Migraine triggers and lifestyle modifications: an assessment of patients’ awareness and the role of healthcare providers in patient education

Introduction

Migraine is a prevalent and debilitating neurological condition with substantial social, economic, and occupational impact. It is characterized by a complex, multifactorial neurobiology involving a series of interactions within both the central and peripheral nervous systems [1, 2].

Clinical observations and electrophysiological studies indicate that individuals with migraines have heightened brain sensitivity compared to those without the condition [3, 4]. Even between migraine attacks, they often experience an increased sensitivity to various sensory inputs [5]. One possible explanation for this altered neurological state is a lack of habituation in the brain of migraine patients [5–7]. Consequently, certain internal or external factors, known as triggers, are thought to precipitate migraine headaches in a brain that is already in a sensitized state [5]. Despite individual differences in migraine triggers, several are consistently recognized as common among those affected. These triggers include stress, certain foods, hormonal changes, sleep disturbances, weather variations, and sensory stimuli. However, migraine attacks can still occur without any identifiable trigger [5].

Prodromal symptoms and triggers likely share an interrelated relationship, with many prodromal features potentially being misidentified as triggers. The role of these triggers in migraine remains a topic of ongoing debate [8, 9]. However, lifestyle modifications and trigger avoidance, along with other non-pharmacological interventions such as stress management and cognitive behavioral therapy, represent accessible and cost-effective strategies for individuals with migraine [10–13]. Woldeamanuel et al. [10] found that individuals with chronic migraine are significantly less likely to engage in regular lifestyle behaviors such as maintaining consistent sleep, exercise, mealtime patterns, and hydration compared to those with episodic migraine, suggesting that these behaviors may have a protective effect. Such approaches offer a practical means of reducing reliance on acute medications and may help prevent both medication-overuse headache and headache chronification, conditions associated with increased healthcare utilization and costs [11].

Most existing global and regional studies have focused on patients’ self-reported triggers and how they personally cope with migraine episodes [12–15]. However, few studies have directly assessed migraine sufferers’ overall knowledge of common triggers and their ability to recognize them. For example, Baldacci et al. [14] found that although 72.5% of patients could name at least one trigger on their own, all patients (100%) were able to recognize at least one trigger when given a list of common options, suggesting limited spontaneous awareness of trigger factors. This gap between recognition and recall indicates that migraine patients may not fully understand or be aware of the range of possible triggers affecting them.

Furthermore, to our knowledge, no studies have systematically evaluated whether healthcare providers discuss migraine triggers and coping strategies with patients, an important aspect of patient education and management.

The current study aimed to assess the knowledge of a sample of migraine patients regarding migraine triggers, strategies for managing these triggers, and the information provided by physicians about potential triggers and effective management approaches.

Methods

Results

Five hundred and fifteen individuals with a confirmed diagnosis of migraine were surveyed. Their median age was 31, with an interquartile range (IQR) of 23–40. Most of them were females (81.9%), while males constituted about 18.1%. Detailed demographic data of the included patients are illustrated in Table 1.

Discussion

Understanding patients’ awareness of migraine triggers, management strategies, and the guidance they receive from healthcare professionals is essential for optimizing treatment outcomes, minimizing the frequency of attacks, and enhancing the overall quality of life for individuals with migraine.

To the best of our knowledge, this is the first study to assess the knowledge of a sample of patients with migraine regarding triggers, strategies for managing these triggers, and the information provided by physicians about potential triggers and effective management approaches.

The current findings highlight gaps in current migraine management paradigms. Although 58.3% of study participants reported that their physicians had discussed migraine triggers with them, and 63.1% said their physicians had addressed lifestyle changes to help reduce migraines, only 43% felt they had sufficient knowledge about migraine triggers. Furthermore, among the strategies reported by participants for managing their migraines, the vast majority (78.1%) indicated they relied on medications when necessary. Additionally, 54.0% followed a consistent sleep schedule, 49.5% used stress management techniques, 34% adhered to a specific diet, and 28.3% reported not actively managing their migraine triggers because they did not know how to do so.

This may indicate a lack of effective communication between healthcare providers and their patients. Specifically, it suggests that only some physicians may be discussing migraine triggers and lifestyle modifications, and even then, the information provided might not be sufficient, clear, or properly understood. As a result, patients may lack sufficient knowledge or fail to apply what they have learned practically.

It is worth noting that the degree of patients’ awareness varied across the wide range of the different triggers studied. Stress, in particular, got the highest awareness level (93.4%). This finding agreed with a meta-analysis, which reported that stress is the most common perceived trigger by patients with migraine [17]. Stress yields dysregulations in the autonomic nervous and neuroendocrine systems that, over time, may increase the sensitization of nociceptors [18]. Yet, only 68.7% of our patients acknowledged that their physician discussed stress management techniques with them. Hence, some experts urge the integration of mindfulness-based stress reduction techniques in migraine management, by which patients with migraine can learn how to manage surrounding stressors and regulate their emotions in response to them [19, 20]. Regrettably, 49.5% of our patients declared their utilization of stress-coping strategies.

Sleep disruption was identified as the second common perceived migraine trigger by a meta-analysis conducting by Pellegrino, Davis-Martin [17]. Expectedly, the current results followed the same path, being well-recognized by most of the participants. Moreover, sleep hygiene improvement was the most frequently discussed lifestyle aspect, as reported by 78.1%. A previous meta-analysis praised the positive effects of different psychological sleep interventions that significantly reduced migraine frequency and severity [21]. Notwithstanding, only 54.0% of the surveyed patients followed a consistent sleep schedule.

Based on a prior report, between 12 and 60% of migraine patients cite foods as triggers [22]. Yet, the proportions of perceived certain foods as a trigger may vary worldwide due to geographical variations in cultural and dietary habits [23]. In the current study, approximately 40% of the patients were aware of common food triggers, including aged cheese, chocolate, and caffeinated beverages. However, a much lower number recognized nuts and citrus fruits as migraine triggers. Fasting or missing meals was another commonly perceived trigger for migraine, as identified by 62.7%. Perhaps practicing Ramadan fasting in Egypt, where the majority of its residents are Muslims, is sufficient to explain the higher level of awareness of this trigger compared to rates reported in other countries [23]. Hypoglycemia, dehydration, and caffeine withdrawal are potential contributing factors [24, 25].

Menstrual cycle and hormonal medications gained another high percentage of awareness (72.4% and 60.0%, respectively). The female predominance in the surveyed sample may account for these findings and reflect past personal experiences they may have had. Hormonal fluctuations, particularly changes in estrogen levels, are well-established triggers for migraine. During the perimenopausal period, women may experience more frequent and severe migraine attacks, which may ease after menopause as hormone levels stabilize [26]. Likewise, some women may experience an exacerbation of their migraines, particularly during the first trimester of pregnancy, and find relief after the first trimester has passed. However, it should be noted that sleep disturbance and stress during pregnancy can also influence the frequency and intensity of migraine attacks [27].

A headache diary is one of the most effective tools for reliable triggers identification [28]. However, the present study observed a very low rate of patients keeping a detailed migraine diary to track their triggers (18%) compared to the adherence rates estimated by Ramsey, Ryan [29] in their systematic review (83–95%). Hence, understanding the barriers to headache diary adherence is a challenging research question that awaits an answer through future studies.

Finally, the current findings hold the key to optimizing treatment efficacy and outcomes in migraine management by embracing a personalized approach that tailors healthy lifestyle recommendations based on an individual’s perception of his own triggers. Empowering patients with in-depth knowledge about migraine triggers and the potential benefits of adopting the recommended lifestyle modifications is imperative for informed decision-making and active contribution to their treatment plans. It is worth noting that the counseling tailored to migraine patients must be primarily based on the concept of coping rather than avoidance of triggers, which may facilitate the process of unpleasant commitment to these lifestyle recommendations [30]. Moreover, the use of tools such as headache diaries and mobile tracking applications can enhance trigger identification accuracy, supporting both patients and clinicians in developing more effective and personalized management strategies.

However, while trigger identification and management are essential components of personalized care, it is important to acknowledge that there is no conclusive evidence of specific triggers for migraines, although a significant number of patients with migraines report that several factors may trigger their attacks. In some patients, the prodrome may induce behaviors that may be falsely perceived as triggers themselves. For instance, some may experience food cravings during their prodrome, leading them to falsely believe that their headaches are triggered by eating this food. Differentiating migraine triggers from prodromal symptoms is a critical research point for more appropriate migraine care [31].

Conclusion

Addressing migraine triggers should be integrated with other therapeutic strategies to achieve more effective migraine management. Physicians should prioritize educating patients on how to identify and manage their triggers as a part of their treatment plan. However, assessing trigger factors can be challenging due to patients’ reliance on retrospective self-reporting, which may result in recall bias and inconsistent data. To overcome these limitations, the use of headache diaries or mobile tracking tools can support this by providing information that helps guide personalized approaches. Encouraging patient education and self-monitoring may reduce the need for abortive medications and lead to improved outcomes.

Supplementary Information

Authors’ contributions

A.E., H.E. and R.M.: research idea, Manuscript writing and revision, M.H., A.E. and A.Y.I.: Manuscript writing, K.E.E., S.M.M.H., N.S.H., H.N.A. and N.M.E. data acquisition, collection of samples MH: data analysis and interpretation. W.O.: Manuscript writing and submission. All authors have read and approved the final manuscript.

Data availability

No datasets were generated or analysed during the current study.

Declarations