Is Alcohol a Migraine Trigger?

A new prospective cohort study reports that alcohol does not trigger migraines, even suggesting that in some instances, it is associated with a lower probability of a migraine attack.

People with migraine often report trigger factors – particular substances or circumstances that provoke a migraine attack. Alcohol is often reported as a trigger among individuals with migraine or other kinds of headaches. However, findings on the association between alcohol intake and migraine are inconclusive for a number of reasons, including cultural, regional, and individual differences in the consumption of alcohol.

But now, a new prospective cohort study suggests that alcohol may be less important as a trigger factor than previously assumed.

Using self-reported alcohol intake and migraine data from a digital health platform designed to track headache symptoms and risk factors, researchers led by Marina Vives-Mestres, Curelator Inc., Cambridge, US, and Universitat de Girona, Spain, found no effect of alcohol consumption on the probability of a migraine attack one day after consumption. The investigators even found a slightly lower probability of a migraine attack on the second day after alcohol consumption.

Michael Marmura, a headache specialist at Thomas Jefferson University, Philadelphia, US, who has written about migraine triggers but was not involved in the current study, agreed with the authors that the role of alcohol as a migraine trigger may have been overestimated.

“There’s a larger question in the field about whether we overestimate triggers in patients with migraine, because triggers can vary not only from patient to patient, but also from time to time,” he told Migraine Science Collaborative.

“So, someone might be sensitive to one thing at one point in their life, but not be sensitive to the same trigger later in life. I think our patients get a bit demoralized when they’re told they can’t do fun activities, eat anything good, or have a beer. This kind of study makes me say, ‘You don’t need to stop drinking alcohol if you don’t notice it to be a trigger for you.’”

In an accompanying editorial, David García-Azorín, Hospital Clínico Universitario de Valladolid, Spain, reached a similar conclusion.

“[T]he association between alcohol and migraine as a trigger may be more complex than anticipated, and could be influenced by additional factors such as the clinical situation of the patient, the amount and type of alcohol consumed prior to the episode, and individual predisposition.”

The study and editorial appeared in the November/December 2022 issue of Headache.

Turning to technology
Study design may also play a role in the inconclusive findings on the relationship between alcohol intake and migraine. For instance, recall biases are a common limitation of retrospective studies. Those studies also face the challenge that a person’s beliefs may be influenced by the knowledge that alcohol is a commonly suspected trigger for migraine, even if alcohol is not a trigger for that particular individual. In contrast, prospective studies don’t face those limitations, and tend to report a lower prevalence of alcohol as a trigger.

To help clarify the association, Vives-Mestres and collaborators turned to people with episodic migraine who used N1-Headache, a digital health platform available as an iOS app sold by the health company Curelator. (Editor’s note: Vives-Mestres and one of her co-authors have received consulting fees from and hold stock options in Curelator, while the remaining study co-authors, from academic and health system settings, have no relationship with the company. The study was also partially funded by Curelator.)

“Our company provides people with migraine a digital platform that allows them to scientifically determine their individual migraine triggers and protectors with the goal of reducing the number of attacks,” Vives-Mestres told MSC in an email.

“After tracking their daily exposure to a wide spectrum of factors including diet, emotions, weather, as well as headache and migraine symptoms for 90 days, the N1-Headache analytics can determine both trigger and protective associations for that individual,” she said.

Study participants reported whether they had consumed alcohol each day, and if so, how many alcoholic beverages they drank. They also reported if they experienced a migraine. The investigators then defined a migraine attack as one migraine day or a series of consecutive migraine days.

Participants were 18 years of age or older who consumed alcohol. They registered to use the platform between October 2014 and March 2018, and subsequently tracked their symptoms and risk factors for at least 90 of 120 days after registration. Those who met the International Classification of Headache Disorders, 3rd edition diagnostic criteria for chronic migraine were excluded, as were people who stated they drank alcohol but did not track their consumption.

Alcohol consumption did not increase migraine probability
Almost 8,000 people with migraine registered for the digital health platform during the study period, with 487 individuals (86% female, mean age 42.4 years) meeting the inclusion criteria and included in the final sample. Thirty-nine percent of the sample were from the US, and 35% from Great Britain. Together, study participants contributed data on 43,830 diary days; migraine was reported on 9,578 (22%) of those days.

Alcohol consumption was low across the final sample of participants (a median of 2.1 drinks/week; 27% of participants reported consuming fewer than one drink per week, on average), although males (a median of 3.4 drinks/week) consumed significantly more alcohol compared to females (a median of 1.9 drinks/week).

When analyzing the entire study population, and after accounting for factors such as sex, age, and average weekly alcohol intake, the researchers found that the probability of experiencing a migraine attack two days after alcohol intake was 25% lower than the probability of an attack two days after no alcohol consumption. There was no association between alcohol intake and the probability of a migraine attack one day after the consumption of alcohol.

When considering the total daily number of alcoholic beverages consumed, rather than the binary measure of alcohol consumption or no alcohol consumption, the researchers found that the results were consistent with the earlier findings: The probability of a migraine attack was 12% lower for each additional alcoholic beverage consumed two days earlier, with no effect on the probability of an attack one day beforehand.

“Tyranny of the trigger”
Vives-Mestres told MSC she was surprised by the results, which directly challenge the widespread belief that alcohol is a common trigger for migraine. She found it somewhat challenging to explain how alcohol reduced the likelihood of migraine attacks.

“We may speculate that alcohol is often consumed under socially relaxing conditions, and that the protective effects of these conditions, but not the alcohol itself, may be responsible for the protective effects on the second day,” Vives-Mestres said.

Interestingly, in a similar vein to the current study, Vives-Mestres, first author Amparo Casanova, also from Curelator, and colleagues reported, in a separate study published in January, that several previously suspected triggers, including alcohol but also caffeine and chocolate, were more often associated with a decreased, rather than increased, risk of migraine attack.

The authors are now studying other factors and behaviors, including stress, anxiety, and sleep, that may affect the association between alcohol intake and migraine onset to better understand the clinical implications of their combined effects.

One important study limitation is that the amount of alcohol subjects consumed was not recorded in a standardized manner. Therefore, the authors were unable to accurately estimate the actual dose of ethanol, nor could they say much about how the type of alcohol factored into the results.

Vives-Mestres acknowledged the evidence suggesting that even low doses of alcohol can cause headache in people with migraine. But she was cautiously optimistic about how the current results might change how people think about the relationship between the two.

“We think it is important for people with migraine to be able to discover their true triggers and protectors. However, there is a ‘tyranny of the trigger’ in migraine, where people needlessly avoid many things they love, resulting in a lower quality of life.”

One additional limitation Marmura pointed to is the potential lack of generalizability of the findings.

“This is a self-selected population; it’s not necessarily reflective of the larger migraine population. Often patients who use the N1-Headache app are very motivated and are keen to identify their triggers,” he said.

Like Vives-Mestres, García-Azorín interpreted the results in a cautious yet optimistic way in his editorial.

“We all must drink responsibly, since the potential noxious effects of alcohol go beyond headache. However, moderate amounts of alcohol in patients with low frequency of migraine may not be as bad as we had previously thought. Cheers to that!”

Lincoln Tracy is a researcher and freelance writer from Melbourne, Australia. You can follow him on Twitter @lincolntracy.

References
Alcohol as a trigger of migraine attacks in people with migraine. Results from a large prospective cohort study in English-speaking countries.
Vives-Mestres et al.
Headache. 2022 Nov; 62(10):1329-38.

The complex relationship between alcohol and migraine.
García-Azorin.
Headache. 2022 Nov; 62(10):1245-6.

The role of avoiding known triggers, embracing protectors, and adhering to healthy lifestyle recommendations in migraine prophylaxis: Insights from a prospective cohort of 1125 people with episodic migraine.
Casanova et al.
Headache. 2023 Jan;63(1):51-61.