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Migraine pass

Possible triggers for the attacks

When triggering migraine attacks, triggering factors – so-called trigger factors – must be strictly separated from the actual “causes” in the sense of “starting” the migraine attack. While the cause is a specific over-reactivity of the organism, trigger factors can be a wide variety of conditions that trigger the migraine cascade. The majority of migraine attacks come as if out of the blue: Even with the best will in the world, no specific trigger factor can be found for the particular migraine attack.

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

  • Sudden stress
  • Changes in circadian rhythms
  • Distinctive emotions
  • Hormonal changes
  • Skipping meals
  • Overexertion and exhaustion

It turns out that the common denominator of all trigger factors is a sudden change in the normal rhythm of life. Which factors, mechanisms and circumstances bring about this change seem to be less important.

Stress – something different for everyone

Views on what constitutes stress vary widely. For some it's stressful what awaits them at work, for others it's the lively hustle and bustle of children. Some people are “stressed” because they want to get something done quickly or because they still haven’t had anything to eat. The scientific ones are at least as different as the popular ideas about stress. To put it somewhat exaggeratedly, one could say that every discipline, be it psychology, biology, ecology or another, has its own definition.

The stimulus-response model

Orbital headache

Orbital headache

The most widespread is a stimulus-response model based on the work of the biochemist and physiologist Hans Selye, who died in 1982. According to this model, stress is seen as a consequence of damaging physical, psychological and social influences (called “stressors” in the model), which trigger a largely identical reaction pattern in those affected. The aim of the reactions of the entire organism is to compensate for the disruptive influences, i.e. to adapt the organism to the stressors (general adaptation syndrome).

The stressors themselves can be anything: cold or heat, physical stress, the loss of a relative, the work situation and much more. For example, there is a scale on which various critical life events are ranked in terms of their stress-inducing potency, the so-called “social change assessment scale”. However, it should be noted that only average values ​​are included in this scale. However, how each individual reacts to such stress-inducing events can be completely different, as everyone perceives something different as “stressful”. What is already stressful for one person - such as meeting new people - is a welcome change for another. So it also depends on the rating. Regardless, the scale gives a good overview of what may be perceived as stressful by many.

Stress doesn't have to be stressful

However, in everyday life there are a whole range of different stress experiences that are not included in the scale. This could be, for example, a telephone ringing at an unexpected moment, constantly changing lighting conditions or even the famous fly on the wall. These everyday stressors can only develop into significant factors when taken together.

In addition, positive experiences in everyday life are very important in order to compensate for such minor stressful experiences. In this way, positive experiences can outweigh small stressors that would otherwise add up. This can be good news, a bouquet of flowers or simply the experience of having a good night's sleep.

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

When does stress trigger migraines?

Stress, strain and emotional influences are most often cited by migraine sufferers as triggering or aggravating factors for migraine attacks. Systematic studies show that it is not the absolute level of stress - i.e. the degree of stress, so to speak - that is important, but rather sudden changes in the level of stress. Accordingly, two conditional sequences can be drawn, viz

  • Stress-relaxation-migraine and
  • Relaxation-stress-migraine

demarcate. If it is possible to reduce the level difference between the relaxed normal state and stress, then the frequency of attacks should actually also be reduced. And that is exactly the case. There is no doubt that relaxation techniques such as progressive muscle relaxation and planning a regular daily routine are among the most important components of non-medicinal migraine therapy.

The sleep-wake rhythm

Most migraine attacks are triggered either in the early morning or in the afternoon. A connection with the sleep-wake rhythm is of course intensively discussed. According to individual case reports, migraines without aura in particular are linked to sleep patterns. If you sleep for a short time, it is only when you reach deeper sleep stages, such as REM phase 3 and REM phase 4, that migraine attacks are triggered. Accordingly, particularly long and deep sleep phases at night are said to be able to trigger migraine attacks on the days in question.

After falling asleep, you first gradually “go down” into the deepest deep sleep phase (non-REM sleep). About 80 to 90 minutes after falling asleep, we enter the first REM sleep phase (REM = rapid eye movement), in which we dream particularly intensively. This phase lasts about five to ten minutes and is followed again by a descent into deep sleep. Depending on the length of the night's sleep, we get four to five of these cycles of non-REM/REM sleep, with the depth of the non-REM phases decreasing and the length of the REM phases increasing.

Although these data are not proven by controlled studies - they are just individual case reports - there is still a lot more that supports a connection between sleep and migraines. For example, the fact that when migraines are linked to certain days of the week, Saturday occurs most frequently as a migraine day. An important reason for this could be that people get up later on Saturday or go to bed later on Friday.

Of course, such monocausal explanation attempts can be masked by other conditions. This includes, in particular, relaxation and changing food intake on the weekend, including coffee consumption. These diverse variables show that monocausal thinking makes little sense when looking for triggers of migraine attacks. Nevertheless, it seems sensible to keep the potential trigger of the sleep-wake rhythm in mind and to further systematically research it.

From alcohol to citrus fruits

Food is often viewed as a potent trigger for migraine attacks, not only by the general public but also by doctors. However, we have to be very, very careful when assessing the extent to which foods actually represent trigger factors. I don't want to give the impression that I don't take patients' opinions seriously. The opposite is the case. I just want to sensitize you to the fact that prejudices can easily creep in here and then resurface on a very widespread basis. It's understandable that when it comes to a condition as debilitating as migraines, one would like to believe any simple explanation. Unfortunately, migraines are not that simple. Therefore, please try to remain as objective as possible - and this basically applies to all aspects and triggers of migraines - if someone wants to explain Columbus' egg to you.

The glass of champagne in the afternoon

Around 20 percent of all migraine sufferers report that food-related trigger factors play a role in them, particularly alcohol. As a rule, this applies to all alcoholic drinks. A few think it's just certain alcoholic drinks, especially red wine and sparkling wine.

What is interesting is that it is often not just the alcoholic drink that plays a role, but also and above all the time of day at which it is consumed. There are people for whom, for example, champagne after 8 p.m. has no consequences, but in the early afternoon when saying goodbye to a work colleague there is almost a 100 percent chance of triggering a migraine attack.

Definitive statements are currently impossible

It is currently not possible to link the triggering of migraine attacks to a specific substance with certainty. It is possible that the situation here is similar to the triggering of migraine attacks by alcohol: it is not the food alone, but the time and type of food intake that must be held responsible for triggering migraine attacks. The usual other suspects

The spice enhancer glutamate was blamed for the so-called Chinese restaurant syndrome. However, a controlled study in a double-blind design has now been carried out, which was unable to confirm the trigger glutamate for Chinese restaurant syndrome, which was previously accepted by headache researchers. This fact also shows once again how careful one must be when interpreting individual factors.

Coffee: A small ray of hope

One finding is now quite well supported by studies: the connection between caffeine and migraine attacks. A double-blind, randomized cross-over study showed that in subjects who normally drink up to six cups of coffee a day, taking decaffeinated coffee was actually associated with an increased likelihood of migraine attacks. The headache usually begins the first day after eliminating caffeine and has a median duration of two to three days.

Double-blind, randomized cross-over studies – what is that actually? Double blind means that neither the examiner, i.e. the person who administers the preparation, nor the test person, knows whether it is a real preparation or a dummy preparation (placebo) that is free of active ingredients. This is intended to prevent the examiner from unconsciously influencing the test subject. Randomized means that the assignment to the respective treatment is made by randomly selecting the test subjects. And the term “cross-over” means that the test subjects not only receive either preparation A or B, but also both preparations one after the other at a certain time interval. Such studies are highly valued among researchers because they exclude numerous possible sources of error.

Medications can also trigger migraines

Headaches are reported as an undesirable side effect for a large number of medications. Unfortunately, it is currently unclear whether the respective headaches are actually migraine attacks or just symptomatic headaches due to an acute or chronic effect of the substance in question.

A number of studies have now been carried out on nitric oxide - which is released in the body, for example, by medications for high blood pressure and poor blood flow to the heart. These indicate that the substance is actually able to trigger headache attacks that are at least similar to migraine attacks.

Medications that often lead to headaches include, in particular, estrogens, ergot alkaloids, caffeine, indomethacin (e.g. used for arthritis, spinal problems or menstrual cramps), reserpine (against high blood pressure), nifedipine (against high blood pressure and angina pectoris) and dipyridamole (prevention of strokes, according to Heart attack).

Maybe the weather is to blame?

Weather factors are viewed by the population as particularly important in triggering migraine attacks. Migraine sufferers living in southern Germany particularly blame the hairdryer. From a scientific point of view, however, the picture looks somewhat different: To date, there are no serious studies that would prove a connection between weather situations and the triggering of migraine attacks. There are also indirect reasons that speak against this supposedly high importance of weather situations as a trigger: the broad agreement in the frequency of migraines in different countries around the world and, in particular, the great agreement worldwide in the frequency of headache days per month or year.

If you analyze in more detail how migraine attacks relate to weather mechanisms, it becomes apparent that only a small proportion of migraine attacks can be associated with specific weather conditions.

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

Hormonal changes

Especially in women with migraines, the connection with hormonal fluctuations during the menstrual cycle is obvious and is mentioned again and again by women. In fact, this connection does exist, although not to the extent that is commonly assumed. Shortly before menstrual bleeding, both estrogen levels and progesterone levels decrease. What is certain is that it is precisely this drop in estrogen that triggers migraine attacks in around five percent of women affected by migraines. A connection with progesterone and the other hormones of the cycle (follicle-stimulating hormone, luteinizing hormone) could not be found.

Migraine pass memory aid

Nobody is perfect, especially not when it comes to remembering possible trigger factors for individual migraine attacks. Therefore, please use the trigger factor checklist in the migraine passport (see download box at the top right) to record all relevant facts. If you consider other factors than those listed to be important, please be sure to include them.