migraine triggers

The Surprising Connection Between Migraines and Nitrates

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Do Nitrates Have Anything to do with Migraines?

A recent article published found that higher levels of nitrates correlate with migraine. This research intrigued me. Many migraineurs I work with in my migraine group on Facebook announce shortly after joining the group that nitrates in their food causes migraines for them. This is very odd because human saliva contains an abundant amount of nitrates (1). I wondered why so many migraineurs would be concerned about nitrates when nitrates occur naturally in their saliva.

Though the research is clear, most folks do not realize that all produce, organic or otherwise, contains nitrates. In fact, anything grown in soil contains nitrates. There is a list of foods high in nitrates here but let me include a few for examples. Let me first say that the nitrate content in foods depends on the soil in which it is grown. The soil in some regions is higher in nitrates than in others, and thus, produces crops with higher nitrate content. Overall however, root vegetables are exceptionally high in nitrate. So, if you eat potatoes, sweet potatoes, carrots, radishes, onions, or yams, you are eating nitrates and your saliva will likely measure high concentrations of nitrates. Celery is very well known for its nitrates and many migraineurs eat celery regularly. And since organic prepared foods often use vegetable nitrates like celery juice, they too are high in nitrates, even though they advertise themselves as “nitrate free”.  Lettuce, beets, carrots, green beans, spinach, parsley, cabbage, radishes, and collard greens are also all high nitrate foods. Fruits have lower nitrate contents. This makes sense since they are not part of the plant per se.

Since nitrates are naturally occurring and we eat them in fresh produce every day, one must wonder if there is anything behind the theory that nitrates cause migraines. On the surface it certainly doesn’t appear so. Could there be something behind this association, beyond a chance correlation?

When this topic was presented to me for research, at first I thought… urgh… nah… there is not much here. Lots of researchers have worked on this and the results are conflicting at best. And given the nitrate content in foods, I thought the correlations observed were incidental. Then, a light bulb when off. Maybe there is something to this correlation, but I would dare say it is not what I thought it would be. Let me take you through the series of connections I made while researching this topic.

The Light Bulb Moment

It is important to start with a fact: our saliva contains nitrates. People with more nitrates in their saliva have more cavities. Many tests have been done to evaluate if salivary nitrite and nitrate (forming nitric oxide) can be used as biomarkers to estimate the likelihood of gingivitis. The correlation found was insignificant. While we all have varying levels of nitrates in our saliva, based on the gingivitis research, nitrates have nothing to do with migraines because not everyone with gingivitis has migraines and not everyone with migraines has gingivitis.

Another type of nitrate research is focused on the area where the esophagus and the stomach meet. Would nitrates have a role in GERD? Some migraineurs have GERD; could there be a connection?  Possibly, but again, unrelated to the cause of migraine because not all migraineurs have GERD and not all people who suffer from GERD have migraines. Then suddenly I found some amazing articles that hit me in the heart. Here is a title that started my heart beating a bit faster: “Dietary Nitrate Provides Sustained Blood Pressure Lowering in Hypertensive Patients” (3). Aha! I can now see a connection. Soon after finding this article, several other articles popped up with similar subject and the connection suddenly became clear.

Migraine, Low Blood Pressure, and Nitrates: The Missing Connection

It is little known that migraineurs, when not in pain, have clinically sub-normal low blood pressure, see hereherehere, and here. When new migraineurs join my migraine group, they frequently sport a blood pressure of 90/50 (normal ranges are 100-139 in systolic and 70-85 in diastolic) or up to 100/60 but rarely ever go over 110/70. What might happen if a chemical compound, such as nitrate, which lowers blood pressure, is given to or consumed by a migraineur? With the drop in blood pressure that follows taking nitrates (in food), and the vasodilating effect of that nitrate has on blood vessels (4), migraineurs are in trouble. Such drop in blood pressure can cause serious hypotension, which is associated with electrolyte disturbance, and that I believe, is the real cause of migraine.

The connection between migraine, nitrate, and low blood pressure has not been mentioned before in the scientific literature; at least I could not find it. Nitrates indeed cause trouble for migraineurs but not because of the harmful effects of nitrates as chemicals themselves, as is believed. After all, nitrates can be life saving for hypertensive patients. Nitrates cause problems for migraineurs because they lower their already low blood pressure, which sets off the cascade of events leading to migraine. This is the light bulb moment. This is the real reason for the correlations found in the article cited above and others. Unfortunately, much confusion still exists in this field of research.

Migraine and MTHFR Mutations: More Connections

Let us unpack the article’s results a bit more and see if we can shed some more light on the migraine-nitrate connection. Returning to the original article by Gonzalez et al., who stated the following:

“Using high-throughput sequencing technologies, we detected observable and significantly higher abundances of nitrate, nitrite, and nitric oxide reductase genes in migraineurs versus nonmigraineurs in samples collected from the oral cavity and a slight but significant difference in fecal samples” (see in abstract)

Suddenly this makes sense, but again, not for the reasons researched in the above article. They were comparing gut microbes and other interesting data but the real important stuff is in the saliva. The nitrate content of saliva is genetically predetermined by the SLC17A5 gene. Migraineurs carry the MTHFR C677T variant, and thus, migraine is genetically determined. Since migraineurs have sub-normally low blood pressure but higher than normal levels of nitrates in their saliva, perhaps there is a genetic connection. If there is a variant of the SLC17A5 gene in migraineurs in addition to the MTHFR gene variant, which we already know migraineurs have, there may be a genetic connection between migraineurs’ low blood pressure and higher nitrate levels in their saliva. If nitrates are given to hypertensive patients to reduce blood pressure, that makes sense, and it suggests that for the hypertensive, consuming foods with nitrates maybe helpful. We cannot state the same for migraineurs where nitrate consumption would reduce blood pressure. The consumption of nitrates would spiral migraineurs into a dangerously low blood pressure and induce the electrolyte imbalance responsible for most migraines!

Thus, the connection between nitrates and migraine is not a chemical one as suggested by Gonzalez et al., it is not similar to chemicals like MSG that many people are sensitive to (which has its own controversy). Rather, nitrates lower blood pressure and the low blood pressure initiates the migraine by two interrelated mechanisms:

  1. Reducing blood pressure relaxes arteries and muscles and thus reduces the volume of the blood available to carry oxygen and other vital nutrition around the body. A blood pressure of 90/50 has a significantly more difficult time pushing blood all the way up to the brain of a migraineur and increases the likelihood of reduced oxygen and reduced electrolyte, which then prevents action potential.
  2. As vasodilation creates the appearance of a reduced blood volume by widening the blood vessels’ diameter, migraineurs may experience dizziness, nausea, may faint and can have serious discomforts, all well-know prodromes of migraines.

While this article is in no way in conflict with any research that has ever been done on the connection between migraine and nitrate consumption, it clearly points to a new cause for the problem and suggests direction for new research. Nitrates may indeed have serious effects on migraineurs by their blood pressure lowering effects.

Sources

  1. Granli T, Dahl R, Brodin P, & Bøckman OC (1989) Nitrate and nitrite concentrations in human saliva: Variations with salivary flow-rate. Food and Chemical Toxicology 27(10):675-680.
  2. Kapil V, Khambata RS, Robertson A, Caulfield MJ, & Ahluwalia A (2015) Dietary Nitrate Provides Sustained Blood Pressure Lowering in Hypertensive Patients; A Randomized, Phase 2, Double-Blind, Placebo-Controlled Study. Hypertension 65(2):320.
  3. Kukovetz WRH, S; Romain, C; (1987) Mechanism of vasolidation by nitrates: role of cyclic GMP. Cardiology 74(Suppl 1):7.

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Please Folks – Migraine Is NOT A Headache

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We continually make strides in migraine disease and headache disorders education but we still have much work to do. As we succeed to reduce the stigma that surrounds migraine and headache, it’s time for a definitive name for migraine. Once migraine is qualified as a disease, its stigma will be reduced and patients will be taken more seriously and most likely receive an accurate diagnosis sooner. In order to do this we need to use the correct terminology when discussing migraine disease and headache disorders; call migraine a migraine and headache a headache. After all they are two very different things.

A Migraine is not a Headache

The majority of people including many in the medical community continue to use ‘migraine headache‘ when discussing migraine disease. This is problem because migraine is a genetic neurological disease that impacts the entire body; migraine is a primary disorder – a disorder by itself. Headache may be either a primary disorder or secondary disorder, and may be a symptom that is caused from another disorder. Migraine disease is not caused by any other disease or condition. It’s not a symptom of any other disease or condition. To that end, many advocates, myself included become extremely aggravated when we hear the term ‘migraine headache.’

Dr. Oz and the TV ‘Experts’

A recent Dr. Oz show entitled The New Science to Reverse Aging included a segment on how to treat ‘migraine headaches‘ holistically. One of the first problems I notice are they talking about migraines or headaches? Neurologist Dr. Majid Fotuhi (who isn’t a board certified doctor in headache medicine from the United Council of Neurological Subspecialties) was one of the featured guests and talked about the various foods can help reduce ‘migraine headache’ pain. To his credit, Dr. Fotuhi said the most important “weapon against frequent ‘headaches‘ is prevention, prevention, prevention.” I’m fairly certain at this point he means migraines – so why not use the correct term? Dr. Fotuhi goes on to say the best way to prevent ‘headaches‘ is exercise, avoid trigger foods that trigger ‘headaches’ and monitor the foods you eat because certain foods may be able to reduce the frequency of certain types of ‘headaches.‘ Trigger identification and management along with exercise are important pieces of any migraine management plan. For some exercise will trigger a nasty migraine attack.

Terminology Matters

At this point in the show, neither doctor has taken the time to distinguish the difference between migraine disease and headache disorders. Dr. Oz goes on to explain ‘migraine headache’ pain occurs on one side of the head, with nausea and light sensitivity. Many times this is true, but not always. Migraine pain can occur on both sides of the head, be mild to moderate and/or severe to debilitating. An attack can last from 4- 72 hours, sometimes longer, and not everyone will experience nausea.

Dr. Fotuhi reports that foods high in riboflavin which is vitamin B2 can “help reduce certain types of headaches and migraine headache.'” Mushrooms, asparagus, quinoa, milk are indeed high in B2 and it’s used for migraine prevention, but again, some of these foods may be strong migraine triggers for certain people. The doctors continue to interchange migraine and headache.

‘Hormonal headache’ and foods used to prevent them include those rich in magnesium like sweet potatoes, spinach, chard and bananas Dr. Fohuti  goes on to say. But eating these foods may be a strong migraine trigger for some. He continues to report that eating these foods can help reduce ‘menstrual headaches‘ and even suggests taking 450 mgs of magnesium will help prevent ‘hormonal headache. No mention here of checking with your doctor before you take the supplement. According to International Headache Society’s International Classification of Headache Disorders – III, 3rd edition, beta version or ICHD-III 3rd ed., beta version there is no diagnosis of ‘hormonal headache‘ or ‘menstrual headaches‘. However, pure menstrual migraine without aura, menstrually related migraine without aura and non-menstrual migraine without aura can all be found in it. Let me stress again how important correct terminology is.

Dr. Oz then describes tension type headache (a real diagnosis) as a “dull pain, band around the head, and the muscles behind your temples are contracting.” Eating foods with high levels of Coenzyme Q10 such as eggs, broccoli, cauliflower, tuna, organ meats and salmon may be beneficial for tension headache according to Dr. Fohuti – or they can be strong migraines triggers for some people. Dr. Fohuti says to avoid a tension type headache it’s imperative to get eight hours of sleep each night and practice daily relaxation. The truth of the matter is it’s more important to go to bed and wake up at the same time every day, seven days a week, then get various eight hour pockets of sleep.

The doctors went over “cold or flu headache” which doesn’t exist in the ICHD-III 3rd edition, beta version. Dr. Fotuhi said when we have a cold we can become dehydrated, so eating foods that have a high water content include strawberries, pineapples, watermelon and cantaloupe will help with that. Becoming dehydrated is not a good idea at any point for people with migraine and can certainly trigger a migraine attack.

Dr. Fotuhi goes on to say not to take aspirin, ibuprofen and/or acetaminophen more than once a week when you have a ‘headache‘ or you may get medication overuse headache or moh, formerly called rebound headache. In part he is correct, but the reality is if we use pain relievers, whether over-the-counter and/or prescription or migraine abortive medication, more than two to three times a week we may get moh. He never discusses how many ‘headaches‘ are too many or when to see a doctor, intimating that we should be able to handle our head pain with these vitamin rich foods and supplements. This is neither true nor accurate.

In my opinion, when discussing migraine disease prevention and treatment, it would be nice to hear from an expert, someone who is board certified in the related field and really knows what they are talking about.

Resources

Dr. Oz offers holistic help for headaches and migraines.” Examiner.com, July 22, 2013.

Foods Solutions to Ease Headache Pain, Part I.” The New Science to Reverse Aging. The Dr. Oz Show. August 15, 2013.

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Summertime Migraine Survival

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Living with Migraine disease can be emotionally and physically exhausting. Getting Migraines during the summer can be especially draining because this is typically a time when families take vacations, relax and have fun. Summer is time for pools, picnics and party’s; three things that can trigger a Migraine attack in a snap. So here are some survival skills to help with the three big summer “P’s”

Spending time by a pool can be very problematic for many Migraineurs.  As we cover ourselves up with sunscreen, wear lightweight protective clothing and put hats our heads, our eyes need to be shielded too. When we sit around a pool, care needs to be taken with our eyes, because the sun may not be the only Migraine trigger.  Any glare that may reflect from the pools surface and from other objects around the pool can also be problematic.  Wearing good sunglasses is a must when around any pool. The Center for Disease Control recommends (however untrendy they may be) wearing wraparound sunglasses with as much UVA and UVB ray protection as you can buy. This type of protective sunglasses may also help reduce the risk of cataracts and protect the fragile skin around our eyes.  Shade may be the only option for some people with lupus, MS and other chronic diseases. Being prepared is important when managing these conditions, so packing a big beach umbrella, or cabana in case you are unable to find shade, is a good idea. Moderation here is important too.

If you plan a picnic this summer, whether a family outing or romantic rendezvous, here are a few things to consideration before you go:

  1. Plan your event for the time of the day that is “normally” good for you. Maybe a lunch time picnic would be better than a dinner one, or vice versa.
  2. Pack items that are trigger “safe” foods – ones you currently know won’t trigger a Migraine.
  3. If it’s a family affair, have your family members help plan the foods they want to eat.
  4. Picking your picnic location is important too. With a little effort, you will be able to find a spot that has both a quiet peaceful area for you and some fun for the family.
  5. When invited to a picnic, pre-planning is essential. Eating a light trigger free snack (if you are unsure of the menu) is not a bad idea. If you don’t think there will be anything for you to eat so you won’t trigger a Migraine, bring you own and have fun!
  6. Make sure you have enough water to stay hydrated  – bring along an extra bottle if need be.

Summer parties are fun, but not when you have a Migraine. To ensure you make the most of you party try maintaining a regular sleep schedule, especially on weekends. Sleep plays a vital role in our Migraine management plan. Consider these things when trying to maintain your sleeping schedule:

  1. Keep the time you go to bed and time you wake the same each day.
  2. Make sure your bedroom is restful and relaxing; a place you want to sleep not read or watch TV.
  3. Try to limit any drinks a couple hours before bedtime.
  4. Eat your last meal four hours before you go to bed.
  5. Try to stop napping  during the day – if you must – only take a 30 minute nap before 3 pm.
  6. Use visualization and relaxation techniques to aid with sleep.

There you have it. These simple, easy to do “survival” tips may help us have a better, less Migraine-filled summer. Don’t forget about keeping a Migraine diary too!

To read other fabulous information  on “Summertime Survival Skills for Migraineurs” check out the July 2011 Headache & Migraine Disease Blog Carnival. 

Thanks for reading and feel well,

Nancy

 

About the Author

Nancy Bonk is a patient advocate for living with migraine, a regular contributor to Hormones Matter and other online journals. To read her story click HERE.

More posts by Nancy

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