S1 E2: Managing Migraine Triggers

Managing Migraine Triggers

Series 1, episode 2

Heads Up is the award-winning podcast series on all things headache, brought to you by the National Migraine Centre.  Produced by leading headache doctors, it’s the trusted source of information and support for all those affected by migraine and headache.

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Transcript:

[00:00:00] Did you know Simon Cowell, Serena Williams, Hugh Jackman, Whoopi Goldberg and Phillip Schofield all suffer with migraine, you are not alone. Welcome to the Head’s Up podcast brought to you by the National Migraine Centre, the only UK charity treating migraine and headache.

Dr Jessica Briscoe [00:00:24] Hello, it’s me, Dr. Jessica Briscoe. I’m joined by Dr. Katy Munro today.

Dr Katy Munro [00:00:29] Hello.

Dr Jessica Briscoe [00:00:30] And we are going to be talking about triggers.

Dr Katy Munro [00:00:34] Oh, yes. Triggers. Migraine sufferers need to think about triggers, but there are some things which are more likely to cause you a migraine than others. And so we’re going to talk about the most common things first.

Dr Jessica Briscoe [00:00:49] Yeah, so the one I always- I think the way I always start thinking about it is the fact that actually triggers are often multiple. So it’s very rarely just one thing that causes migraine. And they can vary from person to person. So one person’s trigger, which is very strong, may not be a potent trigger for someone else. So it’s important to talk to people about triggers, but don’t expect things to react with different people in different ways, basically.

Dr Katy Munro [00:01:18] I think sometimes people think that if they can find the one thing that gives them a migraine, then they’ll be fine and be able to stop it and it’s never that simple unfortunately. There’s a thing called a threshold theory of migraine, which I sometimes talk to people about, which is basically if you have one trigger, you probably get away with it, two triggers you build your brain sensitivity so that it’s nearer to the threshold of having an attack and then three or four things all changing at the same time and we know the migraine brain is sensitive to change. And so it might be a whole different combination of things adding together to push your brain over that threshold and that’s when you get your attack.

Dr Jessica Briscoe [00:01:57] Yeah, if you have a look at the website, there’s actually a diagram which shows exactly that process.

Dr Katy Munro [00:02:02] Yeah, I like that diagram, it’s quite helpful. I think the other thing about triggers is that they can be occurring in the 24 hours before you actually get the headache. It’s not straight immediately before the pain. Assuming that your migraine is a headache, which we know it isn’t just a headache. And so, yes, think about the whole day before your attack starts.

Dr Jessica Briscoe [00:02:25] Yeah. So what kind of things can be triggers? I tend to think of them as things that basically- well the way we put it in medicine is anything that sort of causes variation to your homeostasis, which in lay terms means anything that takes you away from your normal basically. So the first thing I tend to think about is food triggers. So not specific food triggers, which tends to be my bugbear, if I’m honest, not things like cheese, chocolate, citrus, which everybody blames on their migraine, but actually is usually caused by a craving just before the attack starts. No, it’s changes in blood sugar level. Now, if you think of the fact that sugar is the fuel for the brain, if you’re someone who suffers with migraine, your brain is much more irritable or irritated by changes in that blood sugar level, so any rapid movements up and down. You want to be keeping that blood sugar level much more even. And you do that by eating nice and regularly, not skipping meals and sometimes by having a snack before bedtime to stop that level dipping down too low.

Dr Katy Munro [00:03:29] Yeah, the other time when the blood sugar can go zooming down is when you’re doing some exercise. And so exercise can be a trigger. And that’s partly, I think due to the blood sugar going down. Sometimes people get dehydrated during exercise because they haven’t drunk enough water, but sometimes just the exercise itself. Although in other general terms exercise is a good thing, but it’s more little and often rather than doing a sudden burst of intense exercise and then not doing anything for another fortnight.

Dr Jessica Briscoe [00:04:00] What do you think about caffeine?

Dr Katy Munro [00:04:04] I love talking about caffeine. It’s quite interesting, isn’t it? So everybody likes a coffee or at least some people like a coffee. Some people like to have half a dozen coffees and if you do that, you will tend to get headaches from too much caffeine. So caffeine overuse headache is definitely a thing. If you then decide to stop all those coffees and go cold turkey, you’ll get caffeine withdrawal headaches. But if you just have the odd coffee now and then, you’ll probably find that if you have a coffee or caffeine containing drink at the beginning of a migraine, it can help. So I generally advise people, keep your caffeine in the morning and keep it moderate. One coffee a day maximum. And also, don’t forget that tea, red bull, Coca Cola, chocolate. There’s chocolate covered coffee beans, do you know those, Jess?

Dr Jessica Briscoe [00:04:52] Yes i love them!

Dr Katy Munro [00:04:52] Do you snack on them? They have a lot of caffeine in them actually.

Dr Jessica Briscoe [00:04:56] I don’t, because I drink too much coffee already.

Dr Katy Munro [00:05:00] So you can have decaf, but even decaf actually has a little bit. So herbal teas in the afternoon, like redbush or other things can be quite useful. And also they don’t interrupt with your sleep. So talking about sleep…

Dr Jessica Briscoe [00:05:14] Yeah, sleep is another big trigger for some people and we’re all obsessed with how much sleep we get. And that’s really important, we all should be getting seven to eight hours if we can, but for people with migraine, it’s actually the change in routine. So it’s that change again. Change is the word you’ll get bored of me saying. It’s that change again that can do it. So you want to be going to bed and waking up at the same time every day where possible. Even shifts of up to an hour either way can make a difference. And that’s often actually what leads to one of the many things that can lead to a weekend attack or attacks when you go on holiday. So jetlag can cause that kind of problems because you’re changing time zones.

Dr Katy Munro [00:05:59] Yeah, but what about my lie in at the weekend? I hear you cry.

Dr Jessica Briscoe [00:06:04] I mean, I would avoid it personally. Unless you are in a period of time where everything- you’re not having too many migraines, everything else is quite stable, you might eventually be allowed to let yourself have the odd lie in.

Dr Katy Munro [00:06:18] I do sometimes say to people, if you really want to have a lie in and let’s face it, who doesn’t like a lie in? Put a little snack by your bed, wake yourself up, have a little quick breakfast and then have a little snooze after that. Do you think that works?

Dr Jessica Briscoe [00:06:30] I think that’s better. It depends which one’s a stronger trigger for you though.

Dr Katy Munro [00:06:33] Yeah, that’s true. So sleep. There was a study actually that showed that probably people with a migraine brain need a little bit more sleep than the general population. So it is really important to get enough sleep. And the other thing is if you have fragmented sleep, so if you’re tossing and turning and sometimes people wake in the night several times because they have a thing called sleep apnoea. So do you see many patients with sleep apnoea?

Dr Jessica Briscoe [00:07:01] I’m seeing more and more. I think it is becoming more- I don’t think we’re very good at diagnosing it, but it’s certainly something that I found can make people’s migraines a lot worse.

Dr Katy Munro [00:07:11] So sleep apnoea is what we call when people are snoring during the night and then they’re suddenly- they’re snoring gets suddenly louder and louder and then they seem to stop breathing. And it’s a thing called obstructive sleep apnoea. The airway closes off, they stop breathing. Their partner nudges them in the ribs and says, are you alright? And then they wake up and then you go back to sleep again and the whole cycle starts over again. The problem with it is that your oxygen levels can dip down. So if you are a big snorer or your partner says, do you know you stop breathing sometimes during your sleep? It’s a good idea to go and see your doctor and have a chat about whether or not you need a sleep study. It does sometimes give morning headaches.

Dr Jessica Briscoe [00:07:59] I think the next one to talk about is stress.

Dr Katy Munro [00:08:02] Yeah, stress and excitement.

Dr Jessica Briscoe [00:08:04] Yes, I think of it as emotion. That’s how I tend to describe it. So essentially people find that- and I think this gets blamed as a trigger by a lot of health care professionals and people who don’t suffer with migraines will say you must be very stressed and anxious and that’s why you’re getting migraines. It’s definitely true that any extreme emotions so being very stressed, can drive migraines. And it’s not often during that period of stress, but it’s actually when that stress level has dropped down again. So people might feel they have a migraine at the beginning of a stressful period and then once the stress has gone away and that often also accounts for weekend migraines or migraines when people have holidays as well because they’ve relaxed. And personally, I think it’s a hormonal response so when people have quite a big emotional sort of they feel very excited, really angry, happy, sad or upset, their emotions, their adrenaline and cortisol levels go up. And then once those emotions have gone out, they drop back down. And I think it’s those levels.

Dr Katy Munro [00:09:07] So we’re back to change again, aren’t we? And of course, the time that you’re stressed or excited, other things can be changing. So it might be that you don’t sleep quite so well and you don’t eat quite so regularly or that you’re running around or you might have neck and shoulder tension because of being a bit worried about something or all sorts of other things can be changing. So it’s never quite as straightforward. Do you find I think that sometimes when people have been told that oh it’s probably just stress. It feels a bit dismissive.

Dr Jessica Briscoe [00:09:37] Yeah.

Dr Katy Munro [00:09:37] But actually it’s really important to take that into account. And so, you know, we often talk about stress reduction using techniques like mindfulness or something like that. We’ll probably cover that later in another episode.

Dr Jessica Briscoe [00:09:47] Yeah, i think that’s a good idea.

Dr Katy Munro [00:09:49] You said about hormones. I’ve just realised there are so many triggers that we haven’t covered. Hormones, weather, light glare, illness…

Dr Jessica Briscoe [00:09:59] Neck and back pain.

Dr Katy Munro [00:10:00] Yeah! I mean, literally, if you have that sensitive brain that migraine sufferers have, change of any sort of thing in your internal environment or your external environment can add together to irritate your brain, to cause you to have an attack. So we’ll probably come back and talk about some of those in more detail in future episodes.

Dr Jessica Briscoe [00:10:19] I think that would be a good idea. I feel like I’ve only just scratched the surface.

Dr Katy Munro [00:10:22] Yes, indeed. Charlotte and Swati spoke to some of our patients about migraine triggers. Here’s what they had to say.

Swati [00:10:32] Hi, Cara. Thank you for joining us. So today I want to know from you what are your migraine triggers.

Cara [00:10:39] I’m still trying to figure them out even after having migraines for such a long time. But for me, I find if I avoid gluten, that really helps. You know, really bright lights can sometimes trigger a headache. So if I’m driving in the sunlight, sometimes the impact of the sunlight. Really strong smells or strong sounds, which are harder to avoid.

Swati [00:11:05] Yeah. So how do you go about avoiding these triggers? How do you manage your triggers basically?

Cara [00:11:11] They’re pretty hard to manage. But I tend to wear sunglasses a lot, even inside which sometimes gets you funny looks in Tesco but that’s OK. I usually will use my computer with the light turned all the way down with a coloured filter over it because that helps sometimes with the light. I often will wear headphones when I’m out in the world so that the noise doesn’t bother me as much.

Swati [00:11:37] Oh, perfect. Thank you for talking to us about your triggers.

Cara [00:11:40] Thank you for having me.

Charlotte [00:11:42] Thank you, Cara and Swati, that was really great. I’m now talking to Norma about her triggers. So lots of things started off your triggers, when did you start getting migraine and do you know what triggered it?

Norma [00:11:54] Well, I first started getting migraines when I was 16 and I started my first job and I had absolutely no idea why suddenly the clock half disappeared and then when I looked at my typewriter keys, they also disappeared.

Charlotte [00:12:08] That must have been quite scary?

Norma [00:12:09] Yeah, it was. And so I just wouldn’t be able to see, things just got blocked out. And then the little zigzaggy lights would start and that was my aura.

Charlotte [00:12:22] So you think maybe that sort of stress of starting your first job and being a little worried about it?

Norma [00:12:26] I do think so. I also thought I should mention my mum and dad used to have the same type.

Charlotte [00:12:33] Oh right. So maybe at least that helped a little to know what it was like.

Norma [00:12:37] Both my mum and dad had it.

Charlotte [00:12:39] And so did anything else sort of bring on the auras, do you think?

Norma [00:12:43] I don’t think so, not in those days, but as time went on, things change. I also think the aura ones could be brought on by if I was doing a crossword puzzle, you know, seeing the black and white.

Charlotte [00:12:58] The little checkered?

Norma [00:12:58] Yeah, and also, like in winter when it snowed and looking out at the bright snow that could set off an aura.

Charlotte [00:13:07] So it could be almost light sensitivity a little bit.

Norma [00:13:09] Yes, I think so, yeah.

Charlotte [00:13:11] And so what about when you actually have like a migraine attack? Do you know what sort of brings that on with the head pain?

Norma [00:13:19] Well with the aura one, once the zigzaggy lights go that’s when the head pain comes on. But then my migraines changed after I had my first baby and I didn’t realise they were migraines at all, but my head used to be so bad, but I didn’t get an aura with it. I could also get vomiting.

Charlotte [00:13:42] So do you think that was- do you think maybe the trigger then could have been maybe hormonal? You had the baby and things changed.

Norma [00:13:49] Yeah, I think it was hormonal for sure, but it was a different type of migraine.

Charlotte [00:13:54] So anything else you think might trigger from then on?

Norma [00:13:59] Eating. If I didn’t eat that would spark one off. And also if I hadn’t eaten and I had a glass of wine or something like that.

Charlotte [00:14:10] When you treat yourself.

Norma [00:14:12] That would also spark a migraine off.

Charlotte [00:14:15] Okay. And what about so things like smells?

Norma [00:14:20] No, not really I don’t think ever smells had any effect on me.

Charlotte [00:14:24] Has weather ever been a thing? Some people find if it’s too hot or if it’s you know.

Norma [00:14:29] I think when there’s a storm brewing.

Charlotte [00:14:31] Oh yes, people say about the pressure.

Norma [00:14:33] Yes.

Charlotte [00:14:34] Interesting. Any other things that, you know, you’ve noticed sort of trigger?

Norma [00:14:38] Oh probably going on holiday, you know, if you’re flying. I might get a migraine before I was flying. Don’t think I really had them during the flight. But then sometimes when you’re relaxed and you know, you’re on the beach and feeling really good and bang! On comes the migraine.

Charlotte [00:14:56] When you least want it.

Norma [00:14:57] Yes.

Charlotte [00:14:58] That’s been really interesting. Thank you, Norma, for joining us.

Norma [00:15:01] You’re most welcome. Thank you very much.

Dr Katy Munro [00:15:06] That’s all we have time for in this episode. The next time we’ll be discussing brain scans and whether or not you need to have one. This is a topic that we get asked a lot. So join us next time for ‘Should I have a brain scan?’

[00:15:23] You’ve been listening to the Heads Up podcast, if you want more information or have any comments. Email us on info@NationalMigraineCentre.org.uk. Till next time.