Can the Ketogenic Diet Help with Migraines?
If you or someone you know experiences migraines, then you know these debilitating attacks are far more than mere headaches. In addition to severe, throbbing pain, migraines often also involve visual disturbances, nausea, vomiting, dizziness, extreme sensitivity to sound, light, touch and smell, and tingling or numbness in the extremities or face.
As many as 25% of migraine sufferers experience a visual phenomenon called an aura. Attacks typically last between 4 and 72 hours and in 15-20% of cases, the head pain is preceded by the other neurological symptoms (1).
Because migraines are increasingly recognized as neurological in origin, it’s possible ketogenic diets may have a therapeutic effect for people afflicted with these attacks. Ketogenic diets exert their effects via several mechanisms that induce multiple biochemical changes in the body and brain that improve neurological function (2, 3). Some of the mechanisms that are beneficial for various neurological disorders may also make them effective for migraines.
No One is Immune to Migraines
Migraines affect up to 15% of adults in North America and Western Europe, and they’re the seventh leading cause of disability in the world (4). In the US, up to 18% of women and 6% of men experience migraines, with many experiencing chronic migraine (at least 15 migraine days per month).
Women are affected disproportionately, partly due to fluctuating estrogen levels as attack triggers: about 28 million women in the US suffer migraines, and women make up 85% of chronic migraine sufferers (1).
Not even children are spared the pain and debilitation that accompany a migraine. About 10% of school-aged children suffer from migraines, and they’re absent from school about twice as much as those who don’t. In contrast to migraine prevalence in adults, in childhood, boys are afflicted more than girls are, but during puberty and adolescence the incidence shifts, and girls are affected more (1).
The Cost of Migraine: Physical, Emotional & Financial
According to the Migraine Research Foundation, healthcare and lost productivity costs associated with migraine are estimated to be as high as $36 billion annually in the US alone (1).
In 2015, the cost for treating chronic migraine was more than $5.4 billion, but the total cost of treating associated issues was over $41 billion. 113 million days of work are lost due to migraine, at a cost of around $13 billion to employers.
Of course, the burden of migraines isn’t limited to the pain and incapacity from the attacks, themselves. Beyond these, migraine increases the risk for other physical and psychiatric conditions, including depression, anxiety, and sleep disturbances. Overall, migraines drastically reduce quality of life.
What Causes Migraines?
It would be nice if all migraines were caused by the same thing, and people could simply avoid whatever that was. Unfortunately, migraine triggers are as diverse as the people who experience them, and even the same person may find that their triggers are unpredictable, causing a migraine sometimes, but not always.
Some migraine sufferers are able to identify dietary or environmental factors that trigger an attack, such as sensitivity to dietary histamines, sulfates or sulfites, monosodium glutamate (MSG), other additives and preservatives, or changes in barometric pressure. Some migraines may also come about due to acute hypoglycemia.
Common Triggers for Migraines
Common culprits for triggering migraines include beer, wine, cheese, and chocolate, so some people may need to avoid these—as if having migraines wasn’t bad enough!
Individuals who are sensitive to histamines and tyramines may find an attack brought on by consuming aged or fermented foods. As for barometric pressure changes, unfortunately, there’s nothing a migraineur can do to control the weather.
Migraines are more prevalent in individuals with celiac disease, gluten sensitivity, and irritable bowel disease (5), and many migraineurs experience relief after removing gluten from their diet. Gluten-free diets have been known to improve a host of physical and psychological ailments, but for many people, going gluten-free isn’t enough.
Often, people replace gluten with gluten-free bread, crackers, cookies, pasta, cereal, and other foods that still present a supra-physiological and highly insulinogenic dose of refined carbohydrate. For those whose migraines are related to wild fluctuations in blood sugar, it’s obvious why a gluten-free diet that’s still high in carbs might fail to have a beneficial impact on attack frequency or severity.
Insulin Resistance and Migraine – is There a Connection?
Knowing that blood sugar fluctuations may trigger migraines in susceptible people, it’s not entirely surprising that people with migraine have a high incidence of insulin resistance and metabolic syndrome, and hyperinsulinemia may cause or exacerbate migraines (6).
In one study, out of 210 patients with metabolic syndrome, migraine prevalence was estimated at 11.9% in men and 22.5% in women—higher than in the general population (7).
A different survey showed that among 135 migraine patients, 32% had metabolic syndrome and 11% had frank insulin resistance (high fasting insulin) (8). Only about 10% were obese or had elevated fasting blood glucose, which tells us that that the connection between metabolic syndrome and increased risk for migraine is not driven by body weight or blood sugar, but by insulin.
Features that track with insulin resistance and metabolic syndrome—such as hypertension, type 2 diabetes, and obesity—are common in patients with chronic migraine (6).
People who experience migraines are at greater risk for hypertension (high blood pressure) and stroke, both of which are vascular complications also commonly seen in people with type 2 diabetes or insulin resistance (9).
Research indicates that people who suffer migraines show adverse changes in blood vessel function throughout the body, which suggests migraines are “a local manifestation of a systemic disease rather than a primary brain phenomenon” (10). What this means in plain English is that migraines aren’t something that happen solely in the brain. In some people, they’re related to metabolic abnormalities in other parts of the body, some of which stem from chronically high insulin.
Among a cohort of adolescent migraineurs with obesity who participated in a weight loss program, compared to those who had remission of migraines, those whose migraines persisted had higher waist circumference, body mass index, triglycerides, and HOMA-IR, all of which indicate worse insulin sensitivity (11). Study subjects who were insulin resistant were 3.5 times more likely to suffer persistent migraines than were subjects who were insulin sensitive.
Is Migraine a Neurological Disorder?
As noted earlier, some migraines are accompanied or preceded by sensory disturbances or tingling or numbness in different parts of the body.
With this in mind, migraines are better thought of as neurological phenomena as opposed to severe headaches. Additionally, migraines have several pathological features in common with epilepsy, and multiple anti-epileptic drugs are effective for migraine (12).
It’s not known for certain what the exact mechanisms are behind migraine, and they may be different in different people. Some of the possibilities include:
- Inflammation in the brain
- Brain nerve excitotoxicity
- Ion (electrolyte) imbalances in the brain, which alter the electrochemical properties of neuronal cell membranes
- Blood glucose instability
Combined with the association between migraine and metabolic syndrome, the similarities between epilepsy and migraine point toward the ketogenic diet potentially being helpful for those with migraine. After all, epilepsy was the first condition for which a ketogenic diet was proven a successful therapy, and it remains the one with the most impressive track record (13).
The Ketogenic Diet for Migraine
Anecdotes about people freeing themselves from migraine abound on low carb and ketogenic forums, but the body of clinical scientific research on this is pretty small. Nevertheless, there are plausible mechanisms by which a KD might reduce or prevent migraines:
- Reduced excitability in neurons
- Reduced inflammation
- Restoration of proper neuronal membrane potential (increased threshold for migraine)
- Reduced fluctuations in blood glucose and insulin
- Correction of fluid balance abnormalities in the inner ear
Some people adopt a ketogenic diet for weight loss and are pleasantly surprised to find that an unexpected “side effect” of keto is a reduction in the frequency and severity of migraines, or in some cases, complete remission.
The Evidence
This was the case for 47-year-old twin sisters in Italy: after implementing a KD for weight loss, they reported a significant reduction in the frequency and severity of their migraines (14).
According to detailed “headache diaries” they kept, they experienced “5—6 attacks/month of severe throbbing headache, of up to 72 hours’ duration; the severity was increased by movement and the attacks were accompanied by photophonophobia [sensitivity to light and sound], nausea and, very occasionally, vomiting.”
In both cases, remission of migraines coincided with following the diet, and migraines returned during periods when they went back to their usual higher-carb diet. However, even when they started eating more carbs, their migraines were reduced in frequency, intensity and duration.
This is in line with what’s been reported in people with epilepsy: some epileptics who experience seizure remission on a KD choose to abandon the diet, but when seizures return, they’re less frequent and severe than before. So it seems that, at least for some people, following a KD for some length of time may correct something at a fundamental level such that even when they go back to eating more carbs, their condition isn’t as severe as it was before doing the KD.
In this case study, the sisters didn’t avoid common dietary migraine triggers, such as aspartame, MSG, nitrates, nitrites, or caffeine. The study authors dismissed some of the potential reasons for migraine remission during the ketogenic periods, writing, “we attribute the improvement observed in these patients to ketogenesis, the sole event found to be time-locked to the disappearance (and recurrence) of their migraine attacks.” In other words, something unique to the KD was responsible for the improvement, rather than an avoidance of common dietary triggers.
Tests for celiac disease were negative in these two subjects, but that doesn’t rule out the possibility of non-celiac gluten sensitivity, which could be a migraine trigger for some people.
There’s increasing recognition in the medical community that some individuals who don’t have overt celiac disease may still have a sensitivity to gluten, and this can affect various tissue systems in the body, manifesting in ways as diverse as ataxia, anxiety, depression, fatigue, brain fog, headache, schizophrenia, psoriasis, dermatitis, inflammatory bowel disease, acid reflux, and autoimmune conditions (15, 16, 17).
Ketogenic diets aren’t grain-free by definition, but people who use low-carb high-fiber crackers or grain-based wraps would be taking in far less gluten than those on high-carb diets.
The promising findings about the KD for migraine in these two sisters prompted a larger study, this one involving 96 overweight female migraine sufferers (4). In the intervention group, 45 subjects followed a very low-calorie KD for one month, followed by a 5-month standard low-calorie diet. The other 51 subjects followed the standard diet for all 6 months.
In the KD group, attack frequency, number of days with headaches, and amount of medication used were significantly lower after the first month on the diet. In the group following the standard diet, the number of days without headaches decreased only after 3 months, and a significant decrease in attack frequency wasn’t seen until 6 months in. (That subjects on the standard diet improved at all might be due to the low-calorie nature of the diet. This might have induced beneficial metabolic changes, although not as substantial as those from the KD.)
Being that it can take a month or even longer to become fully “keto-adapted,” and some of the neurologically protective effects of a KD might take longer to be established, it would be nice to see studies looking at migraineurs who follow a KD for a longer period of time. But it’s encouraging that the KD showed favorable results even after just one month.
Should You Try a Ketogenic Diet for Migraine?
A better question than “should you try it” is, why wouldn’t you try it?
If you experience migraines, and medications and other interventions have failed you, you truly have nothing to lose by giving keto a go.
You might have to go without some of your favorite foods for a while, but there’s a chance that in exchange, you’ll be free of migraines, or at least get them less often and they won’t be as incapacitating. (And thanks to great keto cookbooks, you don’t actually have to give up your favorite treats!)
Considering the reduced quality of life migraineurs experience at the mercy of these disabling attacks and the lack of effective preventive strategies, the KD is certainly worth trialing.
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