Diet in Women With and Without Severe Headache or Migraine
This study includes a thorough analysis of dietary intake patterns in a nationally representative sample of women with and without severe headache or migraine. Contrary to our hypothesis, findings suggest that dietary intake patterns, including reported total energy intake, percent of energy from macronutrients, sodium, caffeine, omega-3 fatty acids, and omega-6 to omega-3 fatty acid ratio, and eating frequency, do not significantly differ between women with and without migraine. Using the USDA's measure of diet quality (HEI-2005), our study demonstrated that among normal weight women, those with migraine had reduced dietary quality compared to those without.
While most women in the sample reported no alcohol consumption, women with migraine were significantly more likely to be alcohol consumers. This finding is surprising, given that alcohol, particularly red wine and dark liquor, is an often identified trigger for migraine. Considering women with migraine are often advised not to drink, we anticipated that this advice would mitigate any association of alcohol consumption with migraine status. Additional studies are needed to elucidate the role of alcohol type and total alcohol intake on migraine onset, duration of illness, and severity.
Although usual dietary intake patterns were generally not different between women with and without migraine, future research is needed to examine whether the pathophysiology of migraine may render women with this disorder more susceptible to specific dietary intake patterns. Of interest is that women with migraine reported consuming 2655.5 ± 65.4 mg of sodium per day, which is more than twice the daily recommended intake for sodium (1500 mg/day). Sodium intake affects hydration status and blood pressure, such that an intake of this amount may be related to migraine onset in the presence of other predisposing physiologic characteristics in women with migraine. This finding may help to inform future research on the pathophysiology of migraine as salt appetite is promoted by orexin, a neuropeptide that is expressed in the lateral hypothalamus and is thought to play a role in migraine via participation in neurogenic inflammatory, vasodilation, and pain perception processes. Further, women with migraine reported an omega-6 to omega-3 fatty acid ratio of 11.4, which suggests that they consume 11 times more pro-inflammatory omega-6 fatty acids as compared to the anti-inflammatory omega-3 fatty acids. Again, while not practically or statistically significantly different from women without migraine (11.3 ± 0.2), excess intake of omega-6 fatty acids in the context of very low omega-3 fatty acid intake may promote inflammation in women who are predisposed to migraine differentially as compared to those without migraine. This is supported by a recent randomized controlled trial that showed increasing omega-3 intake while reducing omega-6 intake reduces headache severity and length in chronic headache patients. More research is needed to understand the roles of sodium intake and the omega-6 to omega-3 fatty acid ratio in migraine onset and severity.
Despite the strong association between obesity and migraine, we did not find that obesity modified the relationship between dietary intake patterns and migraine status as anticipated. As aforementioned, diet is a risk factor for obesity, which through shared inflammatory and other physiological pathways is independently associated with migraine. It is therefore possible that women with worse dietary intake patterns are at higher risk for obesity, and in turn, migraine. Moreover, it is also possible that obese women, independent of migraine status, have less variability in their dietary intake patterns and dietary quality. Given the cross-sectional study design, we cannot address whether obesity is a mediator in the relationship between diet and migraine. Therefore, longitudinal analyses examining the relationship between diet, obesity, and migraine are warranted.
Our analyses support that dietary quality differs between normal weight women with and without migraine. This difference is attributable to the fact that normal weight women without migraine report diets that more closely align with DGA, 2005 recommended intakes for total fruit, dark green and orange vegetables and legumes, and energy from SoFAAS. Interestingly, women in all weight status groups, with and without migraine, reported a low-quality diet. Whereas the difference in diet quality between obese women with and without migraine was not statistically significant, obese women with migraine reported consuming a lower quality diet than those without migraine (46.6 ± 0.09 vs 48.8 ± 0.7; P = .09). Additional research using valid migraine diagnostic measures is needed to determine if dietary quality in obese women is associated with migraine characteristics including frequency, intensity, and duration.
This study has several strengths. To our knowledge, this is the first study to examine the relationships between dietary intake patterns and migraine status, along with the influence of weight status, in a nationally representative sample. Finally, another strength provided by the use of NHANES data is the detailed dietary information provided by the 24-hour diet recall collected using the USDA's validated CADI and AMPM. Both methods review the diet multiple times using questions and memory aids. Whereas use of a single dietary recall may be viewed as a limitation, we examined dietary intake patterns and dietary quality at the group level. Therefore, the use of a single 24-hour diet recall is appropriate.
This study is not without limitations. First, the data are cross-sectional in nature. While we can make no conclusions with respect to causality, this analysis does provide valuable insight into the typical dietary intake patterns of women with migraine. Second, migraine status was determined based on self-report of migraine and severe headache. It is likely that some participants do not meet the ICHD-II criteria for migraine; however, the frequencies observed in this nationally representative sample are similar to those reported elsewhere. Finally, the data used for these analyses are from 1999 to 2004. Whereas these data are not from the most recent cycles of NHANES, migraine status was not assessed after 2003–2004; therefore, these are the only nationally representative data available in which both migraine status and diet were concurrently examined.
This study showed that dietary intake patterns in women with migraine are not substantially different from those of women without migraine. Whereas weight status does not appear to modify the relationship between diet and migraine status, differences were found for dietary quality. Normal weight women with migraine consume, on average, lower quality diets than women without migraine. Given the poor dietary quality of women with migraine, these findings suggest that addressing diet during migraine treatment may improve the overall health of women with migraine. Future studies should prospectively examine how dietary intake patterns and dietary quality relate to migraine onset, characteristics, and clinical features in individuals of varying weight status.
Discussion
This study includes a thorough analysis of dietary intake patterns in a nationally representative sample of women with and without severe headache or migraine. Contrary to our hypothesis, findings suggest that dietary intake patterns, including reported total energy intake, percent of energy from macronutrients, sodium, caffeine, omega-3 fatty acids, and omega-6 to omega-3 fatty acid ratio, and eating frequency, do not significantly differ between women with and without migraine. Using the USDA's measure of diet quality (HEI-2005), our study demonstrated that among normal weight women, those with migraine had reduced dietary quality compared to those without.
While most women in the sample reported no alcohol consumption, women with migraine were significantly more likely to be alcohol consumers. This finding is surprising, given that alcohol, particularly red wine and dark liquor, is an often identified trigger for migraine. Considering women with migraine are often advised not to drink, we anticipated that this advice would mitigate any association of alcohol consumption with migraine status. Additional studies are needed to elucidate the role of alcohol type and total alcohol intake on migraine onset, duration of illness, and severity.
Although usual dietary intake patterns were generally not different between women with and without migraine, future research is needed to examine whether the pathophysiology of migraine may render women with this disorder more susceptible to specific dietary intake patterns. Of interest is that women with migraine reported consuming 2655.5 ± 65.4 mg of sodium per day, which is more than twice the daily recommended intake for sodium (1500 mg/day). Sodium intake affects hydration status and blood pressure, such that an intake of this amount may be related to migraine onset in the presence of other predisposing physiologic characteristics in women with migraine. This finding may help to inform future research on the pathophysiology of migraine as salt appetite is promoted by orexin, a neuropeptide that is expressed in the lateral hypothalamus and is thought to play a role in migraine via participation in neurogenic inflammatory, vasodilation, and pain perception processes. Further, women with migraine reported an omega-6 to omega-3 fatty acid ratio of 11.4, which suggests that they consume 11 times more pro-inflammatory omega-6 fatty acids as compared to the anti-inflammatory omega-3 fatty acids. Again, while not practically or statistically significantly different from women without migraine (11.3 ± 0.2), excess intake of omega-6 fatty acids in the context of very low omega-3 fatty acid intake may promote inflammation in women who are predisposed to migraine differentially as compared to those without migraine. This is supported by a recent randomized controlled trial that showed increasing omega-3 intake while reducing omega-6 intake reduces headache severity and length in chronic headache patients. More research is needed to understand the roles of sodium intake and the omega-6 to omega-3 fatty acid ratio in migraine onset and severity.
Despite the strong association between obesity and migraine, we did not find that obesity modified the relationship between dietary intake patterns and migraine status as anticipated. As aforementioned, diet is a risk factor for obesity, which through shared inflammatory and other physiological pathways is independently associated with migraine. It is therefore possible that women with worse dietary intake patterns are at higher risk for obesity, and in turn, migraine. Moreover, it is also possible that obese women, independent of migraine status, have less variability in their dietary intake patterns and dietary quality. Given the cross-sectional study design, we cannot address whether obesity is a mediator in the relationship between diet and migraine. Therefore, longitudinal analyses examining the relationship between diet, obesity, and migraine are warranted.
Our analyses support that dietary quality differs between normal weight women with and without migraine. This difference is attributable to the fact that normal weight women without migraine report diets that more closely align with DGA, 2005 recommended intakes for total fruit, dark green and orange vegetables and legumes, and energy from SoFAAS. Interestingly, women in all weight status groups, with and without migraine, reported a low-quality diet. Whereas the difference in diet quality between obese women with and without migraine was not statistically significant, obese women with migraine reported consuming a lower quality diet than those without migraine (46.6 ± 0.09 vs 48.8 ± 0.7; P = .09). Additional research using valid migraine diagnostic measures is needed to determine if dietary quality in obese women is associated with migraine characteristics including frequency, intensity, and duration.
This study has several strengths. To our knowledge, this is the first study to examine the relationships between dietary intake patterns and migraine status, along with the influence of weight status, in a nationally representative sample. Finally, another strength provided by the use of NHANES data is the detailed dietary information provided by the 24-hour diet recall collected using the USDA's validated CADI and AMPM. Both methods review the diet multiple times using questions and memory aids. Whereas use of a single dietary recall may be viewed as a limitation, we examined dietary intake patterns and dietary quality at the group level. Therefore, the use of a single 24-hour diet recall is appropriate.
This study is not without limitations. First, the data are cross-sectional in nature. While we can make no conclusions with respect to causality, this analysis does provide valuable insight into the typical dietary intake patterns of women with migraine. Second, migraine status was determined based on self-report of migraine and severe headache. It is likely that some participants do not meet the ICHD-II criteria for migraine; however, the frequencies observed in this nationally representative sample are similar to those reported elsewhere. Finally, the data used for these analyses are from 1999 to 2004. Whereas these data are not from the most recent cycles of NHANES, migraine status was not assessed after 2003–2004; therefore, these are the only nationally representative data available in which both migraine status and diet were concurrently examined.
This study showed that dietary intake patterns in women with migraine are not substantially different from those of women without migraine. Whereas weight status does not appear to modify the relationship between diet and migraine status, differences were found for dietary quality. Normal weight women with migraine consume, on average, lower quality diets than women without migraine. Given the poor dietary quality of women with migraine, these findings suggest that addressing diet during migraine treatment may improve the overall health of women with migraine. Future studies should prospectively examine how dietary intake patterns and dietary quality relate to migraine onset, characteristics, and clinical features in individuals of varying weight status.
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