Poll: Should Migraineurs Avoid Headache Triggers?

The following article is part of conference coverage from the 2018 American Headache Society Annual Scientific Meeting in San Francisco, California. Neurology Advisor’s staff will be reporting breaking news associated with research conducted by leading experts in neurology. Check back for the latest news from AHS 2018.

SAN FRANCISCO — Attendees at the 60th Annual Scientific Meeting of the American Headache Society were privy to an enthusiastic debate between 2 experts in the field who debated the validity of trigger avoidance in patients with migraine headache.¹

Richard Lipton, MD, professor of neurology at Albert Einstein College of Medicine and director of the Montefiore Headache Center in the Bronx, New York, spoke in favor of avoidance of triggers in a very straightforward approach to migraine management.

“People with migraine should avoid all of their individual avoidable triggers,” he told the audience. “Trigger factors are highly variable within and between people. It’s important that if we are going to advise avoidance, we must correctly identify trigger factors.”

Dr Lipton identified common flaws in studies examining triggers, noting that results are often influenced by recall bias and patient beliefs, which are often inconsistent with what is learned from direct observation.

In order to identify what matters most to the patient in front of you, Dr Lipton said, conducting “N of 1” studies is especially useful. Doing so allows you to introduce individual proposed triggers and have the patient self-report migraine frequency, which in turn can help quantify associated risk for migraine headache.

Dr Lipton told the audience about a specific case, in which a patient presented to him complaining of migraine attacks related to drops in barometric pressure. When he asked the patient why he thought there was a connection between the two, the patient presented his watch, which alerted him to changes in barometric pressure. He noted that whenever he was alerted to a drop in pressure, he developed a migraine. In turn, Dr Lipton took the patient’s watch from him, which resulted in fewer reported migraines. After some time, he re-introduced the watch to the patient. “I taught him to avoid the trigger that mattered; in this case, the anticipatory anxiety associated with his belief that a drop in barometric pressure” would cause him to develop a migraine.

Dr Lipton argued that avoidance has many forms, including direct avoidance, which can help in the case of a direct biological effect, as well as education, which can help in the case of a more psychological mechanism.

Presenting the counter argument was Professor Paul Martin, OAM, FBPsS, Hon FAPS, DPhil, director of the Research School of Psychology at the Australian National University in Canberra.

Dr Martin began his argument by listing commonly reported headache triggers, from stress and anxiety, noise and smells, certain foods, and seasonal weather conditions to sleep (too much or lack thereof), sex, and body pain, emphasizing how far reported triggers penetrate our lives.

He noted deep-rooted conceptual, practical, and empirical issues with avoidance, explaining that avoiding situations that make you anxious in turn causes more anxiety. He compared avoidance of triggers with hiding in a hole, “and I don’t think that is a good prescription for life,” he said.

Dr Martin explained common and highly effective treatments for anxiety, including desensitization, flooding, and implosion, which involve long exposures to anxiety-provoking stimuli, in contrast to short exposure, which contributes to maintenance of phobias. He noted that while avoidance of triggers may lead to fewer headaches in the short term, “it may result in more headaches in the long term as tolerance for triggers decreases.” Ultimately, avoidance provides a lack of opportunity for learning to cope with the trigger, he said.

He argued that counseling avoidance should be replaced with learning to cope with triggers, as it is all about “changing their tolerance.” Still, Dr Martin emphasized that this approach is not a one-size-fits-all solution.

“No one strategy can be singled out as the best way of managing all headache triggers,” he said. “Sometimes avoidance will be the strategy of choice, but more often, approach, engagement, and exposure strategies will be the strategies of choice.”

He pointed to results from the MaTCH study,² in which 127 patients with a headache disorder were randomly assigned to 3 different treatments: complete avoidance of triggers, avoidance plus cognitive behavioral therapy, or Learning to Cope with Triggers (LCT), which involved exposure to some triggers and avoidance of others. Patients in the LCT group saw a 35.9% reduction in headache frequency and a 27.9% reduction in medication use compared with reductions of 30.0% and 19.4%, respectively, in the avoidance plus cognitive behavioral therapy group. Notably, change in headache frequency and medication use in the avoidance-alone group did not differ significantly from the control group.

A fan of pop-culture quotes, Dr Martin closed his argument with an appropriate statement from The Lion King’s resident intellectual, Rafiki: “The way I see it, you can either run from it, or learn from it.”