Stephen D Silberstein, MD, and William B Young, MD, Jefferson Headache Center

Lifestyle is crucial to migraine management. Significant research

demonstrates that engaging in certain consistent, healthy behaviors reduces migraine severity and attack frequency. In November 2020, the American Academy of Neurology updated its Headache Quality Measurement Set to reflect those findings,

 with a directive that providers should now counsel migraine patients on behavior modification at each visit.

However, less well known among neurologists and primary care providers is 

 to counsel migraine patients on behavior modification. Not long ago, belief was that lifestyle changes for migraine revolved around negative strategies such as avoiding triggers and lowering activity levels. It has since emerged that taking a proactive, multimodal approach to positive lifestyle changes is more effective.

As headache specialists for over 30 years, we have seen that proactive lifestyle changes are a powerful complement to pharmaceutical approaches. But initiating and implementing lifestyle changes is also challenging for patients with migraine, who need education, guidance, and support. Here, we present Part 2 of our overview of the lifestyle interventions shown most helpful for migraine, as well as specific strategies to recommend to patients with both episodic and chronic migraine.

 discussed the 3 most fundamental lifestyle changes for migraine: sleep, hydration, and nutrition. In this installment, we will address the 3 “higher order” interventions crucial for migraine management. They include the following categories:

Research shows that moderate, aerobic exercise 3 times per week at 30 minutes per session reduces the pain, intensity, frequency, and duration of future migraine attacks.

 Exercise may be as effective for migraine as the medications amitriptyline and topiramate.

However, movement can be a frightening topic for patients with migraine. Up to 78% of people with migraine avoid exercise,

 either because they feel it has triggered an attack or due to limited energy; but lack of movement actually results in worsening migraine.

Pacing and consistency are essential components for exercise with migraine. We emphasize that each person has their own exercise “FITT”: frequency, intensity, time, and type. For some, that may be the ideal of 3 30-minute aerobic sessions per week. For others, it may be a twice-weekly stretching session of 5 minutes. Truly, the best exercise routine for each patient is whatever they can sustain on a consistent basis.

Start by anchoring a movement routine to everyday activities, such as taking a walk after dinner, doing yoga upon waking, or adding a little more movement into their everyday household chores like vacuuming.

We advise a 10-minute rest period for every 5- to 10-minute exercise period until the patient learns to gauge their own overexertion signals.

A patient handout on movement for migraine is available here

Eighty percent of people with migraine report stress as a migraine trigger;

 stress can also make attacks worse and harder to treat. Migraine itself can be a powerful stressor: As a painful condition, it inevitably influences processes of the mind, usually in negative ways, which exacerbates pain. However, the mind can also learn to positively modulate the experience of pain to reduce suffering.

Self-awareness practices like mindfulness, meditation, relaxation, and emotion regulation help train the brain to be less reactive to stressful thoughts, feelings, and situations in ways that positively modulate the experience of pain and reduce suffering.

 By strengthening vagal tone, patients can train their bodies to more flexibly shift between the stress response and the parasympathetic response as needed. It is also anti-inflammatory.

Regular meditation reduces the intensity and frequency of headache, as well as the psychological distress that inevitably comes with headache and migraine.

 Twenty minutes per day are recommended, but even 2 minutes of mindfulness practice per day are beneficial.

Ask the patient to set a timer for 1 minute, then breathe a little more slowly and deeply, paying full attention to the flow of breath.

When thoughts appear in the mind, they should notice the thought, then turn the attention back to the breath.

A patient handout on stress management for migraine is available here

Migraine is highly comorbid with mental health disorders and the relationship is bidirectional.

 More than 50% of migraine patients have anxiety, depression, or both, the presence of which make migraine worse and harder to treat.

 In addition, migraine is a stressful, lonely, and isolating condition. Patients require good emotional coping skills and self-awareness to manage difficult feelings and improve their quality of life. Such skills also markedly reduce headache frequency and intensity: Studies show that talk therapy can reduce headaches by 20%to 67%.

The psychological components that help improve migraine include:

 The ability to accept migraine pain, and not fight or deny it, enables a patient to reduce their level of suffering. It frees them to focus their energies on the things they can control, thus emphasizing their wellness and reinforcing their identities as much more than a person with a neurological disorder.

 Connecting to the people, work, or activities that bring joy, support, and meaning leads to neurochemical shifts that mimic medications for mood and migraine, including training the vagus nerve to initiate the relaxation response and the release of oxytocin, which is an inhibitor of calcitonin gene-related peptide (CGRP).

 By building confidence in their ability to achieve specific goals, patients can overcome the learned helplessness that can result from living with migraine, which may otherwise inhibit them from making the changes necessary for their health goals.

 Decades of research have shown that a fixed pain mindset—rumination about pain, helplessness, and an expectation that pain will only get worse—is associated with higher pain intensity and disability from pain, and reduced success of multimodal treatment approaches. Developing a growth mindset by reframing unhelpful thoughts and celebrating successes can reduce suffering as a consequence of migraine, and sometimes even downregulate the pain response itself.

Ask them to incorporate 1 form of connectedness per day, ie, engaging with friends, family, work, an interest, a hobby, a pet. Inquire about the things that would bring them a sense of satisfaction.

A patient handout on connectedness for migraine is available here

Lifestyle changes are a valuable complement to medical approaches to managing migraine. The sheer number and variety of options for behavioral changes and psychological wellness assures an entry point for every patient.

However, current evidence-based, expert-reviewed programs are rare. That is a guiding reason why we at the Jefferson Headache Center and Thomas Jefferson University have partnered with Ctrl M Health, whose app-delivered program makes this information widely accessible. We have created a world-respected advisory panel to help in this important endeavor.

Spreading the word about the essential role of lifestyle change is a significant step toward helping the estimated 40 million Americans with migraine. Importantly, behavioral modifications are factors within a patient’s control, giving them tools they can use every day to help them improve.

For part 1 of the “Lifestyle Changes for Migraine” series, addressing sleep, nutrition, and hydration, 

The Jefferson Headache Center and Thomas Jefferson University have partnered with Ctrl M Health to create comprehensive, evidence-based programming and support for people with migraine. For free provider resources, best practice tips, and patient handouts,

REFERENCES
1. Buse DC, Greisman JK, Baigi K, Lipton RB. Migraine progression: a systematic review. 

. 2019; 59(3):306-338.doi:10.1111/head.13459
2. Wober C, Wober-Bingol C. Triggers of migraine and tension-type headache. 

. 2010;97:161-72. doi:10.1016/S0072-9752(10)97012-7
3. Silberstein SD. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the quality standards subcommittee of the American Academy of Neurology. 

. 2000;55(6):754-62. doi:10.1212/wnl.55.6.754
4. Zhang Y, Dennis JA, Leach MJ, et al. Complementary and Alternative Medicine Use Among US Adults With Headache or Migraine: Results from the 2012 National Health Interview Survey. 

. 2017;57(8):1228-1242. doi:10.1111/head.13148
5. Wells RE, Bertisch SM, Buettner C, Phillips RS, McCarthy EP. Complementary and alternative medicine use among adults with migraines/severe headaches. 

. 2011;51(7):1087-1097. doi:10.1111/j.1526-4610.2011.01917.x
6. Penzien DB, Rains JC, Lipchik GL, Nicholson RA, Lake AE, Hursey KG. Future directions in behavioral headache research: Applications for an evolving health care environment. 

. 2005;45(5):526–534. doi:10.1111/j.1526-4610.2005.05105.x
7. Park, SY, Chen, Y. Individual and Social Recognition: Challenges and Opportunities in Migraine Management. Presented at: 18th ACM Conference on Computer Supported Cooperative Work and Social Computing; March 14-18, 2015; Vancouver, BC, Canada. P1540.
8. Krause SJ, Stillman MJ, Tepper DE, Zajac D. A Prospective Cohort Study of Outpatient Interdisciplinary Rehabilitation of Chronic Headache Patients. 

. 2017;57(3):428-440. doi:10.1111/head.13020
9. Lemstra M, Stewart B, Olszynski WP. Effectiveness of Multidisciplinary Intervention in the Treatment of Migraine: A Randomized Clinical Trial. 

. 2002;42(9):845-854. doi:10.1046/j.1526-4610.2002.02202.x
10. Robblee J, Starling AJ. SEEDS for success: Lifestyle management in migraine. 

. 2019;86(11):741-749. doi:10.3949/ccjm.86a.19009
11. Robbins MS, Victorio MCC, Baily M, et al. Quality improvement in neurology: Headache Quality Measurement Set. 

. 2020;95(19):866-873. doi:10.1212/WNL.0000000000010634
12. Lemmens J, De Pauw J, Van Soom T, et al. The effect of aerobic exercise on the number of migraine days, duration and pain intensity in migraine: a systematic literature review and meta-analysis. 

. 209;20(1):16. doi:10.1186/s10194-019-0961-8
13. La Touche R, Fernández Pérez JJ, Acosta AP, et al. Is aerobic exercise helpful in patients with migraine? A systematic review and meta-analysis. 

. 2020;30(6):965-982. doi:10.1111/sms.13625
14. Varkey E, Cider A, Carlsson J, Linde M. Exercise as migraine prophylaxis: a randomized study using relaxation and topiramate as controls. 

. 2011;31(14):1428–1438. doi:10.1177/0333102411419681
15. Farris SG, Thomas JG, Abrantes AM, et al. Anxiety sensitivity and intentional avoidance of physical activity in women with probable migraine. 

. 2019;39(11):1465-1469. doi:10.1177/033310241986171
16. Koppen H, van Veldhoven PLJ. Migraineurs with exercise-triggered attacks have a distinct migraine. 

. 2013;14(1):99. doi:10.1186/1129-2377-14-99
17. Kelman L. The triggers or precipitants of the acute migraine attack. 

. 2007;27(5):394-402. doi: 10.1111/j.1468-2982.2007.01303.x
18. Borsook D, Maleki N, Becerra L, McEwaen B. Understanding migraine through the lens of maladaptive stress responses: a model disease of allostatic load. 

. 2012;73(2):219-34. doi:10.1016/j.neuron.2012.01.001
19. Buse DC, Andrasik F. Behavioral medicine for migraine. 

. 2009;27(2):445-465.doi:10.1016/j.ncl.2009.01.003
20.Cramer H, Hehlke M, Vasmer J, et al. Integrated care for migraine and chronic tension-type headaches: A prospective observational study. 

. 2019;36:1-6. doi:10.1016/j.ctcp.2019.04.001
21. Dikmen PY, Yavuz BG, Aydinlar EI. The relationships between migraine, depression, anxiety, stress, and sleep disturbances. 

. 2015;115(2):117-22. doi:10.1007/s13760-014-0312-0
22. D’Souza PJ, Lumley MA, Kraft CA, Dooley JA. Relaxation training and written emotional disclosure for tension or migraine headaches: a randomized, controlled trial. 

. 2008;36(1):21-32. doi:10.1007/s12160-008-9046-7
23. Feuille M, Pargament K. Pain, mindfulness, and spirituality: A randomized controlled trial comparing effects of mindfulness and relaxation on pain-related outcomes in migraineurs. 

. 2015;20(8):1090-1106. doi:10.1177/1359105313508459
24. Grazzi L, Bernstein C, Raggi A, et al. ACT for migraine: effect of acceptance and commitment therapy (ACT) for high-frequency episodic migraine without aura: preliminary data of a phase-II, multicentric, randomized, open-label study. 

. 2019;40(1):191-192.doi:10.1007/s10072-019-03802-w
25. Grazzi L, Sansone E, Raggi A, et al. Mindfulness and pharmacological prophylaxis after withdrawal from medication overuse in patients with Chronic Migraine: an effectiveness trial with a one-year follow-up. 

. 2017;18(1):15. doi:10.1186/s10194-017-0728-z
26. Hilton L, Hempel S, Ewing BA, et al. Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis. 

. 2017;51(2):199-213. doi:10.1007/s12160-016-9844-2
27. Holroyd KA, Drew JB. Behavioral approaches to the treatment of migraine. 

. 2006;26(2):199-207. doi:10.1055/s-2006-939920
28. Inan LE, Akturk T, Tanik N. Cognitive Behavioral Therapy Approach in cases with Migraine Disease. 

. 2020;9(1):67-72. doi:10.5455/JCBPR.40831
29. Mayhami K, Moradi O, Dadgar M, Ezatpour EE. Investigation of the educational effectiveness of cognitive-behavioral approach (CBT) coupled with relaxation on migraine pain. 

. 2019;6(2):27-37. doi:10.29252/shenakht.6.2.27
30. Pérez-Muñoz A, Buse DC, Andrasik F. Behavioral interventions for migraine. 

. 2019;37(4), 789-813. doi:10.1016/j.ncl.2019.07.003
31. Wells RE, Seng EK, Edwards RR, Victorson DE, et al. Mindfulness in migraine: A narrative review. 

. 2020;20(3):207-225. doi:10.1080/14737175.2020.1715212
32. Wells RE, Burch R, Paulsen RH, Wayne PM, Houle TT, Loder E. Meditation for migraines: a pilot randomized controlled trial. 

. 2014;54(9):1484-95. doi:10.1111/head.12420
33. Wachholtz A, Vohra R, Metzger A. A reanalysis of a randomized trial on meditation for migraine headaches: Distraction is not enough but meditation takes time. 

. 2019;46:136-143. doi:10.1016/j.ctim.2019.08.011
34. Seng EK, Singer AB, Metts C, et al. Does Mindfulness‐Based Cognitive Therapy for Migraine Reduce Migraine‐Related Disability in People with Episodic and Chronic Migraine? A Phase 2b Pilot Randomized Clinical Trial. 

. 2019;59(9):1448-1467. doi:10.1111/head.13657
35. Pressman A, Law H, Stahl R, et al. Conducting a pilot randomized controlled trial of community-based mindfulness-based stress reduction versus usual care for moderate-to-severe migraine: protocol for the Mindfulness and Migraine. 

. 2019;20:257. doi:10.1186/s13063-019-3355-y
36. Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. 

. 1985;8(2):163-90. doi:10.1007/BF00845519
37. Bakhshani NM, Amirani A, Amirifard H, Shahrakipoor M. The Effectiveness of Mindfulness-Based Stress Reduction on Perceived Pain Intensity and Quality of Life in Patients With Chronic Headache. 

. 2015;8(4):142-51.doi:10.5539/gjhs.v8n4p142
38. Bawa FLM, Mercer SW, Atherton RJ, et al. Does mindfulness improve outcomes in patients with chronic pain? Systematic review and meta-analysis. 

 . 2015;65(635):e387-400. doi:10.3399/bjgp15X685297
39. Maleki N, Becerra L, Borsook D. Migraine: maladaptive brain responses to stress. 

. 2012;52(Suppl 2):102-106. doi:10.1111/j.1526-4610.2012.02241.x
40. Klenofsky B, Pace A, Natbony LR, Sheikh HU. Episodic migraine comorbidities: avoiding pitfalls and taking therapeutic opportunities. 

. 2019;23(1):1. doi:10.1007/s11916-019-0742-8
41. The Link Between Migraine, Depression and Anxiety. American Migraine Foundation. Published May 2, 2018. Accessed August 18, 2021. https://americanmigrainefoundation.org/resource-library/link-between-migraine-depression-anxiety/
42. Hamelsky SW, Lipton RB. Psychiatric comorbidity of migraine. 

. 2006;46(9):1327-33. doi: 10.1111/j.1526-4610.2006.00576.x
43. Peres M, Mercante J, Tobo PR, Kamei H, Bigal ME. Anxiety and depression symptoms and migraine: a symptom-based approach research. 

. 2017;18(1):37. doi:10.1186/s10194-017-0742-1
44. Sullivan A, Cousins S, Ridsdale L. Psychological interventions for migraine: a systematic review. 

. 2016;263(12):2369-2377. doi:10.1007/s00415-016-8126-z
45. Dindo LN, Recober A, Calarge CA, et al. One-Day Acceptance and Commitment Therapy Compared to Support for Depressed Migraine Patients: A Randomized Clinical Trial. 

. 2020;17(2):743-753. doi:10.1007/s13311-019-00818-0
46. Hooker SA, Masters KS, Park CL. A meaningful life is a healthy life: a conceptual model linking meaning and meaning salience to health. 

. 2017;22(1):11-24. doi:10.1037/gpr0000115
47. House JS, Landis KR, Umberson D. Social relationships and health. 

.1988;241(4865):540-545. doi:10.1126/science.3399889
48. Kok BE, Fredrickson BL. Upward spirals of the heart: Autonomic flexibility, as indexed by vagal tone, reciprocally and prospectively predicts positive emotions and social connectedness. 

. 2010;85(3):432-436. doi:10.1016/j.biopsycho.2010.09.005
49. Magnuson CD, Barnett LA. The playful advantage: How playfulness enhances coping with stress. 

. 2913;35(2):129-144.doi:10.1080/01490400.2013.761905
50. Martelletti P, Schwedt TJ, Lanteri-Minet M. et al. My Migraine Voice survey: a global study of disease burden among individuals with migraine for whom preventive treatments have failed. 

. 2018;19(1):115. doi:10.1186/s10194-018-0946-z
51. McQuoid J. (2017). Finding joy in poor health: The leisure-scapes of chronic illness. 

. 2017;183:88-96. doi:10.1016/j.socscimed.2017.04.044
52. Tzabazis A, Kori S, Mechanic, J, et al. Oxytocin and Migraine Headache. 

Articles

Trigger avoidance-only strategies don’t actually help migraine patients improve. These are the proactive behaviors that do.

Lifestyle Change for Migraine Management: Practical Tips for the Neurologist and PCP, Part 2

Lifestyle is crucial to migraine management. While it was previously believed that medication was the best way to 

, we now understand that medication is only 1 part of comprehensive treatment. Significant research

 demonstrates that engaging in certain consistent, healthy behaviors reduces migraine severity and attack frequency. In November 2020, the American Academy of Neurology updated its Headache Quality Measurement Set

 to reflect those findings, with a directive that providers should now counsel migraine patients on behavior modification at each visit.

Less well known among neurologists and primary care providers is how to counsel migraine patients on behavior modification. In the past, a long-held belief was that lifestyle changes for migraine revolved around avoidance strategies. Patients were instructed to avoid “triggering” foods, environmental sensitivities, and activities that could contribute to a migraine attack, but this belief has since changed for the better. Taking a proactive, multimodal approach to positive lifestyle changes which address the multiple causes of migraine is more effective than negative strategies such as avoiding triggers and lowering activity levels.

As headache specialists for over 30 years, we have seen that proactive lifestyle changes are a powerful complement to pharmaceutical approaches. But initiating and implementing lifestyle changes is also challenging for patients with migraine, who need education, guidance, and support. Here, we present an overview of the lifestyle interventions shown most helpful for migraine, as well as specific strategies to recommend to patients with both episodic and chronic migraine.

In this article, part 1 of a 2-part series, we will address the first 3 of 6 categories of lifestyle changes. These represent the most fundamental interventions for migraine:

Obtaining consistent, quality sleep is the single most impactful lifestyle change for migraine.

Sleep and migraine have a bidirectional relationship: Sleep deprivation worsens migraine intensity and frequency, and migraine begets poor sleep. The result is that patients with migraine are 2 to 8 times more likely to have a sleep disorder than those without migraine.

 This is most likely because the glymphatic system, which clears waste from the central nervous system, only functions during deep sleep.

Because even small changes in sleep can benefit migraine, this is often the ideal starting point for patients who are ready to make lifestyle changes. Helpful approaches to improving sleep quality are:

. We find that patients are generally familiar with the concept that certain good habits can condition the brain to prepare itself for sleep; however, most have dismissed the notion as ineffective, inconvenient, or overwhelming. Adherence tends to improve once patients are first educated on how and why sleep hygiene practices work, and then are asked to choose a specific practice or two to try.

. Stress is incompatible with sleep. The more tools we can give patients with migraine for self-regulation, the more we can help them meet their physical stress response with a relaxation response. Mindfulness, meditation, and relaxation training are all excellent techniques for sleep. Cognitive behavioral therapy is also helpful.

Urge them to create a consistent bedtime routine.

Ask them to keep a sleep diary for 1 week to better understand baseline habits and patterns.

For the next 2 weeks, they should go to bed at the same time every night, noting any health changes.

Their goal is for a sleep efficiency (time in bed and actually asleep) of 85% or higher.

A patient handout on sleep for migraine is available here

Even in people without migraine, mild dehydration of 2% body water results in a reduction in concentration and cognitive ability, and a rise in fatigue.

 For people with the increased sensitivities of migraine, water imbalance can increase the likelihood of an attack. Preventing dehydration is an impactful strategy patients can use to protect against migraine. One study found that increasing water intake by 1.5 liters per day reduced patients’ headache duration by 21 hours over 2 weeks.

US adults drink an average of only 39 ounces (4.87 cups) of plain water each day—far less than current recommendations of 11.5 cups for women and about 15.5 cups daily for men. Patients find that increasing their water intake is among the easiest lifestyle changes for migraine to implement, and often experience positive results quickly.

Make them aware of daily water intake recommendations.

Ask them to spend 1 week increasing their own intake to get closer to those goals.

Have them keep a water bottle with them and know how many times they need to fill it each day to hit their goal.

A patient handout on hydration for migraine is available here

Due to long standing myths about food triggers and migraine, patients tend to be quite curious about foods to eat for migraine and, especially, foods to avoid.

 However, there is no universally accepted diet for migraine

; research so far has created a range of conflicting advice.

 In addition, while avoiding certain foods can be impactful for the minority of people with migraine who have true food triggers, in practice food avoidance tends to be unhelpful for most patients, leading instead to overly restrictive diets, stress around eating, and self-blame.

Instead, a combination of research and clinical insights point to a multifaceted approach to nutrition for migraine that is both effective and sensible. It involves building quality, consistency, and balance into the diet in ways that raise a person’s migraine resistance:

through healthy weight management and adding anti-inflammatory foods, especially anti-inflammatory fats.

 Our preferred approach is to add quality foods to the diet rather than take foods away.

Consistency is important for the migraine brain.

 Eating on a regular basis, maintaining blood sugar levels,

 all play a role. Consistent use of certain dietary supplements, such as magnesium, also support migraine health.

Promising data is emerging about the ways fiber-rich, probiotic, and prebiotic foods that promote gut health may also reduce migraine frequency and severity.

Ask the patient to keep a food journal for 2 weeks.

Because nutrition for migraine can feel overwhelming, it’s important to help the patient choose an approach that feels manageable. A food journal charting their nutritional patterns will reveal some natural starting points for intervention.

The focus should be on adding anti-inflammatory fruits, vegetables, and proteins, rather than a singular focus on the avoidance of triggers.

A patient handout on nutrition for migraine is available here

Lifestyle changes are a valuable complement to medical approaches to managing migraine. Research has shown that a multi-modal approach further enhances the benefits. The sheer number and variety of options for behavioral changes and psychological wellness means there’s an entry point for every patient.

Current evidence-based, expert-reviewed programs are rare. That is a guiding reason why we at the Jefferson Headache Center and Thomas Jefferson University have partnered with Ctrl M Health, whose app-delivered program makes this information widely accessible. We have created a world-respected advisory panel to help in this important endeavor.

Getting the word out about the essential role of lifestyle change is a significant step toward helping the estimated 40 million Americans with migraine. Importantly, lifestyle changes are factors within a patient’s control, giving them tools they can use every day to help them improve.

In Part 2 of our “Lifestyle Changes for Migraine” series, we’ll address the remaining 3 categories of lifestyle interventions for migraine: exercise/movement, mindfulness/stress management, and psychological health.

The Jefferson Headache Center and Thomas Jefferson University have partnered with Ctrl M Health to create comprehensive, evidence-based programming and support for people with migraine. For free provider resources, best practice tips, and patient handouts, 

1. Buse DC, Greisman JK, Baigi K, Lipton RB. Migraine progression: a systematic review. Headache. 2019; 59:306–338.

2. Silberstein SD. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the quality standards subcommittee of the American Academy of Neurology. 

3. Zhang Y, et al. Complementary and alternative medicine use among US adults with headache or migraine: results from the 2012 national health interview survey. Headache. 2017;57(8):1228-1242. doi: 10.1111/head.13148.

4. Wells RE, Bertisch SM, Buettner C, Phillips RS, McCarthy EP. Complementary and alternative medicine use among adults with migraines/severe headaches. Headache. 2011;51:1087-1097.

5. Penzien DB, Rains JC, Lipchik GL, Nicholson RA, Lake AE 3rd, Hursey KG (2005) Future directions in behavioral headache research: Applications for an evolving health care environment. Headache. 45(5):526–534.

6. Park, SY, Chen, Y. (2015). Individual and social recognition: challenges and opportunities in migraine management. CSCW ‘15: Proceedings of the 18th ACM Conference on Computer Supported Cooperative Work and Social Computing, 15:40-1551.

7. Krause S. A prospective cohort study of outpatient interdisciplinary rehabilitation of chronic headache patients. Headache. 2017;57(3):428-440. doi:10.1111/head.13020

8. Lemstra M, Stewart B, Olszynski WP. Effectiveness of multidisciplinary intervention in the treatment of migraine: a randomized clinical trial. Headache. 2002;845-854.

9. Robblee J, Starling AJ. SEEDS for success: Lifestyle management in migraine. Cleve Clin J Med. 2019;86(11):741-749. doi:10.3949/ccjm.86a.1900

10. Wells RE, O’Connell N, Pierce CR, et al. Effectiveness of mindfulness meditation vs headache education for adults with migraine: a randomized clinical trial. JAMA Intern Med. Published online December 14, 2020. doi:10.1001/jamainternmed.2020.7090

11. Buse DC, Andrasik, F. Behavioral medicine for migraine. Neurologic Clinics. 2009;27(2), 445-465.

12. Robbins MS., et al. Quality improvement in neurology: Headache Quality Measurement Set. Neurology. 2020;95(19): 866-873. doi:10.1212/WNL.0000000000010634

13. Woldeamanuel YW, Cowan RP. The impact of regular lifestyle behavior in migraine: a prevalence case–referent study. J Neurol. 2016;263:669–676. Doi:10.1007/s00415-016-8031-5

14. Tiseo C, Vacca A, Felbush A, et al. Migraine and sleep disorders: a systematic review. J Headache Pain. (2020).

15. Buse DC, Rains JC, Pavlovic JM, Fanning KM, Reed ML, Manack Adams, A, et al. Sleep disorders among people with migraine: results from the chronic migraine epidemiology and outcomes (CaMEO) study. Headache. 2019;59(1)32–45.

16. Riebl SK, Davy BM. The hydration equation: update on water balance and cognitive performance. 

17. Spigt MG, Kuijper EC, Schayck CP, Troost, J, Knipschild PG, Linssen VM, et al. Increasing the daily water intake for the prophylactic treatment of headache: a pilot trial. Eur J Neurol. 2005;12(9)715-718.

18. Razeghi Jahromi S, Ghorbani Z, Martelletti P, et al. Association of diet and headache. J Headache Pain 2019;20(106).

19. Slavin M, Li H, Frankenfeld C, Cheskin LJ. What is needed for evidence‐based dietary recommendations for migraine: a call to action for nutrition and microbiome research. Headache. 2019;59:1566-1581. doi:10.1111/head.13658

20. Hartman TJ, Albert PS, Zhang Z, Bagshaw D, Kris-Etherton PM, Ulbrecht J, et al. Consumption of a legume-enriched, low-glycemic index diet is associated with biomarkers of insulin resistance and inflammation among men at risk for colorectal Cancer. J Nutr . 2009;140(1):60–67

21. Bunner AE, Agarwal U, Gonzales JF, Valente F, Barnard ND. Nutrition intervention for migraine: a randomized crossover trial. J Headache Pain. 2014;15(1):69. doi:10.1186/1129-2377-15-69

22. Vadell AKE, Bärebring L, Hulander E, Gjertsson I, Lindqvist HM, Winkvist A. Anti-inflammatory diet in rheumatoid arthritis (ADIRA)-a randomized, controlled crossover trial indicating effects on disease activity. Am J Clin Nutr. 2020. doi:10.1093/ajcn/nqaa019

23. Bigal ME, Rapoport AM. Obesity and chronic daily headache. Curr Pain Headache Rep. 2012;16(1):101–109.

24. Ford ES, Li C, Pearson WS, Zhao G, Strine TW, Mokdad AH. Body mass index and headaches: findings from a national sample of US adults. Cephalalgia. 2008;28(12):1270‐1276. doi:10.1111/j.1468-2982.2008.01671.x

25. Razeghi Jahromi S, Ghorbani Z, Martelletti P, et al. Association of diet and headache. J Headache Pain. 2019;20(106).

26. Recober A, Goadsby PJ. Calcitonin gene-related peptide: A molecular link between obesity and migraine? Drug news & perspectives. 2010;23(2)112–117.

27. Dalton K. Food intake prior to a migraine attack--study of 2,313 spontaneous attacks. Headache. 1975;15(3):188‐193. doi:10.1111/j.1526-4610.1975.hed1503188.x

28. Dexter JD, Roberts J, Byer JA. The five hour glucose tolerance test and effect of low sucrose diet in migraine. Headache. 1978;18(2)91–94. doi:10.1111/j.1526-4610.1978.hed1802091.x

29. Zhang DG, Amin FM, Guo S, Vestergaard MB, Hougaard A, Ashina M. Plasma glucose levels increase during spontaneous attacks of migraine with and without aura. Headache. 2020;60(4):655‐664. doi:10.1111/head.13760

30. Finocchi C, Sivori G. Food as trigger and aggravating factor of migraine. Neurological Sciences. 2012;33(S1)77–80. doi:10.1007/s10072-012-1046-5

31. Hering-Hanit R, Gadoth N. Caffeine-induced headache in children and adolescents. Cephalalgia. 2003;23(5):332‐335. doi:10.1046/j.1468-2982.2003.00576.

32. Lee MJ, Choi HA, Choi H, Chun CS. Caffeine discontinuation improves acute migraine treatment: a prospective clinic-based study. Headache. 2016;17(1)71.

33. Scher AI, Stewart WF, Lipton RB. Caffeine as a risk factor for chronic daily headache: A population-based study. Neurology. 2004;63(11)2022-2027. doi:10.1212/01.wnl.0000145760.37852.ed

34. Arzani M, Jahromi SR, Ghorbani Z, et al. Gut-brain axis and migraine headache: a comprehensive review. J Headache Pain.2020;21(15).

35. Lee JJ, Kwon Y, Kim JH, Sohn JH. Clinical implications of associations between headache and gastrointestinal disorders: a study using the Hallym Smart Clinical Data Warehouse. Front Neurol. 2017;8:526.

36. Knight R, et al. Migraines are correlated with higher levels of nitrate-, nitrite-, and nitric oxide-reducing oral microbes in the american gut project cohort. mSystems. 2016. doi:10.1128/mSystems.00105-16.

37. Jahromi SR, et al. The effects of a multispecies probiotic supplement on inflammatory markers and episodic and chronic migraine characteristics: A randomized double-blind controlled trial. Cephalalgia. 2019;39(7).

It’s time to stop just recommending trigger avoidance strategies to patients. These are the proactive behaviors that will actually help improve migraine.