Migraine triggers: a list with how strong the evidence is

Triggers ranked by evidence

A flat list of triggers makes everything look equally proven. It is not. In a 2018 review, Marmura says clinical studies have verified fasting, premenstrual periods in women, “letdown” after stress and, most likely, low barometric pressure as migraine triggers, while many other triggers rest on surveys and diaries.

The grades below follow the cited sources and are not a medical ranking. Verified means clinical studies, not only what people report. Reported means surveys and diaries. Mixed means the evidence is unsettled.

• Verified in clinical studies, per Marmura: fasting, premenstrual periods and the let-down after stress.
• Likely: low barometric pressure.
• Reported most often in surveys: stress and sleep problems. Reports show what people believe, not cause.
• Mixed: caffeine, alcohol, specific foods such as chocolate or cheese, bright or flickering light, strong smells, heat and dehydration. They are listed as common triggers, but are hard to separate from early symptoms.

What surveys show, and why they are not enough

A 2018 meta-analysis of 85 studies and 27,122 people found that about four in five people with migraine or tension-type headache endorse at least one trigger. The most common were stress (58%) and sleep (41%). The review adds that the answers depend on how people are asked, and that more experimental studies are needed.

So a survey tells you what people believe sets off their attacks. That is a useful hint, but it can include things that are not true triggers.

Prodrome versus trigger: when a craving is a symptom

Many attacks have a warning phase hours before the pain, called the premonitory phase or prodrome. In an electronic diary study of 97 patients, the most common premonitory symptoms were feeling tired, difficulty concentrating and a stiff neck, and patients predicted the headache correctly from 72% of diary entries with such symptoms.

Marmura notes these early symptoms, such as neck pain, fatigue and sensitivity to light, sound or smell, can mimic triggers. The same logic is often applied to food cravings, such as wanting chocolate before an attack: the craving may be part of the early attack, and the food may get blamed. None of the cited sources settles it for chocolate, so treat it as an open question. The NHS lists craving certain foods among the symptoms at the start of an attack.

Why one trigger rarely acts alone

The American Migraine Foundation says everyone has different triggers and lists stress, irregular sleep, hormones, caffeine and alcohol, weather, diet, dehydration and light among the most common ones. Marmura notes natural triggers are much less predictable than experimental ones and vary in importance between people.

In practice, a poor night’s sleep, a skipped lunch and a stressful day can add up, and then the weather tips it over. A food that is fine on a good day may be blamed on a bad one. That is why a single bad meal rarely proves anything.

How to test a trigger

Keep a diary for at least several weeks. Record each attack with its start time, intensity, symptoms and medication, and also record sleep, meals, water and stress on days with no attack, so you have something to compare. NHS advice is to keep a diary to work out what might trigger your attacks.

Then change one thing at a time. If you suspect a food, ask your doctor how to test it, and do not cut out many foods at once or stop prescribed medicine.

What to do about triggers you cannot avoid

Marmura says many common triggers are not easily modifiable, and avoiding them may not be realistic. Healthy habits such as exercise, adequate sleep, stress management and regular eating may prevent triggers and a shift to chronic migraine over time. NHS advice includes sleeping or lying in a dark room during an attack, drinking enough water and limiting caffeine and alcohol.

Get emergency help right away for a headache that comes on suddenly and is extremely painful, or that comes with trouble speaking or remembering, confusion, vision loss, a seizure or weakness on one side of the body; the NHS lists these as reasons to call 999. See a doctor if attacks are severe, getting worse or happen more than once a week. The American Migraine Foundation also warns that taking acute medication on more than 10 days a month can itself cause more attacks, so raise it with your doctor.