Guest: Heba Bani Hani, BSc Pharm., MBA, MHD

View the recording from our Migraine Clinician Masterclass, developed in partnership with IVPN Neuropsychiatry. In this webinar, we hear from pharmacist, Heba Bani Hani, who talks about Migraine Triggers and Lifestyle. Please note that this video is intended for healthcare providers.

TRANSCRIPT

Heba Bani Hani, BSc Pharm., MBA, MHD: Today, the subject I will be talking about is triggers and lifestyle management, possibly something that is very close to pharmacists’ hearts and also practice, but also it’s something that everybody who’s working with migraine faces every day when you see a migraine patient. 

When we talk about triggers and lifestyle, the first question that I get is, what is a trigger? We know there are symptoms. We know that migraine does not hit suddenly. There’s always things that happen before. There are a lot of symptoms that patients feel or experience before the migraine, sometimes 48 hours before an actual migraine attack. So a trigger is something that is either endogenous or exogenous, and these are things that actually make it more possible or reduce the threshold of a migraine attack, but only in those predisposed to migraine.

An endogenous agent, for instance, is menses. Not everybody who has menses does get a migraine, but if you do have migraine or you’re predisposed to migraine, that is something that can actually bring it on either faster or more acutely. Exogenous agents are something like red wine, a drop in barometric pressure, food, stress, and we’re going to talk about exogenous more than we’re going to talk about endogenous today, but I will also allude to why it is important to look at things that are [cuts out].

So the first question we have, are there any differences in triggers? Are the triggers that can trigger a migraine in women the same as men? Of course, hormonal differences are the first one that is different, so there are gender differences, but they’re mainly because of the hormonal differences. In one of the reviews that were just done and published in Cephalalgia in 2021, they found that sex hormones do differentiate between males and females, and they contribute to a different fluctuation in neuronal brain excitability. That actually affects your internal threshold or the patient’s internal threshold, and that leads to an increased potential of an external trigger to provoke a migraine in women.

Why do we know that hormones do change that threshold, is because at menopause we found that the total number of trigger factors that are reported by post-menopausal women that have already stabilized their sex hormones are very comparable to those in men. 

Now, a cross-sectional study that was again published in Cephalalgia, in 2021, tried to study what are the most common stressors or triggers, and that was the biggest in the world. There were around 7,000 patients, more females than males as you can see, but that is also because of the distribution of the condition where more females live with migraine than males.

Number one was stress, no surprise, a lot of our patients tell us that when stress is more, it’s more likely that they’re going to have the worst migraine of their lives, like the more stress you have, the more likely you are going to have a migraine, and the more likely it is going to be worse than other migraines. Migraine by itself causes stress because of their unpredictability, we don’t know when it’s going to happen, so that actually leads to increased stress triggered by migraine. Is it causative or is it relative, there is a very, very clear link between increased stress leading to worsening of migraine or causing a migraine to come on.

Hormones come next, or second, then missing a meal, hunger, and fasting, we’re going to talk about this. Because of all these new trends that we have now with intermittent fasting, we know that we’re hearing more and more about more people doing a lot of longer periods of no food, and we see that this is actually a big contributor to or a trigger for migraine. Weather changes. For a long time people were saying no, no, that doesn’t happen, but now we know for sure that almost half of our patients do get a migraine with weather changes. Sleep disturbances, another big one, again half of our patients. Perfume or odor, and that is something that is very interesting because now we know that there’s more to the pathophysiology of migraine that might explain why perfume or odor might trigger migraine.

Neck pain, another big one, light alcohol, smoke, sleeping late, heat. So sleep disturbance is 50% and sleeping a little bit later is another 32%. Heat, food, exercise, and sexual activity, 5.2%. 

Now, how many triggers do we know? We know that self-reported by patients, we have 68,000 different types of triggers reported by people living with migraine. And we use an app, it’s called Migraine Buddy, they have around 3 million users. And of these 68,000 different types of triggers, 2,600 are recurring triggers, the things that keep on triggering a migraine every time. 

What I see in my practice, weather changes, I hear this a lot, but again, I’m living in North America where there’s a lot of weather changes, a lot of tornadoes, and a lot of storms, so that means that patients actually experience it more. We know that people who live at high altitudes, so when they go to the mountains or they go to different altitudes, different countries, you see more prevalence only because of these different altitudes and barometrics. The weather changes are more linked to barometric pressure changes. Flights, long car trips, wearing hair in a ponytail, and that is something that I was like, oh, if it’s this simple, then why do you put your hair in a ponytail? Obviously, most people try to avoid it, but if you have long hair and it’s bothering you. There’s allodynia as well, there’s a lot of reasons why people still would do something that they know is a trigger.

Avocados, that was one of the first ones that actually I thought was very weird. Loud noises, certain smells, citrusy food, lemon, lime, all food that tastes different sometimes does trigger. Certain spices. Sunlight, rain, and the one that really I thought was very weird, white plates. If they eat out of a white plate, it actually triggers migraine. One of the things you might say is, oh, is it really a trigger? And the answer to this is, if it’s the trigger for them, just make sure that we do not tell them, no, it shouldn’t be a trigger, because that’s how they feel and we don’t know still why these triggers. We know the pathophysiology of the disease that is related to some triggers, but we really don’t know enough to say, yeah, this can be a trigger or not. Accept it, and let’s find ways to deal with it. 

So why do we need to identify triggers? What is the value of identifying triggers? And there’s something called threshold theory, and that means for you to have a migraine attack, you need to reach a certain threshold. And if we’re able to reduce these triggers, possibly you will not have the attack. And it’s like a cup that overspills. So if you’re stressed, and there’s going to be a weather coming, and you didn’t sleep well, and then you skipped a meal, you had a drink, then most probably you’re going to have an attack. The value of identifying these triggers means that we’re going to find the ones, like if I know that all of these have happened already, I don’t skip a meal. And that means that I still am at the tip of the cup, kind of. And this is what threshold theory is. 

So let’s talk about lifestyle changes and migraine. Can you really control migraine with lifestyle changes? And a study that was a prevalence case, a different study that was published, in 2016, in the Journal of Neurology, they looked at lifestyle interventions, and they saw the impact of regular lifestyle behavior in migraine. And they found that the number needed to treat, so remember. the NNT, how we studied in universities, that if you have, how many patients do you need, or how many interventions, how many patients get the same intervention, how many of them respond? And the number needed to treat here was two. And I don’t think we have any medication at this point of time that is in the NNT, 2.

So this is the best thing that you can do for someone living with migraine, and that is initiating and having the discussion around lifestyle changes. So 2 meaning of every 2 that had lifestyle changes, one of them had benefited from that intervention and showed improvement in their migraine. What this means is that taking a proactive, don’t wait until you have a migraine, be proactive, and multimodal approach, and that is do more than one thing. Have the medication, have the abortive medication, have the preventive, do the supplements, and have lifestyle. All of these, alongside positive lifestyle changes, definitely will help. 

And do not say avoid triggers. We still say this in our practice, we say avoid your triggers. Instead, encourage positive lifestyle changes. The best, I think, way to communicate to other healthcare providers and to also communicate to your patients is to use SEEDS for Success, which was actually a great, great content. That was, I have the reference here, please go, it’s a big document that is very, very easy to follow, but also is very detailed in what you can do in each of those. So SEEDS is the mnemonic that we use, and seeds stand for sleep, exercise, eat, diary, and stress. So if you remember these, and if you try to address these, you’ve basically covered most of lifestyle changes that are needed for people living with migraine. 

So I start with S and S for sleep, and the advice I’m going to give here is not only for people living with migraine, it’s for all of us, because we know sleep is one of these things that affect all our lives. So we know that migraine is associated with a lot of comorbidities, there are a lot of comorbidities that are associated with migraine, and sleep comorbidities, including sleep apnea and insomnia are some of these comorbidities. Poor sleep itself has been described as a migraine trigger. So we know it’s a trigger, but we also know that people living with migraine also have interrupted sleep because of the pain sometimes, because of the interruption, because they’re too tired.

Some of these medications, once they take their medications, they feel sleepy, they fall asleep during the day, they don’t sleep well at night. So there’s a lot of interruption in sleep and migraine. But we know that people who do not have regular sleep, people who have shift work, nurses have higher incidence of migraine. We know doctors report more migraine. We know people who work with shifts, security, any of these professions that have interrupted sleep and have lifestyle or a career that does mean that they do have sleep interruption, have higher risk of migraine, and they have poorer migraine management. And they have poorer lifestyle habits as well, because that increases their stress, increases their lower socioeconomic status, more mood disorders. 

Behavioral modification for sleep hygiene can convert chronic migraine to exotic migraine. And this is the one that I thought was like, so if you intervene with sleep, if you are able to improve sleep, do you really have an impact on migraine? And one of these studies actually showed that you can. People who lived with chronic migraine, once they had modification and behavioral modification for sleep, they were actually changed from chronic migraine to exotic migraine. 

Now remember, sleep apnea is one of these conditions that is very easy for you to find, very easy for you to fix. And if you fix that, then you will see, especially with people who have chronic daily headache. When they wake up with chronic headache, they’re tired, they are really not sleeping. You can tell that there’s sleep apnea, or you think that sleep apnea might be contributing. I love this tool, it’s called STOP-BANG, and it is available at stopbang.ca/osascreeningphp.

So you just put, it’s a yes or no. Do you snore? Are you tired when you wake up? Has anybody seen you or observed you stopping breathing during your sleep? Do you have hypertension? What’s your body mass index? Are you over 50? And your neck circumference and then gender. If you answer these, it’s an online screening tool, you click it, and then it tells you what the odds are of someone having sleep apnea. So the first thing you need to do is definitely try and exclude sleep apnea from your diagnosis. 

Good sleep hygiene. We all know that we can do better with our sleep hygiene, all of us. These are general sleep hygiene, let’s say, ideas that you can share with your patients. And the first thing is definitely avoiding excessive intake of caffeinated drinks. Restrict in the evenings. And caffeinated drinks are not only coffee. You know that tea also has caffeine. We know that a lot of carbonated drinks like Pepsi or Cola or whatever, they do have caffeine. Very, very common now to see a lot of people having these caffeinated drinks because they’re energy drinks and they’re supposed to be healthy, especially if they go to the gym. Sometimes they do not know, and they think that it’s only a rehydrating solution, but sometimes they also have caffeine. So be very detailed in taking the history of your patients, find out what do they drink, and make sure that you restrict caffeine. 

The bedroom, I’m going to say bedroom protocol is a big one in sleep hygiene. The first thing is definitely the room needs to be quiet, dark, and cool. If you cannot have it dark, make sure that they have a sleep mask or find ways to actually make sure that it is quieter. We do know there’s some white noise machines or just things in the background to help people fall asleep.

Sleep, too little sleep, and if someone has too little sleep and they oversleep, they think that the migraine will go away. That’s a myth. Too much sleep is as bad as too little sleep. So make sure that they have a routine where they go to sleep every day at the same time and they wake up at the same time. Most of my patients, again, say that sometimes on the weekends they oversleep because they’re tired from the weekend and they wake up with the worst migraine or it builds up during the day. And we know we have let-down migraine that is reported for people who have very stressful jobs. As soon as the weekend comes, they have the worst migraine ever, and some of it is related to sleep. So make sure that you address sleep. 

Your bed should always be and should only be associated with sleep. You don’t eat there. Even reading. Try to read in your living room and when you go to your bed, make sure that it’s associated with sleep because it makes it easier to fall asleep in bed. If patients are unable to fall asleep within 20 to 30 minutes, they should get out of bed.

I know I’m as guilty. If I’m not able to sleep, then I stay there and I try harder and harder. Make it a point that within 20 to 30 minutes they need to leave the room and then they come back, try to read, do a cup of herbal tea or like chamomile or something to just calm you down. And this way, your bed will not be associated with frustration or anxiety. Phones, tablets, TV, blue light, we know we all know about that other than the excitation that comes with and all these new apps that you cannot stop. Sometimes you cannot stop because it is actually designed for you not to stop. So make sure that you avoid them in bed or in your bedroom. 

E is for exercise and remember in the ICHD criteria for migraine, avoidance of physical activity is a main characteristic. Low levels of physical activity are associated or a sedentary lifestyle. But if someone is in pain and you tell them you have to exercise, there’s a big chance they will not be able to because it becomes a little bit. This is one of the most difficult for me to actually counsel on and that is E for exercise. However, in two studies of migraine, we found that exercise benefits were equivalent to those of migraine preventives such as amitriptyline and topiramate. Combination of a preventive alongside exercise was more beneficial than exercise alone. So the best thing is that you do provide a preventive and you encourage exercise. 

Some patients, as I said, will identify it as an exacerbating factor in migraine. By definition, avoiding exercise is one of the things that we identify migraine with or that we link to migraine. These might not work. You’ll not be able to have them to start the exercise without actually making sure that they have the right preventive and abortive as well. If a patient is not able to exercise, try to start with even once a week, shorter time periods, and then do low-intensity exercise and intervals of 20 minutes. Do not make it exercise that is like aerobics, go for something that is very aerobic. The best is cardiorespiratory exercise.

And again, another study that said that jogging, walking, cross training, and cycling were done for at least 6 weeks for 30 to 50 minutes, 3 to 5 times a week. And they found that this is when you get impact. It’s not only that they need to start. Make sure that it’s small and then they add to that.

The next letter in the mnemonic is E for eat. And of course, eat is food and drink. And we all know I’m one of these people that every time Ramadan came, I knew that I was going to have a headache. We’re not talking only about the headache, we’re talking about migraine. We’re talking about the headache also starting as a headache because you missed a meal or you’re hungry or you were fasting and that because of the predisposing migraine tendency of a patient that goes into a migraine. 57% and alongside that 27%.

What’s the difference between missing a meal and between food as a trigger? Missing a meal might actually be interfering with your blood glucose levels. It’s also dehydration. It’s different from food triggers because food triggers or food being reported means that it’s something that they drink or they eat, and as soon as they eat it, it triggers a migraine. The one I hear again, as I said, I have citrusy food. I heard about avocados/hot dogs. One of the things was MSG in Chinese food, and that was a little bit conflicting. It’s not for us to say which ones they are. Our job as healthcare providers is to help patients identify what these triggers are, and we need to work with them to identify them.

Again, caution that triggers are different from cravings. For years, we were telling patients do not eat chocolate because chocolate might trigger a migraine, and now we know it’s a craving. It’s one of these 48 hours before a migraine, some of these premonitory symptoms that we see with people living with migraine.

I think all of you have heard of all the popular diets that are out there. I know that the one that everybody I know on is now keto and intermittent fasting. We know that intermittent fasting might actually trigger, so we do not recommend it for people living with migraine unless they have the migraine under control and then they can start working with migraine diets or with diets that are different.

Keto, we have seen some initial studies that said that going keto will help with migraine, but we know that this was not maintained. It starts and it might be because they lose weight with keto and they limit a lot of food substance and blood sugar fluctuations, but that was not maintained and that was not sustained over time. 

Elimination diet is the one that is very popular and they call it the headache diet. And that is they start by eliminating everything and then introduce one by one different types of food, and then they have a diary and they report and they’re able to see if there’s something. I think it makes sense. It needs a lot of work from the patient, and they need to work with someone to help them. Gluten-free, we know a lot of comorbidities, lactose-free and gluten-free, we know a lot of IBS and GI comorbidities are very common with people living with migraine.

Low glycemic, vegan. The one I really, really like is high omega-3 because we know there was a BMJ article that was published a couple of years ago that said high omega-3, low omega-6 is a very good diet, and they were able to show that there is benefit. 

So the best advice you can give on food and drink, definitely hydration is the number one. And this one makes me worry a little bit when I say it’s number one because most of my patients keep on complaining that every time they tell someone I have a headache they tell them drink water and it’s not as simple as drinking water. We’re saying what else can we do? It’s that threshold theory. Make sure you’re hydrated. And one study said 4 L per day. We know that we need 1.5 to 2 L but one study showed value in as much as 4 L. I also tell my patients make sure that you also have electrolytes, not just water, make sure that you are not restricting a lot of sodium and that you’re not restricting also electrolytes in your diet.

Regular meals is something that is very important. Do not skip meals, make sure that you have regular meals, you have snacks throughout the day. Breakfast is something that is always missed or is something that we all can do better with. Try to have breakfast within 30 to 60 minutes of awakening, and this can be linked to the next one. Replace your simple carbohydrates with protein, fat, and fibre. And within 30 to 60 minutes from waking make sure that you have your biggest protein meal of the day. If you can have an egg or if you can have a smoothie that’s protein rich, that’s a great idea. Fat and fibre is also very good for you. Limit caffeinated drinks, as I said. Increase omega 3 and reduce omega 6. We know omega 3 is anti-inflammatory when omega 6 does cause inflammation. Increase gut microbiome health and that is try to get probiotics, prebiotics, fibre in your diet. And always focus on positive change instead of avoidance, like add natural anti-inflammatory food. Do not say avoid but replace and start might actually have better uptake from patients.

D is for diary and we know keeping a food diary is very important, but a food diary is not only to identify food triggers, there are a lot of apps that are coming up for a headache diary is something that is very crucial for someone. If you’re the primary healthcare provider that you’ve seen the patient or if you are a neurologist, a headache diary is something that is very very useful. It also helps people feel that they’re in control, they can see, they can intervene and they can see if changes that they do will actually have an impact on migraine.

We know that electronic diaries are very very popular now, I know a lot of my patients do use apps, but I have a lot of patients that say I want a paper one. And we do have printable ones that are available online, you can just download it from online and you ask them to put it on their fridge and just do an x for number of attacks that they have or the day that is good. Very simple ones are more likely to be filled than more complicated ones. 

S is for stress. And who doesn’t know that stress is bad for you? There’s a lot of things that we can do for stress and behavioral management is the number one. Cognitive behavioral therapy has been shown to be most important in managing migraine and in supporting people with migraine. Catastrophizing is something that I always see with people living with migraine because they are very worried about what people will say, what will happen, am I going to be affecting someone else. So catastrophizing, I’m going to have a migraine on that important day. I’m not going to be able to go. Or if I’ve just apologized to an event or to an invitation, then in their head, they start thinking, oh, I’m never going to be approached again or I’m never going to be invited again.

And the most important thing is to try and work with them to try and manage these catastrophizing ideas and to try and decrease them and decrease the disability that is associated with migraine. Either in one-on-one, cognitive behavioral therapy is one-on-one, or it could be also in group therapy. And the effects actually are most experienced after 5 weeks into treatment. Biofeedback uses behavioral techniques with physiologic autonomic measures, and this has been extensively studied and does show benefit in migraine.

Mindfulness, it’s like everybody now hears about mindfulness. We are taught, like I hear mindfulness in everything, and that is to be in the moment and to be aware of the thoughts. Do not dismiss your thoughts and do not dismiss or judge what you’re feeling as this is bad, I shouldn’t be feeling like this, but acknowledge them, acknowledge the thought, and that helps reduce the stress. If I say, yeah, I’m upset or I’m disappointed, but it’s okay, it’s something that is not bad, I’m not doing something bad by acknowledging. And being in the moment, enjoying the today, the good days are good days, enjoy them, live in them instead of worrying about the other days that you will not be able to do things. 

Relaxation techniques, again, can be either done alone or can be done with other techniques. They are based on deep breathing, muscle relaxation, and the best thing is to actually combine relaxation techniques and help patients develop the skills. You start with working with a professional but then be able to progress to do this on their own. 

In conclusion, when we talk about SEEDS for success, remember SEEDS is sleep, exercise, eat, diary, and stress. Standard sleep hygiene recommendations are very important to maximize sleep quality and quantity. Exercise, the aim is to reach 30 to 60 minutes, three to five times per week, but can be as much as 20 minutes once a week, progressive, low impact, and then you build up. The value that was seen with exercise was not with how much exercise, is how much more you’re able to do over time, and that is not only for people living with migraine. We know the best value of exercise comes from how much more can you do over time. 

Eat regular meals, adequate hydration, and low or stable caffeine intake. I always get the question, how much caffeine is good? How much caffeine can people take without actually it affecting their migraine, and can I stop caffeine? Because we have this cold turkey, how do I stop caffeine? Do not stop suddenly because you will basically risk a rebound similar to medication overuse headache. It can have the same characteristics, start slow, say reduced by half a cup, two, three days, then another half a cup, and the idea is that you need one to two cups per day. That is not seen as, it might not actually become something that affects migraine. It will neutralize the effect of caffeine. Unless it’s a trigger, then obviously you try to take it out. People who know that it’s a trigger don’t usually use it. 

Smoking is something we didn’t talk about, so also reduce smoking, make sure that patients are supported to stop smoking.

Diary, a baseline pattern is very important. Again, if you’re in primary health, if someone is going to go see a specialist and they go with a diary, it makes it much easier for the specialist to actually give better advice. Then stress, cognitive behavioral therapy, mindfulness, relaxation, biofeedback, and provide the patient trust to minimize anxiety. If your patient trusts you, they’re going to be absolutely more likely to accept advice from you. 

I’m going to talk about pharmacists because I’m a pharmacist and that’s what I do. Just remember that we are available, we are accessible. You don’t need an appointment to see a pharmacist, so encourage your patients to go talk to a pharmacist if they do not have immediate access to their family doctor, to their specialist, at least to triage if there’s a need for triage. Migraine is a neurological disorder and there are a lot of comorbidities, so do not only look at migraine; look at the human being. Treat this as a person, not a disease.

Migraine presents in the community pharmacy for different reasons. People come to the pharmacy for OTC supplements or prescription dispensing. These are excellent intervention points for education, for support, and for building trust with the patient.

Lifestyle discussions are very often overlooked by specialists and that is not because they don’t want to do it. Everybody wants to talk to a patient about how else they can improve their lifestyle and manage their migraine, but there are time restrictions and there is expectation that other allied health professionals like family physicians, nurses, and pharmacists will be involved in migraine management. It takes a village. When we said it’s multi-modal, it’s also multidisciplinary. Not one person is enough to manage and support people living with migraine. This is a condition that can be a lifelong condition. 

In terms of resources, as you know, the Association of Migraine Disorders is an organization that aims to educate, support, and advocate for people living with migraine. They have resources for patients that you can just print out and give to your patient, but they also do have educational resources that are for healthcare providers, and you can see these. We have a webpage that’s only on migraine triggers, migraine treatments, migraine diary, PDF that I talked about how you can actually print it that is available. Migraine safe foods blog, people talk about safe foods. And five lifestyle changes for managing migraine is a podcast and if you have the time to listen to podcasts, I think the Association of Migraine Disorders migraine podcast is the best out there not only for patients, I listen to it. They have also migraine minute that is only one minute about the latest in research. So if you’re interested, that’s a great, great resource.

If you’re a pharmacist, the Ontario Pharmacists Association in Canada has just released a training program, a Canadian CME training program that you can take. I think it’s open for everybody; anybody can take it. You can go register and you can actually know more as a pharmacist. I know that, again, there’s a lot of organizations that do provide free of charge education that’s open for allied health. 

My final thoughts on lifestyle changes is remember that you’re not the one who’s going to apply these changes that we’re talking about. Patient needs to be willing, and they need to be accepting, and they need to be trusting that you have their best interest, that you’re not trying to sell them something or give them one extra pill, that they need to feel that you’re supporting them.

And the changes required are not easy. People are living with disability, and they need to be introduced very slowly, one at a time. And the best thing that can be done for people living with migraine is to provide them with the best management strategy, whether it is with medication, with prevention, with abortive that actually works, with reducing side effects and making sure that they have the best tools and the best medication and the best support and listening and hearing them out.

Thank you. Empowering patients is something that I’m really very passionate about, but also I hope that this helps you in your day-to-day practice in talking to patients about triggers.