The influence of environmental factors on the clinical manifestation of migraine has been a matter of extensive debate over the past decades. Migraineurs commonly report foods, alcohol, meteorologic or atmospheric changes, exposure to light, sounds, or odors, as factors that trigger or aggravate their migraine attacks. In the same way, physicians frequently follow this belief in their recommendations in how migraineurs may reduce their attack frequency, especially with regard to the consumption of certain food components. Interestingly, despite being such a common belief, most of the clinical studies have shown conflicting results. The aim of the review is to critically analyze clinical and pathophysiological facts that support or refute a correlation between certain environmental stimuli and the occurrence of migraine attacks. Given the substantial discrepancy between patients' reports and objective clinical data, the methodological difficulties of investigating the link between environmental factors and migraine are highlighted.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of outstanding importance
Kelman L. The triggers or precipitants of the acute migraine attack. Cephalalgia. 2007;27:394–402.
Spierings EL, Ranke AH, Honkoop PC. Precipitating and aggravating factors of migraine vs tension-type headache. Headache. 2001;41:554–8.
Turner L, Molgaard C, Gardner C, Rothrock J, Stang P. Migraine trigger factors in a non-clinical mexican-american population in San Diego county: Implications for etiology. Cephalalgia. 1995;15:523–30.
von Mackensen S, Hoeppe P, Maarouf A, Tourigny P, Nowak D. Prevalence of weather sensitivity in Germany and Canada. Int J Biometeorol. 2005;49:156–66.
Wöber C, Holzhammer J, Zeitlhofer J, Wessely P, Wöber-Bingöl Ç. Trigger factors of migraine and tension-type headache: Experience and knowledge of the patients. J Headache Pain. 2006;7:188–95.
Wöber C, Wöber-Bingöl Ç. Chapter 12 - Triggers of migraine and tension-type headache. In: Michael J. Aminoff FB, Dick FS, Eds. Handbook of Clinical Neurology: Elsevier. 2010;pp 161–72.
•• Houle TT, Turner DP. Natural experimentation is a challenging method for identifying headache triggers. Headache. 2013;53:636–43. This study challenges the feasibility of identifying migraine triggers in clinical practice by using natural experimentation.
Turner DP, Smitherman TA, Martin VT, Penzien DB, Houle TT. Causality and headache triggers. Headache. 2013;53:628–35.
Schurks M, Buring JE, Kurth T. Migraine features, associated symptoms and triggers: A principal component analysis in the Women's health study. Cephalalgia. 2011;31:861–9.
Goadsby PJ, Silberstein SD. Migraine triggers: Harnessing the messages of clinical practice. Neurology. 2013;80:424–5.
Charles A. The evolution of a migraine attack - a review of recent evidence. Headache. 2013;53:413–9.
Finocchi C, Sivori G. Food as trigger and aggravating factor of migraine. Neurological Sciences. 2012;33:77–80.
Selby G, Lance JW. Observations on 500 cases of migraine and allied vascular headache. J Neurol Neurosurg Psychiatry. 1960;23:23–32.
Camboim Rockett F, Castro K, Rossoni de Oliveira V, Da Silveira Perla A, Fagundes Chaves ML, Schweigert Perry ID. Perceived migraine triggers: Do dietary factors play a role? Nutr Hosp. 2012;27:483–9.
Pascual J, Oterino A. IgG-mediated allergy: A new mechanism for migraine attacks? Cephalalgia. 2010;30:777–9.
Arroyave Hernandez CM, Echavarria Pinto M, Hernandez Montiel HL. Food allergy mediated by IgG antibodies associated with migraine in adults. Rev Alerg Mex. 2007;54:162–8.
• Alpay K, Ertas M, Orhan EK, Ustay DK, Lieners C, Baykan B. Diet restriction in migraine, based on IgG against foods: A clinical double-blind, randomised, cross-over trial. Cephalalgia. 2010;30:829–37. This study suggests that individualized elimination diet may be useful and feasible to prevent migraine.
Aydinlar EI, Dikmen PY, Tiftikci A, Saruc M, Aksu M, Gunsoy HG, et al. IgG-based elimination diet in migraine plus irritable bowel syndrome. Headache. 2013;53:514–25.
Mitchell N, Hewitt CE, Jayakody S, Islam M, Adamson J, Watt I, et al. Randomised controlled trial of food elimination diet based on IgG antibodies for the prevention of migraine like headaches. Nutr J. 2011;10:85.
Panconesi A, Bartolozzi M, Guidi L. Alcohol and migraine: What should we tell patients? Curr Pain Headache Rep. 2011;15:177–84.
Panconesi A, Bartolozzi ML, Mugnai S, Guidi L. Alcohol as a dietary trigger of primary headaches: What triggering site could be compatible? Neurol Sci. 2012;33 Suppl 1:S203–5.
Littlewood JT, Gibb C, Glover V, Sandler M, Davies PT, Rose FC. Red wine as a cause of migraine. Lancet. 1988;1:558–9.
Panconesi A, Franchini M, Bartolozzi ML, Mugnai S, Guidi L. Alcoholic drinks as triggers in primary headaches. Pain Medicine. 2013
Nicoletti P, Trevisani M, Manconi M, Gatti R, De Siena G, Zagli G, et al. Ethanol causes neurogenic vasodilation by TRPV1 activation and CGRP release in the trigeminovascular system of the guinea pig. Cephalalgia. 2008;28:9–17.
Schulman J, Leviton A, Slack W, Porter D, Graham JR. The relationship of headache occurrence to barometric pressure. Int J Biometeorol. 1980;24:263–9.
Barrie MA, Fox WR, Weatherall M, Wilkinson MIP. Analysis of symptoms of patients with headaches and their response to treatment with ergot derivatives. QJM. 1968;37:319–36.
Wilkinson M, Woodrow J. Migraine and weather. Headache. 1979;19:375–8.
Osterman PO, Lövstrand KG, Lundberg PO, Lundquist S, Muhr C. Weekly headache periodicity and the effect of weather changes on headache. Int J Biometeorol. 1981;25:39–45.
Cull RE. Barometric pressure and other factors in migraine. Headache. 1981;21:102–3.
Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33:629–808.
Rasmussen BK. Migraine and tension-type headache in a general population: Precipitating factors, female hormones, sleep pattern and relation to lifestyle. Pain. 1993;53:65–72.
Robbins L. Precipitating factors in migraine: A retrospective review of 494 patients. Headache. 1994;34:214–6.
Larmande P, Hubert B, Sorabella A, Montigny E, Belin C, Gourdon D. Influence of changes in climate and the calendar on the onset of a migraine crisis. Rev Neurol (Paris). 1996;152:38–43.
Zebenholzer K, Rudel E, Frantal S, Brannath W, Schmidt K, Wober-Bingol C, et al. Migraine and weather: A prospective diary-based analysis. Cephalalgia. 2011;31:391–400.
Villeneuve PJ, Szyszkowicz M, Stieb D, Bourque DA. Weather and emergency room visits for migraine headaches in Ottawa. Canada Headache. 2006;46:64–72.
Hoffmann J, Lo H, Neeb L, Martus P, Reuter U. Weather sensitivity in migraineurs. J Neurol. 2010:1–7.
Kimoto K, Aiba S, Takashima R, Suzuki K, Takekawa H, Watanabe Y, et al. Influence of barometric pressure in patients with migraine headache. Intern Med. 2011;50:1923–8.
Prince PB, Rapoport AM, Sheftell FD, Tepper SJ, Bigal ME. The effect of weather on headache. Headache. 2004;44:596–602.
Messlinger K, Funakubo M, Sato J, Mizumura K. Increases in neuronal activity in rat spinal trigeminal nucleus following changes in barometric pressure—relevance for weather-associated headaches? Headache. 2010;50:1449–63.
Walach H, Betz HD, Schweickhardt A. Sferics and headache: A prospective study. Cephalalgia. 2001;21:685–90.
Vaitl D, Propson N, Stark R, Walter B, Schienle A. Headache and sferics. Headache. 2001;41:845–53.
Vaitl D, Propson N, Stark R, Schienle A. Natural very-low-frequency sferics and headache. Int J Biometeorol. 2001;45:115–23.
Martin GV, Houle T, Nicholson R, Peterlin A, Martin VT. Lightning and its association with the frequency of headache in migraineurs: an observational cohort study. Cephalalgia. 2013.
Kato Y, Johansson O. Reported functional impairments of electrohypersensitive japanese: A questionnaire survey. Pathophysiology. 2012;19:95–100.
Preece AW, Georgiou AG, Dunn EJ, Farrow SC. Health response of two communities to military antennae in Cyprus. Occup Environ Med. 2007;64:402–8.
Baliatsas C, Van Kamp I, Bolte J, Schipper M, Yzermans J, Lebret E. Non-specific physical symptoms and electromagnetic field exposure in the general population: can we get more specific? A systematic review. Environ Int. 2012;41:15–28.
Kowacs PA, Piovesan EJ, Werneck LC, Tatsui CE, Lange MC, Ribas LC, et al. Influence of intense light stimulation on trigeminal and cervical pain perception thresholds. Cephalalgia. 2001;21:184–8.
Chu MK, Im HJ, Chung CS, Oh K. Interictal pattern-induced visual discomfort and ictal photophobia in episodic migraineurs: An association of interictal and ictal photophobia. Headache. 2011;51:1461–7.
Hay KM, Mortimer MJ, Barker DC, Debney LM, Good PA. 1044 Women with migraine: The effect of environmental stimuli. Headache. 1994;34:166–8.
Chronicle EP, Mulleners WM. Visual system dysfunction in migraine: A review of clinical and psychophysical findings. Cephalalgia. 1996;16:525–35. discussion 3.
Wray SH, Mijovic-Prelec D, Kosslyn SM. Visual processing in migraineurs. Brain. 1995;118(Pt 1):25–35.
Hauge AW, Kirchmann M, Olesen J. Trigger factors in migraine with aura. Cephalalgia. 2010;30:346–53.
Vijayan N, Gould S, Watson C. Exposure to sun and precipitation of migraine. Headache. 1980;20:42–3.
•• Hougaard A, Amin FM, Hauge AW, Ashina M, Olesen J. Provocation of migraine with aura using natural trigger factors. Neurology. 2013;80:428–31. This study demonstrates that bright lights do not trigger migraine with aura in an experimental setting..
Hauge AW, Kirchmann M, Olesen J. Characterization of consistent triggers of migraine with aura. Cephalalgia. 2011;31:416–38.
Vingen JV, Sand T, Stovner LJ. Sensitivity to various stimuli in primary headaches: A questionnaire study. Headache. 1999;39:552–8.
Salvesen R, Bekkelund SI. Migraine, compared to other headaches, is worse during midnight-sun summer than during polar night. A questionnaire study in an Arctic population. Headache. 2000;40:824–9.
Bekkelund SI, Hindberg K, Bashari H, Godtliebsen F, Alstadhaug KB. Sun-induced migraine attacks in an Arctic population. Cephalalgia. 2011;31:992–8.
Alstadhaug KB, Bekkelund S, Salvesen R. Circannual periodicity of migraine? Eur J Neurol. 2007;14:983–8.
Lilleng H, Bekkelund SI. Arctic environment triggers migraine attacks. Can Fam Physician. 2010;56:549–51.
Alstadhaug KB, Salvesen R, Bekkelund SI. Seasonal variation in migraine. Cephalalgia. 2005;25:811–6.
Bekkelund SI, Alstadhaug KB, Salvesen R. Lack of seasonal variation in menstrually-related migraine. Cephalalgia. 2008;28:1277–81.
Sjostrand C, Savic I, Laudon-Meyer E, Hillert L, Lodin K, Waldenlind E. Migraine and olfactory stimuli. Curr Pain Headache Rep. 2010;14:244–51.
Lima AM, Sapienza GB, Giraud Vde O, Fragoso YD. Odors as triggering and worsening factors for migraine in men. Arq Neuropsiquiatr. 2011;69:324–7.
Silva-Neto R, Peres M, Valenca M. Odorant substances that trigger headaches in migraine patients. Cephalalgia. 2013
Saisu A, Tatsumoto M, Hoshiyama E, Aiba S, Hirata K. Evaluation of olfaction in patients with migraine using an odour stick identification test. Cephalalgia. 2011;31:1023–8.
Demarquay G, Royet JP, Mick G, Ryvlin P. Olfactory hypersensitivity in migraineurs: A H(2)(15)O-PET study. Cephalalgia. 2008;28:1069–80.
Stankewitz A, May A. Increased limbic and brainstem activity during migraine attacks following olfactory stimulation. Neurology. 2011;77:476–82.
• Martin PR. Managing headache triggers: Think 'coping' not 'avoidance'. Cephalalgia. 2010;30:634–7. This perspective article challenges the common practice of trigger avoidance and suggests flexibility when adivising patients regarding triggers..
Martin PR, MacLeod C. Behavioral management of headache triggers: Avoidance of triggers is an inadequate strategy. Clin Psychol Rev. 2009;29:483–95.
Martin PR, Reece J, Forsyth M. Noise as a trigger for headaches: Relationship between exposure and sensitivity. Headache. 2006;46:962–72.
This work was supported by the National Institutes of Health (National Institute of Neurological Disorders and Stroke) [K08 –NS066087].
Compliance with Ethics Guidelines
Conflict of Interest
Dr. Jan Hoffmann received a grant from Deutsche Forschungsgemeinschaft-DFG and payment for manuscript preparation from the Journal Watch Neurology. Dr. Hoffmann had travel/accommodations expenses covered or reimbursed by Allergan, International Headache Society, and American Headache Society.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
This article is part of the Topical Collection on Migraine
About this article
Cite this article
Hoffmann, J., Recober, A. Migraine and Triggers: Post Hoc Ergo Propter Hoc?. Curr Pain Headache Rep 17, 370 (2013). https://doi.org/10.1007/s11916-013-0370-7
- Environmental stimuli