Summer School | What to Eat for Migraines

Welcome to summer school. Okay, I never thought I'd be excited to say those words, but this is a kind of summer school that we can all enjoy. I'm Colleen Sloan, a PA and dietitian, and this is a special series of the Exam Room Nutrition Podcast, where I'm bringing back a few of my favorite conversations from the archives. Today we're chatting with Kelly, a registered dietitian who specializes in migraine nutrition. We talk about food triggers, hydration, caffeine, supplements, and why handing patients a long list of foods to avoid may not be the best approach. So grab your coffee, take your seat, and welcome to class. Kelly, I am so excited for our discussion today. Thank you so much for being here. Welcome to the show. Yeah, thank you so much for having me. I'm excited. So let's first start off by discussing if there are any specific foods that actually trigger migraines.

Yeah, so that's a really common question and a common approach to migraine, I think, is to look for any foods that could be causing a problem. And migraine patients can have food triggers that increase their likelihood of experiencing an attack. It's not necessarily going to cause an attack, but it can contribute to the onset of one. But there truly are no specific foods that just because you have migraine, you should avoid. Like there's no universal migraine food triggers. And some patients have no food triggers at all. This is actually more common than we might even think. So food triggers are very unique patient to patient. So if a patient is coming to you concerned about food triggers, or if you're concerned yourself for a patient, a food and symptom journal would be a really good tool to attempt to uncover some food triggers that could be contributing to their symptoms.

How about any nutritional deficiencies that might be linked as the cause of a migraine that as clinicians we need to be aware of?

Yes. So there are some relatively common nutritional deficiencies that are linked with worsening migraine. So the ones I see most often are going to be magnesium, iron, B12, vitamin D, and then even like omega-3 fatty acids can be something that we want to think about as well, because we know that the ratio of omega-3 to omega-6 fatty acids can be really important for migraine patients. Now, they of course don't cause migraine, but they can contribute to it. They can lower a patient's threshold for experiencing an attack. So if we can uncover and address these deficiencies, it can really help them see a big improvement in their ability to control migraine, and of course in their health overall and other symptoms that they may be experiencing.

All right, so let's kind of go over this. And I think you alluded to it in the beginning, but is there a migraine-friendly diet?

Yes. So I do think there is in general a migraine-friendly diet. And this can be another really big tool when used thoughtfully and appropriately for patients. However, I don't think that the basis of a migraine-friendly diet should be about restricting foods or removing any specific foods in general, right? Like oftentimes you might hear we need to remove chocolate or we need to remove, you know, aged cheeses, or, you know, there are a bunch of uh different foods out there that are flagged as problematic. However, when we're looking to construct a migraine-friendly diet for a patient, there are some things that I think about. And that's going to be supporting blood sugar balance, which is nice for everyone, but particularly helpful for people who have migraines. So eating regularly, not skipping meals, having balanced meals, you know, protein, carbs, fat, nutrient density is going to be another really helpful one. So helping prevent those deficiencies that we talked about, making sure we're getting plenty of antioxidants from fruits and veggies and different plant foods. And then we also want to think about some other things like supporting gut health, because this is a newer area of research for migraine. And we know that supporting a healthy gut environment and a healthy microbiome can be really beneficial for that gut brain connection and in turn for migraine itself. So fermented foods, prebiotic foods, so foods that support the microbiome, those can be really helpful. Fiber can make a huge difference. And then we also want to be practical and search for ways that we can make eating easy for someone with migraine because oftentimes migraine can be debilitating. And some people deal with attacks every single day. So we really want to look for ways to make putting together balanced meals easy and doable. We want to look for ways to help them eat despite nausea or high pain or, you know, vertigo. So that's another really important strategy that we can help patients with to actually incorporate all of the other things I just talked about.

Oh my gosh, that was talk full of so much information. And that was just so helpful. You mentioned about kind of helping the patient navigate when they're having like a really bad attack and alleviating those symptoms and making sure that they are eating during those symptoms of vertigo and nausea and when the pain is just debilitating. Are there any specific foods that can actually help alleviate migraine symptoms when they are currently in an attack?

So there are some foods that have been looked at a little bit for their ability to help alleviate some of the symptoms that we might experience during a migraine attack. Now, we also, again, have to be practical in this situation because there are some attacks where a patient won't be able to eat. So in that situation, you know, sipping on electrolyte solutions or, you know, broths or something like that can be helpful. You can also look for like a meal replacement shake or protein shake that the patient might tolerate well that can help them get some calories and some protein. Even a homemade smoothie can be really beneficial. And then honestly, for some of my clients, I'll recommend a Greek yogurt ice cream kind of product because that can be really soothing. Even on, you know, some head pain, that cold food can be really helpful. And then some patients can tolerate a soup really well, like a puree vegetable soup that they can keep in the freezer. That's another tool that I'll use. But if they can continue eating every three to four hours or whatever works for that patient, then we can look to incorporate some foods like ginger, which can be helpful for some patients with a little bit of, you know, pain support, nausea support, even like a ginger tea can be really soothing for a patient dealing with nausea. And same thing with peppermint teas or adding peppermint to smoothies, that can be really helpful for some nausea. So there are some foods that may have a therapeutic benefit for some patients, but with migraine, one thing isn't going to work for everyone. So it's really helpful to help the patient experiment to figure out what's going to work for them.

That is so helpful. So before we jump into kind of some supplements and vitamins that can help to prevent and treat migraines, I want to talk about some big three things that can be kind of triggers or that maybe I've heard that are triggers. So let's first jump into the association between hydration and water intake and if there is any impact on migraine occurrences and how important is water for those who suffer from migraines.

Yes, water is a big one. Dehydration is a big one. Even mild dehydration can act as a migraine trigger. And, you know, even those of us or people who don't have migraine know if you get dehydrated, you're likely going to experience a headache, maybe some lightheadedness. So we know that lower water intake is associated with significant increases in migraine disability, as well as attack severity, frequency, duration. So it is a big deal. And honestly, most migraine patients do know that. But I think a big part of helping them get the amount of water that they need each day is actually figuring out where they're starting from. I think a lot of people think they're drinking more water than they may actually be. So the first thing I like to do with clients is doing a water intake log, figuring out where we're starting from, and then help them gradually get to a goal of about 65 to 100 ounces a day, depending on the person. And then looking for, you know, electrolytes that we can maybe add to increase hydration, really educating the patient on what counts as a hydrating fluid. Those are all some things that we can look into to help prevent that dehydration that is such a prominent trigger for migraine.

So, what is the best way, number one, to ask if they're getting enough water? Because it's so easy to be like, do you drink water during the day? Yes. Okay, then they're good, right? But like you said, most people underestimate how much water they're actually drinking. So, what are some really good ways to actually find out how much they're drinking? And how do we determine how much they need?

Yes. So honestly, I will like to ask if you're doing especially a telehealth session like this, I'll ask my client, what do you typically drink your water out of? We figure out how many ounces is in their typical water bottle or their water glass. And then that's a really easy way to figure out how much they're drinking because they can probably more easily say, I'm drinking like one and a half of these a day, rather than I'm drinking 35 ounces of water a day. Most people don't know how many ounces they're drinking a day. So we can use that as a good tool. And then for most people, at least for adults, that two-liter or, you know, 65 ounces is a good end goal. So we can just work up gradually to that rather than going from 35 ounces to 65 overnight. We can just gradually increase that for them. And then using tools like adding, you know, citrus fruits or other flavorings to water if they really hate water can be another good way to get that up too. We can also be thinking about, you know, if they're making smoothies, the fluid that they're putting in there absolutely counts. Any decaffeinated or herbal teas that they're drinking will count. Any, you know, soups that have broth in them, we can count that. So there are a lot of sources that I think people are forgetting about and not giving themselves credit for. Even like a seltzer water or something like that can also count. And oftentimes people will enjoy that more than plain water. So these are all things we can be adding to the tally to help them get to that, you know, 65 to 100 ounces a day.

Thank you so much for that, Kelly. That is such a good, helpful number. I hope you guys store that in your pocket for later today. So I want to move on to my favorite beverage, and this is coffee or caffeine. And so this is another big one. And is there a connection between caffeine and migraines? Should it be limited? Does this trigger migraines or treat migraines? So give us the facts on coffee and please don't tell me that I need to stop drinking my coffee.

Well, I definitely won't do that because I'm also a daily coffee drinker. And the role of caffeine in migraine is very confusing, honestly, for everyone, for patients and providers alike, because it does depend on the person. With like so much with migraine, it depends on the person. And caffeine can help, it can hurt. So let's talk a little bit about how to figure that out for the patient and kind of what we know about caffeine. Each patient's tolerance and sensitivity is going to be a little bit different. So I think it's really helpful to have a conversation with the patient to figure out one, if they're even consuming caffeine and if that's something they care about. And two, how they feel when they're drinking caffeine, which they may not know just right off the top of their head, might be something you need to revisit. But figuring out if they feel, you know, jittery or anxious or even headache after having a cup of coffee in the morning that they may just be kind of pushing through for that energy, that's some really helpful information to tell us, okay, this may be an issue for them. We might want to dial that back. Caffeine can act as a trigger for some patients. So assessing that response can help you figure that out, as can that food and symptom journal that we talked about earlier. But in general, if someone is drinking caffeine daily and they want to continue doing that, which, like I said, I'm a coffee drinker. So it's fine if that's something that they want to work into their life. Then keeping it below 200 milligrams of caffeine per day is where we want to be. And then to make sure that we're considering sleep quality, we want to cut that caffeine intake off at 3 p.m. max, 12 noon, if they have trouble with sleep already, is going to be where we want to cut it off. Drinking too much caffeine every day can be an issue, as can variations in caffeine intake. So if they're gonna be a caffeine drinker, they need to drink it every day or, you know, just save it for acute management. Otherwise, they can start to have some withdrawal symptoms, and that can be a trigger as well. So avoiding variability in intake and keeping it below 200 milligrams is what we want to tell our coffee drinkers. And then for people who have episodic migraine, so like less than 15 migraine days a month, and they don't drink caffeine every single day. We can use a cup of coffee as an acute migraine management tool, and that can actually be pretty effective for helping cut down the severity of a migraine attack. So that's where the helpfulness of caffeine can come in.

That was so helpful. So again, you're just giving us these little golden nuggets of numbers that we can keep in our pockets and suggest to patients. So 200 milligrams, I want you to educate us a little bit on that because all I know is I like my cup of coffee. So how many cups of coffee is 200 milligrams?

Yes. So that is where it gets a little bit tricky because it's gonna depend on how it's brewed, the strength of the coffee, all kinds of stuff. But in general, I typically tell people that a cup of coffee in the morning, not a big huge cup, but like eight-ish ounces of coffee, you can call that 100 milligrams. That's gonna be a good average. So two cups of coffee max a day is gonna be where you want to sit. Awesome. Very, very helpful. What about espresso? It does that have more, about the same? Espresso, I believe, is about 70 milligrams per little shot.

Okay.

So it's actually a little bit less. So we're gonna move nicely into my next question, and that's about the role of sugar in migraines. Because as we talk about coffee, unfortunately, so many people are putting so much sugar in there and sweetened creamer in there. So I'm curious what role does sugar in all forms play in triggering migraines?

Yes. And this is a really common question you'll hear from patients too, because sugar is kind of the new fat, right? We were all afraid of fat for a while. Now we're all afraid of sugar. And just like fat, sugar is not evil, but it is something we want to be thoughtful around. Because if we're consuming it in excess or on its own, then it can act as a migraine trigger for a lot of people. So the biggest issue when we're thinking about sugar is the potential for it to cause those blood sugar spikes and then blood sugar dips. And that, like blood sugar roller coaster, is what can act as a trigger for a lot of people with migraines. So that's what we're looking to avoid. And for patients who are sensitive to sugar, which is going to be a lot of them, then combining sugar with fat protein fiber can help slow that blood sugar response, slow the absorption of sugar, and prevent those spikes and dips that are going to be so problematic. So that's one really helpful education piece for patients when it comes to sugar. Strict avoidance of sugar is honestly not something I recommend for anyone unless there's a special circumstance. It can lead to cravings, you know, binging, disordered eating, just stress and anxiety around food. So we can really help our patients learn how to have not only healthy blood sugar responses, but also how to have an easier and healthy relationship with food at the same time because of that, you know, kind of imbalanced conversation that's happening around sugar right now. And we can help kind of correct some of that. But moderation and balance is definitely key, as with most things when we're talking about sugar for migraine.

What an excellent point because unfortunately, I hear way too many clinicians tell patients you need to cut out all sugar. And I think that's a horrible recommendation. Cause number one, well, what is all sugar? Like, what does that mean? I mean, sugar is in everything that's baked, cooked, you know, like it's it's in sauces, it's in everything. I think that's just a terrible recommendation. And so, like what you had said, helping our patients have that healthy relationship with food is so important just for their life and vitality in general. And I want to linger here a little bit because I love that you said, hey, you could still have, you know, a cookie at the end of the day or a cake because it's your birthday. I love that all the dietitians I have on talk about that add-in approach rather than making it to strict avoidance. So let's say if a patient does, you know, want to have some sweets, you had mentioned pairing it with a protein or a fat. What would that look like? Can you give us just an example of how they can include some sugar foods in their diet, but still managing their blood sugar and preventing those spikes?

Oh, absolutely. This is a conversation I have all the time. So let's use the cake example. So it's someone's birthday, they want to have a piece of cake. Awesome. Sounds amazing. So, what we can do to make that an easier experience when it comes to migraine is to try and have that piece of cake after a balanced meal. So if we're having it as dessert and we've just had a nice, you know, protein-rich, fiber-rich meal, then we're probably going to have a pretty easy time tolerating that cake because we've already got that good foundation hanging out in our stomach. So that's one thing that we can be thinking about. I think also helping your patients get in tune with those hunger and fullness cues can be another really powerful tool because that can help them manage their intake of those sweets more easily. So they can have maybe a few bites of that cake and then realize actually, I'm satisfied, I'm full, I'm good, I don't need any more cake. Or of course, if they want more, they can have it. But that's another way that they can use their own body's cues to manage sugar intake along with those, you know, balancing blood sugar reactions.

So I'm gonna round out this conversation with if there are any supplements or vitamins that are effective in preventing or treating migraines that we can suggest our patients try.

Yes. So there are kind of the migraine prevention supplement trifecta that we talk about. So that's gonna be magnesium, riboflavin, and coQ10. Those are probably the most recommended supplements for managing migraine. And there are recommended dosages for these. Of course, you want to make sure it makes sense for your individual patients, but with magnesium, we're usually looking around 400 to even 1200 milligrams per day, depending on the person. Riboflavin is 400 milligrams a day, and then CoQ10 between 100 and 300 milligrams is what we're looking at. So these can be pretty helpful again, depending on the patient. They're not gonna work for everyone. But trialing these one at a time, I think can be really helpful just to make sure that they're gonna tolerate it in the first place. And then seeing if it's worth keeping in their routine can also be good to evaluate.

So we try them one at a time. Let's just say we do magnesium first and it's working really well. Do you recommend adding on any of the other ones? Like, is there any benefit to, you know, more is better, or just kind of sticking with one of them?

So it depends on what type of response you get, you know. So usually I will start with magnesium. And that one I find tends to be the most helpful for the most amount of people. So if we add that in, you know, let's say three months later they're doing pretty well, but they're still dealing with some major fatigue or maybe some brain fob, lingering migraine symptoms, of course, then we might try something like CoQ10, which is going to help with mitochondrial support, energy production. We might add that in and see if we can get any further improvements. So that's kind of how I would evaluate whether we need to use all three of these or not with somebody.

And now, where should people buy these? Because I know that's not a prescription. What should they look for specifically on a label when they are kind of in the madness of a vitamin store? Because there's probably like 30 different kinds that they can look at. So can you give us a little bit of guidance on selecting a high-quality vitamin?

So if you are buying a supplement, then buying it from a store or from if your provider has a formulary that they use, those are going to be your best options rather than Amazon, because believe it or not, there are counterfeit supplements out there, which is hard to believe, but it happens all the time. So you wanna make sure you're buying from somewhere reputable that's Number one. And then if you can find a product that is third party tested, that means that a separate, you know, third party, a separate company that isn't the supplement brand itself has evaluated that product for purity, for potency. Basically, it says, you know, this product has what it's supposed to have in it and it doesn't have anything that it's not supposed to have in it. So that third party testing, if I can find it, that's going to be my gold standard. And it will specifically say that on the label that this was third-party tested or something like that. Ideally, sometimes you'll need to find that information on the website. And you can even email or call the company. I have done that many times to check. And then you can even request results. That's awesome.

So good to know. Oh, Kelly, this has been so wonderful. So I love to finish with what is the worst piece of advice a clinician could tell a patient who suffers with migraine?

Okay, so I may get a little bit of uh flack for this one, but honestly, I think the worst piece of advice you can just hand someone on the way out the door is to give them a list of foods to eliminate. This is a very common practice. And honestly, it can leave the patients very confused and very anxious around foods. So I think if if that's something that's part of your practice, that might be something to reevaluate and see if it's actually helping people. And if not, maybe we can start to play around with some of the stuff we've talked about today because I think that can be a lot more helpful for the patients and an easier intervention for them to play around with.

So good. And you honestly looped it right back around to where we started, whereas they are not a full, you know, migraine-friendly diet, and keeping that food symptom log is so important. So I think it's better to just give them a piece of paper that says, what are you eating? What are your symptoms? rather than an elimination diet. So I think that would be a really, really good way to change kind of how you practice. Kelly, thank you so much for being with us. You were so helpful. I learned so much from you. I would love to have you back on again. Yeah, absolutely. And thank you so much for having me. This was fun. Awesome. So if you guys want to learn more about migraine management, you can follow Kelly at the migraine dietitian on Instagram. If you have any questions for me or any other topics that you would like me to cover, go ahead and find me on Instagram as well at Exam Room Nutrition. Thank you so much, Kelly. We'll see you soon. Bye, thanks. All right, guys, now it's time for my nutrition notes. In this section, I leave you with a nutrition tip, an encouraging quote, or an interesting case that I think might add value to your day. So I wanted to give you a few questions that you can ask your patients to really help direct your nutrition education. Triggers are so important, but it's really important to remember that migraines are not always triggered by a food. Sometimes it is, but sometimes it's not. And it could be multiple triggers at once. So you can easily just ask your patient, hey, do you know what triggers you? Sometimes they already know this, and sometimes they don't, because it might be a few things. A couple things that patients might think about is smells. So very strong perfumes or cleaning supplies can trigger them to have a migraine. Light, such as bright sunlight or really bright fluorescent lights in a room, and lack of sleep. So it's very important to be asking about your patient's sleep quality. We do know that poor sleep is associated with increased migraine burden. So make sure you're asking about how long they're sleeping and how well rested they feel when they wake up. So I hope this served as a reminder to not only consider food triggers, but to treat your patient holistically to help them get the relief they deserve. Thank you so much for spending time with me today. If you know of any friends or colleagues who would benefit from this information, feel free to grab the link and share this episode with them. Well, that's it for today. So as always, let's continue to make our patients healthier, one exam room at a time. I'll see you next time.