“Many people living with migraine believe that their migraine attacks are triggered by factors such as weather, some foods, reaction to stress, or the menstrual cycle,” Amparo Casanova, MD, PhD, explains. “There are many factors and behaviors that have been selfreported as possible triggers, but little evidence that self-reported triggers can induce migraine attacks. As a result, people living with migraine often find themselves in the ‘tyranny of triggers,’ unnecessarily avoiding things that they love. Patients may also reduce their physical and social activities, which only amplifies their disability and lowers their QOL.

As a result, there was an “urgent and obvious need” to examine the accuracy of self-reported triggers in migraine attacks, according to Dr. Casanova. “The aim of this study was to investigate how reliably people with migraine are able to correctly identify potential triggers of their migraine attacks,” she says. For a study published in Headache, the researchers analyzed data from 328 participants who tracked their headaches daily for 90 days via a smartphone application.

“Instead of asking participants to tell us when they had a migraine headache attack, we asked them to report the characteristics of the attack (headache duration, severity, light sensitivity, etc.), and then we applied the diagnosis criteria of migraine following the International Classification of Headache Disorders (ICHD-3),” Dr. Casanova says. “This way, we standardized the study primary endpoint, since not all patients are able to distinguish between a migraine headache and other types of headaches.”

‘Extremely Difficult’ for Patients to Identify Actual Migraine Triggers

Most participants (88.4%) were female and the mean number of migraine attacks per month was 4.2. The mean number of triggers moderately or highly endorsed per patient was 28.0 among individuals presented with as many as 38 potential triggers. Of these, an average of 2.2 triggers per patient was statistically associated with a greater risk for migraine attacks. Even the most frequently endorsed triggers, such as sleep quality, stress, dehydration, neck pain, eye strain, and anxiety, were statistically associated in fewer than one third of individuals suspecting each, except for neck pain (38.7%).

“An important finding is that it is extremely difficult for people to self-recognize what actually triggers their migraine attacks,” Dr. Casanova notes. “Participants self-reported an average of 28 triggers, while the average number of self reported triggers that were associated with an increased risk for attacks in the individual analyses was only 2.2. Sophisticated analytical tools, like the N1- Headache™ app used in this study, show that even when patients strongly believed a factor to be a trigger for them, those beliefs were almost always not supported by scientific evidence.”

The self-reported triggers most associated with migraine attacks included neck pain (39%), eye strain (21%), and tiredness/fatigue (20%), Dr. Casanova continues (Figure). “Among people who believed that neck pain was a trigger for their migraine attacks, a statistical association with increased risk for attacks was found in only 39% of them,” she notes. “The most commonly self-reported trigger, sleep quality, was seldom associated with increased risk for attacks. It is important to note that the statistical associations we did find, such as neck pain, eye strain, and tiredness, are likely not triggers but rather premonitory symptoms of an impending attack.

Using Digital Tools to Accurately Identify Migraine Triggers

A key take-home message from this study “is that people believe that many factors may be contributing to the onset of their migraine attacks,” says Dr. Casanova.

“This belief might have great implications for the quality of their lives, as they struggle to change their lifestyle to avoid those triggers or to learn to cope with them,” she notes. “Using a tool like the N1-Headache™ tool that not only serves as an electronic diary but also calculates statistical associations based on cumulative data could be a great aid for trigger identification and management.”

Patients and physicians could use the results from the patient’s personal records and findings confirmed through clinical examinations to determine a plan for coping with confirmed migraine triggers, according to Dr. Casanova.

“Future research on migraine triggers may benefit from the use of electronic headache diaries with analytical tools like the one used in this study during extended periods of time,” she says. “There is also a need to enhance analytical tools to account for multiple triggers, using multivariable models, and to empower patients to develop strategies to cope with their specific migraine triggers.”