Precipitating Factors in Migraine: A Retrospective Review of 494 Patients

Lawrence Robbins, M.D.

Lawrence Robbins, M.D., Asst. Prof., Rush Medical College and University of Illinois, Director, RobbinsHeadache Clinic

Address all correspondence to: Lawrence Robbins, M.D., Northbrook Court Professional Center, 1535 LakeCook Road, Suite 211, Northbrook, IL 60062

Accepted for publication: November 7, 1993

SYNOPSIS

The predominance of certain triggers for migraine was assessed in 494 migraine patients. Stress (62%) was themost frequently cited precipitant. Weather changes (43%), missing a meal (40%), and bright sunlight (38%)were also prominent factors. Sexual activity (5%) was the precipitant cited by the least number of patients.Significant differences were found between men and women in their responses to weather changes, perfumes,cigarette smoke, missing a meal, and sexual activity.

Spring was cited by 14% of patients as a time for increased migraine attacks, followed by fall (13%), summer(11%), and winter (7%).

Key words: Migraine, precipitating factors, migraine triggers

(Headache 1994; 34: 214-216)

INTRODUCTION

A variety of external and internal stimulating factors have been demonstrated to precipitate migraines. Most migraineurslist several triggers, and we utilize the presence or absence of precipitating factors in aiding the formulation of thediagnosis of migraine. However, trigger factors are rarely consistent in producing a headache, and migraineurs are ableto identify precipitating factors in only a minority of attacks. Sensitivity to various stimuli may begin years after the onsetof headache, or patients can become less suceptible to triggers over time. Because trigger factors are helpful indiagnosing migraine, we assessed these factors retrospectively in 494 migraineurs.

SUBJECTS AND METHODS

Included in the study were 494 randomly selected migraineurs: 393 women, and 101 men. The larger number of womenis not surprising since more women than men suffer from this disease. All were long-term patients of the RobbinsHeadache Clinic. Each patient had a well-established diagnosis of migraine, with or without aura. Data was gatheredfrom the Headache Intake Assessment Form, completed by the patient and neurologist on the first visit to the Clinic.

The questions on the form pertained only to migraine, not to coexistent tension or daily headaches. Patients were askedto circle the factors on the Assessment Form that consistently trigger their migraine and to indicate the effect of theseasons. The physician then interviewed the patient and recorded sensitivity to the various trigger factors.

RESULTS

The patients were between the ages of 18 and 60. Table 1 summarizes the percentages of patients who were sensitiveto each of the various precipitating factors. The leading trigger factors for migraine were: stress, weather changes,premenstrual, and sunlight. Men and women differed in their response to various factors.

Table 1Percentage of Patients Sensitive to Trigger Factors

Percent of patients affectedTrigger Factor Female Male Combined

(393) (101) (494)During Stress 64% 54% 62%Weather Changes 47% 32% 43%Increase Perimenstrually 50% ---- ----(past or present)Missing a Meal 43% 31% 40%Sunlight 40% 31% 38%Undersleeping 33% 23% 31%Foods 31% 28% 30%Perfume 34% 10% 29%Cigarette Smoke 29% 13% 26%After Stess is Over 25% 22% 24%Oversleeping 26% 19% 24%Exercise 14% 16% 15%Sexual Activity 4% 9% 5%

Our 494 migraineurs reported slight seasonal variations, with increased headaches during spring and fall.

Table 2Seasonal Variation: Percentage of Patients Reporting

Increased Headache in Various Seasons

Female Male CombinedSpring 15.5% 7.9% 13.9%Summer 12.7% 2.9% 10.7%Fall 15.0% 3.9% 12.7%Winter 8.3% 4.9% 7.6%

Among seasons, there were differences between men and women at the 1% confidence level in summer and fall. In spring, therewas a difference at the 5% confidence level. Winter produced no difference between men and women.

We assessed whether the two sexes differed in frequency of the trigger factors. We pooled the two sample variances to computethe standard error of the difference between means. A two-tailed test was utilized to determine the difference between occurrencein the two sexes. This is summarized in Table 3:

Table 3Men vs. Women: Differences in Response to Triggers

In comparing men to women, the response to the following were found to be significantlydifferent at the 1% confidence level:Weather ChangesPerfumeCigarette SmokeThe following were found to be significantly different at the 5% confidence level:Missing a MealSexual ActivityThe following were found to be significantly different at the 10% confidence level:During StressSunlightUndersleepingThe following were not significantly different, even at a 10% confidence level:Foods After StressOversleepingExercise

DISCUSSION

Stress is a common precipitating factor in migraine, and was the major trigger reported by our patients. Migraineurs simply mayrespond to stress with a headache.1,2 Intense stress is common as an initiating factor for the first attack of migraine.3

Weather changes were a major trigger in our study. Previous studies have suggested that weather may affect the severity but notthe frequency of migraine.4 Geomagnetic activity may play a role in weather-related migraine,5 as may ionic and serotonergicchanges in the bloodstream. Platelet serotonin has been experimentally decreased by the inhalation of negative ions.6

In this study, migraines were significantly increased perimenstrually in 50% of women. Previous studies of hormonal cycles andlevels in women have reported conflicting results. The decrease in plasma estradiol appears to be the primary event triggering themenstrual-related migraines,7 but prostaglandin effects may play a crucial role in hormonal headache.8,9,10

Missing meal, or hunger, was listed by 40% of our patients as a precipitant for migraine. Migraineurs probably do not suffer fromtrue hypoglycemia, but rather it is a reaction of the nervous system to a normal drop in blood sugar.

Sunlight or bright light exposure was a trigger factor for 38% of our patients. Bright lights usually exacerbate a pre-existingmigraine headache. Migraineurs tend to wear sunglasses more often than non-headache-prone individuals. As with other weatherchanges, sunlight may affect the severity of the headaches more than the frequency.11

Undersleeping was listed as a precipitant by 31% of migraineurs, and oversleeping was stated to be a factor by 24%. Earlierstudies have recognized the relationship between sleep and migraine.12,13 Much evidence links the regulation of migraine withsleep mechanisms.14,15,16

Sensitivity to certain foods was a trigger for 30% of migraineurs. Red wine, beer, chocolate, and monosodium glutamate (MSG)have traditionally been listed as common precipitants for migraine.17 Previous studies have suggested that foods play a majorrole as migraine triggers,18,19 but this has been difficult to prove.20

In our examination of seasonal variation in migraine, spring was listed as an increased time for migraine by 13.9% of respondents,while 12.7% listed fall, 10.7% listed summer, and 7.6% stated that winter was a time of increased migraine. One previous studyfailed to demonstrate seasonal variation among migraineurs.21

Comparing the responses of men and women, the factors where the sexes differed significantly at the 1% confidence level were:weather changes, perfumes, and cigarettes. Differences were significant at the 5% level for missing a meal and sexual activity. Inmost categories, a lower percentage of men reported being influenced by a particular trigger factor.

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