Stephen Silberstein, MD: Peter, I want you to talk to us about identifying triggers and protectors.

Peter Goadsby, MBBS: Yeah, it’s a popular pastime, you know; identification of triggers and the identification of protectors is a more recent development. I mean, I tell patients, “If something reliably triggers your attack, you should avoid it,” which seems like good advice but hardly terribly insightful. And I think there are 2 sorts of triggers. There are things that are easy to understand, you might say. And for me,  a trigger has to be reliable and biologically plausible. So nitroglycerine or alcohol and menstruation they’re plausible, they’re reliable, they’re something you can hold on to. If you contrasted that trigger with chocolate, which would be the one we could most easily dismiss—it is neither reliable nor biologically plausible nor actually stands up to any study that’s being done. I think that sometimes triggers get mistaken for exacerbations of an underlying condition that irritate migraines, so celiac disease would be a very good example of these.

If you have migraine, you have an unstable biology, basically. That unstable biology can be tilted by altering another biology that you have—thyroid disease, celiac disease, whatever biology you have—and that’s referred to as a trigger, whereas what actually is happening is simply your migraine biology getting irritated by some other biology. I didn’t think of that as triggers so much as comorbidity.

I think that as we start to understand things, perhaps some of these things are going to fall away. Many of the food triggers will. I’m interested in some literature I saw recently, which is that something you find in oranges apparently interacts with 1 of the CGRPs [calcitonin gene–related peptides]. And so for some patients, you almost think that all of a sudden, oranges might make sense for some patients. But just like we don’t have any therapy that’s good for everybody and nitroglycerine might trigger everybody, nor will alcohol, nor does menstruation. No one should be disappointed that if they get triggers from some magazine, if they don’t apply to them, I would worry about that, because the crucial thing is the interaction with the individual. So if it triggers patients, if it’s reliable, and we have a discussion and it sort of makes sense, then you should avoid it. But otherwise, don’t torture yourself.

As for protectors, it’s a more modern concept, I have to say. I think at the moment, the things I’ve seen written about…are more likely to be statistical associations of less sensitivity to migraine rather than protection, as such, from the conditions. So I think I would put myself in the certainly agnostic category when it comes to thinking about protectors.

One underlying principle about this—and I think it runs through everything we’ve been saying—is that if you understand things and you start to dig apart the biology, then things that make sense make sense, and the rest of it you can kind of get rid of. And migraines have come a long way in the last 25 to 30 years, in terms of understanding detailed biology. And we were talking earlier on about individual transmitters involved in aura, for example. We’ve started to understand these things in a way that—they’re sort of old wives’ tales, migraine craziness stuff—is going away. And it says that research works, particularly if it’s funded, and it would be better if there was more of the funding, if we could say that. And it encourages us to think about patients with migraine as having a serious biologically determined problem. And if we could just understand what’s going on, we’ll do a better job, and we’ll be above to treat them so much better.

Stephen Silberstein, MD: I often look at some of the triggers of monetary features, and my best example to my patients is that you went out and ate pickles and ice cream and you find out 4 or 5 days later that you’re pregnant—nobody thinks of pickles and ice cream when there’s pregnancy. And the question is, If you have the desire for something that you know might trigger your headache and you do it anyway, is that really part of the premonitory features of migraine?

Let’s assume for the sake of argument that chocolate’s a treatment for migraine, and let’s say it’s as good as the triptan—it works half the time. So you eat chocolate every time you get a headache, and it works half the time, but you remember when it doesn’t work and you blame it the chocolate. So that’s another potential.

David Dodick, MD: Well, the trouble with triggers also is what you said is the blaming. And so often we, as providers use it to blame the patient. The patients will blame themselves. In another manner, they feel a sense of control if they have a giant list of triggers and they can control some of them. Even if there’s no change in their underlying disease state, they feel like they’re doing something actively. And that can be very harmful if they fixate on this and they don’t try to actually get appropriate care.

Stewart Tepper, MD: It actually goes back to what Peter said, too. It’s really important to have a conversation with them about the fact that a trigger is not a cause of migraine. As we understand the biology of migraine and we understand more and more about what actually is associated with the genesis of migraine, we clearly understand that eating chocolate is not a cause of migraine. And the patients will often need a gentle persuasion in that regard.