Life with migraine is hard enough, without missing out on one of life’s great pleasures – chocolate.
It’s entirely understandable how you would just try and avoid everything that you suspect might possibly trigger an episode, but the research tells a story that might suggest a change in eating habits won’t bring on an attack for the majority of sufferers.
For the rest, decreasing the underlying sensitivity in the brainstem using a natural drug free treatment may mean what was once a trigger is now a pleasure!
Migraine Triggers - Why Chocolate?
Whenever I ask someone during a consultation what their triggers are, or what they avoid to try and keep migraines at bay, there are several that come up in most cases. Stress is number one without question, and this supports the research with up to 80% of migraineurs reporting stress as a trigger (1)– it’s rare that this won’t be listed, along with hormonal changes, sleep disturbance and skipping meals. When it comes to dietary triggers alcohol is in a similar boat with an overwhelming majority reporting this, however not far behind is chocolate. The odd thing about chocolate is that a relatively small percentage of those who say they avoid it will say it is definitely a trigger. They just avoid it because it could potentially be.
Anecdotal evidence of clients saying their migraine attack came on not long after eating chocolate led researchers to speculate on how chocolate could be a migraine trigger.
The first suspect was tyramine, a natural byproduct of the breakdown of proteins in certain foods when they age, leading people to avoid leftovers and cheeses. Tyramine is another migraine trigger ‘suspect’ with little proof to support its villain status.
Decades of research have not been able to establish whether tyramine does or does not trigger migraine attacks, but research from Pastore and colleagues (2) makes the presence of tyramine irrelevant to the 'chocolate migraine trigger' debate. Not only did they show that chocolate contains very little tryamine, but it in fact contains two substances more likely to have a protective impact in dopamine and serotonin.
The next suspect was caffeine. Caffeine enjoys a complicated relationship with migraine, and with 100g of dark chocolate containing up to 81mg of caffeine, (similar to a double espresso), the impact could be significant. Read more on Migraine Headache and Caffeine here.
On the one hand caffeine has been added to headache and migraine medication due to it’s ability to increase absorption from the gut, helping the action of acute pain relieving medications.
Secondly it binds to adenosine receptors which prevents drowsiness in some parts or the brain, but inhibits pain transmission and sensitisation in the brainstem where migraine and recurrent headache occurs. This is why many migraineurs report a ‘strong black coffee’ as their ‘go to’ to abort an attack.
Despite the mechanism and anecdotal evidence, research into caffeine suggest it is no more effective than placebo at stopping attacks. Consuming more than 300mg of caffeine per day has been shown to increase the risk of chronification (i.e. increase the frequency of attacks), and people taking around 200mg per day might decrease the effectiveness of their abortive migraine medication. So again the role of caffeine is not clear and it’s certainly not ‘an obvious trigger’
Migraine Triggers - Chocolate Research
According to Professor Peter Goadsby (3), for something be considered a migraine trigger it should trigger an episode 9 times out of 10 and within a couple of hours (e.g. glycerine trinitrate triggers >90% in under 10 minutes).
As far back as 1974 researchers Moffett, Swash and Scott (4), began exploring the possible links between chocolate and headaches.
In their double-blind placebo controlled trial in 80 subjects who all reported small amounts of cocoa products as a trigger, found only two subjects responded consistently having headaches after consuming chocolate. Their findings suggest that chocolate on its own rarely is a precipitant of migraine.
Another double blinded trial (5) comparing chocolate to carob also found that chocolate does not appear to play a significant role in triggering headaches in typical migraine, Tension-Type Headache or combined headache sufferers.
So why is the anecdotal case strong against chocolate? The current accepted theory was outlined by Prof Peter Goadsby at the 2017 Migraine World summit (3):
‘Part of the presentation with migraine is the premonitory phase, which occurs 6-10 hours (can be up to 2 days) before pain (or typical migraine) symptoms present. One of the features is cravings for certain foods – sweet foods, salty foods etc and this is driven by the hypothalamus. So people will eat certain foods not knowing that they are in the premonitory phase and then associate that food with the migraine, when in all likelihood they were going to have a migraine anyway.’
Is it possible that your migraine has started anyway when you suddenly get the urge to eat some chocolate?
Migraine Treatment - Can Chocolate help?
The main health benefit of eating dark chocolate (>70% cocoa dark chocolate) comes from the antioxidants (oligomeric procyanidins or flavanoids) found in raw cocoa beans, which can help promote blood flow to the brain, keep arteries elastic, and lower inflammation. Antioxidants neutralise free radicals and prevent oxidative stress (damage that free radicals inflict on tissues in the body), helps to increase good cholesterol levels and decrease blood pressure (6).
We have seen that chocolate contains serotonin and dopamine both of which play significant roles in dampening excitability of pain nerves, and 30g of 84% dark chocolate shown to decrease inflammation in diabetic patients (7). It is also a rich source of magnesium with 100g block containing around 230mg of magnesium.
Researchers (8) looking more specifically at cocoa found that ‘diets enriched in cocoa increase proteins that prevent your nerve cells from becoming excited and releasing inflammatory molecules (cytokines) that are though to be involved in migraine pathology’
Every person who suffers migraine is different, so it is important to filter all of this through what you understand from your own story.
Migraine Diet - Chocolate
Chocolate - to eat or not to eat, that is the question.
If you know that every time you have eaten chocolate you have had a migraine, I am not suggesting you tempt fate. If on the other hand you think that sometimes it has been a trigger, but other times not, or if you have only avoided chocolate assuming that it is a migraine trigger then you may wish to reconsider your view.
What you should consider when deciding to try it is whether or not you have a number of other trigger factors building and whether or not you might already be in the premonitory phase.
The key is to avoid trying it if you are craving it, or feeling lethargic, yawning excessively and moody. It also makes sense that if you have been short on sleep and are feeling like your stress levels are high, or the timing of hormonal changes (leading into the start of your cycle or mid cycle) then that may not be the best time to try it.
An important note to avoid leading to increased frequency of migraines is that 100g contains up to 80mg of caffeine – as strong as a double shot espresso. Over 300g per day can lead to increased risk of chronic headaches, so be careful with how much chocolate, coffee, tea you have. You can read more about caffeine and migraines here.
Regardless of triggers - stress foods, sleep hormones, the all have to interact with an overstimulated trigeminal nucleus. This is what is at the heart of migraine, tension-type headache along with the other major headache types.
If you don't have an overloaded trigeminal nucleus - you don't get symptoms. Avoiding triggers is one thing, but dealing with the overstimulation of the trigeminal nucleus is far more significant, and will have a much bugger impact.
Picture the trigeminal nucleus in the brainstem as a coffee cup. In non-headache sufferers this cup starts the day almost empty. In migraineurs and recurrent headache sufferers the cup starts at ¾ full.
There is less capacity to absorb more input into the system, and different people will be sensitive to different inputs - these are the triggers.
Rather than walking on eggshells all the time trying to avoid spilling the coffee cup over, use a treatment that 'empties some coffee from the cup'.
That is exactly what the treatment at the Melbourne Headache Centre does. The three nerves from the top of the neck feed directly into this part of the brainstem. We can test your neck to see if they are causing some of this irritation and treat it.
Empty the coffee cup.........give yourself more capacity to 'absorb triggers' and who knows.......maybe you can have an easter egg or two!!
(1) Pavlovic, J.M., Buse, D.C., Sollars, M., Haut, S., and Lipton, R. B. (2014) Trigger Factors and Premonitory Features of Migraine Attacks: Summary of Studies.Headache; Nov/Dec 1670-1679.
(2) Pastore, P. Favaro, G. Badocco, D. Tapparo, A. Cavalli, and Saccani, G (2005) Determination of biologic amines in chocolate by ion chromatographic separation and pulsed integrated amperometric detection with implemented wave-form at Au disposable electrode.Journal Chromatography A, Dec 9; 1098 (1-2): 111-5.
(3) Professor Peter Goadsby (2017) The Top 10 Myths to Bust. Migraine World Summit
(4) Moffett, A. M., Swash, M. and Scott, D.F. (1974) Effect of Chocolate in Migraine: a double-blind study. J Neurol Neurosurg Psychology. Apr, 37 (4): 445-8.
(5) Marcus, D.A., Scharff, L. Turk, D. and Gourley, L.M. (1997) A double-blind provocative study of chocolate as a trigger of headache. Cephalalgia, Dec; 17 (8): 855-62.
(6) Saxelby, C (2010) Myths busted - How healthy dark chocolate.
(7) Jafarirad, S., Ayoobi, N., Karandish, M, Jalali, MT, Haghighizadeh, M. H., and Jahanshahi, A. (2018) Dark Chocolate Effect on serum adiponectin, biochemical and inflammatory parameters in diabetic patients: A randomized clinical trial. Int J Prev Med, Oct; 12,(9); 86.
(8) , Cady, R., Denson, J.E. and Durham, P.L. (2012) Inclusion of Cocoa as a dietary supplement represses cytokine expression in spinal trigeminal nucleus in response to chronic trigeminal nerve stimulation. Presented at 54th Annual Scientific Meeting, American Headache Society, June 21-24, 2012. Program Abstracts, Headache: May, 862-914.
What type of headache do you have?
The answer should be simple. The diagnostic criteria set out for each disorder are clear and distinct, however there are many sufferers who’s symptoms blur the boundary between headache types, and will shift from one definition to another as the headache progresses, and they just don’t fit the arbitrary boundaries that have been set by the International Classification of Headache Disorders.
What does this mean for the treatment of these people, and what does it mean for the medical approach to headaches?
In National Headache Awareness week 2018 I was fortunate enough to attend a talk given by Dr Michael Eller on ‘Migraine management and treatment options’. He began the talk with a little of the history of headache management through time and went on to talk about how migraines are classified – in other words how you can tell it’s a migraine compared to other forms of headache. I was a little shocked, but overwhelmingly in agreement with Dr Eller’s comment that the classification system is ‘a little bit silly really’.
In other words lots of people don’t fit the neat description we have for each headache type, and at different times of the day their classification would change depending on how the episode is behaving.
Anyone who has been to see more than 2 or 3 doctors for their condition will know exactly why a leading specialist in Melbourne would make such a comment. You will rarely end up with the same diagnosis from the same doctors, and despite the attestation of experts that ‘an accurate diagnosis is essential to good care’ the facts remain that this diagnosis is difficult to obtain.
The classification system is based on the differences in how each headache type looks, but many experts over the years have argued there are more similarities between headache types than there are differences, and that instead of ‘headaches being separated diagnostically by subtle clinical nuances of dubious reliability’ we should view headaches as slightly different manifestations of the same underlying process (Cady et al 2002).
So what does a migraine look like? Some people would say if they have aura then it’s a migraine, but aura only occurs in 20% of cases. Others would say if they feel nausea or the headache throbs then its migraine, but as we will see sometimes that’s not the case.
We have the following definitions according to the International Classification of Headache Disorders (ICHD) 3:
A.At least 5 attacks fulfilling criteria B-D
B.Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
C.Headache has at least two of the following four characteristics
3.Moderate or severe pain intensity
4.Aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)
D.During the headache at least one of the following:
1.Nausea and/or vomiting
2.Photophobia and phonophobia
E.Not better accounted for by another ICHD-3 diagnosis
So to satisfy the criteria for a migraine we could have moderate pain on one side of the head with nausea. Easy right?
So let’s compare to a frequent tension-type headache (TTH):
A patient reporting moderate throbbing/pulsing pain on one side of the head with sensitivity to light, but no nausea or sensitivity to sound will not meet the criteria for migraine. Those having a unilateral and pulsing headache will not meet the criteria for tension-type headache either. So what do they have? That depends on the doctor you see. Is it important to know? Probably not.
What about a client with bilateral headache of moderate intensity and no nausea or sensitivity to light and sound? That’s a TTH according to the rules. If we add nausea then it’s a migraine – simple. Unless it’s occurring more than 15 days per month. Chronic TTH can have nausea as part of the diagnosis – so which do you have?
If you think you’re confused, you’re not the only one. Dr Lawrence Newman at the recent Migraine World Summit gave a talk on the differences between tension-type headache and migraine. His first comment was tension-type headache ‘is not a headache that is disabling, or one that tends to drive people to see a doctor. There is no nausea, light or sound sensitivity. It’s just a mild to moderate headache that comes and goes’.
Very little of what he said reflects the diagnostic criteria. There is nothing mentioned of the level of disability of the headache in ICHD-3, most likely because that is a very subjective quality. In contrast, the presence of one of sensitivity to light or sound is permitted in the tension type headache classification, yet not by Dr Lawrence.
Migraines are defined as lasting 4-72 hours whereas a TTH may last 30 minutes to 7 days. If either of those two is ‘coming and going’ it is the migraine rather than a 7 day long TTH.
Later in the same talk he mentions nausea and says ‘by definition you can have mild nausea associated with tension-type headache’. For episodic TTH that is in fact the exact opposite of the diagnostic criteria – which specifically state no nausea or vomiting and no more than one of light and sound sensitivity.
Confusing, and to quote an expert ‘a bit silly’.
A majority of the clients we see at Melbourne Headache centre would be diagnosed with Chronic migraine. That is, more than 15 headache days per month with at least 8 being migraine. Typically many of the other days include headache that fits the TTH criteria.
Despite the fuss made over an accurate diagnosis, as Dr Lawrence points out, may of the same drugs are used to try and treat both cases, such as amitriptyline (Endep) or topiramate (topomax). In fact we regularly see people who have bilateral moderate headache with mild nausea but no sensitivity to light or sound (Chronic TTH) that have been treated with Botox - a drug only available under PBS to Chronic Migraine patients. Clearly in these cases the diagnosis is not reflecting the symptoms necessarily, but might be more reflective of what treatments your doctor wants to try with you. As Dr Newman puts it:
'it doesn't matter what you call it, it's the frequency of headache that's often going to guide the treatment'.
We treat a condition that is common to all headache types, which is a sensitized brainstem, so the diagnosis isn’t particularly important. What is critical is what the source of sensitization is.
Imagine each headache type is a different train, all sitting at the platform at a major centralized railway station (i.e. Southern Cross Station). Each train begins its journey in the same place, in the same way, and looks basically the same. Then as they move out of the station some trains will head north, some south, east and west, and others elevate or go underground. From that point the journey of each train looks quite different to each other.
When your job is to try and disrupt the journey of each train at different points along its journey, (i.e. drugs targeting specific pathways of different headaches) you need to try and understand which headache type you are dealing with.
When your treatment involves stopping the train from leaving the platform at the first station (i.e. decreasing brainstem sensitivity – Melbourne Headache Centre) then it really doesn’t make a huge difference which train you are referring to. We can potentially deal with all of them.
Cady R, Schreiber C, Farmer K, and Sheftell (2002) Primary Headaches: A Convergence Hypothesis. Headache 42 ; 204-216.
The American Headache Society: International https://www.ichd-3.org
Roger O'Toole is the Director and Senior Clinician of the Melbourne Headache Clinic and has over 10 years experience as a physiotherapist.