stop migraine dr deb

Can the ketogenic diet help prevent migraine headaches?

Can the ketogenic diet help prevent migraine headaches?

stop migraine dr deb

Migraine headaches are characterized by recurrent episodes of moderate to severe throbbing pain that are typically associated with nausea, vomiting, along with light and sound sensitivity. Currently, it is estimated that between 12-14% of the population, or over 37 million people in the United States suffer from migraine headaches. Migraines are more common in females of childbearing age. One out of four women will have a migraine sometime during their lives. Despite the fact that it is the 3rd most prevalent and the 6th most disabling illness in the world, there are still very few effective treatment options.

As a headache specialist I am always looking for better treatment options for migraine headaches. For those who know me, know that I prefer conservative treatment options, such as exercise or dietary changes. For the past two years I have been doing research on all the potential neurological benefits of ketones and the ketogenic diet (KD).

The ketogenic diet mimics fasting by restricting the amount of carbohydrates that are eaten. This triggers the break down of fats, producing ketones. Research has shown that ketones have many beneficial effects both for the brain and the body. Specifically, research has shown that ketones decrease inflammation, decrease brain cortical excitability, improves mitochondria function, and decrease the amount of reactive oxygen species (ROS) thus reducing oxidative stress.

So why would the ketogenic diet or having ketones potentially help with migraine headaches?

Ketogenic diet has been used since the 1920’s for treatment for epilepsy. Many of the same medications are used to treat both conditions. Specifically, the anti-seizure medications, Topamax and Depakote are also used to prevent migraine headaches. Both migraine headaches and seizures involve paroxysmal excitability of the brain. So measures that decrease this excitability may improve both conditions. Ketones have been found to decrease the levels of the excitatory neurotransmitter glutamate. (Stafstrom, C. 2016) Decreasing glutamate levels decreases cortical excitability and decreases central sensitization. Central sensitization is a condition of the nervous system that is associated with the development and maintenance of chronic pain syndromes such as chronic migraine headaches and fibromyalgia.(Pomeror, 2017)

Decreased cortical excitability has also been shown in rat models looking at cortical spreading depression (CSD). CSD is a wave of cortical excitability that is thought to correlate with migraine aura and may be a trigger for the start of a migraine. (Stafstrom, C. 2016) It has been shown that rats treated with a KD had decreased CSD. (Di Lorenzo C. , 2015) Why CSD occurs is unclear but one hypothesis is that it is due to dysfunctional mitochondria. Mitochondria are where the cells produce ATP needed for cellular energy. When the mitochondria are dysfunctional, this lead to decreased ATP production. This decreased ATP then increases the occurrence of CSD and potentially migraines. (Sparaco, 2006) Thus, another reason ketones may be beneficial in preventing migraines is that ketones have been shown to improve mitochondrial function. (Di Lorenzo C. , 2013)

Another reason that ketones or being on the KD would be helpful in prevention of migraines is because of the anti-inflammatory effect of ketones. Neuroinflammation is inflammation medicated by the release of neuropeptides of the nerve fibers in the brain. It is the physiological mechanism of a migraine attacks. Indirect evidence that inflammation is the mediator of a migraine attack is during a migraine attack is based on the increased levels of inflammatory peptides during a migraine and the fact that non-steroidal anti-inflammatory drugs are often effective treatment for acute migraine headache.(Pietrobon, 2013)

There are several different mechanisms for the anti-inflammatory effects of ketones.   First of all, compared to glucose metabolism, ketone metabolism produces fewer reactive oxygen species (ROS). ROS contribute to inflammation. Secondarily, the neurotransmitter Adenosine is increased with the KD. Adenosine has been shown to decreases both central and peripheral inflammatory. (Masino, 2013) (Dupuis, 2016) Lastly, ketones have been shown to block the NLRP3 inflammasome. Activation of NLRP3 inflammasome leads to the release of pro-inflammatory cytokines. (Youm, 2015)

So what does this mean clinically? Can the KD decrease the frequency of migraine headaches?

The first report of using the KD for migraine was in 1928. That study, 9 of the 28 patients reported some improvement, despite the fact that there was low compliance with the diet. (Stafstrom, 2016) More recently a larger observational study was done in 96 obese females. In this study, the females were randomized to either eat a KD or standard diet (SD) for 1 month. During the month on the ketogenic diet, there was a significant decrease in the frequency of migraine, the number of days with migraine, and medications used to treat migraine headaches. After that month all were transitioned back to a SD, during which their headaches again worsened. (Di Lorenzo C. , 2015) 

headache study

So, if you have migraine headaches, and would like to try something conservative as a means to decreasing the frequencies of your headaches consider starting a ketogenic diet. If starting making this significant dietary changes scares you, consider jumping in the easy way by starting a ketone supplement*. Other benefits that you might notice when you have ketones in your system include fat loss, improved energy, and improved mental focus. When was the last time you heard those ‘side effects’ when discussing medication options for migraines?!?


Di Lorenzo, C. (2013). Diet transiently improves migraine in two twin sisters: possible role of ketogensis. Functional Neurology, 28 (4), 305-308.

Di Lorenzo, C. (2015). Migraine improvement during short lasting ketogenesis: a proof of concept study. European Journal of Neurology, 22, 170-177.

Dupuis, N. P. (2016). Anti-inflammatory Effects of a Ketogenic Diet. In S. Masino (Ed.), Ketogenic Diet and Metabolic Therapies (pp. 147-155).

Masino, S. (2013). Ketogenic Diet and Pian. Journal of Child Neurology, 28 (8), 993-1001.

Pietrobon, D. M. (2013). Pathophysiology of Migraine. Annual Review of Physiology, 75, 365-91.

Pomeror, J. L. (2017). Ketamine Infusion for Treatment Refractory Headache. Headache, 57 (2), 276-282.

Sparaco, M. (2006). Mitochondrial dysfunction and migraine: evidence and hypotheses. Cephalalgia, 361-372.

Stafstrom, C. (2016). Dietary Therapy for Neurolgical Disorders. In S. A. Masino (Ed.), Ketogenic Diet and Metabolic Therapies. Oxford.

Stafstrom, C. (2012). The ketogenic diet as a treatment paradigm for diverse neurological disorders. Frontiers in Pharmacology, 3, 1-8.

Youm, Y.-H. (2015). Ketone body Beta Hydroxybutrate blocks the the NLRP3 inflammasome-mediated inflammatory disease. Nature Medicine, 21, 263-269.


The medical information on this site is provided as an information resource only. This information does not create any patient-physician relationship, and should not be used as a substitute for professional diagnosis and treatment.
*These products are not intended to are not intended to diagnose prevent treat or cure any disease. If you are under medical supervision for any allergy, disease, taking prescription medications or you are breastfeeding contact your medical provider before adding any new supplements to your daily regimen.



Migraine Triggers

What are migraine triggers and

Why do I have migraine headaches?

As a headache specialist I get asked this all the time.   Migraine unfortunately is all too common. The lasted estimates are that there are over 36 million people who suffer from migraines in the United States. Not only is it very common, but also migraine headaches are also very disabling. Migraine headaches are listed as the 4th leading cause of disability in women and the 7th leading cause overall.

The pathophysiology of migraine is not completely known. What is known is that some ‘triggers’ activate the neurons in the brain these neurons release neurochemical, CGRP, Substance P, and Kinins. These neurochemical then cause a localized neurogenic inflammation and localized vasodilation. If the trigger remains or if more neurons become activated eventually the abnormal electrical sign will propagate up into the cerebral cortex and you will start to feel the pain of a migraine.

If the conditions are just right, any one probably can have a migraine that is if they have enough ‘triggers’. However the people who suffer from regular migraine headaches have a genetically induced hypersensitive brain.   What does hypersensitivity mean? Basically the way I like to describe it is, that in these genetically predisposed individual it does not take as many of the triggers to trigger a migraine. Another way to think about it is that the migrainour’s brain does not like change, and any change in the external or internal environment may just be enough to trigger a migraine.

What are triggers?

Triggers can be either internal or external factors that can initiation the process of a migraine. Not everyone has the same triggers and the same triggers do not always ‘trigger’ a migraine. Here are some of the more common triggers reported.

  • Change in routine – the brain does not like change, so any change your regular routine can trigger migraine.
    • This includes changes in sleeping patterns. Both lack of sleep and too much sleep may be a trigger.
    • Skipping meals, or fasting
    • Changes in external environment temperatures – i.e. going from a hot outdoor temperature to a cold air-conditioned room.
    • Changes in hormones: Both around the time of their menstrual cycle and being premenopausal are often times that women are more prone to migraine headaches.
    • Changes in weather specifically; barometric pressure changes are often reported as times when migraines become more frequent.
  • Dehydration
  • Certain foods and additives
    • Red Wines
    • MSG
    • Artificial Sweeteners
    • Processed foods
  • Stress: but not only can stress it self trigger a migraine, but frequently people experience a migraine after a “let- down” of stress. So often see increase in migraines after school finals are over, or after that completely that big project at work.
  • Strong smells such as perfumes or certain scented cleaning products can trigger migraines in some people.

As you might notice not all the triggers are avoidable but I always encourage my patients to do the best that they can to get in a regular pattern/routine and do the best to stick to it. Then also eliminating the triggers that they can control. I also stress the importance of starting/continuing a regular exercise program. As discussed in prior blog post, this can also help prevent migraines.

Dr Deb


Obesity increases risk of migraines

Yes, being obese can actually increase your risk of having more migraines headaches!

Obesity affects one and a half billion adults worldwide, with estimates of a third of adults in United States being obese. Obesity is associated with many health issues including heart disease, stroke, diabetes, and cancer, making obesity is a significant health problem.  Obesity also has a negative effect on quality of life due to increased back and joint pain. What may be surprising to some people is the fact that obesity is also associated with an increased risk of migraine headaches.

Studies have shown obesity is a strong risk factor for having migraines. Being overweight or obese is associated with a two-fold increased risk of having migraines. As the BMI increases so does the risk of having migraine headaches. Additionally, obesity is also associated with having greater than five times the risk of developing chronic migraines. By definition, a chronic headache is having >15 migraines a month, which are typically more difficult to treat.

The fact that obesity increases the risk of both chronic and episodic migraines has been shown in multiple studies.   The first was in 2003 by a study by Ann Scher.  This study showed that not only that the risk of having migraines increased with obesity, but also that compared to those with normal weight, individuals with episodic headaches who also had obesity at baseline were at increased odds of developing chronic migraine at follow up. These results have since been confirmed in several other studies.

What is the mechanism?

The cause of increased migraine in obesity is not exactly known, but most likely it is related to the pro-inflammatory properties of adipose tissue. Adipose tissue is more than just fat that piles up where we don’t want it; it is also a functioning active endocrine organ. Adipose tissue produces and releases pro-inflammatory cytokines including tumor necrosis factor and interleukin-1. Additionally, several hypothalamic peptides adiponectin and orexin, typically felt to be anti- inflammatory, are low in people who are obese.   This increased systemic inflammation has been implicated in the pathogenesis of migraine headaches.  Increased inflammation also is associated with increased central sensitization, which then lead to more frequent and harder to treat migraines.

Can weight loss help prevent migraines?

Currently the only studies on the effects of weight loss in adults were in people who underwent surgical treatment for weight loss. The two small clinical studies that looked at headache frequency after weight loss from bariatric surgery, found that at 6 months after surgery the frequency of migraine did indeed decrease from a pre-surgery average of four per month down to 1-2 per month. There was also an improvement in headache duration, pain severity, disability, and use of pain medications.

The only study looking at non-surgical intervention for weight loss to date was in adolescents. This study looked at whether a behavioral weight loss intervention would reduce migraine frequency. The behavior intervention consisted of encouragement of exercise program and dietary education of the adolescent and their parents. This study showed that a decrease in BMI was associated with a reduction in migraine frequency. With the greater decrease in BMI was a greater decrease in migraine frequency.

How can weight loss cause an improvement in migraine headaches?

Just as obesity is associated with pro-inflammation, weight loss is anti-inflammatory. Weight loss decreases pro-inflammatory cytokines (TNF and IL-1) and the peptides leptin.   Weight loss also increases anti-inflammatory peptides; Orexin A, and adiponectin. Thus with weight loss, there is less neurogenic inflammation resulting in less frequent migraines but also less central sensitization and decreased severity of those migraines.

Additionally, there are also the benefits of physical activity on prevention of migraines. Several studies have been published that have reported beneficial effects on both migraine frequency and severity. Also a study showed that exercise might be just as beneficial as topiramate in the prevention of migraines. Exercise is also felt to be anti-inflammatory and also increases the feel good, pain-reducing chemicals in your brain. In addition, people who exercise, tend to eat better, sleep better and have less stress which all can also decrease migraines.


Given that there is proven benefits seen with both exercise and weight loss in improvement in both frequency and severity of migraines, what is stopping you from giving it a try. I would love to help find an exercise and weight loss program that is right for you.

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Evan, R. W. (2012, February). The Association of Obesity with Episodic and Chronic Migraine. Headache .

Lockett, D. C. (1992). The effects of aerobic exercise on migraine. Headache, 32 (1), 50-54.

Peterlin BL, R. A. (2010). Migraine and obesity: Epidemiology, mechanisms, and implications. Headache, 50, 631-648.

Varkey, E. e. (2011). Exercise as migraine prophylaxis: A randomized study using relaxation and topiramate as controls. Cephalalgia, 31 (4), 1428-1438.

Verrotti, A. e. (2013). Impact of a weight loss program on migraine in obese adolescents. Euroean Journal of Neurology (20), 394-397.


What is new in migraine

What is new is in Migraine?

My top 5 take away from:

2014 American Headache Society Scottsdale Headache Symposium


  1. Migraine facts: One billion people on this planet have migraine headaches. One out of every four households has someone who suffers from migraines. 10% of children have migraines. Between 1-3% of people who have migraines will develop chronic migraines. Less than 50% of people who have migraines seek medical treatment.
  1. Neuromodulation:  Neuromodulation via either direct transcranial magnetic stimulation of the brain or stimulation peripherally, is the new wave of future treatment options for both migraine and cluster headaches. They are not yet ready for prime time but the future looks promising. Some of the most promising include the sphenopalatine ganglion stimulator for cluster headaches and the vagal nerve stimulator for both migraine and cluster headaches.   Currently available for purchase is a transcutaneous supraorbital neurostimulator (cephaly). In the studies it was reported to have a responder rate of 38% with 1/3rd of responders having a 25% reduction in headaches and decrease in headache severity. The most common side effect was strong paresthesias.
  1. Nutraceuticals: More and more people are reaching for a more natural treatment options for migraines. However, just because it is natural does not mean it that is always safe. Butterbur (petasites hybridus) is a popular nutraceutical often given for migraine prevention. Butterbur in its natural plant form contains pyrrolizidine alkaloids, which are hepatotoxic if not processed correctly.   Petoladex formulation of butterbur previously had the most trusted processing standards to which the butterbur was purified to contain less than the detectable limit of this hepatotoxic alkaloid.   Because Petoladex safety has recently come to be questioned it has been taken off the market in Europe and is no longer recommended by the AHS.
  1. Food Sensitivities:  The scientific community is slowly coming around to what my patients have been telling me for a while now.   That is, that the foods that we are eating may be triggering our migraines. Some foods have long been associated with triggering migraines such as MSG or Red Wines.   New triggers or food sensitivities can be found by testing for IgG sensitivities instead of relying on food diaries or IgE skin testing.   Removal of those food sensitivities from the diet may make significant difference headaches frequency.  (For more information on food/gluten sensitivities check out my recent post).   Also discussed was that a specific diet i.e., a diet in high Omega 3 vs Omega 6 has been shown decrease the frequency of migraines.  (For more information on this study of high omega 3 diet see my recent post).
  1. Obesity: Obesity is a strong risk factor for both having migraines and progressing into chronic migraines (>15 migraines a month). As your BMI increases so does the risk of having migraines, specifically, up to 2 times the risk of having migraines and 5.28 times the risk of developing chronic migraines.   The reason why is probably multifactorial but one interesting theory is based on the fact that adipose tissue produces cytokines that are pro- inflammatory (IL-6 and TNF alpha). Studies currently are under way looking at the potential benefits weight loss might have on the treatment of migraines.

This information is for education only, it is not intended to replace the advice of your physician .


Medication Overuse Headaches

Is your medication making your migraines worse?

Did you know one of the leading causes of chronic daily headaches (having headaches more than 15 days out of a month) is the over use of pain medication? Did you know the number one cause of medication over use is Excedrin?

What is Medication Overuse Headache?

Medication Overuse Headache (MOH) is a very frequent cause of chronic daily headaches. It has been reported as the cause of chronic daily headaches between 50-80% of the time. Medication Overuse Headache is also called rebound headache, analgesic rebound headache, or drug-induced headache. By definition it is having greater than 15 headaches a month for at least the past three months. Additionally, the headaches have to have worsened during the time of regular overuse of pain medication. Overuse is defined in terms of treatment days per month and depends on the drug.

Which medications cause Medication Overuse Headache?

The most common medication to cause Medication Overuse Headache is Excerdrin, followed by the Butalbital containing medications, then opioids. Triptans, Ergotamine, acetaminophen and NSAIDS may also cause Medication Overuse Headache but to a lesser degree.

How much medication is too much?

How much medication is too much depends on the offending medication. For the combination medications containing either Butalbital or opioids, triptans and ergotamine it can be as little as taking the medication >10 times a month to cause Medication Overuse Headache. For simple analgesics such as acetaminophen and NSAIDS,  Medication Overuse Headache is reported to occur with use >15 times per month.

How do I know if I have Medication Overuse Headaches?

Clinically, if you have Medication Overuse Headache, you may notice that you have to take more of a medication to treat the headache, or the medication that once previous worked is no longer treating your headaches. Often if the medication does decrease or relieve your headache, the headache will come back after the medication has worn off. That is why many people with Medication Overuse Headache will complain of headaches in the morning.

How do you treat Medication Overuse Headache?

Patients with Medication Overuse Headache can be difficult to treat. Typically, when you withdrawal the offending medication, the headache gets worse before it gets better. It is similar to what you experience when you stop drinking caffeine, the headaches can get worse while your body is going thru the withdrawal process. Sometimes getting off the over used medication requires a hospital stay both to help with the physical symptoms from the withdrawal of the medication and also the treatment of the headache. I also recommend starting a preventive medication to decrease the frequency of headaches thus decreasing the reliance on acute medication. However, preventive medications may not be as effective until they are off the offending medications, especially if they have been using opioids.

The best treatment for Medication Overuse Headache is prevention of it in the first place. One of the biggest reasons Medication Overuse Headache occurs is because the migraine is not properly being treated. Instead of using the most specific medication to treat a migraine such as a triptan, people start with either a over the counter medication which only partially decrease the pain, but is often not strong enough to completely get rid of the migraine. They often then try a Butalbital or opioid containing medication which may help them sleep but really has no effect on the migraine pathophysiology at all. Consequently, the migraine continues to build and thus becomes harder and harder to treat, requiring more and more medications and the cycle continues. The best treatment is using the most specific medication for migraine, ie triptans or ergotamines, but it is also just as important to use most the optimal dose and route for the treatment of their migraine.  Or as I described in earlier post, make sure you pull the weeds from the roots.

Now don’t get me wrong, Excedrin and other over the counter medication such as Aleve and Motrin can have a role in the treatment of migraines for some people, typically for mild or very infrequent headaches.   The problem occurs when people start taking these medications regularly. So if you buy this super size bottle of Excedrin and go thru it in a month much less in a year you may be causing a disservice to yourself and your migraines.

gluten.foods 300

Gluten Sensitivity

What is gluten sensitivity and how do I know if I have it?

I routinely recommend to my patients who have frequent migraines to try going gluten free.  Often the first response is that they have been tested and they do not have Celiac disease. Well that may be true but, unfortunately, that does not exclude the possibility that their frequent migraines are not from underlying gluten sensitivity.

So what is Gluten?

Gluten is a protein that is found in grains (wheat, barley and rye). It is the component of wheat that makes it doughy. It is often added to foods to help foods maintain their shape. It is found in many foods but also in some other unexpected places.  For a list of where gluten is found, check out a recent post SOURCES OF GLUTEN.

What is Celiac disease?

Celiac disease is an autoimmune disorder that is seen in a small amount of people who have an inherited susceptibility. When people who have celiac disease eat gluten, their body mounts an antigen specific immune response to their body’s own tissue. This response, in turn causes damage to the small intestine so that their body has a hard time absorbing nutrients. If left untreated celiac disease can lead to additional serious health problems.

What then is gluten sensitivity?

Gluten sensitivity is much more common than celiac disease. Research estimates that 18 million Americans or 1 out 20 may have gluten sensitivity. People who have gluten sensitivity often report the same symptoms as those with celiac disease but lack the same antibodies and intestinal damage as seen in celiac disease. Gluten sensitivity is a normal response to the abnormal appearance of gluten in the body. It is not a true food allergy nor is it an antigen specific immune response like celiac disease. It, instead, is a response of the innate immune system, i.e., it is nonspecific and does not have immunological memory to invading organisms.

What are some signs that you might have sensitivity to Gluten?

  • Frequent migraine headache
  • Chronic fatigue or fibromyalgia
  • Brain fog or lack of focus
  • Fatigue or lack of energy despite getting a good night sleep
  • Mood swings, anxiety, depression, or irritability
  • Autoimmune disease such as Hashimoto’s thyroiditis, Rheumatoid arthritis, Ulcerative colitis, Lupus, Psoriasis or Scleroderma
  • Hormonal imbalances such as PMS or PCOS
  • Inflammation, swelling or pain in joints
  • Digestive issues such as gas, bloating, diarrhea or constipation

How can I find out if I have Gluten sensitivity?

There are blood tests that shows the antibodies that are specific in celiac disease including; anti-gliadin, anti-tissue transglutaminase, and endomysial antibody.  However, since gluten sensitivity is not antigen specific these test are often negative in gluten sensitivity.  Also, since it mediated by the innate immune system, it is not mediated by IgE; thus, most laboratory or skin tests, will miss it. The test that I use in my office is the Mediator Release Test. It looks at the endpoint of the innate immune response or the hypersensitivity reactions, thus catching the food/gluten sensitivities that are not medicated by IgE.  This test is expensive, thou it is cheaper through a physician’s office, but not widely available.

How do you treat Gluten sensitivity?

The best way is just completely eliminating it from your diet.  For best results I would recommend doing this in conjunction with a clinically proven safe detox such as the Ultimate Reset, to remove other toxins as well. Of note, gluten is a very large protein, meaning that it may take months to get it out of your system and, therefore, it may be months before you see any benefits with your headaches or other symptoms. I typically recommend being off of it for at least 2 months before you reintroduce it back into your diet.

So if you have frequent migraines or any of the symptoms listed above I would recommend a trial of several months of going gluten free to see how you feel. What harm can it do and it just might help. You might be surprised just how great your body can once again feel and that’s worth any sacrifice you are making in giving up certain foods.

If you would like me to help you get off Gluten contact me I will be happy to help.

This information is for education only, it is not intended to replace the advice of your physician .


Is there a specific diet that can prevent migraine headaches?


  A Low Omega 6 and High Omega 3 diet has been shown help to prevent migraines




As a headache specialist I am often asked, “Are there specific foods that I should be eating to prevent migraines?”  Until recently, I would just recommend avoiding specific foods, such as MSG and red wines, that can trigger migraines, but not a specific type of diet.  Recently, evidence is mounting that the foods that you eat not only can trigger a migraine, but also can alter the metabolic pathway of pain and increase systemic inflammation.  This results in elevating your risk of having a migraine even after the food is out of your system.  A likely culprit of doing this is Omega 6 fatty acids (N-6).  Unfortunately, N-6 is bigger part of our diet then one may realize.

The Omega 6 fatty acids (N-6) include Linoleic acid (LA) and Arachidonic acid (AA).  Linoleic acid is the predominant polyunsaturated fatty acid (PUFA) in US western diet.  High LA oils include soybean, corn, cottonseed, safflower, and sunflower.  It is also found in salad dressing, margarines, mayonnaises and cooking oils.  LA oils are also added to a lot of packaged foods including breads, cereals, cookies and chips.  Since the early 1960s, intake of LA has increased three fold due to the dietary advice to substitute vegetable oil instead of animal fats.

It has been hypothesized that the overabundance of N-6 in the nervous system is a fundamental metabolic basis for central pain sensitization.  Dietary patterns of high N-6 are felt to promote pain by increasing the amount of Arachidonic acid (AA), the breakdown product of LA, in the nervous system.  High AA is believed to increase pain by inducing inflammation and by directly stimulating pain triggering N-methyl-d-aspartate (NMDA) receptors.

Omega 3 acids (N-3) are the “good” omega fatty acids, which have been shown to have anti-inflammatory and anti-pain properties.  Alpha linolenic acid (ALA) is the vegetable sources of Omega 3, found mainly in flaxseed.  Docosahexaemoic acid (DHA) and 3-eicosapentaenic acid (EPA) is the Omega 3 fatty acid that are found in fatty fish.

N-6 and N-3 fatty acids compete for enzymatic conversion, tissue incorporation and metabolism to bioactive derivatives.  So, if there is too much of N-6 in your diet or not enough N-3, N-6 will win.  Your body will be more in a pro-inflammatory, pro-nociceptive (pro-pain) state.  This state potentially would then cause headaches in headache susceptible people.

A recent study published in the journal Pain was a12 week study looking to see if a dietary intervention would improve headaches.  Patients with chronic headaches were randomized into 2 groups.  The first group reduced N-6 intake while eating ‘normal’ levels of N-3.  The second group were to reduced the N-6 intake but were to also eat high levels of N-3.  The rest of the diet was to remain the same. To decrease N-6 levels, both groups were to use only low LA oils and fat sources such as macadamia nut oil, coconut oil, low LA olive oil, butter and fat free mayonnaise.  The participants in the second group, who were to also increase the N-3, were also encouraged to eat flaxseed and 4 oz servings of fatty fish a day.

This randomized trial found that both groups showed improvements in clinical outcomes compared to the pre-intervention phase.  The high N-3 + low N-6 group however, produced significantly greater improvement in all clinical measures.  The HIT-6 disability scores decreased from 61 at baseline down to 53.5 at follow up.   The number of headache days per month was also significantly improved in the high N-3 + low N-6 group, from 23.3 at baseline down to 14.5 at follow up.  The headache hours per day decreased from 10.2 at baseline down to 5.6.   The probability of experiencing a severe headache day was also improved.   The amount of medication that was used to treat headache compared to base line was also significantly reduced by 43% in the N-3 + low N-6 group.

Thus, the study showed that the combination of increasing dietary N-3 with concurrent lowering of N-6 fatty acids produced a clinically relevant and significant improvement in headache days, hours per day, severe headache days, and headache related quality of life compared to base line and compared to just lowering N-6.

A prior study looking at the effects of just supplementing N-3 without lower N-6 levels showed no clinical benefit.  A possible explanation to why just adding more N-3 did not improve migraines is when there is too much N-6 around.  This is secondary to their competing for enzymatic conversion and metabolism.  The high level of N-6 does not allow the N-3 to be active despite taking in extra N-3.

Currently, the average American eats N-6 to N-3 omega fatty acids at a ratio of 16:1 where the ratio should be closer to 1:1.  To get your ratio closer to those recommended in this diet, there are 3 steps you can do to improve your diet.



The first step is to limit the amount of N-6 omega fatty acids.  Unfortunately, it is almost impossible t avoid N-6 entirely.  Thus, focus on avoiding as many vegetable oils such as safflower, corn, sunflower, cottonseed, and soybean as possible.  Also avoid the processed fat-based foods that utilize these oils including mayonnaise and bottled salad dressings.

The second step is to replace those oils with the oils that have better ratios of N-6 to N-3 including olive oil, avocado oil, coconut oil and organic butter.

The third step to improve your ratio of N-6 to N-3 fatty acids is to increase the amount of N-3 in your diet.  Foods that are rich in omega-3 fatty acids include fatty fish (salmon, mackerel, tuna, sardines, and anchovies) and some grass feed animal products.  Vegetarian sources include: flax seed, chia seed, sachi inchi, walnuts, quinoa, brussels sprouts, kale, and spinach.  My favorite source of N-3 is Shakeology, which contains sachi inchi, flax seed, chia seed, spinach and quinoa.

I realize changing your diet is difficult, but so is living with chronic migraines.  Isn’t having less headaches worth giving it a try?

Works Cited

Finkel, A. G. (2013). Dietary Considerations in Migraine Management: Does a consistent Diet Improve Migraine? Current Pain Headache Report , 17 (373), 1-8.
Ramsden, C. E. (2011). Low omega-6 vs low omega-6 plus high omega-3 dietary intervention for Chronic Daily Headache: Protocol for a randomized clinical trial. Trials , 12 (97), 1-11.
Ramsden, C. E. (2013). Targeted alteration of dietary n-3 and n-6 fatty acids for the treatment of chronic headaches: A randomized trial. Pain (154), 2442-2451.

5 Things You Should Question About Your Migraines

 5 Things you should question your Doctor about your Migraines

Here are 5 things that American Headache Society task force recommends to help physicians and patients make wise decisions about the most appropriate migraine care.

1.  There is no need to preform neuroimaging studies when you have stable migraine headaches.  This is based on the fact that there is numerous evidence-based guidelines have shown that the risk of intracranial disease is not elevated in people with migraine headaches.   A migraine diagnoses however needs to be made based on the International Classification of Headache Disorders criteria to avoid missing patients with more serious headache.

2. If you are going to get neuroimaging, make sure you get a MRI instead of CT scan, except in emergency setting.  A MRI is more sensitive than CT scan for the detection of many of the secondary causes of headache.  CT scan should only be obtained in the emergency setting when hemorrhage or acute stroke is suspected.

3.  Do not get surgical deactivation of migraine trigger points outside of a clinical trial.  The value of the form of ‘migraine surgery’ is still under question with limit evidence that it is effective or safe.  Long term side effects from these types of procedures are also unknown.
4.  Do not take opioids or butalbital containing medications as first line treatment for your migraines.  These medications  can impair alertness,  produce dependence or addiction.  They may worsen your headaches by increasing the frequency of your headaches and may make your headaches harder to treat.  These medications may also produce heightened sensitivity to pain.

5.  Do not use prolonged or frequent use of over the counter medication for your migraines.  Over the counter medications (OTC) can be used for occasional headaches if they work reliably without side effects.   Frequent use (especially of the caffeine containing medications) can lead to an increase in headache frequency/medication overuse headaches.   Overuse of Acetaminophen containing medications can cause liver damage.   Overuse of non-steroidal anti-inflammatory drugs can lead to gastrointestinal bleeding.  Thus it is recommended that you do not take OTC more than 2 days a week.



Loder E, Weizenbaum E, Frischberg B, Siberstein S.  Choosing Wisely in Headache Medicine: The American Headache Society’s List of Five Things Physicians and Patients Should Question. Headache. 2013:53:1651-1659.

Moran, M. From the American Headache Society: ‘Choosing Wisely’ in Headache Medicine: The American Headache Society’s List of Five Things Physicians and Patients Should Question about Migraine. Neurology Today. 2014:14.


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Exercise to prevent your migraines


Exercise can prevent your migraines!

Did you know that exercise can prevent migraines?  Well it is true, and there is recent study that proves it.  As a headache specialist, I always try to encourage my migraine patients to start a regular exercise program as a conservative way to decrease their migraine headaches, but up until now we did not much scientific evidence for this.

Individuals with migraine and other headaches have been shown to be less physically active than those without headache.  It is well recognized that individual with migraines there headaches can worsen with physical activity; this is even one of the major criteria on which migraines are diagnosed based on the International Headache Classification definition of migraine.  So it is unclear if the lack of exercise in individuals with migraines is the cause or effect of having migraines.

The reason why exercise can decrease migraines is unclear.  Some of the things that we do know are that exercise can increase the natural endorphins (feel good chemicals) in your brain.  Exercise can also decrease migraine triggers such as anxiety and stress.   Your sleep pattern is improved with regular exercise which can lessen migraines.  Other risk factors for migraine headaches such as obstructive sleep apnea, hypertension, and obesity are also improved with regular exercise.

In a randomized, controlled trial of adults with migraine where patients were randomized into three groups; an exercise group, a relaxation training group, or a group that received the preventive medication topiramate (Topamax).  The exercise group exercised three times a week for 40 minutes.  The study looked at how frequent migraines occurred compared to their base line migraine frequency. The study lasted three months.  What was found was that there was no significant differences between the groups, all decreased the frequency of migraines compared with the baseline.   No adverse effects were reported in the exercise or relaxation groups.  Adverse effects were reported in 33% of the participants in the topiramate group.  Restated, participants in this randomized controlled study who exercised regularly (3times a week) experienced an improvement in the frequency of their migraine attack that was not significantly different from the participants who received drug preventive medication topiramate without any side effect.1

No I am not saying that routine exercise will prevent all migraines.  However neither does medications.  So wouldn’t you rather try something that is good for you anyway either in addition to or instead of medications?

For more information on the causes and ways to prevent migraines see my Migraine Headache post.

As always please discuss with your physician before starting any strenuous physical activity. Also, please do not suddenly stop any of your medications without discussing with your physician first.  

Sites referenced:

1Emma Varkey, A. C. (2011). Exercise as migraine prophylaxis: A randomized study using relaxation and topiramate as controls. Cephalagia, 1428-1438.


Migraine Headaches

 What are migraines and how can I prevent them?

As a Neurologist with a specialty in Headache Medicine;  This is what I tell patients with migraine headaches

What are migraines?  Migraines are a primary headache disorder of recurrent attacks of moderate to severe pain.  The pain is often described as a throbbing or a pulsing pain which is typically located on one side of the head.  This can be accompanied by light and noise sensitivity, upset stomach, and visual changes (aura).  Migraines may present in different ways and maybe misdiagnosed by as tension headaches or sinus headaches.

What causes migraines? For many years it was believed that migraine attacks were due to changes in the blood vessels in the brain.  It is now believed that migraines are probably genetically induced hypersensitivity of the neurons in the central nervous system. This results in the brain neurons being more sensitive to their environment and thus has a lower threshold for developing a headache. Hormones, foods, noises, smells, lights, and stress all play a part in causing headaches.

How are migraines diagnosed? Migraines are diagnosed clinically by talking with your doctor. There are no x-rays or blood tests that will diagnose migraines. Generally, no tests are needed when migraine is suspected.

Who gets Migraines? Migraines affect 12 % of the U.S. population. Men and women of any age can get migraine headaches. However, migraines are most common in women in their teens to menopause.  Migraines often run in families.

Why did I get migraines? Every person has a headache threshold.  For a lucky few, it may take a sledgehammer to give them even a mild headache.  However for those with frequent headaches, something as simple as a missed meal may lower their headache threshold enough to start a disabling migraine.  Everyone has different migraine triggers to increase their headache threshold. The way I like to describe migraine is to think of it like a cup; once the cup is full = migraine.  Some people start with a cup that is already almost full and only one other trigger such as hormonal issue can make the cup full and thus trigger a migraine.  Other people have very little in the cup to begin with so it takes multiple triggers before the cup is full, and thus harder to trigger a migraine.

What are some common migraine triggers?

  1.     Sleep pattern changes, either too much or too little
  2.     Increased stress in everyday life
  3.     Menstrual cycles or hormonal changes (for women)
  4.     Weather changes/fronts
  5.     Foods; There a lot of foods that has been reported to trigger migraines in some people.  Some of the most commonly reported causes include
    1. Caffeine
    2.  Aspartame
    3.  MSG from Chinese food
    4.   Nitrates and nitrites
    5.   Red wines and alcohol
  6.  Dehydration

For more information on migraine triggers see recent blog post on triggers.

Conservative ways to prevent/decrease migraines:

  1. Get good restorative sleep; try to wake up and go to sleep at about the same time every day.  If you snore please seek medical evaluation and treatment for this, it may be sign of obstructive sleep apnea which can cause headaches, and also other medical problems such as high blood pressure, heart attack, and strokes.
  2. Stress reduction; obviously it is hard to get rid of all the stress in your life, but you need to find ways to better deal with the stress.  Such as: talking about problems, relaxation, messages, and exercise.
  3. Make exercise a routine part of your life.  Migraine may worsen when you exercise with a headache.  Recent studies however show that participants who routinely exercise had a decrease in the frequency and severity of their migraines.  I recommend exercising 5-6 times a week.  Exercise also help to decrease other migraine triggers such as anxiety and stress. It can improve sleep, decrease weight, increases natural pain reducing chemicals, and increases natural endorphins (feel good chemicals) in the brain.  For more information see “Exercise to prevent your migraines” post.
  4. Practice relaxation exercises on a daily basis. Whether it is through biofeedback, deep breathing, mediation, guided relaxation, cognitive-behavioral treatment, yoga, or Tai Chi, these practices can help decrease the hyperexcitation of the brain, thus decreasing likelihood of getting a migraine, help you deal with the migraine better, and help you deal with other outside stressors.
  5. Weight loss: Obesity is associated with an increase in frequency of migraines in people with migraines.  It is unclear why, some feel it is due to the higher levels of inflammation in the body.
  6. Hydration:  Drink at least eight 8 ounces of water daily, this may need to be increased in the summer months, if exercise regularly, or drink dehydrating fluids such as caffeine or alcohol.
  7. Limit or stop drinking caffeine: If suddenly stop drinking caffeine may get caffeine withdraw headache.  If must drink caffeine try to drink less than two servings a day.
  8. Eat regularly: do not skip meals, especially breakfast. I also recommend eating smaller more frequent meals.  (See addition information in “Migraine Diet” blog)
  9.  Maintain a headache diary: this helps you keep track of any possible triggers (lack of sleep, food, hormones, stress) that might have trigger but also shows if migraine frequency is improving or worsening.

Medical treatment for migrainesThere are medications that can decrease the frequency of your migraines and also medication to take when you have a migraine.  For more information please discuss with your Neurologist.

This site is purely informative and should not be considered medical advice. It is not intended to be used to diagnosis or treat any disease.  Please consult your physician before starting any fitness program or new supplement.