Care Tuner: Dr. Marmura, you published a fascinating review in the journal Current Pain and Health Reports, in which you found that much of the conventional wisdom about what triggers migraine attacks is wrong: that most reported triggers don’t actually cause migraine, and that the ones that do are mostly unrealistic to avoid.
Dr. Michael Marmura: That’s right. And that’s why generally we don’t recommend trigger avoidance as a strategy for managing migraines. It’s much more effective to focus on a healthy lifestyle: your sleep, exercise, stress management, nutrition.
If I were to rename your study, I would call it “Triggers Are Overrated.”
[Laughs] I would agree with that.
Why do people get so caught up in trigger theories, then? Where does that preoccupation come from?
There’s a misconception that migraine is straightforward: You did this, and that’s why you got that. That’s rarely the case. Underlying causes of migraine are unpredictable and complicated. I would argue that people like the idea of triggers because migraine is so chaotic. It’s a way of imagining some kind of order because people think it should be more manageable than it is.
Where does that misconception come from?
There are so many misconceptions about migraine out there, and some of them affect the way most doctors practice. In medical school, you don’t learn much about migraine. If you’re a family practice doctor, your entire background in migraine may consist of having gone to a lecture. Our culture reinforces the idea that migraine is easily solved, with books that promise you can cure your migraine through diet. On TV, you see medication commercials with a woman playing with her dog and having a good time. Problem solved!
Not only is that perspective wrong — migraines are very difficult to prevent — but focusing on what triggers migraine attacks has an overall negative effect, because it turns all the responsibility and the blame back on the patient. “I had a Snickers bar, no wonder I had a migraine.” “I did something wrong, the migraine was my fault.” It’s disempowering. And then the real problem becomes: there’s no conversation about how to actually manage migraine.
Let’s have that conversation.
When it comes to triggers for migraine, it helps to talk about management strategies only if it empowers a person. So for example, if a patient says, “I notice my migraine is always a day before my menses,” we have treatment options for that. But then there are the patients who say, “almost everything is a trigger,” or “the weather.” Then, we’re not going to focus on triggers — it’s not productive.
Why is that? A lot of weather-sensitive people track the weather to prepare themselves for pressure drops. Is that not productive?
If your weather migraines are the treatable kind, it can be productive. So if you’re the kind of person who can take an aspirin and a Coke and you’ll be okay, then it can be helpful. But if there’s no treatment, then thinking about weather changes is just going to upset you. And might do you harm! Some people get very weather obsessed.
There’s a great story [neurologist] Dr. Richard Lipton tells. He had a patient who said, “I have this watch that alerts me when the barometric pressure drops. It beeps to let me know. I’m so glad to have the watch because I’ve been having more weather migraines than ever.” And the treatment was to get rid of the watch. [Laughs]
What other trigger trends do you notice with your patients?
People associate whatever happens before the migraine with being the trigger. So one of the most common “triggers” of migraine is neck tightness. People will say, “I know my migraines are coming from my neck.” But what they’re actually talking about is a prodrome symptom, a warning sign. Some people have emotional changes before they have a migraine, or they get hyper or are super-productive the day before. And then they say, “Oh it must be that I was overdoing it.” People may crave salty food or chocolate before they get a migraine, and then they train themselves to think one led to the other.
Let’s talk about the migraine prevention strategies you recommend. They revolve around engaging with things, rather than avoiding things.
Trigger avoidance generally doesn’t lead to good outcomes. That’s not unique to migraine. With back pain, for example, people who lie in bed do much worse than those who continue to be adaptively active. Obviously, when you have a migraine it’s understandable to lie down in a dark room. But the answer isn’t to be inactive in general. Patients with migraine who spend 16 hours a day in bed tend not to do very well. You don’t want people to stop being active — over time it can erode their capacity to tolerate those activities.
You want them to have a healthy lifestyle to the extent they can. If you have to go out wearing sunglasses, go out wearing sunglasses. If you can only manage a few hundred steps a day, then do that. We want people to function. When it comes to migraine prevention, I encourage people to think about it in terms of doing things that will raise their “threshold” for migraine.
Everyone has a point where they’re vulnerable to migraine. Even people who don’t normally get migraine will experience something like it if they’re exposed to enough factors — someone who has too much alcohol might get a hangover, someone who drinks caffeine daily will have withdrawal headache. It has something to do with the level of excitability in your brain. People who have migraine have more easily excitable brains than other people. And there’s a lot of variabilities there.
So for example, I had a patient who was doing so well, she had only one headache per month, her threshold was generally pretty high. But she was a lawyer who closed a big deal out on the West Coast and they celebrated over drinks. She hopped on the red-eye, came home, and had her worst migraine in years! The combination of factors — the alcohol, the lack of sleep, the stress let-down, all those things overcame her threshold. On the opposite end, someone who says “Every time it rains, I get a severe migraine for three days,” your threshold is low, you’re having more bad days than good, so in that case, we focus on increasing your threshold.
How does someone increase their threshold?
And within that list, there are so many options. Whether that’s preventive medication, meditation, yoga, whatever helps you. It doesn’t matter to me what you do, it’s that you’re doing something. And not necessarily one thing, but any combination of things. Explore. And whatever you choose, you have to do so on a regular basis to give yourself a chance to get the benefits. If you get acupuncture, you have to go more than once, you have to commit to several sessions. Same with therapy, biofeedback, whatever it is — you have to commit. If you don’t have the time or money to do something, don’t commit to that thing and try something else.
Raising your threshold is an effective strategy in preventing migraines. And I happen to prefer the phrase “raising the threshold” to “preventing migraines,” because it’s more empowering and realistic at the same time. If you think of what you’re doing as “preventing migraine” and then you get one, you’re disappointed, it feels like, “Hey, it didn’t work!” Most of our patients — the vast majority — can’t prevent migraine from happening. But you can raise your threshold through any number of approaches, and that’s empowering.