The Role of Food and Diet on Migraine – Webinar

0:00 and let me say happy National nutrition
0:02 month
0:04 um Canada’s theme for the month is to
0:06 unlock the potential of food so I think
0:08 this is very apt for us to be meeting
0:11 tonight so let’s see if we can unlock
0:13 the potential of food for a migraine
0:16 um
0:17 I like to start by talking a little bit
0:21 about me
0:23 um partly because there is no shortage
0:25 of opinions on food and migraine and I
0:30 like to start by explaining who I am so
0:32 you know where I’m coming from you know
0:34 what my credentials are my training and
0:36 and what are my biases because we all
0:39 have them so we might as well get them
0:41 out there so I am a registered dietitian
0:44 nutritionist and credentials in the
0:46 United States
0:48 um rdns are the credentialed nutrition
0:51 professionals working in clinical
0:52 nutrition so hospitals long-term care
0:55 facilities and so forth so
0:58 I have that clinical nutrition training
1:00 I’m also I have a PhD in food science
1:04 which may be a little bit of a unique
1:06 combination for some my specialist
1:09 specialization was in food composition
1:11 analysis
1:13 and so I know food down to a molecular
1:15 level how to analyze what’s in it how
1:18 the molecules interact with each other
1:21 um
1:22 so add that to the fact that I have
1:24 migraine um and I have for a number of
1:27 years now and not that that’s necessary
1:29 to be here talking
1:31 um but I do think it gives me a
1:33 different perspective and certainly
1:35 empathy
1:36 um for anyone living with this condition
1:39 and roll all of that together and that’s
1:42 how I became and was motivated to become
1:44 a migraine researcher in this specific
1:47 area
1:48 so I have published peer-reviewed
1:51 articles on this topic in journals like
1:54 headache and nutritional Neuroscience I
1:57 presented at various scientific
1:59 conferences
2:01 um so I really come at this from an
2:03 evidence-based approach and you’ll hear
2:04 that woven throughout
2:06 so that’s me
2:08 in order to do research we need to get
2:10 funding so I have some disclosures about
2:12 my various funding sources of the
2:15 research I do in migraine and other
2:17 places other topics and those are listed
2:21 here
2:22 so today’s questions these are some of
2:25 the questions that were posed to me that
2:27 I could talk about tonight and there are
2:29 way too many questions that we could
2:31 possibly get to tonight
2:33 um but this is the plan so we’ll talk
2:35 about Recent research about overall
2:37 eating patterns and how they might
2:39 influence migraine outcomes over time
2:42 um we’ll talk about what you should know
2:44 about skipping meals and fasting and
2:46 what that means for migraine a little
2:49 bit about food triggers for migraine
2:51 what we know what we don’t should we
2:53 take supplements and then last but not
2:55 least how long do we need to follow a
2:57 diet to see if it helps with migraine I
3:00 will leave that throughout as well and
3:03 in addition to the other disclosures
3:05 already stated of course you know
3:06 consult with your Healthcare
3:08 professional for anything specific to
3:09 you I’m really presenting evidence as it
3:12 relates to adults
3:13 um it’s it’s already tight to fit all
3:16 this in for adults um I won’t be talking
3:17 about Pediatrics or kids today
3:22 so first I want to keep things in
3:24 perspective
3:26 um and and talk about how and just maybe
3:28 acknowledge that the landscape of
3:30 nutritional evidence for migraine is
3:32 changing in a good way there is more
3:34 evidence coming in frankly it’s getting
3:36 difficult to keep up with all the papers
3:38 coming in around the world so that’s
3:40 great
3:41 um but I do want to caution also there’s
3:43 still so much we don’t know so I need to
3:45 beg for your patience we still need
3:47 patience in interpreting this and
3:49 especially when we get to the Q a at the
3:51 end you will all have amazing questions
3:53 that would make an amazing research
3:55 studies that I won’t have answers for
3:58 um so so bear with me
4:01 um but the landscape is changing we’re
4:03 making progress here
4:05 the other thing that I want to say about
4:08 evidence is this
4:10 um and this is this balance between the
4:12 burden of doing a dietary intervention
4:14 making a change to your own diet and you
4:18 know the strength and the evidence that
4:20 said that says it will help my brain and
4:23 the research evidence that we have to
4:26 there and so we’re sort of in this
4:28 Balancing Act balancing the burden
4:30 versus evidence in making dietary
4:32 recommendations for a migraine and I
4:35 don’t know that we’ve always got this
4:36 balance correct in the past at times I
4:40 think we’ve sort of thrown dietary
4:42 recommendations around for migraine
4:44 um you know saying things like oh just
4:47 you know eliminate these many foods from
4:50 your diet and see what happens just give
4:52 it a try when in fact that might be
4:54 changing everything about your eating
4:56 pattern and not fully recognizing that
4:58 so I want to mention that this is
5:00 something that I see um and that I weigh
5:02 heavily as I think about what to
5:04 recommend for diet and migraine
5:09 and here’s the last thing I want to put
5:10 in context before we really start to
5:12 jump in I want to recognize that dietary
5:15 migraine research is advancing at the
5:18 same time as our General Nutrition
5:20 guidelines are advancing and what we’re
5:22 seeing in the nutrition Community is
5:24 this evolution of guidelines away from
5:27 the specific nutrients focusing on you
5:29 know get enough nutrient X don’t avoid
5:32 nutrient why and we’re seeing the shift
5:35 to kind of what you see on the screen
5:37 which is overall eating patterns and
5:39 recommending overall eating patterns
5:42 like we see here so for example this is
5:45 from Health Canada this is something I
5:47 use actually in a lot of presentations
5:48 not just for you guys I love this image
5:51 and and this aligns with some common
5:54 recommendations to try to fill your
5:56 plate every meal half with fruits and
5:59 vegetables a variety of fruits and
6:01 vegetables a quarter with whole grains
6:03 and a quarter with with lean proteins
6:05 and then unsweetened beverages water
6:08 when you and so this is what I’m trying
6:11 to you know emphasize when I talk about
6:13 what you know food patterns eating
6:15 patterns it’s this idea that we don’t
6:17 eat nutrients we eat Foods we eat Foods
6:20 in combination in meals and recognize
6:22 that we eat Foods together with our
6:25 friends with our family to celebrate to
6:28 mourn to just get together and socialize
6:31 and so food
6:32 um
6:33 is a sort of better way for us to be
6:36 talking about nutrition recommendations
6:37 and so you’ll see that and how I talk
6:40 about some of the evidence for migraine
6:42 as well I think
6:44 so then
6:46 let’s take this opportunity and jump
6:48 into talking about eating patterns that
6:51 have been studied for migraine
6:54 so if we look in and dive into the
6:57 literature and really look at all the
6:58 things the eating patterns that have
7:00 been studied for migraine there are
7:02 quite a few many different diets have
7:05 been tested in relation to migraine in
7:07 one way or another and some of them are
7:09 listed here I’m sure I missed some so a
7:12 low glycemic diet low lipids low-fat
7:14 vegan various ways of attempting to
7:16 remove triggers from the diet
7:18 various ways of controlling fat like
7:21 omega-3 and omega-6 Ratio or ketogenic
7:24 um
7:25 and if we look at all of these studies
7:29 individually the interesting thing
7:32 um is that many of them if not actually
7:34 most of them see some benefit from
7:38 modifying the diet if you measure how
7:40 many migraines frequency someone has
7:42 before they start a diet put them on
7:44 this dietary intervention one of the
7:46 ones you see here and then measure how
7:48 many migraines they they’re having have
7:50 frequently after they’ve been on the
7:52 diet for a while most of these diets
7:54 show some sort of benefit usually a
7:56 couple days per month decrease in in
7:59 migraine days
8:02 um and so that’s great on one hand but
8:05 on the other hand it can’t you know it
8:08 can’t all be true
8:10 um and so this is a potential problem
8:14 for us and so you might be asking well
8:16 if all of this evidence shows all these
8:18 scientific studies why aren’t we seeing
8:20 strong recommendations for nutrition and
8:22 migraine
8:23 um and the big reason is that most of
8:26 these studies if we evaluate them based
8:28 on the quality of the scientific design
8:30 most of them are considered low quality
8:33 low quality evidence for dietary
8:36 interventions for migraine and what this
8:38 means is mostly that we can’t isolate
8:41 the dietary intervention as the thing
8:45 that caused the change that we saw that
8:48 there there’s a lot of potential for
8:50 other things to be happening in the
8:52 background that maybe weren’t controlled
8:54 properly in the study design that may be
8:56 influencing the migraine outcome as well
8:58 and we don’t know if it’s the diet
9:00 causing the change or the stress causing
9:03 the change or even the fact that they
9:05 knew they were eating and changing their
9:07 diet maybe that gave a placebo effect
9:09 so
9:11 that’s why we’re not seeing these huge
9:13 sweeping recommendations but there are a
9:15 lot of studies out there at this point
9:16 that have attempted to answer this
9:18 question so take heart from that
9:22 um but what we are doing is we’re
9:23 learning from these studies
9:26 um skeptical of some of the results but
9:28 we’re learning from these studies and
9:30 learning to design better ones so we’re
9:32 getting there
9:34 um
9:35 so then let’s talk about the studies
9:38 that I think have the best evidence
9:41 that’s out there for overall eating
9:43 patterns that help to reduce migraines
9:46 so specifically this is someone who has
9:48 migraine and is looking to modify your
9:50 diet to see to hopefully see reductions
9:53 in migraine frequency or severity or
9:55 some sort of outcome
9:57 and so I have a few I have three
9:58 separate diets to talk about kind of in
10:00 this this level of detail and each of
10:03 them will follow the same pattern that
10:05 we’ll talk about what is the diet
10:06 briefly briefly what’s the evidence who
10:09 might benefit from this specific diet so
10:12 if you’re trying to find one you know
10:14 which would you consider
10:16 how long do we need to follow a diet to
10:19 see the results and what does this diet
10:21 look like in real life if I actually
10:23 want to try it so
10:25 here we go so I’ve heard there may be
10:28 questions already about the ketogenic
10:30 diet so we’re jumping in let’s talk
10:32 about the ketogenic diet
10:34 um this as you as many of you probably
10:36 already know
10:38 um is a diet that restricts
10:39 carbohydrates to very low levels it also
10:42 restricts protein
10:44 um to generally moderate levels and in
10:47 order to make up for the reduction in
10:50 energy from carbs and proteins it
10:52 increases fat intake to pretty high
10:55 levels as a result and and the the diet
10:59 was originally designed for epilepsy for
11:03 as a treatment for epilepsy and it was
11:05 shown
11:07 um in the early 1900s to to have a
11:09 benefit of reducing epileptic seizures
11:12 and so it was studied as early as I
11:14 found the 1930 actually 1920s late 1920s
11:17 looking at the relationship between the
11:20 ketogenic diet and migraine partly
11:22 because of the similarities of these
11:24 diseases
11:25 and originally it was observed that when
11:30 when people with epilepsy were in a
11:32 fasting state so they hadn’t eaten for a
11:35 while they had less seizures and so what
11:38 the ketogenic diet does is sort of fools
11:42 the your body’s metabolism to act as
11:45 though you’re in a fasting state to to
11:47 metabolize fats as though you haven’t
11:49 eaten in a long time even though you’re
11:51 continually eating fat but you’re just
11:53 you’re keeping the carbohydrates so low
11:56 that you’re tricking the body into
11:57 thinking you’re not eating as much
12:00 um anyway so that’s where it came from
12:01 so the evidence for the ketogenic diet
12:03 for migraine so there was that Splurge
12:06 of research in the 30s and men not so
12:09 much for a number of decades and then in
12:11 the past decade or so we’ve seen a
12:13 couple clinical trap randomized
12:15 controlled trials our highest level of
12:16 evidence come out for the ketogenic diet
12:19 and migraine they are small they are
12:21 varied they’re not perfect
12:23 um
12:24 and so this is why we don’t see you know
12:27 people singing from from the rooftops
12:28 about this but they do show Fairly
12:31 consistent decreases in headache days
12:33 per month
12:35 um for the people who finish the study
12:36 it is a difficult diet so you do get
12:38 people who don’t finish
12:41 um and generally for most studies we’re
12:42 talking again a few headache days per
12:44 month for people
12:47 um the for who might the ketogenic diet
12:50 benefit the most who might be most
12:52 interested because it’s a difficult diet
12:54 and it’s it’s not something that if you
12:56 just have a few migraines once in a
12:58 while very episodic it’s probably not
13:01 worth it for you but for someone with
13:02 four or more migraine days per month
13:04 it’s been recommended that you might
13:06 consider it
13:08 um
13:09 for someone who’s overweight or someone
13:11 with metabolic syndrome so metabolic
13:14 syndrome could involve
13:16 impaired fasting glucose levels
13:19 abdominal obesity so carrying extra fat
13:22 around the waistline
13:25 um high triglycerides and minimum weight
13:28 as well so
13:30 um that may be someone who who could
13:32 look into it and this is again because
13:34 it is Shifting the metabolism it
13:36 actually it has benefits for insulin
13:38 sensitivity
13:39 and blood glucose control and then the
13:42 other person who might benefit from the
13:43 ketogenic diet is someone who genuinely
13:45 wants to try it wants to do it it’s not
13:47 the type of diet that you can go into
13:49 lightly so so you’d really have to be
13:51 motivated to to make all these changes
13:54 for how long to follow the diet again
13:56 I’m really going by the evidence here
13:58 the studies the interventions
14:01 um that have tested it have lasted
14:02 generally from one to three months and
14:05 so some Studies have seen a benefit at
14:07 the end of about a month
14:10 um others have looked out to about three
14:13 months and seen a reduction in headache
14:15 frequency
14:16 for those that have observed longer even
14:19 out to something like six months the
14:21 person might not be on the diet the
14:23 whole time they might they return to
14:25 their diet and for some people it seems
14:27 like there could be lasting effects that
14:29 it the benefits gained from doing the
14:31 ketogenic diet might linger a little
14:33 longer at least a few months than than
14:36 the time you’re actually on the diet so
14:38 something interesting to consider
14:41 so again what does it actually look like
14:43 so high high fat low carbs moderate
14:46 protein and because of the way it works
14:48 with your metabolism it’s not the type
14:50 of diet that you can cheat there are no
14:52 cheat days when you’re you know in the
14:54 throws in the ketogenic diet
14:56 so if the typical diet is here typical
14:59 Western diet the way we eat in the U.S
15:02 and Canada
15:03 um typical diet would be about half of
15:07 your calories coming from carbohydrates
15:08 about a third coming from fat and rest
15:11 coming from protein and so again
15:14 majority of calories energy coming from
15:18 carbohydrates the classic ketogenic diet
15:20 the one originally tested and
15:22 demonstrated in the epilepsy is on the
15:24 far left where you see the vast vast
15:26 majority of calories are coming from fat
15:29 a very minimal amount from carbs and us
15:32 you know smidge from protein as well and
15:35 this is because protein in the
15:37 metabolism can some types of amino acids
15:41 can be converted to glucose in the body
15:43 and so what we’re really looking at is
15:45 the ratio of carbs plus protein versus
15:48 fat and so
15:51 that’s why we do also have to restrict
15:54 protein on the ketogenic diet and so
15:57 this again the classic ketogenic diet we
15:59 found ways to to work with metabolism to
16:02 maintain a state of ketosis where your
16:04 body is still metabolizing fats in this
16:07 altered pathway producing ketones and
16:10 the modified Atkins and the medium
16:12 change triglyceride diet are two
16:13 different ways that we can do that and
16:15 we can liberalize the amount of
16:17 carbohydrates that you can eat while
16:20 still maintaining a state of ketosis and
16:22 this is part of what complicates the
16:24 evidence for the ketogenic diet as well
16:26 because we actually see different
16:27 versions of the ketogenic diet and not
16:30 all of them are even represented here
16:31 but we see different versions studied in
16:33 the research and so even when looking at
16:36 two studies of ketogenic diet and
16:38 migraine were not necessarily even
16:39 looking at the same thing
16:42 but just to get a sense of what this
16:45 might look like this is the classic
16:46 ketogenic diet so this is most strict of
16:49 the three
16:50 um but here this is a menu
16:52 put out
16:53 um in some guidelines by The Academy of
16:55 nutrition and dietetics a couple years
16:57 ago and this is what it my diet might
17:00 look like so for breakfast you might
17:01 have an egg scramble but you wouldn’t
17:03 have a side of toast
17:05 um your egg scramble would be made with
17:06 lots of fats and butter or cream feta
17:09 cheese olive oil spinach mushrooms
17:12 um
17:13 for breakfast caught your lunch could be
17:15 a Cobb salad so mixed greens avocado
17:18 hard-boiled egg bacon heart cheese olive
17:21 oil and a controlled amount of vinegar
17:23 because vinegar does have some some
17:24 carbs in it
17:26 um and then for dinner chicken with
17:27 zucchini noodles or zoodles styled
17:30 zucchini baked chicken breast olive oil
17:32 and basil pesto and then the snack could
17:35 be a stock of celery with full fat cream
17:37 cheese and again this is the strictest
17:39 of the the diets this I believe produced
17:43 about seven was about 1700 calories per
17:46 day and in general the the benefit other
17:49 benefit that we haven’t talked about in
17:51 addition to to weight loss comment on
17:53 the ketogenic diet is it really
17:55 suppresses appetite it works with the
17:58 hormones in such a way that you don’t
17:59 feel hungry nearly the same way
18:02 um so so I understand I see in the
18:04 comments it wouldn’t be able to do it I
18:06 get it
18:07 um but even once you get into it there
18:10 is some help there for near metabolism
18:12 believe it or not
18:14 um that you you don’t necessarily crave
18:16 Foods in the same way
18:17 so that’s the ketogenic diet so let’s
18:20 move on to the next pattern I think that
18:22 has pretty good evidence and this is a
18:24 diet that is high in omega-3 fatty acids
18:27 and low in omega-6 fatty acids and this
18:30 is an overall eating pattern so what is
18:33 it so it’s a diet eating pattern really
18:36 designed to control intake of these
18:38 they’re both essential fatty acids so
18:41 omega-3 is one type of essential fatty
18:44 acid omega-6 is another type of
18:46 essential fatty acids they are both
18:48 polyunsaturated and they differ in the
18:50 arrangement of the chemical bonds in the
18:53 structure
18:54 we’ve seen over time in different
18:57 research studies benefits to health
19:00 um
19:01 when intake of Omega-3 is high and
19:05 intake of omega-6 is lower
19:07 um and we’ve seen benefits in in
19:11 Contracting inflammation generally but
19:14 also some autoimmune diseases as well
19:16 and so people have been looking at this
19:19 in migraine and there are two very
19:21 well-designed randomized controlled
19:23 trials again that highest level of
19:25 evidence one was looking at Chronic
19:27 daily headache but mostly people with
19:29 migraine and the other was looking at
19:31 specifically people with migraine and
19:33 both of these studies very well
19:35 controlled
19:37 control diet versus I omega-3 omega-6
19:41 they saw improvements in migraine days
19:44 and it was about a reduction in people
19:46 who started with 6 16 headache days per
19:49 month
19:50 um they saw reductions by about four
19:53 headache days so reduction of six from
19:56 16 to 12 if you will the other thing I
20:00 really like about this research is they
20:02 didn’t just walk into it and say let’s
20:04 study this eating pattern they really
20:06 spent years a decade at least looking at
20:10 biomarkers for pain
20:13 um
20:14 and they in the second study the second
20:17 RCT they also demonstrated not only did
20:20 they see a reduction in migraine days
20:22 but they also saw a reduction in the
20:24 biomarker that they expected would be
20:27 associated with pain the type of oxy
20:29 lipid and so this has this kind of
20:32 validation of yes the the clinical
20:34 outcome
20:36 um what you see in the in what I can
20:38 tell you yes my headache days have
20:40 decreased by filling out my diary but
20:42 also some blood markers to validate that
20:45 so so good evidence there
20:47 strictly the studies looked at people 5
20:50 to 20 migraine days per month the second
20:52 study at least and so that’s what I’ve
20:55 listed as who might it benefit
20:57 um but generally again I mentioned it’s
21:00 this eating style increasing Omega-3s
21:03 lowering omega-6s has been shown to be
21:06 good for inflammation generally so I
21:07 don’t know that I would limit this
21:09 recommendation to people with more
21:11 migraine days I think it could
21:13 potentially be helpful for others
21:15 the study itself lasted studies lasted
21:18 16 weeks and so that’s what I’ve listed
21:21 here
21:22 um generally speaking this would my my
21:25 intuition this is it hasn’t been tested
21:28 but my intuition is that this would take
21:30 longer to show up at your level you know
21:33 something you would notice than the
21:35 ketogenic diet and so the study lasted
21:38 16 weeks I would give it you know at
21:40 least three months before
21:43 um making a verdict on this one and what
21:45 does it look like so high omega-3 High
21:48 fish intake and then low omega-6 would
21:51 be foods that are low in vegetable oil
21:53 so what do I mean at that
21:57 um
21:58 so vegetable oil as at least here in the
22:01 states is listed on food labels and it
22:04 could mean a number of different oils
22:06 the one that’s not in my picture here is
22:08 soybean oil is actually the most common
22:09 in our food supply
22:11 um but soybean oil sunflower canola
22:13 safflower all have pretty high amounts
22:17 of omega-6 fatty acid in them
22:20 um
22:21 and so those are the ones that you want
22:24 to potentially if you’re considering
22:26 this pull out of your cabinet and start
22:28 cooking with olive oil if you could
22:30 that’s sort of an easy swap I know olive
22:32 oil doesn’t fit in every recipe it gets
22:35 Smoky
22:36 um it probably isn’t the best in a lot
22:38 of baked goods but where you can that’s
22:41 an easy substitution to get rid of some
22:43 omega-6s and replace it with some
22:46 monounsaturated fats like all from olive
22:49 oil the other thing to know about
22:51 omega-6s and vegetable oils is that
22:53 really they’re the predominant oils in
22:56 processed foods in our food supply so
22:59 chips and frozen dinners and pasta
23:02 sauces and even peanut butter and so
23:05 forth a lot of these fats just you know
23:08 in processed foods used to cook foods
23:11 contain high levels of omega-6 so that
23:14 is probably the hardest part about doing
23:16 this eating pattern following this
23:19 eating pattern is that it really goes
23:21 kind of against what we commonly eat in
23:24 our regular day-to-day and so it would
23:26 take some really careful label reading
23:29 um
23:29 you try to choose foods and with with
23:32 without vegetable oils and then omega-3
23:36 really what I’m talking about is what we
23:38 call the long chain Omega-3s these are
23:41 the ones found in fish especially fatty
23:43 fish salmon mackerel Herring
23:46 um
23:48 Omega-3s are also found in some
23:50 plant-based foods like flax seeds and
23:53 chia seeds have a pretty good amount
23:55 those are
23:58 not long chain they’re they’re a shorter
24:01 chain of fatty acid again referring to
24:03 the chemical structure they’re still
24:04 good they’re still beneficial and so I
24:07 would still recommend getting them but
24:09 they’re they’re sort of not as good as
24:11 the long chain that we get from fish the
24:13 EPA and DHA versions and so that’s what
24:16 you’re looking for with those two diets
24:18 the challenges they’re both difficult to
24:22 follow as we’ve alluded to
24:24 um but I want to say don’t be
24:25 discouraged we have evidence for these
24:28 diets partly because they’re so
24:30 different from our typical eating
24:32 patterns and it’s easier I think from a
24:35 research perspective to demonstrate when
24:37 you make such a big change from a
24:40 typical diet we can see changes in
24:42 migraine patterns more easily right so I
24:45 think the reason we have evidence for
24:47 these diets first and not kind of the
24:50 easier diets is because exactly because
24:54 they’re so different
24:55 um
24:56 but I do recommend seeking nutrition
24:58 counseling from a dietitian to implement
25:00 them correctly if if you’re endeavoring
25:03 in them especially the ketogenic diet
25:05 and a dietitian could definitely help
25:07 make the omega-3 omega-6
25:09 um eating pattern easier so the last
25:12 pattern I’ll talk about is increasing
25:14 evidence for a low glycemic diet I think
25:16 we’re starting to see more evidence here
25:18 and this is an eating pattern that
25:20 prioritizes foods that have a lesser
25:22 impact on blood glucose what do I mean
25:26 by that so let’s talk so if you eat a
25:30 food let’s say over here at time zero
25:32 and we measure your blood glucose levels
25:35 every couple minutes for up to two hours
25:38 some foods will digest and get absorbed
25:42 as glucose into your bloodstream very
25:44 quickly and that’s what we see here in
25:46 the red so this is like a soda pop
25:49 um soft drink Cola sugar sweetened that
25:52 if you eat it or drink it I should say
25:54 passes through your stomach hits your
25:56 small intestine very quickly doesn’t
25:58 need any digestion in your blood glucose
26:00 immediately starts to rise
26:02 pancreas kicks in starts secreting
26:04 insulin and then tells the cells of your
26:07 body to pull glucose out of the blood
26:09 and so the levels in the blood drop
26:12 um what we see is actually sometimes we
26:15 secrete a little too much insulin
26:17 relatively speaking and blood glucose in
26:20 order to counter that really high level
26:22 of glucose we see the level drop and
26:25 this is where you might get cranky or
26:27 hungry afterwards and so a low glycemic
26:30 diet or eating pattern is really looking
26:33 and trying to get encourage you to eat
26:34 the foods that look more like this
26:36 yellow curve which is after you eat the
26:39 food think of oh something like kidney
26:41 beans or garbanzo beans
26:44 um you eat it it enters your stomach
26:46 takes a while to empty into the small
26:48 intestine and once it gets there it has
26:50 to be digested by enzymes before it
26:53 becomes is digested all the way down to
26:55 glucose and those carbs can enter the
26:57 bloodstream as glucose so it takes a lot
26:59 longer to digest hit the bloodstream and
27:02 then the effect on blood glucose is a
27:04 lot more gentle so the glycemic index is
27:07 a low glycemic diet is emphasizing that
27:10 eating pattern the evidence we’re seeing
27:12 increasing what I would call basic
27:15 science evidence metabolic evidence
27:17 again pointing us at biomarkers and kind
27:20 of pieces of the puzzle that say this
27:22 this is kind of falling into place more
27:24 recently we have several randomized
27:27 controlled trials that also support this
27:29 showing lower headache days per month
27:31 for someone who follows this evening
27:34 pattern
27:35 studies were generally three months
27:38 um and
27:40 until they saw a difference and one of
27:42 them followed people out even longer and
27:44 saw a greater difference over time so it
27:47 again it’s one of those you might need
27:48 to be a little patient who might benefit
27:51 actually similar to the ketogenic diet
27:53 and for ways if you have metabolic
27:55 syndrome or even diabetes you know just
27:57 to promote genital health and what does
27:59 it look like eating non-starchy veggies
28:02 whole grains proteins healthy fats low
28:05 sugar
28:05 one of the studies used personalized
28:08 nutrition as well and they had people
28:10 wear a continuous glucose monitor and
28:14 fed them different foods and was were
28:16 able to personalize recommendations
28:18 based on their personal response to
28:20 specific Foods
28:22 um so that’s kind of that’s exciting
28:24 ushering in a new era for us
28:28 on a similar note this transitions us
28:31 into what should we know about skipping
28:32 meals and it’s related
28:35 um meal skipping has been recognized
28:37 anecdotally for a long time as both a
28:40 headache trigger and more specifically a
28:41 migraine trigger and objective evidence
28:44 is start is building more and more to
28:46 recognize this and we see this in
28:48 different studies that show skipping
28:50 breakfast was associated with more
28:51 migraines in a group of college students
28:54 snacking at night was found to reduce
28:57 the odds of a migraine attack the next
28:59 day migraine attacks increased during
29:02 the Ramadan fast from morning till some
29:05 up to sundown and we also see against
29:08 basic science piece where hunger
29:10 hormones shift in ways during fasting
29:13 that we would expect to correlate with
29:15 with an increased risk of migraine
29:19 other things to know is that we don’t
29:21 know the full story yet a more recent
29:23 study
29:24 observing Ramadan fasts
29:28 um sought divided the month up into
29:31 three 10-day periods and they looked at
29:34 migraines increased a little bit for
29:36 people on average during the first 10
29:38 days of The Fast and then started to
29:42 subside after that and so that indicates
29:45 there may be some sort of adaptation
29:46 that’s possible with fasting over time
29:49 we also know that one of the main
29:51 reasons people skip meals is stress uh
29:54 time availability and so stress of
29:57 course is a major trigger for migraines
29:59 so there may be a really complex
30:01 relationship there that you know really
30:03 prevents us from being able to study
30:05 this quite readily
30:07 and other another way of reducing stress
30:10 or practicing mindfulness was associated
30:13 with reduced meal skipping given the
30:16 evidence for mindfulness and supportive
30:18 using mindfulness to to help with
30:19 migraine I thought that was interesting
30:21 as well
30:22 but we still don’t have a good study
30:25 pointing to you know if I say I can’t
30:27 give you a number and say eat every X
30:30 hours we don’t have evidence for that so
30:33 this is starting to come together we’re
30:35 starting to put it all together for
30:37 blood glucose meal skipping glycemic
30:39 index metabolism
30:41 um I think it’s all kind of wrapped up
30:43 and and researchers are excited about it
30:45 so stay tuned
30:48 and that brings us to a big question of
30:51 food triggers
30:53 um and I not Everyone likes my my
30:56 thoughts on food triggers and I’ll warn
30:58 you that they’re at the
30:59 um I think professional opinions are
31:01 divided on these
31:03 um and so I will say that the I don’t
31:05 see the evidence bearing out for most
31:07 triggers from avoiding those true
31:09 triggers or for diets designed to remove
31:12 them there are a few that I think have
31:14 the best evidence and those are caffeine
31:16 and alcohol and again we can point to
31:19 the specific mechanisms and say
31:21 um what we think is happening there in
31:22 terms of triggering attacks
31:25 couple this
31:27 um well I’ll say that a lot of the
31:28 evidence for food triggers identifying
31:31 them is very poor quality and so in
31:34 trying to to redo research or improve
31:38 research and food triggers it’s it’s a
31:41 difficult thing to study
31:43 um but one of the the points of evidence
31:45 that’s come out in recent years suggests
31:49 that food cravings that occur during the
31:52 prodromal phase of an attack so the
31:54 phase before the pain hits
31:56 these studies Imaging in which parts of
31:59 the brain are active suggest that food
32:03 cravings during that phase before the
32:05 pain hits may be a symptom of the attack
32:07 and not a cause of the attack so it’s
32:10 possible if chocolate may be a trigger
32:12 for for some people it is possible
32:15 really pay attention
32:17 um is it possible that your attack
32:18 already started and you are craving
32:20 chocolate and happen to consume it that
32:23 way it may not be but something to
32:26 really pay attention to and and I do
32:28 want to be careful here I do not want to
32:30 minimize anyone’s experience I do
32:32 believe there are more triggers out
32:34 there but I don’t expect that food
32:36 triggers are as common as we once
32:38 thought they were
32:40 um
32:41 and because of that it sort of shifted
32:44 my thinking and the diets to remove
32:45 triggers without better evidence I think
32:48 put an unnecessary burden on a lot of
32:51 people
32:52 um and so I think it’s important for us
32:54 to develop more research on this but
32:57 developing these research design to
32:59 study what can be and seem to be very
33:02 personalized triggers is very difficult
33:04 so maybe more for personalized nutrition
33:07 to attack in future years
33:10 so moving on to supplements I will say
33:14 there’s pretty strong consensus in the
33:16 migraine Community about these
33:18 supplements this came from the migraine
33:20 Canada website go go guys
33:23 um and so for these I will say magnesium
33:26 vitamin B2 CoQ10 all have pretty good
33:29 evidence again consult with your health
33:31 care provider but but the doses are
33:34 listed here these are these are safe
33:36 supplements to take
33:38 um magnesium the one thing you if you’ve
33:41 tried to take 600 milligrams a day right
33:43 out the bat you know there are some side
33:45 effects
33:47 um it is not well absorbed not terribly
33:49 bioavailable
33:51 bioavailable and so what’s left in the
33:54 gastrointestinal tract and not absorbed
33:56 can pull water into the intestine and
33:59 cause diarrhea and cramps
34:01 um so often it’s recommended with
34:03 magnesium this is great these are the
34:05 forms that are most bioavailable so
34:07 you’ll have the least symptoms with
34:09 magnesium citrate or glycemate most like
34:10 we
34:12 um but still you might be probably we
34:14 want to start at a lower dose maybe half
34:16 of this maybe even 200 milligrams to
34:18 start and work your way up until you get
34:21 to a point um where the symptoms happen
34:23 it’s not dangerous to have these
34:26 symptoms and unless you know do it for a
34:29 long period of time
34:31 um but generally it’s sort of a
34:33 self-limiting thing you kind of learn
34:34 when you hit your limit
34:36 uh vitamin B2 you won’t have that
34:38 problem but you will see your urine will
34:40 become much darker yellow
34:42 um so if you use your urine to monitor
34:45 your hydration status and we watch the
34:46 color of your urine you won’t be able to
34:48 do that as readily while taking vitamin
34:50 B2 supplements and coenzyme Q10 and
34:55 probably one of the things to consider
34:57 here is it tends to be more expensive
34:59 than the other supplements so so keep
35:02 that in mind I’ve crossed out butterbur
35:05 it had good evidence for reducing
35:07 migraine over time but it also came with
35:12 some concerns about liver toxicity and
35:14 so the recommendations and I agree
35:17 um or that it’s not used anymore
35:19 um until and if we can get better
35:21 evidence of it being this this is a
35:24 Botanical plant until we can get better
35:26 instead of it being purified
35:28 um
35:30 where we can be confident and then the
35:32 last supplement he listed here is fever
35:34 few again another Botanical with some
35:37 evidence but when you get into
35:39 Botanicals you get into potential for
35:41 more medication interaction so
35:43 definitely check with your your
35:44 Healthcare professional there
35:49 so for this how long do we need to
35:51 follow a diet to see whether it helps
35:52 with migraine so it depends I tried to
35:55 cover this along the way but generally
35:57 the research on diet looks at a time
36:00 frame of about following a diet or
36:02 eating pattern for about three months
36:04 same thing with supplements typically
36:05 three months and then measuring to see
36:08 if there’s an effect
36:11 so that’s sort of the safe answer
36:15 three months what the study says but
36:18 what I would encourage you to do is be
36:20 really really mindful pay attention to
36:22 how you feel along the way or something
36:25 like if you try the low glycemic diet
36:27 really pay attention to your hunger
36:29 signals if you’re real if you’re
36:32 you’re eating a lot of low glycemic
36:34 foods
36:35 are you as hungry do you get food
36:37 cravings as often you can start to pay
36:40 attention along the way and this is
36:42 where if you do practice mindfulness if
36:44 if that’s part of your your lifestyle
36:46 then then that’s a good thing to build
36:48 into and paying attention as you’re as
36:50 you’re following these diet
36:51 interventions
36:53 all right
36:55 so that brings us to My overall
36:57 recommendations and I’ll keep it I’ll
36:59 try to keep this quick
37:01 um so for everyone overall my
37:03 recommendation is an overall healthy
37:05 diet that follows General dietary
37:07 guidelines I know this is not sexy this
37:10 is not the most amazing
37:12 um thing you came to hear tonight but
37:15 I think the evidence is starting to Bear
37:17 out in different ways
37:20 um
37:20 that kind of these overall healthy
37:24 eating patterns
37:26 seem to be helping so lots of
37:28 non-starchy vegetables a range of fruits
37:30 and veggies limit Ultra processed foods
37:33 that are high in sugars and solid fats
37:34 choosing whole grains when possible
37:36 prioritizing unsweetened Beverages and
37:39 going back to this plate
37:41 um kind of as an example of in your mind
37:43 of what you want to be eating
37:46 um if we do that it’s already built in
37:51 um it may not be you know truly low
37:54 glycemic According to some definitions
37:56 but in general it’s lower glycemic than
37:59 a typical diet would be so you’re
38:01 getting that kind of built-in benefit
38:03 the other thing is this General healthy
38:05 eating pattern is beneficial for
38:07 conditions that are comorbid with
38:09 migraine that co-occur with migraines so
38:11 things like heart disease and diabetes
38:12 and obesity that we tend to be at higher
38:16 risk for this diet would help with those
38:18 two so kind of a built-in benefits if
38:22 you also want to work in a little bit
38:24 about fasting
38:26 um again I don’t have specific numbers
38:29 to give you but I do think the evidence
38:31 Bears out to try to avoid skipping meals
38:33 or avoid doing an extended fast maybe
38:36 consider small frequent meals or snacks
38:40 um and eat carbs paired with protein or
38:43 fat I haven’t mentioned that yet but
38:46 that helps to slow down the blood of
38:49 glucose absorption as well
38:52 and then for the omega-3 omega-6 could
38:55 also be incorporated into this with some
38:58 moderate changes you don’t necessarily
39:00 have to go all in but eat fish twice a
39:03 week according to the recommendations
39:04 and again make olive oil kind of your
39:06 default cooking oil and then limit
39:08 processed foods or limit the use of
39:11 these vegetable oils in your own pantry
39:16 um again you can take this piece by
39:18 piece this is um you don’t necessarily
39:20 have to jump in and do all at once
39:23 um again this is not something that’s
39:25 been studied necessarily with relation
39:27 to migraine but it there is evidence to
39:29 say that if you take these lifestyle
39:32 changes and dietary modifications and
39:34 more slowly and build them into your
39:36 routine they’re more likely to stick
39:38 than if you change everything at once so
39:41 if that’s how you know if that’s what
39:42 works for you consider that you can
39:44 consider setting smart goals and a
39:46 dietitian could help you do this as well
39:49 um
39:49 and you can Google smart goals and and
39:52 learn about setting them but generally
39:54 it’s a small goal time-bound very
39:56 specific measurable relevant to your
39:59 goal that you can can change and work on
40:02 and so my example is you know with the
40:04 olive oil during the next two weeks
40:06 every time I cook I will convert the
40:08 recipe I’m making if it uses vegetable
40:10 oil to own boil if possible and that’s
40:13 my focus for the next two weeks and it
40:15 just gives you something kind of latch
40:17 onto
40:18 um and then you can you know reevaluate
40:20 at the end of two weeks do I have this
40:23 is this part of my routine do I feel
40:25 comfortable yes maybe it’s time to add
40:28 another bowl no I’m going to keep
40:30 working on this for a little while
40:32 um
40:34 for those who want to again there are
40:37 more things you could do but either the
40:39 evidence is a little less solid or these
40:43 are harder things to work in and so if
40:46 you want to try the ketogenic diet I do
40:48 think there’s evidence um that it it
40:51 very well may work for migraine
40:54 um and there’s enough hope that it might
40:56 work for you but you’ve got to want to
40:58 do it it’s not an easy diet to do
41:01 um
41:03 similarly if you want if you really want
41:05 to go all in on that high omega-3 low
41:08 omega-6 diet the recommendations were
41:10 1.5 from the second study the
41:13 recommendations were 1.5 grams of
41:15 Omega-3 per day and all the way down to
41:16 two percent of calories from omega-6
41:19 which is about a quarter of what we
41:21 usually eat
41:23 um so again a strict thing
41:26 and then you could also discuss triggers
41:28 with your health care provider and
41:30 definitely you can discuss supplements
41:32 especially magnesium and riboflavin with
41:34 them as well
41:37 so in conclusion I think there are a lot
41:40 of reasons to be optimistic in this
41:42 space that we’re getting closer and
41:43 closer to more complete answers for for
41:46 nutrition and food and migraine and
41:48 while there is still a lot of research
41:49 to do there are nutrition and food
41:51 options for you to try that balance
41:54 available evidence type things with the
41:57 challenge of making these dietary
41:59 changes and I think might be worth
42:00 giving a try
42:02 um and I’ll just put one last plugin
42:04 that dietitians can help Implement these
42:06 diets
42:07 um and especially to help
42:09 um for the stricter ones to help
42:11 mitigate any any problems that might
42:13 arise if you try to follow them
42:16 so with that I will say thank you
42:20 um and there’s