The Caffeine Paradox for People Living with Migraine Disease

Medically reviewed by: Andrea D. Murphy, MSN, APRN, ANP-BC, NEA-BC, AQH

If you have migraine disease, you’ve likely heard plenty of conflicting advice about caffeine. Does it cause migraine attacks? Does it stop migraine attacks? Should I have more or less? When we talk about anything having to do with migraine disease, the answer is often, “It depends.” Here’s what we know about caffeine and how you can figure out your best options.  

The Caffeine Paradox

Healthcare professionals have known for decades that caffeine plays a role in treating tension headaches and migraine attacks. People who typically consume a lot of caffeine may get non-migraine-type headaches if they skip or delay their morning coffee.  People living with migraine are sometimes counseled to avoid regular caffeine use, but many acute migraine medications, from over-the-counter remedies to prescription treatments, contain caffeine. How can someone with migraine disease decide what to do?

Clues in New Science

Experts used to believe that changes in blood flow caused migraine attacks, which led them to think that because caffeine might constrict the blood vessels, pain relief may result. Thanks to advances in science, experts currently believe that migraine attacks are caused by irregular electrical activity that spreads over the surface of the brain, causing changes in brain activity and blood vessels. In response, the trigeminal nerve is activated, which releases neurotransmitters and other substances that cause inflammation leading to many migraine symptoms such as head pain, nausea and vomiting.  Blood vessels constricting and expanding may play roles in the migraine process, but they’re no longer believed to be the root cause. Instead, caffeine may help abort an attack by blocking the action of adenosine, a protein involved in many cellular and molecular functions.¹ Adenosine dilates blood vessels and may play a role in headache and pain.¹ There is also speculation that caffeine affects the gut microbiome, which we’re learning may affect migraine disease and many other conditions.²

Caffeine and the “Goldilocks Spot”

Remember the story of Goldilocks and the Three Bears? Goldilocks thought this bowl of porridge was too hot but that one was too cold. Migraine brains can be as sensitive as Goldilocks, demanding that all kinds of conditions be just right to avoid migraine attacks. Well, there may be a “Goldilocks spot” regarding caffeine for people with migraine, an optimal zone in between “no caffeine” and “enough caffeine to trigger an attack.” A 2019 study published in the American Journal of Medicine asked 98 people with migraine disease to keep detailed records of their caffeine consumption, attacks, and other details.² The result: 

• Three or more servings of caffeine per day seems to be the point at which caffeine is more likely to trigger an attack that day or the following day.³ 
• Participants who typically had one or two servings of caffeine per day did not show any statistical difference.³ 
• Participants who usually had less than one serving of caffeine per day faced an increased likelihood of an attack on the day when they had one or two servings of caffeine.³

A new 2023 study published in Nature surveyed 8,993 adults who self-reported having severe headaches/migraine and found that for every 100 mg increase in caffeine per day, there was a 5% increase in the prevalence of severe headache or migraine attacks.⁴ They found that the prevalence of severe headache or migraine was 42% higher with a caffeine intake greater than 400 mg/day compared to a caffeine intake of 0-40 mg/day.⁴ Note, the condition of the people who took the survey that reported having severe headaches/migraine disease was not confirmed by a physician, ICHD-3 definition or ICD-10 code.

What Should YOU Do?

First, if you usually don’t have caffeine often, you don’t have to start now. Your threshold for caffeine might be lower than that of your friend, who downs a few cups every day. Save caffeine for special occasions or acute medications, and pay attention to your reactions for that day and the next day. You may detect a pattern that helps you decide if you want to use caffeine at all or avoid it. If you usually have one or two servings of caffeine on a regular schedule, pay attention to your responses when you change that schedule. Are you more likely to have an attack if you have an extra cup of coffee? Or if you skip the caffeine? How do you feel the day after a change from your regular consumption? If you notice you’re more likely to experience an attack after a change in your regular caffeine intake, you may decide that keeping your consumption at the same level every day works best for you. If you usually have three or more servings of caffeine daily, it might be worth experimenting with reducing your caffeine intake. The general consensus is to keep caffeine intake to < 200 mg per day (ie. two 8 oz of brewed coffee). Remember, the migraine brain hates big changes, so if you decide to try reducing your caffeine intake, take small steps and go slowly. Instead of dropping one or two servings right away, you could try reducing by half a serving for several days. If that step works with minimal migraine revenge, you can continue to go down half a serving at a time. You can adjust the size of those steps as you need to.

How Much Caffeine Is In Your Favorite Drink?

The average can of cola has about 50 milligrams of caffeine, but a medium cup of brewed coffee might have double that or more. Some beverages, like sodas and energy drinks, will have labels on the cans and bottles. Others, like coffee or tea from your local coffee shop, might require you to look at a menu or ask for a handout. It’s worth the effort to find out, especially if you decide to adjust your caffeine intake in either direction. What feels like a small step might pack a bigger punch than you expected if your favorite food or drink has a LOT of caffeine!  Some over-the-counter and prescription medications contain caffeine. If you think you’re consuming a small amount of caffeine daily but use these medications intermittently, you may be getting more caffeine than you think.  The Center for Science in the Public Interest publishes a comprehensive chart of caffeine content of many beverages, foods, and over-the-counter medications and supplements. We recommend you save links to this kind of information.

A few highlights:⁵

Whether you’re caffeine-free or your local barista knows your usual order by heart, caffeine may play a role in managing your migraine disease. Determining your threshold and finding your optimal caffeine dose may take trial and error but spending more time in your “Goldilocks spot” is worth it!

This article is sponsored in part by Pfizer and AbbVie.⁠

References

1. Brain Science, “The Role of Adenosine Signaling in Headache: A Review,” 3/13/17,  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5366829/

2. https://pubmed.ncbi.nlm.nih.gov/35057580/

3. American Journal of Medicine, “Prospective Cohort Study of Caffeinated Beverage Intake as a Potential Trigger of Headaches among Migraineurs,” 8/8/19, https://pubmed.ncbi.nlm.nih.gov/31402050/

4. https://www.nature.com/articles/s41598-023-36325-8

5. Center for Science in the Public Interest caffeine chart: https://cspinet.org/eating-healthy/ingredients-of-concern/caffeine-chart

Author

Lisa had migraine attacks for most of her adult life before being diagnosed with migraine disease. A communications strategist, writer, and former radio announcer, she lives in the Boston area, where she advocates for her fellow migraine patients every chance she gets.