Migraine triggers tricky to pinpoint

(Press-News.org) WINSTON-SALEM, N.C. – April 8, 2013 – Women often point to stress, hormones, alcohol, or even the weather as possible triggers for their migraines. But a new study from Wake Forest Baptist Medical Center found that it is nearly impossible for patients to determine the true cause of their migraine episodes without undergoing formal experiments.

The majority of migraine sufferers try to figure out for themselves what causes their headaches based on real world conditions, said lead author Timothy T. Houle, Ph.D, associate professor of anesthesia and neurology at Wake Forest Baptist.

"But our research shows this is a flawed approach for several reasons," he said. "Correctly identifying triggers allows patients to avoid or manage them in an attempt to prevent future headaches. However, daily fluctuations of variables – such as weather, diet, hormone levels, sleep, physical activity and stress – appear to be enough to prevent the perfect conditions necessary for determining triggers."

For example, said Houle, the simple act of drinking a glass of wine one day and not on the next could be complicated by inconsistencies in other factors. Similarly, a patient may drink wine for several days, but adding cheese to the mix one day could further skew results. In fact, a valid self-evaluation requires such perfect conditions that only occur about once every two years, he said.

"Many patients live in fear of the unpredictability of headache pain. As a result, they often restrict their daily lives to prepare for the eventuality of the next attack that may leave them bedridden and temporarily disabled," Houle said. "They may even engage in medication-use strategies that inadvertently worsen their headaches. The goal of this research is to better understand what conditions must be true for an individual headache sufferer to conclude that something causes their headaches."

Houle and co-author Dana P. Turner, M.S.P.H., also of the Wake Forest Baptist anesthesiology department, have published two related papers on the subject in the journal Headache, which were published online ahead of print this month.

For the study, nine women who had regular menstrual cycles and were diagnosed with migraine either with or without aura provided data for three months by completing a daily diary and tracking stress with the Daily Stress Inventory, a self-administered questionnaire to measure the number and impact of common stressors experienced in everyday life. Morning urine was also collected daily for hormone level testing. Houle and Turner also reviewed three years worth of weather data from a local weather station.

Because of the difficulty in recreating identical conditions each time a patient evaluates a potential trigger, determining triggers proves difficult even for physicians, said Turner. "People who try to figure out their own triggers probably don't have enough information to truly know what causes their headaches," she said. "They need more formal experiments and should work with their doctors to devise a formal experiment for testing triggers."

### The research was supported by the National Institute of Neurological Disorders and Stroke and of the National Institutes of Health (1R01NS06525701).

Co-authors include: Todd A. Smitherman, Ph.D., University of Mississippi, Donald B. Penzien, Ph.D., Head Pain Center, University of Mississippi Medical Center, and Vincent T. Martin, M.D., University of Cincinnati College of Medicine.

Wake Forest Baptist Medical Center is a fully integrated academic medical center located in Winston-Salem, North Carolina. The institution comprises the medical education and research components of Wake Forest School of Medicine, the integrated clinical structure and consumer brand Wake Forest Baptist Health, which includes North Carolina Baptist Hospital and Brenner Children's Hospital, the commercialization of research discoveries through the Piedmont Triad Research Park, as well as a network of affiliated community-based hospitals, physician practices, outpatient services and other medical facilities. Wake Forest School of Medicine is ranked among the nation's best medical schools and is a leading national research center in fields such as regenerative medicine, cancer, neuroscience, aging, addiction and public health sciences. Wake Forest Baptist's clinical programs have consistently ranked among the best in the country by U.S.News & World Report for the past 20 years. END