What causes pre-migraine syndrome


Possible triggers for the attacks

When the migraine attacks are triggered, the triggering factors - so-called trigger factors - must be strictly separated from the actual "causes" in the sense of "initiating" the migraine attack. While the cause is a specific excessive readiness of the organism to react, trigger factors can be very diverse conditions that cause the migraine cascade to take place. The majority of migraine attacks come out of the blue: Even with the best will, no specific trigger factor can be found for the particular migraine attack.

However, the following trigger factors are particularly potent candidates for setting off a migraine attack:

  • Sudden stress
  • Changes in the daily rhythm
  • Pronounced emotions
  • Hormonal changes
  • Skipping meals
  • Overexertion and exhaustion

It turns out that the common denominator of all trigger factors is a sudden change in the normal rhythm of life. The factors, mechanisms and circumstances by which this change is brought about seem to be of less importance.

Stress - something different for everyone

There is a wide gap between views on what stress is. For some it is stress that awaits them at work, for others it is the hustle and bustle of children. Some people are “under stress” because they still want to get something done quickly or because they still haven't got anything to eat. At least as different as the popular ideas about stress are the scientific ones. To put it in a somewhat exaggerated way, one could say that every discipline, be it psychology, biology, ecology or another, has its own definition.

The stimulus-response model

Orbital headache

The most widespread is a stimulus-response model based on the work of the biochemist and physiologist Hans Selye, who died in 1982. According to this model, stress is understood as a consequence of damaging physical, psychological and social influences (called “stressors” in the model), which trigger a largely identical reaction pattern in those affected. The aim of the reactions of the entire organism is to compensate for the disruptive influences, i.e. to adapt the organism to the stressors (general adaptation syndrome).

The stressors themselves can be anything: cold or heat, physical stress, the loss of a loved one, the work situation and much more. For example, there is a scale on which various critical life events are ranked with regard to their stress-inducing potency, the so-called “social change assessment scale”. It should be noted, however, that this scale only includes mean values. But how each individual reacts to such stress-inducing events can be completely different, since everyone perceives something different as "stressful". What is already stress for some - such as getting to know new people - is a welcome change for others. So it also depends on the rating. Regardless of this, however, the scale gives a good overview of what can be perceived as stress by many.

Stress doesn't have to be stressful

In daily life, however, there are a whole range of different stress experiences that are not on the scale. This can be, for example, the ringing of a telephone at an unexpected moment, constantly changing lighting conditions or the famous fly on the wall. These everyday stressors can only develop into significant factors when taken together.

In addition, positive experiences in everyday life are very important to compensate for such minor stress experiences. In this way, positive experiences can outweigh small stressors that would otherwise add up. That can be good news, a bouquet of flowers, or simply the experience of having a good rest.

In addition to the actual stressful situation and its assessment, however, the ability of the individual to influence the stressful situation and develop possible behavioral strategies in order not to let a certain situation degenerate into stress in the first place (coping skills) is also important.

When does stress trigger migraines?

Stress, strain and emotional influences are the ones most frequently cited by migraineurs as triggering or aggravating factors for migraine attacks. Systematic studies show that what matters is not the absolute stress level - so to speak, the degree of stress - but rather sudden changes in the stress level. Correspondingly, two sets of conditions can be found, namely

  • Stress relaxation migraines and
  • Relaxation stress migraines

delimit. If it succeeds, one can conclude from reducing the level difference between relaxed normal state and stress, then the frequency of seizures should actually also be reduced. And that is exactly the case. Undoubtedly, relaxation methods such as progressive muscle relaxation and the planning of a regular daily routine are therefore among the most important components of non-drug migraine therapy.

The sleep-wake rhythm

Most migraine attacks are triggered either in the early morning or in the afternoon. A connection with the sleep-wake rhythm is therefore of course intensely discussed. According to individual case reports, there should be a connection to the sleep pattern, especially in migraines without aura. In the case of a short sleep, only reaching deeper sleep stages, such as in particular REM phase 3 and REM phase 4, then triggers migraine attacks. Accordingly, particularly long and deep sleep phases at night should be able to trigger migraine attacks on the days in question.

After falling asleep, the first step is “down” gradually to the deepest phase of deep sleep (non-REM sleep). About 80 to 90 minutes after falling asleep, we dive into the first REM sleep phase (REM = rapid eye movement), in which we dream particularly intensely. This phase lasts about five to ten minutes and is again followed by a descent into deep sleep. Depending on the length of the night's sleep, we come to four to five of these cycles of non-REM / REM sleep, with the depth of the non-REM phases decreasing and the length of the REM phases increasing.

Although these data are not backed up by controlled studies - they are just individual case reports - there is still a lot more to suggest a connection between sleep and migraines. For example, the fact that when migraines are linked to certain days of the week, Saturday is the most frequent migraine day. An important reason for this could be that you get up later on Saturday or go to bed later on Friday.

Of course, such monocausal attempts at explanation can be covered by other conditions. This includes in particular relaxation as well as changing food intake at the weekend, including coffee consumption. These diverse variables show that monocausal thinking makes little sense when looking for factors that trigger migraine attacks. Nevertheless, it seems sensible to keep the potential trigger sleep-wake rhythm in the back of your mind and to continue researching it systematically.

From alcohol to citrus fruits

Food is very often viewed as a potent trigger of migraine attacks not only by the general public, but also by doctors. However, we have to be very, very careful when assessing the extent to which foods are actually trigger factors. In no way do I want to give the impression that I am not taking the opinions of patients seriously. The opposite is the case. I would just like to sensitize you to the fact that prejudices can easily creep in here, which on top of that reappear very widely. It is understandable that one would like to believe any simple explanation for a disabling disease like migraine. Unfortunately, migraines are not that easy. So please try - and this basically applies to all aspects and triggers of migraines - to remain as objective as possible when someone wants to explain the egg of Columbus to you.

The glass of champagne in the afternoon

About 20 percent of all migraine sufferers report that diet-related trigger factors play a role in them, especially alcohol. As a rule, this then applies to all alcoholic beverages. A few think that there are only certain alcoholic drinks, especially red wine and sparkling wine.

It is interesting that it is often not just the alcoholic drink that plays a role, but also and above all the time of day at which it is consumed. There are people for whom, for example, sparkling wine has no consequences after 8 p.m., but in the early afternoon when saying goodbye to a work colleague, on the other hand, there is almost a 100% probability that a migraine attack will trigger.

Definitive statements so far impossible

At the moment it is not possible with certainty to associate the triggering of migraine attacks with a specific substance. The situation here may be similar to the triggering of migraine attacks by alcohol: It is not the food alone, but the time and type of food consumption that must be held responsible for triggering migraine attacks. The usual other suspects

The spice booster glutamate was blamed for the so-called China restaurant syndrome. However, a controlled study in a double-blind design has now been carried out, which has not been able to confirm the previously accepted trigger of glutamate for the Chinese restaurant syndrome by headache researchers. This fact, too, shows in detail how careful one has to be when interpreting individual factors.

Coffee: A small ray of hope

One finding is now well supported by studies: the connection between caffeine and migraine attacks. In a double-blind, randomized cross-over study, for example, it was shown that in subjects who normally drink up to six cups of coffee a day, the consumption of decaffeinated coffee is actually associated with an increased likelihood of migraine attacks. The headache usually starts on the first day after leaving out the caffeine and has a mean duration of two to three days.

Double-blind, randomized cross-over studies - what exactly is it? Double-blind means that neither the examiner, i.e. the person who administered the preparation, for example, nor the test person know whether it is a real preparation or a dummy preparation (placebo) that does not contain any active substances. This is to rule out that the examiner unconsciously influences the test person. Randomized means that the assignment to the respective treatment is made through a random selection of the test persons. And the term “cross-over” means that the test persons not only receive either preparation A or B, but rather both preparations one after the other at a certain time interval. Such studies are highly valued by researchers, as they rule out numerous possible sources of error.

Medicines can also trigger migraines

Headache is reported as an undesirable side effect for a variety of medications. So far, however, it is unfortunately unclear whether the respective headaches are actually migraine attacks or only symptomatic headaches due to an acute or chronic effect of the respective substance.

A number of studies are now available for nitric oxide - it is released in the body, for example, from drugs for high blood pressure and insufficient blood flow to the heart. These indicate that the substance is actually able to trigger headache attacks that are at least similar to migraine attacks.

Medicines that often lead to headaches are, in particular, estrogens, ergot alkaloids, caffeine, indomethacin (e.g. used for arthritis, spinal problems or menstrual cramps), reserpine (for high blood pressure), nifedipine (for high blood pressure and angina pectoris) and dipyridamole (for preventing stroke, after Heart attack).

Could the weather be to blame?

Weather factors are viewed by the population as being particularly important in triggering migraine attacks. Migraineurs living in southern Germany blame the hair dryer in particular. From a scientific point of view, however, the picture looks a little different: To date, there are no serious studies that would prove a connection between weather situations and the triggering of migraine attacks. In addition, there are indirect reasons that speak against this supposedly high priority of weather situations as a trigger: The broad correspondence of the frequency of migraines in the different countries of the world and, in particular, the worldwide agreement of the frequency of headache days per month or year.

A closer analysis of how migraine attacks relate to weather mechanisms shows that only a small proportion of migraine attacks can be associated with certain weather conditions.

Even if the data on this is still not clear, it must be said that particularly sensitive people can react to rapidly changing weather conditions with migraine attacks.

Hormonal changes

Especially in women with migraines, the connection with the hormonal fluctuations during the menstrual cycle is obvious and is mentioned again and again by women. Indeed, this relationship does exist, albeit not to the extent commonly believed. Shortly before menstrual bleeding, both estrogen and progesterone levels decrease. What is certain is that it is precisely this drop in estrogen that triggers migraine attacks in around five percent of women affected by migraines. A connection with the progesterone as well as the other hormones of the cycle (follicle-stimulating hormone, luteinizing hormone) could not be found.

Memory aid migraine pass

Nobody is perfect, especially not when it comes to remembering possible trigger factors for individual migraine attacks. Therefore, please use the trigger factor checklist in the migraine pass (see download box at the top right) to record all relevant facts. If you consider other factors than those listed to be important, please be sure to include them.