Title: The management of food intolerances in migraine

 

Key words: migraine, stress, hormonal, drugs, diet, genetic factors, food intolerance, vasoactive amines, serotonin, mitochondrial function, magnesium, calcium, food allergies, food allergy, IgG, elimination diets, tension headache, exclusion diets, milk, cheese, chocolate, red wine, fish, legumes, citrus, eggs, remission, tyramine, desensitisation, histamine, vitamin B6, azo dyes, contraceptive pill, flavonoids, biogenic amines, salicylate, aspirin, monosodium glutamate, MSG, exercise, stress

 

Date: Oct 2006

 

Category: Specific conditions

 

Nutrimed Module:

 

Type: Article

 

Author: Morgan, G

 

The management of food intolerances in migraine

Migraine is a multifactorial complaint that can be precipitated by stress, hormonal changes, environmental factors, drugs and diet. This review will consider the role played by diet in its aetiology and treatment.

 

Food as the sole cause of migraine is rare (Vaughan 1991). Genetic factors play an important part. A recent cross-cultural study has put the heritability of migraine at between 34-57% (Mulder 2003). Genetic polymorphisms are common (Estevez 2004), with variants affecting neurotransmitter and other key metabolic pathways (Lea 2000). Low serotonin levels and dysphasic release of serotonin by platelets has been closely linked to food-induced migraine (Bic 1999). Platelet deficiency of the enzyme phenolsulphotranferase, thought to potentiate vasoactive amines such as serotonin, is present in migraine sufferers (Alam 1997).

 

Other factors linked to migraine are impaired mitochondrial function (Schoenen 1998), reduced intracellular magnesium and ATP production (Lodi 2001), and elevated homocysteine levels (Kara 2003) – factors associated with altered membrane stability and the release of inflammatory mediators and vasoactive substances. These factors both have a genetic basis and interact closely with nutritional factors.

 

The incidence of food-induced migraine in studies has ranged from 30% (Mansfield 1985) to 93% (Egger 1983, Carter 1985). A higher figure is the more likely as Mansfield’s study only looked at food allergies rather than food intolerances. Food intolerances are more common and comprise IgG-mediated and chemically-mediated intolerances (Millichap 2003). The position of food as a diagnostic marker for migraine appears ambiguous – one survey (Peatfield 1995) reporting a specificity for migraine, another survey (Savi 2002) reporting no difference between a migraine and a tension headache group. Biochemical markers, such as reduced phenolsulphotransferase activity, appear to be more accurate differential prognosticators (Alam 1997). The above surveys relied on elimination diets and food challenges to identify food intolerances. Such protocols remain the ‘gold standard’ in the diagnosis and treatment of food-induced migraine. Although, given the multifactorial nature of the condition, there remain many theoretical and practical concerns with such protocols, it nevertheless remains true that, in practice, such exclusion diets lead to around a 33% reduction in migrainous attacks (Metcalfe 1991).

 

The main foods incriminated have been milk, cheese, chocolate, alcohol, especially red wine, beverages, fermented products, fish, legumes, citrus and eggs . Excluding these foodstuffs totally for a period of 10 days utilising the Stone Age or another exclusion diet, such as the one recommended by Joneja (Anthony 1997, Joneja 1998), will lead to remissions in a high percentage of cases. Reintroduction of individual foodstuffs in graded amounts every 2 days will enable most intolerances to be identified (Joneja 1998). Such a programme may take 6 weeks to complete. It may not identify delayed reactions, interactions between other foods and other factors, and may not be a viable alternative for some patients, for whom serological diagnosis – with a 70% correlation with food challenge intolerances (Monro 1980) – may provide a more practical approach.

 

Once identified, a 4 day rotation diet can be instituted for a period of 6 months. Highly provocative foodstuffs, such as chocolate and red wine, may need to be excluded in the long-term.

 

Neutralisation or EPD desensitisation remains an option (Egger 1993, Anthony 1997). It is now clear the biogenic amines present in foods, such as chocolate, red wine, cheese, sausage, fish and fermented products, are particularly active in precipitating non-immunologically mediated migraine (Raiteri 1986, Zietz 1991, Leira 1996). Histamine is emerging as particularly important. Diaminoxidase activity, the enzyme involved in histamine degradation, is halved in migraine sufferers, with a higher incidence in women (Jarisch 1996). Red wines contain 20-200 times the levels of histamine compared with white wines, cause suppression of phenolsulphotranferase activity, and lead to the release of vasoactive compounds from platelets (Jarisch 1996). Moreover, diaminoxidase is vitamin B6-dependent (Wantke 1993). Vitamin B6 metabolism is depressed by the azo-dyes (Jarisch 1996), common in food additives, and by the contraceptive pill (Bermond 1982, Lussana 2003). B6 intake is inadequate in many women (Epstein 2003), particularly amongst the less well off (Widga 1995), for whom these factors may pose a threat. Azo-dyes, flavonoids and salicylates, found in food and food additives have all been shown to depress phenolsulphotransferase activity (Gibb 1986, Alam 1997, Harris 1998) and may potentiate the effect of biogenic amines.

 

Salicylate, a non steroidal anti-inflammatory drug, is also one of a number of analgesics whose chronic use has been associated with an increased rate of migraine (Mansfield 1985, Harris 1998).

 

In summary, a nutritional approach to migraine is one that has been validated by many surveys. A diet which is broad-based, not unduly exclusive, and with a reduced content of biogenic amines, saturated fats, and food additives such as azo-dyes, nitrates, MSG and aspartame, is widely recommended on a long-term basis (Joneja 1998, Millichap 2003). It should form part of a holistic programme which addresses stress, exercise, hormonal, medical and environmental factors.

 

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