trigger

Possible triggers of the attacks

When considering the triggering of migraine attacks, it is crucial to distinguish between triggering factors—those that initiate the attack—and the actual underlying causes. While the underlying cause lies in a specific overreactivity of the body, trigger factors can encompass a wide variety of conditions that set the migraine cascade in motion. Most migraine attacks appear out of nowhere: even with the best intentions, it is impossible to identify a specific trigger factor for any given migraine attack.

However, the following trigger factors are particularly potent candidates for initiating a migraine attack:

• Sudden stress
• Changes in daily rhythm
• Strong emotions
• Hormonal changes
• Skipping meals
• Overexertion and exhaustion

It is becoming clear that the common denominator of all trigger factors is a sudden change in the normal rhythm of life. The specific factors, mechanisms, and circumstances that bring about this change seem to be of less importance.

Stress – something different for everyone

Opinions on what constitutes stress vary widely. For some, it's the stress of their workplace, for others, it's the lively activity of children. Some are "stressed" because they have to quickly get something done or because they still haven't had anything to eat. Scientific definitions of stress are at least as diverse as popular perceptions. To put it somewhat bluntly, one could say that every discipline, be it psychology, biology, ecology, or another, has its own definition.

The stimulus-response model

The most widely used stimulus-response model is still based on the work of the biochemist and physiologist Hans Selye, who died in 1982. According to this model, stress is understood as a consequence of damaging physical, psychological, and social influences (called "stressors" in the model) that trigger a largely identical reaction pattern in those affected. The goal of the organism's overall reactions is to compensate for the disruptive influences, that is, to adapt the organism to the stressors (general adaptation syndrome).

The stressors themselves can be anything: cold or heat, physical exertion, the loss of a loved one, work situations, and much more. For example, there's a scale that ranks various critical life events according to their stress-inducing potential, the so-called "Social Change Rating Scale." However, it's important to note that this scale only incorporates average values. How each individual reacts to such stressful events can vary significantly, as everyone perceives something different as "stressful." What one person finds stressful—such as meeting new people—might be a welcome change for another. It all comes down to perception. Regardless, the scale provides a good overview of what many people might experience as stressful.

Stress doesn't have to be stressful

However, daily life presents a whole range of diverse stress experiences that are not included in the scale. These can include, for example, a phone ringing unexpectedly, constantly changing lighting conditions, or even the proverbial fly on the wall. These everyday stressors can only develop into significant factors when they accumulate.

Furthermore, positive experiences in everyday life are very important for compensating for such minor stressors. Positive experiences can offset small stressors that would otherwise accumulate. This could be good news, a bouquet of flowers, or simply the feeling of having had a good night's sleep.

In addition to the actual stressful situation and its evaluation, the individual's ability to influence the stressful situation and develop possible behavioral strategies to prevent a particular situation from escalating into stress in the first place (coping skills) is also important.

When does stress trigger migraines?

Stress, strain, and emotional influences are most frequently cited by migraine patients as triggering or aggravating factors for migraine attacks. Systematic studies show that it is not the absolute stress level—that is, the degree of stress—that matters, but rather sudden changes in the stress level. Accordingly, two consequences of conditions can be identified, namely

• Stress-Relaxation-Migraine and
• Relaxation-Stress-Migraine

To differentiate between the two, one can conclude that if it is possible to reduce the difference in levels between a relaxed, normal state and stress, then the frequency of attacks should also decrease. And that is precisely the case. Therefore, relaxation techniques such as progressive muscle relaxation and planning a regular daily routine are undoubtedly among the most important components of non-pharmacological migraine therapy.

The sleep-wake cycle

Most migraine attacks are triggered either in the early morning or in the afternoon. A connection to the sleep-wake cycle is therefore naturally a subject of intense discussion. According to anecdotal reports, a link to sleep patterns is particularly evident in migraine without aura. With short sleep durations, it is only upon reaching deeper sleep stages, especially REM phases 3 and 4, that migraine attacks are triggered. Accordingly, particularly long and deep sleep phases at night are also thought to be capable of initiating migraine attacks on the days in question.

After falling asleep, we gradually descend into the deepest sleep phase (non-REM sleep). About 80 to 90 minutes after falling asleep, we enter the first REM sleep phase (REM = rapid eye movement), during which we dream particularly vividly. This phase lasts approximately five to ten minutes and is followed by another descent into deep sleep. Depending on the length of the night's sleep, we experience four to five of these non-REM/REM sleep cycles, with the depth of the non-REM phases decreasing and the length of the REM phases increasing.

Although this data is not supported by controlled studies – it consists only of anecdotal reports – there is still much more that suggests a connection between sleep and migraines. For example, when migraines are linked to specific days of the week, Saturday is the most frequently affected day. An important reason for this could be that people tend to get up later on Saturdays and go to bed later on Fridays.

Of course, such monocausal explanations can be masked by other factors. These include, in particular, relaxation and altered dietary habits on weekends, including coffee consumption. These diverse variables demonstrate that monocausal thinking is of little use when searching for triggers of migraine attacks. Nevertheless, it seems worthwhile to keep the potential trigger of the sleep-wake cycle in mind and to investigate it systematically further.

From alcohol to citrus fruits

Foods are frequently considered potent triggers for migraine attacks, not only by the general public but also by doctors. However, we must be very, very careful when assessing the extent to which foods actually constitute trigger factors. I certainly don't want to give the impression that I don't take patients' opinions seriously. Quite the opposite. I simply want to make you aware that prejudices can easily creep in here, which then resurface in a very widespread way. It's understandable that with such a debilitating condition as migraine, one would like to believe any simple explanation. But unfortunately, migraine is not that simple. Therefore, please try—and this basically applies to all aspects and triggers of migraine—to remain as objective as possible when someone tries to explain the big picture to you.

A glass of sparkling wine in the afternoon

Approximately 20 percent of all migraine patients report that dietary triggers play a role, with alcohol being particularly common. This usually applies to all alcoholic beverages. A few believe it's only certain alcoholic drinks, especially red wine and sparkling wine.

What's interesting is that it's often not just the alcoholic beverage itself that plays a role, but also, and especially, the time of day at which it's consumed. For example, some people experience no adverse effects from sparkling wine after 8 p.m., while drinking it in the early afternoon when saying goodbye to a colleague almost certainly triggers a migraine attack.

Definitive statements are not yet possible

At present, it is not possible to definitively link the triggering of migraine attacks to a specific substance. However, the situation may be similar to that of alcohol triggering migraine attacks: not the food itself, but rather the timing and type of food consumption must be responsible for triggering migraine attacks. The usual other suspects

The so-called Chinese restaurant syndrome was blamed on the flavor enhancer glutamate. However, a controlled, double-blind study has since been conducted that failed to confirm glutamate as the trigger for Chinese restaurant syndrome, a theory previously accepted by headache researchers. This fact underscores once again how cautious one must be when interpreting individual factors.

Coffee: A small ray of hope

One finding is now quite well supported by studies: the link between caffeine and migraine attacks. A double-blind, randomized crossover study showed that in participants who normally drink up to six cups of coffee a day, consuming decaffeinated coffee was indeed associated with an increased likelihood of migraine attacks. The headaches typically begin on the first day after abstaining from caffeine and have an average duration of two to three days.

Double-blind, randomized crossover studies – what exactly are they? Double-blind means that neither the investigator (the person administering the treatment, for example) nor the test subject knows whether it is the actual treatment or an inactive placebo. This is to prevent the investigator from unconsciously influencing the test subject. Randomized means that the assignment to each treatment is made by randomly selecting the test subjects. And the term "crossover" means that the test subjects do not receive either treatment A or B, but rather both treatments consecutively at certain intervals. Such studies are highly valued by researchers because they eliminate numerous potential sources of error.

Medications can also trigger migraines

Headaches are listed as an unwanted side effect for a large number of medications. However, it is currently unclear whether these headaches are actually migraine attacks or merely symptomatic headaches resulting from an acute or chronic effect of the respective substance.

A number of studies have now been conducted on nitric oxide – which is released in the body, for example, from medications for high blood pressure and reduced blood flow to the heart. These studies indicate that the substance is indeed capable of triggering headache attacks that are at least similar to migraine attacks.

Medications that frequently cause headaches include estrogens, ergot alkaloids, caffeine, indomethacin (e.g., used for arthritis, spinal disorders, or menstrual cramps), reserpine (for high blood pressure), nifedipine (for high blood pressure and angina pectoris), and dipyridamole (for stroke prevention after a heart attack).

Could the weather be to blame?

Weather factors are widely considered to play a significant role in triggering migraine attacks. Migraine sufferers living in southern Germany particularly blame the Foehn wind. However, from a scientific perspective, the picture is somewhat different: To date, there are no reliable studies that prove a link between weather conditions and the onset of migraine attacks. Furthermore, there are indirect reasons that argue against this supposedly high importance of weather conditions as a trigger: The largely consistent prevalence of migraines across different countries worldwide, and especially the high degree of global agreement in the number of headache days per month or year.

A more detailed analysis of how migraine attacks relate to weather mechanisms reveals that only a small proportion of migraine attacks can be linked to specific weather conditions.

Even though the data on this is still not entirely clear, it must be noted that particularly sensitive people can indeed react to rapidly changing weather conditions with migraine attacks.

Hormonal changes

Especially in women with migraines, the connection to hormonal fluctuations during the menstrual cycle is obvious and frequently mentioned by women. This connection does indeed exist, although not to the extent commonly assumed. Shortly before menstruation, both estrogen and progesterone levels drop. It is certain that this drop in estrogen is the trigger for migraine attacks in about five percent of women affected by migraines. No connection has been found with progesterone or the other hormones of the cycle (follicle-stimulating hormone, luteinizing hormone).

Migraine passport memory aid

Nobody's perfect, especially when it comes to remembering potential triggers for individual migraine attacks. Therefore, please use the trigger factor checklist in your migraine passport (see the download box in the upper right corner) to record all relevant facts. If you consider any factors other than those listed to be important, please be sure to include them.