avoid going into overdraft. If I know that anxiety and stress trigger migraines, I can make a difference through relaxation, distraction, stress management training, or cognitive behavioral therapy. Patients often ask me: What else can I do? My answer: It's not about doing more or anything complicated. The most effective thing is what migraine sufferers find particularly difficult: simply doing nothing, pausing, experiencing boredom. Relaxing, sitting on a bench, watching the clouds and listening to the birds. Not letting the nervous system work and preventing energy depletion.
How do you find the right balance between a regular daily routine and fun?
Some migraine sufferers wish for a magic bullet that would eliminate their migraines, allowing them to live as they please. Unfortunately, it doesn't work that way. Due to certain genetic predispositions, maintaining an active health lifestyle is essential. Brushing your teeth is crucial to prevent cavities. Similarly, someone with high blood pressure isn't likely to enjoy a low-salt diet, taking their medication, and avoiding stress. But they must. Likewise, someone with diabetes must adhere to a strict diet, monitor their blood sugar, and perhaps inject insulin, making lifestyle changes and adjustments. If a migraine sufferer says, "I don't want to do any of that and I want a magic solution," they haven't grasped the seriousness and complexity of their condition. These patients should bear in mind that improperly treated migraines significantly increase the risk of high blood pressure, stroke, heart attack, anxiety, depression, and personality changes. Personal responsibility, knowledge, and behavioral adjustments are essential for effectively managing the condition.
Shouldn't we be careful not to worry too much again?
The myth persists that migraines are something that can be treated with alternative methods lacking sufficient evidence of effectiveness. The idea is that if you avoid cheese, take homeopathic remedies, and undergo acupuncture, everything will be fine. This belief stems from a time when there was little scientifically sound knowledge about migraines. As a result, sufferers were often disappointed with conventional medicine and sought alternatives, feeling that medicine didn't care. However, in the last 30 years, we have experienced an enormous explosion of knowledge. We understand the processes within the nervous system, know about specific genetic predispositions, are aware of connections to other diseases, and know effective acute therapies and preventative treatments.
Perhaps it's not taken so seriously because migraines are an invisible illness and others might laugh at you for them?
It's often thought that everyone gets headaches. But migraine is a serious and complex neurological condition. It's frequently confused with everyday headaches, which almost everyone experiences. Those affected suffer from the fact that many things are lumped together. In reality, there are 367 different types of headaches, each requiring very specific treatment.
Does this make it all the more important to accept migraines?
A predisposition to migraines is genetically determined. You can't simply wish migraines away or run from them. You have to prepare for them and adapt your life accordingly. Understanding this alone is crucial. It doesn't work to find supposed triggers and then expect to be migraine-free. The predisposition remains; you can't shake it off. With this knowledge, you can develop proactive health habits, effectively manage your migraine susceptibility, and avoid complications.
The complete interview was conducted by Bianca Leppert for her book
“I have migraines – And what is your superpower?: Your companion through good & bad days”,
Bianca Leppert produces a regular podcast on the topic of migraines: “I have migraines – And what is your superpower?” ( https://www.biancaleppert.de/links )
That's a comprehensive yet understandable explanation of the phenomenon, which has clarified a lot for me. Excellent!
I really enjoyed this article; it's very easy to understand and therefore also ideally suited to informing those who aren't affected by this issue. I've also had the thought that the cravings are a sign that the brain isn't getting enough nutrients, simply because nature has designed it so that hunger means that certain nutrients are lacking, and because I've often become aware during these attacks that, due to some stressful days, I've neglected things like drinking enough water and getting some fresh air. In addition to oxygen, water, and carbohydrates, I also suspect a deficiency in healthy fats/oils. For many years, a low-fat diet was touted, and since I've been consuming more healthy fats again, I've noticed that I can concentrate better and don't tire as easily. Are there any studies on this?
Hello everyone,
I finally feel understood. I'm so happy that this illness is finally being examined more closely. I was starting to doubt myself. This post gives me so much hope and confidence. I've had migraines with aura for 38 years, and as a 13-year-old, I used to spend seven days in a dark room with pain, vomiting, and paracetamol. Today, with triptans, metoclopramide, and painkillers, I can manage it quite well (at least for me). Even though my quality of life suffers and the anxiety remains, thank you so much for this post. It makes so much clearer, and I'm going to consider doing something for my mental health!
Excellent post, thank you very much.
This is the best thing I've read on the subject in a long time. I see myself reflected in many aspects of it. This helps a lot in living better with the illness. Thank you!
Very helpful and informative. Thank you for this information
So many key insights into migraines packed into just half an hour. Absolutely fantastic! A heartfelt thank you to Prof. Göbel and Bianca Leppert for their very engaging migraine podcast!
Written straight from the heart, it couldn't be better expressed.
An outstanding interpretation!