Migraine triggers not as strong as patients believe?

Medscape article today:
Trying to provoke an attack of migraine with aura in a laboratory setting by using patients' self-reported triggers was successful in very few cases, a new study shows, leading the study authors to conclude that migraine triggers may not be as strong as patients believe.

The study, published online January 23 in Neurology, was conducted by a group led by Anders Hougaard, MD, from the Danish Headache Center, Copenhagen.

Dr. Hougaard suggested that these new results could have implications for advice given to patients about triggers.

"Migraine patients are usually advised to identify triggers and try and avoid them," he told Medscape Medical News. "But our research suggests that this may be limiting people's lives and causing unnecessary stress in trying to avoid a wide range of factors which may turn out not to be triggers after all."

"Of course patients need to try to identify triggers but they need to establish that they are true triggers before cutting them out of their lives. So I would advise that they allow several exposures before defining a trigger. Many people avoid a whole array of factors such as red wine, chocolate, cheese, coffee, exercise, and sunlight. This can make life very difficult and it might not be necessary."

Dr. Hougaard also pointed out that migraine trigger is not a simple "yes or no" issue.

"It is much more complicated than that. The threshold for a migraine attack probably varies according to many other factors including stress, tiredness, hormone levels etc. Patients are more vulnerable to attacks at certain times," he said. "The lab setting is artificial. We can't replicate the stress of everyday life. It would be better to test in an everyday life setting but that's hard for a scientific study."

Trigger or Premonitory Symptom?

Dr. Hougaard also raised the possibility of triggers being confused with cravings or certain behaviors that are actually part of the start of the migraine, or a premonitory symptom. "Migraines are often preceded by certain feelings such as tiredness, excitement or depression or cravings for certain foods. It might be that a craving for chocolate which is a premonitory symptom could be misinterpreted as a migraine trigger."

For the study, the researchers recruited 27 patients with migraine aura who reported that bright or flickering light or strenuous exercise would trigger their migraine attacks.

They underwent provocation with different types of photo stimulation, strenuous exercise, or a combination of these 2 factors. This resulted in attacks of migraine with aura in only 3 (11%) patients. An additional 3 patients reported migraine without aura. Exercise was a stronger trigger than photo stimulation.

Dr. Hougaard told Medscape Medical News that bright light and physical activity are 2 of the most common triggers for migraine with aura, the other two being stress and emotional influences, which are more difficult to simulate in a laboratory environment.

"While we can't extrapolate our results for sure to other triggers and to migraine without aura, I would think there is a strong possibly that the results would also apply to these too," he added.

Explore efficacy data
In an accompanying editorial, Peter J. Goadsby, MD, from the University of California, San Francisco, and Stephen D. Silberstein, MD, Thomas Jefferson University, Philadelphia, Pennsylvania, agree with Dr. Hougaard that the classic advice of avoiding triggers may be wrong.

"If migraine is a disorder of habituation of the brain to ordinary sensory signals, should one try to train the brain to habituate rather than avoid the trigger?" they ask. "Many questions are unresolved and require continued careful, bedside approaches to studying this common, disabling brain disorder."

Yes, the problem is that that a lot of triggers only increase the probability of a migraine. It doesn't guarantee one. So getting it to occur in those circumstances may be tough. It also doesn't say what the time frame was. You may not get the migraine until 6-24 hours after the trigger in many cases. I don't think I'd put too much weight on that study.

Yes, I've read that triggers might not be as important as we've thought. Here's what I've noticed....when we are given a set of facts that go against what we have believed for a long time we tend to discount them. We have a hard time changing what we have believed. I think this only works against us. It's good to keep an open mind. g.

Perhaps, and I don't have a lot of discernible triggers myself. Those I have found only increase the probability of a headache (like 48% compared to a 30% baseline).

But there are many people on here who will swear that chocolate or msg or whatever is a major trigger for them with loads of experience to back it up. And I know a lot about how studies like this are done. So I'm a lot more inclined to believe these people's experience than I am to say its not true because a migraine couldn't be produced in a laboratory in 2 hours time based on that trigger. We all know time delays can be much longer and there is often not a one to one correlation where every time you experience the trigger you get the migraine.

I think the likelihood this guys poor results were due to poor methodology is well within the realm of probability. Other researchers don't seem to find this problem. That's why any one study needs to be viewed carefully and with a grain of salt. Ths article fails to do that. Not scientific, just pop reporting of science which is often distorted.

charmed quark wrote:Dr. Hougaard also raised the possibility of triggers being confused with cravings or certain behaviors that are actually part of the start of the migraine, or a premonitory symptom. "Migraines are often preceded by certain feelings such as tiredness, excitement or depression or cravings for certain foods. It might be that a craving for chocolate which is a premonitory symptom could be misinterpreted as a migraine trigger."

I definitely agree with this and have experienced it myself. For many years I would get an undeniable urge to take a nap in the day. It was so severe I could not think of anything but sleep and eventually would have to give in and take a nap. 99% of the time I woke up with a migraine.

I used to think, understandably, that naps triggered my migraines. Eventually I tried to resist taking the nap and sometimes succeeded - but I would still get a migraine a few hours later! I finally realized that the strong urge to sleep was a precursor to a migraine, not a cause.

The strong urge to nap before migraines has since disappeared, now that I have stopped eating artificial food colorings.

I have a book called Breaking the Headache Cycle by Ian Livingstone M.D. He is a neurologist. He feels we put too much importance on triggers. This may or not be. Since reading this I try to keep an open mind. I also feel one of my triggers is chocolate. Now I am wondering if that is perhaps a premonitory symptom and not a trigger. I think only experimenting with this would prove this one way or the other. g.

I am genuinely surpriised that so much validity is attached to sudy of such a complex issue as migraine triggers, after such a small and isolated sudy, by these prominent neuroligists. I am saying small because it mentions that 3 patients being 11% who, responded to ecercise and light triggers, which means that it was rather small trial group. This does not seem like a very convincing trial.

I also think that the test was too simplistic (because only two triggers were tested in isolation from all other factors). Those of us who suffer from triggers know, that triggers often act more powerfully when certain conditions combine and that one or two triggers will be fine, but getting say three or more close to each others, will definitely get the migraine going.

I have also observed that M would arrive sometimes as late, as 48 hours after the specific trigger, especially if there is also weather change, or I am tired or stressed etc. After a decades of suffering from M, some of my triggers remain the same, but others might fade a little, only to be replaced by some new triggers which were harmless in the past. All this means that the situation with triggers is more complex then this study covered.

I definitely think that what these Drs say, that being exposed to triggers will make us less sensitive to them is, with due respect, an absolute nonsense. In my earlier years I have been exposed to one cigarette smoking member of close family for many, many years, something that I could not escape, and something that has caused me constant misery of very frequents M as a result.

A cinsatnt exposure to this trigger never made me less sensitive only more. And even now, whenever I am in presence of that memeber of my family, or any other smoker, even a whiff of tobaco, I get almost instant M.
Also, ever since I was in my late teens I had a favourite scent (it is French, and very light and subtle) and I was using it for many, many years, and adored it, but suddenly for no reason, this scent became a bad trigger for me, and to this day I cannot bear to be near it (or any other scent) without risking a bad M.
I could go on with other such examples, as I am sure many of us could.

I do think that all these important doctors often come to very quick and wrong conclusions in order to produse the latest theories, when they run of ideas about how to really help us with this complex condition, becasue they have no answers for us. After all , any such new "theory" will allowe them to publish the next "scientific" paper to show that they are doing something, to have something to talk about at their conferences. This what they do, this is what gives them aura of progress.

The outcome is that they are confusing us, the patients, further without providing any viable solutions.
Sorry if I sound cynical, but I have seen, and read, over the years as the same doctors often contradict themselves as one theory follows another, but nothing much changes for us. NOt for a long time, anyway.

I wish that some of my triggers would go away, I really do, but they are here, and I am too tired and too weary, to start experimenting with getting dozens of deliberate M perhaps for several months, by exposing myself time and time again to my most viscious triggers. NO, thank you I will pass on that one.