Meals

Because migraines are affected by changes in routine, regular meals are a necessity. However, regular meals may be difficult in a disease such as migraine that is accompanied by significant nausea and vomiting. In a study from Ankara University with children in grades four through twelve, 52% of children with migraine, compared to 28% of those without headaches, did not regularly eat breakfast. Certain comorbidities such as eating disorders, which are more frequent in kids with migraine, may also make eating regular meals challenging.

Though it may be challenging to convince children, especially adolescents, to eat regular meals, there are ways to encourage this practice. Some potential options are prepreparing breakfasts to make the morning routine easier, offering regular snacking, and having backup options for meals that may be more palatable for someone who is nauseated.

Food/diet

The role of specific dietary choices in headache control is a recurrent point of controversy in the headache clinic. Since knowledge about specific diets and advice on avoiding triggers are highly publicized through the news media and social media, healthcare providers must be educated in these areas.

Questions about triggers, especially foods, are especially common in the headache clinic. Most patients believe that certain foods may trigger migraines, though they recognize that one patient’s triggers may not necessarily be a problem for another. A connection between food triggers and migraines was made long ago through multiple studies employing the use of headache diaries to track activities, diet, hydration, weather, etc. and comparing this information to the frequency and intensity of headaches. A study from Belgium from 1987 found that 45% of patients with migraine reported specific foods that trigger an attack. Commonly accepted triggers include monosodium glutamate (MSG), nitrite-containing foods (hot dogs, cured meats), tyramine-containing foods (such as cheese), aspartame (from diet sodas), and alcoholic beverages.

However, we are now learning that these “triggers” may not play as big of a role as we previously thought. The studies employing diaries tracked when patients had a headache, and then examined activities preceding the headache to infer a cause. The studies compared kids with headache and their food intake to kids without a headache and their intake, rather than comparing the diet of the same child with and without a headache. While possibly showing an association, this type of study is unable to prove cause and effect and is subject to “recall bias”; that is, when looking back in time certain events or behaviors may seem more or less pronounced or important than they were or may be forgotten completely. To show cause and effect, prospective studies are needed (looking forward rather than looking backward). Some small studies have been done this way. One such study found that even though children reported that certain foods would trigger a headache, the data collected in their prospective diaries did not show any trigger from food, though did show triggers from stress and lack of sleep. Instead, the data showed that a few substances (in meat and caffeine) had a small protective effect against headaches. In particular, this study found that tyramine-containing foods were not associated with headaches. Also, a controlled trial studying chocolate as a trigger for migraines, found that chocolate did not provoke a headache more often than placebo (which was carob in this trial). Last, in a trial of patients who described bright or flickering light or strenuous exercise as a migraine trigger, exposure to these triggers in a controlled setting rarely produced any headache or aura.

One reason that people believe that triggers produce headaches may be that the body may be more sensitive to different stimuli prior to a migraine. When a migraine patient was scanned in a functional MRI every day for 30 days, and the information was correlated with a headache diary, it was found that, 24 h prior to a migraine, the signaling between the hypothalamus and the areas that act as the hub for pain sensation in the head was changed. When hormones that control sleep, appetite, mood, etc. are altered, it may appear that lack of sleep may be a trigger, when in fact the inability to sleep is part of the changes prior to a headache (an effect of an oncoming headache rather than the cause).

These studies suggest a downside to judicious tracking of a child’s activities and comparing them to frequency of headaches. This kind of comparison entrenches the idea of headaches as a central factor of daily activity. Headaches become a defining characteristic of every moment of the child’s day, taking the focus off of being functional and happy. For this reason and those above, the use of headache diaries outside of research may not yield worthwhile results for the effort invested. Focus on keeping a diary could create a point of friction between parent and child.

Hydration

Dehydration is a significant trigger for migraines. Especially in an era filled with sodas, juices, and other water substitutes, children today generally do not drink enough water and are more prone to dehydration. In the clinic, it is common to hear parents say that their child “can’t be dehydrated,” since they drink what is thought of as an adequate amount. How much is enough? The only clear recommendation for children and adolescents is 2–3 L of water per day, but this guideline is one source and must be individualized for the size of the child, environment (a hot day outside working compared to a relaxing day indoors), and other comorbid conditions. Conditions such as orthostatic hypotension (OH), postural orthostatic tachycardia syndrome (POTS), renal disease, and heart disease, can raise or lower the daily fluid intake (see the chapter on POTS and Dysautonomia for further information).

Caffeine

Another common topic of discussion in the headache clinic is caffeine intake. Children today consume a lot of caffeine, in the forms of coffee, tea, energy drinks, and soda.

The role of caffeine in headache and pain is unclear. Treating a headache by drinking a cup of coffee or taking over-the-counter medications caffeine is commonplace. Some small studies showing that adding caffeine (as a pill, or even as an IV medication, at doses ranging from 50 mg to over 500 mg) to other pain medicines may result in a small amount of extra pain relief. However, specifically for headache, this practice may be problematic. Children with headaches have been shown to consume caffeine more regularly than children who do not have headaches, though in another patient series of patients at a pediatric headache center, caffeine consumption at the initial visit was associated with lower probability of headache worsening at the second visit. These types of studies may show a correlation between caffeine use and worsening headaches, but once again, correlation does not prove causation and prospective studies would be needed.

One concern related to headaches is the concept of caffeine-withdrawal headaches. Some patients who regularly drink multiple cups of coffee per day, such as at work or on the way to school, may notice they are developing headaches on the days they abstain, for example, on a weekend when they depart from their usual weekday routine. This connection is another entrenched belief that has been investigated with surprising results. In a prospective study of patients who responded on a survey that they had headaches when withdrawing from caffeine, only about one-third of patients who were then abruptly stopped from consuming caffeine developed a headache, and those who were weaned more gradually did not report any headaches.

Another important consideration is the dose of caffeine and the type of food or drink that contains the drug. In the past, coffee has been the main source of caffeine used by patients, as well as what has been studied. However, a growing source of caffeine for children and adolescents today comes from various energy drinks or supplements. A typical energy drink may contain anywhere from 80 to 300 mg of caffeine (the American Academy of Pediatrics recommends children and adolescents aged 12–18 to consume no more than 100 mg of caffeine per day, see Table 1 ), and may contain as much as 35 g of processed sugar as well as other additives such as taurine, guarana, and ginseng in just one eight ounce drink. Very little data exist on how consuming energy drinks affects patients with headaches, and the data collected so far are mostly retrospective or cross-sectional. In a cross-sectional study (observing a large portion of patients across a population at one single time point) of high school age children in Canada, children who were “frequent users” of energy drinks (more than once per month) were more likely to have headaches, to seek medical care for headaches in the past 6 months, and to have difficulties with sleep as well as with anger. In another large population-based study in Korea, frequent (> 3 times per week) consumption of energy drinks was found to be associated with a three times higher chance of attempting suicide. Side effects such as these, as well as the lack of FDA regulation (as these drinks are marketed as “supplements”), were some of the reasons that the American Academy of Pediatrics stated that “caffeine and other stimulant substances contained in energy drinks have no place in the diet of children and adolescents”.

Healthcare providers may experience situations related to beneficial effects of caffeine in the setting of postdural puncture headache (PDPH, also known as post LP headache). One such situation is a lumbar puncture, or even an epidural, where the patient exhibits a headache that is positional (worse with upright position). Here, caffeine has been investigated as a potential treatment with strong initial data (though more study is needed). Caffeine in an oral or IV form (the dose is unclear) is generally recommended to treat or prevent this kind of headache, and studies have shown that it may resolve PDPH in as little as 1–2 hours. This effect is thought to be due to the action of caffeine causing increased cerebrospinal fluid production, though in rat studies this increased CSF has been seen with chronic caffeine use; in acute use, CSF production is decreased.

Conclusion

Counseling patients regarding nutrition and hydration may be difficult for healthcare providers when time with patients is already short; however, this is a topic that is often front and center in the minds of the patient and his or her family. These issues can help or hinder a patient’s progress in his or her migraine journey and should thus be deliberately investigated by patient and provider alike. However, it is important to critically view beliefs regarding issues such as triggers that have been commonly accepted in the past but may not play as much of a role as we have previously thought. Time and effort previously focused on these subjects may be better served working on other more impactful interventions, such as those discussed in the other chapters of this book.